Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients aged 70 years or older: a multicenter randomized controlled trial

Superior functional outcome following reverse shoulder arthroplasty compared to hemiarthroplasty for displaced three- and four-part fractures in patients 65 and older: results from a prospective multicenter randomized controlled trial - The shoulder hemiarthroplasty or reverse polarity arthoplasty (SHeRPA) trial

BACKGROUND

Acute unreconstructible 3- or 4-part proximal humerus fractures can be treated with hemiarthroplasty or reverse polarity shoulder arthroplasty. Randomized trials using implants from multiple different companies or uncemented implants have found superior results with reverse polarity arthroplasty.

HYPOTHESIS

We tested the hypothesis that cemented reverse polarity arthroplasty produces a superior outcome compared to cemented hemiarthroplasty using one implant system in patients aged 65 years and over at 12 months follow-up as measured with the Constant Score.

METHODS

A prospective patient and assessor blinded multicenter randomized controlled trial was conducted of shoulder hemiarthroplasty or reverse polarity arthroplasty in patients aged 65 years and older with acute 3- and 4-part proximal humerus fracture not amenable to osteosynthesis. The primary outcome was the Constant Score at 12 months with total follow-up to 24 months. Block randomization by site was undertaken using random number generation and sealed envelopes. Power analysis indicated that 17 patients were required in each arm to achieve 80% power with an alpha-value of 5%. Secondary outcome measures were the difference in the mean Constant Score, Quick Disabilities of the Arm Shoulder and Hand Questionnaire (QuickDASH), Oxford Shoulder Score, American Shoulder and Elbow Surgeons Score, and EQ5D-5L up to 2 years; differences in complication rate at 1 and 2 years; differences in revision and implant failure at 1 and 2 years.

RESULTS

Eighteen patients were randomized to hemiarthroplasty and 18 to reverse polarity arthroplasty across 4 sites. The primary outcome as measured by the Constant Score at 12 months was better in the reverse polarity shoulder arthroplasty group (mean 51.1, s.d. 14.9) compared to the hemiarthroplasty group (mean 35.0, s.d. 13.5) (P = .004). No significant difference was reported at 24 months but this may be due to high rates of attrition (22%). The mean EQ-5D-5 L patient rated health status score was significantly higher in the reverse polarity shoulder arthroplasty group compared to the hemiarthroplasty group at 12 months. One hemiarthroplasty was revised due to implant uncoupling and one reverse polarity shoulder replacement was revised due to instability. No other complications were recorded.

DISCUSSION

Treatment of unreconstructible 3- or 4-part proximal humerus fractures with reverse polarity shoulder arthroplasty results in a superior outcome compared to shoulder hemiarthroplasty at 12 months measured with the Constant Score with no increased risk of failure up to 24 months in patients age 65 years and over. High attrition rates are observed in this older population due to cognitive decline and death from other causes.

Optimal combination of arthroplasty type, fixation method, and postoperative rehabilitation protocol for complex proximal humerus fractures in the elderly: a network meta-analysis

BACKGROUND

The purpose of this study was to define the optimal combination of surgical technique and postoperative rehabilitation protocol for elderly patients undergoing either hemiarthroplasty (HA) or reverse total shoulder arthroplasty (rTSA) for acute proximal humerus fracture (PHF) by performing a network meta-analysis of the comparative studies in the literature.

METHODS

A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of MEDLINE, EMBASE, and Cochrane Library was screened from 2007 to 2023. Inclusion criteria were level I-IV studies utilizing primary HA and/or rTSA published in a peer-reviewed journal, that specified whether humeral stems were cemented or noncemented, specified postoperative rehabilitation protocol, and reported results of HA and/or rTSA performed for PHF. Early range of motion (ROM) was defined as the initiation of active ROM at ≤3 weeks after surgery. Level of evidence was evaluated based on the criteria by the Oxford Centre for Evidence-Based Medicine. Clinical outcomes were compared using a frequentist approach to network meta-analysis with a random-effects model that was performed using the netmeta package version 0.9-6 in R.

RESULTS

A total of 28 studies (1119 patients) were included with an average age of 74 ± 3.7 and mean follow-up of 32 ± 11.1 months. In the early ROM cohort (Early), the mean time to active ROM was 2.4 ± 0.76 weeks compared to 5.9 ± 1.04 weeks in the delayed ROM cohort (Delayed). Overall, rTSA-Pressfit-Early resulted in statistically superior outcomes including postoperative forward elevation (126 ± 27.5), abduction (116 ± 30.6), internal rotation (5.27 ± 0.74, corresponding to L3-L1), American Shoulder and Elbow Surgeons score (71.8 ± 17), tuberosity union (89%), and lowest tuberosity nonunion rate (9.6%) in patients ≥65 year old with acute PHF undergoing shoulder arthroplasty (all P ≤ .05). In total there were 277 (14.5%) complications across the cohorts, of which 89/277 (34%) were in the HA-Cement-Delayed cohort. HA-Cement-Delayed resulted in 2-times higher odds of experiencing a complication when compared to rTSA-Cement-Delayed (P = .005). Conversely, rTSA-Cement-Early cohort followed by rTSA-Pressfit-Early resulted in a total complication rate of 4.7% and 5.4% (odds ratios, 0.30; P = .01 & odds ratios, 0.42; P = .05), respectively. The total rate of scapular notching was higher in the cemented rTSA subgroups (16.5%) vs. (8.91%) in the press fit rTSA subgroups (P = .02).

CONCLUSION

Our study demonstrates that patients ≥65 years of age, who sustain a 3-or 4-part PHF achieve the most benefit in terms of ROM, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing rTSA with a noncemented stem and early postoperative ROM when compared to the mainstream preference-rTSA-Cement-Delayed.

Reverse shoulder arthroplasty or nothing for patients with displaced proximal humeral fractures: a randomized controlled trial

BACKGROUND

The benefits of reverse shoulder arthroplasty compared to nonoperative treatment for patients presenting with complex proximal fractures have been rarely explored. The aim of this prospective study was to compare the functional results of reverse shoulder arthroplasty with those of nonsurgical treatment in patients with displaced proximal humeral fractures.

METHODS

A multicentric prospective randomized control trial of patients older than 70 years who sustained an acute proximal humeral fracture (3 or 4 parts), with less than 3 weeks of evolution, and had no previous condition or surgery on the affected shoulder was conducted. Patients were randomly assigned to the intervention group (implantation of a reverse shoulder arthroplasty and tuberosities reattachment) or the control group (nonoperative treatment). Functional outcome was assessed using the Constant-Murley score (CMS) at the 1-year follow-up. Complications and reinterventions were considered secondary outcomes. The power of the study relied on the inclusion of 81 patients to recognize a statistically significant difference of 10 points between CMS scores in the groups. Analysis was performed based on the intention to treat principle.

RESULTS

Eighty-one patients were randomized to surgical treatment or nonoperative treatment, while 66 patients completed the 1-year follow-up evaluation. There was no significant difference between the groups in terms of age (76.1 yo vs. 77.43 yo, P = .43), sex (81.08% women in the surgical group vs. 84.09% in the nonoperative group, P = .72), or type of fracture according to Neer's classification system (P = .06). At the 1-year follow-up, the group assigned to undergo the intervention had better functional outcomes than the nonoperative treatment group (mean CMS; 61.24, SD: 13.33 vs. mean CMS: 52.44, SD: 16.22, P: .02), with a mean difference of 8.84 points, 95% CI (1.57, 16.11). Two patients in the intervention group (6.5%) suffered major complications (periprosthetic joint infection and axillary nerve palsy). No major complications were observed in the nonoperative group. One patient in the intervention group underwent secondary surgery for a periprosthetic joint infection.

CONCLUSIONS

Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. The difference in CMS is close to the clinically significant thresholds, and some harms are associated with the operative treatment.

Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: A Review of Current Evidence

PURPOSE OF REVIEW

The aim of this review is to summarize information published in the recent peer-reviewed literature on reverse shoulder arthroplasty (RSA) for proximal humerus fractures.

RECENT FINDINGS

Although there is still some debate regarding which may be the best treatment for proximal humerus fractures in certain age ranges, RSA seems to offer more predictable results than other surgical treatments for elderly patients. Successful tuberosity healing seems to correlate with better outcomes. Recent trends indicate interest in cementless fixation, fracture-specific stems and a 135-degree polyethylene opening angle. RSA provides a successful surgical solution for selected proximal humerus fractures. Indications, design features, and surgical execution have continued to evolve over the last few years.

