Displaced Proximal Humeral Fractures: Fix or Replace?

Nonoperative management of proximal humerus fractures in the elderly used to be fairly common, but multiple studies have shown poor outcomes. Open reduction and internal fixation (ORIF) with locked-plate constructs has shown some promise, but it has been fraught with complications. Most recently, reverse total shoulder arthroplasty (rTSA) has emerged as a possible surgical solution, but this is a complicated procedure, and questions have arisen about long-term outcomes.  Compounding this conundrum are the varying degrees of severity of proximal humeral fractures.

In the March 18, 2020 issue of The Journal, Fraser et al. share 2-year results from a multicenter, single-blinded randomized trial that compared rTSA to ORIF for severely displaced proximal humeral fractures in patients 65 to 85 years of age. Included patients (n=124) had OTA/AO 11-B2 or 11-C2 fractures with >45° valgus or >30° varus in the anteroposterior view, or >50% displacement of the humeral head. Using the Constant shoulder score as the primary outcome measure, the authors demonstrated both a statistically significant and clinically meaningful difference favoring rTSA in this cohort.

The mean Constant score was 68.0 points for the rTSA group compared to 54.6 points for the ORIF group. The mean between-group difference, 13.4 points, was significant (p<0.001) and exceeded the minimal clinically important difference of 10 points.  The Constant-score difference between ORIF and rTSA was most pronounced (18.7 points) in patients with C2 fractures, but there was no significant score difference in those with B2 fractures. Secondary outcomes (Oxford Shoulder Scores) showed a consistent trend of the rTSA group scoring higher than the ORIF group at 2 years.

Although this study indicates an advantage for rTSA, one must consider that only severely displaced fractures were investigated and that 2-year follow-up for joint arthroplasty is considered short term. In a Commentary about this article, Peter A. Cole, MD points out that “if there was a 25% revision rate for reverse TSA at 5 to 10 years, then the superior results would be reversed, and we would be reinventing another wheel in orthopaedics.”

Clearly, longer-term studies in this population are a necessity, and Fraser et al. say they plan to follow these patients in 5-year intervals.

Matthew R. Schmitz, MD
JBJS Deputy Editor for Social Media