Clinical and radiographic long-term outcomes of hemiarthroplasty for complex proximal humeral fractures.

BACKGROUND: Hemiarthroplasty (HA) is a treatment option for complex proximal humeral fractures not suitable for conservative treatment or open reduction-internal fixation. Long-term outcomes using a large-metaphyseal volume prosthesis in the management of proximal humeral fractures have not been reported thus far. METHODS: Between 2006 and 2010, 41 patients with proximal humeral fractures were treated with HA at our institution (average age, 62 years; age range, 38-85 years). Nine patients underwent revision surgery, 3 were lost to follow-up, and 7 died unrelated to the index surgical procedure. Twenty-two patients were reviewed clinically and radiographically after a mean period of 10.4 years (range, 9-13 years). RESULTS: Of the 9 HA failures, 7 occurred within the first 2 postoperative years: 2 patients had infections and 5 had greater tuberosity nonunions or malunions. The other 2 patients underwent revision for rotator cuff deficiency >5 years after initial surgery. Among the patients available for final follow-up, the implant survival rate was 71% (22 of 31 patients). At final follow-up, these patients showed a mean relative Constant score of 76% (range, 49%-96%), mean active elevation of 116° (range, 60°-170°), and mean external rotation of 28° (range, 0°-55°). The majority had good or excellent internal rotation, with internal rotation to the 12th thoracic vertebra in 13 patients (59%) and to the eighth thoracic vertebra in 7 (31%). The mean Subjective Shoulder Value was 76% (range, 40%-100%). Clinical outcomes did not significantly deteriorate over a period of 10 years, except for flexion (P < .001) and internal rotation (P = .002). On analysis of greater tuberosity healing, 1 patient had a nonunion and 10 patients (45%) had a malunion, whereas the greater tuberosity had healed in an anatomic position in 12 patients (55%). Patients with a displaced malunion of the greater tuberosity did not have inferior clinical results at last follow-up. Only 2 patients showed glenoid erosion, and in no patients could stem loosening be identified at final follow-up. CONCLUSION: The revision rate following large-metaphyseal volume HA to treat a proximal humeral fracture was 29% after 10 years postoperatively, with failure within 2 years largely related to greater tuberosity nonunion or malunion and failure later related to rotator cuff insufficiency. Patients with a retained implant showed good clinical and radiographic long-term results, without relevant deterioration over time even when the greater tuberosity healed in a nonanatomic position.

Clinical and radiological outcome following trauma-related reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is a frequently used therapy for complex proximal humeral fractures and posttraumatic disorders. The present study's purpose was to assess the clinical and radiological outcome of primary and secondary RSA, and to analyze the impact of refixation of the greater tuberosity (GT). PATIENTS AND METHODS: 28 patients with primary fracture RSA and 18 patients with RSA due to posttraumatic disorders were examined with a mean clinical follow-up of 2.5 ± 1.73 years. Operative details and radiographs were retrospectively reviewed. Additional analyses were performed for healed and non-healed GT in primary RSA. RESULTS: Patients with fracture RSA had higher Constant-Murley score (CMS) than secondary RSA without reaching significance (p = 0.104). No significant difference was present for the quality of life measured by the Short Form 36 (SF 36) and the range of motion. In primary RSA, 78.6% GT healed anatomically. Compared to non-healed GT, patients with healed GT had a significantly higher CMS (p = 0.011), external rotation (p = 0.026) and forward flexion (p = 0.083), whereas DASH score was lower without a significant difference (p = 0.268). SF 36 showed no significant difference. Patients with healed GT had a more neutral glenoid version (p = 0.009). CONCLUSION: Superior range of motion and clinical outcome scores were present for anatomically healed GT. Therefore, refixation of the tuberosities is recommended. Secondary RSA can result in inferior results compared to primary RSA, so patients need to be adequately informed.

Tuberosity refixation improves functional outcome following primary reverse shoulder arthroplasty in proximal humeral fracture.

