Single-stage bilateral uncemented reverse shoulder arthroplasty for traumatic proximal humerus fractures: a case report

Proximal humerus fractures (PHFs) are the seventh most frequent fracture in adults and have an unadjusted incidence of 82 per 100,000 person-year 27Iglesias-Rodríguez S. Domínguez-Prado D.M. García-Reza A. Fernández-Fernández D. Pérez-Alfonso E. García-Piñeiro J. et al.Epidemiology of proximal humerus fractures.J Orthop Surg Res. 2021 Jun 22; 16: 402https://doi.org/10.1186/s13018-021-02551-xCrossref PubMed Scopus (37) Google Scholar,34Launonen A.P. Lepola V. Saranko A. Flinkkilä T. Laitinen M. Mattila V.M. Epidemiology of proximal humerus fractures.Arch Osteoporos. 2015; 10: 209https://doi.org/10.1007/s11657-015-0209-4Crossref PubMed Scopus (181) Google Scholar. Although they are commonly associated with high-energy mechanisms of injury in younger patients, they also occur with increasing incidence in older patients through low-energy trauma 34Launonen A.P. Lepola V. Saranko A. Flinkkilä T. Laitinen M. Mattila V.M. Epidemiology of proximal humerus fractures.Arch Osteoporos. 2015; 10: 209https://doi.org/10.1007/s11657-015-0209-4Crossref PubMed Scopus (181) Google Scholar. The bimodal distribution of these injuries indicates that PHFs are the third most common osteoporotic fracture behind the distal radius and vertebrae 11Calvo E. Morcillo D. Foruria A.M. Redondo-Santamaría E. Osorio-Picorne F. Caeiro J.R. et al.Nondisplaced proximal humeral fractures: high incidence among outpatient-treated osteoporotic fractures and severe impact on upper extremity function and patient subjective health perception.J Shoulder Elbow Surg. 2011 Jul; 20: 795-801https://doi.org/10.1016/j.jse.2010.09.008Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar. Furthermore, stratifying the demographics of PHFs in the older population found that women were more likely to suffer from a PHF than men by a ratio of 7:3 14Court-Brown C.M. Caesar B. Epidemiology of adult fractures: A review.Injury. 2006 Aug; 37: 691-697https://doi.org/10.1016/j.injury.2006.04.130Abstract Full Text Full Text PDF PubMed Scopus (2162) Google Scholar. The incidence of bilateral PHFs has not been studied to the extent of unilateral cases, although there have been case reports published describing these events 3Austin D.C. Torchia M.T. Cozzolino N.H. Jacobowitz L.E. Bell J.-E. Decreased Reoperations and Improved Outcomes With Reverse Total Shoulder Arthroplasty in Comparison to Hemiarthroplasty for Geriatric Proximal Humerus Fractures: A Systematic Review and Meta-Analysis.J Orthop Trauma. 2019 Jan; 33: 49-57https://doi.org/10.1097/BOT.0000000000001321Crossref PubMed Scopus (40) Google Scholar,12Ceri L. Mondanelli N. Sangaletti R. Bottai V. Muratori F. Giannotti S. Simultaneous bilateral reverse shoulder arthroplasty for bilateral four-part fracture of the proximal humerus in an elderly patient: A case report.Trauma Case Rep. 2019 Oct; 23100242https://doi.org/10.1016/j.tcr.2019.100242Crossref PubMed Scopus (7) Google Scholar,19Ellanti P. Harrington P. Functional Outcome after Simultaneous Bilateral Four-Part Proximal Humerus Fracture: A Comparison of ORIF and Hemiarthroplasty in an Individual Patient.Case Rep Orthop. 2012; 2012941829https://doi.org/10.1155/2012/941829Crossref Google Scholar,28Iijima Y. Sasanuma H. Saito T. Nakama S. Takeshita K. A case of simultaneous bilateral reverse shoulder arthroplasty for bilateral comminuted proximal humerus fractures in an elderly patient.JSES Int. 2021 Jul; 5: 688-691https://doi.org/10.1016/j.jseint.2021.03.003Abstract Full Text Full Text PDF Scopus (2) Google Scholar,49Sato K. Hatta T. Shinagawa K. Okuno H. Nobuta S. Simultaneous Reverse Shoulder Arthroplasty and Open Reduction With Internal Fixation for Bilateral Proximal Humerus Fractures in the Elderly: A Report of Two Cases.Cureus. 