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Consider reverse shoulder arthroplasty for treatment of proximal humerus fractures in elderly patients
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LAHAINA, Hawaii — Orthopedic surgeons can consider reverse shoulder arthroplasty in the treatment of proximal humerus fractures in elderly patients, according to a speaker at Orthopedics Today Hawaii 2017.
“Consider the reverse [shoulder arthroplasty (RSA)] in the elderly or have it as a bail-out [procedure]. If you are go in to fix an older patient and you feel a bit concerned, then have the reverse available so you can bail to it at the time of surgery. I think it works out well,” Mark A. Mighell, MD, said here.
In the treatment of proximal humerus fractures, he said the most critical factors for success are to mobilize the tuberosities with heavy sutures, to avoid biceps tenodesis in 4-part fractures, use K-wires to maintain reduction, use structural graft to fill defects, use plates as a buttress for the head and to perform tuberosity reconstruction. His four technical points for internal fixation: mobilize the tuberosities with heavy sutures; use K-wire to maintain reduction; use structural graft to fill the defect rather than impaction of the shaft into the head; and tuberosity reconstruction.
However, elderly patients with compromised healing, severe osteoporosis or tuberosity comminution should be considered for RSA. He said RSA can be indicated for patients with severely comminuted/displaced 3-part or 4-part proximal humerus fractures, patients older than 70 years, those with osteoporotic bone or a history of rotator cuff disease. Reverse procedures are less reliant on tuberosity healing due to use of deltoid function, can offer faster rehabilitation than open reduction and internal fixation, and can be used for older patients.
“I think reverse [shoulder arthroplasty] is a new comer on the block. There are still complications and I think if it is an older patient, [then] it is going to be more difficult to fix,” he said.
Mighell said the problems with RSA for proximal humerus fractures include scapular notching, acromial fractures and instability. – by Kristine Houck, MA, ELS
Reference:
Mighell MA. Proximal humerus fractures: Pearls of treatment. Presented at: Orthopedics Today Hawaii 2017; Jan. 8-12, 2017; Lahaina, Hawaii.
Disclosure: Mighell reports he is on the speakers bureau and is a paid consultant for DJO Surgical and Stryker; and receives royalties and research support from DJO Surgical.