The Open Orthopaedics Journal


ISSN: 1874-3250 ― Volume 11, 2017
REVIEW ARTICLE

Humeral Head Replacement and Reverse Shoulder Arthroplasty for the Treatment of Proximal Humerus Fracturesm



Aaron Andrew Frombach, Kendra Brett, Peter Lapner*
Division of Orthopaedics, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada

Abstract

Acute proximal humeral fractures in the elderly are generally treated non-operatively if alignment is acceptable and in stable fracture patterns. When operative treatment is indicated, surgical fixation is often difficult or impossible to obtain. Hemiarthroplasty has long been the standard of care. However, with its reliance on tuberosity healing, functional outcomes and patient satisfaction are often poor. Reverse shoulder arthroplasty has emerged as a new technology for treating proximal humeral fractures but the indications for its use remain uncertain. While not conclusive, the evidence suggests that reverse shoulder arthroplasty yields more consistent results, with improved forward elevation and higher functional outcome scores. The primary advantages of hemiarthroplasty are improved shoulder rotation and shorter operative time. Complication rates do not vary significantly between the two options. Although higher quality trials are needed to further define the role of reverse shoulder arthroplasty, current evidence suggests that this is a reasonable option for surgeons who are highly familiar with its use.

Keywords: Humeral head replacement, Proximal humerus fracture, Proximal humerus fracture-dislocation, Proximal humerus hemiarthroplasty, Reverse shoulder arthroplasty, Tuberosity.


Article Information


Identifiers and Pagination:

Year: 2017
Volume: 11
Issue: Suppl-6, M3
First Page: 1108
Last Page: 1114
Publisher Id: TOORTHJ-11-1108
DOI: 10.2174/1874325001711011108

Article History:

Received Date: 06/02/2017
Revision Received Date: 12/05/2017
Acceptance Date: 14/05/2017
Electronic publication date: 30/09/2017
Collection year: 2017

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© 2017 Frombach et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Division of Orthopaedics, Ottawa Hospital Research Institute, University of Ottawa, 501 Smyth Road, Room W1648, Ottawa, ON, K1H 8L6, Canada; Tel: 613-737-8377; Fax: 613-737-8837; E-mail: plapner@toh.on.ca




1. INTRODUCTION

Acute fractures of the proximal humerus are the third most common type of fracture in the elderly [1Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury 2006; 37(8): 691-7.[http://dx.doi.org/10.1016/j.injury.2006.04.130] [PMID: 16814787] ]. Depending on patient and fracture characteristics, these can often be effectively treated non-operatively, as is the case in 80-85% of patients [2Neer CS II. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970; 52(6): 1077-89.[http://dx.doi.org/10.2106/00004623-197052060-00001] [PMID: 5455339] ]. When surgery is indicated, options include shoulder arthroplasty, or reconstructive options including fixation with proximal humeral locked plate constructs in the physiologically young with adequate bone stock [3Cadet ER, Ahmad CS. Hemiarthroplasty for three- and four-part proximal humerus fractures. J Am Acad Orthop Surg 2012; 20(1): 17-27.[PMID: 22207515] ]. When arthroplasty is indicated, humeral head replacement arthroplasty (HHR) has historically been the treatment of choice for proximal humeral fractures as advocated initially by Neer [2Neer CS II. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970; 52(6): 1077-89.[http://dx.doi.org/10.2106/00004623-197052060-00001] [PMID: 5455339] ]. However, in recent years there has been a trend towards reverse total shoulder arthroplasty (RSA). This has occurred in part due to the prevalence of rotator cuff deficiency in the affected patient population. In addition, non-union or malunion of the tuberosities have been associated with poor results with hemiarthroplasty; complete healing does appear to be necessary for a successful outcome following RSA [4Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg 2015; 23(3): 190-201.[http://dx.doi.org/10.5435/JAAOS-D-13-00190] [PMID: 25630370] ]. Finally, RSA may allow for a shorter period of immobilization post-operatively given its semi-constrained design.

2. BASIC SCIENCE

2.1. Epidemiology

Fractures of the proximal humerus are very common in the elderly population, resulting in approximately 6% of all fractures in adults [1Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury 2006; 37(8): 691-7.[http://dx.doi.org/10.1016/j.injury.2006.04.130] [PMID: 16814787] ]. While up to 85% are minimally displaced and can be treated non-operatively, this still leaves a significant number of fractures that require operative treatment.

