Review article
Reverse shoulder arthroplasty for proximal humeral fractures: update on indications, technique, and results

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The introduction of the reverse shoulder arthroplasty has provided shoulder surgeons with more options for the treatment of complex proximal humeral fractures in the elderly. Early reported results suggest that the average functional outcome may be better than hemiarthroplasty in certain patients and specific clinical scenarios. In addition, these results seem to be reached more quickly with less dependence on rehabilitation. The reverse prosthesis may be particularly useful in patients aged older than 70 years, especially those with severely comminuted fractures in osteopenic bone. These factors likely have a negative impact on the results of hemiarthroplasty and internal fixation. Despite the potential benefits of reverse arthroplasty for fracture, there is a significant learning curve with the use of this prosthesis, and it has its own set of complications. The surgeon must show appropriate judgment when selecting a reverse arthroplasty in the setting of a proximal humeral fracture and, furthermore, be well acquainted with the surgical technique and prosthetic options at the time of surgery. Although the longevity of this prosthesis remains unknown, midterm outcomes are promising.

Section snippets

Evolving indications for RSA

Traditional indications for RSA have been rotator cuff arthropathy, fracture sequelae with arthritis, and failure of a prior arthroplasty. Boileau et al7 reported their initial results using this technology for the aforementioned indications and showed improved function and elevation. These early results have prompted the expanding use of the RSA to treat other complex shoulder problems.49

Given the versatility afforded by the RSA, this prosthesis has become a salvage option for a failed

Nonoperative management

Nonoperative management is best reserved for nondisplaced fractures of the proximal humerus or those patients who are medically unfit for surgery. Three- and 4-part fractures have been treated nonoperatively but with poor results. Predicting which 3- or 4-part fracture will do well with nonoperative management is difficult, and a patient’s decision not to undergo surgery may have its own untoward consequences.42 Complications with this method of treatment have been nonunion and malunion, as

RSA for acute proximal humeral fractures

The complexity of treating proximal humeral fractures combined with the variable results obtained through nonoperative management, ORIF, and hemiarthroplasty has led to a shift toward the use of RSA for complex proximal humeral fractures, especially in patients aged older than 70 years (Fig. 1). RSA is attractive for the treatment of proximal humeral fractures because it is less reliant on a functioning rotator cuff for proper function and pain relief. However, results with reverse arthroplasty

Surgical approach

The surgical approach for an RSA has been either the standard deltopectoral approach or the anterosuperior approach. Each approach has its advantages and disadvantages. The deltopectoral approach is the universal and familiar approach to the shoulder. It allows adequate access to the fracture fragments for suture fixation and provides excellent glenoid exposure after fracture fragment mobilization. However, exposure and reduction of the greater tuberosity can be challenging through the

Complications

Various complications have been reported since the introduction of the RSA, including hematomas, infections, acromial stress fractures, early implant failures/loosening, and scapula fractures, as well as neurologic injuries. No specific complications with regard to using an RSA for a proximal humeral fracture can be mentioned. The most common postoperative complication is instability, with an incidence of 4.7%.13, 53 Scapular notching is a frequently discussed complication, although the

Rehabilitation

Currently, there is no evidence in the literature validating the optimal postoperative program after an RSA. Zumstein et al53 found in a recent systematic review that most patients were placed in a sling or brace for 3 to 6 weeks. Active shoulder motion was allowed as early as 2 weeks and as late as 6 weeks. Our current protocol after an RSA for a proximal humeral fracture is to place the patient in a sling with an abduction pillow in neutral rotation for 6 weeks. Neutral rotation or an

Conclusion

RSA for certain proximal humeral fractures in the elderly can show improved outcomes and may have more predictable functional results than hemiarthroplasty based on the current evidence. The longevity and cost-effectiveness of this relatively expensive implant are currently unknown.14 The use of this new technology should be limited to surgeons with appropriate experience, and indications must be tailored to the patient’s needs and functional goals.

Disclaimer

Drs. Acevedo and Vanbeek have no conflict of interest to report. Dr. Abboud is a consultant, paid speaker, and has received royalties from Integra. Dr. Williams is a consultant for Tornier and Depuy; has received royalties from Depuy; and has been paid to lecture for Depuy. Dr. Lazarus is a consultant for and has been paid to lecture for Tornier.

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