Reverse shoulder arthroplasty for the treatment of acute complex proximal humeral fractures: Influence of greater tuberosity healing on the functional outcomes

The effect of tuberosity healing on functional outcomes after reverse shoulder arthroplasty for proximal humerus fractures: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis compared clinical outcome measures in patients undergoing reverse shoulder arthroplasty (RSA) for proximal humerus fracture (PHF) with healed versus non-healed greater tuberosity (GT).

METHODS

We performed a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines querying PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane for studies that stratified results by the GT healing status. Studies that did not attempt to repair the GT were excluded. We extracted and compared clinical outcomes including postoperative forward flexion (FF), external rotation (ER), internal rotation (IR), Constant score, and complications and revision rates.

RESULTS

Of the included patients, 295 (78.5%) demonstrated GT healing while 81 did not (21.5%). The healed GT cohort exhibited increased postoperative FF (P < .001), ER (P < .001), IR (P = .006), and Constant score (P = .006) compared to the non-healed GT cohort. The overall dislocation rate was 0.8% with no study differentiating GT status of dislocation cases.

CONCLUSION

Healing of the GT after RSA for PHF yields improved postoperative range of motion and strength, whereas patient-reported pain and function were largely not affected by GT healing indicating merit to RSA for PHF regardless of the likelihood of the GT healing.

Locked Stem Reverse Total Shoulder Arthroplasty for Complex Proximal Humerus Fracture in the Elderly: Clinical and Radiological Short-Term Results

Purpose

To evaluate both the short-term clinical and radiological results of reverse shoulder arthroplasty (RSA) with uncemented locked stem in the management of a proximal humerus fracture (PHFs) in the elderly.

Methods

Retrospective study including 40 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 24 months follow-up. In all the cases, the greater tuberosity (GT) was reattached with a standardized suture technique and a local horseshoe bone graft. All the patients were assessed at the 24-month follow-up with Constant-Murley Score (CMS) and Visual Analog Score (VAS). Radiographic healing of the greater tuberosity was noted in addition to stem locking screws radiographic changes. Complications and revision rates were reported.

Results

Mean final CMS for this cohort was 80 points. The greater tuberosity healed in the anatomic position in 90% of the cases (N = 36), obtaining an average CMS of 80 in these patients. Healing of the greater tuberosity did not occur in 10% of the cases (N = 4), obtaining an average CMS of 60. All patients scored above 100° in forward elevation with a mean of 140°. Mean active external rotation was 30°. Low-grade scapular notching was reported in <1% of the cases. Major complications were reported in one patient with an acromial fracture. No complications or loosening of stem locking screws were noted. There were no reoperations.

Conclusion

In the elderly population, reverse shoulder arthroplasty utilizing a fracture-specific locking stem, low-profile metaphysis, suture-friendly groove, meticulous suture technique, and local bone grafting allows adequate fixation, variable prosthesis height adjustment, and enhances greater tuberosity healing. This approach yields positive short-term clinical outcomes without complications related to the stem's locking screws.

Level of Evidence

Level IV Retrospective Case Series.

Clinical and radiological outcome following trauma-related reverse shoulder arthroplasty

BACKGROUND

Reverse shoulder arthroplasty (RSA) is a frequently used therapy for complex proximal humeral fractures and posttraumatic disorders. The present study's purpose was to assess the clinical and radiological outcome of primary and secondary RSA, and to analyze the impact of refixation of the greater tuberosity (GT).

PATIENTS AND METHODS

28 patients with primary fracture RSA and 18 patients with RSA due to posttraumatic disorders were examined with a mean clinical follow-up of 2.5 ± 1.73 years. Operative details and radiographs were retrospectively reviewed. Additional analyses were performed for healed and non-healed GT in primary RSA.

RESULTS

Patients with fracture RSA had higher Constant-Murley score (CMS) than secondary RSA without reaching significance (p = 0.104). No significant difference was present for the quality of life measured by the Short Form 36 (SF 36) and the range of motion. In primary RSA, 78.6% GT healed anatomically. Compared to non-healed GT, patients with healed GT had a significantly higher CMS (p = 0.011), external rotation (p = 0.026) and forward flexion (p = 0.083), whereas DASH score was lower without a significant difference (p = 0.268). SF 36 showed no significant difference. Patients with healed GT had a more neutral glenoid version (p = 0.009).

CONCLUSION

Superior range of motion and clinical outcome scores were present for anatomically healed GT. Therefore, refixation of the tuberosities is recommended. Secondary RSA can result in inferior results compared to primary RSA, so patients need to be adequately informed.

Reverse Shoulder Arthroplasty versus Non-Operative Treatment of Three-Part and Four-Part Proximal Humerus Fractures in the Elderly Patient: A Pooled Analysis and Systematic Review

Background: The treatment of complex proximal humerus fractures in elderly patients is not yet fully elucidated. Of all treatment options, reverse shoulder arthroplasty (RSA) and non-operative treatment (NOT) appear to provide the best results. Evidence to guide the choice between the two is sparse. Therefore, this review provides an overview of the available evidence on RSA versus NOT. Methods: Studies comparing complex proximal humerus fractures in patients aged >65 years treated either with RSA or NOT were included for systematic review and direct comparison via pooled analysis of patient-rated outcome and range of motion. Indirect comparison of case series and non-comparative studies on either treatment was performed separately. Results: Three comparative studies including 77 patients treated with RSA and 81 treated non-operatively were analysed. The RSA group scored better for both the Constant-Murley score (mean difference 6 points) and DASH score (mean difference 8 points). No differences were detected in ASES, PENN score, pain scores, or range of motion between treatment groups. The most common complications for RSA were infection (3%), nerve injury (2%), and dislocation (2%). Reoperation was required in 5%. In the NOT group, common complications included malunion (42%), osteonecrosis (25%), and non-union (3%); no reoperation was required. Patient satisfaction was equal in both groups. Conclusions: The functional outcomes and range of motion after RSA seemed satisfactory and potentially superior to NOT in elderly patients. Patient satisfaction was comparable despite a high malunion and osteonecrosis rate in the non-operative treatment group, which did not require re-interventions.

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.