2.2. Diagnosis/Classification

In 1970, Neer described the classification that is most prevalent today [2Neer CS II. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970; 52(6): 1077-89.[http://dx.doi.org/10.2106/00004623-197052060-00001] [PMID: 5455339] ]. This classification system is based on the number of main anatomical fragments, or parts (two, three, or four) which are defined as the humeral head, greater tuberosity, lesser tuberosity and humeral shaft, having displacement of 1cm or angulation of 45 degrees from their anatomic position. Variant patterns include head splitting fractures which are generally treated with arthroplasty except in the physiologically young and active patients, fracture dislocations which have a high incidence of associated neurovascular injury, and fractures of the anatomic neck with minimal calcar remaining that are prone to avascular necrosis of the humeral head [3Cadet ER, Ahmad CS. Hemiarthroplasty for three- and four-part proximal humerus fractures. J Am Acad Orthop Surg 2012; 20(1): 17-27.[PMID: 22207515] ].

3. CLINICAL DECISION MAKING

High demand and physiologically young patients may have increased tolerance for repeat surgery and it may be reasonable to attempt a reconstruction even in higher grade proximal humerus fractures in this population. Low functional demand patients may be better served with a replacement, and those with pre-morbid symptoms of rotator cuff pathology or evidence of rotator cuff arthrosis may be better served with RSA [4Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg 2015; 23(3): 190-201.[http://dx.doi.org/10.5435/JAAOS-D-13-00190] [PMID: 25630370] ]. RSA is contraindicated in the setting of axillary nerve injury however.

Based on radiographic criteria, primary arthroplasty may be indicated if healing is unlikely or if there is vascular compromise of the humeral head [5Hertel R. Fractures of the proximal humerus in osteoporotic bone. Osteoporos Int 2005; 16(Suppl 2): S65-72.[http://dx.doi.org/10.1007/s00198-004-1714-2] [PMID: 15526090] ]. Fractures of articular surface (head splitting fractures) are considered a strong indication for primary arthroplasty. Factors associated with vascular compromise of the humeral head constitute relative indications for primary arthroplasty and include the following: anatomic neck fractures with minimal blood supply remaining for the humeral head (calcar spike < 8mm remaining attached to the humeral head), lack of a medial hinge and gross angulation and/or displacement of the fragments, specifically the humeral head and/or the tuberosities [5Hertel R. Fractures of the proximal humerus in osteoporotic bone. Osteoporos Int 2005; 16(Suppl 2): S65-72.[http://dx.doi.org/10.1007/s00198-004-1714-2] [PMID: 15526090] ]. Radiographs are often sufficient for preoperative planning but a CT may be obtained to confirm a head splitting fracture and to further delineate the extent of articular surface involvement, the degree of comminution, and the relative positions of the fragments.

4. OPERATIVE TECHNIQUES

Both HHR and RSA have been extensively described in the literature and the operative techniques are not within the scope of this article [6Voos JED. J. S.; Dines D. M. Arthroplasty for Fractures of the Proximal Part of the Humerus.Instructional Course Lectures 60 1st ed. 1st ed.2011; 105-12.]. With rare exception, both techniques utilize a deltopectoral approach to the shoulder with various options for subscapularis management. In hemiarthroplasty the component stem is generally inserted with cemented technique and the prosthetic humeral head articulates with the native glenoid. If the fracture involves the tuberosities, they are fixated to the shaft and bone graft may be used to augment healing potential. With fracture treatment, RSA fixation is generally with cement although cementless options exist.

5. HUMERAL HEAD REPLACEMENT – CLINICAL OUTCOMES

In one systematic review of patients treated with HHR for proximal humeral fractures, 41% of patients reported unsatisfactory outcomes [7Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br 2008; 90(11): 1407-13.[http://dx.doi.org/10.1302/0301-620X.90B11.21070] [PMID: 18978256] ]. However 40% also reported satisfactory to excellent outcomes, which included pain only with vigorous activity. Overall, with an analysis of over 800 HHR cases, the mean forward elevation was 106 degrees, external rotation 30 degrees and the Constant score was 56.6. Eleven percent of patients had complications related to tuberosity fixation and 6.8% had superior subluxation of the humeral head on follow-up radiographs [7Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br 2008; 90(11): 1407-13.[http://dx.doi.org/10.1302/0301-620X.90B11.21070] [PMID: 18978256] ].

