Outcomes of Reverse Total Shoulder Arthroplasty Versus Other Surgical Fixation Methods for Proximal Humerus Fractures in Elderly Patients

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.

First-line management of distal humerus fracture by total elbow arthroplasty in geriatric traumatology: Results in a 21-patient series at a minimum 2 years’ follow-up

Distal humerus fractures in elderly patients are difficult to treat as these fractures are often complicated by varying degrees of comminution intra-articular involvement and osteoporosis. We retrospectively reviewed the results of primary total elbow arthroplasty in the treatment of distal humerus fractures in seven patients followed for a minimum of 1 year. Between July 2000 and June 2002, seven patients with distal humerus fractures were treated electively with total elbow arthroplasty using the semiconstrained Coonrad-Moorey elbow replacement prostheses. The Mayo Elbow Performance Score was used to assess the outcomes. The mean age of our patients was 72.9 years. The mean duration of postoperative hospitalization stay was 7.6 days. The average length of follow up was 24.9 months. Six of these patients had no pain, and one patient had mild pain. The mean arc of flexion was 88.6 degrees. Six elbows had excellent results, while 1 elbow had good result. The mean Mayo score was 94.3 points. One elbow developed blisters postoperatively but resolved with dressings and antibiotics. Our review suggests that total elbow arthroplasty can give good to excellent short term results when used in the treatment of distal humerus fractures in elderly Asian patients.

To evaluate clinical and radiographic outcomes and complications of three- and four-part proximal humerus fractures (PHF) in elderly patients treated with angular locking plate (LP) combined with calcium sulfate (CaSO4) paste graft. A prospective case series evaluating patients aged ≥ 60 years with three- or four-part PHF treated with LP and 10 ml of CaSO4 paste graft. Primary outcome was clinical evaluation using the Constant-Murley (CM) score at 12 months. Secondary outcomes included scores from the University of California, Los Angeles (UCLA), American Shoulder and Elbow Surgeons (ASES), Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder and Elbow (DASH), bilateral active range of motion (ROM), abduction strength, Constant Relative Index (CRI), radiographic findings, and complications. Thirty patients were evaluated. At 12 months, the mean scores were: 67.7 (CM), 30.5 (UCLA), 86.5 (ASES), 0.7 (VAS), and 18.9 (DASH). The mean active ROM was 121° (flexion), 109° (abduction), 53° (external rotation), and thumb-T12, with abduction strength of 5.7 kg. The mean head-shaft angle (HSA) on the first postoperative day was 133°, with minimal change to 129° at 12 months, and the mean humeral height (HH) remained unchanged (11 mm). There were five complications in four patients (13.3%): three cases of severe varus collapse (difference between the neck-shaft angle (NSA) on the first postoperative day and the 12th month postoperative > 20°), and two cases of cutout. Two reoperations (6.0%) were performed to remove screws that had penetrated the joint. Clinical and radiographic outcomes of three- or four-part PHF in elderly patients treated with LP and CaSO4 paste graft are satisfactory, with relatively low complications and reoperation rates.

The employment of reverse shoulder arthroplasty for dislocated proximal humerus fractures of elderly patients becomes increasingly relevant. The standard inclination angle of the humeral component was 155°. Lately, there is a trend towards smaller inclination angles of 145° or 135°. Additionally, there has been an increased focus on the lateralization of the glenosphere. This retrospective comparative study evaluates clinical and radiological results of patients treated for proximal humerus fractures by reverse shoulder arthroplasty with different inclination angles of the humeral component, which was either 135° or 155°. Additionally, a different lateral offset of the glenosphere, which was either 0mm or 4mm, was used. For this retrospective comparative analysis, 58 out of 66 patients treated by reverse total shoulder arthroplasty for proximal humerus fractures were included. The minimum follow-up was 24months. Thirty (m = 3, f = 27; mean age 78years; mean FU 35months, range 24-58months) were treated with a standard 155° humeral componentand a glenosphere without lateral offset (group A), while 28 patients (m = 2, f = 26; mean age 79years; mean FU 30months, range 24-46months) were treated with a 135° humeral componentand a glenosphere with a 4 mm lateral offset (group B). We determined range of motion, Constant score, and the American Shoulder and Elbow Surgeons Shoulder score as clinical outcomes and evaluated tuberosity healing as well as scapula notching. Neither forward flexion (A = 128°, B = 121°; p = 0.710) nor abduction (A = 111°, B = 106°; p = 0.327) revealed differences between the groups. The mean Constant Score rated 63 in group A, while it was 61 in group B (p = 0.350). There were no differences of the ASES Score between the groups (A = 74, B = 72; p = 0.270). There was an increased risk for scapula notching in group A (47%) in comparison to group B (4%, p = 0.001). Healing of the greater tuberosity was achieved in 57% of group A and in 75% of group B (p = 0.142). The healing rate of the lesser tuberosity measured 33% in group A and 71% in group B (p = 0.004). Both inclination angles of the humeral component are feasible options for the treatment of proximal humerus fractures in elderly patients. Neither the inclination angle nor the lateral offset of the glenosphere seem to have a relevant influence on the clinical outcome. The healing rate of the lesser tuberosity was higher in implants with a decreased neck-shaft angle. There is an increased risk for scapula notching, if a higher inclination angle of the humeral component is chosen. III. Retrospective comparative study.

