Reverse Shoulder Arthroplasty After Complex Proximal Humerus Fracture — An Advantage at 7 Years?

Polish version · Trauma — Literature for Clinicians

Key finding: at approximately 7.5 years, patients treated with reverse shoulder arthroplasty had a better Constant score than those treated nonoperatively. There was no advantage in pain or overall quality of life, however, and the long-term analysis included only 29 of the original 62 participants. This is an important clinical signal, but not a decisive argument for routine surgery.

Why is this study interesting?

In very elderly patients with displaced three- or four-part proximal humerus fractures, choosing between nonoperative treatment and reverse shoulder arthroplasty remains difficult. Early results do not necessarily reflect shoulder function several years later. The authors therefore returned to participants from a previous randomised trial and assessed them after a mean follow-up of more than seven years.

Question and methods

The original trial included 62 patients aged at least 80 years with displaced three- or four-part fractures. Reverse shoulder arthroplasty was compared with nonoperative treatment. Twenty-nine patients were available for long-term analysis: 17 after arthroplasty and 12 after nonoperative treatment. Mean follow-up was 7.6 and 7.4 years, respectively.

Outcomes included the Constant score for shoulder function, DASH for upper-limb disability, pain on a visual analogue scale, SF-12 quality of life and radiographic findings. In the long-term subgroup, patients in the arthroplasty group were older on average: 92 versus 88 years.

Results

• The mean Constant score was 62 after reverse shoulder arthroplasty and 51 after nonoperative treatment; p=0.039.
• DASH scores were 16 and 25, respectively; the difference did not reach statistical significance, p=0.069.
• Pain was similar in the two groups: 1.5 versus 1.4 points.
• No differences were found in either the physical or mental components of SF-12.
• All fractures treated nonoperatively healed in malunion, but none of those patients later required reverse shoulder arthroplasty.
• In the operative group, one patient required revision because of prosthetic dislocation.

Clinical interpretation for an orthopaedic surgeon

The advantage in Constant score suggests that in some relatively fit patients aged 80 years or older, reverse shoulder arthroplasty may preserve useful shoulder function better over the long term. At the same time, similar pain scores and the absence of a difference in SF-12 show that an improvement in a shoulder-specific measure does not necessarily translate into an equally large difference in overall wellbeing.

Malunion after nonoperative treatment was not automatically equivalent to later surgical failure. In very elderly patients, the decision should still take into account pre-injury independence, functional expectations, deltoid function, perioperative risk, ability to participate in rehabilitation and patient preference.

Limitations

• Only 29 of the 62 originally enrolled patients remained in the long-term analysis. This substantial attrition can introduce survival and follow-up bias.
• The small sample limits precision and the ability to assess uncommon complications.
• After years of attrition, the original randomisation no longer fully protects against differences between the groups.
• The groups differed in age at long-term follow-up.
• A statistically significant difference was found in the Constant score, but not in DASH, pain or SF-12.
• The findings should not be extrapolated to younger patients or to simpler fracture patterns.

What might this change in practice?

The study strengthens the case for discussing a possible long-term functional benefit of reverse shoulder arthroplasty with selected active patients of very advanced age rather than judging treatment only by the first few months. It does not justify automatic selection for surgery based on the fracture image alone.

What does the study not prove?

It does not prove that reverse shoulder arthroplasty is the best treatment for every patient over 80. It does not show an advantage in pain or overall quality of life, and the sample is too small for a precise comparison of complication risk. It also does not mean that every malunion after nonoperative care requires later reconstruction.

Reference

Lopiz Y, Alcobía-Díaz B, Coderch J, et al. Long-term outcomes of reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humerus fractures in elderly patients: results from a prior randomized clinical trial. Journal of Shoulder and Elbow Surgery. 2026;35(9S):S32–S38. DOI: 10.1016/j.jse.2026.05.029. PubMed.

Content prepared by: Tomasz Poboży - orthopaedic surgeon.