CORR® Synthesis: What Is the Role of Reverse Shoulder Arthroplasty for the Treatment of Proximal Humerus Fractures in Patients Older Than 65 Years?

In the Beginning Proximal humerus fractures are the third most common fracture in people older than 65 years and are the second most common fracture in the upper extremity [10, 12, 15, 27]. Most of these fractures occur in patients older than 65 years after low-energy trauma, and osteoporosis is a known risk factor [15]. The incidence of these fractures in the United States is increasing and parallels the increasing average age of the population [15]. Historically, proximal humerus fractures were treated without surgery. Hemiarthroplasty was introduced by Charles Neer in the 1970s for a treatment of glenohumeral arthritis [19]. Before that, he used hemiarthroplasty exclusively for the treatment of proximal humerus fractures and their sequelae. At that time, hemiarthroplasty was the operative treatment of choice for comminuted proximal humerus fractures [10, 12, 19]. In the early 2000s, locking plates were developed, which led to more comminuted proximal humerus fractures being treated with open reduction internal fixation (ORIF) [10, 12, 15]. Despite these advances, the complication risk remained high in patients treated with both ORIF and hemiarthroplasty [9, 37]. There has been considerable evolution in the treatment of proximal humerus fractures over the past two decades. Although most proximal humerus fractures in patients older than 65 years of age can be treated without surgery, in certain scenarios, surgical treatment is indicated. Percutaneous or minimally invasive osteosynthesis, internal fixation with locked plates or intramedullary nails, hemiarthroplasty, and reverse total shoulder arthroplasty (RTSA) are the main surgical options [10, 12, 15, 19, 32]. RTSA has seen increased use to treat proximal humerus fractures in patients older than 65 years of age during the past decade [21]. However, some important gaps remain in our understanding of when to use this approach to give patients the best possible restoration of function and relief of pain, and how to minimize complications of the intervention. Argument The ideal treatment for displaced proximal humerus fractures in patients older than 65 years of age continues to be debated [18]. Perhaps most importantly, the decision-making process for the treatment of proximal humerus fractures in this patient population is not dictated solely by the radiographic classification of the fracture. The main goals of treatment include pain relief and regaining physiologic ROM and strength to allow for functional use of the arm. RTSA is a constrained arthroplasty that, unlike hemiarthroplasty or total shoulder arthroplasty (TSA) does not rely on the rotator cuff for elevation in the forward plane. Reverse articulation with a medialized and distalized center of rotation recruits the deltoid muscle to function as an effective forward elevator and abductor of the shoulder. In patients with proximal humerus fracture, RTSA with tuberosity reconstruction provides predictable pain relief, restores forward elevation (in most patients, more than 90° is achieved [6, 25, 31]), and rotationally controls the arm in space [6, 9, 17, 25, 31]. However, RTSA carries a substantial risk of both short-term and long-term complications, which occur in patient between 5% and 40% of the time after these procedures [37], with complications being more likely to occur when performed in patients with rheumatoid arthritis, for acute proximal humerus fractures, and in those undergoing revision arthroplasty [37]. Prosthetic dislocation after RTSA for fractures is the most common complication [3, 12]. Acromial, glenoid, and periprosthetic humeral fractures can occur as well, especially given the frequent co-occurrence of osteoporosis in this patient population. Despite these risks, RTSA has certain advantages compared with other surgical options such as hemiarthroplasty and internal fixation, including the ability to obtain a good functional outcome irrespective of rotator cuff function and the ability to avoid dependance on fracture fixation into osteoporotic bone [4]. For these reasons, the use of RTSA is increasing in the treatment of patients with proximal humerus fractures [1, 6, 9, 16, 25, 31, 36]. Despite the success of locking plates compared with previous fracture fixation techniques, internal fixation of proximal humerus fractures, especially in osteoporotic bone, is still associated with a high complication risk (studies reporting complications in 20% to 30% of patients are