Reverse Shoulder Arthroplasty for the Treatment of ... · Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures Michael S. George, MD Michael Khazzam, MD Paul

Reverse Shoulder Arthroplasty forthe Treatment of ProximalHumeral Fractures

Michael S. George, MD

Michael Khazzam, MD

Paul Chin, MD, PhD

Guillaume Dumont, MD

Robert Russell, MD

Investigation performed at KSFOrthopaedic Center, Houston, Texas,and University of Texas SouthwesternMedical Center, Dallas, Texas

COPYRIGHT © 2014 BY THEJOURNAL OF BONE AND JOINTSURGERY, INCORPORATED

» Reverse shoulder arthroplasty for the treatment of complex fracturesof the proximal part of the humerus appears to have good results atshort and intermediate-term follow-up.

» Malunion or nonunion of the tuberosities does not affect thefunctional result after reverse total shoulder arthroplasty as much as itdoes after hemiarthroplasty, but it does lead to decreased postoper-ative external rotation.

» Long-term outcomes of reverse shoulder arthroplasty for thetreatment of fractures have still not been well established.

Proximal humeral fractures ac-count for approximately 5% offractures that are seen in theemergency department and can

present difficult challenges to the treatingphysician1. These fractures are most com-monly classified according to the systemproposed by Neer2. Complex proximalhumeral fractures that require operativetreatment can be treated with osteosyn-thesis, hemiarthroplasty, total shoulderarthroplasty, or, more recently, reverseshoulder arthroplasty3. While locked plat-ing may result in improved fixation inosteopenic bone compared with traditionalunlocked plating, the outcomes may stillbe limited by the risk of complications,including stiffness, osteonecrosis, implantfailure, and loss of reduction4,5. Hemiar-throplasty traditionally has been performedfor the treatment of three or four-partfractures, particularly in patients withosteopenic bone, and can yield good results

for low-demand patients6,7. The outcomesof hemiarthroplasty for the treatment ofproximal humeral fracture are satisfactoryfor long-term pain relief but are lesspredictable in terms of shoulder motion8.Reverse shoulder arthroplasty can be usedfor the treatment of cuff tear arthropathyand recently has gained popularity for thetreatment of severe proximal humeralfractures. The present review of the currentliterature on the use of reverse shoulderarthroplasty for the treatment of complexproximal humeral fractures focuses onindications, preoperative planning, surgicaltechniques, and complications.

BackgroundDemographic CharacteristicsInjuries involving the proximal part of thehumerus prompted approximately184,000 visits to the emergency depart-ment in 2008 in the United States. Theoverwhelming majority of these injuries

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via

his or her institution), from a third party in support of any aspect of this work. None of the

authors, or their institution(s), have had any financial relationship, in the thirty-six months prior

to submission of this work, with any entity in the biomedical arena that could be perceived to

influence or have the potential to influence what is written in this work. Also, no author has

had any other relationships, or has engaged in any other activities, that could be perceived to

influence or have the potential to influence what is written in this work. The complete

Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the

online version of the article.

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JBJS REVIEWS 2014;2(10) :e1 · http:/ /dx.doi .org/10.2106/JBJS.RVW.M.00140 1

occurred inpatients older than fifty yearsof age, with the number peaking in theeighty to eighty-five-year age range. Theincidence increased exponentially be-tween the ages of forty and eighty-fouryears for women and between the ages ofsixty and eighty-nine years for men9.The most common mechanism of frac-ture in elderly patients is a fall fromstanding.

DiagnosisA complete history and physical exami-nation, including an assessment ofgeneral health status, is necessary whenevaluating a patientwhohas a suspectedproximal humeral fracture. Rangeof motion and strength are usuallylimited because of pain. A detailedneurovascular examination of theaffected extremity should be performedbecause injuries to the axillary andsuprascapular nerves and the axillaryartery can occur in association withproximal humeral fractures10,11. In theacute setting, axillary and suprascapularnerve function can be evaluated bytesting isometric muscle contractionas well as sensibility in the distributionof the axillary nerve.

