Reverse shoulder arthroplasty for proximal humerus fracture using a dedicated stem: radiological outcomes at a minimum 2 years of follow-up—case series
© Garofalo et al. 2015
Received: 31 May 2015
Accepted: 12 July 2015
Published: 22 August 2015
Complex proximal humeral fractures are very difficult to treat particularly in patients older than 65 years with an osteoporotic bone and tuberosities compromised. The goal of this paper is to evaluate radiological outcomes at mid-term follow-up of proximal humerus fractures treated with reverse shoulder arthroplasty using a dedicated fracture stem.
Materials and methods
The study population included 98 patients who underwent reverse shoulder with a dedicated fracture stem for an acute proximal humerus fracture; 87/98 patients were available for analysis. There were 62 female and 25 male patients, and the mean age was 76.2 years at the time of surgery (range 61–90 years). Clinical and radiological outcomes were evaluated at a mean follow-up of 27 months after surgery.
Average active elevation was 137.7°, external rotation 29.1°, and internal rotation 40.7°. Overall, the tuberosity healing rate was 75 %. There was a significant increase in active anterior elevation, external rotation, and internal rotation among patients who demonstrated radiographic evidence of tuberosity healing. All tuberosity nonunions (21 cases) occurred preferentially in females, but this number did not reach statistical significance.
RSP using a dedicated stem is a very viable solution to treat complex humerus proximal fracture. Reliable restoration of elevation can be expected. However, in patients in whom tuberosity healing occurs, a better active elevation other than restoration of active rotational movement can be observed.
The majority of proximal humerus fractures in patients over the age of 65 are minimally displaced and can be treated nonoperatively with satisfactory clinical outcomes . However, certain fractures in this age population requiring surgical treatment are often not amenable to repair because of poor bone quality, potential loss of fixation, and a high risk of nonunion or osteonecrosis. In these cases, primary arthroplasty is a viable option. Hemiarthroplasty (HA) has historically been considered the standard of care for patients greater than 65 years of age in whom arthroplasty is performed for proximal humerus fracture. Clinical studies have demonstrated a significative advantage in terms of pain and quality of life after HA compared with nonoperative treatment for displaced proximal humerus fractures in the elderly . However, HA for fracture remains a challenging procedure as clinical outcomes are largely influenced by proper implant placement and tuberosity healing which has yielded unpredictable results with respect to functional outcomes [3–7].
Recently, reverse shoulder arthroplasty (RSA) has emerged as an alternative option for the treatment of acute, comminuted proximal humeral fractures in elderly patients [8–10]. RSA is an attractive option in this population because the design does not rely on a functioning rotator cuff for overhead shoulder range of motion. Furthermore, patients with RSA typically require less intensive and prolonged physical therapy to regain functional shoulder range of motion . The purpose of this study was to evaluate mid-term clinical and radiographic outcomes in a cohort of elderly patients treated with RSA using a dedicated fracture stem for an acute proximal humerus fracture. Our hypothesis was that RSA with a dedicated fracture stem leads to satisfactory clinical outcomes that can be correlated to the presence of radiographic healing of the greater tuberosity.
Materials and methods
Radiographs were also used to judge implant loosening on the humeral or glenoid side as well as scapular notching. Humeral component loosening was measured using the grading system described by Sperling . Glenosphere and baseplate fixation was graded in a manner previously described as stable, at risk, or loose . Scapular notching was measured using the grading system of Sirveaux et al. .
Statistical analysis was performed using SPSS (Statistical Package for the Social Sciences) software. Continuous data were evaluated using two-tailed unpaired t tests to compare the equality of variance. Categorical data was analyzed using chi-square and Fisher’s exact tests. Regression analysis was performed to assess correlation for Pearson’s correlation coefficient. Statistical significance was indicated at p < 0.05. Active shoulder ROM was correlated with the presence of radiographic healing of the greater tuberosity.
This retrospective study was approved by the Institutional Ethics Committee of Miulli Hospital and was conducted in accordance with the latest version of the Helsinki Declaration. All patients were informed about the study and signed an informed consent form.
Postoperatively, patients are placed in a sling for 5 weeks. Immediate passive motion is started with flexion to 90° and external rotation to 30°. Full passive forward flexion begins at week 5. Active assisted motion in all planes is initiated starting at week 7. At this time, the use of arm for light home activities was allowed.
Clinical outcome about the range of motion data at final follow-up
Range of motion
135.2 ± 31.5
33.5 ± 15.6
39 ± 17.3
138.2 ± 20.9
28.1 ± 14.7
41.1 ± 21.5
145.3 ± 19.3
34.3 ± 11.8
45.6 ± 18.9
114.1 ± 15.8
12.9 ± 11.6
25.7 ± 19.1
Comparison of tuberosity healing with gender and age
75.6 ± 7
78.1 ± 8.6
Surgical management for displaced three- and four-part proximal humeral fractures in the elderly remains a challenge. Despite the advent of locking plate technology, open reduction and internal fixation (ORIF) of complex proximal humeral fractures in this group of patients is often not a viable option because of high complication rates .
For many years, HA has been considered the standard for the treatment of complex, displaced proximal humeral fractures in the elderly. However, HA carries its own set of technical challenges including proper prosthetic height, version, and tuberosity fixation. These are all critical factors to ensure a satisfactory functional outcome, and dedicated fracture stems have been previously shown to improve radiographic tuberosity healing rates and functional outcomes [3, 16].
The main findings of previous and the present study are reported
Active forward elevation (mean degree)
Active external rotation (mean degree)
Percentage of GT healing
Gallinet et al. 
Garrigues et al. 
Lenarz et al. 
Sirveaux et al. 
Cazeneuve et al. 
Bufquin et al. 
Klein et al. 
Cuff et al. 
145 (GT healed)
34.3 (GT healed)
114 (GT not healed)
12.9 (GT not healed)
In our series, performing RSA with a dedicated fracture stem for the treatment of acute proximal humerus fractures resulted in a radiographic tuberosity healing rate of 75 %. Contrary to previous reports, we found that tuberosity healing is associated with significantly better active forward flexion, internal rotation, and external rotation. Patients in which the tuberosity was not healed still demonstrated satisfactory range of motion that is similar to previous reports in the literature. It is interesting to note that all cases of tuberosity nonunion/resorption were observed in female patients only which may be a result of poorer bone quality with less capacity for healing.
This study does have several weaknesses. We performed a retrospective evaluation of patients with no control group. Patients included were operated on by two different surgeons which may predispose to subtle differences in the execution of critical components of the procedure that otherwise may have affected the final outcome.
In summary, RSA using a dedicated fracture stem results in satisfactory range of motion at mid-term follow-up in the surgical treatment of displaced proximal humerus fractures in elderly patients. Radiographic tuberosity healing appears to result in improved active range of motion in all planes.
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