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

doi:10.1016/j.jse.2014.06.035

Journal of Shoulder and Elbow Surgery

Volume 23, Issue 10, October 2014, Pages 1419-1426

https://doi.org/10.1016/j.jse.2014.06.035 Get rights and content

Background

There is no consensus on what type of arthroplasty is best for the treatment of complex proximal humeral fractures in elderly patients. The purpose of this prospective study was to compare the outcomes of reverse shoulder arthroplasty (RSA) and hemiarthroplasty (HA).

Methods

Sixty-two patients older than 70 years were randomized to RSA (31 patients) and HA (31 patients). One HA patient died at 1 year, and she was excluded. The mean follow-up was 28.5 months (range, 24-49 months).

Results

Compared with HA patients, RSA patients had significantly higher (P = .001) mean University of California–Los Angeles (29.1 vs 21.1) and Constant (56.1 vs 40.0) scores, forward elevation (120.3° vs 79.8°), and abduction (112.9° vs 78.7°) but no difference in internal rotation (2.7° vs 2.6°; P = .91). The Disabilities of the Arm, Shoulder, and Hand score was higher in the HA patients (17 vs 29; P = .001). In the HA group, 56.6% of tuberosities healed and 30% resorbed. Patients with failure of tuberosities had significantly worse functional outcomes. There were 2 complications (intraoperative humeral fracture and superficial infection). One patient was manipulated under general anesthesia because of postoperative stiffness. Six patients with HA had proximal migration that required revision to RSA. In the RSA group, 64.5% of tuberosities healed and 13.2% resorbed. Functional outcome was irrespective of healing of the tuberosities. Notching was observed in only 1 RSA patient. One patient developed a hematoma and another a deep infection requiring a 2-stage revision to another RSA.

Conclusion

RSA resulted in better pain and function and lower revision rate. Revision from HA to RSA does not appear to improve outcomes.

Section snippets

Materials and methods

A blinded, randomized, controlled prospective study was designed to compare the outcomes between RSA and HA in elderly patients with acute complex proximal humeral fractures. The study was considered blinded because the surgeons were not involved in the randomization process, and the clinical and radiologic evaluations were performed by independent observers who had not participated in the surgeries.

Baseline information

Between 2009 and 2011, 62 consecutive patients were included for study. They were allocated to treatment with RSA (31 patients) or HA (31 patients). The mechanism of injury in all patients was a fall on the upper extremity. Before fracture, normal function of the shoulder was reported in all but 1 patient in the HA group and 2 patients in the RSA group. All but 1 patient completed the minimum follow-up of 2 years. In the HA group, 1 patient died at 1 year postoperatively for reasons not related

Discussion

HA has commonly been recommended as the treatment of choice for complex proximal humeral fractures in the elderly when internal fixation is not an option,¹ but recent studies have reported inconsistent results with HA.13, 18, 27 The functional outcome largely depends on the anatomic healing of the tuberosities,⁴ but this healing is difficult in most elderly patients with comminuted fractures.² RSA has been proposed as an alternative treatment for these acute complex fractures7, 11 on the basis

Conclusions

The findings of this study indicated that RSA was superior to HA with respect to pain, functional outcome, and revision rate. Revision from HA to RSA does not appear to improve outcomes. Our study confirms the place of RSA in patients older than 70 years with complex proximal humeral fractures. Although short-term results with RSA are promising, more long-term prospective studies are necessary. In addition, our results could not be extrapolated to other designs of RSAs.

Disclaimer

The authors, their immediate families, and any research foundation 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.

References (36)

D.C. Acevedo et al.
Reverse shoulder arthroplasty for proximal humeral fractures: update on indications, technique, and results
J Shoulder Elbow Surg
(2014)
S.A. Antuña et al.
Shoulder hemiarthroplasty for acute fractures of the proximal humerus: a minimum five-year follow-up
J Shoulder Elbow Surg
(2008)
P. Boileau et al.
Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus
J Shoulder Elbow Surg
(2002)
M.J. Boyle et al.
Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures
J Shoulder Elbow Surg
(2013)
J.F. Cazeneuve et al.
Long term functional outcome following reverse shoulder arthroplasty in the elderly
Orthop Traumatol Surg Res
(2011)
C.R. Constant et al.
A review of the Constant score: modifications and guidelines for its use
J Shoulder Elbow Surg
(2008)
E.T. Ek et al.
Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years
J Shoulder Elbow Surg
(2013)
E. Esen et al.
Factors affecting results of patients with humeral proximal end fractures undergoing primary hemiarthroplasty: a retrospective study in 42 patients
Injury
(2009)
D. Gallinet et al.
Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty
J Shoulder Elbow Surg
(2013)
D. Gallinet et al.
Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases
Orthop Traumatol Surg Res
(2009)

C.M. Grönhagen et al.