Radiographs include a minimumof two orthogonal radiographs of theglenohumeral joint12. A true antero-posterior (Grashey) radiograph andan axillary lateral radiograph can beused to assess the congruity of theglenohumeral joint13. When painprecludes abduction of the arm for anaxillary lateral radiograph, a truescapulolateral (scapular-Y) and/or aVelpeau axillary radiograph should bemade14,15. Computed tomography(CT) with three-dimensional recon-struction can provide excellentvisualization of fracture fragmentsand also can be used to evaluate forassociated fractures of the glenoid andscapular body. Magnetic resonanceimaging (MRI) can be used to deter-mine the status of the rotator cuff andto aid in surgical decision-making,particularly when choosing betweenhemiarthroplasty and reverse shoulderarthroplasty.

Fracture ClassificationThe most commonly employed classi-fication system for proximal humeralfractures is the Neer classificationsystem2. This system describes frac-tures in terms of displacement offour segments of the proximal partof the humerus as identified originallyby Codman: the greater tuberosity,lesser tuberosity, head, and shaft16.Displaced fractures include two-part,three-part, and four-part fractures;the definition of a part requires anindividual fragment to be displacedby.1 cm or rotated 45° from itsnormal anatomic position. Minimallydisplaced fractures, therefore, canhave fracture lines through multiplefragments but are classified as one-part fractures. Furthermore, thesystem classifies articular surface head-splitting fractures as well as fracture-dislocations according to parts andanterior or posterior displacementof the head. The AO Muller classifi-cation system divides proximalhumeral fractures into three groups(A, B, C) with three separatesubgroups (A1, A2, A3, etc.), withconsideration being given to thenumber of fracture lines, the locationof fractures, impaction, dislocation,and displacement17.

The limitations of the Neerand AO Muller proximal humeralclassification systems rest in their lowintraobserver reproducibility andinterobserver reliability15; neverthe-less, they represent the best attemptsat organizing a natural continuumof injury into separate categorieswith prognostic and treatmentimplications.

Surgical IndicationsThe majority of proximal humeralfractures in elderly patients can besuccessfully treated nonoperativelywith an initial period of immobilizationin a sling followed by a gradual returnto activities. However, nonoperativetreatment of three and four-part frac-tures often results in a poor functionalresult because of nonunion, malunion,

posttraumatic glenohumeral arthritis,or stiffness18,19. Surgical options in-clude closed reduction and percutane-ous pinning, open reduction andinternal fixation with locked orunlocked plating, lockedintramedullary nailing, or shoulderarthroplasty, depending on the fracturepattern and on patient and surgeonpreference.

Adequate reduction and fixationof three and four-part fractures istechnically very difficult to obtain andmaintain with closed reduction andpercutaneous pinning.Open reductionand internal fixation is possible but isassociated with a high rate of compli-cations, including screw penetration,loss of fixation, and osteonecrosis ofthe humeral head, leading to pooroutcomes and a failure rate of 15%to 20%20,21.

Neer described the use of hemiar-throplasty to treat three and four-partfractures of the proximal part of thehumerus6. Although Neer reportedgood results, subsequent studies failedto produce predictably good functionaloutcomes8,22,23. Complications ofhemiarthroplasty for the treatmentof proximal humeral fracture haveincluded poor range of motion, glenoiderosion, component loosening ormigration, and persistent pain. Themost common complication associatedwith a poor outcome after hemiar-throplasty for the treatment of aproximal humeral fracture is malunionor nonunion of the greater tuberosity,which occurs in 39% to 50% ofcases3,23-25.

Because of a lack of consistentlygood outcomes for patients managedwith the above-mentioned techniques,surgeons began to explore the efficacy ofreverse shoulder arthroplasty for thesecomplicated and difficult fractures.Fractures associated with severe tuber-osity comminution may be associatedwith a higher rate of failure when treatedwith traditional open reduction andinternal fixation or hemiarthroplasty,and, therefore, reverse shoulder arthro-plasty may be a better option for these

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fractures. Reverse shoulder arthroplastymay be indicated for acute, comminutedthree or four-part proximal humeralfractures in elderly patients or acutefractures in patients with preexistingrotator cuff deficiency. In addition,reverse shoulder arthroplasty is indi-cated for the treatment of fracturesequelae in patients who have under-gone osteosynthesis that has resultedin rotator cuff or tuberosity deficiencyor those who have had a failed hemi-arthroplasty that has resulted intuberosity deficiency. Reverse shoul-der arthroplasty should be avoidedin younger, active patients as theresults have been shown to deteriorateas early as six years postoperatively26.The surgeon should be very familiarwith the operative technique ofreverse shoulder arthroplasty, andconsideration should be given tomastering the technique on a cadaverspecimen.

