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


A total of 381,459 patients with proximal humeral fracture were identified in the database (Figure 1), of whom 315,490 (82.7%) patients received nonsurgical treatment and 65,969 (17.3%) patients underwent operative treatment In total, 8,163 patients (2.1% of total patients and 12.4% of surgically managed patients) underwent primary rTSA within a year of fracture. In total, 5,137 patients had a greater than 1-year follow-up and were included in this study, with 4,245 (82.6%) patients receiving acute primary rTSA treatment and 892 (17.4%) receiving delayed primary rTSA treatment. Patients who underwent delayed primary rTSA demonstrated higher rates of obesity (P < 0.001), diabetes (P = 0.022), and tobacco use (P < 0.001) and had a higher Elixhauser comorbidity index score (P < 0.001) compared with patients who underwent acute primary rTSA (Table 1). The average age of patients fell within in the reported age range of 75 to 79 years for both the acute and delayed groups. No significant difference was observed in sex compared between the two groups (% male patients: acute 14.5%, delayed 16.8%; P = 0.076). The follow-up time for patients in both the acute and delayed groups was 1 year.

The acute treatment cohort showed a higher average surgery day cost of treatment ($15,770 ± $8,383 versus $14,586 ± $7,271; P < 0.001) and had a longer average length of hospital stay (3.9 ± 3.1 versus 2.7 ± 1.6, P < 0.001) compared with the delayed treatment cohort. Patients treated with delayed primary rTSA experienced a higher 1-year revision rate (4.5%) compared with acute primary rTSA patients (1.7%; P < 0.001; Figure 2). Univariate analysis of 1-year postoperative surgical complication rates demonstrated significant differences between the cohorts for dislocation (acute 2.8%, delayed 6.1%; P < 0.001) and mechanical complications (acute 1.9%, delayed 3.4%; P = 0.007). The cohorts showed no significant differences in rates of postoperative infection (acute 3.0%, delayed 3.7%; P = 0.25). Of the 74 revisions done in the acute group, 33 patients had record of only dislocation complications (44.6%), 15 patients had record of only mechanical complications (20.3%), 8 patients had record of only postoperative infection (10.8%), and 18 patients had record of multiple or no recorded complications that were investigated in this study (24.3%). Of the 40 revisions done in the delayed group, 22 patients had record of only dislocation complications (55.0%), 8 patients had record of only mechanical complications (20.0%), 2 patients had record of only postoperative infection (5.0%), and 8 patients had record of multiple or no investigated complications (20.0%).

Figure 2.

Chart showing 1-year rates of revision and surgical complication compared between acute and delayed primary rTSA treatment for proximal humeral fracture in elderly patients. Error bars represent 95% CI. CI, confidence interval, rTSA = reverse total shoulder arthroplasty

Multivariate analysis identified delayed primary rTSA treatment as independently associated with increased rates of revision (OR: 2.29, 95% CI 1.53 to 3.40; P < 0.001) and dislocation (OR: 2.05, 95% CI 1.45 to 2.86; P < 0.001). Mechanical complications, which included but were not limited to aseptic loosening, periprosthetic fracture, and periprosthetic osteolysis (OR: 1.54, 95% CI 0.98 to 2.34; P = 0.051) and postoperative infection (OR: 1.05, 95% CI 0.69 to 1.53; P = 0.82), were not statistically significant after multivariate analysis.