Conserve or reverse? Outcomes of conservative treatment vs. reverse shoulder arthroplasty in displaced 3- and 4-part proximal humeral fractures in patients over 60 years

Abstract

Background: The optimal treatment of 3- and 4-part proximal humeral fractures in older adults remains controversial. The aim of this study was to compare patient reported outcomes following reverse shoulder arthroplasty (RSA) or nonoperative management in patients over 60 years old.

Methods: A retrospective review was undertaken of patients following 3- or 4-part proximal humeral fractures treated with RSA or nonoperative treatment with minimum 2-year follow-up. Patient-reported outcome measures were collected including Oxford Shoulder Score (OSS), Quick-Disabilities of the Arm Shoulder and Hand (QDASH), subjective shoulder score (SSV), and visual analog score pain. Minimal clinically important difference (MCID) thresholds were set for OSS (5), QDASH (8), and SSV (12) points. Patient acceptable symptom state threshold of 75% was set for SSV.

Results: Comprising the largest study to date, 99 patients (35 RSA: 64 nonoperative) were matched for age, sex, and hand dominance, at mean follow-up of 35 months with a median age of 71 at time of injury. The mean OSS was significantly higher for the RSA group (42 vs. 36; P = .048). Similarly, QDASH (14.4 vs. 25.4, P = .046) and SSV (84% vs. 70%, P = .006) were significantly higher in the RSA cohort. MCID thresholds were reached for OSS (8), QDASH (11), and SSV (14). Patient acceptable symptomatic state threshold of 75% for SSV was reached in 88% of RSA patients, compared to 46% in nonoperative patients (P = .003). Visual analog score pain did not have a significant effect on outcomes (1.5 vs. 2, P = .063). Complication rates were higher (51%) in nonoperative patients, including 15% mortality at follow-up, compared to 10% in the RSA group with 1.5% mortality. Reintervention rate was 13% within the nonoperative group and 2.9% within the RSA group.

Conclusion: These results contribute to a growing body of evidence supporting the use of RSA in 3- and 4-part proximal humeral fractures. Highlighting that RSA can offer significant benefits in terms of improved patient reported outcome measures and patient satisfaction with low complication rates.

Keywords: DASH; Fracture; OSS; conservative treatment; functional outcome; proximal humerus; quality of life; reverse shoulder arthroplasty.