Primary reverse TSA in elderly low-demand patients with comminuted 3- or 4-part fractures, head-split patterns or fracture-dislocations · advanced
- Reverse TSA converts the glenohumeral joint into a semi-constrained ball-and-socket with the glenosphere on the glenoid and the humeral socket on the humerus. Deltoid-driven elevation is possible even when the rotator cuff and tuberosities do not heal. This is the decisive advantage over hemiarthroplasty or ORIF when tuberosity bone quality is poor.
- Primary reverse TSA is indicated in elderly low-demand patients with comminuted 3- or 4-part fractures, head-split fractures, fracture-dislocations, or when the rotator cuff is deficient or the tuberosity bone is too fragmented for reliable ORIF or hemiarthroplasty fixation. Age older than 70 years and low functional demand are the dominant selection criteria.
- The deltopectoral approach is used. The critical technical points are accurate glenoid baseplate positioning (inferior tilt and version correction), humeral stem height and version that allow anatomic tuberosity reduction around the prosthesis, and robust bone grafting of the tuberosities to the humeral shaft and prosthesis to maximise healing and rotation recovery.
- Major complications that alter outcome include scapular notching (prevented by inferior glenosphere placement and lateralised designs), instability (version and soft-tissue balance), acromial stress fracture (avoid deltoid overtensioning), tuberosity nonunion (meticulous reduction and grafting), axillary nerve injury, and periprosthetic infection.
When & Why
Indication. Primary reverse total shoulder arthroplasty for an acute proximal humerus fracture — the operation that restores deltoid-driven elevation in the elderly, low-demand shoulder when the tuberosities are too comminuted to reconstruct reliably. Absolute indications
- Comminuted 3- or 4-part proximal humerus fracture in a patient older than 70 years with low functional demand
- Head-split fracture patterns where anatomic reconstruction is impossible
- Fracture-dislocation with a rotator cuff tear or tuberosity comminution precluding ORIF
- Pre-existing rotator cuff deficiency or a massive irreparable tear with fracture
- Failed ORIF or hemiarthroplasty with tuberosity nonunion or cuff failure in an elderly patient Relative indications
- 4-part fracture with poor bone quality where the surgeon judges ORIF fixation unreliable
- Valgus-impacted 4-part fracture with greater tuberosity comminution greater than 50 percent
- Patient preference for a single definitive procedure over staged reconstruction Contraindications — absolute
- Active infection
- Severe glenoid bone loss precluding baseplate fixation
- A non-functional deltoid (axillary nerve palsy)
- A high-demand younger patient where joint preservation or ORIF is feasible Contraindications — relative
- Moderate glenoid retroversion greater than 20 degrees without augmentation capability
- Poor medical optimisation (uncontrolled diabetes, anticoagulation)
- Cognitive impairment limiting rehabilitation compliance The one decision that matters. For a given elderly fracture, three operations are technically possible, and the choice rests on age, demand, bone quality and the tuberosity pattern:
For the elderly low-demand patient with a 4-part, head-split or fracture-dislocation pattern and greater than 50 percent tuberosity comminution. Reliable deltoid-driven elevation even if the tuberosities fail to heal, and a lower reoperation rate than ORIF in patients older than 70 years.
When reverse is contraindicated (for example glenoid bone loss, infection risk) or the cuff is intact and tuberosity healing is genuinely feasible. Outcomes are exquisitely dependent on tuberosity healing — nonunion of 30 to 50 percent means poor elevation and rotation.
For younger, higher-demand patients with good bone quality and a reducible fracture. In osteoporotic 4-part fractures it carries high reoperation rates from screw cut-out and avascular necrosis, which is why reverse is preferred in the elderly.
Decision threshold. Age older than 70 years, low demand, and fracture patterns with greater than 50 percent tuberosity comminution or head-split morphology shift the balance toward primary reverse TSA. In younger or higher-demand patients, ORIF with modern locking-plate constructs, or hemiarthroplasty with meticulous tuberosity repair, remains preferred when bone quality permits. Consent. Discuss the risk of axillary nerve injury, instability, scapular notching, acromial fracture, infection, and tuberosity nonunion, and the possibility of limited rotation even with a successful operation. Be clear that functional elevation for activities of daily living is the primary goal — not full rotation. Setup. Beach-chair position with the head secured, the arm free or on a padded Mayo stand, fully exposed from sternum to scapula and from neck to elbow. General anaesthesia with an interscalene block for postoperative analgesia, and hypotensive anaesthesia to reduce bleeding. Prophylactic antibiotics — cefazolin, or vancomycin if penicillin-allergic — at induction. A pneumatic arm holder or assistant holds the limb.