Is malunion of the greater tuberosity after reverse shoulder arthroplasty in patients with complex proximal humerus fracture associated with worse clinical outcomes? A prospective cohort study

PURPOSE

To assess patient outcomes following reverse shoulder arthroplasty in patients with complex proximal humerus fracture and the clinical implications of greater tuberosity malunions.

METHODS

This prospective study included 56 patients who underwent RSA (DELTA XTEND™, DePuy Synthes, Warsaw, IN, USA) to treat proximal humerus fractures. We used a standardized suture technique to reattach the tuberosities. Demographic, comorbidity, and radiological parameters were collected. Assessments at 2-year follow-up (n = 49) are given as follows: range of motion (ROM), pain level, Constant Murley scores (CS), subjective shoulder value (SSV), and tuberosity healing.

RESULTS

Anatomic tuberosity healing was achieved in 31 (55%) patients (group 1), 14 (25%) had a malunion (group 2), and complete migration occurred in 11 (20%) (group 3). No statistically significant differences between groups 1 and 2 were detected: CS (p = 0.53), SSV (p = 0.07), ROM (forward flexion (FF) p = 0.19, internal rotation (IR) p = 0.34, and external rotation (ER) p = 0.76). Group 3 had poorer outcomes (median [IQR]) than group 1: CS (59 [50-71]) vs. 72 [65-78]), FF (120 [100-150]) vs. 150 [125-160] and ER (- 20 [- 20 to 10] vs. 30 [20-45], respectively. Three complications (group 1) occurred: one-stage revision after low-grade infection, haematoma due to early rivaroxaban intake, and open reduction and internal fixation for acromion insufficiency fracture. No patients showed signs of stem or glenoid loosening after 2 years.

CONCLUSION

Cases with complete superior migration experienced poorer clinical outcomes than those with anatomic healing. Despite a relatively high malunion rate, the outcomes were not significantly worse in these patients compared to anatomically healed GT cases.

Anatomic greater tuberosity healing does not influence the functional outcomes of reverse shoulder arthroplasty for acute proximal humerus fractures

Background

To investigate the functional outcomes of reverse shoulder arthroplasty (RSA) in acute complex proximal humerus fractures (PHF) in patients with an anatomic greater tuberosity union in comparison to patients with a displaced or resorbed tuberosity.

Method

It is a retrospective study with prospective data collection including 32 consecutive PHF with a minimum two-year follow-up treated with RSA. A radiological study and a CT scan were performed specifically for the study. Two shoulder surgeons and a musculoskeletal radiologist assessed the position and union of the greater tuberosity. The functional outcomes were assessed with the Constant-Murley, DASH, ASES and ADLER scores.

Results

The mean overall CS was 59.55. In 17 cases, the greater tuberosity healed in an anatomical position. In 15 cases, it was non-anatomical. In 53% of patients, greater tuberosity union was obtained. The CS was 62.76 in the anatomic union group and 55.9 in the non-anatomic union group. No significant differences were observed. No differences were observed in the ASES, DASH and ADLER scores.

Conclusion

After RSA for PHF, anatomic greater tuberosity healing was obtained in 53% of patients. The influence of the position and union of the greater tuberosity on the functional results could not be evidenced.

[Translated article] Influence of lateralized reverse shoulder prosthesis design on tuberosity union in proximal humerus fractures

INTRODUCTION

Proximal humerus fractures are the third most frequent type of fracture in elderly patients. Nowadays, surgical treatment is indicated one third of the time, being the reverse shoulder prosthesis an option especially in complex comminuted patterns. In this study we analyzed the effects of a lateralized reverse prosthesis in tuberosity union and its relationship with the functional results.

MATERIAL AND METHODS

Retrospective case study of patients with proximal humerus fractures treated with a lateralized design reverse shoulder prosthesis with one-year minimum follow-up. Tuberosity nonunion was defined as a radiological concept: absence of tuberosity, distance >1cm from the tuberosity fragment to the humeral shaft or tuberosity above the humeral tray. Subgroup analysis was performed, group 1 (n=16) tuberosity union vs. group 2 (n=19) tuberosity nonunion. Groups were compared with the following functional scores: Constant, American Shoulder and Elbow Surgeons and Subjective Shoulder Value.

RESULTS

A total of 35 patients were included in this study with a median age of 72.65 years. Postoperative radiographic analysis at one year after surgery revealed a tuberosity nonunion rate of 54%. Subgroup analysis revealed no statistically significant differences in terms of range of motion or functional scores. However, there were differences regarding the Patte sign (p=0.03) which was positive in a larger proportion of patients in the group with tuberosity nonunion.

CONCLUSION

Even though there was a large percentage of tuberosity nonunion with the use of a lateralized prosthesis design, patients obtained good results in a similar manner to those found in the union group in terms of range of motion, scores, and patient satisfaction.

Reverse total shoulder arthroplasty for complex proximal humerus fracture in the elderly: clinical and radiological results

Background

The use of reverse total shoulder arthroplasty (RSA) for the treatment of proximal humeral fractures (PHFs) is steadily increasing. Better clinical outcomes of RSA have been correlated with tuberosity reattachment and healing. The purpose of this study was to evaluate both the clinical and radiological results of reverse shoulder arthroplasty in the management of a proximal humerus fracture in the elderly.

Methods

Retrospective study including 400 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 12-month follow-up. In all the cases, the greater tuberosity was reattached with a standardized suture technique and a local bone graft. All the patients were assessed at the 12-month follow-up with Constant-Murley Score (CMS). Radiographic healing of the greater tuberosity was noted. Complications and revision rates were reported.

Results

Mean final CMS for this cohort was 82 points. The greater tuberosity healed in anatomic position in 85% of the cases (N = 340), obtaining an average CMS of 85 in these patients. Healing of the greater tuberosity did not occur in 13% of the cases (N = 52) and displacement more than 5 mm occurred in 2% (N = 8) of the patients for an average CMS of 60. All patients scored above 120° in forward elevation with a mean of 150°. Mean active external rotation was 35°. The lateralization shoulder angle had a mean of 91° and the distalization shoulder angle had a mean of 54°. Low-grade scapular notching was reported in <1% of the cases. A total of 60 patients presented failure of healing or displacement of the greater tuberosity. Major complications were reported in nine patients. Of these nine patients, two acquired superficial wound infections, while two had deep shoulder prosthetic infection. Two other patients developed hematomas, one sustained an acromial stress fracture, and two had a stem loosening. There were 4 reoperations.