not unusual), with complications including screw cutout, varus collapse, and fixation failure being among the more common and serious ones observed [7, 11, 13]. Pain relief and postoperative ROM after ORIF also depends on the retention of the vascularity of the humeral head, which is considerably compromised in the setting of dislocation, displaced anatomic neck fractures, and head-splitting fractures [7, 13]. Because RTSA replaces the humeral head and functions independently of the rotator cuff, it is not susceptible to the same complications as ORIF, although, as mentioned, RTSA carries very real risks of the complications one would expect after complex arthroplasty in patients with osteopenia or osteoporosis. Before the advent of RTSA, hemiarthroplasty was more commonly used as a surgical solution in lieu of ORIF. However, postoperative pain relief, ROM, and achievement of satisfactory validated patient-reported outcome scores were unpredictable with hemiarthroplasty; in addition, tuberosity healing and rotator cuff integrity both were inconsistent (yet important in terms of achieving satisfactory results), which is not the case with RTSA [6, 10, 24, 25, 28]. Tuberosity malunion and resorption after hemiarthroplasty occurs in up to 43% of shoulders, and these patients have poor function postoperatively, usually with a limited ROM in all planes [6, 10, 24, 25, 28]. Hemiarthroplasty after a proximal humerus fracture also may be complicated by prosthetic instability, preexisting rotator cuff deficiency, and subacromial mechanical impingement from a high-riding (proud) prosthesis. Despite its advantages over other surgical options, RTSA may not be the ideal way to treat every proximal humerus fracture. Therefore, we critically reviewed existing studies to determine the role of RTSA for treating proximal humerus fractures in patients older than 65 years. We limited this review to studies evaluating patients older than the age of 65 years. Essential Elements We systematically reviewed the PubMed, Embase, and Cochrane Central Register of Controlled Trials databases from inception to November 2020 based on the Preferred Reporting Items for Systematic Review and Meta-analyses guidelines [26]. Identified articles were uploaded and screened. The terms used in the search were proximal humerus, proximal humerus fracture, proximal humeral fracture, fractures of the proximal humerus, reverse total shoulder arthroplasty, clinical, trial, and clinical trials. All search terms were grouped by “OR” and subsequently combined using “AND.” Two reviewers (MAB and another who was not an author) screened the titles, abstracts, and full text of studies based on specific eligibility criteria. Studies were included based on the agreement of the two reviewers, with the senior author (MSV) consulted in the event of disagreement. We included studies evaluating RTSA after acute proximal humeral fractures that reported on ROM, validated patient-reported outcome scores, or complications. We limited inclusion to Level I or Level II clinical studies comparing RTSA with an alternative treatment method, studies that enrolled skeletally mature patients, and articles that were published in peer-reviewed journals and were written in English. We excluded studies that did not evaluate RTSA after acute proximal humerus fractures, studies that focused on patients who were skeletally immature, animal studies, case reports, case series, reviews, and articles written in a language other than English. Data were extracted into a Microsoft® Excel datasheet. The variables collected included the treatment, inclusion criteria, gender ratio per protocol, mean age, comorbidities, bone graft use, greater tuberosity repair, implants, and final or mean follow-up. The number of shoulders treated in per-protocol analyses were recorded for each study group. We collected outcomes (as they were available) including the total American Shoulder and Elbow Surgeons shoulder score, Simple Shoulder Test score, Constant score, DASH score, University of California-Los Angeles score, VAS score, patient satisfaction score, forward elevation, abduction, external rotation, internal rotation, greater tuberosity healing, survival, secondary procedures, and complications. Since not all outcomes were reported in all studies, we did not make quantitative comparisons between or among studies. We assessed the included studies’ evidence using three different techniques: level of evidence, quality of evidence, and conflicts of interest. Criteria published by The Journal of Bone and Joint Surgery, American Volume, were used to