These authors reviewed 26 patients having reverse total shoulder (RSA) for the sequelae of proximal humeral fractures. Twenty patients had follow-up beyond two years, averaging 44 months (range 27-97). The average age at surgery was 67 years (31-89).
The primary diagnosis was proximal humeral malunion in eighteen shoulders, complicated by osteonecrosis in four cases and a humeral shaft nonunion in one. Seven shoulders were considered to have proximal humeral nonunions, including one shoulder that had the proximal humeral resected as primary treatment and a case of an infected, failed internal fixation. Three shoulders had head collapse from osteonecrosis or impaction with minimal tuberosity malunion, six had a surgical neck nonunion, and 17 had severe tuberosity displacement.
Co-morbidities were common in this patient population. Sixteen patients had hypertension, eight dyslipidemia, eight diabetes, four coronary heart disease, three reported tobacco use, two were on chronic steroid use, and one had chronic obstructive pulmonary disease.
Fifteen of the shoulders had had at least one attempt at internal fixation of the fracture, another shoulder had resection of the fractured fragments, and one final shoulder had open rotator cuff repair performed after fracture healing. Three shoulders required proximal humeral allografts in conjunction with the RSA to compensate for bone loss, another shoulder strut allografts for reinforcement of weakened humeral bone, and one shoulder internal fixation of a humeral shaft nonunion performed simultaneously with the RSA. Finally, one shoulder was treated with a two-stage implantation of the RSA to permit treatment of the infected non-union with internal fixation.
The authors considered the results in twenty patients to be excellent in 8 shoulders, satisfactory in 6, and unsatisfactory in 6.
The average scores were not good: mean ASES score of 65 and the mean SST of 6. Complications included one deep infection, two transient brachial plexopathies, and two cases of dislocation.
Comment: This article underscores the complexities presented by patients with post-traumatic arthritis. It emphasizes that each case is highly individualized and that even in the hands of these expert surgeons the results are modest.
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