Reverse Shoulder Arthroplasty Is Superior to Plate Fixation for Displaced Proximal Humeral Fractures in the Elderly: Five-Year Follow-up of the DelPhi Randomized Controlled Trial

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Short Uncemented Metaphyseal Stem and Long-Stem Reverse Shoulder Arthroplasty in Proximal Humerus Fractures: Preliminary Study at 2-Year Follow-Up

Introduction: In the last few years, short metaphyseal-socket prosthetic humeral stems have been introduced for reverse shoulder arthroplasty (RSA). A short stem may have advantages in humeral force distribution, reducing shear stress and preserving bone stock, keeping in mind the need for possible future revision surgery. The main objective of our study was to validate the use of a short stem prosthesis in the surgical treatment of humeral fractures by comparing clinical and radiological outcomes of our studied implant with those obtained with the use of traditional long-stem implants. Methods: In this multicentric, controlled prospective study, 125 patients with proximal three- or four-fragment humerus fractures were selected and treated with RSA. A short stem was used in group A (n = 53, mean age: 75.6 ± 5.6 years old), and a long stem was used in group B (n = 72, mean age: 71.76 ± 3). Active range of motion (ROM), Constant score (CS), Quick DASH, American Shoulder and Elbow Surgeons Shoulder (ASES) score, and Visual Analog Scale (VAS) scores were collected and analyzed at 2 years mean follow-up, as well as humeral and glenoid bone resorption (sum Inoue scores and Sirveaux scores were used). Results: No statistically significant differences were observed between group A and B in ROM, Constant score (51.69 ± 15.8 vs. 53.46 ± 15.96, p > 0.05), Quick DASH (31.5 ± 21.81 vs. 28.79 ± 13.72, p = 0.85), ASES (82.53 ± 17.79 vs. 84.34 ± 15.24, p = 0.57), or the VAS (0.53 ± 1 vs. 0.56 ± 1.07, p = 0.14) at the final follow-up. No statistically significant differences were found in the radiographic parameters between the two groups. No statistically significant differences were found for the average degree of humeral and glenoid bone resorption either. Conclusions: The use of a short metaphyseal-socket stem can be considered a safe, effective, and feasible option in reverse shoulder arthroplasty for treating proximal humerus fractures. Our results are encouraging, with no statistically significant differences identified between the proposed treatment and traditional long stems.

Straight intramedullary MultiLoc nails for displaced proximal humeral fractures: health status, radiographic results, clinical outcome, and complications

BACKGROUND

The treatment of the displaced proximal humerus fractures (PHF) still facing a lot of unsolved problems. The aim of this study was to evaluate the clinical effect of MultiLoc nails for the treatment of PHF and present outcomes of patients with different Neer's classification and reduction quality.

METHODS

Adult patients with PHFs were recruited and treated with MultiLoc nail. Intraoperative data, radiographic and functional outcomes, as well as occurrence of postoperative complications were assessed.

RESULTS

48 patients met inclusion and exclusion criteria and were included in this study. The DASH Score were 32.2 ± 3.1 points at 12 months, and 37.3 ± 2.5 points at the final follow-up. The mean ASES score at 12 months and final follow-up were 74.4 ± 6.2 and 78.8 ± 5.1, respectively. The mean CM Score in all 48 patients reached 68 ± 6.4 points at the final follow-up, relative side related CM Score 75.2 ± 7.7% of contralateral extremity. The incidence rate of complications was 20.8%. Patients with fracture mal-union, adhesive capsulitis were observed but no secondary surgeries were performed. There was no significantly difference of DASH Score 12 months after surgery and at the last follow-up among patients with different Neer's classification or reduction quality. However, functional outcomes such as ASES score and CM score were significantly influenced by severity of fracture and the quality of fracture reduction.

CONCLUSIONS

Our study demonstrated that MultiLoc nails is well suited for proximal humeral fractures, with satisfactory health status recovery, good radiographic results, positive clinical outcomes and low rates of complications. The treatment for four part PHF still faces great challenges. Accurate fracture reduction was an important factor for good functional result.

The fragility of statistical findings in the reverse total shoulder arthroplasty literature: a systematic review of randomized controlled trials

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) has seen increasing utilization as an effective intervention for a wide variety of shoulder pathologies. The scope and indications for growth are often driven by findings from randomized controlled trials (RCTs) guiding surgical decision-making for RTSA. In this study, we utilized the fragility index (FI), reverse fragility index (rFI), and fragility quotient (FQ) to assess the robustness of outcomes reported in RCTs in the RTSA literature.

METHODS

PubMed, Embase, and MEDLINE were queried for RCTs (Jan. 1, 2010-Mar. 31, 2023) in the RTSA literature reporting dichotomous outcomes. The FI and rFI were defined as the number of outcome reversals required to alter statistical significance for significant and nonsignificant outcomes, respectively. The FQ was determined by dividing the FI by the sample size of each study. Subgroup analysis was performed based on outcome category.

RESULTS

One hundred seventy-six RCTs were screened with 18 studies included. The median FI across 59 total outcomes was 4 (interquartile range [IQR]: 3-5) with an associated FQ of 0.051 (IQR: 0.029-0.065). Thirteen outcomes were statistically significant with a median FI of 3 (IQR: 1-4) and FQ of 0.033 (IQR: 0.012-0.066). Forty-six outcomes were nonsignificant with a median rFI of 4 (IQR: 3-5) and FQ of 0.055 (IQR: 0.032-0.065). The most fragile outcome category was revision/reoperations with a median FI of 2.50 (IQR: 1.00-3.25), followed by clinical score/outcome (median FI: 3.00), complications (median FI: 4.00), "other" (median FI: 4.00), and radiographic findings (median FI: 5.00). Notably, the number of patients lost to follow-up was greater than or equal to the FI for 59% of outcomes.

CONCLUSION

The statistical findings in RTSA RCTs are fragile and should be interpreted with caution. Reversal of only a few outcomes, or maintaining postoperative follow-up, may be sufficient to alter significance of study findings. We recommend standardized reporting of P values with FI and FQ metrics to allow clinicians to effectively assess the robustness of study findings.

International trends in shoulder replacement: a meta-analysis from 11 public joint registers

BACKGROUND AND PURPOSE

International variation exists in the types of shoulder replacement used for treatment of specific diseases. Implant choice continues to evolve without high-quality evidence. Our aim was to evaluate trends in incidence rates of shoulder replacement and assess any recent changes in practice between countries by using registry data.

METHODS

Patient characteristics, indication and year of surgery, type of replacement, and collection methods of patient-reported outcomes (PROMs) was extracted from 11 public joint registries. Meta-analyses examined use of reverse total shoulder replacement (RTSR) for osteoarthritis, cuff tear arthropathy, and acute fracture; use of anatomical total shoulder replacement (TSR) for osteoarthritis; and use of humeral hemiarthroplasty for fracture.

RESULTS

The annual growth rate of shoulder replacements performed is 6-15% (2011-2019). The use of RTSR has almost doubled (93%). RTSR is now universally performed for cuff tear arthropathy (97.3%, 95% confidence interval [CI] 96.0-98.1). Its use for avascular necrosis, trauma, and inflammatory arthropathy is increasing. The use of RTSR was similar (43.1%, CI 30.0-57.2) versus TSR (44.7%, CI 31.1-59.1) for osteoarthritis. The types of PROMs used, collection time points, and response rates lack standardization. COVID-19 had a varying inter-registry impact on incidence rates.

CONCLUSION

The incidence of shoulder replacements has grown. Use of RTSR has increased for all disease indications despite limited high-quality evidence driving this change in indications outside of cuff arthropathy. Consequently, less variation is observed in international practice. Existing differences now relate to use of newer implant types and methodology of PROMs collection, which prevents international comparison and outcome analysis.

Great tuberosity fixation does not affect healing and clinical outcomes in RSA performed in proximal humeral fractures in elderly patients

PURPOSE

Aims of our study were to define whether the great tuberosity (GT) positioning fixation in reverse shoulder arthroplasty (RSA) after proximal humeral fracture (PHF) could predict tuberosity healing and its impact on clinical outcomes.

METHODS

We enrolled 59 patients treated with cementless reverse shoulder arthroplasty after PHF in our institute between 2012 and 2018. The mean follow-up was 57 months (± 23.4). We divided patients into two groups according to GT positioning after fixation: Group 1 GT in contact and Group 2 GT detached at least 1 mm from humeral diaphysis. Clinical and radiographic evaluations were conducted at last follow-up.

RESULTS

Overall GT healing rate was 64.4%, (Group 1 70.7%-Group 2 50%). A statistically significant difference (P = 0.047) was found in cortical thickness narrowing at one-third of stem length. We found a correlation between lateral cortical narrowing and GT fixation in non-anatomical position, but we observed no statistically significant differences about GT healing according to GT anatomical or non-anatomical fixation. No differences were found in shoulder function in patients whose tuberosity was healed or failed to heal.

CONCLUSION

GT reduction is not a predictive factor for GT healing; external stress shielding, instead, seems to be decreased in patients with postoperative anatomically reduced GT. In our study, GT healing did not affect clinical outcomes or patient's satisfaction in elderly low-demanding patients.

Comparative efficacy and safety of medical treatments for proximal humerus fractures: a systematic review and network meta-analysis

BACKGROUND

Various surgical techniques and conservative therapies are useful tools for treating proximal humerus fractures (PHFs), but it is important to understand how to properly utilize them. Therefore, we performed a systematic review and network meta-analysis to compare and rank the efficacy and safety of medical treatments for PHF.

