CORR Insights®: In-hospital Complications Are More Likely to Occur After Reverse Shoulder Arthroplasty Than After Locked Plating for Proximal Humeral Fractures

Following the introduction of the locking plates in the United States during the early 2000s, there was a relative increase in the use of open reduction and internal fixation (ORIF) for proximal humerus fractures among Medicare beneficiaries, despite a stable incidence of these fractures [²]. Similarly, after FDA approval of reverse total shoulder arthroplasty (RTSA) for rotator cuff–deficient arthritis, its use among older patients in the setting of complex proximal humerus fractures has increased dramatically [¹¹]. Although these two approaches are the most commonly utilized surgical interventions for displaced proximal humerus fractures, many studies on outcomes and complications have focused primarily on individual implant-specific issues and frequency of reoperation [^{6, 12}]. Less work has been done comparing the medical and surgical complication risks between these two techniques directly [⁴].

Köppe and colleagues [⁵] used a large insurance claims database in Germany and found that the risk for major in-hospital adverse medical events and perioperative surgical complications among patients older than 65 years of age was higher for those undergoing RTSA than among those who underwent locked plating. The authors also demonstrated that the in-hospital and 30-day mortality risk following RTSA was not different than that after locked plating, even after adjusting for age, sex, and comorbidities. They concluded that selection of treatment for proximal humerus fractures in patients over 65 years of age, particularly with regard to RTSA, should be individualized based on patient risk assessment. Their well-done study represents the largest comparative assessment of short-term complications between RTSA and locked plating.

The findings of the current study are somewhat unexpected given prior publications reporting on the significant mid-term complication and reoperation risk following the use of locked plating for proximal humerus fractures [¹²]. In light of these results, surgeons treating patients older than 65 years of age with proximal humerus fractures that are indicated for surgical intervention may need to reconsider the routine use of RTSA over locked plating until consistent evidence emerges and demonstrates an advantage of RTSA over ORIF, particularly regarding functional outcomes or risk for reoperation.