Treatment of proximal humerus fractures using reverse shoulder arthroplasty: do the inclination of the humeral component and the lateral offset of the glenosphere influence the clinical outcome and tuberosity healing?

Reverse total shoulder arthroplasty versus locked plate fixation for proximal humeral fractures in the elderly: a systematic review

INTRODUCTION

For surgical treatment of proximal humeral fractures (PHF) in older patients, there is no consensus if locked plate fixation (LPF) or reverse total shoulder arthroplasty (RTSA) yields better clinical results. The purpose of this study was to systematically review the clinical and functional outcomes of LPF and RTSA. We hypothesized that RTSA would outperform LPF in patients with PHF aged 65 years or older.

MATERIALS & METHODS

A comprehensive literature search was performed on PubMed and Google Scholar from 1 July 2022 up to 12 January 2024 by two independent reviewers. Comparative studies reporting on the functional outcome using the Constant-Murley score (CMS) in patients aged 65 years or older, treated after 2012 for PHF with LPF or RTSA and with a mean follow-up time of at least 12 months were included. Ten studies with 244 LPF and 287 RTSA patients were included into the statistical analysis. We used a frequentist network meta-analysis to assess the comparative effectiveness of the treatments. Individual risk of bias of the studies was assessed using the ROB2 and ROBINS-I tools.

RESULTS

Our network meta-analysis of the CMS resulted in the following order ranked from lowest to highest: LPF, LPF +  screw augmentation, hemiarthroplasty (HA), RTSA +  cemented stem, non-surgical treatment, LPF +  fibular allograft, RTSA with an inclination angle of 135° (RTSA IA 135°), RTSA. However, none of the direct or indirect comparisons resulted in statistically noticeable differences.

CONCLUSION

In conclusion, functional superiority of either treatment method is still unknown, with even high-powered RCT not being able to detect statistically noticeable differences in terms of function. Patient-individual factors, such as bone quality, sex and age have to be included when making treatment decisions.

Complications following reverse total shoulder arthroplasty for proximal humeral fractures: a systematic review

Background

Reverse total shoulder arthroplasty (rTSA) is an increasingly common procedure for proximal humerus fractures (PHFs), but postoperative complications have not been well characterized. The purpose of this systematic review is to assess complications and revision rates following rTSA in the management of PHFs as documented in current literature.

Methods

A systematic review was performed on primary rTSA for PHFs. In adherence to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search was conducted between September and December of 2023, utilizing the databases PubMed, Scopus, and the Cochrane Library to include relevant articles from any period. A total of 102 studies were identified for inclusion after initial screening of 3800 query results. Extracted data from each article included the publishing journal, level of evidence, study design, number of patients, mean age, age range, percent female, mean follow-up, specific postoperative complications, total complications, complication rate, number of revisions, and revision rate. Overall complication rates were determined by dividing total complications by total patients and multiplying by 100, which also applied to revision rates.

Results

Among 10,797 primary rTSA cases for PHFs identified from 102 studies, the mean age of patients was 75.6 ± 3.6 years, and 82.6% of patients were female. The average follow-up was 38.9 ± 21.0 months. The overall complication rate was 7.0% (754/10,797) with a range of 0% to 46.9%. The most common postoperative complications were prosthetic instability/dislocation (2.3%, 244/10,797; range: 0%-7%) and infection (1.2%, 131/10,797; range: 0%-2.5%). Periprosthetic fracture (0.8%), nerve injury (0.3%), and other complications were also documented. The overall revision rate was 3.3% (355/10,797; range: 0%-28%).

Conclusion

This systematic review summarizes the most common postoperative complications of rTSA for PHFs. The most frequent complication was prosthetic instability/dislocation, followed by infection. While the average total complication and revision rates were relatively low, there was wide variability, with some studies reporting rates as high as 46% and 28%, respectively.

Medialized vs. Lateralized Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Reverse shoulder arthroplasty (RSA) is increasingly used in the treatment of proximal humerus fractures (PHFs) with reliable clinical improvement. Lateralized RSA implants have conferred superior outcomes compared with the original Grammont design in patients with nontraumatic indications. However, in the setting of a PHF, lateralized components can place increased tension across the tuberosity fracture site and potentially compromise tuberosity healing and outcomes. This systematic review and meta-analysis sought to determine the effect of implant design on clinical outcomes after RSA for PHFs.

METHODS

A systematic review was performed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed/MEDLINE, EMBASE, Web of Science, and Cochrane were queried for clinical studies on RSA performed for PHFs that reported implant manufacturer details. Our primary outcomes included postoperative external rotation (ER), forward elevation (FE), abduction, Constant score, rate of greater tuberosity (GT) healing, and the incidence of complications compared between medialized vs. lateralized global implant design.