Conclusion

Reverse shoulder arthroplasty, with the use of a fracture-specific stem, allows an improved rate of greater tuberosity healing and short-term clinical outcomes in the elderly population.

Is the Position and Union of the Tuberosities Assessable by Means of the Simple Radiograph After Reverse Shoulder Arthroplasty for Complex Proximal Humerus Fractures?

Background

The assessment of tuberosity position and union in reverse shoulder arthroplasty (RSA) for complex proximal humerus fractures (PHF) has been carried out by means of routine simple radiographs. To evaluate the interobserver agreement and intraobserver reproducibility of the simple radiograph in comparison to the CT scan.

Methods

The position and consolidation of the tuberosities in 2 radiographic projections and in a CT scan of 32 consecutive patients operated on a RSA for PHF was assessed by 5 observers. Interobserver agreement and intraobserver reproducibility in both imaging tests were also assessed.

Results

The interobserver agreement for the greater tuberosity position was 0.52 in the simple radiograph and 0.45 in the CT scan. For the greater tuberosity union, agreement was moderate in the simple radiograph (0.52), but fair in the CT scan (0.35). For the lesser tuberosity position and union, the agreement was fair in the radiograph and poor in the CT scan.

Conclusion

Only moderate agreement was observed in the assessment of the position and union of the tuberosities in the RSA for PHF in the simple radiograph and no improvement in it was seen for the 2D CT scan.

Influence of lateralized reverse shoulder prosthesis design on tuberosity union in proximal humerus fractures

INTRODUCTION

Proximal humerus fractures are the third most frequent type of fracture in elderly patients. Nowadays, surgical treatment is indicated one third of the time, being the reverse shoulder prosthesis an option especially in complex comminuted patterns. In this study we analyzed the effects of a lateralized reverse prosthesis in tuberosity union and its relationship with the functional results.

MATERIAL AND METHODS

Retrospective case study of patients with proximal humerus fractures treated with a lateralized design reverse shoulder prosthesis with one-year minimum follow-up. Tuberosity nonunion was defined as a radiological concept: absence of tuberosity, distance>1cm from the tuberosity fragment to the humeral shaft or tuberosity above the humeral tray. Subgroup analysis was performed, group 1 (n=16) tuberosity union vs. group 2 (n=19) tuberosity nonunion. Groups were compared with the following functional scores: Constant, American Shoulder and Elbow Surgeons and Subjective Shoulder Value.

RESULTS

A total of 35 patients were included in this study with a median age of 72.65 years. Postoperative radiographic analysis at one year after surgery revealed a tuberosity nonunion rate of 54%. Subgroup analysis revealed no statistically significant differences in terms of range of motion or functional scores. However, there were differences regarding the Patte sign (p=0.03) which was positive in a larger proportion of patients in the group with tuberosity nonunion.

CONCLUSION

Even though there was a large percentage of tuberosity nonunion with the use of a lateralized prosthesis design, patients obtained good results in a similar manner to those found in the union group in terms of range of motion, scores, and patient satisfaction.

Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures: Current Concepts

Complex proximal humeral fractures, especially in elderly patients, often require arthroplastic surgical treatment. Traditionally, shoulder hemiarthroplasty (HA) is the method of choice, resulting in long implant survival and a painless shoulder; however, shoulder HA has heterogeneous clinical outcomes related to the correct position of the implant, both in terms of height and version, and the anatomical consolidation of tuberosities. Today, reverse shoulder arthroplasties are increasingly used to treat such fractures. These techniques result in better functional outcomes compared to HAs, especially regarding anterior flexion, but implant longevity has not been established. The development of specific prosthetic humeral components for the treatment of fractures, which were recently introduced in the clinical practice, led to better clinical outcomes.

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.

The reliability of the Neer classification for proximal humerus fractures: A survey of orthopedic shoulder surgeons

Background

The Neer classification is among the most widely used systems to describe proximal humerus fractures (PHF) despite the poor interobserver agreement. The purpose of this study was to verify whether or not blinded shoulder surgeons and trainees agree with the authors of articles published in the highest impact-factor orthopedic journals.

Methods

All articles regarding PHF published between 2017 and 2019 in the top 10 orthopedic journals as rated by impact factor were searched. Articles were included if the authors used the Neer classification to describe at least 1 PHF in the figures. Figures were extracted without the legend, and X-rays ± computed tomography scan images were included when available. An international survey was conducted among 138 shoulder surgeons who were asked to record the Neer classification for each de-identified radiograph in the publications. The type of fracture mentioned in the legend of the published figure was considered as the gold standard.

Results

Survey participants agreed with the published article authors in 55% of cases overall (range 6%-96%, n = 35). The most common response disagreed with the article authors in 13 cases (37%), underestimating the number of parts in 11 of 13 cases. The interobserver agreement between the 138 responders was fair (k = 0.296). There was an association between the percentage of concordant answers and greater experience (number of years of shoulder surgery practice) of the responders (P = .0023). The number of parts, the number or type of available imaging modalities, and the geographic origin of participants did not influence the agreement between responders and authors.

Discussion

In more than one-third of cases, specialized shoulder surgeons disagree with article authors when interpreting the Neer classification of de-identified images of PHF in published manuscripts. Morphologic classification of PHF as the sole basis for treatment algorithms and surgical success should be scrutinized.

Clinical outcomes of reverse total shoulder arthroplasty for elective indications versus acute 3- and 4-part proximal humeral fractures: a systematic review and meta-analysis

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) has continued to increase in clinical utility and popularity as an effective treatment for cuff tear arthropathy (CTA), irreparable rotator cuff tears (RCTs), osteoarthritis, and acute 3- and 4-part proximal humeral fractures. Performing RTSA for acute proximal humeral fractures presents the unique challenges of tuberosity management, bone loss, and instability compared with elective indications such as CTA or irreparable RCTs. The purpose of this study was to compare the clinical outcomes, active range of motion (ROM), radiographic outcomes, and complications between patients undergoing elective RTSA (RTSA-E) and those undergoing RTSA for fracture (RTSA-F).

