A cadaveric study demonstrated the incidence of full-thickness tears increased with increasing age. In cadavers less than 60 years of age the incidence of rotator cuff tears was 6 % compared to 30 % in over 60 years of age [14]. This study excluded all partial-thickness tears. The incidence of rotator cuff tears and the severity of these full-thickness tears are likely exacerbated with displaced proximal humerus fractures. This might explain some of the poor functional results with >60 year old patients with ORIF or Hemiarthroplasty after displaced proximal humerus fractures.

Prosthetic replacements with hemiarthroplasty and reverse total shoulder arthroplasty have consistently shown good results in pain relief [15]. Recent studies have shown that RTSAs have greater function in the >65 years age group than does Hemiarthroplasty or ORIF. In our experience even poor outcomes with RTSA generally do better than poor outcomes with hemi-arthroplasty. Reverse total shoulder arthroplasty outperformed hemiarthroplasty and ORIF with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score in proximal humeral fractures [15]. RTSA appears to provide superior range of motion early and more predictably when followed over time. Many authors have noted that cost is a reason for HA or ORIF over RTSA. However, the total or overall cost on the system with RTSA has significant cost saving to Medicare [8]. These studies bear out our clinical experience of primary reverse shoulder arthroplasty vs. hemiarthroplasty or ORIF for the elderly patient population with displaced proximal humerus fractures.

We recommend RTSA for acute elderly (physiologically >70 year old) patients with poor biologic potential for fracture healing, three or four-part proximal humerus fractures that have an articular head split, fracture dislocation, or comminution of the greater tuberosity. In addition to these criteria in the acute setting, deltoid function must be reasonably preserved. Glenoid bone stock and quality must be able to accept the implant and screws for secure fixation. The ease of postoperative care and the lack of need for formal rehabilitation may be of importance for the selection of RTSA to manage acute fractures in elderly patients with severe osteopenia [16] (Fig. 8.2a–d).

In addition these chronic criteria are also acceptable: tuberosity malunion in the elderly, tuberosity nonunion, proximal humerus malunion, proximal humerus nonunion, and fractures with a deficient rotator cuff.

Nonsurgical management is generally reserved for patients with significant medical comorbidities that would preclude them from undergoing a surgical procedure. Patients who refuse or are unable to follow postoperative protocols (dementia or ipsilateral lower extremity fracture) will likely have poor results and unsatisfactory outcomes. Complete axillary nerve palsy is a contraindication because of the very high probability of recurrent instability and the minimal potential gain in function [8]. Nonoperative management should be considered in these situations. Infection, neuroarthropathy, and substantial glenoid bone loss (defects or severe erosion) are also contraindications.

Adequate X-rays of the fracture are essential to plan the procedure. Complete anterior/posterior, axillary Y, and axillary lateral views of the shoulder will aide in glenoid bone stock evaluation. If these films are unobtainable or poor quality a CT scan of the shoulder should be obtained to evaluate the glenoid and fracture pattern. A/P and lateral images of the humerus may reveal segmental humeral shaft injuries that could preclude the use of certain implants. Available OR staff that are knowledgeable of the implants and procedure decrease operative duration and likelihood of unexpected complications.

We perform the majority of our RTSA in an academic setting, and as such we believe the hood is of benefit to avoid bacterial shedding during cases where discussion is necessary. The use of hoods may also protect the surgical team from potential contamination from the patient if they have Hepatitis or HIV. However, using a surgical hood is not required.

Because of the emergence of P. acnes we have included in our preoperative regiment Ancef and Vancomycin given 30 min before the skin incision is made. The Vancomycin is only given during the procedure and then discontinued. Ancef is given during the procedure and continue for three doses postoperatively as in most arthroplasty cases.

Surgical intervention can be undertaken in the immediate postinjury period or delayed if other injuries or medical conditions need to take precedence.