Use Of Reverse Shoulder Arthroplasty Research Articles

The impact of the reverse prosthesis on revision shoulder arthroplasty: analysis of a high-volume shoulder practice

Since the approval of reverse shoulder arthroplasty (RSA) in 2004, the use of shoulder arthroplasty increased dramatically. Although the success of RSA in the revision setting has been demonstrated, there remains a paucity of studies examining the epidemiology of RSA in revision arthroplasty. This study describes trends of revision arthroplasty during the "era of the reverse," from 2005 through 2016. In a multicenter retrospective analysis, we analyzed 274 revision shoulder arthroplasties converted to a RSA (n = 182), anatomic total shoulder arthroplasty (TSA, n = 68), or hemiarthroplasty (n = 24) from 2005 to 2016. Demographics, surgical indications, and types of prosthesis were analyzed. The number of revision arthroplasties increased over 12 years. From 2005 to 2010, TSA (33%) or hemiarthroplasty (16%) were used in similar rates as RSA (51%). From 2011 to 2016, there was a much higher incidence of revision arthroplasty with RSA (78%) compared with TSA (19%) or hemiarthroplasty (3%). Specifically, the number of RSAs increased in 2011 to 2016 compared with 2005 to 2010 in patients aged younger than 60 years, obese patients, patients with indications of glenoid loosening, and those with a diagnosis of diabetes mellitus or rheumatoid arthritis. The use of RSA for revision arthroplasty increased over the "era of the reverse" and became the majority by 2016. The reverse prosthesis has had expanding indications regarding both patient demographics and pathology. This study demonstrates the reverse prosthesis has had a similar and even more profound effect on revision shoulder arthroplasty than what has previously been well documented in the primary setting.

Reverse shoulder arthroplasty: Current trend in elective surgery

While reverse shoulder arthroplasty (RSA) is not generally accepted as a successful procedure until recent years, the concept of RSA has long been proposed. Several RSA designs were originally developed for treatment of cuff tear arthropathy (CTA) in the 1970’s, which all underwent in failure. From 1987 to 1995, Paul Grammont and his team proposed successful modern reverse designs of total shoulder arthroplasty for CTA. Medializing and distalizing the center of rotation are the most distinguished principles of Grammont’s RSA. The use of RSA has been increased dramatically over the past decades. The indications for RSA have expanded to massive irrepairable rotator cuff tears, proximal humerus fractures, fracture sequelae, inflammatory arthropathy, osteoarthritis with abnormal glenoid morphology, revision cases following failed shoulder arthroplasty, and tumor reconstruction, in addition to CTA. Contraindications to RSA includes infection, complete axillary nerve palsy, neuroarthropathy, and substantial glenoid bone erosion or defects. The number of complications and reoperations of RSA has been increased significantly with the wide application of RSA. RSA complications can be classified into non-specific complications, specific complications associated with RSA and brand-related specific problems. Glenoid bone loss is not uncommon in patients undergoing RSA, which is a challenging problem. Current methods for addressing glenoid bone loss during RSA include asymmetric reaming, use of a lateralized implant, bone grafting, and use of an augmented baseplate. Three-dimensional imaging preoperative planning software and patient-specific instruments have become commercially available for guidance in the insertion of the glenoid component in RSA in recent years. Surgeons performing RSA should select proper patients, be familiar with new surgical techniques and pay attention to technical details, so that the currently high complication rate of RSA can be reduced.

Outcomes of reverse shoulder arthroplasty in small- and large-stature patients

As the worldwide use of reverse shoulder arthroplasty (RSA) increases, a range of implant sizes may be required to match regional and ethnic variation in patients' stature. Size-mismatched implants may possibly result in poorer surgical outcomes. The purpose of this study was to compare the outcomes of primary RSA in patients at the extreme ends of the growth curve with those in average-stature patients in the United States. A multicenter shoulder arthroplasty database was retrospectively reviewed to identify all primary RSAs using a single implant system with a minimum 2-year follow-up. Small patients were defined as the height of <155 cm, tall as >183 cm, and average as 162-178 cm. Active range of motion (ROM), visual analog scale pain score, and patient-reported outcomes (PROs) were compared among the 3 groups. The study included 552 shoulders (130 small, 384 average, and 38 tall stature). Preoperatively, the average height group had significantly less ROM than the other groups, but there were no significant differences in postoperative ROM. This resulted in poorer improvements in postoperative ROM in the small and tall groups, with the small-stature patients having significantly less ROM improvement compared with average-stature patients. However, these differences did not result in poorer PROs between groups. Small- and large-stature patients showed inferior improvements in ROM after RSA compared with average-stature patients. Our results suggest that current implants optimize ROM gains for average-stature patients and improve PROs independently of patient stature at a minimum 2-year follow-up.