The Operation
The goal is to restore a stable, deltoid-powered shoulder through the deltopectoral approach: expose and protect the axillary nerve, tag and mobilise the tuberosities, remove the fractured head and bank its bone, place the glenoid baseplate low with inferior tilt and overhang, set the humeral stem at the height and version that let the tuberosities reduce anatomically, then reconstruct the tuberosities around the prosthesis with autograft. The exposure — the deltopectoral interval, the axillary nerve, and the tuberosity sleeves — is laid out as the first steps below.
Operative sequence
- Beach-chair, arm free on a Mayo stand, interscalene block and prophylactic antibiotics already running.
- Expose from sternum to scapula and from neck to elbow. Palpate and mark the coracoid process, the deltopectoral interval, the acromion and the deltoid insertion.
- Recall that the axillary nerve courses on the deep surface of the deltoid about 5 to 7 cm distal to the acromion — keep that line in mind before any deltoid retraction.
- A 12 to 15 cm skin incision from the coracoid to the deltoid insertion, following the deltopectoral groove.
- Identify and protect the cephalic vein — it marks the interval; preserve it or ligate it laterally with the deltoid.
- Develop the internervous plane between deltoid (axillary nerve) laterally and pectoralis major (lateral and medial pectoral nerves) medially.
- Release the upper 1 to 2 cm of the pectoralis major insertion if extra humeral exposure is needed (repair it at closure). Place a self-retaining retractor.
- Palpate the axillary nerve on the deep surface of the deltoid, 5 to 7 cm distal to the acromion — it exits the quadrilateral space and runs with the posterior circumflex humeral vessels.
- Pass a Penrose drain or vessel loop around it for protection during all humeral work.
- Avoid excessive or prolonged deltoid retraction — traction neuropraxia is the mechanism of injury.
- Identify the long head of biceps in the bicipital groove and perform a tenotomy or tenodesis — it improves exposure and reduces postoperative pain.
- The fracture lines usually separate the greater tuberosity (supraspinatus, infraspinatus, teres minor) and the lesser tuberosity (subscapularis) from the head and shaft. Mobilise each as a sleeve, preserving its soft-tissue attachments.
- Tag each tuberosity now with heavy non-absorbable sutures (No. 2 or 5) placed through the tendon-to-bone junction, before any further dissection — this preserves orientation for later reconstruction.
- Deliver and remove the humeral head fragment.
- Save the cancellous bone from the head — this is your autograft for the tuberosity reconstruction.
- Assess the remaining tuberosity fragments and shaft for comminution; irrigate the joint and clear loose fragments.
- Retract the humeral shaft posteriorly with a Fukuda or glenoid retractor. Release the anterior capsule and subscapularis if contracted to fully expose the glenoid face.
- Native glenoid version averages 5 to 10 degrees retroversion (measure it precisely on the preoperative CT). Place the baseplate guide pin low on the glenoid face with slight inferior tilt, using a version guide or navigation referenced to the scapular axis.
- Ream to bleeding subchondral bone, correcting retroversion to less than 10 degrees (anterior reaming, or an augmented baseplate when correction would remove more than 5 to 7 mm of bone).
- Impact the baseplate and secure it, usually with four peripheral screws. Choose the glenosphere size and offset to give 2 to 4 mm of inferior overhang.
- Expose the humeral canal and prepare it with sequential reamers and broaches.
- Trial the stem at the height that lets the greater tuberosity reduce anatomically around the prosthetic head — typically referenced about 5 to 5.5 cm distal to the top of the head from the pectoralis major insertion.
- Set humeral retroversion to 20 to 30 degrees relative to the epicondylar axis (the bicipital groove is a cross-check). Trial the humeral socket and reduce the joint.
