Reverse Shoulder Arthroplasty Improves Forward Flexion Over ORIF in Elderly Fracture Patients

This systematic review and meta-analysis compared reverse shoulder arthroplasty (RSA) with open reduction and internal fixation (ORIF) for the treatment of complex proximal humeral fractures in patients aged 65 years or older. The analysis included data from over 34,000 patients drawn from randomized controlled trials and cohort studies. The specific setting (e.g., academic vs. community hospitals) was not reported. The primary outcome was not explicitly defined; instead, the review assessed multiple functional and clinical endpoints.

Regarding range of motion, RSA was associated with greater forward flexion compared to ORIF, though the exact effect size and confidence intervals were not reported. There was a trend toward improved abduction with RSA, but this did not reach statistical significance. Internal rotation favored ORIF, but the difference was not significant. External rotation showed no significant differences between the two procedures.

Functional outcomes were assessed using the Constant-Murley score and the Oxford Shoulder Score. Both scores were similar between RSA and ORIF, with no significant differences reported. Complication rates and reoperation rates also did not differ significantly between the two groups. Specific adverse events, serious adverse events, and discontinuation rates were not reported in the review.

The findings suggest that RSA offers a modest advantage in forward flexion compared with ORIF, but this does not translate into consistently better overall functional scores or reduced complications. This aligns with prior literature indicating that RSA may be beneficial for elderly patients with poor bone stock or rotator cuff pathology, where ORIF may have higher failure rates. However, the review did not provide quantitative effect sizes or confidence intervals, limiting the precision of these conclusions.

Key methodological limitations include the lack of a clearly defined primary outcome, absence of reported effect sizes and confidence intervals, and reliance on observational data from cohort studies alongside RCTs. The review did not report on specific biases or heterogeneity among included studies. The certainty of evidence is low, and the authors note that high-quality RCTs are needed to confirm these findings.

Clinically, RSA may be preferred in elderly patients with poor bone stock or rotator cuff pathology, whereas ORIF remains appropriate for patients in whom joint preservation is feasible. However, given the similar functional scores and complication rates, the choice between RSA and ORIF should be individualized based on patient factors and surgeon expertise. Important unanswered questions include the long-term outcomes, cost-effectiveness, and patient-reported outcomes beyond range of motion and functional scores.