Shoulder & Elbow

Non-operative management for complex proximal humeral fractures: is reverse shoulder arthroplasty the challenger?

X-ref

The literature on the role of reverse shoulder arthroplasty for fractures of the proximal humerus is increasing. A large data study we recently discussed in 360 documented an almost threefold increase in the use of primary reverse shoulder arthroplasty for fractures of the proximal humerus.⁶ This potentially poses the awkward question: is reverse shoulder arthroplasty the next potential comparator with non-operative treatment for these complex fractures, particularly given the recent results of the PROFHER study? ⁷ This is the question posed by authors from Greenville, South Carolina (USA) who, realising that there are no comparative series of reverse total shoulder arthroplasty operative versus non-operative treatments in the literature, set out to fill the evidence gap with their own retrospective review of all three- and four-part proximal humeral fractures treated with either reverse shoulder arthroplasty or non-operative treatment.⁸ The study is reported to a minimum one-year follow-up, although of course there is some significant selection bias. Nonetheless, this series is better than some in that all patients in the non-operative cohort were offered RSA but declined. Outcomes were reported through both a notes review and extensive patient-reported outcomes obtained at follow-up, including the Visual Analogue Scale (VAS) score, Single Assessment Numeric Evaluation (SANE) score, Penn Shoulder Score (PSS), American Shoulder and Elbow Surgeons (ASES) score, resiliency score, and Veterans Rand 12-Item Health Survey (VR-12) score. A total of 39 patients (20 reverse shoulder, 19 non-operative) were included in the study, although there was some marked difference in the follow-up intervals (29 months in non-operative group and 53 months in reverse shoulder group). The authors (despite the plethora of outcome measures) were unable to find any differences in any of the patient-reported outcome scores or range of movement. This is one of those interesting papers where, despite every attempt to demonstrate an advantage, the authors concluded that there were only minimal benefits for reverse shoulder arthroplasty. Once again, for these complex fractures, non-operative management is yet to be outdone. This is a very small study with some significant limitations and, although there is clearly a role for reverse shoulder arthroplasty for these complex injuries, in light of these results the indications are somewhat unclear and longer-term outcome data alongside larger studies are clearly needed here.

Reverse total shoulder arthroplasty: a follow-up of a previous study

As summarised succinctly in our feature this month, there are some significant potential benefits to the reverse prosthesis, and although the short-term results in the literature are good, longer-term objective clinical studies are conspicuous by their absence. We were delighted to read the results of this study from Tours (France) which reports the longer-term outcomes at a minimum of ten years of follow-up for a previously reported series of 191 reverse shoulder arthroplasties.⁹ There were 87 prostheses available to report at a mean follow-up of 150 months. The authors had lost 17 prostheses to follow-up and 79 patients had died before the ten-year mark. The overall ten-year revision rate in this series was 93% using revision for any cause as an endpoint. In terms of functional scores, the outcomes were significantly poorer than the mid-term follow-up reported from the same series, with a relative constant score of 86 points (absolute score 55 points). In terms of undesirable complications, the majority (73%) of shoulders exhibited scapular notching, and a third of patients had an operative complication. Although the longer-term outcomes reported by this study were good as regards the selected endpoint of revision, there is one significant problem: when taken in combination with the poor functional results and deterioration since mid-term follow-up, this series represents a group of patients whose shoulders have clinically failed or are failing. However, with no feasible revision option beyond the reverse, they are then not revised and consequently not counted as a ‘success’.