INTRODUCTION: The purpose of this prospective study was to examine clinical results of tuberosity refixation in RSA for the treatment of displaced PHF in elderly patients. We hypothesized that tuberosity refixation would increase clinical outcome. METHODS: In this prospective study, 50 patients were included after receive a primary RSA for complex proximal humeral fracture between March 2013 and December 2015 for follow-up after three, 12 and 24 months. A functional and radiological assessment was performed on the patients. RESULTS: At final follow-up after a mean period of 25.1 months, data were available for 30 women and 6 men (74% of the included overall study collective) with a mean age of 77 years (range 55-93 years) at time of surgery. The tuberosities were refixated in 74% (n = 37) and in 26% (n = 13) resected. RSA with tuberosity refixation resulted in better clinical shoulder function compared to RSA with non-refixated tuberosities. The data show an external rotation with a significant difference (24.9° vs. 14°, p < 0.05) in favor of participants with refixation. The raw CMS was statistically significant (71.3 vs. 56.3, p < 0.05) after refixation, and SSV was significant improved (82.7% vs. 68%, p < 0.05) in the same group. Among 3 of 50 patients a total of 3 complications occurred with a total of 6% surgical revision. CONCLUSIONS: In this prospective study, tuberosity refixation as part of fracture treatment using RSA results in better external rotation, subjective assessment of shoulder recovery (measured by SSV and by raw CMS) in elderly patients, compared with tuberosity excision. LEVEL OF EVIDENCE: II, Prospective comparative study.

Treatment of proximal humerus fractures using reverse shoulder arthroplasty: do the inclination of the humeral component and the lateral offset of the glenosphere influence the clinical outcome and tuberosity healing?

INTRODUCTION: The employment of reverse shoulder arthroplasty for dislocated proximal humerus fractures of elderly patients becomes increasingly relevant. The standard inclination angle of the humeral component was 155°. Lately, there is a trend towards smaller inclination angles of 145° or 135°. Additionally, there has been an increased focus on the lateralization of the glenosphere. This retrospective comparative study evaluates clinical and radiological results of patients treated for proximal humerus fractures by reverse shoulder arthroplasty with different inclination angles of the humeral component, which was either 135° or 155°. Additionally, a different lateral offset of the glenosphere, which was either 0 mm or 4 mm, was used. METHODS: For this retrospective comparative analysis, 58 out of 66 patients treated by reverse total shoulder arthroplasty for proximal humerus fractures were included. The minimum follow-up was 24 months. Thirty (m = 3, f = 27; mean age 78 years; mean FU 35 months, range 24-58 months) were treated with a standard 155° humeral component and a glenosphere without lateral offset (group A), while 28 patients (m = 2, f = 26; mean age 79 years; mean FU 30 months, range 24-46 months) were treated with a 135° humeral component and a glenosphere with a 4 mm lateral offset (group B). We determined range of motion, Constant score, and the American Shoulder and Elbow Surgeons Shoulder score as clinical outcomes and evaluated tuberosity healing as well as scapula notching. RESULTS: Neither forward flexion (A = 128°, B = 121°; p = 0.710) nor abduction (A = 111°, B = 106°; p = 0.327) revealed differences between the groups. The mean Constant Score rated 63 in group A, while it was 61 in group B (p = 0.350). There were no differences of the ASES Score between the groups (A = 74, B = 72; p = 0.270). There was an increased risk for scapula notching in group A (47%) in comparison to group B (4%, p = 0.001). Healing of the greater tuberosity was achieved in 57% of group A and in 75% of group B (p = 0.142). The healing rate of the lesser tuberosity measured 33% in group A and 71% in group B (p = 0.004). CONCLUSIONS: Both inclination angles of the humeral component are feasible options for the treatment of proximal humerus fractures in elderly patients. Neither the inclination angle nor the lateral offset of the glenosphere seem to have a relevant influence on the clinical outcome. The healing rate of the lesser tuberosity was higher in implants with a decreased neck-shaft angle. There is an increased risk for scapula notching, if a higher inclination angle of the humeral component is chosen. LEVEL OF EVIDENCE: III. Retrospective comparative study.