2022 Sep; 14e28777https://doi.org/10.7759/cureus.28777Crossref Google Scholar. In addition to the paucity of literature available for bilateral PHFs in older patients, treatment options for these fracture patterns are also a controversial topic. This includes a nonoperative approach, closed reduction and percutaneous fixation, suture fixation, operative fixation with plate and screw construct (ORIF), intramedullary fixation, hemiarthroplasty (HA), and reverse shoulder arthroplasty (RSA)30Jo M.J. Gardner M.J. Proximal humerus fractures.Curr Rev Musculoskelet Med. 2012 Sep; 5: 192-198https://doi.org/10.1007/s12178-012-9130-2Crossref PubMed Scopus (44) Google Scholar. Treatment choice predominantly depends on the patient's age, comorbidities, preexisting arthritis or rotator cuff pathology in the fractured shoulder and fracture characteristics such as Neer classification, bone quality, and the amount of calcar that remains which corresponds to risk of avascular necrosis 26Hertel R. Hempfing A. Stiehler M. Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus.J Shoulder Elbow Surg. 2004 Jul 1; 13: 427-433https://doi.org/10.1016/j.jse.2004.01.034Abstract Full Text Full Text PDF PubMed Scopus (552) Google Scholar. In elderly patients with Neer 3 and 4-part fractures, reverse total arthroplasty has been shown to have better functional outcomes and lower complication rates than ORIF or HA making RSA the predominant surgical treatment for these patients3Austin D.C. Torchia M.T. Cozzolino N.H. Jacobowitz L.E. Bell J.-E. Decreased Reoperations and Improved Outcomes With Reverse Total Shoulder Arthroplasty in Comparison to Hemiarthroplasty for Geriatric Proximal Humerus Fractures: A Systematic Review and Meta-Analysis.J Orthop Trauma. 2019 Jan; 33: 49-57https://doi.org/10.1097/BOT.0000000000001321Crossref PubMed Scopus (40) Google Scholar,8Bonnevialle N. Tournier C. Clavert P. Ohl X. Sirveaux F. Saragaglia D. et al.Hemiarthroplasty versus reverse shoulder arthroplasty in 4-part displaced fractures of the proximal humerus: Multicenter retrospective study.Orthop Traumatol Surg Res. 2016 Sep; 102: 569-573https://doi.org/10.1016/j.otsr.2016.02.014Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar,13Chalmers P.N. Slikker W. Mall N.A. Gupta A.K. Rahman Z. Enriquez D. et al.Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty.J Shoulder Elbow Surg. 2014 Feb; 23: 197-204https://doi.org/10.1016/j.jse.2013.07.044Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar,25Heo S.M. Faulkner H. An V. Symes M. Nandapalan H. Sivakumar B. Outcomes following reverse total shoulder arthroplasty vs operative fixation for proximal humerus fractures: a systematic review and meta-analysis.Ann R Coll Surg Engl. 2023 Dec; 1https://doi.org/10.1308/rcsann.2022.0120Crossref Google Scholar,33Lanzetti R.M. Gaj E. Berlinberg E.J. Patel H.H. Spoliti M. Reverse Total Shoulder Arthroplasty Demonstrates Better Outcomes Than Angular Stable Plate in the Treatment of Three-part and Four-part Proximal Humerus Fractures in Patients Older Than 70 Years.Clin Orthop Relat Res. 2023 Apr 1; 481: 735-747https://doi.org/10.1097/CORR.0000000000002480Crossref Scopus (7) Google Scholar,43Papalia A.G. Romeo P.V. Kingery M.T. Alben M.G. Lin C.C. Simcox T.G. et al.Trends in the treatment of proximal humerus fractures from 2010 to 2020.J Shoulder Elbow Surg. 2024 Feb; 33: e49-e57https://doi.org/10.1016/j.jse.2023.07.038Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,45Pizzo R.A. Gianakos A.L. Haring R.S. Gage M.J. Stevens N.M. Liporace F.A. et al.Are Arthroplasty Procedures Really Better in the Treatment of Complex Proximal Humerus Fractures? A Comprehensive Meta-Analysis and Systematic Review.J Orthop Trauma. 