Dataset Information

Primary Versus Salvage Reverse Total Shoulder Arthroplasty for Displaced Proximal Humerus Fractures in the Elderly: A Systematic Review and Meta-analysis.

ABSTRACT:

Background

There is currently no established consensus on best treatment for complex proximal humerus fractures (PHFs) in the elderly. Reverse total shoulder arthroplasty (RTSA) is a viable option in this population but many times is used as a salvage procedure.

Methods

A systematic review of studies comparing RTSA as a primary treatment for PHF versus as a salvage procedure following failed open reduction internal fixation (ORIF), humeral intramedullary nailing, hemiarthroplasty (HA) or non-operative treatment was conducted using PRISMA guidelines. Pooled outcomes and sub-group analyses assessing range of motion, patient reported outcomes and complications were examined using RevMan.

Results

Five articles were included in final analysis with 104 patients in the primary RTSA group and 147 in the salvage RTSA group compromising 251 total patients. Primary RTSA had a statistically significant advantage in range of motion (forward flexion and external rotation), patient reported outcomes, and complications compared to salvage RTSA.

Conclusions

Based on the best available evidence, primary RTSA may result in slightly better patient reported outcomes, range of motion and a lower rate of complication when compared to salvage RTSA. Further high-quality prospective studies are needed to confirm the findings of the current review.

SUBMITTER: Nelson PA

PROVIDER: S-EPMC8282171 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundAlmost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate.MethodsThe DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients.ResultsThere were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, -3.8 to 19.1 points; p = 0.19).ConclusionsAt a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients.Level of evidenceTherapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Project description:BackgroundThe implantation rates of reverse total shoulder arthroplasties (RTSAs) are increasing worldwide, resulting in higher absolute numbers of the associated complications and revision surgeries. This requires the discussion of salvage therapies for failed RTSAs without revision to a new RTSA. Revision to hemiarthroplasty may offer a valid fallback option in certain cases. This study aimed to analyze the incidence, indications, and clinical outcomes, especially the reduction in pain levels compared to a matched control group.MethodsOur prospectively enrolled patient cohort of RTSA implantations at a tertiary referral center between January 2005 and December 2018 was retrospectively queried for revision to a hemiarthroplasty. For clinical outcome evaluation, a minimum follow-up duration of 2 years after revision to hemiarthroplasty was required. Clinical outcome measures were compared to two matching groups, one with RTSA preserving revision and one without any reintervention. The outcome measures were the absolute and relative Constant-Murley score (aCS and rCS), Subjective Shoulder Value (SSV), range of motion, and pain.ResultsA total of 21 out of 1237 RTSAs (1.7%) underwent salvage revision to hemiarthroplasty at a mean time of 20 ± 21 months (range, 1-75 months). Of those, 12 were available for a minimum follow-up of 2 years after revision to a hemiarthroplasty. The main indications were glenoid loosening (8/12), scapular spine fracture (2/12), and instability (2/21). Clinical outcome was analyzed at a mean follow-up period of 46 ± 26 months (24 months to 123 months) after revision to a hemiarthroplasty. The revision significantly reduced CS pain from 6 ± 4 points to 12 ± 3 points (scale 0 to 15 with 15 as optimum, P < .01). The aCS, rCS, SSV, and range of motion did not improve. Comparison with the RTSA preserving revision group and the RTSA group without reintervention showed significantly worse outcome scores for aCS (33 ± 10 vs. 55 ± 19 vs. 69 ± 12 points), rCS (41 ± 14% vs. 67 ± 20% vs. 84 ± 13%), SSV (35 ± 19% vs. 64 ± 20% vs. 81 ± 15%), flexion (53 ± 27° vs. 64 ± 20° vs. 128 ± 24°), and abduction (50 ± 23° vs. 109 ± 42° vs. 142 ± 24°). Pain was similar in all groups at the last follow-up visit.ConclusionIn a few cases, RTSA retention or revision to another RTSA is impossible. For those patients, conversion to hemiarthroplasty is a valid fallback option to reduce the patient's pain levels and provide low-level function.

