It is currently widely accepted that a four part proximal humerus fracture in the elderly is more reliably approached with a reverse total shoulder replacement (rTSA) compared to a hemiarthroplasty. There is argument that the rTSA provides better relief of pain and that if the tuberosities do not heal after a hemiarthroplasty then the outcome is poor in terms of motion of the shoulder.
In the case illustrated below a hemiarthroplasty was chosen as the patient had balance problems and potential falls can be more forgiving for the hemiarthroplasty when compared to a reverse. A reverse shoulder replacement has a dislocation rate of up to 40% when done for fracture.
The Grashey xray shows consolidation of the bone graft in the "window" of the stem proximally and although someone may say that the greater tuberosity did not heal, it did heal but it is healed posterolaterally due to the pull of the infraspinatus. The proof is on the axillary x-ray shown below.
At 6 months the patient had no pain and active forward elevation to 140 degrees.
Individualizing the approach is the key to success for these cases although it is difficult to predict the outcome.