METHODS

PubMed, Embase, the Cochrane Library, and the ClinicalTrials.gov databases were systematically searched for eligible randomized controlled trials (RCTs) from inception until June 2022. Conservative therapy-controlled or head-to-head RCTs of open reduction internal fixation (ORIF), intramedullary nailing (IMN), hemiarthroplasty (HA), and reverse total shoulder arthroplasty (RTSA) used for the treatment of adult patients with PHF were included. The surface under the cumulative ranking (SUCRA) probabilities were applied to compare and rank the effects of medical treatments for PHF.

RESULTS

Eighteen RCTs involving 1,182 patients with PHF were selected for the final analysis. Mostly baseline characteristics among groups were well balanced, and the imbalanced factors only included age, injury type, medial comminution, blood loss, and cognitive function in single trial. The SUCRA probabilities found that RTSA provided the best effect on the Constant-Murley score (SUCRA: 100.0%), and the disabilities of the arm, shoulder and hand (DASH) score (SUCRA: 99.0%). Moreover, HA (SUCRA: 85.5%) and RTSA (SUCRA: 68.0%) had a relatively better effect on health-related quality of life than the other treatment modalities. Furthermore, conservative therapy (SUCRA: 84.3%) and RTSA (SUCRA: 80.7%) were associated with a lower risk of secondary surgery. Finally, the best effects on the risk of complications are varied, including infection was observed with conservative therapy (SUCRA: 94.2%); avascular necrosis was observed in HA (SUCRA: 78.1%), nonunion was observed in RTSA (SUCRA: 69.6%), and osteoarthritis was observed in HA (SUCRA: 93.9%).

CONCLUSIONS

This study found that RTSA was associated with better functional outcomes, while the comparative outcomes of secondary surgery and complications varied. Optimal treatment for PHF should consider patient-specific factors.

Does age affect patient outcomes after humeral head replacement in the treatment of acute proximal humeral fractures? A comparative cohort study with a minimum 10 years long-term follow-up

BACKGROUND

Humeral head replacement (HHR) is now rarely recommended for complex proximal humeral fractures (PHFs) in older patients. However, in relatively young and active patients with unreconstructable complex PHFs, controversy still exists regarding the treatment options of reverse shoulder arthroplasty and HHR. The goal of this study was to compare the survival, functional, and radiographic outcomes of HHR in patients aged <70 years and those aged ≥70 years after a minimum 10 years follow-up.

METHODS

Eighty-seven out of 135 patients undergoing primary HHR were enrolled and then divided into 2 groups based on age: <70 years and ≥70 years. Clinical and radiographic evaluations were performed with a minimum follow-up of 10 years.

RESULTS

There were 64 patients (mean, 54.9 years) in the younger group and 23 patients (mean, 73.5 years) in the older group. The younger and older groups had comparable 10-year implant survivorship (98.4% vs. 91.3%). Patients aged ≥70 years had worse American Shoulder and Elbow Surgeons scores (74.2 vs. 81.0, P = .042) and lower satisfaction rates (12% vs. 64%, P < .001) than younger patients. At the final follow-up, older patients had worse forward flexion (117° vs. 129°, P = .047) and internal rotation (17 vs. 15, P = .036). More greater tuberosity complications (39% vs. 16%, P = .019), glenoid erosion (100% vs. 59%, P = .077), and humeral head superior migration (80% vs. 31%, P = .037) were also identified in patients aged ≥70 years.

CONCLUSIONS

Unlike the increased risk for revision and functional deterioration over time after reverse shoulder arthroplasty for PHFs in younger patients, a high implant survival rate with lasting pain relief and stable functional outcomes could be observed in younger patients after HHR during long-term follow-up. Patients aged ≥70 years had worse clinical outcomes, lower patient satisfaction, more greater tuberosity complications, and more glenoid erosion and humeral head superior migration than those aged <70 years. HHR should not be recommended for the treatment of unreconstructable complex acute PHFs in older patient populations.

A network meta-analysis of multiple modalities for the treatment of complex proximal humeral fractures in older adults

OBJECTIVE

Four principal treatment modalities are applied to treat complex proximal humeral fractures in older adults: conservative treatment, open reduction internal fixation, hemiarthroplasty, and reverse shoulder arthroplasty. However, among these, the optimal treatment modality has yet to be determined. Therefore, a network meta-analysis was carried out to compare treatment modalities and assess their effectiveness.

METHODS

The databases PUBMED, EM-BASE, the Cochrane Central Register of Controlled Trials, Web of Science, and CNKI were searched for randomised controlled trials on complex proximal humeral fractures in older people, ranging from inception of each database to May 2023.

RESULTS

This meta-analysis included 14 randomised controlled trials, containing 791 patients aged over 60 years who were treated for complex proximal humeral fractures. Reverse shoulder arthroplasty and hemiarthroplasty yielded the highest Constant shoulder scores, whilst conservative treatment performed poorly. Hemiarthroplasty and open reduction internal fixation yielded the best performances on the visual analogue pain scale, whilst conservative treatment performed poorly. Reverse shoulder arthroplasty and open reduction internal fixation allowed for maximum forward flexion and outreach of range of motion, whilst hemiarthroplasty allowed for the least. Open reduction internal fixation and reverse shoulder arthroplasty allowed for maximum internal rotation of the range of motion, whilst conservative treatment allowed for the least. Hemiarthroplasty and conservative treatment allowed for maximum external rotation of the range of motion, whilst open reduction internal fixation allowed for the least.

CONCLUSION

Compared with open reduction internal fixation, reverse shoulder arthroplasty yields better Constant shoulder scores and allows for greater forward flexion and outreach of range of motion of the shoulder joint in complex proximal humerus fractures in older patients. Meanwhile, hemiarthroplasty yields the best visual analogue scale scores and allows for maximum external rotation of the range of motion. However, open reduction with internal fixation remains the preferred clinical treatment for complex proximal humeral fractures in older patients.

Quality of Life and Pain after Proximal Humeral Fractures in the Elderly: A Systematic Review

Background and Objectives: The proximal humeral fracture (PHF) is one of the most common fractures in elderly patients. A PHF might influence the quality of life (QoL) on several different levels, especially in elderly patients, but it is unclear which treatment option results in a better QoL outcome. Therefore, we aimed to systematically review the current literature for studies that have analyzed the QoL and pain of elderly patients treated either surgically or non-operatively for PHF. Materials and Methods: A comprehensive search of the literature was performed in the PubMed database from January to April 2023. Studies describing the QoL or the level of pain of patients older than 60 years with the EuroQoL-5 Dimension (EQ-5D) score or the visual analogue scale (VAS) after the treatment of PHF, either non-operatively (non-OP), with open-reduction and internal fixation using a locking plate (LPF), or with reverse total shoulder arthroplasty (RTSA) were included. Twelve studies were analyzed descriptively and the individual risk of bias was assessed using the ROB2 and ROBINS-I tools. Results: A total of 12 studies with 712 patients at baseline were included (78% female sex, mean age 75.2 years). The reported VAS scores at 12-month follow-up (FU) ranged from 0.7 to 2.5. The calculated overall mean VAS score across all studies showed a decreasing tendency for all treatments, with an increasing FU time up to 12 months after PHF. None of the studies reported any significant differences of the EQ-5D across the groups. The overall calculated EQ-5D indices showed an increasing trend after 6-8 weeks FU, but did not differ significantly between the three treatments. Conclusions: In conclusion, the current literature suggests that there are no clinically important differences between the QoL or pain in elderly patients with PHF after non-operative treatment or surgical treatment with LPF or RTSA. However, the number of studies and level of evidence is rather low and further trials are urgently needed.

Is there still a place for anatomic hemiarthroplasty in patients with high functional demands in primary, nonreconstructable proximal humeral fractures? A clinical and radiographic assessment

BACKGROUND

Vitality-threatening proximal humerus fractures often provide an indication for prosthetic treatment. We investigated the issue of how anatomic hemiprostheses perform in younger, functionally challenging patients with the use of a specific fracture stem and systematic tuberosity management in medium-term follow-up.

METHODS

Thirteen skeletally mature patients with a mean age of 64 ± 9 years and a minimum follow-up of 1 year after primary open-stem hemiarthroplasty for 3- and 4-part proximal humeral fractures were included. All patients were followed up regarding their clinical course. Radiologic follow-up included fracture classification, healing of tuberosities, proximal migration of the humeral head, evidence of stem loosening, and glenoid erosion. Functional follow-up included range of motion, pain, objective and subjective performance scores, complications, and return to sports rates. We statistically compared treatment success based on the Constant score between the cohort with proximal migration and the cohort with regular acromiohumeral distance by means of the Mann-Whitney U test.

