Special considerations of reverse total shoulder arthroplasty in the treatment of comminuted proximal humeral fractures in elderly: a narrative review

Proximal humeral fracture is one of the most common non-vertebral fracture pattern seen in the ageing population whose complexity is shown to be proportional to the patient's age. There is still a shortage of evidence-based recommendations regarding its optimal treatment. Among many suggested methods and implants which have not shown satisfactory results, reverse shoulder arthroplasty has turned into a promising treatment option. As this method was initially proposed for treatment of rotator cuff tear arthropathy, special situations like associated complex bone injury and changed anatomy have not been recognized by guidelines yet. Also, techniques and recommendations did not evolve with the expansion of indications. Proximal humeral fractures with functionally intact rotator cuff and associated glenoid or extended diaphyseal fracture present a challenge for surgeons who are left to rely only on their experience. Recent literature offers several methods for each situation even though none of those is still accepted as the optimal one. The present paper offers a critical review of preoperative and intraoperative decision making which confronts every surgeon who manages complex proximal humeral fractures with reverse total shoulder arthroplasty in the elderly.