6. REVERSE SHOULDER ARTHROPLASTY VS. HUMERAL HEAD REPLACEMENT

No long term outcome studies have been published on RSA in the fracture setting. This has led many authors to question its durability and the wisdom of using this implant in physiologically younger patients for fracture [4Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg 2015; 23(3): 190-201.[http://dx.doi.org/10.5435/JAAOS-D-13-00190] [PMID: 25630370] ]. Current indications for RSA include advanced age and decreased functional demand, rotator cuff arthropathy, chronic fractures, or failed hemiarthroplasty [8Sirveaux FN, Roche G, Mole O, Williams D. Reverse prosthesis for proximal humerus fracture, technique and results. Tech Shoulder Elbow Surg 2008; 9(1): 15-22.[http://dx.doi.org/10.1097/BTE.0b013e31815dca3c] ]. Risks specific to RSA include glenoid component loosening, glenoid notching, infection, complex regional pain syndrome, and proximal bone resorption. Intraoperative fracture of the glenoid may prevent insertion of the glenoid baseplate [8Sirveaux FN, Roche G, Mole O, Williams D. Reverse prosthesis for proximal humerus fracture, technique and results. Tech Shoulder Elbow Surg 2008; 9(1): 15-22.[http://dx.doi.org/10.1097/BTE.0b013e31815dca3c] ]. In systematic reviews comparing RSA with HHR, both Ferrell et al. and Namdari et al. found increased complication rates with RSA as compared to HHR, while Mata-Fink et al. reported better outcomes overall with RSA compared to HHR based on the Constant score, ASES and OSS [9Ferrel JR, Trinh TQ, Fischer RA. Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: A systematic review. J Orthop Trauma 2015; 29(1): 60-8.[http://dx.doi.org/10.1097/BOT.0000000000000224] [PMID: 25186842] -11Mata-Fink A, Meinke M, Jones C, Kim B, Bell JE. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: A systematic review. J Shoulder Elbow Surg 2013; 22(12): 1737-48.[http://dx.doi.org/10.1016/j.jse.2013.08.021] [PMID: 24246529] ].

Range of motion (ROM) comparison between the two procedures by Mata-Fink et al. demonstrated superior forward elevation with RSA with mildly decreased external rotation [11Mata-Fink A, Meinke M, Jones C, Kim B, Bell JE. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: A systematic review. J Shoulder Elbow Surg 2013; 22(12): 1737-48.[http://dx.doi.org/10.1016/j.jse.2013.08.021] [PMID: 24246529] ]. Ferrell et al. similarly found superior forward elevation without a significant decrease in external rotation with RSA [9Ferrel JR, Trinh TQ, Fischer RA. Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: A systematic review. J Orthop Trauma 2015; 29(1): 60-8.[http://dx.doi.org/10.1097/BOT.0000000000000224] [PMID: 25186842] ]. However, Namdari et al. did not observe any significant range of motion differences between the two prostheses [10Namdari S, Horneff JG, Baldwin K. Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review. J Bone Joint Surg Am 2013; 95(18): 1701-8.[http://dx.doi.org/10.2106/JBJS.L.01115] [PMID: 24048558] ], and with follow-up averaging under 30 months, the Constant and ASES scores were not significantly different between HHR and RSA in their analysis. Complication rates were higher with RSA but revision rates were higher with HHR in the analysis by both Ferrell et al. and Namdari et al. [9Ferrel JR, Trinh TQ, Fischer RA. Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: A systematic review. J Orthop Trauma 2015; 29(1): 60-8.[http://dx.doi.org/10.1097/BOT.0000000000000224] [PMID: 25186842] , 10Namdari S, Horneff JG, Baldwin K. Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review. J Bone Joint Surg Am 2013; 95(18): 1701-8.[http://dx.doi.org/10.2106/JBJS.L.01115] [PMID: 24048558] ]. Mata-Fink et al. did not find a significant difference in either revision or complication rates [11Mata-Fink A, Meinke M, Jones C, Kim B, Bell JE. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: A systematic review. J Shoulder Elbow Surg 2013; 22(12): 1737-48.[http://dx.doi.org/10.1016/j.jse.2013.08.021] [PMID: 24246529] ]. It is important to consider however that a revision option exists for HHR (to RSA) which may explain why this option may be more readily considered than revision of a RSA in which reconstructive options are far more limited.

