Functional outcomes of reverse shoulder arthroplasty
compared with hemiarthroplasty for acute proximal
Matthew J. Boyle, MBChBa,*, Seung-Min Youn, MBChBa,
Christopher M.A. Frampton, PhDb, Craig M. Ball, FRACSa
aDepartment of Orthopaedic Surgery, Auckland City Hospital, Auckland, New Zealand
bDepartment of Medicine, The University of Otago, Christchurch, New Zealand
Background: Complex acute proximal humeral fractures may require prosthetic replacement of the
proximal humerus. Reverse shoulder arthroplasty (RSA) has been suggested as an alternative to hemiar-
throplasty in the management of such fractures. This study compared the functional outcomes of RSA
with hemiarthroplasty in patients with acute proximal humeral fractures.
Materials and methods: All patients who underwent RSA or shoulder hemiarthroplasty for acute
proximal humeral fractures between January 1, 1999, and December 31, 2010 were identified from The
New Zealand Joint Registry. Baseline information, operative characteristics, and postoperative outcomes
(Oxford Shoulder Score [OSS] at 6 months and 5 years, revision rate, and mortality rate) were examined
and compared between the study groups.
Results: During the study period, 55 patients underwent RSA and 313 underwent shoulder hemiarthro-
plasty for acute proximal humeral fractures. Compared with hemiarthroplasty patients, RSA patients
were significantly older (mean age, 79.6 vs 71.9 years; P < .001) and more often women (93% vs 78%,
P ¼.013). The 6-month OSS was 28.1 for RSA and 27.9 for hemiarthroplasty, which was not significantly
different (P ¼ .923); however, the RSA group had a significantly better 5-year OSS than the hemiarthro-
plasty group (41.5 vs 32.3; P ¼ .022). There was no significant difference between the RSA and hemiar-
throplasty groups in revision rate per 100 component-years (1.7 vs 1.1; P ¼ .747) or in 1-year mortality
(3.5% vs 3.6%; P > .99).
Conclusions: Patients with acute proximal humeral fractures who undergo RSA appear to achieve superior
5-year functional outcomes compared with patients who undergo hemiarthroplasty.
Level of evidence: Level III, Retrospective Case Control Design, Treatment Study.
? 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Functional outcome; shoulder arthroplasty; reverse shoulder arthroplasty; hemiarthroplasty;
proximal humeral fracture; shoulder fracture
Proximal humeral fractures are increasingly common in
societies with aging populations and represent the third most
common fracture in people aged older than 65 years.3
Undisplaced or minimally displaced fractures can generally
be managed nonsurgically with satisfactory results.21,24
This study was approved by the Multi Region Ethics Committee, New
Zealand (study reference number: MEC/11/EXP/088).
*Reprint requests: Matthew J. Boyle, MBChB, Department of Ortho-
paedic Surgery, Auckland City Hospital, Private Bag 92024, Auckland
Mail Centre, Auckland 1142, New Zealand.
E-mail address: firstname.lastname@example.org (M.J. Boyle).
J Shoulder Elbow Surg (2013) 22, 32-37
1058-2746/$ - see front matter ? 2013 Journal of Shoulder and Elbow Surgery Board of Trustees.
Displaced fractures may require operative intervention;
however, there is no consensus regarding the ideal manage-
ment of these fractures.
Historically, complex proximal
including 4-part fractures, 3-part fractures in osteoporotic
bone, fracture-dislocations, head-splitting fractures, and
impression fractures involving >40% to 50% of the artic-
ular surface have been managed with shoulder hemi-
arthroplasty.20Shoulder hemiarthroplasty is technically
demanding, however, and anatomic tuberosity reconstruc-
tion, restoration of humeral length, and ideal retroversion
are often difficult to achieve. Long-term studies have
identified limitations with this procedure,1and functional
outcomes dependon several
displacement of the tuberosities.5Satisfactory results can
be achieved; however, even in the hands of experienced
shoulder surgeons, clinical failures are common.6
Reverse shoulder arthroplasty (RSA) has shown prom-
ising results in patients with cuff tear arthropathy, degener-
ative arthritis with concurrent cuff deficiency, painful
pseudoparalysis, or proximal humeral malunion4,14,26-28and
has been proposed as an alternative management option for
acute complex proximal humeral fractures.7,8,18,19RSA
holds a number of theoretic advantages over hemi-
outcomes appear to depend less on tuberosity healing and
rotator cuff integrity, and patients have been observed to
recover more quickly, with less requirement of careful
patients.14The aim of this study was to compare the func-
tional outcomes of RSA with hemiarthroplasty in patients
with acute proximal humeral fractures.