2021 Mar 1; 35: 111-119https://doi.org/10.1097/BOT.0000000000001926Crossref PubMed Scopus (18) Google Scholar. Although there is a general trend to treat Neer 3 and 4-part fractures in elderly patients with reverse total shoulder arthroplasty, there are still differences in technique and in decision-making when a patient presents with bilateral PHFs. Various case studies have been reported for the treatment of bilateral PHFs including the use of nonoperative treatment46Rodriguez-Corlay R.E. Velutini-Becker R. Aguilar-Alcalá L.D. Conservative Treatment for Bilateral Displaced Proximal Humerus Head Fracture.Cureus. 2016 Jun 27; 8e657https://doi.org/10.7759/cureus.657Crossref Google Scholar, bilateral open-reduction internal-fixation (ORIF)49Sato K. Hatta T. Shinagawa K. Okuno H. Nobuta S. Simultaneous Reverse Shoulder Arthroplasty and Open Reduction With Internal Fixation for Bilateral Proximal Humerus Fractures in the Elderly: A Report of Two Cases.Cureus. 2022 Sep; 14e28777https://doi.org/10.7759/cureus.28777Crossref Google Scholar, ORIF and hemiarthroplasty19Ellanti P. Harrington P. Functional Outcome after Simultaneous Bilateral Four-Part Proximal Humerus Fracture: A Comparison of ORIF and Hemiarthroplasty in an Individual Patient.Case Rep Orthop. 2012; 2012941829https://doi.org/10.1155/2012/941829Crossref Google Scholar, reverse shoulder arthroplasty (RSA) and intramedullary nailing49Sato K. Hatta T. Shinagawa K. Okuno H. Nobuta S. Simultaneous Reverse Shoulder Arthroplasty and Open Reduction With Internal Fixation for Bilateral Proximal Humerus Fractures in the Elderly: A Report of Two Cases.Cureus. 2022 Sep; 14e28777https://doi.org/10.7759/cureus.28777Crossref Google Scholar, and bilateral RSA12Ceri L. Mondanelli N. Sangaletti R. Bottai V. Muratori F. Giannotti S. Simultaneous bilateral reverse shoulder arthroplasty for bilateral four-part fracture of the proximal humerus in an elderly patient: A case report.Trauma Case Rep. 2019 Oct; 23100242https://doi.org/10.1016/j.tcr.2019.100242Crossref PubMed Scopus (7) Google Scholar,28Iijima Y. Sasanuma H. Saito T. Nakama S. Takeshita K. A case of simultaneous bilateral reverse shoulder arthroplasty for bilateral comminuted proximal humerus fractures in an elderly patient.JSES Int. 2021 Jul; 5: 688-691https://doi.org/10.1016/j.jseint.2021.03.003Abstract Full Text Full Text PDF Scopus (2) Google Scholar. The differences in technique were primarily identified in case reports of bilateral RSA being utilized where the majority of surgeons opted for cementing their stems12Ceri L. Mondanelli N. Sangaletti R. Bottai V. Muratori F. Giannotti S. Simultaneous bilateral reverse shoulder arthroplasty for bilateral four-part fracture of the proximal humerus in an elderly patient: A case report.Trauma Case Rep. 2019 Oct; 23100242https://doi.org/10.1016/j.tcr.2019.100242Crossref PubMed Scopus (7) Google Scholar,28Iijima Y. Sasanuma H. Saito T. Nakama S. Takeshita K. A case of simultaneous bilateral reverse shoulder arthroplasty for bilateral comminuted proximal humerus fractures in an elderly patient.JSES Int. 2021 Jul; 5: 688-691https://doi.org/10.1016/j.jseint.2021.03.003Abstract Full Text Full Text PDF Scopus (2) Google Scholar,54Tokuhiro T. Urita A. Kameda Y. Motomiya M. Watanabe N. Iwasaki N. Simultaneous Bilateral Proximal Humerus Fractures Treated with Single-Stage Bilateral Reverse Shoulder Arthroplasty.Case Rep Orthop. 