RSA may yield superior outcomes for proximal humerus fractures vs. hemiarthroplasty
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Key takeaways:
- Reverse shoulder arthroplasty yielded superior Constant scores with no increased risk of failure vs. hemiarthroplasty at 1 year.
- Patients were treated for an acute three- or four-part proximal humerus fracture.
Published results showed reverse shoulder arthroplasty yielded superior Constant scores at 1 year with no increased risk of failure compared with hemiarthroplasty for patients with proximal humerus fractures.
Adam C. Watts, FRCS (Tr & Orth), research and governance director of the upper limb research department at Wrightington Hospital in Lancashire, England, and colleagues randomly assigned 36 patients aged 65 years and older with an acute three- or four-part proximal humerus fracture to undergo either cemented reverse polarity shoulder arthroplasty (n = 18) or cemented hemiarthroplasty (n = 18). The primary outcome measure was mean Constant scores at 1-year and 2-year follow-ups.
At 1 year, patients who underwent RSA had a mean Constant score of 51.1, while patients who underwent hemiarthroplasty had a mean Constant score of 35. Watts and colleagues found mean EuroQoL 5-dimension 5-level patient-rated health status scores were also significantly higher in the RSA cohort (85.6) vs. the hemiarthroplasty cohort (68.5) at 1 year. They found no differences in mean Constant scores between the cohorts at 2 years; however, they noted this may be due to the high attrition rate (22%) at 2-year follow-up.
Watts and colleagues noted one RSA was revised for instability, while one hemiarthroplasty was revised for implant uncoupling.
Perspective
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The authors present a prospective, randomized controlled trial of three- and four-part proximal humerus fractures in patients older than 65 years who were randomly assigned to surgical intervention with either reverse shoulder arthroplasty or hemiarthroplasty. Their data demonstrate that those treated with RSA achieved improved outcome scores and more predictable shoulder function to the extent that the study was terminated prior to the end of the recruitment period due to clearly superior outcomes among RSA patients. These results are consistent with those seen in our own patients, as well as in the current literature.
One important aspect of the study to note is that it does not include long-term outcomes, and several patients in the study were deceased prior to final 24-month follow-up, which may have skewed the data.
Improved outcomes seen with RSA can be attributed to improved joint reconstruction, specifically tuberosity repair, rotator cuff status and soft tissue tension. The current trends in utilization of shoulder arthroplasty demonstrate a significant reduction of hemiarthroplasty in the treatment of proximal humeral fractures.
Future studies should further define whether these patients who underwent surgical intervention for their proximal humerus fracture might have achieved similar outcomes had they been treated nonoperatively. In addition, future research should seek to determine which technical factors can optimize outcomes when performing RSA for a proximal humeral fracture. Therefore, while this study provides an important addition to the literature, the ideal treatment for these complex injuries remains a challenging topic.
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