Improved outcomes of older patients with acute and displaced proximal humerus fractures treated with window bone ingrowth fracture-specific stem reverse shoulder arthroplasty

Abstract

Background: The optimal treatment of displaced proximal humerus fractures (PHFs) in the older people population remains controversial. Reverse shoulder arthroplasty (RSA) is a popular surgical treatment option that provides improved and reproducible results. However, the relevance of fracture-specific stem designs for RSA to improve tuberosity consolidation and shoulder function remains debatable. Methods: This study included all patients 70 years or older with acute and displaced PHFs primarily treated with RSA at a single institution in Portugal, between January 2010 and December 2019 who participated in a minimum follow-up of 2 years. Results: A total of 112 patients (15 men and 97 women) with a median clinical follow-up of 52 months were included. The mean age at the time of fracture was 78.6 years. All fractures were classified as Neer types 3 and 4 (n = 50 and n = 62, respectively). A window bone ingrowth fracture-specific stem was used for 86 patients, and a conventional humeral stem was used for 26 patients. Regarding the tuberosity fixation technique, 76 tuberosities were attached using technique A (according to Boileau's principles), 36 tuberosities were attached using technique B (not following Boileau's principles) and 11cases were classified as technique C (if fixation was not possible). The overall survival rate during the 2-year follow-up was 88.2%; however, this decreased to 79% at 5 years. Only three patients had complications (two infections and one dislocation) requiring revision surgery. In the multivariable analysis, the tuberosity fixation technique (P = 0.012) and tuberosity anatomical consolidation (P < 0.001) were associated with improved Constant scores (median Constant Score 62.67 (technique A), 55.32 (technique B), 49.70 (technique C). Fracture-specific humeral implants (P = 0.051), the tuberosity fixation technique (P = 0.041), tuberosity anatomical consolidation (P < 0.001), and dementia influenced the achievement of functional mobility (P = 0.014). Tuberosity anatomic consolidation was positively associated with bone ingrowth fracture-specific humeral implants (P < 0.01) and a strong tuberosity fixation technique (P < 0.01). Conclusion: RSA is used for complex and displaced fractures of the proximal humerus in older patients. Dementia was negatively correlated with functional outcomes. A window bone ingrowth fracture-specific stem combined with strong tuberosity fixation can yield better clinical and radiological results. Level of evidence: Level II; prospective comparative study; treatment study.