RSA may be more effective than plate fixation for displaced proximal humerus fractures
At 2 years, reverse total shoulder arthroplasty yielded better clinical outcomes than plate fixation for patients older than 65 years with type B2 and C2 proximal humerus fractures, according to presented results.
Alexander Nilsskog Fraser, a consultant orthopedic surgeon in the division of orthopedic Surgery at Oslo University Hospital, presented findings of his randomized controlled trial on RSA vs. plate fixation at the Orthopaedic Trauma Association Annual Meeting, which was held as a virtual event.
“Treatment of proximal humeral fractures (PHFs) is so controversial. Should one operate or not?” Fraser said. “Although several studies show that operative treatment is increasing, there is sparse evidence on which operative treatment to prefer.”
Fraser and colleagues analyzed 124 patients (mean age of 75 years) who were diagnosed with displaced PHFs type B2 and C2 (Orthopaedic Trauma Association/AO Foundation 2007 revision) from January 2013 to May 2017. Researchers allocated 64 patients to RSA and 60 patients to plate fixation.
According to the study, outcome measures included Constant score at 2 years, Oxford Shoulder Score and radiologic results. Fraser also noted seven patients in the RSA group and 13 patients in the plate fixation group were lost at 2-year follow-up. Additionally, 90% of the included patients were women.
Overall, mean constant scores favored RSA.
Mean Constant scores at 2 years were 68 for the RSA group and 54.6 for the plate fixation group, a “significant mean difference,” according to investigators. After adjusting for type C2 PHFs, they found mean Constant scores at 2 years were 69.3 for the RSA group and 50.6 in the plate fixation group. After adjusting for type B2 PHFs, investigators found mean Constant scores at 2 years were 66.2 for the RSA group and 58.5 for the plate fixation group.
Adverse events and secondary surgeries were doubled in the plate fixation group compared with the RSA, Fraser said. Eight patients in the plate fixation group had a secondary surgery including four patients who were converted to RSA.
“Elderly patients with displaced PHFs profit more from RSA than plate fixation,” Fraser concluded. “In the subgroup analysis, patients aged 65 to 75 years and patients with C2 fractures showed the most profit from RSA,” he added.
Perspective
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I would like to congratulate the authors for an important study. To this date, much of our knowledge about reverse shoulder replacement compared to ORIF in proximal humerus fracture has been limited to cohort studies and retrospective reviews. A large, randomized controlled trial of this scale can be challenging to manage, and I commend the authors on their work. This abstract, along with the accompanying “Delphi” manuscript in JBJS brings us one step closer to understanding the optimal treatment for this complex patient population.
This series compares patients with OTA B2 and C2 fractures, and only patients aged 65 to 85 years old. The results presented favor reverse shoulder arthroplasty at 2 years as compared to ORIF, particularly in patients with a C2 fracture pattern. Those patients treated for a B2 fracture did not show a statistically significant difference in the Constant score.
As with any paper evaluating proximal humerus fractures, there can be a number of other patient and surgeon variables. Individual practice patterns can come into play. For instance, a surgeon can be extremely facile with ORIF but more unfamiliar with arthroplasty or vice versa. Patient factors, such as smoking, diabetes, osteoporosis and activity, may come into consideration during preoperative counseling. Fortunately, patients can do well with either treatment modality.
This study adds to our understanding and management of complex proximal humeral fractures. The authors continue to monitor this cohort, and I look forward to the 5-year follow-up of these patients.
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Fraser AN, et al. Reverse shoulder arthroplasty superior at 2 years compared with plate fixation for displaced proximal humeral fractures in the elderly: A multicenter randomized controlled trial. Presented at: Orthopaedic Trauma Association Annual Meeting; Oct. 20-24, 2020 (virtual meeting).
