Complications After Surgical Treatment of Proximal Humerus Fractures in the Elderly-an Analysis of Complication Patterns and Risk Factors for Reverse Shoulder Arthroplasty and Angular-stable Plating

Background: To date, there is a lack of consensus regarding surgical treatment recommendations for complex proximal humerus fracture (PHF) patterns, especially between joint preservation and joint replacement techniques.

Methods: Between 2012 and 2017, 146 patients (aged 74.1 ± 8.0 years) with complex PHF were treated with locking plates (open reduction-internal fixation [ORIF]) or reverse total shoulder arthroplasty (RTSA). Complications and unplanned revision surgery were recorded in a mid-term follow-up. Potential patient and surgical risk factors for complications were extracted. Univariate and multivariate analyses were conducted.

Results: Follow-up data were available for 125 patients, 66 (52.8%) of whom were treated with locking plates, and 59 (41.2%) with RTSA. Both groups had comparable Charlson indices. The overall complication rate was 37.8% for ORIF and 22.0% for RTSA, with a revision rate of 12.1% and 5.1%, respectively, as driven primarily by persistent motion deficits. Multivariate analyses demonstrated no significant differences between the 2 procedures (P = .500). However, age was an independent protective factor against overall complications (P = .018). Risk factors for major complications in ORIF included osteoporosis, varus impaction fractures, posteromedial metaphyseal extensions <8 mm, head-shaft displacements >4 mm, and multifragmentary greater tuberosities. For RTSA, higher complication rates were seen in patients with higher Charlson indices, diabetes, or altered (greater) tuberosities. In contrast, Neer's classification system was not predictive in either group.

Conclusions: RTSA led to fewer complications than ORIF and thus can be considered a valuable option in complex PHF of the elderly. Paying attention to specific prognostic factors may help to reduce the complication rate.