Operative TechniqueA standard deltopectoral approachwith the patient in the beach-chairposition allows for exposure of theproximal humeral fracture as well asfor identification and mobilizationof the greater and lesser tuberosities.Although a superolateral approachfrequently is used in the setting ofreverse shoulder arthroplasty for thetreatment of rotator cuff tear arthrop-athy, this approach can also be usedin the fracture setting, but access tothe lesser tuberosity fragment may bedifficult.

The rotator interval is delineated,and the greater and lesser tuberosities aremobilized. The greater and lesser tu-berosities should be mobilized enoughso that they can be retracted out of theway for access to the glenoid. Heavytraction sutures are placed through thegreater and lesser tuberosities and therotator cuff, with any comminuted tu-berosity fragments being left attached tothe rotator cuff. Any remaining soft-tissue attachment of the lesser tuberosityis left undisturbed. A subpectoral soft-tissue biceps tenodesis is performedwith

heavy nonabsorbable suture, and theintra-articular biceps tendon stump isresected.

The fractured humeral head isextracted and measured. No furtherhumeral resection is typically needed.The humeral canal is sequentiallyreamed by hand to prevent iatrogenicfracture propagation. A trial humeralcomponent is placed to confirm properhumeral canal sizing and to approximatehumeral height, although proper hu-meral height cannot be confirmed untilafter the glenosphere is placed. The hu-meral trial component is then removed,and attention is turned to glenoidpreparation.

The greater tuberosity is retractedposteriorly, and the lesser tuberosityis retracted anteriorly, with care beingtaken not to detach any remainingsoft-tissue attachment. The labrumand the biceps tendon stump arecircumferentially excised. The glenoidcentral drill hole is placed slightlyinferior and posterior to the centerof the glenoid. The glenoid is thenreamed to remove articular cartilage,which is usually present in the settingof acute fractures. The glenoid base-plate is placedwith a 10° to 15° tilt frominferior to superior to avoid scapularnotching27-29. The proper glenosphereis selected, keeping in mind that alarger glenosphere provides optimalrange of motion and stability. Whenthe glenosphere is placed and stabilityis confirmed, attention is then turnedto the humeral side.

It is critical to place the humeralcomponent at the proper height toensure that proper soft-tissue tension-ing is achieved in order to preventcomponent instability and to maxi-mize range of motion. Humeral heightcan be established with use of one ofseveral methods, including use ofpreoperative radiographs of thecontralateral humerus to measureanatomic humeral height30 and therelationship of the superior aspectof the humeral head and the upperborder of the pectoralis major tendon(approximately 5.6 cm)31,32, with the

goal being anatomic reconstructionso that the normal position of thegreater tuberosity relative to thehumeral shaft can be restored.

Trial humeral stem and polyeth-ylene components are placed. Provi-sional suture fixation of the tuberositiesprovides an approximation of appropri-ate height and proper tension. A trialreduction is performed to further assessproper humeral height and tension.After removal of the trial componentand thorough canal irrigation, heavynonabsorbable sutures are placed inthe humerus through drill holes fortuberosity repair. A cemented humeralcomponent should be used as the frac-tured proximal part of the humeruscannot provide enough osseous stabilityto stabilize a press-fit humeral stem.The humeral stem is cemented in placein minimal posterior version with useof the markings on the trial componentas a guide to the appropriate height.Humeral version can be confirmed withuse of a guide pin in the humeral stemhandle or by marking the handle withamarkingpen. Placing the stembetweenneutral and 20° of retroversion has beenshown to provide optimal stabilityand to minimize scapular notching33,34.The trial humeral cup is again inserted.The proper tension can be assessed onthe basis of the tension of the deltoid andconjoined tendon. The tuberosities arerepaired horizontally to each other andto the prosthesis itself or around themedial neck of the prosthesis and thenare repaired vertically with transosseoussutures.

