What is the recommended evaluation and management for a patient with an old healed fracture of the right humeral neck and suspected significant osteoarthritis of the right shoulder?

Management of Old Healed Humeral Neck Fracture with Suspected Glenohumeral Osteoarthritis

Begin with a stepwise approach starting with nonsurgical management (physical therapy, NSAIDs, and corticosteroid injections), but if symptoms are severe enough to warrant surgery, proceed directly to total shoulder arthroplasty rather than hemiarthroplasty, as TSA provides superior pain relief and lower revision rates.

Initial Evaluation

Your patient requires specific assessment of:

• Rotator cuff integrity - This is critical as an irreparable rotator cuff tear is an absolute contraindication to anatomic TSA 1
• Severity of glenoid erosion - Determines surgical approach if needed
• Functional limitations and pain severity - Dictates urgency of intervention
• Age and activity level - Influences treatment selection

Imaging Workup

Beyond the plain radiographs you already have:

• MRI without contrast to assess rotator cuff integrity and degree of glenohumeral arthritis
• CT scan if surgical intervention is being considered, to characterize the healed fracture anatomy and glenoid bone stock 2

Treatment Algorithm

Stage 1: Nonsurgical Management (First-Line)

The AAOS guidelines acknowledge that evidence for nonsurgical treatment is limited, but these remain standard initial approaches 1:

• Physical therapy - Though evidence is inconclusive 1, this remains a reasonable first step
• NSAIDs and activity modification
• Intra-articular corticosteroid injections - Evidence is inconclusive but widely used in practice 1
• Viscosupplementation - Weak recommendation (Grade C) based on limited evidence 1

Important caveat: The guidelines note that "barely any data exist to guide nonsurgical treatment of GH OA" 1, so these recommendations are largely extrapolated from hip and knee arthritis literature.

Stage 2: Surgical Decision-Making

If nonsurgical management fails and symptoms significantly impact quality of life, surgical options depend on specific patient factors:

Critical Pre-Surgical Assessment:

1. Rotator Cuff Status (Most Important)

• If irreparable rotator cuff tear is present → Reverse shoulder arthroplasty is indicated, NOT anatomic TSA 1
• If rotator cuff is intact → Proceed with anatomic arthroplasty decision tree below

2. For Anatomic Arthroplasty Candidates:

Total Shoulder Arthroplasty (TSA) is preferred over hemiarthroplasty (Grade B recommendation - the strongest in the guidelines) 1:

• TSA provides significantly better pain relief and global health scores
• 14% of hemiarthroplasties require revision to TSA due to progressive glenoid arthritis
• 0% of TSAs required revision to hemiarthroplasty 1
• This is particularly relevant in your case with pre-existing arthritis

3. Special Considerations for Post-Fracture Anatomy:

Your patient's healed humeral neck fracture creates unique challenges:

• Metaphyseal bone defects >3 cm are negative prognostic factors 3
• Surface replacement may be an option if humeral head anatomy is preserved 4
• The healed fracture position (valgus vs. varus impaction) affects outcomes - valgus impacted fractures have better results 4

Surgical Contraindications and Warnings:

• Do NOT perform TSA if irreparable rotator cuff tear exists (Consensus recommendation) 1
• Surgeon volume matters: Avoid surgeons performing <2 shoulder arthroplasties per year (Grade C recommendation) 1
• Use perioperative VTE prophylaxis (mechanical and/or chemical) - Consensus recommendation 1

Post-Fracture Sequelae Specific Considerations

Given the old healed fracture:

• If considering arthroplasty, acute intervention would have been preferable - delayed RSA after fracture sequelae shows worse outcomes than acute RSA (lower ROM, lower functional scores, higher complication rates) 5
• However, RSA for fracture sequelae still provides significant improvement (mean Constant Score increase from 16.9 to 54.1 points) 3
• Teres minor integrity should be assessed - degeneration negatively impacts outcomes 3

Key Pitfalls to Avoid

1. Do not perform hemiarthroplasty when TSA is feasible - the revision rate is unacceptably high (14% vs 0%) 1
2. Do not proceed with anatomic TSA without confirming rotator cuff integrity
3. Do not underestimate glenoid bone loss from the old fracture - may require bone grafting or reverse arthroplasty
4. Avoid oversizing the humeral component - this increases glenoid erosion risk and revision rates 6

Evidence Quality Note

The AAOS guidelines explicitly state that "management of glenohumeral osteoarthritis remains controversial; the scientific evidence on this topic can be significantly improved" 1. Of 16 recommendations, only one received a moderate grade (TSA over hemiarthroplasty), while most were inconclusive. This means clinical judgment based on individual patient factors remains paramount, but when surgery is indicated, TSA over hemiarthroplasty is the single strongest evidence-based recommendation available 1.