Mortality After Complex Displaced Proximal Humerus Fractures in Elderly Patients: Conservative Versus Operative Treatment With Reverse Total Shoulder Arthroplasty

Abstract

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.

Outcome of geriatric proximal humeral fractures: a comparison between reverse shoulder arthroplasty versus open reduction and internal fixation

“…After 6 months, 84% of the patients after rTSA for proximal humeral fractures were back at their previous level of activity. [ 12 ] In the present study, the hospital stay was significantly shorter and the subsequent risk of losing independence was lower in the ORIF group. In contrast to the rTSA group, no delirium was observed in the ORIF group.…”

“…If surgical treatment is required, the treatment options in this patient group include open reduction and internal fixation (ORIF), hemi- and total arthroplasty, and reverse shoulder arthroplasty (rTSA). According to available data, numerous studies document good functional scores and acceptable complication rates after both primary rTSA and internal fixation for proximal humeral fractures in the elderly, but there appears to be a growing consensus that complication rates are in general lower and function better after rTSA [7–15] …”

Proximal humerus fractures: epidemiology and trends in surgical management of hospital-admitted patients in Portugal

“…These may represent a nondespicable proportion of polytraumatized patients and, as suggested in previous studies, illustrate that PHFs are an indirect sign of patients' frailty. 4 , 26 , 29 …”

Analysis of predictors of mortality after surgical and non-surgical management in proximal humerus fractures

“…Neuhaus et al [15] note that open reduction and internal fixation of these fractures is associated with a high risk of adverse events and increased mortality compared with conservative treatment, and add that surgical treatment involves significant short-term risks that must be taken into account when making decisions, especially with elderly patients. In the field of arthroplasty, Rotman et al [27] compared conservative treatment with reverse total shoulder arthroplasty in patients with complex displaced PHF. They found no significant differences in mortality over a year, although they reported a trend that shows lower mortality with arthroplasty, especially in men.…”