The results of these three systematic reviews did not demonstrate clear superiority of one prosthetic option over the other. Both appear to be viable options; further prospective studies are needed to further elicit differences in functional outcomes and to further define optimal indications.

Sebastia-Forcada et al. conducted the only randomized trial in the literature to date comparing RSA with HHR for acute proximal humeral fractures [12Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg 2014; 23(10): 1419-26.[http://dx.doi.org/10.1016/j.jse.2014.06.035] [PMID: 25086490] ], Table 1. All patients underwent CT scan imaging. There was a minimum 2 year follow-up. A single modular system was used and the post-operative rehabilitation program was standardized across both groups. Functional outcome measures including the Constant, DASH, UCLA scores, active range of motion and tuberosity healing, were significantly higher in patients treated with RSA. The revision rate was lower with RSA. Functional outcomes were poorer with revision of HHR to RSA compared to cases treated with RSA primarily. Successful outcomes in the HHR group were dependent on tuberosity healing. The presence of an irreparable rotator cuff was a strong predictor of failure in HHR [12Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg 2014; 23(10): 1419-26.[http://dx.doi.org/10.1016/j.jse.2014.06.035] [PMID: 25086490] ].

Baudi et al. [13Baudi P, Campochiaro G, Serafini F, et al. Hemiarthroplasty versus reverse shoulder arthroplasty: Comparative study of functional and radiological outcomes in the treatment of acute proximal humerus fracture. Musculoskelet Surg 2014; 98(Suppl 1): 19-25.[http://dx.doi.org/10.1007/s12306-014-0322-3] [PMID: 24659199] ] reported greater improvement in the Constant, ASES score and ROM in patients treated with RSA over hemiarthroplasty. Sub-group analysis demonstrated that this difference was most pronounced in the most elderly patient group (>75 years). No significant differences were observed in the DASH scores between groups however [13Baudi P, Campochiaro G, Serafini F, et al. Hemiarthroplasty versus reverse shoulder arthroplasty: Comparative study of functional and radiological outcomes in the treatment of acute proximal humerus fracture. Musculoskelet Surg 2014; 98(Suppl 1): 19-25.[http://dx.doi.org/10.1007/s12306-014-0322-3] [PMID: 24659199] ].

Cuff and Pupello [14Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am 2013; 95(22): 2050-5.[http://dx.doi.org/10.2106/JBJS.L.01637] [PMID: 24257664] ] compared HHR and RSA in a prospective study. Fifty-three patients with three and four part fractures in patients older than 70 years were included. ASES, SST scores, ROM, and patient satisfaction were significantly higher in RSA than in HHR. Functional outcome measures and ROM were significantly higher in patients with healed tuberosities, although these scores were lower than in patients treated with RSA regardless of tuberosity healing [14Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am 2013; 95(22): 2050-5.[http://dx.doi.org/10.2106/JBJS.L.01637] [PMID: 24257664] ].

Table 1
Summary of studies comparing humeral head replacement and reverse shoulder arthroplasty.


In another retrospective study that compared HHR with RSA, Gallinet et al. [15Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L. Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: A comparative study of 40 cases. Orthop Traumatol Surg Res 2009; 95(1): 48-55.[http://dx.doi.org/10.1016/j.otsr.2008.09.002] [PMID: 19251237] ] observed that 21 patients treated with HHR had worse Constant scores and decreased forward elevation and abduction than the 19 patients treated with RSA. However, the DASH scores were not significantly different and the RSA group had increased rotation. Radiographic complications included three patients with tuberosity malunion or non-union in the HHR group compared with 15 cases of scapular notching in the RSA group. However, the clinical relevance of the notching was not discussed; patients with malunited or non-united tuberosities in the HHR group had significanty worse functional outcomes [15Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L. Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: A comparative study of 40 cases. Orthop Traumatol Surg Res 2009; 95(1): 48-55.[http://dx.doi.org/10.1016/j.otsr.2008.09.002] [PMID: 19251237] ].