RESULTS

After an average follow-up period of 4.8 years, satisfactory results were obtained. The absolute Constant-Murley score was 73.2 ± 12.4 points. The disabilities of the arm, shoulder, and hand score was 13.2 ± 13.0 points. Patients reported their mean subjective shoulder value as 86.6% ± 8.5%. Pain was reported as 1.1 ± 1.3 points on a visual analog scale. Flexion, abduction, and external rotation values were 138 ± 31°, 134 ± 34°, and 32 ± 17°, respectively. 84.6% of the referred tuberosities healed successfully. Proximal migration was observed in 38.5% of cases and was associated with worse Constant score results (P = .065). No patient showed signs of loosening. Mild glenoid erosion was apparent in 4 patients (30.8%). All patients who were interviewed and participated in sports before surgery were able to return to their primary sport after surgery and continued to do so during the final follow-up.

CONCLUSIONS

With narrow indications, use of a specific fracture stem and adequate tuberosity management, successful radiographic and functional results are presented after a mean follow-up of 4.8 years after hemiarthroplasty for primary nonreconstructable humeral head fractures. Accordingly, open-stem hemiarthroplasty appears to remain a possible alternative to reverse shoulder arthroplasty in younger, functionally challenging patients with primary 3- or 4-part proximal humeral fractures.

The statistical fragility of the management options for reverse shoulder arthroplasty: a systematic review of randomized control trial with fragility analysis

Reverse shoulder arthroplasty (RSA) is used in the treatment of traumatic and arthritic pathologies, with expanding clinical indications and as a result there has been an increase in clinical research on the topic. The purpose of this study was to examine the statistical fragility of randomized control trials (RCTs) reporting outcomes from RSA. A systematic search was undertaken to find RCTs investigating RSA. The Fragility Index (FI) was calculated using Fisher's exact test, by sequentially altering the number of events until there was a reversal of significance. The Fragility Quotient (FQ) was calculated by dividing the FI by the trial population. Each trial was assigned an overall FI and FQ calculated as the median result of its reported findings. Overall, 19 RCTs warranted inclusion in the review, representing 1146 patients, of which 41.2% were male, with a mean age of 74.2 ± 4.3 years and mean follow-up of 22.1 ± 9.9 months. The median RCT population was 59, with a median of 9 patients lost to follow-up. The median FI was 4.5, and median FQ was 0.083, indicating more patients did not complete the trial than the number of outcomes which would have to change to reverse the finding of significance. This review found that the RCT evidence for RSA management may be vulnerable to statistical fragility, with a handful of events required to reverse a finding of significance.

Fracture Dislocations of the Glenohumeral Joint

PURPOSE OF REVIEW

Proximal humerus fracture dislocations typically result from high-energy mechanisms and carry specific risks, technical challenges, and management considerations. It is vital for treating surgeons to understand the various indications, procedures, and complications involved with their treatment.

RECENT FINDINGS

While these injuries are relatively rare in comparison with other categories of proximal humerus fractures, fracture dislocations of the proximal humerus require treating surgeons to consider patient age, activity level, injury pattern, and occasionally intra-operative findings to select the ideal treatment strategy for each injury. Proximal humerus fracture dislocations are complex injuries that require special considerations. This review summarizes recent literature regarding the evaluation and management of these injuries as well as the indications and surgical techniques for each treatment strategy. Thorough pre-operative patient evaluation and shared decision-making should be employed in all cases. While nonoperative management is uncommonly considered, open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder replacement are at the surgeon's disposal, each with their own indications and complication profile.

Western Ontario Osteoarthritis of the Shoulder Index (WOOS) - a validation for use in proximal humerus fractures treated with arthroplasty

BACKGROUND

The Swedish shoulder and Arthroplasty Registry (SSAR) use the Western Ontario Osteoarthritis of the Shoulder Index (WOOS) as their shoulder-specific score in the follow-up. WOOS is not yet validated for use as the Patient Reported Outcome Measurement (PROM) for proximal humerus fractures (PHF) treated with shoulder hemiarthroplasty (SHA) in the Swedish registry. The aim of this study was to examine the validity, the reliability and the responsiveness of WOOS as a PROM for proximal humerus fractures treated with shoulder arthroplasty.

METHODS

Data was collected from the SSAR from the 1st of January 2008 to the 31st of June 2011. A total of 72 subjects were identified with at least 1 year of follow-up. Of these 43 completed all the shoulder-specific PROM together with a clinical examination, including a WOOS retest and general health scores. A group of 29 did not undergo any clinical examination, but they completed all the questionnaires not requiring a clinical examination. The validity was assessed with WOOS compared to satisfaction level, and the Spearman rank coefficient was used for the correlation between WOOS and the shoulder-specific scores (Constant-Murley Score, Oxford Shoulder Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form and EQ-5D. For reliability, Intra Class Correlation (ICC) was used for the test-retest assessment and Cronbach´s alpha for the construct reliability.

RESULTS

The validity for WOOS had an excellent correlation (> 0.75) with all the shoulder-specific scores and a good correlation (> 0.6) with EQ-5D. The reliability with the test-retest of the total WOOS score and the subgroups had an excellent correlation. Cronbach´s alpha also supports the construct of WOOS. There were no floor or ceiling effects.

CONCLUSIONS

We found that WOOS is a reliable tool for evaluating patients with SHA after PHF. Based on our study, we recommend the continued use of WOOS in shoulder arthroplasty registries and observational studies.

Assessment of surgical management for locked fracture-dislocations of the proximal humerus in patients of different ages

Background

Locked fracture-dislocation of the proximal humerus (LFDPH) is a very severe complex injury; neither arthroplasty nor internal plating are fully satisfactory. This study aimed to evaluate different surgical treatments for LFDPH to determine the optimal option for patients of different ages.

Methods

From October 2012 to August 2020, patients who underwent open reduction and internal fixation (ORIF) or shoulder hemiarthroplasty (HSA) for LFDPH were retrospectively reviewed. At follow-up, radiologic evaluation was performed to evaluate bony union, joint congruence, screw cut-out, avascular necrosis of the humeral head, implant failure, impingement, heterotopic ossification, and tubercular displacement or resorption. Clinical evaluation comprised the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire and Constant-Murley and visual analog scale (VAS) scores. Additionally, intraoperative and postoperative complications were assessed.

Results

Seventy patients (47 women and 23 men) with final evaluation results qualified for inclusion. Patients were divided into three groups: group A: patients aged under 60 years who underwent ORIF; group B: patients aged ≥60 years who underwent ORIF; and group C: patients who underwent HSA. At a mean follow-up of 42.6 ± 26.2 months, function indicators, namely shoulder flexion, and Constant-Murley and DASH scores, in group A were significantly better than those in groups B and C. Function indicators in group B were slightly but not significantly better compared with group C. Regarding operative time and VAS scores, there were no significant differences between the three groups. Complications occurred in 25%, 30.6%, and 10% of the patients in groups A, B, and C, respectively.

Conclusions

ORIF and HSA for LFDPH provided acceptable but not excellent results. For patients aged <60 years, ORIF might be optimal, whereas, for patients aged ≥60 years, both ORIF and HSA provided similar results. However, ORIF was associated with a higher rate of complications.

A novel "7 sutures and 8 knots" surgical technique in reverse shoulder arthroplasty for proximal humeral fractures: tuberosity healing improves short-term clinical results

BACKGROUND

Complex proximal humeral fractures (cPHFs) represent an important public health concern, and reverse shoulder arthroplasty (RSA) has emerged as a feasible treatment option in the elderly with high functional demands. Recent studies have shown that tuberosity healing leads to better clinical outcomes and an improved range of motion. However, the best surgical technique for the management of the tuberosities is still a topic of debate. The purpose of this retrospective observational study is to report the radiographic and clinical outcomes of a consecutive series of patients who underwent RSA for cPHFs using a novel "7 sutures and 8 knots" technique.

MATERIALS AND METHODS

A consecutive series of 32 patients (33 shoulders) were treated with this technique by a single surgeon from January 2017 to September 2021. Results at a minimum follow-up of 12 months and a mean ± SD follow-up of 35.9 ± 16.2 (range 12-64) months are reported.

RESULTS

The tuberosity union rate was 87.9% (29 out of 33 shoulders), the mean Constant score was 66.7 ± 20.5 (range 29-100) points, and the mean DASH score was 33.4 ± 22.6 (range 2-85) points.

CONCLUSIONS

The "7 sutures and 8 knots" technique, which relies on three sutures around the implant and five bridging sutures between the tuberosities, is a relatively simple procedure which provides a reliable means for anatomic restoration of the tuberosities and allows functional recovery of the shoulder in elderly patients with cPHFs treated with RSA.

LEVEL OF EVIDENCE

IV; retrospective atudy.

TRIAL REGISTRATION

At our institution, no institutional review board nor ethical committee approval is necessary for retrospective studies.