Preservation of the tuberositiesallows as much rotator cuff function aspossible and provides bone stock tosupport the implant. Bone graft fromthe humeral head is packed betweenthe tuberosities as well as between thetuberosities and the implant. Therotator interval is usually nonrepairablebecause of the inferior tension on thehumeral component. Intraoperativefluoroscopy with C-arm imaging isused to confirm tuberosity and implantplacement as well as concentricglenohumeral reduction as well as the

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avoidance of intraoperative glenoid orhumeral fracture (Fig. 1).

Each step in glenoid and humeralpreparation is performed with an eyetoward avoiding the most commoncomplications of reverse shoulderarthroplasty, including dislocation,intraoperative fracture, hematoma,infection, and scapular notching10,35-37.Risk factors that contribute to instabilityafter reverse shoulder arthroplasty in-clude poor soft-tissue tension, improperhumeral version, and deltoid dysfunc-tion38. Repair of the subscapularistendon and lesser tuberosity is importantgiven the increased rate of dislocationafter reverse shoulder arthroplasty inpatients with a nonrepairable subscapu-laris tendon39. Meticulous hemostasisis achieved, and the wound is closed overa drain. The risk of scapular notching canbe reduced by inferior placement andinferior angulation of the glenosphere.

Physical therapy involving gentlepassive range of motion is started im-mediately after surgery. Active abduc-tion and internal and external rotationare avoided for the first six weeks

postoperatively. The patient is instruc-ted to absolutely avoid using the affectedarm to push up from a seated position,particularly for the first six weeks post-operatively. Active range of motionand strengthening are advanced aftertuberosity healing is confirmedradiographically.

Results of Reverse ShoulderArthroplasty for ProximalHumeral FractureReverse shoulder arthroplasty for thetreatment of complex fractures of theproximal part of the humerus appears tohave acceptable short and intermediate-term results for as long as six years(Table I and Table II). Patients aretypically able to achieve the ultimatefunctional result by twelve monthspostoperatively35. Furthermore, mal-union or nonunion of the tuberositiesdoes not affect the functional result asmuch as it does in patients who haveundergone hemiarthroplasty, but it doeslead to decreased postoperative externalrotation10,35. Although some studieshave demonstrated superior outcomes

after reverse shoulder arthroplasty ascompared with hemiarthroplasty, mostreports have presented Level-IVevidence40-42, and we are not aware ofany prospective randomized trials com-paring reverse shoulder arthroplastywith hemiarthroplasty.

A review of the literature revealedfive case series10,35-37,43, includingone Level-III case-control study10, ofpatients undergoing reverse shoulderarthroplasty for the treatment of threeand four-part fractures of the proximalpart of the humerus (Table I). Thereview also revealed three retrospectivereviews40-42, one Level-III retrospectivecase-control study44, and one Level-IIprospective cohort11 in which theoutcomes of hemiarthroplasty werecompared with those of reverse shoulderarthroplasty for the treatment ofcomplex fractures of the proximal partof the humerus (Table II). Twostudies37,40 on reverse shoulder arthro-plasty involved patients as young as fifty-eight years old; otherwise, all patientswere sixty-five years or older. Theduration of follow-up ranged from four

Fig. 1Radiograph made after reverse shoul-der arthroplasty for the treatment of aproximal humeral fracture.



months to sixteen years. Reported out-comes data included range of motion;pain scores; complication rates; andoutcome scores, including the Constantscore45, American Shoulder and ElbowSurgeons (ASES) score46, OxfordShoulder Score (OSS)47, Simple Shoul-der Test (SST) score48, Disabilities ofthe Arm, Shoulder and Hand (DASH)score49, University of Pennsylvania(Penn) Score50, and Single AssessmentNumeric Evaluation (SANE) score51

(Table I and Table II). In addition,Mata-Fink et al.52 performed a system-atic review comparing the functionaloutcomes of reverse shoulder arthro-plasty with those of hemiarthroplasty forthe treatment of proximal humeralfractures in older adults. The authorsconcluded that reverse shoulderarthroplasty resulted in improvedrange of motion and functional out-come scores (ASES, Constant, andOxford scores), with no difference inthe rate of complications betweengroups. Furthermore, the authorsrecommended that patients should becounseled that the long-termoutcomes

of reverse shoulder arthroplasty for thetreatment of fractures have still notbeen well established.

