Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review

doi:10.1016/j.jse.2013.08.021

Journal of Shoulder and Elbow Surgery

Volume 22, Issue 12, December 2013, Pages 1737-1748

https://doi.org/10.1016/j.jse.2013.08.021 Get rights and content

Background

Displaced proximal humeral fractures have traditionally been treated with hemiarthroplasty in older adults, but sometimes hemiarthroplasty results in poor functional outcomes due to rotator cuff deficiency. Reverse shoulder arthroplasty (RSA) can offer potentially improved outcomes in these situations. We assessed the functional outcomes of older adults treated with RSA for proximal humeral fractures compared with hemiarthroplasty.

Methods

We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, and 3 clinical trials registries. We included all studies treating proximal humeral fractures with RSA in adults with a mean age older than 60 years and 1 year of follow-up. We calculated weighted mean differences (WMD) for range of motion and standardized mean differences (SMD) for shoulder scores. Postoperative complications were evaluated qualitatively.

Results

Fifteen studies met inclusion criteria, including 377 patients treated with RSA and 504 patients treated with hemiarthroplasty. In controlled studies, the RSA group had improved forward flexion (WMD, 21°;, P = .02) and functional outcome scores (SMD, 0.44; P = .005) compared with the hemiarthroplasty group but decreased external rotation (WMD, −5°; P < .0001). Postoperative complications were similar between the 2 groups.

Conclusion

RSA results in improved forward flexion and functional outcome scores compared with hemiarthroplasty for older adults with proximal humeral fractures. Complications do not appear to be appreciably higher in the RSA group in the existing follow-up. The results of this review suggest that RSA is a reasonable alternative for treating older adults with proximal humeral fractures, but more research and longer follow-up are needed.

Section snippets

Review protocol

We wrote a protocol outlining a planned approach for the identification and selection of relevant studies and conducted this systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.²⁹ A log of all changes made to the protocol once the formal review was begun can be found in Appendix 1 (available on the journal's website at www.jshoulderelbow.org). The original protocol is available from the authors upon request.

Study eligibility criteria

We included

Results of search

We identified 898 unique references through our search methods. After screening titles and abstracts, we retrieved 88 references for full-text review. After a full-text review, 15 studies fulfilled our inclusion criteria after full text review (Fig 1).3, 4, 8, 14, 15, 16, 19, 20, 22, 24, 26, 33, 34, 35, 37, 38, 42

Summary of main results

RSA improves active forward flexion and functional outcome scores compared with hemiarthroplasty for older adults with proximal humeral fractures in the short-term and medium-term. Assessing the differences in complications between RSA and hemiarthroplasty was difficult due to inconsistencies in reporting complications, but the differences in number and clinical relevance of reported complications did not appear to be appreciable. No long-term data were available on function and survival of RSA.

Conclusions

The results of this systematic review suggest that RSA offers improved forward flexion and functional outcome scores compared with hemiarthroplasty in older adults with proximal humeral fractures. However, long-term follow-up studies of functional outcome and implant survival of RSA after proximal humeral fractures are necessary to make an informed decision about appropriate treatment options. This review supports the practice of treating proximal humeral fractures in older patients with