High tuberosity healing rate associated with better functional outcome following primary reverse shoulder arthroplasty for proximal humeral fractures with a 135° prosthesis.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is a common treatment for proximal humeral fractures. (PHF) in the elderly. This study evaluates the functional outcome and the influence of. tuberosity healing (TH) following RSA with 135° humeral inclination and a neutral glenosphere without lateralization for PHFs. METHODS: In this retrospective case series, all patients with an acute PHF treated with primary RSA with 135° humeral inclination and a standard glenosphere without lateralization during a four-year period were followed up. Constant score (CS), patient satisfaction (subjective shoulder value (SSV)), TH and glenoid notching were analyzed. RESULTS: 38 patients with a mean age of 77 ± 8 years were available for follow-up at 34 ± 5 months. The mean adjusted CS was 61 ± 9 points. TH of the greater tuberosity (GT) was 82% and resulted in significantly improved abduction (117° vs. 81°; P < 0.001), forward flexion (139° vs. 99°; p < 0.001), external rotation (28° vs. 10°; p = 0.002), CS (65 vs. 41 points; p < 0.001) and patient satisfaction (SSV 79% vs. 48%; p < 0.001). TH of the LT was 87% without affecting internal rotation or overall outcome. The complication- and revision rate was 5%; implant survival was 100%. Scapular notching occurred in 3 (8%) cases (all grade 1). CONCLUSION: RSA with 135° humeral inclination and a standard glenosphere for PHF leads to good functional outcome in combination with a high rate of TH and a low rate of scapular notching. The short-term revision rate is low and the results are predictable and continuous. TH is associated with improved ROM, patient satisfaction and functional outcome.

The role of greater tuberosity healing in reverse shoulder arthroplasty: a finite element analysis.

BACKGROUND: The lack of greater tuberosity (GT) healing in proximal humerus fractures has been negatively correlated with outcomes for hemiarthroplasty; however, there is still debate regarding the effects of GT healing in reverse shoulder arthroplasty (RSA). Our goal was to examine the effects of GT healing using a kinematic finite element analysis (FEA) model. MATERIAL AND METHODS: Computer-aided design models of a medialized glenoid with a lateralized humerus (MGLH) RSA design were uploaded into an FEA shoulder model in 2 different configurations: healed greater tuberosity (HGT) and nonunion greater tuberosity (NGT). Deltoid muscle forces and joint reaction forces (JRFs) on the shoulder were calculated during abduction (ABD), forward flexion (FF), and external rotation (ER). RESULTS: Force magnitude of the anterior, middle, and posterior deltoid muscle as well as JRFs modeled in both GT scenarios were similar for ABD (muscle forces P = .91, P = .75, P = .71, respectively; and JRF P = .93) and for FF (muscle forces P = .89, P = .83, P = .99, respectively; and JRF P = .90). For ER, the force magnitude between 2 GT settings showed statistically significant differences (HGT: 9.51 N vs. NGT: 6.13 N) (P < .001). Likewise, during ER, JRFs were different, and the NGT group showed a steep drop in JRF after 10° of ER (HGT: 28.4 N vs. NGT: 18.38 N) (P < .001). CONCLUSION: GT healing does not seem to impact RSA biomechanics during abduction or forward flexion; however, it does affect biomechanics during external rotation. Overall orthopedic surgeons can expect good results for patients after RSA even with poor GT healing.

A systematic review of tuberosity healing and outcomes following reverse shoulder arthroplasty for fracture according to humeral inclination of the prosthesis.

BACKGROUND: Proximal humerus fractures are common in the elderly population and are often treated with reverse shoulder arthroplasty (RSA). The purpose of this systematic review was to compare tuberosity healing and functional outcomes in patients undergoing RSA with humeral inclinations of 135°, 145°, and 155°. METHODS: A systematic review was performed of RSA for proximal humerus fracture using Preferred Reporting Items for Systemic Reviews and Meta-Analyses (PRISMA) guidelines. Radiographic and functional outcome data were extracted to evaluate tuberosity healing according to humeral inclination. Analysis was also performed of healed vs. nonhealed tuberosities. RESULTS: A total of 873 patients in 21 studies were included in the analysis. The mean age was 77.5 years (range of 58-97) and the mean follow-up was 26.2 months. Tuberosity healing was 83% in the 135° group compared with 69% in the 145° group and 66% in the 155° group (P = .030). Postoperative abduction was highest in the 155° group (P < .001). No significant difference was found in forward flexion, external rotation, or postoperative Constant score between groups. Patients with tuberosity healing demonstrated 18° higher forward flexion (P = .008) and 16° greater external rotation (P < .001) than those with unhealed tuberosities. CONCLUSION: RSA for fracture with 135° humeral inclination is associated with higher tuberosity healing rates compared with 145° or 155°. Postoperative abduction is highest with a 155° implant, but there is no difference in in postoperative forward flexion, external rotation, or Constant score according to humeral inclination. Patients with healed tuberosities have superior postoperative forward flexion and external rotation than those with unhealed tuberosities.