2022; 20222162331https://doi.org/10.1155/2022/2162331Crossref Google Scholar. Differences were also observed in treatment planning as either acute or delayed treatment of PHFs with RSA. However, Lu et al. recently determined that acute treatment of PHFs with RSA provided better clinical outcomes compared to delayed treatment37Lu V. Jegatheesan V. Patel D. Domos P. Outcomes of acute vs. delayed reverse shoulder arthroplasty for proximal humerus fractures in the elderly: a systematic review and meta-analysis.J Shoulder Elbow Surg. 2023 Aug; 32: 1728-1739https://doi.org/10.1016/j.jse.2023.03.006Abstract Full Text Full Text PDF Scopus (1) Google Scholar. Earlier fixation of these fractures with early arm use for activities of daily living (ADLs) may also allow these elderly patients to return to activities and independent living faster which is important in this patient population. In this report, we present the case of a 74-year-old woman with bilateral 3-part PHFs following a fall from standing height who underwent simultaneous uncemented bilateral RSA with early range of motion (ROM) for activities of daily living (ADLs) postoperatively. Consent was obtained from the patient for this case report. A 74-year-old right-hand dominant woman (body mass index, 47.64 kg/m2) with a history of diabetes mellitus and deep vein thrombosis, on treatment with warfarin (INR on presentation 1.4), presented to an outside emergency department following a traumatic fall from standing height off a curb. The patient attempted to catch herself prior to landing on bilateral outstretched hands. The patient did hit her head but denied any loss of consciousness. Initial radiographic imaging (Fig. 1) at the outside hospital revealed bilateral PHFs. Due to the complexity of the fractures, the outside hospital elected to transfer the patient to our level 1 trauma center for further surgical evaluation. Upon arrival at our hospital, a level 1 trauma center, the patient was evaluated by our orthopedic team and reported bilateral shoulder pain with no other acute complaints. Prior to this injury, the patient reported having chronic right shoulder pain for which she had been receiving physical therapy, although she was unclear of her exact diagnosis. She lived and functioned independently and worked as a hotel manager. On physical exam, she was in bilateral slings with no visible deformity. No focal neurological or vascular deficits were noted, compartments were soft and compressible, and there was significant tenderness to palpation of shoulders bilaterally. Computed tomography (CT) (Fig. 2) was performed and determined the patient had bilateral 3-part proximal humerus fractures. The patient remained in bilateral slings and was admitted to the hospital. Considering the patient's age, fracture pattern, and activity level, we deemed surgical intervention would be the best option for her to attempt to allow early use of her arms and return to independence. The surgeon felt that RSA using an uncemented fracture stem with a robust tuberosity repair to allow early ROM was indicated. Given that the patient did not have significant cardiac or pulmonary comorbidities, it was felt that both PHFs could safely be repaired in a single anesthesia event. The patient was brought to the OR four days after presentation to allow for adequate time for preoperative medical optimization. General anesthesia was induced, and the patient was positioned in a beach chair position with both arms prepped and draped. An interscalene block was not utilized on either side to reduce the risk of bilateral phrenic nerve paralysis.56Urmey W.F. Talts K.H. Sharrock N.E. One hundred percent incidence of hemidiaphragmatic paresis associated with interscalene brachial plexus anesthesia as diagnosed by ultrasonography.Anesth Analg. 