METHODS

A systematic review of the literature was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We queried 3 electronic databases (Embase, Cochrane, and PubMed) using the search term "reverse" AND "shoulder" AND "arthroplasty." Studies investigating the clinical outcomes of RTSA for traumatic and/or elective indications were included. Studies were excluded if they included RTSA performed for fracture sequelae, inflammatory arthritis, post-traumatic osteoarthritis, or avascular necrosis. Data collected included patient demographic characteristics, subjective outcome measurements, ROM, and complications. The pooled means and proportions along with their 95% confidence intervals were generated by a random-effects model that incorporated the between-study variations in weighting.

RESULTS

A total of 134 studies (11,651 shoulders) investigating the clinical outcomes of RTSA-E patients and 66 studies (3117 shoulders) investigating RTSA-F patients were included in this systematic review. Analysis of patient-reported outcomes demonstrated that RTSA-F patients experienced significantly lower Constant scores than RTSA-E patients; however, relative Constant scores, Simple Shoulder Test scores, Disabilities of the Arm, Shoulder and Hand scores, American Shoulder and Elbow Surgeons scores, and visual analog scale pain scores were similar. RTSA-F patients also had significantly lower forward elevation, abduction, and external rotation. RTSA-F patients experienced tuberosity complications at a significantly higher rate than RTSA-E patients (25.9% vs. 4.1%). There was no significant difference between the 2 groups in terms of other complications such as heterotopic ossification, radiographic loosening, revision, nerve injury, postoperative stiffness, infection, dislocation, and component loosening.

DISCUSSION

RTSA performed for acute 3- and 4-part proximal humeral fractures yields overall worse clinical outcomes and active ROM compared with RTSA performed for elective indications including CTA, massive irreparable RCTs, and osteoarthritis with deformity. Tuberosity healing may be a major contributing factor to the difference in clinical outcomes. In the setting of RTSA-F, patient and surgeon expectations may need to be tempered and appropriate measures undertaken to optimize tuberosity healing.

Fracture-Dedicated Prosthesis Promotes the Healing Rate of Greater Tuberosity in Reverse Shoulder Arthroplasty: A Meta-Analysis

Introduction: Reverse shoulder arthroplasty (RSA) is becoming popular in the treatment of complex proximal humeral fractures (PHFs). Greater tuberosity healing may influence functional outcomes and range of motion (ROM) of shoulder after RSA. In addition, the design of prosthesis may impact the healing rate of greater tuberosity. The purpose of this study is to know: (1) does the healing of greater tuberosity affect the functional outcomes and ROM of shoulder? and (2) does the design of prosthesis affect the healing rate of greater tuberosity? Materials and Methods: PubMed, Ovid/Embase, and the Cochrane Library were searched for studies comparing the clinical outcomes between the healed groups and the non-healed groups after RSA. Results: For functional outcomes, the results showed that the healed group had better Constant scores (CSs) (p < 0.0001). For ROM, the healed group showed better flexion (p < 0.0001), abduction (p = 0.02), and external rotation (p < 0.00001) of shoulder. For the design of prosthesis, the mean healing rate of greater tuberosity (82.7%) in patients with fracture-dedicated prosthesis was higher than those (63.0%) in patients with standard prosthesis. Subgroup analyses showed that the CS (p = 0.12) and abduction (p = 0.96) of patients using fracture-dedicated prostheses were not different between the healed groups and the non-healed groups. Meta-regression showed that there was no significant relationship between the design of prosthesis and CS (p = 0.312), flexion (p = 0.422), or external rotation (p = 0.776). Conclusion: Our meta-analysis showed that the healed groups could obtain better functional outcomes and ROM than the non-healed groups. In addition, fracture-dedicated prostheses promoted the healing rate of greater tuberosity. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020157276, PROSPERO: CRD42020157276.

Complications and Intraoperative Fractures in Reverse Shoulder Arthroplasty: A Systematic Review

Introduction

The reverse shoulder arthroplasty is nowadays a treatment option for a variety of shoulder problems. As its incidence rose, also the number of complications increased, including intraoperative fractures.

Significance

We performed a systematic review and critical analysis of the current literature following the PRISMA guidelines. Our purpose was to: 1) determine incidence, causes, and characteristics of intraoperative fractures; 2) evaluate their current treatment options, possible related complications, reoperation rates, and the patients’ outcome; and 3) determine the overall incidence of each complication related to reverse shoulder arthroplasty. The articles were selected from PubMed medical database in April 2020 using a comprehensive search strategy. Rayyan software was used to support the selection process of the records. A descriptive and critical analysis of the results was performed.

Results

The study group included a total of 13,513 reverse shoulder arthroplasty procedures. The total number of complications was 1647 (rate 12.1%). The most common complication was dislocation (340 cases, rate 2.5%). Forty-six studies reported a total of 188 intraoperative fractures among the complications (rate 1.4%). The intraoperative fracture rate was 2.9% and 13.6% in primary and revision settings, respectively. There were 136 humeral fractures, 60% of them occurred in revision RSAs, during the removal of the previous implant, and involved the shaft in the majority of cases (39%). Glenoid fractures were 51 and occurred mostly during the reaming of the glenoid. We observed 7 further related complications (rate of 4%) and 3 reoperations (rate of 1.5%). The outcome was satisfactory in the majority of cases.

Conclusions

A comprehensive review on intraoperative fractures in reverse shoulder arthroplasties is presented. Results suggest favorable outcomes for all treatment methods, with a modest further complication rate. This investigation may aid in the treatment decision-making for these complications.

Non-medical patient-related factor influence in proximal humeral fracture outcomes: a multicentric study

PURPOSE

Age, sex, and type of fracture have traditionally been described as prognostic factors for proximal humeral fractures (PHFs). Some non-medical patient-related factors may play a role in the outcome. This paper evaluates the association of comorbidities and socioeconomic factors with clinical outcomes for PHF.

METHODS

A total of 217 patients with PHF were evaluated according to Neer's classification with X-ray. Comorbidities were assessed through the Charlson comorbidity index and, non-medical patient-related factors were determined with a 52-item questionnaire concerning personal behaviors such as social activities, family support, economic solvency, and leisure-time activities. The clinical outcome was assessed with the Constant-Murley Score (CMS), with a minimum 1-year follow-up. The minimal clinically relevant difference for the CMS was set at 10 points. A multivariable analysis was performed to adjust for comorbidities and non-medical patient-related factors, such as age, sex, fracture classification, and treatment.

