In the JournalsPerspective

Reverse shoulder arthroplasty for fracture sequelae had better results after conservative care vs ORIF

Results showed reverse shoulder arthroplasty yielded better outcomes and fewer complications among patients who developed proximal humeral fracture sequelae after conservative treatment compared with open reduction and internal fixation.

Researchers recorded functional outcomes in 27 patients who underwent reverse shoulder arthroplasty (RSA) for treatment of proximal humeral fracture sequelae following either conservative treatment or open reduction and internal fixation (ORIF) from September 2006 to December 2013. Researchers also collected plain X-rays and a CT scan prior to surgery and plain X-rays after surgery and recorded all complications and reoperations during follow-up.

Although both groups experienced significantly increased Constant scores after surgery, results showed patients in the conservative group had significantly better outcomes for the total Constant score, forward elevation and external rotation. Researchers found patients in the conservative group had a mean postoperative forward elevation of 95° compared with 77° among patients in the ORIF group. Patients in the conservative treatment and ORIF groups also had a mean postoperative abduction of 74° and 68°, respectively. During the follow-up period, researchers noted an overall complication rate of 14.8%, with one infection in the conservative group and two dislocations and one infection in the ORIF group.

“Conservative treatment of acute proximal humeral fractures should be more frequently considered because, despite [that] RSA offers limited outcomes in patients with [proximal humeral fracture sequelae] PHFS, the complications of RSA after failed conservative treatments are low,” the authors wrote. “Therefore, indication for ORIF in acute proximal humeral fracture should be limited to those cases where a good outcome is likely, being especially cautious when indicating ORIF in elderly individuals.” – by Casey Tingle

Disclosures: The authors report no relevant financial disclosures.

Results showed reverse shoulder arthroplasty yielded better outcomes and fewer complications among patients who developed proximal humeral fracture sequelae after conservative treatment compared with open reduction and internal fixation.

Researchers recorded functional outcomes in 27 patients who underwent reverse shoulder arthroplasty (RSA) for treatment of proximal humeral fracture sequelae following either conservative treatment or open reduction and internal fixation (ORIF) from September 2006 to December 2013. Researchers also collected plain X-rays and a CT scan prior to surgery and plain X-rays after surgery and recorded all complications and reoperations during follow-up.

Although both groups experienced significantly increased Constant scores after surgery, results showed patients in the conservative group had significantly better outcomes for the total Constant score, forward elevation and external rotation. Researchers found patients in the conservative group had a mean postoperative forward elevation of 95° compared with 77° among patients in the ORIF group. Patients in the conservative treatment and ORIF groups also had a mean postoperative abduction of 74° and 68°, respectively. During the follow-up period, researchers noted an overall complication rate of 14.8%, with one infection in the conservative group and two dislocations and one infection in the ORIF group.

“Conservative treatment of acute proximal humeral fractures should be more frequently considered because, despite [that] RSA offers limited outcomes in patients with [proximal humeral fracture sequelae] PHFS, the complications of RSA after failed conservative treatments are low,” the authors wrote. “Therefore, indication for ORIF in acute proximal humeral fracture should be limited to those cases where a good outcome is likely, being especially cautious when indicating ORIF in elderly individuals.” – by Casey Tingle

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    April D. Armstrong

    April D. Armstrong

    I read with interest “Reverse shoulder arthroplasty for fracture sequelae: How the initial fracture treatment influences the outcomes of joint replacement.” Although the sample size is small in this case series, I think that this preliminary data challenges us to ask the question, “Why is there a difference between the two groups?” In future studies with larger numbers, for instance, we will need to explore the effect of the fracture sequelae type and tuberosity quality and alignment (ie, how did the two groups specifically differ with respect to the tuberosities?), the impact of two surgeries on the deltoid and other patient parameters which could affect outcome.

    I think most would agree that the tuberosity plays an important role in outcome. In fact, ORIF may not be inferior to conservative treatment if the tuberosity actually healed in a better position after ORIF compared to a nonoperatively treated shoulder with tuberosity left medialized and displaced.

    • April D. Armstrong, BSc(PT), MSc, MD, FRCSC
    • James E. Bobb Professor in Orthopedics and Rehabilitation
      Vice chair, clinical affairs and quality
      Chief, shoulder and elbow surgery
      Penn State Milton S. Hershey Medical Center
      Bone and Joint Institute
      Hershey, Pennsylvania

    Disclosures: Armstrong reports she is a consultant for Zimmer Biomet and Globus.