Background: The ageing of the population is steadily increasing the frequency of displaced proximal humerus fractures (PHFs) in elderly patients. The last decade has seen a shift from hemi-arthroplasty (HA) to reverse shoulder arthroplasty (RSA) in these patients. The primary objective of this study was to assess short- and long-term outcomes of RSA in a large cohort of elderly patients with recent PHFs. The secondary objectives were to evaluate radiological outcomes and short- and long-term morbidity and mortality rates.
Hypothesis: Outcomes of RSA to treat PHFs in older patients are satisfactory, reliable, and sustained over time.
Material and methods: This retrospective multi-centre study included 898 patients with a mean age of 79 years, among whom 422 underwent a standardised clinical and radiological evaluation at least 1 year after RSA. Some patients were re-evaluated twice. An evaluation within the first 5 years was available for 420 patients (≤5-Y group), whereas 119 patients were re-evaluated more than 5 years after RSA (>5-Y group). Some patients had one re-evaluation either within or after 5 years and others had both an early and a late re-evaluation; thus the total number of re-evaluation was greater than the number of patients.
Results: Mean active forward elevation was 115°±29°, mean external rotation with the elbow by the side was 17°±19°, mean internal rotation (hand-to-back) was 4.3±2.5 points, mean absolute Constant score was 57±15, and mean Subjective Shoulder Value was 70%±18%. Re-implantation of the tuberosities followed by healing in the anatomical position was associated with significantly better outcomes, notably regarding rotations. Even in the absence of healing in the anatomical position, tuberosity repair was associated with better clinical outcomes compared to tuberosity excision. Humeral loosening occurred in 3.5% of patients and was associated with tuberosity excision. Glenoid loosening was seen in 3.5% of patients and was associated with superior tilt of the glenoid component. The main complication was prosthesis instability, which occurred in 2.5% of patients, a proportion similar to that seen in the general population. Post-operative patient survival was not significantly different from that in the general population of the same age. Prosthesis survival was 91% after 20 years.
Conclusion: Clinical outcomes of RSA for PHF in elderly patients were not only satisfactory but also reproducible and sustained over time. Tuberosity re-implantation around the prosthesis is the key step for optimising the functional outcomes, notably by restoring rotations and decreasing the risk of complications (prosthesis instability and humeral loosening).
Level of evidence: IV, retrospective observational study.
Keywords: Fracture; Reverse shoulder arthroplasty; Shoulder; Tuberosity repair.
Copyright © 2019 Elsevier Masson SAS. All rights reserved.