Reverse Shoulder Arthroplasty for Acute Trauma vs Trauma Sequalae following failed conservative management: A cohort study using data from the National Joint Registry and Hospital Episode Statistics for England.

Abstract

Introduction: While the majority of proximal humerus fractures (PHFs) can be managed conservatively, for some, particularly complex 3- or 4-part fractures, management is controversial. The decision-making process can be challenging, especially in older patients when considering whether secondary surgery for failed non operative management comes with more risk than acute surgical treatment. There is limited evidence in the literature that compares the outcomes of patients having an acute reverse shoulder arthroplasty (rTSA) for trauma against those having an rTSA for trauma sequalae following failed previous conservative management. This study aims to use the National Joint Registry (NJR) and Hospital Episode Statistics (HES) for England to compare outcomes of rTSA for acute trauma against those of rTSA for trauma sequalae following failed conservative management.

Methods: NJR data from April 2012 to March 2022 was linked to HES. All patients undergoing an rTSA for acute or trauma sequalae were included. Primary outcome was revision. Secondary outcomes were non revision re-operation, mortality, medical complications within 30 & 90 days of primary procedure and length of stay.

Results: In the propensity matched cohorts, there were 2488 patients in the acute trauma group and 1267 patients in the trauma sequalae group. rTSA for trauma sequalae had a higher cumulative revision rate at 1,3,5,7 and 10 years and statistically significant increased risk in overall revision (HR of 2.44 (1.68-3.55 p<0.001) in comparison to acute trauma rTSA. There was no statistical difference in incidence of non-revision re-operation (p=0.17). At one year the mortality rate was 4.11% (3.38-5.00) for acute trauma and 3.07% (2.23-4.23) for trauma sequalae and this was not statistically different (HR 0.74 (0.51-1.09) p=0.13). In the acute trauma group, there was a statistically significant increase in medical complications at 30 & 90 days post procedure as well as length of stay (p<0.001).

Conclusion: Based on this national joint registry analysis, patients are twice as likely to require a revision surgery if they undergo rTSA after conservative management has failed, compared to those who receive the procedure immediately following a proximal humerus fracture. While this may inform decision making and the consent process, given some of the limitations around registry analysis, the findings underline the importance of well-designed prospective trials in establishing the optimal timing of surgery.

Level of evidence: Level III; Retrospective Cohort Comparison using Large Database; Treatment Study.