Fatty degeneration of the deltoid muscle associated with displaced proximal humerus fractures

The use of reverse shoulder arthroplasty (RSA) has increased dramatically over the last two decades, with many surgeons now indicating RSA for the acute management of displaced proximal humerus fractures (PHF) in the elderly. RSA relies on adequate deltoid muscle function to obtain a good outcome, yet no literature to date exists which discusses preoperative assessment of deltoid structure prior to RSA. The purpose of this study was to assess for preoperative fatty deltoid-degeneration in patients with displaced PHF. We reviewed the axial CT scans of 100 consecutive patients with a displaced PHF. Fatty degeneration within each of the three deltoid-heads was graded at three levels, according to Goutallier and colleagues. Fractures were classified according to Neer. Seventy-nine percent of the patients were female, 75% showed 3 or 4 parts fractures. The average cross-sectional area of the posterior deltoid was greatest-representing 37%, 40% and 42% of total area at each level, respectively. Severe fatty degeneration (Stages 3 and 4) was observed in the posterior deltoid only (26%). Absence of fatty degeneration (Stage 0) was observed in < 25% of cases. The Inter-Observer-Reliability for the continuous variables proved to be high. Preoperative deltoid fatty degeneration is common in displaced PHF in the elderly. Because CT is commonly obtained to assess fracture morphology and for preoperative planning purposes, it is an ideal tool to assess the deltoid additionally. Future studies are warranted to determine whether preoperative fatty infiltration of the deltoid correlates with mid and long term functional outcomes when RSA is used acutely to manage a PHF. Level IV-consecutive case series.

Paper #23 - Early vs. late reverse shoulder arthroplasty for proximal humerus fractures: does it matter?

Background: There is recent support in the literature for the use of reverse shoulder arthroplasty (RSA) for treatment of displaced proximal humerus fractures in elderly patients. Despite the recent enthusiasm for RSA in the treatment of proximal humerus fractures, there is currently no study comparing outcomes when this operation is performed early for acute fracture or late for failed alternative treatment (non-operative, open reduction internal fixation (ORIF), hemiarthroplasty). The purpose of this study is to compare the outcomes between patients who underwent early RSA for proximal humerus fracture to those patients who underwent an alternative initial treatment for their fracture and subsequently required RSA.

Pre-operative factors influence the recovery of range of motion following reverse shoulder arthroplasty.

Recently the use of reverse shoulder arthroplasty (RSA) has increased because of a clinical perception of durable functional outcome. However, some patients unexpectedly have a poor recovery of range of motion (ROM) after surgery. Objective factors such as initial diagnosis, pre- and intra-operative ROM, deltoid impairment or arm lengthening have previously been associated with anterior forward flexion (AFF). This study sought to determine if subjective pre-operative factors influence the rate and timing of ROM recovery after RSA. Between January 2011 to January 2012, all RSAs performed by a single surgeon were prospectively enrolled in this study. The cohort was divided into two groups based on AFF <90 or ≥90 after surgery. A multivariate analysis was performed to define independent predictive factors of post-operative ROM. Factors assessed included: age, sex, dominant arm, patient activity, body mass index (BMI), pre-operative diagnosis, deltoid status, pain and Constant scores, subjective shoulder value (SSV), simple shoulder test (SST) and radiographic findings. Patients were reviewed at sixweeks, and three, six, 12 and 24months. One hundred and one RSAs were available for analysis. Poor post-operative AFF at sixweeks was significantly related to poor pre-operative deltoid strength. Poor post-operative AFF at one-year follow-up was related to surgery of non-dominant arm, pre-operative poor AFF, pre-operative activity, poor subjective shoulder value (SSV), and a low contralateral Constant score. AFF and Constant score improved until sixmonths and then plateaued. In contrast, both external and internal rotation continued to improve beyond sixmonths after surgery. AFF and Constant scores after RSA plateau at sixmonths after surgery whereas internal and external rotation continue to improve up to twoyears post operation. Several pre-operative factors including poor pre-operative AFF, surgery on the non-dominant arm, and lower SSV and Constant scores are correlated with post-operative ROM following RSA. Identification of these factors may be useful for counseling on functional expectations as well as customizing rehabilitation plans. Level II, Prospective Cohort Study, Treatment Study.