In 2013, Boyle et al. [16Boyle MJ, Youn SM, Frampton CM, Ball CM. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. J Shoulder Elbow Surg 2013; 22(1): 32-7.[http://dx.doi.org/10.1016/j.jse.2012.03.006] [PMID: 22652065] ] reported their findings from the New Zealand Joint registry. This is currently the largest study in the literature, with 368 patients skewed heavily to HHR (313 vs 58 RSA). The Oxford Shoulder Score was higher in the RSA group than the HHR group at 5 years. Revision rates were not significantly different between groups [16Boyle MJ, Youn SM, Frampton CM, Ball CM. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. J Shoulder Elbow Surg 2013; 22(1): 32-7.[http://dx.doi.org/10.1016/j.jse.2012.03.006] [PMID: 22652065] ].

In a much smaller study, Young et al. [17Young SW, Segal BS, Turner PC, Poon PC. Comparison of functional outcomes of reverse shoulder arthroplasty versus hemiarthroplasty in the primary treatment of acute proximal humerus fracture. ANZ J Surg 2010; 80(11): 789-93.[http://dx.doi.org/10.1111/j.1445-2197.2010.05342.x] [PMID: 20969685] ] did not observe any significant differences in functional scores (ASES, Oxford), ROM or complications rate between 10 RSA and 10 matched HHR patients.

Garrigues et al. [18Garrigues GE, Johnston PS, Pepe MD, Tucker BS, Ramsey ML, Austin LS. Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients. Orthopedics 2012; 35(5): e703-8.[http://dx.doi.org/10.3928/01477447-20120426-25] [PMID: 22588413] ]. reported on 19 patients with proximal humerus fractures Fig. (1) treated with HHR or RSA with followup averaging 3.6 years. Patients with RSA had significantly better functional outcomes scores and satisfaction. The RSA patients were older, with a mean age of 80 years compared to 69 years in the HA group; RSA patients had better forward elevation, and higher functional scores as measured by ASES, University of Pennsylvania score and Single Assessment Numeric Evaluation. Quality of life measures and rotation were not significantly different between groups [18Garrigues GE, Johnston PS, Pepe MD, Tucker BS, Ramsey ML, Austin LS. Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients. Orthopedics 2012; 35(5): e703-8.[http://dx.doi.org/10.3928/01477447-20120426-25] [PMID: 22588413] ].

In a cost-effectiveness analysis, Chalmers et al. [19Chalmers PN, Slikker W III, Mall NA, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg 2014; 23(2): 197-204.[http://dx.doi.org/10.1016/j.jse.2013.07.044] [PMID: 24076000] ] observed that RSA was less expensive overall when total cost including all factors including post-operative rehabilitation were considered.

CONCLUSION

In summary, both HHR and RSA appear to offer good pain relief with no difference in DASH scores, a measure of disability in daily life, in studies that used this outcome measure. However, functional outcomes in HHR are significantly lower when the tuberosities do not heal, a factor which does not appear to affect the functional outcomes in RSA with the exception of rotation. Survivorship continues to remain a concern with RSA, although revision rates appear to be higher with HHR. The cost of hemiarthroplasty prosthesis is considerably lower than RSA implants; however data suggests that HHR is more expensive when the higher rehabilitation costs are considered. While both HHR and RSA are reasonable implant choices for elderly patients with acute proximal humerus fractures, RSA appears to carry certain advantages, particularly in elderly and low-demand patients, because a successful outcome is much less contingent on tuberosity healing.

Fig. (1)
A) plain xrays of comminuted acute proximal humerus fracture-dislocation. Note comminution of tuberosities and humeral head displacement with minimal calcar remaining. B) AP of post-operative day one humeral head replacement showing dislocation of prosthesis from glenoid. C) Six month post-operative follow-up AP imaging following revision to reverse total shoulder arthroplasty. Patient was doing functionally well with no complaints of pain and range of motion continuing to improve.


LIST OF ABBREVIATIONS

HHR  = Humeral Head Replacement
RSA  = Reverse Shoulder Arthroplasty

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Not applicable.