Long-term outcomes of reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4- part proximal humerus fractures in elderly patients: Results from a prior randomized clinical trial

Reverse shoulder arthroplasty for four-part proximal humerus fracture in elderly patients: can a healed tuberosity improve the functional outcomes?

This study described surgical treatment patterns for proximal humerus fractures among elderly patients, focusing on reverse total shoulder arthroplasty (TSA), and evaluated how the type of fixation affects inpatient factors (cost, length of stay), transfusion rates, and patient disposition (home vs skilled nursing facility). With Nationwide Inpatient Sample data from 2011 to 2013, the authors identified patients 65 years and older who had proximal humerus fractures and divided them into 3 groups: (1) open reduction and internal fixation (ORIF); (2) hemiarthroplasty; and (3) reverse TSA. From 2011 to 2013, 38,729 surgically treated proximal humerus fractures were identified. The rate of reverse TSA increased 1.8-fold during this time, from 13% of operative cases in 2011 to 24% of operative cases in 2013 (P<.001). At the same time, the rates of hemiarthroplasty and ORIF decreased (hemiarthroplasty, from 28% to 21%; ORIF, from 59% to 55%). Although reverse TSA accounted for 32.2% of arthroplasty procedures for proximal humerus fractures in 2011, this value was 53.3% in 2013 (P<.001). In 2013, mean total hospital cost for reverse TSA was $24,154, which was significantly higher than that for ORIF ($16,269) or hemiarthroplasty ($19,175) (P<.001). In a multivariable model, patients undergoing reverse TSA were less likely than those undergoing hemiarthroplasty to be discharged to a skilled nursing facility (odds ratio, 0.75; P=.027). The national rate of reverse TSA nearly doubled from 2011 to 2013. As of 2013, reverse TSA replaced hemiarthroplasty as the most commonly performed arthroplasty procedure for proximal humerus fractures for patients 65 years and older. Patients undergoing reverse TSA were more likely than those undergoing hemiarthroplasty to be discharged home. [Orthopedics. 2017; 40(6):e982-e989.].

There is still no consensus about treatment distal humerus fractures (DHF) in elderly patients. This retrospective study compare the mid-term outcomes of intraarticular DHF in patients over 60 years of age treated with open reduction and internal fixation (ORIF) and total elbow arthroplasty (TEA). We have evaluated 64 patients who have undergone treatment for intra-articular DHF (AO types C, 31 TEA vs. 33 ORIF). Our assessment included: range of motion, Mayo Elbow Performance Score (MEPS), Quick-DASH score and numeric pain score (NRS). Rate of complications and reoperations were examined. All patients were followed for a minimum of three years. At the final follow-up, mean flexion-extension ROM was 119,9° +/-27.8° vs 79.3° +/-23.8° for TEA group and ORIF group respectively and prono-supination ROM was 167.8°+/-16.2° vs 150.2°+/-36.9°. Mean MEPS was 82.6+/-12.6 vs 70.3+/-13.6 for TEA and ORIF respectively. Mean DASH score was lower in the TEA group, 22.7+/-15.5 vs 37.6+/-21.2. The number and rate of complications was higher in the ORIF group. Reoperation rates were 30.3% and 19.35% for ORIF and TEA respectively. TEA could lead to a satisfying functional outcomes with more predictable results and less complication then ORIF for DHF in the elderly.

Background The management of proximal humerus fractures, particularly in older adults, has evolved significantly with the advent of various surgical techniques. Among these, open reduction and internal fixation (ORIF) using locked plates and screws and reverse shoulder arthroplasty (RSA) are two prominent interventions. Aim To assess outcomes of ORIF by locked plates and screws in comparison to RSA for proximal humerus fractures in elderly patients. Methods This was a systematic review and meta-analysis conducted in orthopedic surgery, faculty of medicine- Ain Shams University. This systematic review, included 8 studies encompassing 975 patients, examined outcomes following locked plate fixation (n = 472) and reverse shoulder arthroplasty (n = 503) for proximal humerus fractures. Results eight studies were included in the present meta-analysis that included a total of 975 patients. Our results supported the RSA as better outcomes in range of motion especially active forward flexion, Oxford shoulder score, Constant score, and DASH score. Whereas, locked plate had significantly higher adverse events rates, and revision surgeries. Conclusion the study shows good clinical outcomes and fewer complications in reverse shoulder arthroplasty group. Significant better clinical and daily living results are reported in RSA compared with ORIF, confirming that RSA is one of the best surgical option in proximal humeral fractures in the elderly patients.