Outcomes of anatomic and reverse total shoulder arthroplasty in patients over the age of 70: a systematic review

Background

Both anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA) reliably improve pain and function for a variety of indications. However, there remain concerns about these procedures among elderly patients due to their general health, the potential for lesser functional gain, and the possible need for revision at an even older age. The purpose of this review is to compare the clinical outcomes, radiographic outcomes, and complications of ATSA and RTSA among patients older than 70 years.

Methods

A systematic review was performed using searches of PubMed, Embase, and Cochrane databases. The inclusion criteria were studies with patients older than 70 years who were treated with a primary ATSA or RTSA and clinical results reported at a minimum of 2 years. All indications for primary RTSA except for tumor were included. Outcomes of interest included patient-reported outcomes (PROs), range of motion, patient satisfaction, radiographic changes, complication and revision rates, and implant survival.

Results

A total of 24 studies met the inclusion criteria. At a mean follow-up of 3.4 years for ATSA and 3.1 years for RTSA, there were significant improvements in pain, range of motion, and PROs for both prostheses. Patients who underwent ATSA generally had better motion and functional outcomes compared to those who underwent RTSA, though these comparisons were made across different indications for arthroplasty. The satisfaction rate was 90.9% after ATSA and 90.8% after RTSA. Furthermore, 10.2% of ATSA patients and 9.9% of RTSA patients experienced a surgical complication, whereas 2.3% of ATSA and 2.2% of RTSA patients underwent a revision. Secondary rotator cuff tear was the most common complication after ATSA, occurring in 3.7% of patients, but only 1.1% of patients required revision surgery. Both ATSA and RTSA implant survivorship was reported to range from 93.1% to 98.9% at 5- and 8-year follow-up, respectively. Patient mortality was estimated to be 19.3% with a mean time to death of 6.1 years.

Conclusions

Elderly patients with primary osteoarthritis and an intact rotator cuff can have predictable pain relief, restoration of functional range of motion, and significant improvement in PROs after ATSA with low complication rates. Secondary rotator cuff failure and revision arthroplasty occur infrequently at early to mid-term follow-up. Although elderly patients who underwent ATSA generally had better functional outcomes compared to those who underwent RTSA for differing indications, patient satisfaction after both procedures were similar.

Update on Shoulder Arthroplasties with Emphasis on Imaging

Shoulder pain and dysfunction may significantly impact quality of life. If conservative measures fail, advanced disease is frequently treated with shoulder arthroplasty, which is currently the third most common joint replacement surgery following the hip and knee. The main indications for shoulder arthroplasty include primary osteoarthritis, post-traumatic arthritis, inflammatory arthritis, osteonecrosis, proximal humeral fracture sequelae, severely dislocated proximal humeral fractures, and advanced rotator cuff disease. Several types of anatomic arthroplasties are available, such as humeral head resurfacing and hemiarthroplasties, as well as total anatomic arthroplasties. Reverse total shoulder arthroplasties, which reverse the normal ball-and-socket geometry of the shoulder, are also available. Each of these arthroplasty types has specific indications and unique complications in addition to general hardware-related or surgery-related complications. Imaging-including radiography, ultrasonography, computed tomography, magnetic resonance imaging, and, occasionally, nuclear medicine imaging-has a key role in the initial pre-operative evaluation for shoulder arthroplasty, as well as in post-surgical follow-up. This review paper aims to discuss important pre-operative imaging considerations, including rotator cuff evaluation, glenoid morphology, and glenoid version, as well as to review post-operative imaging of the various types of shoulder arthroplasties, to include normal post-operative appearances as well as imaging findings of complications.

"Champagne Fracture": A Superior Fracture-Dislocation of the Proximal Humerus: A Case Report

A 79-year-old right-handed woman presented with an indirect trauma to her left shoulder after a fall down the stairs. X-rays and computed tomography showed a four-part glenohumeral fracture-dislocation with a subcutaneous ectopic location of the humeral head in the retroclavicular space. A reverse total shoulder arthroplasty was performed using a deltopectoral approach with direct superior extraction of the humeral head. The result at 2 years was a subjective shoulder value of 80%, an absolute Constant score of 59, and a relative Constant score of 92/100. To the best of our knowledge, this is the first description in the literature of such a lesion of superior glenohumeral fracture-dislocation and its treatment.

Two-year clinical and radiographic outcomes following uncemented reverse shoulder replacements for proximal humerus fractures

BACKGROUND

Uncertainty remains regarding the role and long-term outcomes following uncemented reverse shoulder replacements (RSRs) in managing displaced proximal humeral fractures (PHFs). Although RSRs for trauma have traditionally undergone cemented fixation of the humeral component, there is increasing interest in uncemented RSRs. Our primary aim was to evaluate 2-year outcomes following uncemented RSR fixation for 3- and 4-part PHFs in the elderly. A secondary aim was to evaluate if timing of surgery affected outcomes.

METHODS

This cohort series evaluated 2-year outcomes for 42 patients with Neer 3- and 4-part PHFs treated with uncemented RSRs between October 2016 and December 2019. Thirty-eight patients (90%) had clinical and radiologic follow-up at a minimum of 2 years. The primary outcomes compared postoperative range of movement, radiographic outcomes, and patient-reported outcome measures (PROMs). The PROMs collected included Oxford Shoulder Scores (OSSs), satisfaction scores, and the Friends and Family Test. The secondary outcome involved a subanalysis to see if outcomes were affected by treatment timing-within 2 weeks, 2-12 weeks, and >12 weeks.

RESULTS

The mean age of patients was 74.1 years (range 58-89). There were 11 males and 31 females. No intraoperative fractures were sustained. There was 1 transient axillary neurapraxia, which fully resolved by 4 months. Three patients required postoperative transfusions. During the study follow-up period, no patients developed either deep infections requiring a washout or dislocation, and none underwent further surgery. At 2-year follow-up, radiologic follow-up demonstrated tuberosity union in 29 of 38 cases (76%). Eight of 38 patients (21%) demonstrated some glenoid notching (Sirveaux 1 or 2 only) on radiographic follow-up. There was no evidence of loosening. The mean OSS was 38 (range 15-48). Mean range of movement achieved at 2 years was as follows: forward flexion 122° (50°-180°), abduction 116° (46°-180°), and external rotation 25° (range 5°-60°). Eighteen patients (47%) described their result as excellent, 17 (45%) as good, and 3 (8%) as poor. When comparing the time from injury to treatment, there was no statistically significant difference in complications or radiographic outcomes between the groups. Patients had a reduced forward flexion when treated between 2 and 12 weeks compared with the other groups (P = .019).

CONCLUSION

Uncemented RSR is a safe treatment option for the management of complex PHFs in the elderly. We report low complication rates, high patient satisfaction, and good outcomes at 2-year follow-up.

Shoulder Surgery Postoperative Immobilization: An International Survey of Shoulder Surgeons

BACKGROUND

There is currently no consensus on immobilization protocols following shoulder surgery. The aim of this study was to establish patterns and types of sling use for various surgical procedures in the United States (US) and Europe, and to identify factors associated with the variations.

METHODS

An online survey was sent to all members of the American Shoulder and Elbow Society (ASES) and European Society for Surgery of the Shoulder and Elbow (ESSSE). The survey gathered member data, including practice location and years in practice. It also obtained preferences for the type and duration of sling use after the following surgical procedures: arthroscopic Bankart repair, Latarjet, arthroscopic superior/posterosuperior rotator cuff repair (ARCR) of tears <3 cm and >3 cm, anatomic total shoulder arthroplasty (aTSA) and reverse TSA (rTSA), and isolated biceps tenodesis (BT). Relationships between physician location and sling type for each procedure were analyzed using Fisher's exact tests and post-hoc tests using Bonferroni-adjusted p-values. Relationships looking at years in practice and sling duration preferred were analyzed using Spearman's correlation tests.

RESULTS

In total, 499 surgeons with a median of 15 years of experience (IQR = 9-25) responded, with 54.7% from the US and 45.3% from Europe. US respondents reported higher abduction pillow sling use than European respondents for the following: Bankart repair (62% vs. 15%, p < 0.0001), Latarjet (53% vs. 12%, p < 0.001), ARCR < 3 cm (80% vs. 42%, p < 0.001) and >3 cm (84% vs. 61%, p < 0.001), aTSA (50% vs. 21%, p < 0.001) and rTSA with subscapularis repair (61% vs. 22%, p < 0.001) and without subscapularis repair (57% vs. 17%, p < 0.001), and isolated BT (18% vs. 7%, p = 0.006). European respondents reported higher simple sling use than US respondents for the following: Bankart repair (74% vs. 31%, p < 0.001), Latarjet (78% vs. 44%, p < 0.001), ARCR < 3 cm (50% vs. 17%, p < 0.001) and >3 cm (34% vs. 13%, p < 0.001), and aTSA (69% vs. 41%, p < 0.001) and rTSA with subscapularis repair (70% vs. 35%, p < 0.001) and without subscapularis repair (73% vs. 39%, p < 0.001). Increasing years of experience demonstrated a negative correlation with the duration of sling use after Bankart repair (r = -0.20, p < 0.001), Latarjet (r = -0.25, p < 0.001), ARCR < 3 cm (r = -0.14, p = 0.014) and >3 cm (r = -0.20, p < 0.002), and aTSA (r = -0.37, p < 0.001), and rTSA with subscapularis repair (r = -0.10, p = 0.049) and without subscapularis repair (r = -0.19, p = 0.022. Thus, the more experienced surgeons tended to recommend shorter durations of post-operative sling use. US surgeons reported longer post-operative sling durations for Bankart repair (4.8 vs. 4.1 weeks, p < 0.001), Latarjet (4.6 vs. 3.6 weeks, p < 0.001), ARCR < 3 cm (5.2 vs. 4.5 weeks p < 0.001) and >3 cm (5.9 vs. 5.1 weeks, p < 0.001), aTSA (4.9 vs. 4.3 weeks, p < 0.001), rTSR without subscapularis repair (4.0 vs. 3.6 weeks, p = 0.031), and isolated BT (3.7 vs. 3.3 weeks, p = 0.012) than Europe respondents. No significant differences between regions within the US and Europe were demonstrated.

