Shoulder & Elbow

Reverse shoulder arthroplasty on the rise for operatively managed proximal humeral fractures

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The reverse shoulder arthroplasty (RSA) is a procedure which seems to be increasing in application. There is no doubt from the small studies in existence that an excellent result can be achieved in the short term for a range of pathologies. However there is still some way to go as far as proving the longer-term advantages, or indeed the longevity of these replacements, when compared with traditional arthroplasties. There is an increasing amount of literature reporting on the use of RSA for fractures of the proximal humerus, but the national trends are still to be established. This large study from Fort Lauderdale, Florida (USA) includes the coded outcomes for 32 150 operatively managed proximal humeral fractures in the Medicare patient population database. The authors evaluated the trends and changes in treatment choice over the four-year period (2009 to 2012). There were no apparent significant changes in the number of fractures managed each year, however, the rate of surgical intervention declined significantly by 14%. Although open reduction and internal fixation was employed consistently, there was an almost threefold rise (11% to 28%) in the use of primary RSA with a corresponding significant decrease in the use of hemiarthroplasty (52% to 39%). Interestingly, the rise in the use of RSAs was seen both in patients older than 65 years of age (11% to 29%, almost threefold) and in those younger than 65 years (doubling, from 6% to 12%). With the recent results of the Proximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) study³ reporting no difference in outcome at two years for displaced proximal humeral fractures managed operatively or non-operatively, it will be interesting to see if the operative decline reported in this study continues when subsequent years are analysed. Although the proportionate use of RSA is on the rise for proximal humeral fractures, the indications and long-term outcome are still to be fully defined.