Disclaimer

The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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ICD-10 diagnosis codes in electronic health records do not adequately capture fracture complexity for proximal humerus fractures
2024, Journal of Shoulder and Elbow Surgery
The ability to do comparative effectiveness research (CER) for proximal humerus fractures (PHF) using data in electronic health record (EHR) systems and administrative claims databases was enhanced by the 10th revision of the International Classification of Diseases (ICD-10), which expanded the diagnosis codes for PHF to describe fracture complexity including displacement and the number of fracture parts. However, these expanded codes only enhance secondary use of data for research if the codes selected and recorded correctly reflect the fracture complexity. The objective of this project was to assess the accuracy of ICD-10 diagnosis codes documented during routine clinical practice for secondary use of EHR data.
A sample of patients with PHFs treated by orthopedic providers across a large, regional health care system between January 1, 2016, and December 31, 2018, were retrospectively identified from the EHR. Four fellowship-trained orthopedic surgeons reviewed patient radiographs and recorded the Neer Classification characteristics of displacement, number of parts, and fracture location(s). The fracture characteristics were then reviewed by a trained coder, and the most clinically appropriate ICD-10 diagnosis code based on the number of fracture parts was assigned. We assessed congruence between ICD-10 codes documented in the EHR and radiograph-validated codes, and assessed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for EHR-documented ICD-10 codes.
There were 761 patients with unilateral, closed PHF who met study inclusion criteria. On average, patients were 67 years of age and 77% were female. Based on radiograph review, 37% were 1-part fractures, 42% were 2-part, 11% were 3-part, and 10% were 4-part fractures. Of the EHR diagnosis codes recorded during clinical practice, 59% were “unspecified” fracture diagnosis codes that did not identify the number of fracture parts. Examination of fracture codes revealed PPV was highest for 1-part (PPV = 0.66, 95% confidence interval [CI] 0.60-0.72) and 4-part fractures (PPV = 0.67, 95% CI 0.13-1.00).
Current diagnosis coding practices do not adequately capture the fracture complexity needed to conduct subgroup analysis for PHF. Conclusions drawn from population studies or large databases using ICD-10 codes for PHF classification should be interpreted within this limitation. Future studies are warranted to improve diagnostic coding to support large observational studies using EHR and administrative claims data.
Surgical Considerations for Osteoporosis, Osteopenia, and Vitamin D Deficiency in Upper Extremity Surgery
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Fracture vs. standard stem for proximal humerus fractures using reverse total shoulder arthroplasty
2024, Seminars in Arthroplasty JSES
Reverse total shoulder arthroplasty (rTSA) and hemiarthroplasty are recognized treatment options for significantly displaced proximal humerus fractures. Repair of the tuberosities and preservation of rotator cuff function is a principle of treatment to enhance function and prevent instability. Humeral fracture stems were developed to improve tuberosity union with hemiarthroplasty, and similarly fracture stems are used with rTSA with promising results. However, there are conflicting studies on the use of fracture stems in improving outcomes in rTSA for proximal humerus fracture. The purpose of this study is to determine the clinical and radiographic outcomes, complication and revision rates, and patient satisfaction for fracture vs. standard stems for acute proximal humerus fracture treated with rTSA.
A prospective multi-institutional institutional review board approved registry with a minimum two-year follow-up was queried and identified 231 patients that underwent rTSA for acute proximal humerus fracture, 187 of which received a fracture stem and 44 that received a standard stem. Patients were excluded if there was a previous fracture repair, malunion, or nonunion. Patient demographics, clinical and radiographic outcomes, complications, revision surgery, and patient reported outcome measures were collected preoperatively and at latest follow-up postoperatively.
The mean follow-up was 48 $\pm$ 24 and 54 $\pm$ 34 months, mean age was 74 $\pm$ 7.9 and 72 $\pm$ 8.6 years, and mean body mass index was 28 $\pm$ 6.1 and 30 $\pm$ 5.3 kg/m² for fracture and standard stems, respectively. Both fracture and standard stem groups showed significant improvements in patient reported clinical outcomes preoperative to postoperatively. Postoperatively, patients with fracture and standard stems had comparable abduction, forward elevation, internal rotation, external rotation, Visual Analog Scale pain, Global Shoulder Function scale, Simple Shoulder Test scale, American Shoulder and Elbow Surgeons scale, University of California Los Angeles Shoulder score, and Shoulder Arthroplasty Smart score. Patient satisfaction was high and did not differ between the two groups. Similar rates of humeral radiolucent lines, scapular notching, complications, and revision rates occurred between the fracture vs. standard stem groups.