Tuberosity healing improves functional outcome following primary reverse shoulder arthroplasty for proximal humeral fractures with a 135° prosthesis.

INTRODUCTION: Reverse shoulder arthroplasty (RSA) is a common treatment for proximal humeral fractures (PHFs) in the elderly. This study evaluates the influence of tuberosity healing (TH) on functional outcome following a 135° humeral inclination RSA for PHFs. METHODS: Retrospectively, all patients with an acute PHF treated with a 135° humeral inclination RSA at four centers during a three-year period were followed up. Constant score (CS), TH and glenoid notching were analyzed. RESULTS: Sixty-four of 100 patients (64%) with a mean age of 76 ± 7 years were available for follow-up at 22 ± 8 months. The mean-adjusted CS was 72%. TH of the greater tuberosity (GT) was 77% and resulted in significantly improved forward flexion (128° vs. 92°; p = 0.003), external rotation (33° vs. 17°; p = 0.03) and adjusted CS (78% vs. 54%, p < 0.005). GT healing rate was 86% with neutral, 70% with lateralized and 33% with an inferior eccentric glenosphere. TH of the lesser tuberosity was 79%. There was 8% complication and 3% revision rate; implant survival was 100%. CONCLUSION: RSA with 135° humeral inclination for PHFs leads to good functional outcome, reproducible results and a high rate of TH. The short-term revision rate is low. TH is associated with improved ROM and functional outcome. LEVEL OF EVIDENCE: III.

Tuberosity healing after reverse shoulder arthroplasty for complex proximal humeral fractures in elderly patients-does it improve outcomes? A systematic review and meta-analysis.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus in older patients. Anatomic tuberosity healing in RSA has been recognized to restore better shoulder function. We compared the reported clinical and functional outcomes of RSA in proximal humeral fractures with and without tuberosity healing. METHODS: We performed a systematic review of literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials. We included all studies with RSA for proximal humeral fractures in patients older than 60 years and compared outcomes based on tuberosity healing with minimum follow-up of 12 months. RESULTS: Seven studies met the inclusion criteria. A total of 381 patients (382 shoulders) were identified. There were 53 men (18.3%) and 236 women (81.7%), with mean age of 76.83 years (range, 74-81 years). Mean follow-up duration was 29.84 months (range, 24-90 months), and the mean rate of greater tuberosity healing was 70.5%. Patients with healed tuberosity had significantly better active forward flexion (134.1° vs. 112.5°, P < .05), abduction (114.8° vs. 95.1°, P < .05), external rotation with elbow by the side (27.8° vs. 7.6°), and mean Constant score (63.5 vs. 56.6, P < .05) than with those with nonhealed tuberosity. CONCLUSION: The RSA group with healed greater tuberosity showed better range of motion, especially forward flexion and external rotation and Constant scores, compared with the nonhealed greater tuberosity group. Tuberosity healing may influence overall shoulder function after RSA for proximal humeral fractures in the elderly, and this needs verification with future prospective studies.

How the greater tuberosity affects clinical outcomes after reverse shoulder arthroplasty for proximal humeral fractures.

