Reverse shoulder arthroplasty for the treatment of three-part and four-part proximal humeral fractures in the elderly

doi:10.1016/j.jse.2014.05.022

Journal of Shoulder and Elbow Surgery

Volume 24, Issue 2, February 2015, Pages 215-222

https://doi.org/10.1016/j.jse.2014.05.022 Get rights and content

Background

The purpose of this study was to review the survivorship, radiologic and clinical outcomes of reverse shoulder arthroplasty (RSA) used for the treatment of 3-part and 4-part proximal humeral fractures in the elderly.

Methods

Between 2003 and 2009, 29 shoulders in 28 elderly patients (87% female) with a 3-part or 4-part fractures were managed with RSA in Brisbane, Australia. Clinical and radiologic outcomes of this continuous cohort were retrospectively reviewed at an average follow-up of 54.9 months. Average age at surgery was 79 years. Survivorship and radiologic outcome assessment for all patients was undertaken. Seven patients died, and 1 was unavailable for clinical review, leaving 21 shoulders in 20 patients available for clinical review.

Results

There were no revisions of the reverse prosthesis. Mean average pain was 2.19 of 100 (standard deviation [SD], 6.97). Mean American Shoulder and Elbow Surgeons score was 89.3 (SD, 13.65). Mean normalized Constant score was 88.03 (SD, 11.24). Grade 1 scapular notching was observed radiologically in 4 shoulders. A scapular spur was observed in 7 shoulders. Class 1 heterotopic ossification was seen in 4 shoulders. Nonprogressive lucent lines were seen in 2 shoulders. Nonprogressive radiolucency was observed around the superior screw in 3 shoulders. No loosening of the glenoid baseplate or of the humeral component was observed. There was 1 complication of an axillary nerve palsy, which spontaneously resolved by 12 months after surgery.

Conclusion

RSA using the shoulder technique described in this series provides good clinical and radiologic outcomes in elderly patients with 3-part and 4-part fractures.

Section snippets

Materials and methods

In this retrospective study, we performed survivorship, clinical, and radiologic review of all consecutive patients who had RSA for treatment of an acute 3-part or 4-part fracture of the proximal humerus between April 2003 and December 2009.

Patients were included in the study if they were at least 24 months since the date of surgery and the operation was performed by one of the senior authors (M.R. or P.F.R.D.) within 6 weeks of the fracture. For the patients who died, their most recent x-ray

Results

The study comprised 29 RSAs for traumatic humeral fractures in 28 patients.

Discussion

We used the deltopectoral approach because it did not require detachment of the deltoid from the acromion. The deltoid is the primary motor in RSA. This approach also assisted in inferior placement of the glenosphere. Furthermore modified tuberosity fixation is easier through a deltopectoral approach. A further potential benefit of the deltopectoral approach may be the possibility of a lower infection rate. Some previous studies on reverse prostheses have reported a higher infection rate than

Conclusions

This series demonstrates excellent outcomes in the use of a reverse total shoulder arthroplasty for the treatment of 3-part and 4-part fractures in elderly patients. The clinical outcomes of this group were superior to most of the previously published studies and the complication rate was also extremely low, with no dislocations, infections, or prosthetic revisions. We believe that careful attention to the very specific aspects of the surgical technique and rehabilitation that we have used in

Acknowledgment

We thank Dr Richard Page and the shoulder section of the ANJR for provision of data on survivorship.

Disclaimer

The Brisbane Hand and Upper Limb Research Institute receives institutional support from Lima, DePuy, Integra Life Sciences, and LMT, and has received funding from Integra Life Sciences and Lima Corporate.

