Survey study suggests that reverse total shoulder arthroplasty is becoming the treatment of choice for four-part fractures of the humeral head in the elderly

Abstract

Purpose: The role of reverse total shoulder arthroplasty (RTSA) for three and four-part proximal humerus fractures is evolving. However, there does not appear to be a clear consensus amongst surgeons. The purpose of this study is to further define the standard of care, assessing surgeon preference and treatment considerations for management of such fractures.

Methods: Orthopaedic surgeons were surveyed on their training, practice setting, and experience regarding management of four-part proximal humerus fractures. The survey also presented five representative cases to assess treatment preferences.

Results: Two hundred five surgeons responded to the survey with fellowship training in shoulder and elbow surgery (114), orthopaedic trauma (35) or sports medicine/other training (56). There was no difference between respondents with years in practice and confidence with performing RTSA, however, surgeons in the academic setting were more confident in performing the surgery. Surgeons preferred RTSA for management of four-part fractures in patients over age 65. However, they also trended to favour hemiarthroplasty with higher co-morbidities. Physicians with more than 11 years of experience were more likely to choose hemiarthroplasty for older and high comorbidity patients. RTSA was not the preferred treatment method for younger, active patients. Patient age and fracture pattern had a greater influence on the surgeon's decision.

Conclusions: There is a consensus in our study population that RTSA is the preferred treatment for four-part proximal humerus fractures for elderly patients with patient age and fracture pattern being the most important factors in making management decisions.

Level of evidence: Level III - Case controlled study.

Keywords: Proximal humerus fracture; Proximal humerus open reduction internal fixation; Reverse total shoulder arthroplasty; Shoulder fracture care; Shoulder hemiarthroplasty; Survey study.