RESULTS

One hundred and eighty-three patients completed the initial research protocol, while 126 of them completed the 1-year follow-up. The mean age was 71.6 years (SD ± 13.3), and 79.3% of the patients were women. In the bivariable analysis, age and comorbidities were correlated with the CMS (correlation coefficient: - 0.34 [- 0.49, 0.17] and 0.35 [0.18, 0.50], respectively), as well as non-medical patient-related factors and the fracture pattern (p value ANOVA < 0.001). In the multivariable regression model, the effects of considering oneself socially active, without economic problems, and self-sufficient were associated with a higher CMS than the effect of the fracture pattern (beta coefficient: 11.69 [6.09-17.30], 15.54 [8.32-22.75], and 10.61 [3.34-17.88], respectively).

CONCLUSION

Socioeconomic status had a higher impact on functional outcomes than fracture pattern in patients with PHF.

Reverse shoulder arthroplasty in complex fractures of the proximal humerus: results after 7 years of follow-up

BACKGROUND

There is still little information about the long-term results of clinical and radiological evolution in patients older than 65 years with complex proximal humerus fractures (CPHF) treated acutely with reverse shoulder arthroplasty (RSA). The aim of this paper was to evaluate function and results 7 years after surgery.

MATERIAL AND METHODS

A prospective cross-sectional cohort study was designed for this purpose. Patients who underwent RSA surgery during 2012 because of a CPHF were included. The surgical approach was randomized (deltopectoral vs anterosuperior). Functional activity, evolution of tuberosities and evidence of scapular notching 7 years after surgery were analyzed.

RESULTS

After evaluating 32 patients, the Constant score improved from 64.83 in the first year to 69.54 at 7 years postoperative. Results were independent of the approach used. Functional outcomes were poorer in patients with scapular notching and when tuberosities were resorbed or displaced.

CONCLUSIONS

At 7 years, function in patients undergoing RSA after CPHF demonstrated improvement in all patients except those who developed scapular notching or when tuberosities did not consolidate in an anatomical position. These results are completely independent of the approach used.

LEVEL OF EVIDENCE

III Controlled cohort study.

Prosthesis Designs and Tuberosity Fixation Techniques in Reverse Total Shoulder Arthroplasty: Influence on Tuberosity Healing in Proximal Humerus Fractures

Reverse total shoulder arthroplasty (RTSA) is increasingly used for the treatment of complex proximal humerus fractures and fracture sequelae. In 2021, half a dozen models of fracture stems are commercially available, reflecting its growing utility for fracture management. Prosthesis designs, bone grafting and tuberosity fixation techniques have evolved to allow better and more reliable fixation of tuberosities and bony ingrowth. Patients with anatomical tuberosity healing not only have an increased range of active anterior elevation and external rotation, but also experience fewer complications and longer prosthesis survival. This review provides an overview of recent evidence on basic and fracture-specific RTSA design features as well as tuberosity fixation techniques that can influence tuberosity healing.

Supraspinatus Tenotomy in Reverse Shoulder Arthroplasty for Fractures: A Comparative Cohort Study

Background

The aim of this study was to evaluate the functional and radiographic outcome in patients with reverse total shoulder arthroplasty (RSA) for displaced proximal humeral fractures (PHF) with or without tenotomy of the supraspinatus tendon.

Methods

Between June 2011 and June 2018, 159 patients (age >65 years) with a displaced proximal humeral fracture underwent reverse total shoulder arthroplasty (Grammont design) in a single-center study and were longitudinally followed up. In all cases, the tuberosities were attached to the prosthesis in a standardized procedure. Functional outcome, range of motion as well as tuberosity integration, resorption and displacement were assessed at final follow-up. Outcomes were compared between patients that underwent RSA in combination with tenotomy of the supraspinatus (ST) and patients that underwent RSA without supraspinatus tenotomy (NT).

Results

At a mean follow up of 22.2 ± 16.4 months 76 patients (mean age 77.1 ± 7.2 years, 83% women) could be evaluated (follow-up rate 47.8%). There were no statistically significant differences between the ST (n = 29) and NT groups (n = 47) in tuberosity integration, resorption </≥50%, or displacement (p = 0.99/0.31/0.7/0.99). Functional outcome was better in ST group (Constant score 76.2 ± 5.9 vs. 64.5 ± 12.8; p < 0.05) especially regarding mean active external rotation (>20°: 65.5% vs. 14.9%, p < 0.05) and active abduction (>120°: 89.7% vs. 21.3%, p < 0.05). Tuberosity integration (ST and NT together: n = 34) showed better functional results than resorption or displacement (p < 0.05).

Conclusions

Tenotomy of the supraspinatus tendon in RSA for displaced PHF leads to similar radiographic results regarding tuberosity integration, resorption and displacement but better functional outcome with regard to range of motion.

Level of Evidence

III.

Higher primary stability of tuberosity fixation in reverse fracture arthroplasty with 135° than with 155° humeral inclination

BACKGROUND

Proximal humeral fractures in elderly patients are frequently treated with reverse total shoulder arthroplasty, and tuberosity healing improves clinical outcome and patient satisfaction. So far reverse prostheses with different humeral inclination (HI) angles have been used. However, it has not been investigated yet if the HI angle affects the primary stability of the tuberosity fixation in primary reverse total shoulder arthroplasty for proximal humeral fractures in a biomechanical setting.

METHODS

A 4-part fracture was created in 7-paired human cadaver proximal humeri after preceding power analysis. After randomization in a pairwise fashion, reverse prostheses with either 135° (n = 7) or 155° (n = 7) were implanted. The tuberosities were reduced anatomically to the metaphysis of the prostheses and were fixed with 3 suture cerclages in a standardized technique. Tightening was performed with a cerclage tension device with 50 Newton meter (N m). Before biomechanical testing, the initial vertical and horizontal gap formation was measured. The humeri were placed in a custom-made test setup enabling internal and external rotation. Cyclic loading with a gradually increasing load magnitude was applied with a material testing machine starting with 20 N m and increasing by 5 N m after each 100th cycle until failure (>15° rotation of the tuberosities). Any motion of the tuberosities was measured with a 3-dimensional camera system.

