Acute versus delayed reverse total shoulder arthroplasty for proximal humerus fractures in the elderly: Mid-term outcomes

Reverse Shoulder Prosthesis for Proximal Humeral Fractures: Primary Treatment vs. Salvage Procedure

Background: The optimal treatment for complex proximal humerus fractures (PHFs) lacks consensus, with reverse total shoulder arthroplasty (RTSA) often being a final resort rather than a primary approach. This study aimed to compare outcomes and satisfaction rates of primary RTSA for PHFs versus salvage RTSA for previously unsuccessful treatments. We hypothesized that primary RTSA would yield superior clinical outcomes, functional scores, and patient satisfaction. Methods: A retrospective analysis of RSA procedures between 2011 and 2021 was conducted, focusing on primary RTSA for PHFs or salvage RTSA for failed osteosynthesis. Patients meeting inclusion criteria underwent clinical and radiological follow-up for at least two years. Demographic characteristics, outcomes scores, and range of motion (ROM) were assessed. Results: Of 63 patients, 42 underwent primary RTSA and 21 underwent salvage RTSA. The median follow-up was 50 months. Statistically significant differences favored primary RTSA in forward flexion, abduction, internal rotation, and Constant shoulder score. Patient satisfaction levels did not significantly differ between groups. Complications occurred in 7.15% of primary RTSA cases and 14.28% of salvage RTSA cases. Conclusions: Primary RTSA may yield slightly better outcomes and lower complication rates compared to salvage RTSA. Further prospective studies are necessary to validate these findings.

Reverse total shoulder arthroplasty within 6 weeks of proximal humerus fracture is associated with the lowest risk of revision

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment strategy in the management of complex proximal humeral fractures (PHFs). However, no definitive consensus has been reached regarding the optimal surgical timing of RTSA following PHF, particularly considering nonoperative management is often a viable option. Therefore, the aim of this study was (1) to identify optimal timing intervals that maximize the likelihood of revision following RTSA and (2) to determine differences in revision etiologies using the identified timing intervals.

METHODS

A retrospective cohort analysis of patients undergoing PHF-indicated RTSA from 2010 to 2021 was conducted using a national administrative claims database. Stratum-specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between PHF and RTSA that maximized the likelihood of revision surgery within 2 years of RTSA. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven strata's association with 2-year revision rates as well as compare the likelihood of various indications for revision including mechanical loosening, dislocation, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF).

RESULTS

In total, 11,707 patients undergoing TSA following PHF were included in this study. SSLR analysis identified 2 timing categories: 0-6 weeks and 7-52 weeks from the time of PHF to TSA surgery. Relative to the 0-6-week cohort, the 7-52-week cohort was more likely to undergo revision surgery within 2 years (OR 1.93, P < .001). Moreover, the 7-52-week cohort had significantly higher odds of revision indicated for dislocation (OR 2.24, P < .001), mechanical loosening (OR 1.71, P < .001), PJI (OR 1.74, P < .001), and PPF (OR 1.96, P < .001).

CONCLUSIONS

Using SSLR, we were successful in identifying 2 data-driven timing strata between PHF and RTSA that maximized the likelihood of 2-year revision surgery. As it can be difficult to determine whether RTSA or nonoperative management is initially more appropriate, considering the results of this study, an early trial of 4-6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA.

How common is nerve injury after reverse shoulder arthroplasty? A systematic review

BACKGROUND

Nerve injury following reverse shoulder arthroplasty (RSA) is a known risk factor with wide ranging incidences reported. This systematic review evaluates the overall incidence of nerve injury following primary and revision RSA and summarizes the characteristics of the nerve injuries reported in the current literature.

METHODS

A systematic review was performed using separate database searches (Pubmed, Embase, Web of Science, Cochrane) following the PRISMA guidelines. Search criteria included the title terms "reverse shoulder," "reverse total shoulder," "inverted shoulder," and "inverted total shoulder" with publication dates ranging from 01/01/2010 to 01/01/2022. Studies that reported neurological injuries and complications were included and evaluated for primary RSA, revision RSA, number of nerve injuries, and which nerves were affected.

RESULTS

After exclusion, our systematic review consisted of 188 articles. A total of 40,146 patients were included, with 65% female. The weighted mean age was 70.3 years. The weighted mean follow-up was 35.4 months. The rate of nerve injury after RSA was 1.3% (510 of 40,146 RSAs). The rate of injury was greater in revision RSA compared to primary RSA (2.4% vs. 1.3%). Nerve injury was most common in RSAs done for a primary diagnosis of acute proximal humerus fracture (4.0%), followed by cuff tear arthropathy (3.0%), DJD (2.6%), and inflammatory arthritis (1.7%). Massive rotator cuff tears and post-traumatic arthritis cases had the lowest nerve injury rates (1.0% and 1.4%, respectively). The axillary nerve was the most commonly reported nerve that was injured in both primary and revision RSA (0.6%), followed by the ulnar nerve (0.26%) and median nerve (0.23%). Brachial plexus injury was reported in 0.19% of overall RSA cases.

CONCLUSION

Based on current English literature, nerve injuries occur at a rate of 1.3% after primary RSA compared with 2.4% after revision RSA. The most common nerve injury was to the axillary nerve (0.64%), with the most common operative diagnosis associated with nerve injury after RSA being acute proximal humerus fracture (4.0%). Surgeons should carefully counsel patients prior to surgery regarding the risk of nerve injury.