assess the level of evidence [35]. The Newcastle-Ottawa scale was used to assess the quality of evidence [5]. Studies with 7 to 9 stars were classified as having very good quality of evidence, those with 5 to 6 stars were considered to have a good quality of evidence, studies with 4 stars were considered to have a satisfactory quality of evidence, and those with 0 to 3 stars were considered to have an unsatisfactory quality of evidence. All included studies were classified as having very good quality of evidence (Table 1). Table 1. - Summary of study and patient characteristics Study Level of evidence Quality of evidence Potential COI Treatment Inclusion criteria Number Cuff and Pupello [6] 2 9 Yes HA; RTSA Four-part fracture, three-part fracture with greater tuberosity comminution, articular split of the humeral head 26; 27 Sebastiá-Forcada et al. [25] 1 9 No HA; RTSA Four-part fracture, fracture-dislocations with three-part fracture, head-splitting fracture with more than 40% articular surface involvement 31; 31 Lopiz et al. [17] 1 9 No Nonoperative management;RTSA Three-part fracture, four-part fracture 32; 30 Spross et al. [31] 2 8 No Nonoperative management;ORIF; HA; RTSA All proximal humerus fractures 132; 36; 4; 20 Fraser et al. [9] 1 8 Yes ORIF; RTSA Severely displaced Type B2 or C2 fractures 60; 64 Study Gender ratio per protocol, men:women Mean age in years Comorbidities Bone graft use Greater tuberosity repair Implants Final/mean follow-up in months (range) Cuff and Pupello [6] 9:14; 10:14 74.1; 74.8 7 (HA) and 9 (RTSA) with diabetes Morselized autograft (HA and RTSA) Suture repair (HA and RTSA) Aequalis fracture stem or Foundation fracture system; DJO Reverse Shoulder Prosthesis 30 (24-48) Sebastiá-Forcada et al. [25] 5:25; 4:27 73.3; 74.7 NR NR Suture repair (HA and RTSA) SMR Trauma prosthesis; SMR modular shoulder replacement system 27.7 (24-49); 29.4 (24-44) Lopiz et al. [17] 4:26; 4:25 85; 82 Mean CCI 6.1; 5.7 Morselized autograft (RTSA) Suture repair (RTSA) Delta XTEND Reverse Shoulder System prosthesis or SMR Modular Shoulder System (RTSA) 12 Spross et al. [31] 58: 134 (total) 58.4 (men): 69.1 (women) NR NR NR NR 12 Fraser et al. [9] 8:52; 5:59 74.7; 75.7 1 (ORIF) and 8 (RTSA) with diabetes NR NR PHILOS angular stable plate; Delta Xtend Reverse Total Shoulder Arthroplasty or Promos Reverse Prosthesis 24 All columns are organized respective to the treatment column unless otherwise specified. Implants: Aequalis fracture stem (Wright Medical), Foundation fracture system (DJO Surgical), DJO Reverse Shoulder Prosthesis (DJO), SMR Trauma prosthesis (System Multiplana Randelli, LIMA-LTO), SMR modular shoulder replacement system (System Multiplana Randelli, LIMA-LTO), Delta XTEND Reverse Shoulder System prosthesis (DePuy Synthes), SMR Modular Shoulder System (System Multiplana Randelli, LIMA-LTO), Delta Xtend Reverse Total Shoulder Arthroplasty (DePuy Synthes), Promos Reverse Prosthesis (Smith and Nephew), PHILOS angular stable plate (DePuy Synthes); COI = conflicts of interest; HA = hemiarthroplasty; NR = not recorded; CCI = Charlson comorbidity index; ORIF = open reduction and internal fixation. We identified five Level I and Level II clinical comparative studies evaluating RTSA to treat acute proximal humerus fractures in patients aged older than 65 years (Fig. 1). Two studies compared proximal humerus hemiarthroplasty and RTSA [6, 25], one study compared nonoperative management with RTSA [17], one study compared ORIF with RTSA [9], and the final study reported on outcomes after patients’ care decisions were directed by an algorithm, with possible treatments including nonoperative management, ORIF, hemiarthroplasty, and RTSA [31]. Each study focused only on patients older than 65 years of age, except for the algorithm-based study, which included all patients aged 18 years and older [31] (Table 1).Fig. 1.: This flowchart shows the studies that were included in this systematic review.What We (Think) We Know In a randomized controlled trial, Lopiz et al. [17] compared the 1-year outcomes of nonsurgical treatment with RTSA for acute three-part or four-part proximal humerus fractures in patients 80 years and older (Table 2). Internal fixation was not considered in the surgical treatment group because of known challenges with internal fixation in osteoporotic bone, as well as the higher complication risk in patients older than 65 years of age. Patients with fracture dislocations and head-splitting fractures were excluded from that study. The study authors found no clinically important differences between the RTSA group and the nonsurgical