Outcome of Reverse Shoulder Arthroplasty for Patients With Parkinson's Disease: A Matched Cohort Study.

Parkinson's disease (PD) is a progressive neurologic disorder that affects the musculoskeletal system. Currently, the use of reverse shoulder arthroplasty (RSA) for patients with PD has not been adequately studied. The authors sought to determine if RSA provided similar functional outcomes for patients with PD compared with a matched cohort of patients without PD. Between 2004 and 2011, 10 patients with PD (4 men, 6 women) underwent RSA. Patients with PD were matched to patients without PD at a 1:4 ratio based on age (average, 76 years; range, 63-85 years), sex (16 men, 24 women), preoperative diagnosis, and length of follow-up (average, 43 months; range, 24-128 months). Outcome measures included range of motion, visual analog scale (VAS) score, Simple Shoulder Test (SST) score, American Shoulder and Elbow Society (ASES) score, and complication rates. Patients with PD had improvements in SST scores, ASES total scores, and forward flexion; however, they did not show statistically significant improvements in VAS scores, ASES function scores, or other range of motion parameters. There was a significant difference in postoperative functional outcome scores, SST scores, and internal/external rotation between the 2 groups, but no difference in postoperative pain scores, ASES total scores, forward flexion, or abduction. Complications occurred in 4 of 10 patients with PD and 6 of 40 patients without PD. Compared with the matched cohort, patients with PD achieved similar reduction of pain but inferior clinical function following RSA. Improvement in range of motion was less predictable and complication rates were significantly higher in patients with PD. [Orthopedics. 2017; 40(4):e675-e680.].

ASSESMENT OF KEY PARAMETERS ON THE PERFORMANCE OF THE DELTOID MUSCLE IN REVERSE SHOULDER ARTHROPLASTY — A MODELING AND SIMULATION-BASED STUDY

Reverse shoulder arthroplasty (RSA), in which anatomic concavities of glenohumeral (GH) joint are inverted, is a popular treatment of arthritic shoulders with deficient rotator cuff. The correct positioning of the glenohumeral center of rotation and initial setting of the deltoid length (Deltoid Tension) plays an important role in the outcome of the RSA. A study of the key literature has shown that despite common use of RSA, its biomechanical characteristics during motion are not fully understood. This study investigates the influence of some of the key parameters on the intensity of the moment in a shoulder after RSA during abduction in scapular plane. The kinematics after RSA are then compared with the anatomic shoulder kinematics and differences are discussed. Mathematical models of both the anatomical and reverse shoulder (RS) were developed in MATLAB and in MSC ADAMS. The anatomical and RSA geometries were defined using measurements obtained from X-ray and magnetic resonance imaging (MRI) images of the shoulder girdle. The results show that in RSA, the intensity of the moment generated in the GH joint improves. However, this improvement does not show a constant trend and its intensity can dramatically decrease in higher GH joint abduction.

Complications of locked plating for proximal humeral fractures—are we getting any better?

