Locking Plate Fixation with Cemented Screws versus Delta Xtend Reverse Shoulder Arthroplasty for Complex Proximal Humerus Fractures in the Elderly: A Matched-Pair Comparative Study.

Abstract

Due to the high complication rates associated with open reduction and internal fixation using locking plates (ORIF-LP) for complex proximal humerus fractures (PHFs) in elderly patients, many authors consider reverse shoulder arthroplasty (rTSA)the treatment of choice. However, the use of cemented screws in locked plating (ORIF-LPc) has been suggested to reduce implant-related complications. The aim of this matched-pair study was to compare clinical and radiographic outcomes, complication and revision surgery rates in patients older than 65 years with complex PHFs treated with cement-augmented locking plate fixation or reverse shoulder arthroplasty. Patients older thant 65 years with complex PHFs who underwent an ORIF-LPc (Philos, DePuy Synthes) were matched 1:1 with patients treated with Delta Xtend rTSA (DePuy Synthes, Warsaw, IN, USA) at a single institution between 2014 and 2023. Exclusion criteria included neurological injury, pathological or open fractures, absence of preoperative CT scan, and follow-up of less than 2 years. Fractures were classified according to the Mayo-FJD Classification. Clinical follow-up was conducted at 6 weeks, and at 3, 6, and 12 months, followed by annual assessments. Demographic data, range of motion, Constant Score (CS), Subjective Shoulder Value (SSV), pain with Visual Analog Scale (VAS), EuroQol-5D scores (EQ-5D), complication rates, and revision surgeries were analyzed. The mean follow-up was 4.7 ± 2.2 years (range 2.1-12.8 years). A p-value < 0.05 was considered statistically significant. A total of 86 patients were included, with 43 patients in each group. The mean age was 75±7 years, 93% were female and 48% had dominant-side involvement. Patients treated with ORIF-LPc demonstrated significantly greater external rotation (49°±21° vs. 27°±19°, p<0.001) and internal rotation (median internal rotation: sacroiliac joint vs waist, p<0.001). No significant differences were observed in forward elevation (130°±37° vs. 136°±28°, p=0.634), CS (p=0.672), pain (p=0.704), or EuroQol-5D (EQ-5D) scores (p=0.25). No statistically significant differences were observed in complication rates (21% ORIF-LPc vs. 18.6% rTSA, p = 1.000) or revision surgery rates (7% ORIF-LPc vs. 9% rTSA, p = 1.000). Both ORIF-LPc and Delta Xtend reverse shoulder arthroplasty were associated with satisfactory clinical outcomes. ORIF-LPc provided greater external and internal rotation, whereas no statistically significant differences were observed in overall functional outcomes, complication rates, or revision rates.