treatment group with respect to VAS pain score (0.9 versus 1.6) and Constant score (56.7 versus 61.7; p = 0.70). Furthermore, at the final follow-up, the authors found no difference between the two study groups in terms of the quality-of-life outcome score and ROM measurements (abduction, external rotation, or internal rotation). The only reported adverse event was suprascapular nerve injury in the RTSA group. In summary, this study did not show any short-term clinically important benefits of treatment with RTSA in three-part and four-part proximal humerus fracturs without dislocation and head-splitting fractures in patients 80 years and older. Table 2. - Summary of outcomes Clinical scores Study Treatment Total ASES score SST score Constant score DASH score UCLA score VAS pain score Patient satisfaction (%) Cuff and Pupello [6] HA; RTSA 62; 77 5.8; 7.4 NR NR NR NR 61; 91 Sebastiá-Forcada et al. [25] HA; RTSA NR NR 40; 56.1 24.4;17.5 21.1;29.1 NR NR Lopiz et al. [17] Nonoperative treatment; RTSA NR NR 55.7;61.7 28.8;20.7 NR 1.6;0.9 93;100 Spross et al. [31] Nonoperative management; ORIF; HA; RTSA NR NR 76; 63;44; 69 NR NR NR NR Fraser et al. [9] ORIF; RTSA NR NR 54.6; 68 NR NR NR NR ROM Study Forward elevation in degrees Abduction in degrees External rotation in degrees Internal rotation in degrees Greater tuberosity healed, % Survival (revision or clinical failure) Secondary procedures, % of patients Complications Cuff and Pupello [6] 100; 139 NR 25; 24 30; 46 61; 83 NR 13; 0 HA: 1 hematoma, 1 apical pneumothorax;RTSA: 1 operative transient ulnar nerve paresthesia, 1 periprosthetic fracture at 8 months Sebastiá-Forcada et al. [25] 79.8;120.3 78.7;112.9 3.3; 4.7 2.6; 2.7 56.7;64.5 40 months:43.3 (95% CI 25.6-65.1); 71 (95% CI 55.1-86.9) 23; 3 HA: 1 intraoperative humerus fracture, 1 superficial infection, 1 MUA for stiffness, 6 revisions to RTSARTSA: 1 hematoma, 1 deep wound infection resulting in revision Lopiz et al. [17] 5.7; 6.9a 5.6; 6.6a 4.4; 5.2a NR Nonoperative 2 suprascapular nerve Spross et al. [31] NR NR NR NR NR 0 Nonoperative 3 greater tuberosity treated with 8 plate 3 with for stiffness, 3 with early of 1 1 secondary HA: 1 1 of for Fraser et al. [9] 4.4; 5.7; NR NR 6 9 screw 1 fracture to 1 1 rotator cuff 2 transient nerve 2 deep wound 2 periprosthetic fractures, 1 fracture All columns are organized respective to the treatment column unless otherwise to anatomic healing as in the with ASES = American Shoulder and Elbow SST = shoulder UCLA = University of California-Los HA = hemiarthroplasty; ORIF = open reduction and internal NR = not recorded; MUA = In another randomized controlled study, Fraser et al. [9] compared RTSA with ORIF for displaced acute proximal humerus fractures Type B2 or in patients 65 to years (Table 2). The authors excluded head-splitting fractures, fracture and proximal humerus fractures from the study. At the final follow-up at 2 RTSA internal fixation with respect to the outcome the total Constant score versus 54.6; p [9] (Table 2). The Constant score was because the RTSA group ROM compared with the internal fixation group Constant 7 versus Constant versus external rotation Constant 7 versus 4.4; p There were adverse in the RTSA group and 12 in the ORIF group. the most common adverse event in the ORIF group was screw which in (in three or RTSA (in The adverse in the RTSA group included deep wound infection (in two transient nerve injury and intraoperative or postoperative fracture patients in the ORIF group and patients in the RTSA group secondary Although this study did not have a nonsurgical treatment it was well a quality of evidence score of 8 of and included patients who were likely to from surgical Furthermore, it the specific surgical risks and common secondary procedures with RTSA versus ORIF for displaced proximal humerus studies have the of RTSA over hemiarthroplasty to treat acute three-part or four-part proximal humerus fractures in patients aged years or older [6, 25, (Table 2). Patients with RTSA have higher American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores, Constant scores, University of California-Los Angeles scores, and DASH scores than those undergoing hemiarthroplasty (Table these scores, the in the American Shoulder and Elbow Simple Shoulder and Constant scores was considered clinically important Forward elevation was also at versus = versus = and versus in the three studies evaluating RTSA and hemiarthroplasty [6, 25, 31]. In one study, was higher after RTSA than after hemiarthroplasty p = The in forward and with RTSA reported in these studies were considered clinically