Complication rates reported after locking plate fixation of proximal humeral fractures still range up to 40%. Whether modifications of surgical techniques, use of primary shoulder arthroplasty, or a fracture-specific management resulted in decreased complication rates during recent years remains unclear. Therefore, the aim of this long-term observation study was to analyze the incidence of complications and revision surgery after locked plating. Between February 2002 and December 2013, 788 patients (aged 67.4 ± 17.3 years) with displaced proximal humeral fractures were treated with locking plate, primary hemiarthroplasty (HA), or reverse shoulder arthroplasty (RSA). Standardized follow-up included radiographs at 1 day, 6 weeks, and 3, 6, and 12 months. Complications and unplanned revision surgery were prospectively recorded over the complete follow-up. Of 788 patients, 646 (82%) were treated with locking plate, 82 (10.4%) with HA, and 60 (7.6%) with RSA. Mean follow-up was 14.8 ± 3.8 months. The mean complication rate associated with locked plating was 12.8%, and revision surgery was necessary in 11.6%. Within the last 5 years, the loss of fixation rate markedly decreased from 14.3% to 4.8%; simultaneously, an increased use of RSA was observed. The overall complication rate of locking plate osteosynthesis for proximal humeral fractures has been decreasing considerably within the last years. Among others, this might be due to an increased use of primary RSA for complex fracture types. In addition to a precise surgical technique, choosing the adequate treatment for each individual fracture to avoid complications and revision surgery is of utmost importance.

The management of bilateral posterior fracture dislocations of the shoulder: a case series illustrating management options.

Although dislocation of the shoulder is a relatively common event, the overwhelming majority of injuries are anterior. Posterior shoulder dislocation is more uncommon, comprising between 3% and 5% of all shoulder dislocations. One percent of shoulder dislocations involve a fracture, whereas only 0.9% of the 1500 cases reported by Neer (J Bone Joint Surg Am 1970; 52:1077-89; J Bone Joint Surg Am 1970; 52:1090-103) concerned posterior fracture dislocations. Bilateral posterior fracture dislocation is an even rarer event, comprising just 5% of all posterior fracture dislocations. Given the rarity and relative poor outcome often observed after these severe injuries, it is important that upper limb function is optimized. Bilateral posterior fracture dislocations of the shoulder pose a difficult clinical challenge that requires careful management planning. To date, there have been three isolated case reports of using contralateral osteochondral humeral autograft and hemiarthroplasty. We report our experiences and clinical outcomes in managing four such cases using a variety and combination of treatments, including the first reported use of reverse shoulder arthroplasty with contralateral osteochondral humeral autografting. Shoulders reconstructed with humeral autograft demonstrated superior Oxford Shoulder Scores and an improved range of motion, as measured by a markerless machine vision system, compared to hemiarthroplasty. Our results support the use of a contralateral humeral autograft in bilateral posterior shoulder fracture dislocation.

Outcomes of reverse shoulder arthroplasty using a mini 25-mm glenoid baseplate.

As worldwide use of reverse shoulder arthroplasty (RSA) increases, a range of implant sizes may be required to match regional and ethnic variation in patients' height and bone size. The purpose of this study was to report the outcomes of RSA using a mini 25-mm-diameter glenoid baseplate in smaller patients with rotator cuff arthropathy. Between 2009 and 2012, 28 patients underwent RSA for cuff-tear arthropathy using a 25-mm circular glenoid baseplate (Aequlais Reversed, Tornier, Bloomington, MN, USA). Twenty-four patients were able to return for comprehensive follow-up. The mean height of the entire cohort was 158 ± 10 cm (5 ft. 2 in.). The indication to use a smaller baseplate was a combination of preoperative templating using computed tomography (CT) and intraoperative measurements of glenoid width. At a mean of 36 ± 8 months' follow-up, there were no revisions or glenoid-sided failures. The mean American Shoulder and Elbow Surgeons (ASES) score was 70 ± 10, the Simple Shoulder Test (SST) was 10 ± 2, the Constant was 60 ± 10 and the Disabilities of the Arm, Shoulder and Hand (DASH) was 18 ± 15. Mean active forward elevation was 140 ± 15°, active external rotation was 21 ± 15° and active internal rotation was to the sacroiliac joint. Mean shoulder strength in flexion was 5.2 ± 1.7 kg, in external rotation was 2.9 ± 1.4 kg and in internal rotation was 4.3 ± 1.2 kg. Radiographs demonstrated no evidence of glenoid loosening. There was, however, a 62 % rate of scapular notching. Short-term outcomes of mini 25-mm baseplate RSA in proportionally smaller patients are good and demonstrate implant safety and effectiveness. Scapular notching rates are worrisome, and additional follow-up is necessary to determine if notching is progressive and becomes symptomatic.

