Displaced proximal humerus fractures in older patients: reverse total shoulder arthroplasty or nonoperative treatment?

Background: Reverse total shoulder arthroplasty (RTSA) for proximal humerus fractures (PHFs) in older patients has been shown to be an effective treatment modality. Recent studies have questioned the superiority of RTSA over nonoperative treatment. The purpose of this study was to compare outcomes after RTSA and nonoperative treatment of PHF. Methods: A retrospective case-matched review of 72 displaced PHFs who underwent either RTSA or nonoperative treatment between August 2016 and August 2019 was conducted. Nine RTSA and 6 nonoperative patients were excluded. Thirty-seven RTSAs in 36 patients (1 bilateral) were compared to twenty patients who met operative criteria for RTSA but did not elect to undergo surgery. Results: Mean VAS pain scores decreased significantly in both groups at the final follow-up. Although there was no statistically significant difference in VAS scores at the time of most-recent follow-up between the two cohorts (1.5 RTSA vs. 1.9 nonop, P =.49), patients who underwent RTSA had a more rapid improvement in pain than nonoperative patients. RTSA patients had significantly lower VAS scores at 2 weeks (2.7 ± 3.1 vs. 5.6 ± 3.2, P =.03), 6 weeks (1.7 ± 2.8 vs. 4.1 ± 3.4, P =.02), and 3 months (1.6 ± 2.8 vs. 3.7 ± 3.2, P =.04) postoperatively. RTSA patients also had better forward flexion (125.4 ± 26.4° vs. 92.1 ± 35.1°, P = 0.001) and abduction (87.1 ± 11.6° vs. 75 ± 13.4°, P =.002) than nonoperative patients at the final follow-up (minimum 6 months). There was a statistically significant difference in mean American Shoulder and Elbow Surgeons scores after RTSA compared with nonoperative patients at the time of final follow-up for acute RTSA and for 3- and 4-part fracture subgroups. Eight patients (21.6%) experienced a complication after RTSA, of which 3 required revision surgery. Discussion/Conclusion: Older patients with displaced PHF have significant improvement in pain and function after both RTSA and nonoperative treatment although RTSA does come with a greater risk of complications. Patients who undergo RTSA have a greater increase in overhead motion and abduction and experience a more rapid improvement in pain, with significantly lower pain scores in the early postoperative period.