Reconstruction or replacement? A challenging question in surgical treatment of complex humeral head fractures in the elderly

Abstract

Introduction Surgical treatment of complex humeral head fractures in the elderly is challenging due to osteoporotic bone, comorbidities and reduced compliance. The treatment strategy (reconstruction versus replacement) should allow for a functional aftercare and result in a high patient satisfaction. Major complications leading to surgical revision are crucial and should be avoided. The purpose of this study was to analyse the major complication rate leading to surgical revision and the patient-based outcome in complex humeral head fractures of the elderly population treated either using locking plate fixation (LCP) or reversed total shoulder arthroplasty (rTSA). Materials and Methods All patients older than 65 years surgically treated due to a four-part fracture of the proximal humerus between 2003 and 2015 were enrolled in our retrospective study. Major complications and revision rates were recorded and functional outcome was assessed using the Munich Shoulder Questionnaire (MSQ) allowing for qualitative self-assessment of the Shoulder Pain and Disability Index (SPADI), of the Disability of the Arm, Shoulder and Hand (DASH) score and of the Constant Score. Results A cohort of 103 patients with a mean age of 73.4 ± 6.2 years suffering from four-part fractures of the humeral head were enrolled. 3 patients were treated using the LCP fixation compared to 40 rTSAs. There were no significant differences in the patient-reported functional outcome. The revision rate was significantly higher in the LCP group (10/63; 15.9%) compared to the rTSA group (1/40; 2.5%). Reasons for revision were avascular head necrosis, cut-out of screws, secondary dislocation of the greater tuberosity and hypersensitivity to metal. Conclusions Reversed total shoulder arthroplasty and locking plate fixation are both established surgical procedures for the management of complex proximal humerus fractures in the elderly leading to similar functional results. However the revision rate in the rTSA group was significantly lower. Primary rTSA should, therefore, be favoured in multimorbid elderly patients with an increased complication risk to avoid repeated anaesthesia.

Indications for reverse total shoulder arthroplasty in chronic locked shoulder dislocation: A case report and review of literature

“…The authors also advocate for more prospective studies on the indications and outcomes for rTSA as a primary treatment for chronic glenohumeral instability and chronic locked glenohumeral dislocation; costs associated with failed surgical interventions might be avoided if reverse total shoulder arthroplasty is used as a first option for patients with a lower likelihood of response to minimally invasive or native joint conserving reconstructions. Several recent studies have found the use of rTSA as a primary treatment for proximal humerus fractures is associated with significantly higher measures function, lower rates of complications, and less need for further revision when compared to other surgical treatment plans like ORIF or hemiarthroplasty, even when those are later revised with rTSA [33,[40][41][42][43] . While there are several studies already cited above that examine the role of rTSA in chronic locked shoulder dislocation, very few have explored the use of rTSA as a primary treatment for this condition [9,33,34] .…”

Anatomically reduced fixation should always be considered when treating B and C proximal epiphyseal humeral fractures

“…In case of four-part fractures in elderly patients, reverse shoulder arthroplasty (RSA) is recommended [ 7 ].…”

Effect of Pore Size of Porous-Structured Titanium Implants on Tendon Ingrowth

“…Arthroplasty is an effective treatment for arthropathy, as it can relieve pain, restore physical activities, and improve the quality of life of patients. In prosthetic surgeries involving malignant bone tumors [ 1 ], revision arthroplasty [ 2 , 3 ], periprosthetic fractures, failed osteosynthesis [ 4 ], and infections, firm attachment between the tendon and the metal prosthesis is necessary to enhance motor function [ 5 , 6 ]. However, this challenge has not been solved because tendon tissue has poor vascularity and healing ability [ 7 , 8 ], and the biocompatibility of prostheses for tissue integration is generally poor.…”