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Reverse Total Shoulder Arthroplasty for a 4-Part Proximal Humerus Fracture

Stahl, Dan MD; Fuente, Guadalupe de la MD

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Journal of Orthopaedic Trauma: August 2016 - Volume 30 - Issue - p S9-S10
doi: 10.1097/BOT.0000000000000607
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Proximal humerus fractures account for approximately 5% of all fractures and they are the third most common fracture seen in the elderly population.1,2 Within the elderly and after high-energy mechanisms, these fractures can be highly comminuted.1 Poor bone quality and the high incidence of rotator cuff tears in the elderly contribute additional concerns in determining the appropriate treatment.3 When using the Neer classification system, complex 3 and 4-part proximal humerus fractures are known to be challenging fractures to manage. This has been demonstrated through both closed and open reduction techniques. Therefore, they have traditionally been amendable to shoulder hemiarthroplasty. However, several limiting factors, including poor patient satisfaction, 61%–62%, and low functional outcomes have guided further exploration for other treatment options.4 Reverse shoulder arthroplasty (RSA) has began to have a role in the management of acute proximal humerus fractures in addition to its traditional indications of rotator cuff arthropathy, massive rotator cuff tears, failed shoulder arthroplasties, and proximal humerus fracture sequelae.

Managing fractures of the proximal humerus requires a complete understanding of each fragment and the deforming forces involved to create the radiographic images which dictate treatment. The humeral head will typically be in either a varus or valgus position. The valgus type of proximal humerus fracture will include humeral head impaction into the metaphysis along with fractures of the greater and or lesser tuberosities. The greater tuberosity is subject to superior migration by the supraspinatus and can also be pulled posteriorly by the infraspinatus muscle, whereas the lesser tuberosity is shifted medially by the pull of the subscapularis muscle. The varus type of fracture is typically more unstable because of the amount of comminution along the medial and lateral cortices.5 Deforming forces include the supraspinatus that will pull the humeral head into a varus position and the pectoralis major, which will pull the humeral shaft medially. Although these concepts are crucial to open reduction and internal fixation techniques, they apply to tuberosity fixation that has been shown to be important in both shoulder hemi and total arthroplasties. Tuberosity fixation, especially with hemiarthroplasty, is associated with improved functional outcomes.

The functional outcomes associated with shoulder hemiarthroplasty have shown to be unpredictable and are less pronounced when compared with RSA when used in similar patient populations. Three important concepts in shoulder hemiarthroplasty are maintaining an appropriate humeral head height, humeral version, and most importantly, tuberosity fixation. Shoulder hemiarthroplasty is heavily dependent on tuberosity fixation for positive functional outcomes. However, tuberosity malposition has been reported to occur in up to 50% of hemiarthroplasty procedures.6 This malposition is associated with higher dissatisfaction rates, reduced range of motion, and persistent pain. In contrast to hemiarthroplasty, RSA procedures are not as heavily dependent on anatomic tuberosity fixation.7 Tuberosity fragments were initially excised and good functional outcomes were reported, but additional studies have reported improved range of motion, specifically external rotation, with tuberosity fixation in RSA.8 Studies of external rotation in RSA have been reported from 20 to 33 degrees. Plus, the reports of improved functional outcomes after RSA are more consistent throughout the literature.9

A satisfactory outcome in the management of proximal humerus fractures has been defined as an active forward elevation (AFE) greater than 90 degree, and hemiarthroplasty has been associated with a satisfactory outcome in less than 50% in one study.10 When comparing the AFE in RTSA to hemiarthroplasty, the AFE was reported to be an average of 122 degrees (range, 90–145 degree) in the RTSA group and 90 degree (range, 30–140 degree) in the hemiarthroplasty group. Within the same study, ER was not statistically significant between the 2 groups, (33 vs. 31 degrees, RTSA vs. hemiarthroplasty).4 However, there have not been any randomized controlled trials comparing hemiarthroplasty, open reduction internal fixation, and RTSA in the treatment of complex proximal humerus fractures.

RTSA has shown to provide reproducible functional outcomes and is a good treatment option for elderly patients with 3-part and 4-part proximal humerus fractures. The supplied video demonstrates a 4-part proximal humerus fracture with a head split that is detailed in preoperative radiographs. During the procedure, tuberosity fixation is performed as this has been associated with improved external rotation. These healed fragments are highlighted in the follow-up radiographs. Plus, postoperative clinical videos show a patient performing AFE greater than 90 degrees with minimal pain.


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5. Gallinet D, Adam A, Gasse N, et al. Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2013;22:38–44.
6. Gallinet D, Clappaz P, Garbuio P, et al. Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases. Orthop Traumatol Surg Res. 2009;95:48–55.
7. Garrigues GE, Johnston PS, Pepe MD, et al. Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients. Orthopedics. 2012;35:e703–708.
8. Mata-Fink A, Meinke M, Jones C, et al. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. J Shoulder Elbow Surg. 2013;22:1737–1748.
9. Neviaser RJ, Resch H, Neviaser AS, et al. Proximal humeral fractures: pin, plate, or replace. Instr Course Lect. 2015;64:203–214.
10. Ross M, Hope B, Stokes A, et al. Reverse shoulder arthroplasty for the treatment of three-part and four-part proximal humeral fractures in the elderly. J Shoulder Elbow Surg. 2015;24:215–222.

reverse shoulder arthroplasty; proximal humerus fracture; tuberosity fixation

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