On the basis of the current litera-ture, it appears that reverse shoulder ar-throplasty for the treatment of complexfractures of the proximal part of thehumerus provides acceptable functionaloutcomes for patients with three andfour-part fractures. In general, the short-term recovery and patient satisfactionafter reverse shoulder arthroplasty forthe treatment of fracture appear to be atleast similar to those after hemiarthro-plasty. However, it is important tonote that these studies included rela-tively few patients and involved shortand intermediate-term follow-up.

ComplicationsComplications of reverse shoulder ar-throplasty include scapular notching,neurologic injury, glenoid fracture,component loosening, dislocation, in-fection, and hematoma (Table I andTable II). The most common compli-cation after reverse shoulder arthroplastyis scapular notching, which occurred in

fifteen of sixteen patients in the study byGallinet et al.40. The clinical importanceof scapular notching is unclear, partic-ularly in the early postoperative period;however, pain and active range of mo-tion have been shown to worsen withscapular notching after five years post-operatively53. Tuberosity-related com-plications are also common andoccurred in nineteen of forty-three pa-tients undergoing reverse shoulder ar-throplasty for the treatment of fracturein the study by Bufquin et al.35. Al-though tuberosity-related complica-tions after reverse shoulder arthroplastyfor the treatment of humeral fractures donot affect outcomes as much as they doafter hemiarthroplasty, one study com-paring tuberosity repair with tuberosityexcision demonstrated lower Constantscores and decreased range of motion,most pronounced in external rotation,for patients who had tuberosity exci-sion10. Finally, the study with the lon-gest reported follow-up for patientsundergoing reverse shoulder arthro-plasty for the treatment of proximal hu-meral fracture demonstrated that Constant

TABLE I Studies Evaluating the Outcomes of Reverse Total Shoulder Arthroplasty for Three and Four-Part ProximalHumeral Fractures

First Author,Year

Level ofEvidence

No. ofPatients Age* (yr)

Duration ofFollow-up* (mo) Outcome*†

ForwardElevation*

(deg)

External*Rotation(deg) Complications‡

Bufquin35,2007

IV 43 78(65 to 97)

22(6 to 58)

Constant,44 (16 to 69);ASES, 9 (0 to 19);DASH, 44 (0 to 92)

97(35 to 160)

30 (0 to 80) CRPS (3), neurologic (5),dislocation (1), tuberositydisplacement (19),scapular notching (10)

Cazeneuve37,2010

IV 36 75(58 to 92)

6.6 yr(1 to 16 yr)

Constant,53 (20 to 80)

— — CRPS (2), infection (1),dislocation (4), baseplateloosening (1), scapularnotching (19)

Gallinet§10,2013

III 41 77(68 to 93)

24(13 to 61)

Constant, 57;DASH, 34

110 10 Infection (2),dislocation (1),lymphedema (1),tuberosity malunion (7),tuberosity nonunion (2),scapular notching (30)

Klein36, 2008 IV 20 75(67 to 85)

33(24 to 52)

Constant,68 (47 to 88);Modified ASES,68 (50 to 90);DASH, 47 (6 to 63)

123(60 to 175)

25 (10 to 35) Dislocations (2 in 1 patient),infection (2), scapularnotching (1)

Lenarz43, 2011 IV 30 77(65 to 94)

23(12 to 36)

ASES, 78 (36 to 98) 138 27 CRPS (1), DVT (1),tuberosity resorption (1),scapular notching (1)

*The values are given as the mean, with or without the range in parentheses. †ASES = American Shoulder and Elbow Surgeons score; DASH = Disabilities of the Arm, Shoulder andHand score. ‡ CRPS = complex regional pain syndrome, and DVT = deep-vein thrombosis. §Case-control study comparing repair to excision of tuberosities.



scores decreased over time and scapularnotching increased over time, althoughthere was no comparison group37.

ConclusionThe results of reverse shoulder arthroplastyfor the treatment of proximal humeralfractures are encouraging. Prospective ran-domized studies are needed to compare theoutcomes of reverse shoulder arthroplastywith those of hemiarthroplasty in this sce-nario. Longer follow-up documentingcomponent longevity and late complica-tions is also necessary.

Source of FundingNo funds were received in support ofthis study.

