What Are the Ramifications of Delaying rTSA in Proximal Humerus Fracture Patients?
Dr. Lewis Shi answers ICJR’s questions about a study he co-authored that evaluated outcomes of acute versus delayed primary reverse total shoulder arthroplasty – including revision rates and medical and surgical complications – in more than 5000 older patients with a proximal humerus fracture.
ICJR: What question did you and your co-authors want to answer with this study?
Lewis L. Shi, MD: Although most older patients with a proximal humerus fracture are still treated non-operatively, [1,2] surgical management is becoming more common. [1,3] Options for surgery include open reduction internal fixation (ORIF), hemiarthroplasty, and reverse total shoulder arthroplasty (rTSA), with data showing a growing preference for rTSA over hemiarthroplasty [1,2,4-8] due to reports of greater predictability of outcomes and lower rates of revision for rTSA. [9-13]
Reverse total shoulder arthroplasty can also be offered as a salvage procedure for patients who fail non-operative management or other surgical procedures (ie, ORIF or hemiarthroplasty). A recent systematic review and meta-analysis showed similar clinical outcomes and reoperation rates for acute and delayed rTSA for proximal humerus fractures. 
The issue of outcomes in acute versus delayed rTSA is by no means settled, however. With that in mind, the question we sought to answer was this: How does the timing between proximal humeral fracture and primary rTSA treatment impact rates of revision and complications in older patients with proximal humeral fractures?
ICJR: What did you conclude about the timing of rTSA in patients with proximal humerus fractures?
Dr. Shi: Ultimately, we found better outcomes with acute rTSA (within 4 weeks of injury) compared with delayed rTSA (more than 4 weeks after injury) for the treatment of proximal humeral fractures. In our study, delayed treatment was associated with higher 1-year rates of revision and dislocation compared with rTSA performed acutely.
ICJR: How did you reach your conclusions? What was your study cohort and what did you find with your analysis?
Dr. Shi: From the PearlDiver national insurance claims database, we identified 4245 patients who had undergone acute primary rTSA and 892 patients who had undergone delayed primary rTSA. As mentioned above, acute treatment was defined as within 4 weeks of fracture, while delayed treatment was more than 4 weeks after the fracture.
The 1-year revision rate was 1.7% in the acute group and 4.5% in the delayed group (P<0.001), and the 1-year rate of dislocation was 2.8% in the acute group and 6.1% in the delayed group (P<0.001). We then performed multivariate analysis to control for patient risk factors of age, sex, obesity, diabetes, and tobacco use. We found that delayed treatment was independently associated with increased rates of revision and dislocation, with an odds ratio of 2.29 (95% CI 1.53-3.40; P<0.001) and 2.05 (95% CI 1.45-2.86; P< 0.001), respectively.
Initially, bleeding complications and mechanical complications were also found to be higher at 1 year in the delayed treatment group, but they were not statistically different in multivariate analysis. In addition, multivariate analysis showed no difference between groups for medical complication rates at 1 year.
ICJR: Why is this significant for clinical practice?
Dr. Shi: Reverse total shoulder arthroplasty is gaining popularity as a treatment option for proximal humeral fractures in older patients; however, the impact of surgical timing on outcomes of primary rTSA is unclear.
Prior studies have suggested that a trial of non-operative management may be warranted in older patients. Our study found that delaying rTSA, whether due to attempted non-surgical treatment or a patient’s lack of access, may result in additional surgery and potentially worse outcomes. This study provides valuable information for counseling patients on reasonable postoperative expectations.
In addition, this study demonstrated that when considering a trial of non-operative management versus acute rTSA for proximal humeral fracture, the benefit of avoiding surgery should be weighed against the potential increased risk for complications and revision associated with delayed rTSA.
Seidel H, Bhattacharjee S, Koth JL, Strezlow J, Shi LL. Does delaying reverse total shoulder arthroplasty treatment of proximal humerus fracture result in higher rates of revision and complication? (Paper 556). Presented at the 2021 Annual Meeting of the American Academy of Orthopaedic Surgeons, August 31-September 3, San Diego, California.
Seidel HD, Bhattacharjee S, Koh JL, Strelzow JA, Shi LL. Acute versus delayed reverse shoulder arthroplasty for the primary treatment of proximal humeral fractures. J Am Acad Orthop Surg. 2021 Oct 1;29(19):832-839. doi: 10.5435/JAAOS-D-20-01375.
About the Expert
Lewis L. Shi, MD, is an Associate Professor of Shoulder Surgery and Sports Medicine in the Department of Orthopaedic Surgery and Rehabilitation Medicine at the University of Chicago Medicine and Biological Sciences, Chicago, Illinois.
Disclosures: Dr. Shi has disclosed that he a paid consultant and paid presenter or speaker for DePuy Synthes and that he is a paid presenter or speaker for Arthrex, Inc.
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