BACKGROUND: Our purpose was to evaluate the clinical and radiologic outcomes of reverse shoulder arthroplasty for proximal humeral fractures in a large cohort of elderly patients and compare the results in the case of tuberosity excision, failed fixation, or anatomic healing. METHODS: In this retrospective multicenter study, 420 patients underwent review and radiography with a minimum follow-up period of 12 months. The patients were divided into 3 groups according to the status of the greater tuberosity (GT) on the last anteroposterior radiographs: anatomic GT healing (group A, n = 169); GT resorption, malunion, or nonunion (group B, n = 131); and GT excision (group C, n = 120). Complications were recorded; shoulder function, active mobility, and subjective results were assessed. RESULTS: At a mean follow-up of 28 months, the mean Simple Shoulder Value in group A (75%) outperformed the results found in groups B (69%, P < .001) and C (56%, P < .001). Overall, the mean adjusted Constant-Murley score was significantly higher in group A (93% ± 22%) than in group B (82% ± 22%) and group C (80% ± 24%) (P < .001), but there was no difference between groups B and C (P = .88). Anterior active elevation and external rotation were significantly better in group A than in groups B and C (P < .001). The instability rate was significantly higher in group C (n = 15 [12.5%], P < .001) than in group A (n = 2) or group B (n = 3). CONCLUSION: In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. GT excision is associated with the worst functional results and increases the risk of postoperative shoulder instability.

Does grafting of the tuberosities improve the functional outcomes of proximal humeral fractures treated with reverse shoulder arthroplasty?

BACKGROUND: Functional outcomes of reverse total shoulder arthroplasty (rTSA) can be improved by fixation of the tuberosities. This study compares clinical and radiologic results of patients with comminuted proximal humeral fractures treated with rTSA, with and without autologous grafting. METHODS: Thirty-three patients with proximal humeral fractures were treated with rTSA and tuberosity fixation. In 18 patients (group I; mean age, 75 years), tuberosity fixation was augmented with autografting; in 15 patients (group II; mean age, 71 years), graft augmentation was not used. The mean follow-up was 16.7 (range, 12-24) months in group I and 16.8 (range, 12-25) months in group II. RESULTS: Radiologic tuberosity union was achieved in 14 of 18 (77.8%) patients who underwent autograft augmentation and in 6 of 15 (40.0%) patients treated without autografting. The mean American Shoulder and Elbow Surgeons (ASES) score was 69.6 ± 13.0 in group I and 51.0 ± 20.0 in group II. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 31.9 ± 24.0 in group I and 58.2 ± 24.6 in group II. A significant difference was detected between groups for ASES and DASH scores. Among shoulder range of motion measures, only forward flexion differed significantly between groups I and II (124° ± 23° vs. 98° ± 30°, respectively). External rotation muscle strength was significantly higher in group I (3.36 ± 1.46 kg) than in group II (2.39 ± 2.00 kg). CONCLUSION: In the treatment of complex proximal humeral fractures in elderly patients by rTSA, cancellous block autograft augmentation can increase the rate of tuberosity union and improve functional outcomes.

Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly.

BACKGROUND: Anatomic reduction and stable internal fixation of complex proximal humeral fractures in the elderly is challenging. Secondary displacement, screw perforation, and humeral head necrosis are common complications. The outcome of hemiarthroplasty is unpredictable and strongly dependent on the uncertain healing of the greater tuberosity. This multicenter study retrospectively analyzes the midterm results of primary reverse total shoulder arthroplasty for the treatment of acute, complex fractures of the humerus in an elderly population. METHODS: Fifty-two shoulders in 51 patients with a mean age of 77 years treated with reverse total shoulder arthroplasty for an acute, complex fracture of the proximal humerus were clinically and radiographically analyzed after a mean follow-up period of 35 months (range, 12-90 months). RESULTS: There were no intraoperative complications. Revision surgery was performed in 4 shoulders. At final follow-up, the absolute and relative Constant scores averaged 62 points (range, 21-83 points) and 86% (range, 30%-100%), respectively, with a mean Subjective Shoulder Value of 83% (range, 30%-100%). Of the patients, 92% rated the treatment outcome as excellent or good. Patients with a resected or secondarily displaced greater tuberosity had an inferior clinical outcome to those with a healed greater tuberosity. CONCLUSION: The midterm clinical results are predictably good, with low complication rates and a rapid postoperative recovery of painfree everyday function. If secondary displacement of the greater tuberosity occurs, revision surgery may warrant consideration in view of potential improvement of ultimate outcome.

Tuberosity healing after reverse shoulder arthroplasty for acute proximal humerus fractures: the "black and tan" technique.