CONCLUSIONS

There is considerable variation in the immobilization advocated by surgeons, with geographic location and years of clinical experience influencing patterns of sling use. Future work is required to establish the most clinically beneficial protocols for immobilization following shoulder surgery.

LEVEL OF EVIDENCE

Level IV.

Mortality following proximal humerus fracture-a nationwide register study of 147,692 fracture patients in Sweden

Little is known about survival after proximal humerus fracture. In this manuscript, we found the mortality to be high (almost four times higher than in age- and sex-matched controls). While frailty hip fracture has gained attention, we hope our manuscript will shed light on frailty proximal humerus fracture patients.

INTRODUCTION

Proximal humerus fractures (PHF) are common and occur mostly after the 6th decade of life. While mortality following PHF has been reported previously, mortality data after longer follow-up on a national level is lacking.

METHODS

We obtained data from the Swedish Hospital Discharge Register (SHDR), on all adult patients (≥ 18 years) with a diagnosis of PHF (S42.2, S42.20, or S42.21) for the period between 2001 and 2016. We used the Swedish Cause of Death Register (SCDR) to investigate mortality in the fracture cohort. We compared the mortality of fracture patients with age- and sex-matched population-based mortality data obtained from Statistics Sweden.

RESULTS

A total of 147 692 PHF patients were identified, with a male to female ratio of 1:3. The mean age was 69 years (range, 18 to 111). Most patients were treated non-surgically (n = 126,487, 86%). The crude mortality rate was 2.2% at 1 month, 4.1% at 3 months, 8.5% at 12 months, and 24% at 48 months after sustaining a PHF. Mortality increased with age; however, the standardized mortality rate (SMR) was highest among young patients. SMR was 5.4 in the 18- to 39-year age group, 3.9 in the 40- to 64-year age group, 1.8 in the 65-79-year age group, and 1.2 in the ≥ 80-year-old population. The age-adjusted SMR was 3.9 in the whole adult PHF population.

CONCLUSION

The mortality rate and SMR suggest that PHF patients are heterogeneous. Some older PHF patients may benefit from specialized care (e.g., orthogeriatric), and this should be evaluated in future studies.

Management of Proximal Humeral Fractures in Adults: A Systematic Review and Meta-Analysis

OBJECTIVES

Differences in function, pain, and reoperation rates were compared between the following treatment options: (1) operative vs. nonoperative treatment and (2) various surgical treatments including open reduction internal fixation, intramedullary nail, hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA).

DATA SOURCES

MEDLINE, Embase, and Cochrane were searched through February 1, 2022. All English-language randomized trials comparing operative and nonoperative treatment of proximal humeral fractures with a control group in patients 18 years or older were included.

DATA EXTRACTION

Demographic data, functional and pain scores and re-operation rates were extracted. Study quality was determined with the Cochran risk of bias tool and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE). Heterogeneity was determined with the I-squared statistic.

DATA SYNTHESIS

Meta-analysis of included studies using mean difference and odds ratios where appropriate.

CONCLUSIONS

Surgical treatment with either locked plates or HA results in similar functional scores and pain outcomes as nonoperative treatment, although plates were associated with higher reoperation rates in 3-part and 4-part fractures. In 3-part and 4-part fractures, RSA results in higher function and pain scores compared with HA. Further high-quality trials should focus on RSA, and further study is required to better define the role of open reduction internal fixation in the younger patient population.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Is early mobilization a viable option after intramedullary nailing of 4-parts proximal humerus fractures?

INTRODUCTION

After centromedullary nailing (CMN) of 4-parts (4P) cephalo-tuberositary fractures of the proximal humerus (PH), shoulder immobilization for a few weeks is usual, although no scientific justification does support this attitude, nor the duration of immobilization. The objective of this study was to assess the impact of early mobilization after CMN of PH 4P fractures on clinical, radiological outcomes and complication rates. The hypothesis was that early mobilization would not lead to a deterioration in results or an increase in the complication rate.

MATERIALS AND METHODS

All patients operated on for a 4P-PH fracture by CMN in our institution between 2010 and 2018 were included retrospectively. 2 groups were formed according to the duration of post-operative immobilization of the shoulder: 0-2 weeks (group A) and 3-6 weeks (group B). All patients had a clinical examination (Range of motion ROM and Constant score) and X-rays of the shoulder at least 24 months of follow-up. 58 patients (average age 66 years (39-89)) were included, with 25 in group A and 33 in group B.

RESULTS

The average follow-up was 38.5 (24-73) months. The active ROM at the last follow-up was: active anterior elevation 149° (80°-180°) in group A versus 134 (60°-180°) in group B (p = 0.099); active external rotation 145° (15°-70°) in group A versus 42° (15-70°) in group B (p = 0.6). The Absolute Mean Constant score was 78.29 for Group A (45-100) versus 68.59 points (45-96) for Group B (p = 0.065). Regarding complications: in group A, we found 2 retractile capsulitis, 2 pseudarthrosis and 2 osteonecrosis of the humeral head. In group B, we found 5 retractile capsulitis, 1 infection of the surgical site, 3 osteonecrosis of the humeral head and 1 pseudarthrosis.

CONCLUSION

Early mobilization after CMN of 4P-PH fractures did not lead to an increase in the complications rate and in particular secondary displacements or osteonecrosis. There was a trend toward improved clinical outcomes with early mobilization, although this trend was not statistically significant.

EVIDENCE LEVEL

IV, retrospective study.

Shoulder Proprioception Following Reverse Total Shoulder Arthroplasty for Unreconstructable Upper Third Fractures of the Humerus: 2-Year Outcomes

Background

Proximal humerus fractures may be comminuted in the elderly or after injury with high-energy mechanisms. Reverse total shoulder arthroplasty that may affect shoulder proprioception (rTSA) has also begun to play a part in treating acute proximal humeral fractures. In this study, the authors aimed to evaluate joint position sense (JPS) after rTSA.

Methods

Humac Norm II isokinetic device was used to evaluate the joint position sense. A joint angle was determined and the ability of the patient to create the same value of the angle by the active movement was evaluated. The difference between the pre-determined angle and the patient's measured angle was recorded. For proprioceptive sense, the initial position was 0° and the determination position was 30°, 60°, and 90° for flexion and abduction, and 15° and 30° for internal rotation and external rotation.

Results

While both the mean Constant and ADLEIR scores did not differ between non-operated and operated sides, the mean proprioception differences in all flexion (30°, 60°, and 90°), abduction (30°, 60°, and 90°), internal rotation (15° and 30°), and external rotation (15° and 30°) were significantly higher in the operated side than that in non-operated side (p < 0.01 for each pairwise comparison).

Conclusion

Reverse total shoulder arthroplasty (rTSA) treatment, which has increasingly become a surgical option in un-reconstructable proximal humeral fractures has significant adverse effects on proprioception on the operated side and may pose a risk for long-term instability, premature loosening, and prosthesis mechanical complications, in this context, well-designed prospective controlled studies are required.

Clinical outcomes of cemented vs. uncemented reverse total shoulder arthroplasty for proximal humerus fractures: a systematic review

BACKGROUND

Reverse total shoulder arthroplasty is an established treatment method for comminuted proximal humerus fractures. Both cemented and uncemented techniques exist, with uncemented reverse total shoulder offering many theoretical advantages, including improved biologic fixation, absence of cement related complications, and ease of revision if necessary. There are few studies comparing the outcomes of the two techniques.

METHODS

The study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A search for studies assessing clinical outcomes of reverse total shoulder arthroplasty for proximal humerus fractures was performed of PubMed, Embase, Web of Science, and Cochrane Library. Main outcomes included Constant Score (CS), American Shoulder and Elbow Surgeons (ASES) score, and complication rate. Inclusion criteria were as follows: indication for arthroplasty was fracture; minimum one year follow up; article in English. Exclusion criteria were as follows: review articles; biomechanical or cadaver studies. Quality analysis was performed using the Cochrane Risk of Bias tool (RoB 2) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) tool.

