Martin, Orthop Clin North Am 2008 - Reverse Total Shoulder Arthroplasty for Acute Fractures and Failed Management after Proximal Humeral Fractures - Article Summary

Reverse Total Shoulder Arthroplasty for Acute Fractures and Failed Management after Proximal Humeral Fractures

Martin, Iannotti·Orthop Clin North Am·2008·68 citations·Review article

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.

Key Findings

RSA for acute complex proximal humeral fractures in elderly patients consistently yields active elevation near 97–107° but limited external rotation (10–30°) across multiple small series. These results are modest but more predictable than hemiarthroplasty, which shows a wider distribution — 50% of hemiarthroplasty patients achieve 90° or less, while nearly all RSA patients exceed 90°.
Tuberosity healing is the decisive variable when comparing RSA to hemiarthroplasty: when the greater tuberosity fails, active elevation is 116° with RSA vs 75° with hemiarthroplasty and Constant scores are 55 vs 41. RSA is substantially more forgiving of tuberosity nonunion.
RSA for fracture sequelae (nonunion, malunion, AVN) improved active elevation from 59° to 114° and Constant scores from 20 to 53, reaching 75% of age-matched normal function. A meaningful gain in a population with preoperative severe disability.
The Neyton fracture sequelae classification guides prosthesis selection:
- Type 1 (cephalic collapse, intact tuberosities): nonconstrained prosthesis preferred for better external rotation
- Type 2 (locked/fracture dislocation): either option; RSA preferred for chronic anterior dislocation
- Type 3 (surgical neck nonunion): RSA has high complication rate; nonathroplasty fixation recommended
- Type 4 (severe malunion, nonfunctional cuff): RSA provides acceptable pain and function despite tuberosity nonunion
Complication rates escalate sharply with revision complexity. Boileau reported 47% complications in the failed hemiarthroplasty revision group vs 5% for primary RSA in cuff tear arthropathy. A multicenter study confirmed RSA in revision carries a complication rate three times that of primary RSA.
External rotation does not reliably recover after RSA regardless of indication. The design medializes the center of rotation, shortening the external rotators and reducing posterior deltoid effectiveness as a secondary external rotator. Latissimus dorsi transfer at the time of revision may address this, but remains unstudied in this population.
Scapular notching is frequent: 37% in the fracture sequelae series and 69% in the acute fracture series. Neither series found notching to negatively affect pain or functional scores at short-to-medium follow-up, though long-term glenoid component stability remains a concern.

Board PearlWhen tuberosity nonunion occurs after proximal humeral fracture treatment, RSA achieves 116° elevation versus 75° with hemiarthroplasty — RSA is more forgiving of tuberosity failure.

Supplemental

Reverse Total Shoulder Arthroplasty for Acute Fractures and Failed Management after Proximal Humeral Fractures

Martin, IannottiOrthop Clin North Am200868 citationsReview article