BACKGROUND: Reverse shoulder arthroplasty has seen increased use for management of complex proximal humeral fractures in the elderly. Recent evidence has shown that tuberosity healing leads to improved active range of motion and functional outcomes. The purpose of this study was to report on the radiographic and clinical outcomes of a consecutive series of patients having undergone reverse shoulder arthroplasty for fracture utilizing the "black and tan" method--a hybrid cementation-impaction grafting technique that uses autogenous cancellous bone graft to create an interface between the proximal cement mantle and the area of tuberosity repair. METHODS: Twenty-five patients (average age, 77 years; range, 63-88 years) were included in the analysis with a mean follow-up of 17 months. All patients underwent reverse shoulder arthroplasty for a complex proximal humerus fracture using the black and tan technique. RESULTS: The tuberosity healing rate was 88%. At final follow-up, mean active elevation was 117° ± 23°, mean abduction was 86° ± 16°, and mean external rotation was 29° ± 18°. External rotation strength averaged 4.9 ± 0.2. The Simple Shoulder Test and Single Assessment Numeric Evaluation scores averaged 7 and 76, respectively. The mean American Shoulder and Elbow Surgeons total score was 71; visual analog scale score for pain, 2; and visual analog scale score for function, 7. Of the 25 patients, 21 (84%) rated their satisfaction with the surgery as excellent or good. CONCLUSIONS: The black and tan technique together with standard suture repair and an implant with features that support tuberosity repair results in a high tuberosity healing rate with restoration of external rotation after reverse shoulder arthroplasty for fracture.

Great tuberosity fixation does not affect healing and clinical outcomes in RSA performed in proximal humeral fractures in elderly patients.

PURPOSE: Aims of our study were to define whether the great tuberosity (GT) positioning fixation in reverse shoulder arthroplasty (RSA) after proximal humeral fracture (PHF) could predict tuberosity healing and its impact on clinical outcomes. METHODS: We enrolled 59 patients treated with cementless reverse shoulder arthroplasty after PHF in our institute between 2012 and 2018. The mean follow-up was 57 months (± 23.4). We divided patients into two groups according to GT positioning after fixation: Group 1 GT in contact and Group 2 GT detached at least 1 mm from humeral diaphysis. Clinical and radiographic evaluations were conducted at last follow-up. RESULTS: Overall GT healing rate was 64.4%, (Group 1 70.7%-Group 2 50%). A statistically significant difference (P = 0.047) was found in cortical thickness narrowing at one-third of stem length. We found a correlation between lateral cortical narrowing and GT fixation in non-anatomical position, but we observed no statistically significant differences about GT healing according to GT anatomical or non-anatomical fixation. No differences were found in shoulder function in patients whose tuberosity was healed or failed to heal. CONCLUSION: GT reduction is not a predictive factor for GT healing; external stress shielding, instead, seems to be decreased in patients with postoperative anatomically reduced GT. In our study, GT healing did not affect clinical outcomes or patient's satisfaction in elderly low-demanding patients.

Locked Stem Reverse Total Shoulder Arthroplasty for Complex Proximal Humerus Fracture in the Elderly: Clinical and Radiological Short-Term Results.

Purpose: To evaluate both the short-term clinical and radiological results of reverse shoulder arthroplasty (RSA) with uncemented locked stem in the management of a proximal humerus fracture (PHFs) in the elderly. Methods: Retrospective study including 40 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 24 months follow-up. In all the cases, the greater tuberosity (GT) was reattached with a standardized suture technique and a local horseshoe bone graft. All the patients were assessed at the 24-month follow-up with Constant-Murley Score (CMS) and Visual Analog Score (VAS). Radiographic healing of the greater tuberosity was noted in addition to stem locking screws radiographic changes. Complications and revision rates were reported. Results: Mean final CMS for this cohort was 80 points. The greater tuberosity healed in the anatomic position in 90% of the cases (N = 36), obtaining an average CMS of 80 in these patients. Healing of the greater tuberosity did not occur in 10% of the cases (N = 4), obtaining an average CMS of 60. All patients scored above 100° in forward elevation with a mean of 140°. Mean active external rotation was 30°. Low-grade scapular notching was reported in <1% of the cases. Major complications were reported in one patient with an acromial fracture. No complications or loosening of stem locking screws were noted. There were no reoperations. Conclusion: In the elderly population, reverse shoulder arthroplasty utilizing a fracture-specific locking stem, low-profile metaphysis, suture-friendly groove, meticulous suture technique, and local bone grafting allows adequate fixation, variable prosthesis height adjustment, and enhances greater tuberosity healing. This approach yields positive short-term clinical outcomes without complications related to the stem's locking screws. Level of Evidence: Level IV Retrospective Case Series.

