RSA for Proximal Humeral Fractures

  • Federico A. GrassiEmail author


RSA for fracture can be implanted either through a deltopectoral or transdeltoid approach, according to surgeon’s preference and experience. The exposure influences some steps of the procedure, but the differences among the two approaches are not substantial.

The advantages of the deltopectoral approach include the excellent exposure of the joint space and the easy extension to the humeral shaft in case of need. The transdeltoid approach allows better access to the greater tuberosity and might facilitate periprosthetic reconstruction of the tuberosities.

There are two critical steps in the procedure: restoration of proper humeral length that can be challenging in fractures with severe shaft comminution and secure reconstruction of the greater tuberosity and posterior cuff around the humeral stem, in order to preserve active external rotation.

The surgical technique described hereinafter is performed through the deltopectoral approach. The humeral component is cemented, and the position of the stem is assessed intraoperatively by means of an extramedullary jig. The subscapularis is not repaired to avoid excessive tension of the anterior soft tissues, a condition that could hinder recovery of external rotation.

After surgery, the arm is kept in a sling for 1 month. Assisted passive mobilization of the shoulder is started at 2 weeks, and active movements are encouraged at 3 weeks.


Reverse shoulder arthroplasty Proximal humerus fracture Deltopectoral Transdeltoid Humeral tuberosity 


  1. 1.
    Neer CS. Indications for replacement of the proximal humeral articulation. Am J Surg. 1955;89:901–7. Scholar
  2. 2.
    Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008;90:1407–13. Scholar
  3. 3.
    Cazeneuve JF, Cristofari DJ. Grammont reversed prosthesis for acute complex fracture of the proximal humerus in an elderly population with 5 to 12 years follow-up. Rev Chir Orthop Reparatrice Appar Mot. 2006;92:543–8. (in French)CrossRefGoogle Scholar
  4. 4.
    Bufquin T, Hersan A, Hubert L, Massin P. Reversed shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly. A prospective review of 43 cases with a short-term follow-up. J Bone Joint Surg Br. 2007;89:516–20. Scholar
  5. 5.
    Wang J, Zhu Y, Zhang F, Chen W, Tian Y, Zhang Y. Meta-analysis suggests that reverse shoulder arthroplasty in proximal humerus fractures is a better option than hemiarthroplasty in the elderly. Int Orthop. 2016;40:531–9. Scholar
  6. 6.
    Boileau P, Krishnan SG, Tinsi L, Walch G, Coste JS, Mole D. Tuberosity malposition and migration: reasons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal humerus. J Shoulder Elb Surg. 2002;11:401–12. Scholar
  7. 7.
    Gallinet D, Adam A, Gasse N, Rochet S, Obert L. Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty. J Shoulder Elb Surg. 2013;22:38–44. Scholar
  8. 8.
    Vourazeris JD, Wright TW, Struk AM, King JJ, Farmer KW. Primary reverse total shoulder arthroplasty outcomes in patients with subscapularis repair versus tenotomy. J Shoulder Elb Surg. 2017;26:450–7. Scholar
  9. 9.
    Routman HD. The role of subscapularis repair in reverse total shoulder arthroplasty. Bull Hosp Jt Dis. 2013;71(Suppl 2):S108–12.Google Scholar
  10. 10.
    Murachovsky J, Ikemoto RY, Nascimento GP, Fujiki EN, Milani C, Warner JP. Pectoralis major tendon reference (PMT): a new method for accurate restoration of humeral length with hemiarthroplasty for fracture. J Shoulder Elb Surg. 2006;15:675–8. Scholar
  11. 11.
    Grassi FA, Zorzolo I. Reverse shoulder arthroplasty without subscapularis repair for the treatment of proximal humeral fractures in the elderly. Musculoskelet Surg. 2014;98(Suppl 1):S5–13. Scholar
  12. 12.
    Boileau P, Walch G, Krishnan S. Tuberosity osteosynthesis and hemiarthroplasty for four-part fractures of the proximal humerus. Tech Shoulder Elbow Surg. 2000;1:96–109.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Orthopaedics and Traumatology, Hospital “Maggiore della Carità”University of East PiedmontNovaraItaly

Personalised recommendations