RESULTS

A total of 682 studies were identified through the initial search, with 36 studies meeting all inclusion criteria. There were 24 studies investigating cemented technique, 10 studies examining uncemented technique, and two studies involving both techniques. There was no difference in mean follow up between patients receiving a cemented vs. uncemented rTSA (32.3 months vs. 30.6 months, p = 0.06). Patients who received a cemented rTSA had a significantly higher Constant-Murley score than those who received an uncemented rTSA (59.4 vs 55.9, p < .001). There was no difference between the two groups when comparing ASES Scores (77.5 vs 78.6, p = 0.54) and overall complication rates (11.1% vs 11.8%, p = 0.23).

CONCLUSION

Both cemented and uncemented rTSA are both valid options for treating acute proximal humerus fractures. Cemented rTSA may portend slightly improved clinical outcomes with similar overall complication rates compared to uncemented rTSA for proximal humerus fractures.

Reverse Total Shoulder Arthroplasty Is the Most Cost-effective Treatment Strategy for Proximal Humerus Fractures in Older Adults: A Cost-utility Analysis

BACKGROUND

Proximal humerus fractures are the second-most common fragility fracture in older adults. Although reverse total shoulder arthroplasty (RTSA) is a promising treatment strategy for proximal humerus fractures with favorable clinical and quality of life outcomes, it is associated with much higher, and possibly prohibitive, upfront costs relative to nonoperative treatment and other surgical alternatives.

QUESTIONS/PURPOSES

(1) What is the cost-effectiveness of open reduction internal fixation (ORIF), hemiarthroplasty, and RTSA compared with the nonoperative treatment of complex proximal humerus fractures in adults older than 65 years from the perspective of a single-payer Canadian healthcare system? (2) Which factors, if any, affect the cost-effectiveness of ORIF, hemiarthroplasty, and RTSA compared with nonoperative treatment of proximal humerus fractures including quality of life outcomes, cost, and complication rates after each treatment?

METHODS

This cost-utility analysis compared RTSA, hemiarthroplasty, and ORIF with the nonoperative management of complex proximal humerus fractures in adults older than 65 years over a lifetime time horizon from the perspective of a single-payer healthcare system. Short-term and intermediate-term complications in the 2-year postoperative period were modeled using a decision tree, with long-term outcomes estimated through a Markov model. The model was initiated with a cohort of 75-year-old patients who had a diagnosis of a comminuted (three- or four-part) proximal humerus fractures; 90% of the patients were women. The mean age and gender composition of the model's cohort was based on a systematic review conducted as part of this analysis. Patients were managed nonoperatively or surgically with either ORIF, hemiarthroplasty, or RTSA. The three initial surgical treatment options of ORIF, hemiarthroplasty, and RTSA resulted in uncomplicated healing or the development of a complication that would result in a subsequent surgical intervention. The model reflects the complications that result in repeat surgery and that are assumed to have the greatest impact on clinical outcomes and costs. Transition probabilities and health utilities were derived from published sources, with costs (2020 CAD) sourced from regional costing databases. The primary outcome was the incremental cost-utility ratio, which was calculated using expected quality-adjusted life years (QALYs) gained and costs. Sensitivity analyses were conducted to explore the impact of changing key model parameters.

RESULTS

Based on both pairwise and sequential analysis, RTSA was found to be the most cost-effective strategy for managing complex proximal humerus fractures in adults older than 65 years. Compared with nonoperative management, the pairwise incremental cost-utility ratios of hemiarthroplasty and RTSA were CAD 25,759/QALY and CAD 7476/QALY, respectively. ORIF was dominated by nonoperative management, meaning that it was both more costly and less effective. Sequential analysis, wherein interventions are compared from least to most expensive in a pairwise manner, demonstrated ORIF to be dominated by hemiarthroplasty, and hemiarthroplasty to be extendedly dominated by RTSA. Further, at a willingness-to-pay threshold of CAD 50,000/QALY, RTSA had 66% probability of being the most cost-effective treatment option. The results were sensitive to changes in the parameters for the probability of revision RTSA after RTSA, the treatment cost of RTSA, and the health utilities associated with the well state for all treatment options except ORIF, although none of these changes were found to be clinically realistic based on the existing evidence.

CONCLUSION

Based on this economic analysis, RTSA is the preferred treatment strategy for complex proximal humerus fractures in adults older than 65 years, despite high upfront costs. Based on the evidence to date, it is unlikely that the parameters this model was sensitive to would change to the degree necessary to alter the model's outcome. A major strength of this model is that it reflects the most recent randomized controlled trials evaluating the management of this condition. Therefore, clinicians should feel confident recommending RTSA for the management of proximal humerus fractures in adults older than 65 years, and they are encouraged to advocate for this intervention as being a cost-effective practice, especially in publicly funded healthcare systems wherein resource stewardship is a core principle. Future high-quality trials should continue to collect both clinical and quality of life outcomes using validated tools such as the EuroQOL-5D to reduce parameter uncertainty and support decision makers in understanding relevant interventions' value for money.

LEVEL OF EVIDENCE

Level III, economic and decision analysis.

The Evolution of Reverse Total Shoulder Arthroplasty and Its Current Use in the Treatment of Proximal Humerus Fractures in the Older Population

Proximal humerus fracture (PHF) is a common injury in the older population. While the majority of these fractures are treated non-operatively, a small subset of patients may benefit from surgical treatment. However, there continues to be an ongoing debate regarding the indications and ideal surgical treatment strategy. The use of reverse total shoulder arthroplasty (RTSA) has resulted in a paradigm shift in the treatment of PHFs in the older population. Unique biomechanical principles and design features of RTSA make it a suitable treatment option for PHFs in the older population. RTSA has distinct advantages over hemiarthroplasty and internal fixation and provides good pain relief and a reliable and reproducible improvement in functional outcomes. As a result, there has been an exponential increase in the volume of RTSA in the older population in last decade. The aim of this paper is to review the current concepts, outcomes and controversies regarding the use of RTSA for the treatment of PHFs in the older population.

Different treatments for 3- or 4-part proximal humeral fractures in the elderly patients: A Bayesian network meta-analysis of randomized controlled trials

Background

Proximal humeral fractures are the third most common fracture in the body, and their incidence is rising year by year as the population ages. However, the treatment of the proximal humerus in parts 3 and 4 is still debatable, necessitating a network meta-analysis to determine the best treatment for each treatment modality.

Methods

We searched PubMed, Embase, Cochrane Library for randomized controlled trials on proximal humeral fractures up to June 21, 2022. We performed data extraction and literature quality assessment by two independent authors and extracted constant score and reoperation rate as indicators for evaluation. Stata software, Revman software, JAGS software and the R-based BlandAltmanLeh package, gemtc package and riags package were used to perform this Bayesian network meta-analysis.

Results

Following screening, 11 papers with a total of 648 participants were included in the analysis. The SUCRA values for the constant score were in the following order: RSA, IMN, Conservative, HA, and LP, and the SUCRA values for the reoperation rate were LP, HA, IMN, Conservative, and RSA.

Conclusion

The elderly with 3- or 4-part proximal humeral fractures should consider RSA because it received the best evaluation ranking in terms of constant score and reoperation rate.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022341209, identifier: CRD42022341209.

Reverse shoulder arthroplasty vs. hemiarthroplasty for the treatment of osteoporotic proximal humeral fractures in elderly patients: A systematic review and meta‑analysis update

The present meta-analysis was conducted to compare the safety and effectiveness of reverse shoulder arthroplasty (RSA) and hemiarthroplasty (HA) in the treatment of osteoporotic proximal humeral fractures in elderly patients. The Embase, Pubmed Central, Cumulative Index to Nursing and Allied Health Literature, ProQuest Dissertations and Theses, Cochrane Library and Chinese Biomedical databases were searched between January 2009 and January 2022 to identify relevant studies. According to the search strategy, a total of 210 associated studies were retrieved and 16 were finally included. Review Manager 5.4 software was used for the data analysis. This study indicated that patients in the RSA group had significantly improved treatment outcomes compared with patients in the HA group, as assessed by Constant-Murley Shoulder Outcome Score (95% CI, 1.69-3.76; P<0.001), American Shoulder and Elbow Surgeons score (95% CI, 11.81-24.88; P<0.001) and shoulder range of motion (ROM; 95% CI, 3.41-9.07; P<0.001). However, the HA group was superior to the RSA group in terms of the Oxford Shoulder score (95% CI, 2.89-11.11; P<0.001). There was no significant statistical difference between the two groups in terms of the Disabilities of the Arm, Shoulder and Hand score and complications. Overall, for the treatment of osteoporotic proximal humeral fractures in the elderly, the RSA group had improved postoperative ROM and functional scores compared with the HA group, without significant difference in the incidence of complications. However, HA remains a safe and reliable treatment option.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015.