Materials and methods
Data covering the period of January 1, 1999, to December 31,
2010, were obtained from The New Zealand Joint Registry.
Registry records of all patients who underwent primary RSA and
those who underwent primary shoulder hemiarthroplasty during
this time with the principle diagnosis of acute proximal humeral
fracture were analyzed.
Patients undergoing RSA were compared with patients under-
going shoulder hemiarthroplasty with respect to baseline infor-
mation (age, sex, surgeon case volume), operative characteristics
(surgical approach, prostheses used, operative time), and post-
operative outcomes, including the Oxford Shoulder Score (OSS)11
at 6 months and 5 years, the revision rate, and mortality rates at
6 months and 1 year.
Baseline demographic and operative measures were compared
between the groups using Fisher exact tests, independent t tests,
and Mann-Whitney U tests, as appropriate. A general linear model
was used to compare OSS outcomes between groups in a multi-
variate analysis that included age, sex, and surgeon case volume.
Mortality rates were compared using Fisher exact tests, and
log-rank tests were used to compare revision rates during the
entire follow-up period. A two-tailed P <.05 was taken to indicate
The New Zealand Joint Registry was established in 1998 and
became fully national early in 1999. The registry prospectively
records baseline characteristics, operative characteristics, and
postoperative outcome measures for patients undergoing arthro-
plasty surgery throughout New Zealand, with the compliance rate
among public hospitals exceeding 98%.25The registry records
patient functional outcomes after shoulder arthroplasty using the
self-assessed OSS,11with questionnaires sent to patients 6 months
and 5 years after surgery. The OSS, a patient-reported outcome
measure designed to assess functional outcomes after shoulder
surgery, has been validated in several studies9,10and correlates
well with the Constant shoulder score in patients with proximal
humeral fractures.2The OSS score ranges from 0 (the most severe
disability) to 48 (normal shoulder function). The New Zealand
Joint Registry classifies OSS results according to the system of
Kalairajah et al,17who have recommended a category of excel-
lence for a score >41, good for a score of 34 to 41, fair for 27 to
33, and poor for scores <27.
During the study period, 55 patients who underwent
primary RSA and 313 patients who underwent primary
shoulder hemiarthroplasty with the principle diagnosis of
acute proximal humeral fracture were identified from New
Zealand Joint Registry records.
At the time of surgery, the RSA patients were significantly
older (mean age, 79.6 vs 71.9 years; P < .001) and more
often women (93% vs 78%, P ¼ .013) than the hemi-
arthroplasty patients (Table I). There was a statistically
significant difference in surgeon case volume between the
2 patient groups, with RSA more frequently performed by
higher-volume shoulder surgeons (73% [RSA] vs 31%
performing ? 10 cases per year, P < .001).
All patients in the RSA and hemiarthroplasty groups under-
went a deltopectoral approach to the shoulder. The most
Modular Shoulder (Limacorporate S.p.a., Udine, Italy)
(DePuy, Warsaw, IN, USA) in 24. The most commonly used
prostheses systems in the hemiarthroplasty patients were the
was no significant difference in operative time between the
Functional outcomes of acute shoulder arthroplasty 33
RSA and hemiarthroplasty groups (mean, 123 vs 118
minutes; P ¼.308; Table I).
Oxford Shoulder Score
No statistically significant difference was noted in the
6-month mean OSS between the RSA (28.1) and hemi-
arthroplasty (27.9) groups (P ¼ .923; Table II). There was,
however, a statistically significant difference at 5 years,
with the RSA group displaying a superior OSS of 41.5 vs
32.3 in the hemiarthroplasty group (P ¼ .022).
With respect to the most commonly used implant
systems, there was no statistically significant difference in
OSS in the RSA group (P ¼ .167) or the hemiarthroplasty
group (P ¼ .80) according to implant system used.