RESULTS

Globally lateralized RSA cohorts (478 RSAs total with cumulative lateral offset achieved through humeral or glenoid lateralization or both humeral and glenoid lateralization) were found to have a greater mean postoperative Constant score compared with globally medialized (medialized glenoid and medialized humerus) RSA cohorts with 1,494 total medialized RSAs (66 vs. 59, p = 0.006), but there was no significant difference regarding mean postoperative ER (30° vs. 22°, p = 0.078), FE (117° vs. 119°, p = 0.708), or abduction (103° vs. 107°, p = 0.377). On meta-regression, neither implant design nor tuberosity status significantly influenced postoperative ER, FE, abduction, or Constant score on meta-regression independent of mean follow-up and age at surgery. The rate of GT healing was greater in lateralized compared with medialized RSAs (88% vs. 72%, p < 0.001). On meta-regression, medialized RSA design was associated with a 73% lower odds of GT healing (odds ratio = 0.27, 95% confidence interval = 0.11-0.68, p = 0.007) independent of mean follow-up and age at surgery.

CONCLUSION

Lateralized RSA implants conferred no significant functional benefit over medialized implants when used in patients with PHFs.

LEVEL OF EVIDENCE

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

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.

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.

The effect of subscapularis repair in reverse total shoulder arthroplasty depends on the design of the implant: a comparative study with a minimum 2-year follow-up

INTRODUCTION

The role of the subscapularis (Ssc) tendon does not yet have a well-defined role in RSA. The purpose of the present study was to evaluate if the repair of the Ssc in RSA improves overall clinical and radiographic results and if it has the same results using a medialized design humeral stem compared to a lateralized design.

METHODS

Eighty-four consecutive patients undergoing RSA were retrospectively analyzed. Nine patients were lost at FU. Two implants with similar glenosphere design and different stem design (medialized and lateralized) were used. The Ssc was repaired in case of good quality of the fibers and reducibility without tension intraoperatively. Patients were divided into four groups for data analysis depending on whether they had received a medialized or lateralized design and Ssc repair or not. Patients were reviewed at an average follow-up of 40.8 ± 13.1 months. Clinical outcome measures included Active range of motion (ROM), strength, visual analog scale (VAS), Constant-Murley score (CMS), and the American Shoulder and Elbow Surgeons score (ASES). Radiographic evaluation at final follow-up was performed to assess scapular notching, stress shielding, and radiolucent lines.

RESULTS

No statistically significant clinical differences (p > 0.05) emerged between Lat/Ssc+ and Lat/Ssc-. Conversely, the patients belonging to the Med/Ssc- group reported statistically worse (p < 0.05) results than the Med/Ssc + group in terms of VAS, ASES and CMS. Statistically worse (p < .05) results in the Med/Ssc- group than in the Med/Ssc + were found also in active ROM achieved in FE, ABD, ER1 and ER2, and in the strength obtained in FE, ABD and ER2. Scapular notching was reported in 3 shoulders (15.7%) in Lat/Ssc+ group and in 7 shoulders (50%) in Lat/Ssc- group, while it was reported in 4 shoulders (14.2%) in Med/Ssc + group and in 6 shoulders (42.8%) in Med/Ssc- group. Stress shielding was observed in 6 cases in Lat/Ssc+ group (31.6%), in 8 cases in Lat/Ssc- group (57.1%), in 3 cases (10.7%) in Med/Ssc + group and 4 cases in Med/Ssc- group (28.6%).

CONCLUSIONS

Patients undergoing RSA show clinical improvements at mid-term follow-up with a low rate of complications, regardless of the use of a medialized or a lateralized humeral stem design. Ssc repair is associated with better functional outcomes in the cohort of medialized stem, while it did not yield significant differences in the cohort of lateralized stem.

LEVEL OF EVIDENCE

Level III; Retrospective Cohort Comparison; Treatment Study.

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.

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.

[Current trends in reverse fracture arthroplasty]

The reliable results of reverse arthroplasty have made this the preferred treatment method for non-reconstructable proximal humeral fractures. The individual consideration of the patient and the morphological features of the fractures are essential. Computed tomography (CT) images provide crucial information on the perfusion of the humeral head relevant for the prognosis and treatment. In this context a differentiation must be made between hard and soft criteria against a reconstruction. Tuberosities should be reduced whenever possible, because reverse arthroplasty with healed tuberosities provides a better range of motion and more strength for external rotation and anteversion, less complications and longer survival rates. In recent years the trend has been towards anatomical designs of prostheses with a humeral inclination of 135°. Revision rates for primary fracture prostheses are overall low with instability as the main reason for revision surgery, followed by periprosthetic fractures and infections. Reverse fracture arthroplasty has comparable or better clinical results compared to conservative treatment, osteosynthesis for geriatric patients, hemiarthroplasty and prosthesis implantation by elective surgery. Reverse arthroplasties, which were implanted in conditions of fracture sequelae, did not achieve significantly poorer clinical outcome at mid-term follow-up and can significantly improve shoulder function.