Proximal humerus nonunion in the elderly - reverse shoulder replacement

The following case illustrates the use of a reverse shoulder replacement in the treatment of a long standing nonunion of the the proximal humerus. This patient has a 4 year hx of proximal humeral surgical neck fracture was treated elsewhere in a conservative fashion. She is a heavy smoker and otherwise indepedent ambulator and very active. She is 68 y/o F who had at the time of presentation active forward shoulder elevation to 30 degrees. She had severe pain and was treated by pain management. Her deltoid muscle was intact.

This radiograph demonstrates cavitation of the humeral head longstanding nonunion of the proximal humerus. 

The treatment options are (1) Osteosynthesis with bone grafting (2) Prosthetic replacement.

We elected to proceed with a reverse shoulder replacement due to the smoking status and the age of the patient. 

At 6 weeks postop she had minimal pain and assistive forward elevation to 140 degrees.

Open reduction and internal fixation with bone grafting would have been the treatment of choice for a patient of younger age and no smoking status.

A reverse total shoulder replacement has the advantage of earlier initiation of motion however it does have the disadvantages of glenoid failure which can be up to 30% at 10 years after surgery as well as the risks of complications related to prosthetic joint replacement.

The patient returned at 2.5 months with full active ROM to the R shoulder