This week’s Orthopaedic Crossfire® debate was part of the 19th Annual Current Concepts in Joint Replacement® (CCJR®), Spring meeting, which took place in Las Vegas. This week’s topic is “Four-Part Fx’s in an Active 65-Year-Old: Reverse is the Preferred Treatment.” For is Leesa M. Galatz, M.D., Icahn School of Medicine at Mount Sinai, New York, New York. Opposing is Evan L. Flatow, M.D., Mount Sinai Health System, New York, New York. Moderating is Thomas S. Thornhill, M.D., Harvard Medical School, Boston, Massachusetts.
Dr. Galatz: It’s a pleasure to come and debate my friend, colleague and co-worker Evan Flatow. Proximal humerus fractures are a challenge. They are technically difficult. They’re one of the few fractures we fix where we can’t actually see the bone fragments because they’re covered in soft tissue. We want to reconstruct normal anatomy but often we are reconstructing poor quality bone fragments. Everything that we do in the proximal humerus depends largely on tuberosity healing—which is absolutely critical in order to make sure we have proper rotator cuff function.
Failure of tuberosity healing is the most common indication for revision of a hemi-arthroplasty as well as a revision to a reverse. What happens when you don’t have proper rotator cuff function, you get a prominent humeral head, superior instability and significant pain.
Looking at the results of hemi-arthroplasty, outcome scores, elevation and satisfaction are very good if the tuberosity healed. However, this has a very high failure rate.
Is a reverse a better option? It solves the problem, allowing immediate reconstruction. It can stabilize the shoulder. And, importantly, you don’t have to wait for tuberosity healing. In fact, there are two recent studies showing that tuberosity healing does not have a significant impact on outcome with a reverse as it does in a hemi-arthroplasty.
It’s an operation where we can tolerate some imperfection because we’re medializing the center of rotation, maximizing deltoid function.
It is important though to know that this is not a “throw the tuberosities in the bucket” operation. There is still tuberosity repair—a very important part of the operation to avoid instability and allow overhead elevation and external rotation. The tuberosities can rotate posteriorly a little bit and still, if they heal, be functional.
A reverse shoulder arthroplasty is a solution for a failed hemi-arthroplasty. So, in talking about our 65-year-old wanting to have one operation and be done with it, is a good argument for a reverse. We use a reverse for fracture sequelae, both non-unions, malunions and also AVN [avascular necrosis]. AVN is a risk for a 4-part fracture in any age group.