OBJECTIVES

To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults.  DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison.

MAIN RESULTS

We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.

Operative Treatment of Proximal Humeral Fractures with Reverse Total Shoulder Arthroplasty in Patients ≥65 Years Old: A Critical Analysis Review

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The majority of proximal humeral fractures (PHFs) in patients who are ≥65 years of age are treated nonoperatively, but certain complex fracture patterns benefit from surgical intervention. However, there continues to be debate regarding the indications for surgery and the optimal surgical treatment (repair versus replacement) in this population.

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Reverse total shoulder arthroplasty (RTSA) has grown in popularity for surgical treatment of fracture-dislocations and displaced complex PHFs in patients who are ≥65 years of age; it has definite advantages over surgical repair and hemiarthroplasty, but this finding requires additional higher-quality evidence.

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RTSA provides early pain relief and return of shoulder function as well as predictable elevation above shoulder level in the forward plane, but the indications for and understanding of the effect of timing on RTSA after a PHF continue to evolve.

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RTSA for an acute PHF is indicated in patients who are ≥65 years of age with 3- and 4-part fracture-dislocations, head-split fractures, and severely displaced fractures, and is an option in patients who are not able to tolerate nonoperative treatment of severely displaced 3- and 4-part fractures.

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RTSA is also indicated as a salvage operation for PHFs that have failed initial surgical repair (i.e., fixation failure, implant failure, rotator cuff failure, or osteonecrosis) and is an option for symptomatic nonunion or malunion after nonoperative treatment.

Cemented vs. uncemented reverse shoulder arthroplasty for proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

The purpose of this systematic review was to compare functional outcomes, complications, and revision rates between cemented and uncemented reverse shoulder arthroplasty (RSA) for proximal humeral fractures (PHFs).

METHODS

A systematic search was performed in April 2021 within PubMed, Scopus Web of Science, and Cochrane Library databases for clinical studies reporting outcomes of RSA performed for PHF. Included studies were published in English, had a minimum 1-year follow-up, specified whether the humeral stem was cemented (cRSA) or uncemented (ucRSA), and were evidence level I-IV. Data including range of motion (ROM), functional status, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score, Constant-Murley score, visual analog scale (VAS) score, tuberosity healing, complications, and reoperations were extracted. DerSimonian-Laird random effects models with subgroup stratification analyses were applied to investigate differences in outcomes between patients with cRSA and ucRSA.

RESULTS

A total of 45 studies comprising 1623 patients were included. The overall pooled age was 75.9 ± 3.4 years. At a mean follow-up of 34.6 (range, 12-108) months, there were no significant differences in ROM, VAS score, Constant-Murley score, rate of tuberosity healing, or reoperation rates between the cRSA and ucRSA cohorts. The mean postoperative ASES score in the cRSA cohort (73.9, 95% CI 71.4-76.5) was significantly lower than the ucRSA cohort (82.9, 95% CI 75.9-90.0, P = .013). The incidence of postoperative all-cause complications was significantly lower in the cRSA cohort (5.5%, 95% CI 4.0%-6.9%) compared with the ucRSA cohort (9.7%, 95% CI 4.5%-14.9%, P = .044).

CONCLUSION

The use of uncemented humeral stems in RSA for PHF confers similar functional results to the use of cemented stems in terms of pain, range of motion, functional scores, and tuberosity healing. Although the rate of complications was significantly higher in the uncemented cohort compared with the cemented cohort (9.7% vs. 5.5%, respectively), the rate of reoperations was similar between the groups (1.6% vs. 1.9%, respectively). The uncemented reverse prosthesis seems to be a valid alternative for the management of patients with complex proximal humerus fractures.

No change in reoperation rates despite shifting treatment trends: a population-based study of 4,070 proximal humeral fractures

Background and purpose - Clear and acknowledged treatment algorithms for proximal humeral fractures (PHFs) are lacking. Nevertheless, a change in treatment trends, including a change towards more reversed shoulder arthroplasties (RSA), has been observed during recent years. We examined the effect of these changes on reoperation rates.Patients and methods - Between 2011 and 2017, 4,070 PHFs treated at Sahlgrenska University Hospital were registered prospectively in the Swedish Fracture Register (SFR) and followed up until 2019 (mean follow-up of 4.5 years). Data on all reoperations were gathered from the SFR and from medical records.Results - The majority of PHFs were treated non-surgically and the proportion increased slightly, but not statistically significantly, during the study period (from 76% to 79%). Of the surgically treated fractures, the proportion fixed with a plate decreased from 47% to 25%, while the use of RSA increased 9-fold (from 2.0% to 19%). 221 patients underwent 302 reoperations. For those primarily treated surgically, the reoperation rate was 17%. Among treatment modalities, plate fixation was associated with the highest reoperation rate (21%). Rate of reoperations remained constant during the study period, both for the entire study cohort and for the surgically treated patientsInterpretation - During the study period, treatment changes that are in accordance with recently published treatment recommendations were observed. However, these treatment changes did not affect the reoperation rate. Treatment with a plate, intramedullary nail, or hemiarthroplasty was associated with the highest reoperation rates. The fact that almost every 4th surgical procedure was a reoperation indicates a need for further improvement of modern treatment concepts for PHFs.

Surgical learning curve in reverse shoulder arthroplasty for proximal humerus fractures

Background

Fracture reverse shoulder arthroplasty (fRSA) in geriatric, complex dislocated proximal humerus fractures is becoming the standard treatment next to conservative treatment. fRSA is a multifaceted, reasonably challenging procedure of which functional outcomes and complication rates are likely to depend on the experience of the surgeon. The goal of this study was to determine whether there is a learning curve for fRSA.

Methods

All patients with a dislocated multipart proximal humerus fracture that were treated with an fRSA between 2013 and 2019 in a specialized institution were included. The functional outcomes (Constant Shoulder Score, Oxford Shoulder Score, and range of motion), complications, and operation time of fRSA were assessed with linear regression plots and cumulative summation analysis to establish whether a learning curve was present.

Results

In this cohort study, 50 patients were included. They had a mean age of 77.1 years and were treated with an fRSA by one trauma surgeon. Learning curves were distinguished for functional outcomes, complications, and operation time based on learning targets for daily activity and the mean complications and operation time. Results indicated that an optimal treatment is achieved after performing 20 fRSAs.

Conclusion

The results show that functional outcomes of PHFs treated with an fRSA improve with surgical experience. Also, outcomes are getting less variable after about 20 procedures. Surgeons starting this procedure should be aware of the learning curve and, therefore, should consider guidance from an experienced surgeon to swiftly optimize functional outcomes and prevent unnecessary complications.

Shoulder conditions and health related quality of life and utility: a current concepts review

Study of the outcome of treatment of shoulder conditions has emphasized subjective evaluation of outcomes including a variety of disease, region, and joint-specific tools. In response to the rapidly rising cost of health care, further interest has been directed to cost-effectiveness and value. Comparison of the outcomes of different shoulder conditions with each other, other musculoskeletal, and nonorthopedic conditions requires more generalized outcome tools, especially when considering cost-effectiveness and utility analysis. The concept of quality of life (QoL) was developed to satisfy this goal, and there are a variety of general health and QoL assessments tools available. The purpose of this study is to review the concept of health-related QoL and discuss health-related QoL measures as they relate to shoulder conditions.

Projections of Primary and Revision Shoulder Arthroplasty until 2040: Facing a Massive Rise in Fracture-Related Procedures

Although the demand for shoulder arthroplasties has reached its highest number worldwide, there remains a lack of epidemiologic data regarding recent and future trends. In this study, data for all shoulder arthroplasties (hemiarthroplasty, reverse/anatomic shoulder arthroplasty) from the nationwide inpatient statistics of Germany (2010–2019) and population forecasts until 2040 were gathered. A Poisson and a negative binomial approach using monotone B-splines were modeled for all types of prostheses to project the annual number and incidence of primary and revision arthroplasty. Additionally, trends in main indicators were also gathered and expected changes were calculated. Overall, the number of primary shoulder replacements is set to increase significantly by 2040, reaching at least 37,000 (95% CI 32,000–44,000) procedures per year. This trend is mainly attributable to an about 10-fold increased use of fracture-related reverse shoulder arthroplasty in patients over 80 years of age, although the number of procedures in younger patients will also rise substantially. In contrast, hemiarthroplasties will significantly decrease. The number of revision procedures is projected to increase subsequently, although the revision burden is forecast to decline. Using these country-specific projection approaches, a massive increase of primary and revision shoulder arthroplasties is expected by 2040, mainly due to a rising number of fracture-related procedures. These growth rates are substantially higher than those from hip or knee arthroplasty. As these trends are similar in most Western countries, this draws attention to the international issue, of: if healthcare systems will be able to allocate human and financial resources adequately, and if future research and fracture-prevention programs may help to temper this rising burden in the upcoming decades.