There were no significant differences in postoperative clinical outcomes, radiographic outcomes, complication rate, revision rate, and patient satisfaction between the fracture and standard stem groups for the treatment of acute proximal humerus fracture using rTSA. Both stems significantly improved clinical outcomes postoperatively. Either a fracture or standard stem may be used to achieve improved clinical outcomes for acute proximal humerus fracture using rTSA.
Inferior surgical outcomes following reverse total shoulder arthroplasty for nonunion and malunion compared to acute arthroplasty: a nationwide matched cohort analysis
2023, Seminars in Arthroplasty JSES
Reverse total shoulder arthroplasty (rTSA) has become popularized in the management of acute proximal humerus fractures (PHFs). Limited evidence exists to compare the outcomes of acute rTSA to management following failed open reduction and internal fixation. We aimed to analyze the differences between acute rTSA for PHF compared to subsequent rTSA for nonunion/malunion.
Patients who underwent primary rTSA from 2016 to 2020 were identified in the Premier Healthcare Database. Nonunion, malunion, and hardware complication patients were identified using International Classification of Diseases Tenth Revision diagnosis codes and compared to acute PHF controls. Patients were matched in a 1:1 fashion to acute fracture based on age (±3 years), sex, race, and presence of pertinent comorbidities. Patient demographics, hospital factors, patient comorbidities, and 90-day complications were assessed and compared between the two cohorts. Descriptive statistics and regression analysis were employed with significance set at P < .05.
Prior to matching, 8561 nonunion/malunion cases and 11,134 acute rTSA controls were identified. Patients undergoing acute rTSA for PHF were older, had longer length of stay, and higher total costs (P < .0001). When compared to acute rTSA for fracture, nonunion/malunion patients were at increased risk of multiple surgical complications including periprosthetic joint infection (odds ratio [OR]: 4.56; 95% confidence interval [CI]: 2.95-7.04; P < .0001), periprosthetic fracture (OR: 2.86; 95% CI: 2.09-3.93), stiffness (OR: 2.01; 95% CI: 1.17-3.44; P = .01), and dislocation (OR: 2.37; 95% CI: 1.80-3.12; P < .0001). However, patients undergoing acute rTSA had higher rates of all medical complications investigated, including deep vein thrombosis, pulmonary embolism, pneumonia, myocardial infarction, acute kidney infection, and sepsis (P < .001).
rTSA after nonunion/malunion of PHFs is associated with increased risk of surgical complications compared to acute rTSA. Initial rTSA for PHFs may mitigate subsequent increased risk of surgical complication and should be considered as the initial treatment option in patients with PHFs. However, the increased risk of medical complications seen in acute PHF warrants attention and diligent medical optimization from providers.
Outcomes of acute vs. delayed reverse shoulder arthroplasty for proximal humerus fractures in the elderly: a systematic review and meta-analysis
2023, Journal of Shoulder and Elbow Surgery
Reverse shoulder arthroplasty (RSA) has become an increasingly popular treatment option for proximal humerus fractures in the elderly. There is however contradictory evidence on the impact of timing of RSA on patient outcomes. It remains unclear if poor results after initial nonsurgical or surgical management can be improved with delayed RSA. The aim of this systematic review and meta-analysis is to compare the outcomes of acute RSA and delayed RSA for the treatment of proximal humerus fractures in the elderly.
A systematic search was performed on 4 databases for studies that compared acute RSA with RSA used after prior nonoperative or operative treatment. Studies with a mean cohort age of <65 years were excluded. Demographical data, clinical outcome scores, range of motion measurements, and postoperative complications were collected from the included studies.