Reverse shoulder prosthesis in patients with rheumatoid arthritis: a systematic review.

To obtain detailed information on the outcomes of patients with rheumatoid arthritis (RA) undergoing reverse shoulder arthroplasty (RSA) METHODS: A literature search was conducted for studies reporting on the use of RSA in RA patients from 1990 to 2014. The inclusion criteria were a report of sufficient information on pre-operative status and surgical outcome allowing evaluation of the therapeutic potential of RSA in RA. The literature search resulted in 586 hits, but only five studies that met the inclusion criteria were assessed. There were 100 shoulders that had been operated on, of which 87 were followed for a mean of 55.4months, the longest follow-up being 11.9years Most patients had glenohumeral erosive lesions of Larsen Grade III or IV. The Delta III prosthesis was implanted in most cases and in three studies bone graft was used for severe glenoid lesions. The main outcome measures employed were the Constant score (Cs) and ASES questionnaire. The mean increase in Cs and ASES score after surgery was 42.4 and 54 points, respectively. The mean post-operative forward elevation was 120.6°, the average increment being 51° and the mean increase of abduction was 58.5°. The mean prevalence of scapular notching was 35.4%. The rate of adverse events was 31%, but the vast majority were of minor severity. Eight prostheses underwent revision, due to infection in four. RSA implanted in RA patients would appear to give similar results to those obtained in massive cuff tears with or without arthropathy.

Shoulder Hemiarthroplasty for Trauma: does a Tuberosity Friendly Prosthesis Improve Outcome?

Reported outcomes of shoulder hemiarthroplasty for proximal humeral fractures have been poor due to tuberosity non-union or rotator cuff disruption. Newer designs provide features to allow secure tuberosity apposition and stabilisation. To evaluate the outcomes of a shoulder hemiarthroplasty system with "tuberosity friendly" features in the treatment of multi-fragmentary proximal humeral fractures. An analysis of 12 patients undergoing Exactech Equinoxe hemiarthroplasty for proximal humeral fractures over a two year period. Radiological and clinical outcomes were assessed. Twelve patients, aged 55 to 84, were examined. Median follow up was 20 months (range 7 to 31). Although tuberosity reduction remained and the tuberosities united radiologically in all cases, 5 patients went on to develop superior migration of the humeral head. The median Oxford shoulder score was 25.7 out of 48 (range 11 to 43). 1. A trauma hemiarthroplasty system combined with good surgical technique can ensure tuberosity fixation and subsequent union. 2. Superior migration of the prosthesis can still occur due to rotator cuff disruption. 3. The use of reverse shoulder arthroplasty may be more appropriate in elderly patients with multi-fragmentary proximal humeral fractures.

Reverse shoulder arthroplasty for the management of proximal humerus fractures.

The use of reverse shoulder arthroplasty is becoming increasingly popular for the treatment of complex three- and four-part proximal humerus fractures in the elderly compared with the often unpredictable and poor outcomes provided by open reduction and internal fixation and by hemiarthroplasty. Inferior results with plate osteosynthesis are often a result of complications of humeral head osteonecrosis, loss of fixation, and screw penetration through the humeral head, whereas major concerns with hemiarthroplasty are tuberosity resorption, malunion, and nonunion resulting in pseudoparalysis. Comparative studies support the use of reverse shoulder arthroplasty in elderly patients with complex proximal humerus fractures because the functional outcomes and relief of pain are reliably improved. Repair and union of the greater tuberosity fragment during reverse shoulder arthroplasty demonstrates improved external rotation, clinical outcomes, and patient satisfaction compared with outcomes after tuberosity resection, nonunion, or resorption. Satisfactory results can be obtained with careful preoperative planning and attention to technical details.

Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures.