Reverse total shoulder arthroplasty for complex proximal humerus fracture in the elderly: clinical and radiological results.

Background: The use of reverse total shoulder arthroplasty (RSA) for the treatment of proximal humeral fractures (PHFs) is steadily increasing. Better clinical outcomes of RSA have been correlated with tuberosity reattachment and healing. The purpose of this study was to evaluate both the clinical and radiological results of reverse shoulder arthroplasty in the management of a proximal humerus fracture in the elderly. Methods: Retrospective study including 400 consecutive 3-4 part proximal humerus fractures treated with reverse shoulder arthroplasty with a minimum of 12-month follow-up. In all the cases, the greater tuberosity was reattached with a standardized suture technique and a local bone graft. All the patients were assessed at the 12-month follow-up with Constant-Murley Score (CMS). Radiographic healing of the greater tuberosity was noted. Complications and revision rates were reported. Results: Mean final CMS for this cohort was 82 points. The greater tuberosity healed in anatomic position in 85% of the cases (N = 340), obtaining an average CMS of 85 in these patients. Healing of the greater tuberosity did not occur in 13% of the cases (N = 52) and displacement more than 5 mm occurred in 2% (N = 8) of the patients for an average CMS of 60. All patients scored above 120° in forward elevation with a mean of 150°. Mean active external rotation was 35°. The lateralization shoulder angle had a mean of 91° and the distalization shoulder angle had a mean of 54°. Low-grade scapular notching was reported in <1% of the cases. A total of 60 patients presented failure of healing or displacement of the greater tuberosity. Major complications were reported in nine patients. Of these nine patients, two acquired superficial wound infections, while two had deep shoulder prosthetic infection. Two other patients developed hematomas, one sustained an acromial stress fracture, and two had a stem loosening. There were 4 reoperations. Conclusion: Reverse shoulder arthroplasty, with the use of a fracture-specific stem, allows an improved rate of greater tuberosity healing and short-term clinical outcomes in the elderly population.

Anatomic greater tuberosity healing does not influence the functional outcomes of reverse shoulder arthroplasty for acute proximal humerus fractures.

Background: To investigate the functional outcomes of reverse shoulder arthroplasty (RSA) in acute complex proximal humerus fractures (PHF) in patients with an anatomic greater tuberosity union in comparison to patients with a displaced or resorbed tuberosity. Method: It is a retrospective study with prospective data collection including 32 consecutive PHF with a minimum two-year follow-up treated with RSA. A radiological study and a CT scan were performed specifically for the study. Two shoulder surgeons and a musculoskeletal radiologist assessed the position and union of the greater tuberosity. The functional outcomes were assessed with the Constant-Murley, DASH, ASES and ADLER scores. Results: The mean overall CS was 59.55. In 17 cases, the greater tuberosity healed in an anatomical position. In 15 cases, it was non-anatomical. In 53% of patients, greater tuberosity union was obtained. The CS was 62.76 in the anatomic union group and 55.9 in the non-anatomic union group. No significant differences were observed. No differences were observed in the ASES, DASH and ADLER scores. Conclusion: After RSA for PHF, anatomic greater tuberosity healing was obtained in 53% of patients. The influence of the position and union of the greater tuberosity on the functional results could not be evidenced.

Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures Treated With Trabecular Metal Prosthesis: Medium-Term Results.