Multivariate analyses showed that patient age (P ¼.931),
sex (P ¼.638), and surgeon case volume (P ¼.375) did not
The difference in revision rate between the RSA group and
the hemiarthroplasty group was not statistically significant
(1.7 vs 1.1 revisions per 100 component-years; P ¼ .747;
Table II). New Zealand Joint Registry recorded reasons for
revision include pain, instability, implant loosening, deep
infection, and fracture. There was no statistically significant
difference in revision rates between the 2 groups for any of
these reasons for revision. The prosthesis-specific revision
rates for the RSA or the hemiarthroplasty groups did not
There was no statistically significant difference in the
mortality rates at 6 months in RSA vs hemiarthroplasty
patients (3.5% vs 2.2%; P ¼ .63) or at 1 year (3.5% vs
3.6%; P > .99); Table II).
The comparable 6-month functional results seen in our
study support the findings of previous studies, which did
not identify substantial early functional benefit of RSA over
hemiarthroplasty in the management of acute proximal
humeral fractures.13,29We have identified an important
midterm difference between the 2 patient groups, however,
with RSA patients achieving 5-year functional results
superior to hemiarthroplasty patients. In addition to patient
functional benefits, this superior OSS is important for ex-
pected implant longevity, because joint registry research
has identified a statistically significant relationship between
the postoperative OSS and the risk of revision at 2 years:
0.18% with an OSS exceeding 42 compared with 4.96%
with an OSS of less than 34.25It is also interesting to note
that although fracture morphology and patient characteris-
tics differ, the promising midterm OSS seen in our RSA
group compares favorably with reports of OSS in proximal
humeral fracture patients managed nonoperatively,2with
Other authors have investigated postoperative function
after hemiarthroplasty for acute proximal humeral fractures
with mixed results. Antuna et al1reported 57 patients with
an average age of 66 years (range, 23-89 years), of which
84% reported no shoulder pain at a mean follow-up of
10.3 years but only 49% graded their overall result as
excellent. Goldman et al15published results of 22 patients
at a mean follow-up of 30 months. Although 73% of
patients reported only slight or no pain, 73% of patients
reported difficulty with at least 3 of 15 functional tasks.
Boileau et al5presented the results of 66 patients, who were
a mean age of 66 years (range, 31-85), with an average
follow-up of 27 months. The Constant score in this group
averaged 56 of 100, 42% of patients were disappointed with
their results, and tuberosity malposition correlated with an
inferior functional result.
Despite a number of theoretic advantages over hemi-
arthroplasty, the published functional outcomes after RSA
for acute proximal humeral fractures have been similarly
mixed: Bufquin et al7published the results of 43 patients
who were a mean age of 78 years (range, 65-97 years). At
a mean of 22 months postoperatively, their mean Constant
score was 44. The authors cautioned against recommending
RSA in this patient group before long-term results were
patients undergoing hemiarthroplasty for acute proximal humeral fracture
Baseline information and operative characteristics for patients undergoing reverse shoulder arthroplasty (RSA) compared with
(n ¼ 55)
123.3 ? 23.9
(n ¼ 313)
118.8 ? 34.2
Patient age, years
Surgeon ?10 cases/yeary
Operative time, min
)Continuous data are recorded as mean (range) or ? standard deviation, and categoric data as number of patients (percentage of group of patients).
ySurgeon case volume for RSA or hemiarthroplasty, respectively.
34M.J. Boyle et al.
Cazeneuve and Cristofari8reported 23 patients (mean
age, 75 years). At an average follow up of 86 months, the
mean Constant score was 60 points.
Klein et al18presented a comprehensive functional
review of 20 patients (mean age, 75 years). After an
average follow-up of 33 months, the mean Constant score
was 68 points, the mean Disabilities of Arm, Shoulder and
Hand (DASH) score was 47 points, the mean modified
American Shoulder and Elbow Surgeons (ASES) score was
68, and the physical and mental components of the Medical
Outcome Study 36-Item Short Form (SF-36) Health Survey
were 38 and 53 points, respectively. The authors felt that
the good functional outcome seen in their series supported
the use of RSA as a treatment option for elderly patients
with complex acute proximal humeral fractures.
The comparative literature contrasting the functional
outcomes of RSAwith hemiarthroplasty in the management
of acute proximal humeral fractures is relatively limited.