Proximal humeral fractures account for approximately 5% of fractures that are seen in the emergency department and can present difficult challenges to the treating physician1. These fractures are most commonly classified according to the system proposed by Neer2. Complex proximal humeral fractures that require operative treatment can be treated with osteosynthesis, hemiarthroplasty, total shoulder arthroplasty, or, more recently, reverse shoulder arthroplasty3. While locked plating may result in improved fixation in osteopenic bone compared with traditional unlocked plating, the outcomes may still be limited by the risk of complications, including stiffness, osteonecrosis, implant failure, and loss of reduction4,5. Hemiarthroplasty traditionally has been performed for the treatment of three or four-part fractures, particularly in patients with osteopenic bone, and can yield good results for low-demand patients6,7. The outcomes of hemiarthroplasty for the treatment of proximal humeral fracture are satisfactory for long-term pain relief but are less predictable in terms of shoulder motion8. Reverse shoulder arthroplasty can be used for the treatment of cuff tear arthropathy and recently has gained popularity for the treatment of severe proximal humeral fractures. The present review of the current literature on the use of reverse shoulder arthroplasty for the treatment of complex proximal humeral fractures focuses on indications, preoperative planning, surgical techniques, …

Reverse shoulder arthroplasty for malignant tumors of proximal humerus

Reverse shoulder arthroplasty (RSA) provides an alternative for shoulder girdle reconstruction after wide transarticular resection of the proximal humerus for malignant tumor. The aim of this study was to evaluate midterm outcomes of this therapeutic option. Ten patients with RSA were included and reviewed with 24months of minimum follow-up. Proximal resection of malignant tumor included the "V" deltoid insertion in 4 patients. The humeral stem was coated (with an allograft in 2 patients and a cement mantel in 3) or left uncoated (5 patients). At a mean follow-up of 42months, among 8 prosthesis available for evaluation (2 patients died), the Constant and Murley score averaged 52 points, the 11-item version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH) score averaged 29.5 points, the Subjective Shoulder Value averaged 58%, and the Musculoskeletal Tumor Society score averaged 20.25 points. Mean forward active elevation reached 122°, external rotation at side was -2°, and internal rotation was to L4. Three prostheses were unstable. The involvement of "V" deltoid insertion at surgery trended to worsen the clinical outcome. Atrophy of the anterior deltoid occurred in most of patients who had a previous transdeltoid biopsy. Radiographic evaluation found 1 stem loosening, 1 stem at risk, and 3 scapular notches without glenoid loosening. Use of RSA after resection of a malignant tumor of the proximal humerus seems to be an acceptable option to preserve function. However, radiographic evolution is worrisome, and long-term study remains necessary to validate this therapeutic option with follow-up.

The incidence of proximal humeral fractures in New York State from 1990 through 2010 with an emphasis on operative management in patients aged 65 years or older

Proximal humeral fractures are commonly encountered injuries. The development of locking plate technology and reverse shoulder arthroplasty may have changed the treatment patterns of these fractures. We used the Statewide Planning and Research Cooperative System database in New York State to determine the incidence of proximal humeral fractures from 1990 through 2010 and the choice of treatment: closed reduction-internal fixation, open reduction-internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). The population-adjusted incidence per 100,000 increased from 15.35 in 1990 to 19.4 in 2010 (P< .0001). In patients aged 65 years or older, the incidence increased from 78.9 in 1990 to 101.0 in 2010 (P < .0001). In 1990, 20.4% of proximal humeral fractures were treated operatively; in 2010, this increased to 28.6% (P < .0001). Closed reduction-internal fixation/ORIF accounted for 58.4% of operative cases in 1990, decreasing to 46.6% in 2001 and increasing to 59.4% in 2010. HA was used in 27.1% of operative cases in 1990, increasing to 41% in 2001 and decreasing to 29.4% in 2010. TSA was used in 6.4% of operative cases in 1990, decreasing to 1.5% in 2001 with an increase to 7.5% in2010. The incidence of proximal humeral fractures in patients aged 65 or older increased by 28% between 1990 and 2010, and operative management increased by more than 40%. The use of ORIF increased between 2001 and 2010, corresponding with the use of locking plate technology. There was an associated decrease in HA. TSA increased between 2006 and 2010, corresponding to the use of reverse shoulder arthroplasty.