Surgical treatment for acute and displaced proximal humerus fractures in elderly patients: hemiarthroplasty vs. reverse shoulder arthroplasty

Introduction:Proximal humerus fractures (PHFs) are a common fragility fracture and have been shown to increase mortality in elderly patients. In the last decade, reverse total shoulder arthroplasty (RTSA) was introduced as a reliable operative treatment option for this indication. In other fragility fractures, most notably hip fractures, urgent surgical treatment can reduce mortality. The purpose of this study is to evaluate whether treatment with RTSA can reduce 1-year mortality in elderly patients with complex displaced PHFs.Materials and Methods:A retrospective study was performed to compare 1-year mortality between 2 groups of elderly patients (>75 years old) who presented to a level 1 trauma center emergency department with complex displaced PHFs. The conservative treatment group (n = 83; mean age, 83.7 years) presented from 2008 to 2010 when RTSA was not yet available, and treatment was nonoperative. The surgical treatment group (n = 62; mean age, 82.2 years) presented from 2012 to 2015 and underwent RTSA.Results:One-year mortality was 8.1% (male 7.1%; female 8.3%) in the surgical treatment group and 10.8% (male 18.8%; female 9.0%) in the conservative treatment group. The reduction in mortality in the surgical treatment group was not significant (entire cohort P = .56; males P = .35; females P = .59).Discussion:Recent studies failed to show better functional results after surgical treatment with RTSA when compared to conservative treatment. This study suggests that a benefit of surgical treatment with RTSA that was not examined until now might exist—a reduction in the increased mortality risk associated with PHFs.Conclusions:There was no significant difference in 1-year mortality between the groups, although there was a trend showing lower mortality with RTSA, mostly in men. Further studies with larger populations and longer follow-up times are needed to determine whether this trend is of clinical significance.

Proximal humerus fractures represent a significant healthcare burden in the elderly population. These injuries are the third most common fragility fractures, after hip and distal radius fractures. The management of proximal humerus fractures in elderly patients is controversial. Treatment options range from conservative management to surgical interventions. The choice depends on multiple factors, including fracture pattern, bone quality, patient functional demands, and comorbidities. This narrative review examines the current evidence regarding both conservative and operative management strategies for proximal humerus fractures in elderly patients. We discuss the classification systems, treatment algorithms, outcomes, and complications. The goal of this review is to provide clinicians with a comprehensive understanding of management options to optimize patient outcomes.

Reverse total shoulder arthroplasty (RSA) is a well-established treatment for proximal humerus fractures in elderly patients. However, the clinical advantages of standard humeral components compared to fracture-specific components remain unclear. This meta-analysis compares the clinical outcomes and complication rates of standard compared with fracture-specific components in RSA. A systematic review and meta-analysis were conducted according to the PRISMA guidelines. PubMed, Scopus, and Cochrane Library databases were searched from inception to 12 August 2024. Comparative studies reporting clinical outcomes between standard components and fracture-specific components in RSA for proximal humerus fractures were included. Data on functional scores, range of motion, tuberosity healing, and complications were extracted. Meta-analyses were performed using fixed or random-effects models based on heterogeneity, and risk of bias was assessed using the Newcastle-Ottawa Scale (NOS) and the Cochrane Risk of Bias Tool (RoB2). Weighted mean difference (WMD) was used as the effect size estimator for continuous outcomes, and risk ratio (RR) for dichotomous outcomes. Sensitivity analysis was performed to assess the robustness of the findings. Six studies involving 436 patients (142 with standard components and 294 with fracture-specific components) were included. The pooled analysis found no significant differences between the two component types in functional outcomes (visual analogue scale (VAS): WMD 0.22; American Shoulder and Elbow Surgeons (ASES): WMD -7.43; Constant score: WMD -3.08) or postoperative range of motion (abduction: WMD 1.08°; internal rotation: WMD 0.35°; external rotation: WMD -2.76°; forward flexion: WMD -4.27°). Complication rates, including tuberosity failure (RR 1.34), scapular notching (RR 1.09), and component loosening (RR 1.64), were also comparable. This meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA, suggesting comparable performance in the treatment of proximal humerus fractures. While the findings offer potentially useful insights, they should be interpreted in the context of the limited number of included studies and possible risk of bias.

Clinical outcomes following reverse total shoulder arthroplasty with tuberosity excision for treatment of proximal humerus fractures: a case series