Review Question - QID 220020

This 78-year-old female sustained a four-part proximal humerus fracture. The most appropriate treatment would be a reverse total shoulder arthroplasty (rTSA). An upper trunk brachial plexopathy, which renders the C5 nerve root and therefore the deltoid muscle ineffective, would pose a contraindication for the procedure (Answer 2).

Proximal humerus fractures (PHF) are among the most commonly encountered fractures in the elderly. Fortunately, the vast majority can be treated with benign neglect (i.e., nonoperative management) with satisfactory outcomes. For three- and four-part PHFs, the risk for avascular necrosis is significantly higher and portends significantly worse functional outcomes. Because of this, the standard of care has been joint replacement, with rTSAs being the ideal treatment in elderly patients because of 1) the inherent poor bone stock in older patients (precluding reconstruction) and 2) the high rate of rotator cuff tear/arthropathy seen in geriatrics. With rTSA, the shoulder's functionality is no longer reliant on the rotator cuff for motion, but instead utilizes the deltoid as the primary mover. However, in those with dysfunctional deltoids, as in those with upper trunk brachial plexopathies, rTSA is contraindicated.

Klug et al. performed a retrospective review where the authors performed a matched analysis of 60 elderly (>65) patients with 3- and 4-part PHFs treated with open reduction internal fixation (ORIF; n=30) or rTSA (n=30). At a minimum follow-up of three years, clinical and radiographic complications were significantly higher in the ORIF group (30 vs. 10%, p=0.028), although the ORIF group did demonstrate higher Oxford Shoulder Scores (p=0.034) and Disabilities of the Arm, Shoulder, and Hand scores (p=0.026). The authors conclude the treatment of PHFs in the elderly remains challenging and surgeons should realize the limitations associated with each procedure.

Yahuaca et al. retrospectively examined functional, radiographic, and surgical outcomes in 425 patients (2- [11%], 3- [41%], 4-part [48%]) with PHFs treated with either ORIF (n=211), hemiarthroplasty (n=108), or rTSA (n=106). No difference in motion was noted between groups at an average of 20 months. The rate of reoperation, however, was noted to be lowest in the rTSA cohort (6.6%) compared to hemiarthroplasty (15.7%) and ORIF (17.5%; p=0.029). The authors conclude that each procedure will likely restore motion, but a thorough understanding of each procedure's complication profile is necessary when choosing the most appropriate treatment.

Kilic et al. reported on a multicenter retrospective review, examining the functional outcomes of 126 patients who underwent anatomic (n=71) and rTSA (n=55) for varying indications (post-traumatic [n=36], primary osteoarthritis [n=51], rheumatic disease [n=15], 'other' [n=11]). Those with primary arthritis experienced the greatest improvement in motion, which was followed by post-traumatic. Concerning only post-traumatic patients, those undergoing rTSA experienced a significantly lesser degree of functional improvement compared to those receiving anatomic shoulders. Ultimately, the authors recommend utilizing an anatomic prosthesis for 'mild' post-traumatic shoulders, while more severe deformity would most likely warrant rTSA.

Figures A and B represent orthogonal views of a left shoulder illustrating a four-part proximal humerus fracture with anterior dislocation of the humeral head.

Incorrect Answers:
Answer 1: irreparable rotator cuff tears serve as a contraindication for hemi- or total shoulder arthroplasties.
Answer 3: non-reconstructable articular surface would serve as a contraindication for ORIF of the proximal humerus.
Answer 4: glenoid retroversion greater than 15 degrees does not serve as a contraindication per se, but does signify the need for glenoid component augmentation regardless of the type of arthroplasty performed (rTSA or anatomic TSA).
Answer 5: coracoacromial ligament disruption serves as a contraindication for hemi- and total shoulder arthroplasties, as the ligament no longer serves as a buttress to proximal humeral head migration.