Reverse total shoulder arthroplasty for the treatment of proximal humeral fractures: patterns of use among newly trained orthopedic surgeons

This study compared the use of reverse and hemishoulder arthroplasty for the treatment of proximal humeral fractures among orthopedic surgeons taking part II of the American Board of Orthopaedic Surgery board examination. We hypothesized that the use of reverse shoulder arthroplasty for fractures in the elderly is increasing amongst newly trained orthopedic surgeons. We queried the American Board of Orthopaedic Surgery database for the cases of proximal humeral fractures treated with arthroplasty submitted between 2005 and 2012. We evaluated the prosthesis used, patient-specific factors, complications, and the difference in use by shoulder fellowship-trained surgeons. From 2005 to 2012, 5395 board-eligible orthopedic surgeons submitted cases to the database. Of these, 435 (mean, 54 per year) were proximal humeral fractures treated with arthroplasty. The overall incidence of reverse shoulder arthroplasty for fracture increased from 2% to 4% during 2005 to 2007 to 38% in 2012. Shoulder surgeons treated 5 times more proximal humeral fractures with shoulder arthroplasty and were also more than 20 times more likely to use a reverse implant (P<.0001). The difference in complication rates between reverse and hemishoulder arthroplasty was not significant (P=.49). Patients who received a hemiarthroplasty tended to be younger (mean age, 70.8 vs 75.7years; P=.0015). Overall, the use of a hemiarthroplasty for fracture is still more common (62% in 2012), although the relative proportion of reverse implants is rising. Among shoulder surgeons, more than 50% of the arthroplasties performed for fractures during the past 3years (2010-2012) have been reverse arthroplasties.

Reverse shoulder arthroplasty in acute fractures of the proximal humerus: A systematic review.

The indications for surgical intervention in complex fractures of the proximal humerus are disputed. In elderly patients with poor bone stock it may be impossible to obtain satisfactory fixation of the tuberosities to a hemiarthroplasty (HA). In such cases primary insertion of a reverse shoulder arthroplasty (RSA) has been suggested. We aimed to review clinical studies reporting benefits and harms of RSA in acute fractures. A systematic review. We included 18 studies containing 430 RSA in acute fractures. We found no randomized clinical trials. Four studies compared outcome after RSA with a historical control group of HA. The median constant score was 58 (range 44-68) which is comparable to previous reviews of HA in 4-part fractures. Complications included dislocation, infection, hematoma, instability, neurological injury, reflex sympathetic dystrophy, intraoperative fractures, periprosthetic fractures, and baseplate failure. Scapular notching was reported in 11 studies with a median value of 25% (range 0-94). Heterogeneity of study designs and lack of primary data precluded statistical pooling of data. No high quality evidence was identified. Based on the available evidence the use of RSA in acute fractures is questionable. The complication rate was high and the clinical implications of long term scapular notching are worrying. Randomized studies with long term follow up using the latest techniques of tubercular reinsertion in RSA toward HA should be encouraged.

Reverse Prostheses in Arthropathies With Cuff Tear: Are Survivorship and Function Maintained Over Time?

The use of reverse shoulder arthroplasty has considerably increased since first introduced in 1985. Despite demonstrating early improvement of function and pain, there is limited information regarding the durability and longer-term outcomes of this prosthesis. We determined complication rates, functional scores over time, survivorship, and whether radiographs would develop signs of loosening. We retrospectively reviewed 527 reverse shoulder arthroplasties performed in 506 patients between 1985 and 2003. Clinical and radiographic assessment was performed in 464 patients with a minimum followup of 2 years and 148 patients with a minimum followup of 5 years (mean, 7.5 years; range, 5-17 years). Cumulative survival curves were established with end points being prosthesis revision and Constant-Murley score of less than 30 points. Eighty-nine of 489 had at least one complication for a total of 107 complications. Survivorship free of revision was 89% at 10 years with a marked break occurring at 2 and 9 years. Survivorship to a Constant-Murley score of less than 30 was 72% at 10 years with a marked break observed at 8 years. We observed progressive radiographic changes after 5 years and an increasing frequency of large notches with long-term followup. Although the need for revision of reverse shoulder arthroplasty was relatively low at 10 years, Constant-Murley score and radiographic changes deteriorated with time. These findings are concerning regarding the longevity of the reverse shoulder arthroplasty, and therefore caution must be exercised when recommending reverse shoulder arthroplasty, especially in younger patients. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.