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.

Keywords: Failed fixation; arthroplasty; malunion; nonunion; reverse total shoulder.

Figure 1.

Flow diagram summarizing the literature search, screening, and selection process. RTSA, reverse total shoulder arthroplasty.

Figure 2.

Pooled mean difference of range of motion in patients undergoing primary RTSA compared with salvage RTSA. A, forward flexion; B, external rotation. RTSA, reverse total shoulder arthroplasty; SD, standard deviation; CI, confidence interval.

Figure 3.

Pooled mean difference of qualitative function measures in patients undergoing primary RTSA compared with salvage RTSA. A, American Shoulder and Elbow Surgeons Shoulder Score (ASES); B, UCLA Shoulder Score; C, Constant Score; D, Simple Shoulder Test (SST). RTSA, reverse total shoulder arthroplasty; SD, standard deviation; CI, confidence interval.

Figure 4.

Pooled odds ratio for (A) complications and (B) reoperations among patients undergoing primary RTSA compared with salvage RTSA. RTSA, reverse total shoulder arthroplasty; CI, confidence interval.