Mark Ross receives consultancy fees from Integra, LMT, Lima, DePuy, and Arthrex, and receives Speakers Bureau payments from DePuy, Lima, and Integra. Phillip Duke receives consultancy fees from Integra, LMT, Lima and DePuy, and receives Speakers Bureau payments from DePuy and Integra. The other

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Cited by (78)

Reverse total shoulder arthroplasty for complex proximal humerus fracture in the elderly: clinical and radiological results
2023, JSES Reviews, Reports, and Techniques
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.
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.
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.
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.
How common is nerve injury after reverse shoulder arthroplasty? A systematic review
2023, Journal of Shoulder and Elbow Surgery
Nerve injury following reverse shoulder arthroplasty (RSA) is a known risk factor with wide ranging incidences reported. This systematic review evaluates the overall incidence of nerve injury following primary and revision RSA and summarizes the characteristics of the nerve injuries reported in the current literature.
A systematic review was performed using separate database searches (Pubmed, Embase, Web of Science, Cochrane) following the PRISMA guidelines. Search criteria included the title terms “reverse shoulder,” “reverse total shoulder,” “inverted shoulder,” and “inverted total shoulder” with publication dates ranging from 01/01/2010 to 01/01/2022. Studies that reported neurological injuries and complications were included and evaluated for primary RSA, revision RSA, number of nerve injuries, and which nerves were affected.
After exclusion, our systematic review consisted of 188 articles. A total of 40,146 patients were included, with 65% female. The weighted mean age was 70.3 years. The weighted mean follow-up was 35.4 months. The rate of nerve injury after RSA was 1.3% (510 of 40,146 RSAs). The rate of injury was greater in revision RSA compared to primary RSA (2.4% vs. 1.3%). Nerve injury was most common in RSAs done for a primary diagnosis of acute proximal humerus fracture (4.0%), followed by cuff tear arthropathy (3.0%), DJD (2.6%), and inflammatory arthritis (1.7%). Massive rotator cuff tears and post-traumatic arthritis cases had the lowest nerve injury rates (1.0% and 1.4%, respectively). The axillary nerve was the most commonly reported nerve that was injured in both primary and revision RSA (0.6%), followed by the ulnar nerve (0.26%) and median nerve (0.23%). Brachial plexus injury was reported in 0.19% of overall RSA cases.
Based on current English literature, nerve injuries occur at a rate of 1.3% after primary RSA compared with 2.4% after revision RSA. The most common nerve injury was to the axillary nerve (0.64%), with the most common operative diagnosis associated with nerve injury after RSA being acute proximal humerus fracture (4.0%). Surgeons should carefully counsel patients prior to surgery regarding the risk of nerve injury.
Comparison of complication rates in reverse total shoulder arthroplasty performed for degenerative conditions versus proximal humerus fractures
2023, Seminars in Arthroplasty JSES
Indications for reverse total shoulder arthroplasty (RTSA) have been expanding. In addition to degenerative joint disease (DJD), RTSA is now being used to treat proximal humerus fractures (PHF). The purpose of this study was to compare postoperative complications in RTSA performed for DJD versus PHF.
A retrospective analysis of the PearlDiver National Database was performed. International Classification of Diseases 10 codes were used to identify RTSA patients from 2015-2018 and separate them into DJD and PHF cohorts. Demographics, comorbidities, and hospital data were identified and compared using a two-sample t-test and chi-squared test. Systemic complications at 90 days and surgical complications at 90 days, 1 year, and 2 years were compared using multivariable logistic regression.
Fifteen thousand six hundred seventy eight patients (92.6% DJD, 7.4% PHF) were identified. PHF patients were more likely to be older (70.3 vs. 69.7 years, P = .026), female (83.5% vs. 62.2%, P < .001), and have more medical comorbidities (Charlson Comorbidity Index 3.42 vs. 3.17, P = .006) than DJD patients. After controlling for patient factors, PHF patients were more likely than DJD patients to develop urinary tract infection (odds ratio [OR] 1.65, P < .001), deep vein thrombosis (OR 1.76, P = .024), and hematoma (OR 3.83, P < .001) within 90 days of RTSA. At 90 days, 1 year, and 2 years postoperatively, RTSA for PHF patients were also more likely than RTSA for DJD patients to sustain a periprosthetic fracture (OR 2.57, P < .001) and instability (OR 2.02, P < .001).
