Reverse Total Shoulder Arthroplasty in Proximal Humerus Fractures with Concomitant Nerve Injury

Axillary nerve dysfunction has been a relative contraindication for reverse total shoulder arthroplasty (RTSA) as it implies deltoid dysfunction which is necessary for a successful outcome and to maintain stability. However, most axillary nerve injuries or brachial plexus injuries in the setting of acute fracture or fracture dislocation are temporary neuropraxias. Therefore, RTSA may be a feasible option in the acute setting in patients with associated axillary/brachial plexus injury. The objective of this study is to compare results of RTSA patients with preoperative nerve injuries to patients without nerve injuries at a minimum of 2 years. A retrospective case series of all proximal humerus fractures treated with rTSA from 2010 to 2018 by a single surgeon was performed. Inclusion criteria were patients with a diagnosis of fracture-dislocation of the proximal humerus. American Shoulder and Elbow Surgeon (ASES) scores, Simple Shoulder Test (SST) scores, range of motion (ROM) as well as complications were obtained at final follow up. A total 29 patients treated with RTSA for fracture-dislocation were identified. Five patients declined to participate in the study, 4 patients died prior to final follow-up, leaving 20 patients in the study group. Two patients were lost to follow-up leaving 18 of 20 patients (90%) with final follow up data. Seven (35%) patients presented with a brachial plexus/axillary nerve injury associated with their fracture. Average follow-up was 5.83 years (range 2-8 years). There were no differences between the two groups regarding age or body mass index (BMI). The American Society of Anesthesiologists (ASA) was higher in the group without nerve injury 2.92 +/- 0.28 vs 2.43 +/- 0.53 (P=0.0130). There was no difference in time to surgery after fracture between the 2 groups. At final follow-up, there was no difference between the 2 groups regarding shoulder ROM, ASES or SST scores. No patients experienced surgical complications, however, two patients were still reporting nerve related symptoms at final follow up. Reverse total shoulder arthroplasty for fracture-dislocation in the acute setting may be a feasible option in patients with concomitant brachial plexus injury.