Project description:BackgroundTotal hip arthroplasty (THA) is the treatment of choice for posttraumatic arthritis with failed internal fixation for hip fractures. However, the postoperative prognosis is not clear.Questions/purposesThe primary aim of the study is to report the postoperative outcome, prognosis, and complication rates of total hip arthroplasty in posttraumatic hip arthritis after failed internal fixation of fractures around the hip. The secondary aim of the study is to report results among different fracture types around the hip.Patients and methodsWe enrolled salvage THA patients after failed internal fixation of fractures around the hip and matched control patients undergoing primary THA for hip osteoarthritis. Subgroup analysis was performed to compare the postoperative outcomes, prognosis, and complication rates of salvage THA in posttraumatic hip arthritis after failed internal fixation of different fracture types around the hip.ResultsA total of 315 THAs (105 salvage THAs and 210 primary THAs) were analyzed. Patients with salvage THA had a longer operative time, lower postoperative hemoglobin (Hb) level, more Hb drop (2.2 ± 1.4 vs. 1.7 ± 1.2 gm/dl, p = 0.002), and delayed ambulation. The salvage THA group also had a higher dislocation rate within 2 months after salvage THA (9.5% vs. 1.9%, p = 0.002), reoperation rate (10.5% vs. 3.8%, p = 0.019, including debridement, open and closed reduction under sedation, revision surgery, surgical fixation for periprosthetic fractures), and revision rate (5.7% vs. 0.5%, p = 0.003) than patients undergoing primary THA. Patients who had failed fixation for acetabular fractures were younger and tended to recover well. Patients with previous intertrochanteric fracture had the longest operative time, more hip pain (83.8%, p = 0.022) and more complications.ConclusionSalvage THA in posttraumatic hip arthritis after failed internal fixation required a longer operative time and led to more blood loss and postoperative complications. The dislocation, reoperation, and revision rates after salvage THA were higher than those after primary THA. Patients with salvage THA after failed internal fixation for intertrochanteric fractures were the most susceptible to more complications compared to those with femoral neck fracture or acetabular fracture. Level of Evidence level III.

Project description:BackgroundAcromion stress fractures (ASF) or scapular spine fractures (SSF) following reverse total shoulder arthroplasty (RTSA) are common complications with impaired clinical outcome. The underlying biomechanical factors remain unclear. The aim of this study was to evaluate basic demographic and radiographic parameters predicting occurrence of different types of ASF/SSF in a large single-center study cohort.MethodsA total of 860 RTSA (805 patients) with available minimum follow-up of 2 years were implanted between 2005 and 2018 at a tertiary academic center. All RTSA with subsequent ASF/SSF (n = 45 in 43 shoulders [42 patients, 5%]) were identified and classified as Levy I to III. Predictive demographic, surgical, and radiographic factors were evaluated for each subtype and compared to the control group (817 RTSA, 763 patients). The radiographic analysis included critical shoulder angle, lateralization shoulder angle (LSA), distalization shoulder angle (DSA), acromio-humeral distance (ACHD), acromial thickness, deltoid tuberosity index, deltoid length, and center of rotation.ResultsOf the 45 ASF/SSF in 42 patients, 8 were classified as Levy I, 21 as Levy II, and 16 as Levy III. Demographic analysis revealed indication as risk factor for Levy I fractures, higher American Society of Anesthesiologists score as risk for Levy type II fractures and higher age as risk factor for Levy type III fractures. None of the measured radiographic parameters were predictive for occurrence of Levy type I and Levy type II ASF. However, analysis of Levy III SSF revealed a higher postoperative LSA (89° ± 10° vs. 83° ± 9°, P = .015), a lower postoperative DSA (45° ± 8° vs. 53° ± 12°, P = .002), less distalization (ACHD of 33 ± 8 mm vs. 38 ± 10 mm, P = .049), and a more medial center of rotation preoperatively (COR-LA 16 ± 8 mm vs. 12 ± 7 mm, P = .048) as predictive radiographic factors.ConclusionThe present analysis showed a significant association of higher postoperative LSA, lower DSA, a lower ACHD, and higher age as predictive factor only for Levy type III fractures. Some of these factors can be surgically influenced and this knowledge can be of value for preoperative planning and surgical execution to avoid these complications.