Patients with DJD and PHF undergoing RTSA represent different patient populations with distinct postoperative clinical outcomes. RTSA for PHF has inferior outcomes, which is significant in an era of bundled payments.
Risk factors for loss of reduction following locked plate fixation of proximal humerus fractures in older adults
2023, Injury
Citation Excerpt :
This data was preferentially obtained from physical therapy visit documentation, as these provided the most precise and standardized values. Achievement of satisfactory functional outcome at final follow up was determined using a previously reported threshold of greater than 90° of active forward flexion [25]. Statistical analysis was performed using Stata/SE® 17.0 for Mac (StataCorp LP, College Station, TX).
To identify characteristics associated with loss of reduction following open reduction and locked plate fixation (ORIF) of proximal humerus fractures in older adults and determine if loss of reduction affects patient reported outcomes (PROs), range of motion (ROM), and complication rates during the first postoperative year.
Patients >55 years old who underwent proximal humerus ORIF were reviewed. Patient and fracture characteristics were recorded. Fixation characteristics were measured on the initial postoperative AP radiograph including humeral head height (HHH) relative to the greater tuberosity (GT), head shaft angle (HSA), screw-calcar distance, and screw tip-joint surface distance. Loss of reduction was defined as GT displacement >5 mm or HSA displacement >10° on final follow up radiographs. Patient, fracture, and fixation characteristics were tested for association with loss of reduction. Outcomes including ROM, visual analog scale pain and PROMIS scores, and complication/reoperation rates during the first postoperative year were compared between those with or without loss of reduction.
A total of 79 patients were identified, 23 (29.1%) of which had a loss of reduction. Calcar comminution (relative risk [RR]=2.5, 95% Confidence Interval [CI]=1.3–5.0, p<0.01), HHH <5 mm above GT (RR=2.0, CI=1.0–3.9, p = 0.048), and screw-calcar distance ≥12 mm (RR=2.1, CI=1.1–4.1, p = 0.03) were risk factors for loss of reduction. Upon multivariate analysis, calcar comminution was determined to be an independent risk factor for loss of reduction (RR=2.4, CI=1.2–4.7, p = 0.01). Loss of reduction led to higher complication (44% vs 13%, p<0.01) and reoperation rates (30% vs 7%, p<0.01), and decreased achievement of satisfactory ROM (>90° active forward flexion, 57% vs 82%, p = 0.02) compared to maintained reduction, but similar PROs.
Calcar comminution, decreased HHH, and increased screw-calcar distance are risk factors for loss of reduction following ORIF of proximal humerus fractures. These morphologic and technical factors are important considerations for prolonged reduction maintenance.
How age and gender influence proximal humerus fracture management in patients older than fifty years
2022, JSES International
As the aging population expands, proximal humerus fractures have become more prevalent. This study aimed to evaluate acute management of proximal humerus fractures in women and men older than the age of 50 years to determine how gender and age have affected definitive treatment selection over the last decade.
Patient records were retrospectively reviewed from a commercially available database, PearlDiver, to identify treatments for proximal humerus fractures between 2010 and 2019. Data were separated by age into two cohorts, patients aged 50-64 years and those aged 65 years and older before stratification by gender. Within each cohort, groups were matched with respect to age, region, and Elixhauser comorbidity index. Logistic regression analyses were performed to determine which gender was associated with a higher risk of undergoing operative treatment, which gender was associated with a higher risk of receiving arthroplasty, and which of the individual surgical operations were more likely given the patient’s gender and age.
