Arthroplasty as Primary Treatment for Metadiaphyseal Proximal Humerus Fractures: A Viable Alternative to Osteosynthesis for the Elderly

Abstract

Introduction: in the elderly patient population, where fracture comminution, osteoporotic fractures, and associated arthritis or rotator cuff pathologies dominate, metadiaphyseal proximal humeral fracture is a challenging subset of fractures to treat. This study reports on cementless long-stem reverse total shoulder arthroplasty (RTSA) as primary treatment of metadiaphyseal proximal humeral fractures in elderly patients.

Materials & methods: Between January 2018 and October 2021, 22 consecutive patients sustained proximal humerus fractures with metadiaphyseal extension and underwent surgery with cementless long-stem RTSA. Patients older than 60 years with minimum 1 year of clinical and radiographic follow-up were included. Patient demographics, range of motion, and patient reported outcomes [Visual Analog Scale (VAS) pain scale, Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), and American Shoulder Elbow Surgeon (ASES) scores] were retrospectively collected. Postoperative X-rays were evaluated for fracture and tuberosity union.

Results: There were 14 eligible patients with a median age of 71 years (range 61-91 years) and a median 13 months follow-up. At final follow-up, the median active elevation was 120° (range 80°-150°), external rotation was 40° (range 0°-50°), and internal rotation was 40° (range 0°-80°). Median VAS was 2 (range 0-8), SST was 71% (range 33%-92%), SSV was 78% (range 20-90%), and ASES was 73 (range 17-90). All patients exhibited radiographic union. There were five minor complications in three patients: postoperative neuropathy, tuberosity nonunion, scapula notching, and proximal humeral stress shielding.

Conclusion: Cementless long-stem RTSA is a viable alternative to primary fracture fixation in the elderly patient population with metadiaphyseal proximal humerus fractures.

Keywords: cementless; diaphyseal fixation; elderly; metadiaphyseal; osseous union; proximal humerus fracture; reverse total shoulder arthroplasty.

Figure 1.

Seventy-seven-year-old woman presenting with metadiaphyseal fracture involving tuberosity s/p fall. XR (A) and 3d CT (B) are shown.

Figure 2.

Intraoperative photo demonstrating bone stitching and cerclage suture to obtain interfragmentary compression.

Figure 3.

Postoperative XR demonstrating surgical fixation with cementless press-fit long-stem RTSA with metaphyseal fragments cerclaged and augmented with tibial allograft strut.

Figure 4.

Radiographs at 6-month follow-up demonstrating osteosynthesis and stable implant.