RSA yielded superior functional outcomes vs. conservative treatment for humeral fractures
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Key takeaways:
- Reverse shoulder arthroplasty yielded better functional outcomes vs. nonoperative treatment for proximal humerus fractures.
- Operative treatment may lead to complications.
Results showed patients with acute displaced proximal humerus fractures who underwent reverse shoulder arthroplasty had better 1-year Constant-Murley scores compared with patients who received conservative, nonoperative treatment.
Researchers performed a multicenter, prospective, randomized control trial of patients with displaced proximal humerus fractures who were randomly assigned to RSA (n = 37; mean age of 76.51 years) or nonoperative treatment (n = 44; mean age of 77.43 years) between October 2015 and July 2021. Outcome measures included Constant-Murley score, complications and revisions.
At 1-year follow-up, mean Constant-Murley score was 61.24 among patients who underwent RSA and was 52.44 among patients who received nonoperative treatment. Researchers noted two patients who underwent RSA had severe complications. One patient developed an acute periprosthetic joint infection that required revision surgery, and the other patient sustained a postoperative axillary nerve injury that did not resolve by 1-year follow-up. No complications were found among patients who received nonoperative treatment at 1-year follow-up, according to the study.
Researchers concluded that the difference in Constant-Murley score between patients who received surgery vs. nonoperative treatment was close to the clinically significant threshold. However, they added that patients may risk complications with operative treatment.
Perspective
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Past studies have had difficulty showing that any surgical intervention improves the relatively poor natural history (ie, nonoperative treatment) for complex acute proximal humeral fractures in patients older than 65 years. The authors of this study from Spain are to be congratulated for their persistence in this area and completion of this randomized trial comparing reverse total shoulder arthroplasty to nonoperative treatment for such patients.
In this group, who are predominately older women, they showed that the reverse arthroplasty in patients had a mean improvement in Constant shoulder score of approximately nine points, at the cost of two significant complications in the surgical group vs. none in the nonoperative group. While it might be argued that, although statistically significant, this difference is below the mean clinically important difference, interestingly, categorically 14 patients in the surgical group obtained a “good or excellent” outcome, with 10 “satisfactory” and seven “poor.” Thus, the chances of having an adequate to poor result was significantly higher in the nonoperative group (63% vs. 23% in the surgical group, P < .001). Interestingly, it made no difference in the surgical group whether a medialized or lateralized glenoid implant was used.
As the authors point out in the conclusion, with its small numbers, questionable significance and potential for a beta-type error (missing a true difference because of small sample size), this is not a definitive study and, like most studies, provokes more questions for researchers to answer. The authors state, “ … this is not a definitive trial.” This study should impel other researchers to, using this data, embark on larger more statistically powerful studies that will help us refine indications, refine technique and provide some definitive answers and data for patients with this problem in the future. In addition, I would be interested to know how many patients in the nonoperative group (whose mean Constant score was only 52) subsequently underwent shoulder reconstruction with reverse arthroplasty.
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