1991 Apr; 72: 498-503Crossref PubMed Google Scholar Hydraulic arm positioners were utilized. The patient was given weight-based doses of antibiotics prior to surgical incision. A standard deltopectoral incision and approach was utilized. The biceps tendon was then tagged with non-absorbable sutures and the bicipital groove opened. The subscapularis and less tuberosity were tagged with sutures and osteotomized. The posterior superior rotator cuff when then tagged and the greater tuberosity mobilized. The fractured humeral head was identified and removed. Once removed, the axillary nerve was identified and grossly intact. Next, the glenoid was exposed. Electrocautery was used to remove the labrum and a cobb was used to clean the glenoid. A guide was used to place the center guide wire into the glenoid in neutral version and inclination. The glenoid was then reamed on power with a size 24 reamer, up to a size 33mm reamer. A 24 mm Arthrex Univers baseplate (Arthrex, Naples, FL, USA) was then placed and a size 33 glenosphere was impacted into place. No lateralization was added to the baseplate or the glenosphere so as not to over-tension the tuberosity repair. The humerus was prepared by gentle reaming of the canal and broaching at 20 degrees of version. The humerus was sequentially broached until a press fit with axial and rotational stability was achieved. Care was taken to not fracture the calcar during broaching. A standard cup and polyethylene were trialed and found to be stable. Height was chosen so that the tuberosities reduced anatomically to the shaft without tension once the humerus was reduced. If the calcar remains attached to the shaft, as is often the case in our older osteoporotic fractures, it can be used as a guide for where to position the humeral stem to when broaching. The senior author often utilizes this as a reference point and places the stem so the medial calcar of the stem is level or just above the medial calcar on the shaft. The stem that had axial and rotational stability was selected. The Arthrex Univers Revers Fracture Stem (Arthrex, Naples, FL, USA) was used. Two number 2 high tensile non-absorbable sutures were placed in the shaft through two drill holes and four number 2 high tensile non-absorbable sutures were placed through the holes in the suture cup for tuberosity repair (two for the greater tuberosity and two for the lesser tuberosity). Prior to impacting the final stem, four 0-Vicryls (Ethicon, Raritan, NJ, USA) sutures were passed around the greater tuberosity to use as passing sutures for the non-absorbable sutures in the stem. The stem was impacted into place in a press-fit fashion at 20 degrees of retroversion. The shoulder was reduced and deemed to be stable. The tuberosities were repaired using the sutures in both the shaft and stem using the technique recommended for the Univers Revers Fracture Stem58FxBridgeTM Tuberosity Repair System: Reverse Total Shoulder Arthroplasty [Internet]. Arthrex. [cited 2024 Apr 4];Available from: https://www.arthrex.com/resources/AN1-000295-en-US/fxbridge-tuberosity-repair-system-reverse-total-shoulder-arthroplastyGoogle Scholar as tuberosity repair and healing has been shown to lead to better function compared to resection. 2Anakwenze O.A. Zoller S. Ahmad C.S. Levine W.N. Reverse shoulder arthroplasty for acute proximal humerus fractures: a systematic review.J Shoulder Elbow Surg. 2014 Apr; 23 (80): e73https://doi.org/10.1016/j.jse.2013.09.012Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar,22Grubhofer F. Wieser K. Meyer D.C. Catanzaro S. Beeler S. Riede U. et al.Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly.J Shoulder Elbow Surg. 2016 Oct; 25: 1690-1698https://doi.org/10.1016/j.jse.2016.02.024Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar,41Ohl X. Bonnevialle N. Gallinet D. Ramdane N. Valenti P. Decroocq L. et al.How the greater tuberosity affects clinical outcomes after reverse shoulder arthroplasty for proximal humeral fractures.J Shoulder Elbow Surg. 2018 Dec; 27: 2139-2144https://doi.org/10.1016/j.jse.2018.05.030Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar First, the two sutures on the greater tuberosity side of the stem were