Medium-term results after primary hemiarthroplasty for comminute proximal humerus fractures: a study of 46 patients followed up for an average of 4.4 years

J Shoulder Elbow Surg

(2007)

B. Lanting et al.

Proximal humeral fractures: a systematic review of treatment modalities

J Shoulder Elbow Surg

(2008)

M.A. Mighell et al.

Outcomes of hemiarthroplasty for fractures of the proximal humerus

J Shoulder Elbow Surg

(2003)

M.P. Noyes et al.

Functional and radiographic long-term outcomes of hemiarthroplasty for proximal humeral fractures

J Shoulder Elbow Surg

(2011)

P. Olerud et al.

Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial

J Shoulder Elbow Surg

(2011)

J. Sanchez-Sotelo et al.

Radiographic assessment of uncemented humeral components in total shoulder arthroplasty

J Arthroplasty

(2001)

I.S. Talkhani et al.

Movement analysis of asymptomatic normal shoulders: a preliminary study

J Shoulder Elbow Surg

(2001)

D.E. Beaton et al.

Development of the QuickDASH: comparison of three item-reduction approaches

J Bone Joint Surg Am

(2005)

Cited by (258)

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.
Poor midterm clinical outcomes and a high percentage of unsatisfying results are reported after seizure-related shoulder injuries, especially after posterior proximal humerus fracture-dislocations
2024, Journal of Shoulder and Elbow Surgery
Treating seizure-related shoulder injuries is challenging, and an evidence-based consensus to guide clinicians is lacking. The aim of this prospective single-center observational clinical trial was to evaluate the clinical results of a cohort of patients undergoing treatment of seizure-related shoulder injuries, to categorize them according to the lesion’s characteristics, with special focus on patients with proximal humerus fracture-dislocations (PHFDs), and to define groups at risk of obtaining unsatisfactory results. We hypothesized that patients with a PHFD, considered the worst-case scenario among these injuries, would report worse clinical results in terms of the quick Disabilities of the Arm, Shoulder, and Hand questionnaire (qDASH) as compared to the other patients.
Patients referred to a tertiary epilepsy center who have seizure-related shoulder injuries and with a minimum follow-up of 1 year were included. A quality-of-life assessment instrument (EQ-5D-5L), a district-specific patient-reported outcome measure (qDASH), and a pain assessment tool (visual analog scale [VAS]) were used for the clinical outcome evaluation. Subjective satisfaction and fear of new shoulder injuries was also documented. Categorization and subgroup analysis according to the presence and features of selected specific lesions were performed.
A total of 111 patients were deemed eligible and 83 were available for follow-up (median age 38 years, 30% females), accounting for a total of 107 injured shoulders. After a median follow-up of 3.9 (1.6-8.2) years, overall moderate clinical results were reported. In addition, 34.1% of the patients reported a VAS score ≥35 mm, indicating moderate to severe pain, and 34.1% a qDASH score ≥40 points, indicating severe disability of an upper limb. These percentages rose to, respectively, 45.5% and 48.5% in the subgroup of patients with PHFDs and to 68.8% and 68.8% in patients experiencing posterior PHFD. Overall, 46.9% of the patients considered themselves unsatisfied with the treatment and 62.5% reported a persistent fear of a new shoulder injury.
Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. Older age, male sex, and absence or discontinuation of antiepileptic drug (AED) treatment were identified as characterizing features of patients with posterior dislocation episodes. In patients with PHFD, a tendency to worse clinical results was observed, with posterior PHFD patients emerging as a definite subgroup at risk of reporting unsatisfying results after treatment.
Longitudinal changes in shoulder arthroplasty stratified by age groups, types of surgical facilities, and geographical regions in Korea from 2010 to 2020
2023, Journal of Shoulder and Elbow Surgery
Shoulder arthroplasty (SA), including hemiarthroplasty, reverse and anatomical total SA (TSA), improves quality of life by reducing shoulder pain and restoring function in patients not only with irreparable rotator cuff tears and/or cuff tear arthropathy but also with osteoarthritis posttraumatic arthritis, proximal humeral fractures, etc. Given the rapid developments in artificial joints and improvements in postoperative outcomes, the number of SA surgeries is increasing worldwide. Therefore, we investigated changes in trends over time in Korea.
We analyzed the longitudinal changes in the incidence of SA including anatomic and reverse TSA, hemiarthroplasty, and shoulder revision arthroplasty (SRA) by changes in the Korean age profile, surgical facilities, and geographical regions using the Korean Health Insurance Review and Assessment Service database from 2010 to 2020. Data were also collected from the National Health Insurance Service and the Korean Statistical Information Service.
