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

Abstract

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.

Treatment of fracture sequelae of the proximal humerus: comparison of hemiarthroplasty and reverse total shoulder arthroplasty

“…There are several studies reporting the results of shoulder arthroplasty for the treatment of acute PHF [7,16,19,22,26,28,31], even comparing anatomic and RSA [6,8,13,24]. Essentially, in the acute scenario, shoulder arthroplasty has demonstrated improvements in pain, function, satisfaction and bone healing [6-8, 13, 16, 19, 22, 24, 26, 28, 31].…”

Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study

“…Although recent studies reported satisfactory results with RSA, 15,20,23,35 they also reported a relevant number of complications. 6,9 Moreover, there were few studies comparing the 2 types of prostheses for these acute fractures. We have found only 4 retrospective comparative studies 5,16,17,36 and 1 other prospective study.…”

Avoiding superior tilt in reverse shoulder arthroplasty: a review of the literature and technical recommendations

“…Successful results with use of the superior approach for RSA have been shown in treatment of acute proximal humeral fractures in a recent systematic review. 7 The results of the systematic review did not show superiority of any specific approach for this indication. In scenarios in which the proximal humerus is fractured, achieving proper baseplate tilt is aided by the lack of intact proximal humeral bone that otherwise hinders correct positioning of the component.…”

“…19 In addition, patients with proximal humerus fractures may be well treated with the AS approach. 7 The surgeon's experience with the particular approach is another critical factor, regardless of whether the AS or DP approach is chosen.…”