Michael S. George, MD1,Michael Khazzam, MD2,Paul Chin, MD, PhD2,Guillaume Dumont, MD2,Robert Russell, MD2

1KSF Orthopaedic Center,17270 Red Oak Drive, Suite 200,Houston, TX 77090

2University of TexasSouthwestern Medical Center,

5323 Harry Hines Boulevard,Dallas, TX 75390

E-mail address for M.S. George:[email protected]

References1. Horak J, Nilsson BE. Epidemiology of fractureof the upper end of the humerus. Clin OrthopRelat Res. 1975 Oct;(112):250-3.

2. Neer CS 2nd. Displaced proximal humeralfractures. I. Classification and evaluation.J Bone Joint Surg Am. 1970 Sep;52(6):1077-89.

3. Boileau P, Trojani C, Walch G, Krishnan SG,RomeoA, SinnertonR. Shoulder arthroplasty forthe treatment of the sequelaeof fractures of the

TABLE II Studies Comparing Reverse Total Shoulder Arthroplasty (RSA) with Hemiarthroplasty (Hemi) for Three andFour-Part Proximal Humeral Fractures

First Author,Year

Level ofEvidence

No. ofPatients Age* (yr)

Duration ofFollow-up*

(mo) Outcome*†

ForwardElevation*

(deg)

External*Rotation(deg) Complications‡

Gallinet40, 2009 IV

RSA 16 74(58 to 84)

12(4 to 18)

Constant,53 (34 to 76)§;DASH, 37 (12 to 65)

98(20 to 150)§

9(0 to 80)§

Infection (2), CRPS (1),scapular notching (15)

Hemi 17 74(49 to 95)

16(6 to 55)

Constant,39 (19 to 61);DASH, 41 (18 to 60)

54(30 to 100)

14(0 to 30)

Neurologic (1), CRPS (2),infection (1), tuberositymalunion (3)

Garrigues42, 2012 IV

RSA 10 80(67 to 97)§

3.6 yr(1.3 to 3.8 yr)

Penn, 82 (73 to 99)§;ASES, 81 (75 to 88)§;SANE, 85 (70 to 95)§

121(90 to 145)§

34(10 to 45)

Scapular notching (1)

Hemi 9 69(57 to 87)

3.6 yr(1.3 to 3.8 yr)

Penn, 53 (29 to 86);ASES, 47 (30 to 81);SANE, 39 (0 to 90)

91 (30 to 140) 31(5 to 60)

Tuberosity nonunion (2),neurologic (2)

Cuff11, 2013 II

RSA 27 74.8(70 to 86)

29(24 to 36)

ASES, 77 (67 to 82)§;SST, 7.4 (6 to 9)§

139(102 to 172)§

24(8 to 42)

Transient ulnarparesthesia (1),periprosthetic fractureafter a fall (1)

Hemi 26 74.1(70 to 88)

39(36 to 48)

ASES, 62 (28 to 84);SST, 5.8 (1 to 9)

100(30 to 170)

25(0 to 48)

Tuberositynonunion (3),hematoma (1),pneumothoraxfrom intrascalenenerve block (1)

Boyle44, 2013 III

RSA 55 79.6(57 to 90)

5 yr Oxford, 41.5§ Revision rate, 1.7%

Hemi 313 71.9(27 to 96)

5 yr Oxford, 32.3 Revision rate, 1.1%

Young41, 2010 IV

RSA 10 77 22(16 to 37)

ASES, 65 (40 to 88);Oxford, 28.7 (15 to 56)

115(45 to 140)

49(5 to 105)

Scapular notching(2; 20%), tuberositynonunion (1)

Hemi 10 76 44(24 to 56)

ASES, 67 (26 to 100);Oxford, 22 (12 to 34)

108(50 to 180)

48(10 to 90)

Tuberosity malunion(2; 20%), infection (1),persistent painrequiring revision (1)

*The values are given as the mean, with or without the range in parentheses. †DASH = Disabilities of the Arm, Shoulder and Hand score; Penn = University of Pennsylvania shoulderscore; ASES = American Shoulder and Elbow Surgeons score; SANE = Single Assessment Numeric Evaluation; SST = Simple Shoulder Test. ‡CRPS = complex regional pain syndrome.§Significantly different from hemiarthroplasty group (p, 0.05).



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Reverse Shoulder Arthroplasty for the Treatment of ... · Reverse Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures Michael S. George, MD Michael Khazzam, MD Paul