From 2010 to 2020, the TSA rate per 1,000,000 person-years increased from 10.571 to 101.372 (time trend = 1.252; 95% CI 1.233-1.271, P < .001). The shoulder hemiarthroplasty (SH) rate per 1,000,000 person-years decreased from 6.414 to 3.685 (time trend = 0.933; 95% CI 0.907-0.960, P < .001). The SRA rate per 1,000,000 person-years increased from 0.792 to 2.315; the increase was significant (time trend = 1.133; 95% CI 1.101-1.166, P < .001).
Overall, TSA and SRA are increasing and SH is decreasing. For both total TSA and SRA, steep increases are evident in the numbers of patients in their 70s and older than 80 years. The SH trend is decreasing regardless of differences in age groups, surgical facilities, and geographical regions. SRA is preferentially performed in Seoul.
A network meta-analysis of multiple modalities for the treatment of complex proximal humeral fractures in older adults
2023, Injury
Four principal treatment modalities are applied to treat complex proximal humeral fractures in older adults: conservative treatment, open reduction internal fixation, hemiarthroplasty, and reverse shoulder arthroplasty. However, among these, the optimal treatment modality has yet to be determined. Therefore, a network meta-analysis was carried out to compare treatment modalities and assess their effectiveness.
The databases PUBMED, EM-BASE, the Cochrane Central Register of Controlled Trials, Web of Science, and CNKI were searched for randomised controlled trials on complex proximal humeral fractures in older people, ranging from inception of each database to May 2023.
This meta-analysis included 14 randomised controlled trials, containing 791 patients aged over 60 years who were treated for complex proximal humeral fractures. Reverse shoulder arthroplasty and hemiarthroplasty yielded the highest Constant shoulder scores, whilst conservative treatment performed poorly. Hemiarthroplasty and open reduction internal fixation yielded the best performances on the visual analogue pain scale, whilst conservative treatment performed poorly. Reverse shoulder arthroplasty and open reduction internal fixation allowed for maximum forward flexion and outreach of range of motion, whilst hemiarthroplasty allowed for the least. Open reduction internal fixation and reverse shoulder arthroplasty allowed for maximum internal rotation of the range of motion, whilst conservative treatment allowed for the least. Hemiarthroplasty and conservative treatment allowed for maximum external rotation of the range of motion, whilst open reduction internal fixation allowed for the least.
Compared with open reduction internal fixation, reverse shoulder arthroplasty yields better Constant shoulder scores and allows for greater forward flexion and outreach of range of motion of the shoulder joint in complex proximal humerus fractures in older patients. Meanwhile, hemiarthroplasty yields the best visual analogue scale scores and allows for maximum external rotation of the range of motion. However, open reduction with internal fixation remains the preferred clinical treatment for complex proximal humeral fractures in older patients.
Why treatment of proximal humeral fractures remains unresolved despite randomized trials
2023, Injury
Most proximal humeral fractures can be treated nonoperatively, but there are specific indications to perform surgery for some of these fractures. Optimal treatment remains subject to debate, since no consensus has been reached for the best therapy for these fractures. This review provides an overview of randomized controlled trials (RCTs) comparing treatment for proximal humeral fractures. Fourteen RCTs comparing different operative and nonoperative types of treatment for PHF are included. Different RCTs comparing the same interventions for PHF have drawn different conclusions. It also highlights reasons why consensus has not been reached based on these data, and how this could be addressed in future research. Previous RCTs have included different patient groups and fracture patterns, may have been prone to selection bias, often were underpowered for subgroup analysis, and showed inconsistency in the outcome measures used. Based on this, and appreciating that treatment may be tailored to specific fracture types and patient characteristic like age, a better way to move forward could be to use a (international) multicenter prospective cohort study. Such a registry-type study should use accurate patient selection and enrollment, well-defined fracture patterns, standardized surgical techniques performed according to the preferences of the surgeon, and with a standardized follow-up.
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.

View all citing articles on Scopus

: This study was approved by the Comité Ético de Investigación Clínica (CEIC), Hospital Universitario de Elda (study reference number: PI2009-11), and informed consent was obtained.

View full text

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

Background

Methods

Results

Conclusion

Section snippets

Materials and methods

Baseline information

Discussion

Conclusions

Disclaimer

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

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

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Shoulder Elbow Surg

J Arthroplasty

J Shoulder Elbow Surg

Development of the QuickDASH: comparison of three item-reduction approaches

J Bone Joint Surg Am

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