RESULTS

Overall, the 155° group reached an average of 1460 ± 270 cycles and the 135° group of 1900 ± 271 cycles (P = .048). In contrast to the 135° group, in the 155° group, a mean initial vertical (0.3 ± 0.7 mm) and horizontal (2.7 ± 3.3 mm) gap formation could be observed before cyclic loading. After 1100 cycles, the 155° group showed increased rotation of both lesser and greater tuberosities in all 3 axes around the humeral shaft compared with the 135° group.

CONCLUSION

Primary stability of the reattached tuberosities is significantly increased, whereas rotational movements are decreased in prostheses with an anatomic HI of 135° compared with a 155° HI according to the original Grammont design. In addition, a 135° HI allows an exact anatomic reposition of the tuberosities, whereas this was not possible for the 155° design. However, transferability and clinical relevance of these biomechanical results have to be verified with clinical studies.

High bone union rate using a locking plate for proximal humeral fractures in patients older than 70 years: importance of the medial column

PURPOSE

This study aimed to evaluate the results of surgical treatment for proximal humeral fractures using a locking plate in patients aged > 70 years.

METHODS

Between September 2010 and March 2018, we retrospectively analyzed the clinical and radiological outcomes of 56 patients aged > 70 years who underwent locking plate fixation for proximal humeral fractures. We analyzed bone union, neck-shaft angle, University of California Los Angeles (UCLA) score, range of motion (compared to that of the opposite side), and complications. Further, clinical and radiological results of unstable medial column fractures were investigated.

RESULTS

Fifty-four patients (96.2%) achieved bone union. The mean time to bone union was 14.7 ± 1.2 weeks, and the mean neck-shaft angle was 126.4° ± 14.2°. The mean UCLA shoulder score was 22.4 ± 6.5. The mean forward flexion, abduction, and external rotation angles were 129.2° ± 19.4°, 112.3° ± 14.8°, and 44.2° ± 18.5°, respectively, with internal rotation to L2/3 (S-T11). The range of motion was significantly different from that in the opposite shoulder motion. Unstable medial column fractures led to a significant loss in the neck-shaft angle compared with fractures with an intact medial cortex.

CONCLUSION

For the surgical treatment of proximal humeral fractures in patients aged > 70 years, using a locking plate helped achieve a high bone union rate with relatively satisfactory results. However, the prevalence of unstable medial column fracture was high. Clinical and radiological outcomes were poor in these patients. Therefore, it is necessary to accurately understand the fracture pattern prior to surgery, and various surgical methods, including conservative treatment, should be considered.

Does healing of both greater and lesser tuberosities improve functional outcome after reverse shoulder arthroplasty for fracture? A retrospective study of twenty-eight cases with a computed tomography scan at a minimum of one-year follow-up

PURPOSE

Reverse shoulder arthroplasty (RSA) is often indicated in elderly patients with displaced proximal humerus fractures (PHF). The rate of greater tuberosity (GT) healing varies from 37 to 90% in this population. The aim of this study was to assess greater and lesser tuberosity (LT) fixation and healing on CT scan after RSA for PHF. Our hypothesis was that both GT and LT healing leads to better functional results after RSA for fracture.

METHODS

Our retrospective cohort consisted of 28 patients treated with an RSA for a four-part PHF during the inclusion period. The mean age at surgery was 77 years. Clinical examination and CT scan were performed at a minimum one year follow-up to assess tuberosity position and healing.

RESULTS

The GT healed in 22 patients (78.5%), the LT in 24 patients (87.5%) and both tuberosities were healed in 20 patients (71.5%). Constant score was significantly improved with GT, LT and both tuberosity healing (p = 0.05, p = 0.04 and p = 0.02 respectively). Motion in anterior elevation was improved with GT and both tuberosity healing (p = 0.01 and p = 0.04 respectively). Motion in external rotation was improved with GT and both tuberosity healing (p = 0.01 and p = 0.02 respectively).

CONCLUSION

GT and LT healing was associated with better functional results and active motion. Anatomical reduction and consolidation of both tuberosities is beneficial with a cumulative effect for functional recovery.

Consolidação dos tubérculos na artroplastia reversa do ombro após fratura proximal do úmero: Existe melhoria nos resultados funcionais?

Objective  To compare the functional results of patients with complex proximal humerus fracture submitted to total shoulder reverse arthroplasty with and without tuberosity healing. The secondary goal was to know the tuberosity healing rate after reverse shoulder arthroplasty with our surgical technique.

Methods  A retrospective, cohort type study, with a prospective database collection. In total, 28 patients fulfilled the inclusion criteria: age ≥ 65 years, reverse shoulder arthroplasty for complex proximal humerus fracture (type-3 or -4, according to Neer), and a minimum of 24 months of follow-up. At six months of follow-up, all of the patients were evaluated radiographically for tuberosity, and then they were divided into 2 groups: those with healed tuberosities and those with non-healed tuberosities. A clinical evaluation using the Constant score, active range of motion and the Visual Analog Scale (VAS) at the last follow-up was also performed.

Results  Tuberosity healing occurred in 21 patients (76.3%). There were statistically significant differences in the Constant scoring system ( p  < 0.001), forward elevation ( p  = 0.020), internal rotation ( p  = 0.001) and external rotation ( p  = 0.003) when comparing the group of healed tuberosities with the group of non-healed tuberosities. No differences were found regarding the VAS score.

Conclusion  Tuberosity healing results in an improvement of the functional outcomes of patients submitted to reverse shoulder arthroplasty as a treatment for complex proximal humeral fractures in the elderly.

Tuberosity union in patients with proximal humerus fractures treated with reverse shoulder arthroplasty: a technical note and exploratory analysis

PURPOSE

The use of reverse shoulder arthroplasty (RSA) to treat complex humerus fractures is increasing, especially in older, osteoporotic patients. Refixation and tuberosity healing are needed to achieve an optimal range of motion (ROM), external rotation, active forward elevation, and patient satisfaction. Proper healing has been reported, however, in only 40-84% of cases. Our study's aim was to describe a simple, reproducible fixation technique designed to improve tuberosity healing.

