Editor’s Choice—JBJS Reviews, October 2014
Technological advances in orthopaedic surgery occur steadily and incrementally. However, every so often, something comes along that really changes orthopaedic practice. Such is the case with the introduction of reverse shoulder arthroplasty, which is a unique, novel procedure that can be used to treat a variety of conditions affecting the shoulder. In this month’s issue of JBJS Reviews, George et al. review the use of reverse shoulder arthroplasty for the treatment of proximal humeral fractures.
Proximal humeral fractures, particularly those that occur in osteoporotic bone, can be complex and difficult to manage. While the majority of these fractures can be successfully treated with initial mobilization in a sling followed by return to activities, three and four-part fractures often are associated with poor functional outcomes, including nonunion, malunion, posttraumatic glenohumeral arthritis, and stiffness. Thus, operative interventions such as closed reduction and percutaneous pinning, open reduction and internal fixation with locked or unlocked plates, and locked intramedullary nailing are available options. However, because of the difficulty associated with reduction of three and four-part fractures, open reduction and internal fixation is associated with a high rate of complications.
Nearly sixty years ago, Neer described the use of hemiarthroplasty for the treatment of three and four-part fractures of the proximal part of the humerus. Implants and techniques steadily improved over the ensuing six decades, but the introduction of reverse shoulder arthroplasty may represent a major step forward. In the article by George et al., the use of reverse shoulder arthroplasty for the treatment of complex fractures of the proximal part of the humerus appears to have led to good results after short and intermediate-term follow up. Malunion or nonunion of the tuberosities did not affect the functional result after reverse total shoulder arthroplasty as much as it did after hemi-arthroplasty, but it did lead to decreased postoperative external rotation.
The long-term outcomes of reverse shoulder arthroplasty for the treatment of these fractures still have not been well established, so we probably should not rush to change our practice on the basis of this article alone. Indeed, since the results have been shown to deteriorate as early as six years postoperatively, reverse shoulder arthroplasty should be reserved for older patients and should be avoided in younger patients. Reverse shoulder arthroplasty can be used for the treatment of rotator cuff arthroplasty and recently has gained popularity for the treatment of severe proximal humeral fractures. This article provides a thorough yet concise overview of the application of this novel technique and implant to the treatment of these difficult and complex injuries.
Thomas A. Einhorn, MD, Editor