passed through the greater tuberosity using the four previously passed 0-Vicryls. All four limbs from the two sutures were passed. The four limbs from the two sutures on the lesser tuberosity side of the cup were passed around the lesser tuberosity through the subscapularis using a free needle. The sutures from the greater and the lesser tuberosity were tied to each other in a linked construct. The sutures from the shaft were then passed through the subscapularis and the supraspinatus at the edge of the tuberosities in a figure-of-eight fashion and tied. The wound was then closed using standard techniques. As the team began to close the first side, the surgeon began to replace the contralateral shoulder using the same technique. Estimated blood loss for the case was 400mL. Total duration in the operating room was 5 hours and 1 minute. Total anesthesia duration was 4 hours and 55 minutes. Radiographic imaging obtained in the operating room showed successful uncemented bilateral RSA (Fig. 3). There were no perioperative complications. The patient was administered cefazolin for 24 hours postoperatively and was given prophylactic lovenox. She was placed in bilateral shoulder slings for comfort only and was non-weight bearing for transfers but allowed to use her hands and arms immediately for ADLs as tolerated. Occupational therapy saw the patient on postoperative day 1 (POD1) to help the patient return to independent function. The patient was discharged to a rehabilitation facility on postoperative day 4. Physical therapy started immediately with passive range of motion until 4 weeks postoperatively. Her self-reported pain score was 2/10 bilaterally at 2 weeks and 0/10 bilaterally at 6 weeks postoperatively. Active ROM (AROM) was assessed by the surgeon at 2 weeks, 6 weeks, 12 weeks, 6 months, and 1 year follow-up. The left arm lagged behind the right arm in AROM throughout the follow-up duration. At 2 weeks, AROM forward flexion was 20º on the right and 0º on the left, and abduction was 30º on the right and 0º on the left. At 6 weeks, AROM forward flexion was 50º on the right and 30º on the left, abduction was 80º on the right and 40º on the left, and external rotation was 10º on the right and 0º in the left. At 6 months AROM forward flexion was 130º on the right and 80º on the left, abduction was 90º on the right and 80º on the left, and external rotation was 30º on the right and 0º on the left. However, at 1-year, bilateral arms had equal AROM with 120º forward flexion, 90º abduction, 30º external and internal rotation to the buttock. American Shoulder and Elbow Surgeons (ASES) score was calculated at 1 year postoperatively to assess shoulder function and was found to be 50 bilaterally. Throughout the 1-year follow-up period, the patient remained satisfied with her treatment and progress. All follow-up radiographic imaging within the 1-year follow-up were taken at our associated clinic and showed stable bilateral RSA without evidence of loosening, dislocation, or failure (Fig. 4). The imaging did not reveal scapular notching and the patient's tuberosity healed well. The patient is scheduled for follow-up again at 2 years postoperatively. This is one of the first reports published on simultaneous uncemented RSA for bilateral PHF in an older patient where the patient was allowed early use of her arms for ADLs. Of note, the current literature available on simultaneous bilateral RSA has primarily been in patients who sustained bilateral posterior fracture-dislocations following a seizure. 