What are the indications for Open Reduction Internal Fixation (ORIF) versus arthroplasty for proximal humerus fractures?

From the Guidelines

For patients older than 50 years with a fragility fracture of the proximal humerus, non-operative treatment is generally recommended for most fractures, while open reduction and internal fixation (ORIF) or arthroplasty may be considered for displaced three-part and four-part fractures. The choice between ORIF and arthroplasty depends on various factors, including fracture pattern, bone quality, patient age, and functional demands 1.

Key Considerations

• For minimally displaced fractures or 2-part fractures in younger patients with good bone quality, ORIF is generally preferred as it preserves the native joint and allows for better long-term function.
• For complex 3- or 4-part fractures in elderly patients with poor bone quality, arthroplasty (either hemiarthroplasty or reverse total shoulder arthroplasty) is often more appropriate, with reverse total shoulder arthroplasty being particularly beneficial in patients over 70 with rotator cuff deficiency or when anatomic reconstruction is unlikely to succeed.
• Hemiarthroplasty may be considered in younger patients with unreconstructable fractures but intact rotator cuff.

Procedure Outcomes

• ORIF typically involves plate and screw fixation, with newer locking plates providing better stability in osteoporotic bone, but is associated with considerable complication, including avascular necrosis, hardware failure, and malunion.
• Arthroplasty risks include instability, infection, and component loosening, but the outcome of hemiarthroplasty is closely related to tuberosity healing, and reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with pre-existing rotator cuff dysfunction or after the failure of first-line treatment 1.

Postoperative Care

• Postoperative rehabilitation is crucial for both procedures, with ORIF patients typically beginning passive motion at 2 weeks and active motion at 6 weeks, while arthroplasty patients may start passive motion earlier.
• The decision between ORIF and arthroplasty should be individualized based on patient factors and surgeon experience, prioritizing morbidity, mortality, and quality of life as the primary outcomes.

From the Research

Comparison of Proximal Humerus ORIF and Arthroplasty

• The treatment of proximal humerus fracture dislocations can be challenging due to the extensive injury to the proximal humeral anatomy and increased risk of devascularization of the humeral head 2.
• Open reduction and internal fixation (ORIF) is a common treatment option for proximal humerus fractures, with studies showing reasonable functional outcomes but relatively high avascular necrosis and reoperation rates 2, 3, 4, 5.
• The rate of avascular necrosis after ORIF for proximal humerus fractures has been reported to be around 20-35% 2, 3, 4.
• Reoperation rates after ORIF for proximal humerus fractures have been reported to be around 30-35% 2, 5.
• Arthroplasty is sometimes necessary after ORIF for proximal humerus fractures, with conversion to arthroplasty rates ranging from 5-20% 2, 3.
• Functional outcomes after ORIF for proximal humerus fractures can be satisfactory, with mean Constant scores ranging from 73-89 points 2, 3, 4.
• Patient-reported outcomes after ORIF for proximal humerus fractures can also be satisfactory, with mean Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores ranging from 71-94 points 5.

Indications and Outcomes for ORIF and Arthroplasty

• ORIF is often indicated for proximal humerus fractures with good bone quality and minimal displacement 3, 6.
• Arthroplasty may be indicated for proximal humerus fractures with severe displacement, comminution, or avascular necrosis 2, 3.
• The choice between ORIF and arthroplasty for proximal humerus fractures depends on various factors, including patient age, bone quality, and fracture pattern 6.
• Outcomes after ORIF and arthroplasty for proximal humerus fractures can vary depending on the specific procedure and patient factors, with ORIF generally offering better functional outcomes for patients with good bone quality and minimal displacement 2, 3, 4, 5.