HUMAN AND ANIMAL RIGHTS

No Animals/Humans were used for studies that are base of this research.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

Three Dr. Frombach and Dr. Lapner have no relevant conflict of interests to disclose.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury 2006; 37(8): 691-7.[http://dx.doi.org/10.1016/j.injury.2006.04.130] [PMID: 16814787]
[2] Neer CS II. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970; 52(6): 1077-89.[http://dx.doi.org/10.2106/00004623-197052060-00001] [PMID: 5455339]
[3] Cadet ER, Ahmad CS. Hemiarthroplasty for three- and four-part proximal humerus fractures. J Am Acad Orthop Surg 2012; 20(1): 17-27.[PMID: 22207515]
[4] Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg 2015; 23(3): 190-201.[http://dx.doi.org/10.5435/JAAOS-D-13-00190] [PMID: 25630370]
[5] Hertel R. Fractures of the proximal humerus in osteoporotic bone. Osteoporos Int 2005; 16(Suppl 2): S65-72.[http://dx.doi.org/10.1007/s00198-004-1714-2] [PMID: 15526090]
[6] Voos JED. J. S.; Dines D. M. Arthroplasty for Fractures of the Proximal Part of the Humerus.Instructional Course Lectures 60 1st ed. 1st ed.2011; 105-12.
[7] Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br 2008; 90(11): 1407-13.[http://dx.doi.org/10.1302/0301-620X.90B11.21070] [PMID: 18978256]
[8] Sirveaux FN, Roche G, Mole O, Williams D. Reverse prosthesis for proximal humerus fracture, technique and results. Tech Shoulder Elbow Surg 2008; 9(1): 15-22.[http://dx.doi.org/10.1097/BTE.0b013e31815dca3c]
[9] Ferrel JR, Trinh TQ, Fischer RA. Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: A systematic review. J Orthop Trauma 2015; 29(1): 60-8.[http://dx.doi.org/10.1097/BOT.0000000000000224] [PMID: 25186842]
[10] Namdari S, Horneff JG, Baldwin K. Comparison of hemiarthroplasty and reverse arthroplasty for treatment of proximal humeral fractures: a systematic review. J Bone Joint Surg Am 2013; 95(18): 1701-8.[http://dx.doi.org/10.2106/JBJS.L.01115] [PMID: 24048558]
[11] Mata-Fink A, Meinke M, Jones C, Kim B, Bell JE. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: A systematic review. J Shoulder Elbow Surg 2013; 22(12): 1737-48.[http://dx.doi.org/10.1016/j.jse.2013.08.021] [PMID: 24246529]
[12] Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg 2014; 23(10): 1419-26.[http://dx.doi.org/10.1016/j.jse.2014.06.035] [PMID: 25086490]
[13] Baudi P, Campochiaro G, Serafini F, et al. Hemiarthroplasty versus reverse shoulder arthroplasty: Comparative study of functional and radiological outcomes in the treatment of acute proximal humerus fracture. Musculoskelet Surg 2014; 98(Suppl 1): 19-25.[http://dx.doi.org/10.1007/s12306-014-0322-3] [PMID: 24659199]
[14] Cuff DJ, Pupello DR. Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients. J Bone Joint Surg Am 2013; 95(22): 2050-5.[http://dx.doi.org/10.2106/JBJS.L.01637] [PMID: 24257664]
[15] Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L. Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: A comparative study of 40 cases. Orthop Traumatol Surg Res 2009; 95(1): 48-55.[http://dx.doi.org/10.1016/j.otsr.2008.09.002] [PMID: 19251237]
[16] Boyle MJ, Youn SM, Frampton CM, Ball CM. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. J Shoulder Elbow Surg 2013; 22(1): 32-7.[http://dx.doi.org/10.1016/j.jse.2012.03.006] [PMID: 22652065]
[17] Young SW, Segal BS, Turner PC, Poon PC. Comparison of functional outcomes of reverse shoulder arthroplasty versus hemiarthroplasty in the primary treatment of acute proximal humerus fracture. ANZ J Surg 2010; 80(11): 789-93.[http://dx.doi.org/10.1111/j.1445-2197.2010.05342.x] [PMID: 20969685]
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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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