METHODS

We included 30 patients with acute proximal humerus fractures undergoing RSA (Global Unite Reverse Fracture, DePuy Synthes, Warsaw, IN, USA) with tuberosity reattachment. The humerus stem was cemented in 24 cases. A standardized suture technique with two fiber tapes was used to reattach tuberosities. Clinical and radiological parameters, which were collected one year post-operatively, included ROM, pain level, Constant scores, subjective shoulder value (SSV), and tuberosity healing.

RESULTS

The mean age of the patients was 79.3 years (± 7; range 65-92), and the tuberosity healing rate was 90.0% (27 of 30). Two patients showed migration (one nonunion, one malunion), and another had complete resorption after an initial period of proper healing. Radiolucent lines around the humerus stem occurred in one case, and three patients had scapular notching. The mean SSV was 86% (± 11; range 60-100), the Constant score was 72 (± 10.3; range 48-92), the active forward flexion was 140° (± 14.3; range 115-165), and external rotation was 23° (± 16.5; range 0-50).

CONCLUSIONS

This reattachment technique, which is simple and reproducible, achieved a higher tuberosity healing rate than previously published rates.

The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part II

Background

Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous.

Methods

Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests.

Results

The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%.

Conclusions

Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.

A systematic review of tuberosity healing and outcomes following reverse shoulder arthroplasty for fracture according to humeral inclination of the prosthesis

BACKGROUND

Proximal humerus fractures are common in the elderly population and are often treated with reverse shoulder arthroplasty (RSA). The purpose of this systematic review was to compare tuberosity healing and functional outcomes in patients undergoing RSA with humeral inclinations of 135°, 145°, and 155°.

METHODS

A systematic review was performed of RSA for proximal humerus fracture using Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. Radiographic and functional outcome data were extracted to evaluate tuberosity healing according to humeral inclination. Analysis was also performed of healed vs. nonhealed tuberosities.

RESULTS

A total of 873 patients in 21 studies were included in the analysis. The mean age was 77.5 years (range of 58-97) and the mean follow-up was 26.2 months. Tuberosity healing was 83% in the 135° group compared with 69% in the 145° group and 66% in the 155° group (P = .030). Postoperative abduction was highest in the 155° group (P < .001). No significant difference was found in forward flexion, external rotation, or postoperative Constant score between groups. Patients with tuberosity healing demonstrated 18° higher forward flexion (P = .008) and 16° greater external rotation (P < .001) than those with unhealed tuberosities.

CONCLUSION

RSA for fracture with 135° humeral inclination is associated with higher tuberosity healing rates compared with 145° or 155°. Postoperative abduction is highest with a 155° implant, but there is no difference in in postoperative forward flexion, external rotation, or Constant score according to humeral inclination. Patients with healed tuberosities have superior postoperative forward flexion and external rotation than those with unhealed tuberosities.

Shoulder arthroplasty for proximal humerus fractures in the elderly: The path from Neer to Grammont

Shoulder replacement is indicated for the surgical treatment of proximal humeral fractures in elderly patients, when severe comminution and osteoporosis jeopardize the chances of success of any fixation technique. Two different implants are available for this purpose: anatomical hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA). HA for fractures was popularized by Charles Neer in the ‘50s and for several decades remained the only reliable implant for these injuries. However, many authors reported inconsistent results with HA as a consequence of the high rate of tuberosity and rotator cuff failure. In 1987, Paul Grammont designed the first successful RTSA, which was the end result of a long thought process on functional surgery of the shoulder. This implant was initially used to treat cuff tear arthropathy and shoulder pseudoparalysis, but indications have gradually expanded with time. Since RTSA does not rely on a functional cuff for shoulder elevation, it was felt that results in fractures could be improved by this prosthesis. In this study, the salient features of these implants are described to understand the rationale behind both approaches and highlight their pros and cons. Several clinical studies comparing HA vs RTSA for proximal humeral fractures have been published during the last two decades. A literature review is carried out to analyze and compare outcomes of both implants, analyzing clinical results, radiographic findings and complications. The final goal is to provide an overview of the different factors to consider for making a choice between these two prostheses.

Reverse Shoulder Arthroplasty for Proximal Humerus Fracture

PURPOSE OF REVIEW

The purpose of this review is to examine trends, outcomes, and principles in treatment of proximal humerus fractures in the elderly with a critical focus on reverse shoulder arthroplasty as a developing treatment option.

RECENT FINDINGS

Recent literature shows an increase in reverse shoulder arthroplasty and a decrease in hemiarthroplasty performed for proximal humerus fractures. More predictable outcomes and lower revision rates are seen in older individuals treated primarily or secondarily with reverse shoulder arthroplasty compared to those treated with hemiarthroplasty. We report current and historical treatments, outcomes, and principles in reverse shoulder arthroplasty for treatment of complex, displaced proximal humerus fractures in older individuals (≥ 65 years old).

The role of greater tuberosity healing in reverse shoulder arthroplasty: a finite element analysis

BACKGROUND

The lack of greater tuberosity (GT) healing in proximal humerus fractures has been negatively correlated with outcomes for hemiarthroplasty; however, there is still debate regarding the effects of GT healing in reverse shoulder arthroplasty (RSA). Our goal was to examine the effects of GT healing using a kinematic finite element analysis (FEA) model.

MATERIAL AND METHODS

Computer-aided design models of a medialized glenoid with a lateralized humerus (MGLH) RSA design were uploaded into an FEA shoulder model in 2 different configurations: healed greater tuberosity (HGT) and nonunion greater tuberosity (NGT). Deltoid muscle forces and joint reaction forces (JRFs) on the shoulder were calculated during abduction (ABD), forward flexion (FF), and external rotation (ER).

RESULTS

Force magnitude of the anterior, middle, and posterior deltoid muscle as well as JRFs modeled in both GT scenarios were similar for ABD (muscle forces P = .91, P = .75, P = .71, respectively; and JRF P = .93) and for FF (muscle forces P = .89, P = .83, P = .99, respectively; and JRF P = .90). For ER, the force magnitude between 2 GT settings showed statistically significant differences (HGT: 9.51 N vs. NGT: 6.13 N) (P < .001). Likewise, during ER, JRFs were different, and the NGT group showed a steep drop in JRF after 10° of ER (HGT: 28.4 N vs. NGT: 18.38 N) (P < .001).

