Shoulder & Elbow

Reverse shoulder arthroplasty OK in trauma

The treatment of displaced four-part proximal humeral fractures is not getting any easier. With the recent reporting of the PROPHER study, describing no difference between operative stabilisation and conservative management along with numerous other RCTs failing to show any real term differences between two interventions, it is difficult to know if patients have been doing universally well or universally badly with traditional treatments. One area where fixation, conservative treatment and conventional arthroplasty are unlikely to yield good results is in the displaced four-part proximal humeral fracture in the elderly where a combination of cuff arthropathy and the technical challenge of the surgery makes many outcomes poor.

An emerging option that offers the tantalising prospect of re-functioning the rotator cuff (which in many cases may be the cause of poor outcomes) while treating the proximal humeral fracture, may offer the answer to this complex problem. The difficulty of course is that like many tantalising options in trauma and orthopaedic surgery, the evidence base does not match the enthusiasm with which surgeons are embracing the new technology. Although randomised trials are ongoing, they will not report for a number of years and, as such, case series can be helpful in judging safety and providing some evidence base for treatment.

Researchers in Chicago (USA) have established a prospective case series of patients, all treated with a reverse total shoulder arthroplasty for three- and four-part proximal humeral fractures.⁴ The research team then age- and sex-matched these to a control group undergoing hemiarthroplasty and ORIF procedures. Outcomes were assessed with clinical outcome scores (American Shoulder and Elbow Surgeons (ASES), Short-Form 12-item (SF-12), and Simple Shoulder Test (SST)), range of movement and treatment cost evaluation.

Sadly, despite an excellent methodology, this is really a rather small study consisting of just nine patients in each group (27 in total) with a minimum follow-up of a year. Unsurprisingly, given the small numbers of patients, there were no real significant differences between any outcome scores although there was a significant improvement in range of movement in the frontal plane in the reverse TSA group.

Quite clearly, better and more robust data are required here. Although we applaud the authors for providing some data, there really isn’t enough here to draw any more meaningful a conclusion than that reverse arthroplasty may be used in the treatment of proximal humeral fractures. We await with baited breath a more robust (and larger!) study.