The reverse total shoulder arthroplasty (RTSA) has continued to increase in clinical utility and popularity as an effective treatment for cuff tear arthropathy (CTA), irreparable rotator cuff tear (RCT), osteoarthritis, and acute three and four-part proximal humeral fractures. Performing RTSA for acute proximal humeral fractures (RTSA-F) presents the unique challenges of tuberosity management, bone loss, and instability compared to elective indications such as CTA or irreparable rotator cuff tears (RTSA-E). The purpose of this study is to compare the clinical outcomes, active range of motion, radiographic outcomes, and complications between RTSA-E and RTSA-F patients.
A systematic review of the literature was conducted in accordance with PRISMA guidelines. We queried 3 electronic databases (EMBASE, Cochrane and PubMed) using the search term “reverse” AND “shoulder” AND “arthroplasty.” Studies investigating clinical outcomes of RTSA for traumatic and/or elective indications were included. Studies were excluded if they included RTSAs performed for fracture sequelae, inflammatory arthritis, post-traumatic osteoarthritis, or avascular necrosis. Data collected included patient demographics, subjective outcome measurements, range of motion, and complications. The pooled means and proportions along with their 95% confidence intervals were generated by random effect model which incorporated the between-study variations in the weighting.
A total of 134 studies (11,651 shoulders) investigating clinical outcomes of RTSA-E patients and 66 studies (3,117 shoulders) investigating RTSA-F patients were included in this systematic review. Analysis of patient reported outcomes demonstrated that RTSA-F patients experienced significantly lower Constant scores than RTSA-E patients, however, relative Constant, SST, DASH, ASES, and VAS pain scores were similar RTSA-F patients also had significantly lower forward elevation, abduction, and external rotation. RTSA-F patients experienced tuberosity complications at significantly higher rates than RTSA-E patients (25.9%. versus 4.1%). There was no significant difference between the two groups in terms of other complications such as heterotopic ossification, radiographic loosening, revisions, nerve injury, postoperative stiffness, infections, dislocations, and component loosening.
RTSA performed for acute three and four-part PHF’s has overall worse clinical outcomes and active range of motion compared to those performed for elective indications including CTA, massive irreparable RCTs, and osteoarthritis with deformity. Tuberosity healing may be a major contributing factor to the difference in clinical outcome. In the setting of RTSA-F, patient and surgeon expectations may need to be tempered and appropriate measures undertaken to optimize tuberosity healing.

Copyright © 2021. Published by Elsevier Inc.