CONCLUSION

GT healing does not seem to impact RSA biomechanics during abduction or forward flexion; however, it does affect biomechanics during external rotation. Overall orthopedic surgeons can expect good results for patients after RSA even with poor GT healing.

High tuberosity healing rate associated with better functional outcome following primary reverse shoulder arthroplasty for proximal humeral fractures with a 135° prosthesis

Background

Reverse shoulder arthroplasty (RSA) is a common treatment for proximal humeral fractures. (PHF) in the elderly. This study evaluates the functional outcome and the influence of. tuberosity healing (TH) following RSA with 135° humeral inclination and a neutral glenosphere without lateralization for PHFs.

Methods

In this retrospective case series, all patients with an acute PHF treated with primary RSA with 135° humeral inclination and a standard glenosphere without lateralization during a four-year period were followed up. Constant score (CS), patient satisfaction (subjective shoulder value (SSV)), TH and glenoid notching were analyzed.

Results

38 patients with a mean age of 77 ± 8 years were available for follow-up at 34 ± 5 months. The mean adjusted CS was 61 ± 9 points. TH of the greater tuberosity (GT) was 82% and resulted in significantly improved abduction (117° vs. 81°; P < 0.001), forward flexion (139° vs. 99°; p < 0.001), external rotation (28° vs. 10°; p = 0.002), CS (65 vs. 41 points; p < 0.001) and patient satisfaction (SSV 79% vs. 48%; p < 0.001). TH of the LT was 87% without affecting internal rotation or overall outcome. The complication- and revision rate was 5%; implant survival was 100%. Scapular notching occurred in 3 (8%) cases (all grade 1).

Conclusion

RSA with 135° humeral inclination and a standard glenosphere for PHF leads to good functional outcome in combination with a high rate of TH and a low rate of scapular notching. The short-term revision rate is low and the results are predictable and continuous. TH is associated with improved ROM, patient satisfaction and functional outcome.

Safety and Effectiveness of Shoulder Arthroplasties in Spain: A Systematic Review

The effectiveness and safety of shoulder arthroplasties in the general context of a Spanish patient population remains unclear. The aim of this study was to ascertain both the effectiveness and safety of primary shoulder arthroplasties and the prosthesis types used in Spain. A systematic review of all the available literature evaluating the effectiveness and safety of primary shoulder arthroplasties in Spain was performed. A narrative synthesis was performed, and evidence tables were created in four dimensions: study design, arthroplasty characteristics, safety, and effectiveness. Orthopaedic Data Evaluation Panel (ODEP) scores were used to evaluate prosthesis types. Twenty-one studies were selected that included a total of 1293 arthroplasties. The most common indication was fractures, while the prosthesis most frequently used was the Delta Xtend (ODEP 10A). The most common complication was scapular notching. Prosthesis revision rate was approximately 6% for follow-ups between 12 and 79 months. In addition, significant improvements were observed in the Constant-Murley test score after the intervention. Currently in Spain, shoulder arthroplasty can be considered a safe and effective procedure with functional recovery and pain reduction for eligible patients with humeral fracture, rotator cuff arthropathy, fracture sequelae and malunion of the proximal humerus, and degenerative disease. Future longitudinal research and population-based studies could serve to confirm these results and identify points of improvement.

Primary reverse shoulder arthroplasty for acute proximal humerus fractures: A 5-year long term retrospective study of elderly patients

BACKGROUND

Reverse shoulder arthroplasty (RSA) in complex shoulder fractures is ever more frequently. This study compares clinical and radiologic results of patients with comminuted proximal humeral fractures (PHFs) treated with RSA, with and without tuberosities grafting.

METHODS

Between January 2009 and June 2014, 55 patients aged ≥65 years with 3- and 4-part PHFs were treated surgically. Patients' files and the hospital's digital database were reviewed retrospectively with at least 5-year of follow up. We constituted three groups according to the tuberosity consolidation: patients in whom the tuberosities showed anatomic consolidation (Group I) and patients either with secondary displacement of the tuberosities (Group II) or without tuberosity repair (Group III).

RESULTS

The 74% of the repaired tuberosities consolidated in anatomic position. Among range of motion (ROM), we reported that forward elevation, abduction and external rotation were significantly better in Group I than those in Group II-III. Furthermore, quick Dash score and Constant score showed more satisfied results in Group I. Regarding complications, not infection or instability were found in group I. On the other hand, in group II, we reported one patient with deep infection, leading to two steps surgery. In group III, we recorded two patients with instability required implant revision and one with deep infection treated by revision.

CONCLUSION

RSA showed satisfied results even at 5 year follow up. Preservation of the tuberosities in anatomic position improves active forward elevation and external rotation as well as patient satisfaction with less complications.

Tuberosity healing after reverse shoulder arthroplasty for complex proximal humeral fractures in elderly patients-does it improve outcomes? A systematic review and meta-analysis

BACKGROUND

Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus in older patients. Anatomic tuberosity healing in RSA has been recognized to restore better shoulder function. We compared the reported clinical and functional outcomes of RSA in proximal humeral fractures with and without tuberosity healing.

METHODS

We performed a systematic review of literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials. We included all studies with RSA for proximal humeral fractures in patients older than 60 years and compared outcomes based on tuberosity healing with minimum follow-up of 12 months.

RESULTS

Seven studies met the inclusion criteria. A total of 381 patients (382 shoulders) were identified. There were 53 men (18.3%) and 236 women (81.7%), with mean age of 76.83 years (range, 74-81 years). Mean follow-up duration was 29.84 months (range, 24-90 months), and the mean rate of greater tuberosity healing was 70.5%. Patients with healed tuberosity had significantly better active forward flexion (134.1° vs. 112.5°, P < .05), abduction (114.8° vs. 95.1°, P < .05), external rotation with elbow by the side (27.8° vs. 7.6°), and mean Constant score (63.5 vs. 56.6, P < .05) than with those with nonhealed tuberosity.

CONCLUSION

The RSA group with healed greater tuberosity showed better range of motion, especially forward flexion and external rotation and Constant scores, compared with the nonhealed greater tuberosity group. Tuberosity healing may influence overall shoulder function after RSA for proximal humeral fractures in the elderly, and this needs verification with future prospective studies.