In the 50- to 64-year-old cohort, men were less likely to be treated operatively than women (odds ratio [OR]: 0.90). However, men in this cohort had a 31% higher likelihood of receiving an arthroplasty procedure than women when given operative treatment. Specifically, men aged 50 to 64 years were more likely to receive hemiarthroplasty (OR: 1.48) and intramedullary nailing (OR: 1.19) and were less likely to have open reduction internal fixation (ORIF) (OR: 0.71). In the 65 years and older cohort, there was no relationship between gender and the likelihood of operative treatment for a proximal humerus fracture. Men older than 65 years had a 29% lower likelihood of receiving an arthroplasty type procedure than women older than 65 years. In addition, men older than 65 years were more likely to receive ORIF (OR: 1.14) and intramedullary nailing (OR: 1.43) and less likely to receive hemiarthroplasty (OR: 0.86) and reverse total shoulder arthroplasty (OR: 0.66) than similarly aged women.
Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade. Women younger than 65 years of age were more likely to undergo operative treatment, although once older than 65 years, there was no influence of gender on operative treatment. Men younger than 65 years were more likely to receive arthroplasty and women, more likely to undergo ORIF; however, as patients reached the age of 65 years and older, this finding was reversed such that women were more likely to receive arthroplasty and men, ORIF. Further exploration into these differences could improve decision-making between surgeons and patients.
The clinical outcomes and tuberosity healing after reverse total shoulder arthroplasty for acute proximal humeral fracture using the turned stem tension band technique
2022, Journal of Orthopaedic Science
Recent studies have reported the clinical effectiveness of tuberosity healing after reverse total shoulder arthroplasty in patients with proximal humeral fractures with respect to joint stability, long-term survival, and postoperative range of motion. However, it is challenging to achieve robust fixation of the fragile bone fragments in elderly patients. This study aimed to report on the radiographic and clinical outcomes of patients who underwent reverse total shoulder arthroplasty for acute proximal humeral fractures using a Turned stem Tension Band technique–a simple suture configuration that can apply a compressive force on both tuberosities at the same time.
Eighteen patients who underwent reverse total shoulder arthroplasty for complex proximal humeral fractures (age 80.4 ± 4.7 years, range 70–87 years), using our Turned stem Tension Band technique, were included in this study and evaluated postoperatively for range of motion, American Shoulder and Elbow Surgeons score, Numerical Rating Scale, and tuberosity healing, with minimum 2-years follow-up (mean 34.5 months, range 24–60 months).
At the final follow-up, mean range of motion results were active flexion, 119 ± 34°; active abduction, 116 ± 35°; active external rotation, 27 ± 12°; and active internal rotation, L3. Six of 11 (55%) patients with 4-part dislocated fractures had neurological disorders from the time of injury; of these, three patients obtained shoulder elevation under 90° at the final follow-up. The mean American Shoulder and Elbow Surgeons score was 77.3 ± 10.7, and the mean Numerical Rating Scale was 1.2 ± 0.9. Fifteen of 18 (83%) patients were satisfied with the results. The tuberosity healing rate was 100% (18 of 18).
The Turned stem Tension Band technique in reverse total shoulder arthroplasty for proximal humeral fractures provides a robust fixation, regardless of the fracture pattern, which results in a high tuberosity healing rate.

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: The Mater Health Services Human Research Ethics Committee approved this study (Protocol Ref No. 1911E).

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ShoulderReverse shoulder arthroplasty for the treatment of three-part and four-part proximal humeral fractures in the elderly

Background

Methods

Results

Conclusion

Section snippets

Materials and methods

Results

Discussion

Conclusions

Acknowledgment

Disclaimer

J Arthroplasty

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Orthop Sci

Ectopic ossification following total hip replacement: incidence and a method of classification

J Bone Joint Surg Am

Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly. A prospective review of 43 cases with a short-term followup

J Bone Joint Surg Br

The reverse shoulder prosthesis in the treatment of fractures of the proximal humerus in the elderly

J Bone Joint Surg Br

The epidemiology of proximal humeral fractures

Acta Orthop Scand

Reverse total shoulder arthroplasty–from the most to the least common complication

Int Orthop

Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients

Orthopedics

Shoulder
Reverse shoulder arthroplasty for the treatment of three-part and four-part proximal humeral fractures in the elderly