important Because of a of evidence, the of which patients be treated continues to be a of [6, 9, 25, 31]. RTSA to have more advantages in patients with proximal humerus fractures who have the most fracture such as displaced head-splitting fractures and fracture this is especially in patients were higher RTSA for other displaced three-part and four-part fractures, in patients are is likely to any over nonsurgical treatment and decision-making for proximal humerus fractures are based on radiographic 17, 31]. important that can outcomes and patient satisfaction include the pain level and or without versus in a on the versus postoperative and the of serious are not well and we studies that can as to how best to factor into our clinical randomized controlled at these specific patient two patients with the same fracture may with respect to pain scores, functional treatment and on the and treating these patients with one treatment versus may not Most are performed by who are than five per some that may be at increased risk for serious complications after this patients to a shoulder in for these fractures using RTSA is one that may to minimize this However, this is not or in the especially in it may be or include in and use of treatment options as for who are not with hemiarthroplasty is to in compared with RTSA, it is considered by to be more to good postoperative ROM and high patient-reported outcomes scores [6, 25, 31]. different of RTSA versus and humeral stem options fracture are is is an ideal to treat proximal humerus humeral have been to be in shoulder arthroplasty for their use in osteoporotic bone, as seen in proximal humerus fractures, is and long-term on this are is no for the and the best tuberosity management continues to be Level and studies have that the in RTSA to external rotation and patient satisfaction studies on comparing specific and surgical in RTSA for proximal humerus fractures to the most treatment The long-term outcomes of RTSA for proximal humerus fractures are not There are challenges when treating patients who have a proximal humerus fracture with RTSA, and these may have important over For we not to complications RTSA dislocation and periprosthetic fractures over follow-up. follow-up on the clinical studies be of the commonly advantages of RTSA over internal fixation is that surgical treatment with RTSA to 3 months after still may good pain relief and postoperative ROM in patients with displaced proximal humerus studies have that patients who malunion and resorption of the and were treated with RTSA were to good function compared with those treated with hemiarthroplasty [6, We have used this to our in decision-making for patients older than 65 years of age with displaced three-part and four-part proximal humerus fractures who have pain and poor function at the who are not certain they have surgery. treatment in the 2 to 3 months patients to the of by the fracture, and they can they to with prosthetic This to and patients who they would from (RTSA) in this Although this has been to and has well in our it is by evidence, and the over nonoperative treatment in these patients is not and to for surgical treatment, including RTSA, to be an for the treatment of proximal humerus fractures in people older than 65 years of age. The of one randomized controlled clinical no of surgical treatment over nonsurgical treatment in proximal humerus fractures the surgical neck However, clinical such as proximal humeral and displaced head-splitting fractures were not in this clinical trial, the clinical of RTSA in patients older than 65 years of age Although these fracture are not and randomized studies evaluating these are to for reasons, we that RTSA hemiarthroplasty and internal fixation in these clinical studies on patient such as pain of the postoperative and to the for RTSA in patients with proximal humeral are no clinical guidelines for the treatment of proximal humerus fractures of which we are and the of such guidelines would be as RTSA is increased use for displaced three-part and four-part proximal humerus fractures and fracture dislocation in patients older than 65 years because of its ability to predictable in pain and shoulder the of the population the use of RTSA is also to surgical and RTSA to patient outcomes and may also as the for the treatment of proximal humerus fractures to radiographic treatment of proximal humerus fractures likely be by an algorithm-based treatment approach that other important as functional age, functional on the comorbidities, and pain that treatment

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.