Outcomes of proximal humerus fractures in children: a study protocol for a retrospective cohort study

INTRODUCTION

Proximal humerus fractures (PHFs) comprise <3% of all fractures in children and adolescents. While it is accepted that minimally displaced PHFs can be treated conservatively, the management of severely displaced PHFs remains controversial, especially in older children. This study will aim to analyse the functional and quality-of-life outcomes of children with PHFs, in order to inform their optimal management.

METHODS AND ANALYSIS

We will conduct a retrospective cohort study to evaluate the outcomes of patients who were diagnosed with a paediatric PHF at the Women's and Children's Hospital (WCH) in South Australia. The primary outcome will be each participant's pain and quality-of-life outcome, determined by use of the Quick Disabilities of the Arm, Shoulder and Hand, Shoulder Pain and Disability Index and Paediatric Outcomes Data Collection Instrument. Secondary outcomes will include rates of non-union, persistent deformity and complications. The information for these variables will be acquired during a brief clinic appointment, and from the medical records and WCH radiology database. Multivariable logistic regression will be performed to determine the clinical variables associated with a worse clinical outcome.

ETHICS AND DISSEMINATION

The study has been approved by the Women's and Children's Health Network Human Research Ethics Committee (protocol number: 2021/HRE00250). The study findings will be submitted to peer-reviewed scientific journals for publication and disseminated at conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12622000176763).

Acute Versus Delayed Reverse Shoulder Arthroplasty for the Primary Treatment of Proximal Humeral Fractures

INTRODUCTION

Reverse total shoulder arthroplasty (rTSA) is gaining popularity as a treatment option for proximal humeral fractures in elderly patients. The impact of surgical timing on outcomes of primary rTSA is unclear. This study compared the rates of revision and complication, and surgery day cost of treatment between acute and delayed primary rTSA patients.

METHODS

Elderly patients with proximal humeral fracture who underwent primary rTSA within a year of fracture were identified in a national insurance database from 2005 to 2014. Patients were separated into acute (<4 weeks) or delayed (>4 weeks) cohorts based on the timing of rTSA. The univariate 1-year rates of revision and complication and surgery day cost of treatment were assessed. Multivariate logistic regression analysis was conducted, accounting for the factors of age, sex, obesity, diabetes comorbidity, and tobacco use.

RESULTS

Four thousand two hundred forty-five (82.6%) acute and 892 (17.4%) delayed primary rTSA patients were identified. Acute rTSA was associated with a higher surgery day cost (acute $15,770 ± $8,383, delayed $14,586 ± $7,271; P < 0.001). Delayed rTSA resulted in a higher 1-year revision rate (acute 1.7%, delayed 4.5%; P < 0.001) and surgical complication rates of dislocation (acute 2.8%, delayed 6.1%; P < 0.001) and mechanical complications (acute 1.9%, delayed 3.4%; P = 0.007). Multivariate analysis identified delayed primary treatment as independently associated with increased risk of revision (odds ratio: 2.29, 95% confidence interval 1.53 to 3.40; P < 0.001) and dislocation (OR: 2.05, 95% confidence interval 1.45 to 2.86; P < 0.001).

CONCLUSION

Delayed primary rTSA was associated with higher short-term rates of revision and dislocation compared with acute primary rTSA. Our results suggest that delaying rTSA, whether because of attempted nonsurgical treatment or patients' lack of access, may result in increased complication and additional surgery.

LEVEL OF EVIDENCE

Level III.

Decision-Making and Management of Proximal Humerus Nonunions

Proximal humerus fracture nonunions are heterogenous group of posttraumatic sequelae in both the operatively and nonoperatively treated proximal humerus fracture. The management of these fractures is largely based on the residual morphology. Understanding the relationship of the nonunited and malunited fragments, anatomic location of the fracture, and viability of the residual bone stock will allow for better surgical planning. Patient optimization with nonoperative care, open reduction internal fixation, intramedullary nailing, and shoulder arthroplasty, all have a role in the treatment of proximal humerus fracture nonunions.

Acute versus delayed reverse total shoulder Arthroplasty for the management of Proximal Humerus Fractures

OBJECTIVES

Proximal humerus fractures (PHF) are common, yet their optimal management remains debated. Reverse total shoulder arthroplasty (rTSA) is an increasingly popular option, particularly for non-reconstructible or osteoporotic fractures. Despite this trend, current literature provides limited guidance with regards to surgical timing and patient selection for rTSA. A trial of non-operative management might be beneficial for many patients who are not clearly indicated for surgery, provided this does not have a major negative impact on results for those who ultimately require rTSA. The purpose of this study was to investigate whether delayed reverse shoulder arthroplasty for fracture (>28 days from injury) is associated with any difference in complication rates or functional outcomes relative to acute surgery.

DESIGN

Retrospective cohort study PATIENTS/PARTICIPANTS: 114 consecutive patients who underwent rTSA as the primary management of a PHF at two Level 1 trauma centers and one academic community hospital between 2004 and 2016.

INTERVENTION

rTSA as primary management of proximal humerus fracture MAIN OUTCOME MEASUREMENTS: Complications, range of motion, and patient-reported functional outcomes scores (DASH, PROMIS physical function, and EQ-5D) RESULTS: Eighty-two of 114 patients (72%) underwent early surgery. Complex (4-part, head-split, dislocated) fractures were significantly more common in the acutely treated group. There was no significant difference in complications. Overall complication rate was 11.4%. There was a significant difference in DASH score favoring early surgery, with an average score of 22.4 in acutely treated patients versus 35.1 in delayed patients (p = 0.034). There was a non-statistically significant trend towards better PROMIS physical function scores and ROM in the acutely treated group.

CONCLUSION

Delay in performing primary rTSA for management of PHF does not lead to an increase in complication rates but it may come at the cost of worse functional outcomes in patients who ultimately require rTSA.