Outcomes of reverse total shoulder arthroplasty vs. other surgical fixation methods for proximal humerus fractures in elderly patients.

BACKGROUND

Proximal humerus fractures (PHFs) are among the most common osteoporotic injuries in elderly patients, typically resulting from low-energy mechanisms such as ground-level falls. Multiple surgical options exist, including reverse total shoulder arthroplasty (rTSA), open reduction and internal fixation (ORIF), and hemiarthroplasty (HA), but the optimal treatment remains debated. This up-to-date systematic review and meta-analysis aimed to evaluate the comparative effectiveness of rTSA, HA, and ORIF for treating PHFs in the geriatric population.

METHODS

A systematic review and meta-analysis were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed (MEDLINE), EMBASE, and Web of Science were searched through January 2025. Eligible studies included randomized controlled trials or cohort studies comparing rTSA with HA and/or ORIF in patients aged ≥ 65 years. Two reviewers independently screened studies using predefined inclusion criteria. The primary outcome was postoperative functional scores; secondary outcomes included: complication rates, revision surgery rates, shoulder range of motion, and quality of life metrics.

RESULTS

Twenty studies met the inclusion criteria. rTSA demonstrated significantly better Constant-Murley Scores (standardized mean difference [SMD] = 0.67, P < .001), visual analog scale pain scores (SMD = -0.36, P = .034), forward flexion (SMD = 0.95, P < .001), abduction (SMD = 0.90, P < .001), and complication rates (risk ratio = 0.79, P = .047) than HA. Compared to ORIF, rTSA was associated with significantly lower revision rates (risk ratio = 0.31, P < .001), with no difference in functional outcomes or complication rates. No significant differences in mortality rates were observed between rTSA and either HA or ORIF.

CONCLUSION

rTSA offers superior functional outcomes and complication rates compared to HA and a more favorable revision profile than ORIF in elderly patients with PHFs. These findings support the growing preference for rTSA as the primary surgical treatment in this population, though further high-quality, long-term studies are needed to guide individualized decision-making.