This narrative review synthesizes early case series on reverse total shoulder arthroplasty (RSA) for two indications beyond its original cuff tear arthropathy use. It addresses acute complex proximal humeral fractures in the elderly and salvage of failed hemiarthroplasty, compiling functional outcomes, complication rates, and a framework for choosing between RSA and nonconstrained prostheses. Evidence level is low throughout, reflecting the small series available at the time of publication.
RSA's mechanical advantage is straightforward: by medializing the center of rotation and lengthening the deltoid moment arm, it restores elevation without requiring an intact cuff. This makes it useful precisely in the situations where hemiarthroplasty fails most — when tuberosity osteosynthesis breaks down.
The core clinical lesson is prosthesis selection by cuff status and tuberosity integrity. For cephalic collapse with intact tuberosities (Neyton Type 1), a nonconstrained prosthesis preserves external rotation. For severe malunion with a nonfunctional cuff (Type 4), RSA is the only option that provides acceptable pain and function despite tuberosity problems.
Set realistic expectations with patients: elevation recovers, external rotation typically does not. RSA cannot replace posterior cuff function, and the medialized center of rotation actually worsens the external rotators' mechanical position.
Revision surgery carries serious risk. When counseling a patient about converting a failed hemiarthroplasty to RSA, the 47% complication rate in Boileau's series and the three-fold increase in complications vs primary RSA are the numbers to know. This is salvage surgery. Improvement in 89% of patients, but only 47% achieve a 30-point functional gain.
This narrative review synthesizes early case series on reverse total shoulder arthroplasty (RSA) for two indications beyond its original cuff tear arthropathy use. It addresses acute complex proximal humeral fractures in the elderly and salvage of failed hemiarthroplasty, compiling functional outcomes, complication rates, and a framework for choosing between RSA and nonconstrained prostheses. Evidence level is low throughout, reflecting the small series available at the time of publication.
RSA's mechanical advantage is straightforward: by medializing the center of rotation and lengthening the deltoid moment arm, it restores elevation without requiring an intact cuff. This makes it useful precisely in the situations where hemiarthroplasty fails most — when tuberosity osteosynthesis breaks down.
The core clinical lesson is prosthesis selection by cuff status and tuberosity integrity. For cephalic collapse with intact tuberosities (Neyton Type 1), a nonconstrained prosthesis preserves external rotation. For severe malunion with a nonfunctional cuff (Type 4), RSA is the only option that provides acceptable pain and function despite tuberosity problems.
Set realistic expectations with patients: elevation recovers, external rotation typically does not. RSA cannot replace posterior cuff function, and the medialized center of rotation actually worsens the external rotators' mechanical position.
Revision surgery carries serious risk. When counseling a patient about converting a failed hemiarthroplasty to RSA, the 47% complication rate in Boileau's series and the three-fold increase in complications vs primary RSA are the numbers to know. This is salvage surgery. Improvement in 89% of patients, but only 47% achieve a 30-point functional gain.