Young et al29published their comparison of 10 patients
receiving RSA with 10 patients receiving hemiarthroplasty
for acute proximal humeral fractures. The patients were
a mean age of 77 years for the RSA group and 75 years for
the hemiarthroplasty group, and the average follow-up was
22 months and 44 months, respectively. The authors found
no statistically significant difference in ASES or OSS
between the two groups.
Gallinet et al13compared 16 patients treated with RSA
and 17 patients treated with hemiarthroplasty for proximal
humeral fracture. Their patients were an average age of 74
years, and the mean follow-up was 12.4 months in the RSA
group and 16.5 months in the hemiarthroplasty group.
Although the authors identified a higher postoperative
Constant score in the RSA group, DASH scores in the 2
groups were identical.
Patients presenting with proximal humeral fractures are
typically elderly, often with significant medical comorbid-
ities. The mortality rates seen in our patients were relatively
low compared with previous studies, however. Olsson et al22
found a 1-year mortality of 9% in 100 patients with a mean
age of 74 years, Johnell et al16detected a 1-year mortality of
et al12founda 90-day mortalityrate of2.9%in5044patients
with a mean age of 71.9 years who received varied
management for proximal humeral fractures. The lower than
expected mortality rates in our study are difficult to explain,
but may suggest that patients with proximal humeral frac-
tures who are medically unwell are less likely to be put
forward for shoulderarthroplasty than patients with minimal
comorbidities. In any case, it was interesting to note that our
RSA group was older than our hemiarthroplasty group but
the difference in early postoperative mortality was not
significant. Although acknowledging the limited statistical
power for this comparison, it does suggest that our 2 groups
were medically comparable.
Our study has several limitations. Firstly, the patient
groups were not equivalent at baseline because they
differed with respect to age, sex, and surgeon case volume.
Multivariate analyses were performed to adjust the OSS
comparison for these potential confounding variables,
however, and this had no effect on the significance of the
differences between the two patient groups.
Secondly, preoperative OSS was not assessed, which
would have assisted interpretation of postoperative function.
However, because the patients in our study were all admitted
and managed acutely after shoulder trauma, the validity of
premorbid shoulder functional assessment is questionable.
Thirdly, the New Zealand Joint Registry does not
include preoperative or postoperative radiographic assess-
ment, assessment of associated soft tissue injury, or the
specific indications for RSA or hemiarthroplasty in each
case, restricting result stratification with respect to fracture
severity, soft tissue damage, tuberosity healing, and treat-
ment algorithm. Tuberosity healing is of particular impor-
tance, because near-anatomic
hemiarthroplasty patients has been shown to significantly
positively affect patient outcomes.5
Fourthly, owing to the registry-based nature of our study,
functional evaluation was restricted to the OSS, which is
purely a subjective scoring system. Objective functional
evaluation, with assessment of range of motion and power,
Finally, the patient diagnosis of acute fracture is entered
into the New Zealand Joint Registry records by the oper-
ating surgeon only and is not validated; although unlikely,
hemiarthroplasty for acute proximal humeral fracture
Postoperative outcomes for patients undergoing reverse shoulder arthroplasty (RSA) compared with patients undergoing
Oxford Shoulder Score)
)Data presented as mean (standard error).
yRevision rate per 100 component-years.
zNumber of patients who died (percentage of group of patients).
Functional outcomes of acute shoulder arthroplasty 35
this could have resulted in an inaccurate diagnosis for
certain patients and consequent information bias.
comparing 55 patients undergoing primary RSA with
313 patients undergoing primary hemiarthroplasty for
acute proximal humeral fractures, RSA appeared to
produce functionally superior results to hemiarthroplasty
at 5 years postoperatively. To our knowledge, this study
reports the largest series with functional postoperative
outcome data comparing RSA with hemiarthroplasty in
the management of acute proximal humeral fractures.
Our results support RSA as a successful surgical option
for patients with acute proximal humeral fractures
requiring prosthetic replacement of the humeral head.
Longer follow-up is required to confirm the functional
benefit of RSA in this patient group.
this nationwide registry-basedcohortstudy
The authors, their immediate families, and any research
foundations with which they are affiliated have not
received any financial payments or other benefits from
any commercial entity related to the subject of this
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Functional outcomes of acute shoulder arthroplasty 37