5Azad A. Antonios J.K. Kang H.P. Omid R. Single-stage bilateral reverse total shoulder arthroplasty for bilateral posterior shoulder fracture-dislocation following seizure: A case report.Int J Surg Case Rep. 2020; 73: 298-302https://doi.org/10.1016/j.ijscr.2020.07.037Crossref PubMed Scopus (6) Google Scholar,18El Rassi G. Dib N. Maalouly J. Moukarzel R. Aouad D. Bilateral Reverse Total Shoulder Arthroplasty with Soft Tissue Release for Bilateral Posterior Fracture Dislocation after Status Epilepticus.Case Rep Orthop. 2021; 20215525316https://doi.org/10.1155/2021/5525316Crossref Google Scholar,57Vitali M. Bettinelli G. Montalbano F. Salini V. One-step Bilateral Reverse Shoulder Replacement for Posterior Fracture-dislocation in a Young Alcoholic.J Orthop Case Rep. 2022; 12: 11-14https://doi.org/10.13107/jocr.2022.v12.i05.2794Crossref Google Scholar) This is an important distinction, as a shoulder dislocation predisposes the patient to increased risks including osteonecrosis, posttraumatic arthritis, and joint stiffness, making the RSA a better treatment choice in a patient with a fracture-dislocation15Doehrmann R, Frush TJ. Posterior Shoulder Instability [Internet]. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Sep 10]. no doi, no ISBNGoogle Scholar. Although our reported case did not experience a concordant dislocation, we still opted for an RSA due to the patients age, poor bone quality, and fracture severity. In patients who have an isolated PHF, alternative treatment options are available, with one of the most popular choices being ORIF. 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An assessment of interobserver reliability and intraobserver reproducibility.J Bone Joint Surg Am. 1993 Dec; 75: 1745-1750Crossref PubMed Google Scholar,52Siebenrock K.A. Gerber C. The reproducibility of classification of fractures of the proximal end of the humerus.J Bone Joint Surg Am. 1993 Dec; 75: 1751-1755Crossref PubMed Scopus (314) Google Scholar. Despite this known disparity, the Neer classification remains the gold standard classification system for PHF at our institution. In regard to operative choice for Neer 3 and 4-part fractures, RSA has been favored over hemiarthroplasty in older patients given the superior functional outcomes and lower risk of complications and reoperations when compared to hemiarthroplasty3Austin D.C. Torchia M.T. Cozzolino N.H. Jacobowitz L.E. Bell J.-E. Decreased Reoperations and Improved Outcomes With Reverse Total Shoulder Arthroplasty in Comparison to Hemiarthroplasty for Geriatric Proximal Humerus Fractures: A Systematic Review and Meta-Analysis.J Orthop Trauma. 2019 Jan; 33: 49-57https://doi.org/10.1097/BOT.0000000000001321Crossref PubMed Scopus (40) Google Scholar. Additionally, RSA utilizes the function of the deltoid muscle and does not rely on the healing of the tuberosities and is therefore a more reliable treatment option for patients with tuberosity fractures16Drake G.N. O'Connor D.P. Edwards T.B. Indications for reverse total shoulder arthroplasty in rotator cuff disease.Clin Orthop Relat Res. 2010 Jun; 468: 1526-1533https://doi.org/10.1007/s11999-009-1188-9Crossref PubMed Scopus (179) Google Scholar. The authors still believe it is important to attempt to anatomically repair the tuberosities as it has been shown that tuberosity healing after RSA for fracture leads to better functional outcomes.2Anakwenze O.A. Zoller S. Ahmad C.S. Levine W.N. Reverse shoulder arthroplasty for acute proximal humerus fractures: a systematic review.J Shoulder Elbow Surg. 2014 Apr; 23 (80): e73https://doi.org/10.1016/j.jse.2013.09.012Abstract Full Text Full Text PDF PubMed Scopus (96) Google Scholar,22Grubhofer F. Wieser K. Meyer D.C. Catanzaro S. Beeler S. Riede U. et al.Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly.J Shoulder Elbow Surg. 2016 Oct; 25: 1690-1698https://doi.org/10.1016/j.jse.2016.02.024Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar,41Ohl X. Bonnevialle N. Gallinet D. Ramdane N. Valenti P. 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