Acute Versus Delayed Reverse Shoulder Arthroplasty for the Primary Treatment of Proximal Humeral Fractures

Henry D. Seidel, BS; Sarah Bhattacharjee, BS; Jason L. Koh, MD; Jason A. Strelzow, MD; Lewis L. Shi, MD


J Am Acad Orthop Surg. 2021;29(19):832-839. 

In This Article

Abstract and Introduction


Introduction: Reverse total shoulder arthroplasty (rTSA) is gaining popularity as a treatment option for proximal humeral fractures in elderly patients. The impact of surgical timing on outcomes of primary rTSA is unclear. This study compared the rates of revision and complication, and surgery day cost of treatment between acute and delayed primary rTSA patients.

Methods: Elderly patients with proximal humeral fracture who underwent primary rTSA within a year of fracture were identified in a national insurance database from 2005 to 2014. Patients were separated into acute (<4 weeks) or delayed (>4 weeks) cohorts based on the timing of rTSA. The univariate 1-year rates of revision and complication and surgery day cost of treatment were assessed. Multivariate logistic regression analysis was conducted, accounting for the factors of age, sex, obesity, diabetes comorbidity, and tobacco use.

Results: Four thousand two hundred forty-five (82.6%) acute and 892 (17.4%) delayed primary rTSA patients were identified. Acute rTSA was associated with a higher surgery day cost (acute $15,770 ± $8,383, delayed $14,586 ± $7,271; P < 0.001). Delayed rTSA resulted in a higher 1-year revision rate (acute 1.7%, delayed 4.5%; P < 0.001) and surgical complication rates of dislocation (acute 2.8%, delayed 6.1%; P < 0.001) and mechanical complications (acute 1.9%, delayed 3.4%; P = 0.007). Multivariate analysis identified delayed primary treatment as independently associated with increased risk of revision (odds ratio: 2.29, 95% confidence interval 1.53 to 3.40; P < 0.001) and dislocation (OR: 2.05, 95% confidence interval 1.45 to 2.86; P < 0.001).

Conclusion: Delayed primary rTSA was associated with higher short-term rates of revision and dislocation compared with acute primary rTSA. Our results suggest that delaying rTSA, whether because of attempted nonsurgical treatment or patients' lack of access, may result in increased complication and additional surgery.

Level of Evidence: Level III


Proximal humeral fractures are the third most common fractures in elderly patients with an increasing incidence that is expected to continue to grow as the population ages.[1–3] These fractures cause substantial patient burden and the goals of care center around reducing pain, restoring functional ability, and preventing future surgery.[4–6] Nonsurgical treatment results in good functional outcomes for most minimally displaced fractures.[7–10] In severely displaced proximal humeral fractures, some disagreement exists in the literature regarding treatment. Although recent evidence has questioned the role of surgical management, three- and four-part fractures are still often treated operatively.[11–14] The nuanced indications that guide surgical decision making are not fully understood. Historically, open reduction and internal fixation (ORIF) has been the most common surgical procedure used to manage these fractures.[15–17] Although ORIF is still widely used, additional procedures such as hemiarthroplasty and reverse total shoulder arthroplasty (rTSA) have become increasingly popular, particularly in elderly patients.[18,19]

Over the past decade, rTSA procedures account for 2% to 5% of all proximal humeral fracture treatment.[17,20] The surgical method and biomechanical properties of rTSA, including stabilization of the glenohumeral joint and less reliance on the rotator cuff, make this form of surgical treatment appealing for the management of complex proximal humeral fractures.[18,21,22] Furthermore, rTSA may be associated with lower complication rates compared with both hemiarthroplasty and ORIF.[4,23–26] Overall reported rates of complication after rTSA range from 5% to 24% in the literature, and patients generally report satisfaction with functional outcome after treatment.[23,25,27–29] In addition to rTSA done in the acute setting of proximal humeral fractures, studies have also noted the value of rTSA as a salvage procedure after the failure of initial treatment.[22,30,31]

The use of rTSA as a salvage procedure has led some authors to examine the role of surgical timing in rTSA treatment.[32–37] However, no definitive consensus has been reached. The literature is particularly scant regarding how the use of rTSA as a delayed primary procedure after nonsurgical treatment compares with acutely done rTSA. Primary treatment with rTSA may be delayed for a variety of reasons, including limited accessibility to surgical care, an initial attempt at nonsurgical treatment, or a patient originally declining surgical treatment but then reversing their decision.[35] If delayed primary rTSA results in similar outcomes as that of acute primary rTSA, patients with borderline cases may benefit from an initial trial of nonsurgical management. This could prevent unnecessary surgery and reduce cost and burden for some patients.

The goal of this study was to evaluate how the timing of rTSA treatment is associated with rates of revision and complication in elderly patients with proximal humeral fractures. Based on the limited evidence available from previous comparative studies,[32,35] we hypothesize that delayed primary rTSA after nonsurgical treatment for proximal humeral fractures in elderly patients results in similar rates of revision and complication compared with acute primary rTSA treatment.