Introduction Reverse shoulder arthroplasty (RSA) is becoming increasingly popular as a primary procedure for complex proximal humeral fractures (PHF) in acute trauma due to more emerging evidence and better patient outcomes. Methods This study is a retrospective case series of 51 patients who underwent a trabecular metal RSA for non-reconstructable, acute three or four-part PHF performed by a single surgeon between 2013 and 2019 with a minimum follow-up of three years. This included 44 females and seven males. Mean age was 76 years (range: 61-91 years). Oxford shoulder score (OSS) along with relevant patient information relating to demographics and functional outcomes were collected at regular intervals in outpatient clinic follow-ups. Complications were addressed accordingly during treatment and follow-up. Results The mean follow-up duration was 5.08 years. Two patients were lost to follow-up and nine patients died due to other causes. Four of them had developed severe dementia and were excluded as an outcome score from them could not be acquired. Two patients who had surgery beyond four weeks post-injury were excluded. Thirty-four patients in total were followed up. Patients had good range of motion and mean OSS of 40.28 post-operatively. The overall complication rate was 11.7%, and none of the patients had deep infections, scapular notching, or acromial fractures. Revision rate was 5.8% at mean follow-up of five years and one month (range: three years to nine years two months). Greater tuberosity union following intra-operative repair was evident on radiographs in 61.7% of the patients. Conclusion RSA is certainly a rewarding surgery in patients with complex PHF and was associated with good post-operative OSS along with patient satisfaction, and positive radiological outcomes at minimum three-year follow-up.

Intra- and Inter-rater Reliability of Postoperative Radiographic Analysis of Reverse Shoulder Arthroplasty in 49 Shoulders After Proximal Humerus Fracture.

Introduction: The lateralization shoulder angle (LSA), the distalization shoulder angle (DSA) and the new "pentagon" concept are tools used in scheduled shoulder surgery to evaluate the positioning of reverse shoulder arthroplasty (RSA) implants. There is no information on the intra- and inter-rater reliability of these tools in the context of RSA for a proximal humerus fracture. The first hypothesis was the high reliability of the intra- and inter-rater analysis of the LSA and DSA angles. The second hypothesis was the reproductibility of the pentagon based on LSA and DSA analysis. Methods: Forty-nine patients were evaluated retrospectively with a minimum of 2 years radiological follow-up after RSA surgery. Tuberosity healing was evaluated using an AP radiograph of the shoulder and their location analyzed within the said "pentagon" defined by the LSA/DSA angles and the maximum lengthening recommended. Results: The intra-rater analysis found strong to an almost perfect agreement for the LSA and DSA. The agreement was moderate to strong for the pentagon. The inter-rater analysis found a fair agreement for the LSA and moderate agreement for the DSA and pentagon. Conclusion: The LSA/DSA is used in patients undergoing RSA for glenohumeral OA. In this context, the tuberosities were intact and certain complications inherent to RSA for humeral fracture were not present. The population studied here (RSA after fracture) creates an interpretation bias due to the difficulty in analyzing tuberosity position. Level of Evidence: 4, retrospective study.

Tuberosity reconstruction baseplate for shoulder hemiarthroplasty: Morphological design and biomaterial application.

Background: Shoulder hemiarthroplasty is prone to tuberosity malposition and migration, reducing the rate of tuberosity healing. We proposed to design a tuberosity reconstruction baseplate to assist in tuberosity integration and to evaluate the mechanical properties of baseplate made from the novel biomaterial carbon fiber reinforced polymer (CFRP) composites. Methods: The three-dimensional model of native proximal humerus was constructed by computed tomography (CT) data. The morphological design of baseplate was based on the tuberosity contour and rotator cuff footprint. Finite element models were created for different thicknesses of CFRP composites, poly (ether-ether-ketone) (PEEK) and titanium-nickel (TiNi) alloy. The permissible load and suture hole displacements were applied to evaluate the mechanical properties. Results: The structurally optimized model made of CFRP composites provided superior strength and deformability, compared to the PEEK material and TiNi alloy. Its permissible load was above 200 N and the suture hole displacement was between 0.9 and 1.4 mm. Conclusion: This study proposed a method for designing tuberosity reconstruction baseplate based on morphological data and extended the application of biomaterial CFRP composites in orthopedics field. The optimized model made of CFRP composites allowed a certain extent of elastic deformation and showed the possibility for dynamic compression of tuberosity bone blocks.