Sixteen studies were included for data analysis. Compared with delayed RSA cohorts, acute RSA cohorts had higher forward flexion (124.3° vs. 114.9°; P = .019), external rotation (24.7° vs. 20.2°; P = .041), and abduction (113.2° vs. 99.8°; P = .03). Compared with RSA after conservative management, acute RSA had greater external rotation (29.9° vs. 21.4°; P = .043). The acute RSA cohort had significantly higher American Shoulder and Elbow Surgeons (76.4 vs. 68.2; P = .025) and Constant-Murley scores (65.6 vs. 57.3; P = .002) compared with the delayed RSA cohort. Subgroup analyses showed significantly greater Constant-Murley (64.9 vs. 56.9; P = .020) and Simple Shoulder Test scores (8.8 vs. 6.8; P = .031) with acute RSA compared with RSA after conservative treatment. The American Shoulder and Elbow Surgeons score was higher in the acute RSA cohort compared with RSA after open reduction internal fixation (77.9 vs. 63.5; P = .008). The overall complication rate per 100 patient-years was 11.7 for the acute RSA cohort and 18.5 for the delayed RSA cohort (risk ratio: 0.55; P = .015).
Based on the current evidence, acute RSA presents better clinical outcome measures and range of motion measurements, with decreased complication rates than RSA performed after prior nonoperative or operative treatment.
Off-label use of reverse total shoulder arthroplasty: the American Academy of Orthopedic Surgeons Shoulder and Elbow Registry
2023, Seminars in Arthroplasty JSES
After the popularity of reverse total shoulder arthroplasty (rTSA) in Europe, the United States Food and Drug Administration (FDA) cleared the Delta rTSA system (DePuy Inc., Warsaw, IN, USA) for use in late 2003. The original FDA approved indications for rTSA in the United States were limited to a “Grossly rotator cuff deficient joint with severe arthropathy or a previous failed joint replacement with a grossly rotator cuff deficient joint.” Surgeons began to use rTSA for many off-label indications: osteoarthritis (OA) without rotator cuff tear (RCT), massive RCT without OA, proximal humerus fractures (PHFx), inflammatory arthritis (IA), and chronic glenohumeral joint dislocation (GHJD). Since 2006, The FDA has approved PHFx as an indication for some but not all reverse implants. The purpose of this study is to evaluate the trends in off-label rTSA use in the American Academy of Orthopaedic Surgeons Shoulder and Elbow Registry (AAOS-SER).
All rTSA procedures reported to the AAOS-SER from January 2015 to March 2021 were analyzed. Diagnoses associated with the use of rTSA including RCT arthropathy, OA without RCT, RCT without OA, PHFx, IA, and GHJD were evaluated, and trends were assessed over the data collection period.
At the time of data analysis the AAOS-SER contained 3850 cases of rTSA. Only 24.4% of rTSA surgeries were performed for original on-label use (RCT arthropathy). Off-label use of rTSA was seen in 75.6% of cases. When reviewing those rTSA done off-label, the majority (41.4%) were done for OA without RCT. Other off-label rTSA use included 15.1% for RCT without OA, 13% potentially off-label for PHFx, 4.6% for IA, and 1.6% for GHJD. Proportionally, off-label use is increasing over time while on-label use is decreasing.
In the AAOS-SER, the majority of rTSA were performed for indications originally considered off-label by the FDA-a trend increasing over time. Some implant manufacturers have expanded indications for rTSA without providing clinical data to support changing FDA approved indications for use. The incremental expansion of indications for use without supportive data, a practice known as predicate creep, is occurring with rTSA. Performing rTSA for off-label indications may create liability risk for surgeons and implant manufacturers. Device manufacturers should formally expand indications of use for rTSA with the FDA to be consistent with published literature and trends.

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: Investigational Review Board approval was not required for this study.

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Review ArticleReverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review

Background

Methods

Results

Conclusion

Section snippets

Review protocol

Study eligibility criteria

Results of search

Summary of main results

Conclusions

Disclaimer

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Rev Chir Orthop Reparatrice Appar Mot

Orthop Traumatol Surg Res

Orthop Traumatol Surg Res

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Injury

J Shoulder Elbow Surg

Orthop Traumatol Surg Res

J Shoulder Elbow Surg

J Shoulder Elbow Surg

Hand Clin

J Shoulder Elbow Surg

Grammont reverse prosthesis: design, rationale, and biomechanics

J Shoulder Elbow Surg

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

J Bone Joint Surg Br

Hemiarthroplasty for three- and four-part proximal humerus fractures

J Am Acad Orthop Surg

Statistical power analysis for the behavioral sciences

The Oxford shoulder score revisited

Arch Orthop Trauma Surg

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

Orthopedics

Reverse total shoulder arthroplasty

J Am Acad Orthop Surg

Reverse total shoulder arthroplasty. Survivorship analysis of eighty replacements followed for five to ten years

J Bone Joint Surg Am

Review Article
Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review