That is counteracted by a study from the United States from 2016 (Solomon, Orthopedics) which showed that the costs for hemiarthroplasty were less than reverse and reverse had better pain and outcome scores but that the functional outcome was the same.
A multicenter study from 2016 (Bonnevialle, Orthop Trauma) showed hemiarthroplasty had higher complications, but again, 20% scapular notching for the reverse; those are real concerns we are going to have to deal with.
This is the biggest concern we have with the reverse compared to hemiarthroplasty—with longer term follow-up, the functional outcome scores decrease as their deltoid starts to peter out.
The advantages of reverse arthroplasty are that you don’t have to worry about tuberosities, rehab is easier, outcomes, I would admit, are better overall but what about cost and what about value ultimately?
The disadvantages are that you don’t get rotation if the tuberosities don’t heal, the scapular notching issue is intense, the restricted function is real, not imaginary. Costs are higher and long-term durability remains a concern.
The pros for hemiarthroplasty: costs, function, no functional limitations and ultimately value.
The cons: it is a hard operation, Dr. Neer talked about that a long time ago. To get the tuberosities to heal is not easy. The outcomes are inconsistent and related to the tuberosity healing. If we get tuberosity failure we get a catastrophic outcome.
So, my final thoughts are that we are operating on far too many proximal humerus fractures. Non-operative options may be better for many and for the active 70-year-old that Tom and Seth asked me to talk about, hemiarthroplasty with tuberosity reconstruction is the better option and is better value and “we know it when we see it.”
Dr. Warner: I’m not going to talk too much about value. Instead, I’m going to present an overview that is really eminence-based and evidence-based.
What is 70 years of age? It’s highly variable and biology says that women age slower than do men.
I think we probably agree on when it’s appropriate to do conservative management. We probably also agree on notching and I can tell you how to solve that.
Our institute is predicated on Codman’s concepts that measuring outcomes is the most important thing. Through critical introspection it is evident that in the last several years there has been virtually no utilization of hemiarthroplasty anymore because it just has been so unpredictable.
How about eminence? There are so many failures of hemiarthroplasty that I see—typically with tuberosity failure.
Yes, it is a difficult operation. Even the specialist doesn’t do that great with this. Why? Because age is a surrogate for bone quality and the problem with the bone quality that you deal with when you do your hemiarthroplasty and expect the tuberosity to heal.
With reverse prosthesis you can circumvent this issue of bone quality and solve your problems very reproducibly…with case after case of good outcomes.
Neer started this whole thing, he was far and away the biggest influence of the last generation. When you look at his approaches, he had beautiful diagrams on how to do it. He even had relatively good series although small numbers for sure.
What’s interesting to me is when you look at those who learned from him first hand, the results are not particularly great. What Bill just showed you is probably not his case after case, it’s his best one. So like Evan Flatow just told me, keep a camera on your desk in order to have it available when you have a good outcome.
A series from the Mayo Clinic (Cofield, et al., JSES 2008): 47% satisfactory, 53% unsatisfactory, good pain relief but unpredictable function.
