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Reverse total shoulder arthroplasty may yield better results than ORIF for head-split fractures
Elderly patients with head-split fractures may have better outcomes with reverse total shoulder arthroplasty compared with open reduction and internal fixation or hemiarthroplasty, according to published results.
Paulina-Marie Peters, of the Center for Musculoskeletal Surgery at Charité – Universitaetsmedizin Berlin in Berlin, Germany, and colleagues assessed subjective shoulder value, simple shoulder test, Constant Score and biplanar radiographs in 30 patients with head-split fractures undergoing open reduction and internal fixation (ORIF; n=24), reverse total shoulder arthroplasty (TSA; n=4) or hemiarthroplasty (n=2). Researchers analyzed fracture pattern, quality of reduction, eventual complications, revision procedures and clinical failure, and calculated risk factors for failure.
Results showed an overall complication rate of 83%, with humeral head osteonecrosis, malunion of the lesser tuberosity and screw protrusion as the most common complications following ORIF and all complications following reverse TSA related to tuberosity problems. Researchers found 29% of patients in the ORIF group underwent revision compared with no patients in the reverse TSA and hemiarthroplasty groups. Among patients who in the ORIF group, 17% underwent conversion to reverse TSA and 12.5% had screw removal due to penetration, according to results.
Researchers noted a 50% overall clinical failure rate, with no significant association between preoperative factors and clinical failure. Results showed higher average clinical outcome scores in the ORIF and primary reverse TSA groups vs. the primary hemiarthroplasty and secondary reverse TSA groups. Worse subjective shoulder values, simple shoulder test and adjusted Constant scores were found among patients who required revision, according to results.
“Head-split fractures of the proximal humerus remain a treatment challenge with high complication rates and unsatisfying clinical outcome in several cases after ORIF,” Peters told Healio Orthopedics. “Even though ORIF remains the preferred treatment option in younger patients for head-split fractures, it needs to critically be considered in elderly patients.” – by Casey Tingle
Disclosures: Peters reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.
Perspective
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The main advantage of this retrospective review on head-split proximal humeral fractures is its size: 30 of 45 patients with this injury were followed for a mean of 4 years, making it the most comprehensive paper in the literature on this topic. Disadvantages include its retrospective nature, the selection bias in choice of treatment and the relatively small size of the subgroups (open reduction and internal fixation, n=24; reverse total shoulder arthroplasty, n=4; hemiarthroplasty, n=2). What is clear from this paper, however, is that the reputation of this fracture as being particularly difficult to deal with is well deserved: The overall complication rate in this series was 83%. The high revision rate observed in the open reduction and internal fixation group was often related to tuberosity problems: This is hardly surprising since most commonly available proximal humeral plating systems do not effectively stabilize tuberosity fractures. The authors were unable to correlate various head-split fracture subgroups with outcome, although the lack of injury CT scans in more than half the patients definitely impaired their ability to do so. What is clear from this paper is that the results of primary fracture surgery were superior to that of secondary reconstruction: The adjusted Constant score in the 23 patients who did not require surgical revision was 50, compared to an adjusted Constant score of 31 in the seven who did. As the old adage says, “Your first shot is your best shot,” and this would appear to be true with this complex fracture pattern.
In general, I would agree with the authors’ conclusions that open reduction and internal fixation (despite the high complication rate) remains the treatment of choice for younger patients, although there is room for improvement, especially with regard to tuberosity fixation, and that reverse total shoulder arthroplasty is preferred for older patients. The question is at what age is this dividing line?
University of Arizona College of Medicine - Phoenix
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