Uncemented, cemented stems yielded similar results in RSA for proximal humeral fracture
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Compared with cemented humeral stems, uncemented stems yielded similar functional outcomes, pain, range of motion and tuberosity healing in patients undergoing reverse shoulder arthroplasty for proximal humerus fractures.
In April of 2021, Luciano Andrés Rossi, MD, PhD, and colleagues used PubMed, Scopus Web of Science and Cochrane Library databases to perform a systematic review of 45 studies reporting outcomes of RSA in 1,623 patients with proximal humerus fractures (PHFs).
According to the study, outcome measures included range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) scores, Constant scores, VAS pain scores, tuberosity healing, complications and reoperations. The researchers also performed subgroup analysis to determine any differences in outcomes between patients who underwent RSA with a cemented humeral stem (cRSA) and patients who underwent RSA with an uncemented humeral stem (ucRSA).
Overall, Rossi and colleagues found no significant differences in ROM, Constant scores, VAS scores, tuberosity healing or reoperation rates between the cRSA and ucRSA cohorts. However, mean ASES score was 73.9 in the cRSA cohort and was 82.9 in the ucRSA cohort. Additionally, all-cause complications were lower in the cRSA cohort (5.5%) compared with the ucRSA cohort (9.7%), the researchers noted.
“As RSA continues to be applied as a first-line surgical approach for PHFs, it is imperative to better understand if differences in fixation methods may influence outcomes,” Rossi and colleagues wrote in the study. “Although the rate of complications was significantly higher in the uncemented cohort compared to the cemented cohort, the rate of reoperations was similar between the groups. The uncemented reverse prosthesis seems to be a valid alternative for the management of patients with complex PHFs,” they added.
Perspective
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I was interested to read the article by Luciano A. Ross and colleagues that evaluated outcomes of uncemented vs. cemented reverse shoulder arthroplasty (RSA) for the treatment of proximal humerus fractures (PHF). There is limited literature on the subject, and this area of study gets at the question of whether we should be cementing our humeral components in the difficult to treat elderly population. This study pooled data for 1,623 patients reported in 45 studies in a meta-analysis and systematic review to help guide surgeons on what has been reported in the literature and what data say on the need for cementing in this setting.
Not surprisingly, these data are a cumulation of the quality of studies reporting outcomes for this population which vary widely from level 1 to 4 evidence and focus on early outcomes (average of 34.5 months) for RSA in the proximal humerus setting. But the results do report significant differences we, as surgeons, need to be aware of both in terms of decision-making and in how we communicate expected outcomes and differences to our patients undergoing an RSA in this setting.
Despite limitations in level of evidence and pooled heterogenous data from a large body of studies, the results are important to understand and review. Specifically, the use of uncemented humeral stems in RSA for PHF confers similar function results in terms of pain, range of motion, functional scores and rates of tuberosity healing. There was a slightly higher reported patient satisfaction for uncemented humeral stems compared with cemented stems but a higher complication rate (9.7% vs. 5.5%, respectively). However, this did not result in a higher rate of reoperations for uncemented RSA.
In my understanding as we continue to expand our indications and implant development for RSA, perhaps the biggest takeaway is that we may not need to cement all humeral components when performing an RSA for PHF, although we must proceed cautiously to better understand the long-term implications of eliminating cement in this setting of PHF based on patient specific factors, complication rates and implant design in an expanding population.
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