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