- Check stability through a full range of motion and assess deltoid tension; adjust height and offset as needed before committing.
- This is the most critical step for rotation recovery. Reduce the greater and lesser tuberosities around the prosthesis so the greater tuberosity sits at the level of the prosthetic head.
- Pack the saved head autograft between the tuberosities, the prosthesis and the humeral shaft.
- Secure the tuberosities with multiple heavy sutures passed through bone tunnels in the shaft and around the prosthesis neck, tied in a cruciate fashion over the tuberosities, plus circumferential sutures around the prosthesis.
- Confirm anatomic reduction with fluoroscopy — any gap greater than 2 mm predicts nonunion.
- Once trialling confirms stability and motion, implant the definitive components. Cement the humeral stem if bone quality is poor.
- Repair the subscapularis if possible (it aids stability and internal rotation). Have cerclage cables available in case of an intraoperative shaft fracture.
- Close the deltopectoral interval in layers over a drain. Apply a sterile dressing and an abduction sling.
The axillary nerve exits the quadrilateral space and lies on the deep surface of the deltoid about 5 to 7 cm distal to the acromion. Excessive or prolonged deltoid retraction, or aggressive inferior capsular release, stretches or lacerates it, producing deltoid paralysis and lateral shoulder anaesthesia. Identify it early by palpation or direct vision, protect it with a Penrose drain or vessel loop, and limit retraction time.
Obtain an intraoperative AP view of the glenoid after baseplate implantation. Confirm the baseplate is low with 5 to 10 degrees of inferior tilt and that the glenosphere will sit with 2 to 4 mm of inferior overhang relative to the glenoid rim. That one view prevents the majority of scapular notching problems.
Placing the baseplate in excessive retroversion or superior tilt causes scapular notching, reduced range of motion and early loosening. Use the preoperative CT to measure version, correct retroversion greater than 15 degrees to less than 10 degrees with eccentric reaming or an augmented baseplate (a 10- or 15-degree posterior augment when correction would remove more than 5 to 7 mm of bone), place the baseplate low with inferior tilt, and confirm with the image intensifier. Over-reaming into the vault risks baseplate loosening.
A stem set too proud prevents anatomic tuberosity reduction; set too low it loses deltoid tension and risks instability. Use the pectoralis major tendon insertion as the landmark (about 5.5 cm from the top of the head prosthesis in most systems), set 20 to 30 degrees retroversion, and confirm the greater tuberosity reduces anatomically on trial before final implantation.
Failure of tuberosity healing eliminates external and internal rotation and converts the reverse TSA into a pure deltoid elevation device. Prevent it with anatomic reduction, generous autograft from the humeral head packed between tuberosity and shaft, secure fixation with heavy non-absorbable sutures through bone tunnels and around the prosthesis, and avoidance of overstuffing the joint. A tuberosity-to-shaft gap greater than 2 mm predicts nonunion.
Excessive humeral lengthening overtensions the deltoid and is the root cause of many acromial stress fractures. Humeral length should restore, but not exceed, native length. Pair this with sling protection and delayed deltoid strengthening to protect the acromion.
Aftercare & Complications
Rehabilitation | Phase | Timing | Immobilisation & activity | |-------|--------|----------------------------| | Immediate | 0 to 2 weeks | Abduction sling at all times except hygiene and exercises; pendulums and passive forward elevation to 90 degrees from day 1 to 2; no active elevation or rotation for 4 to 6 weeks to protect the tuberosity repair. Wound review and suture or staple removal at 10 to 14 days | | Early | 2 to 6 weeks | Continue passive and active-assisted elevation in the scapular plane; gentle external rotation to 30 degrees at 4 weeks; isometric deltoid and periscapular work at 4 weeks; sling weaned at 4 to 6 weeks | | Late | 6 to 12 weeks | Active elevation and rotation; progressive resistance for deltoid and scapular stabilisers; functional training for activities of daily living | | Return to function | 3 to 6 months | Light activities from 6 weeks; driving once the sling is off and reaction time is normal (about 6 to 8 weeks); manual work or sport at 4 to 6 months. Full elevation expected by 3 to 6 months; rotation may keep improving to 12 months | If intraoperative tuberosity fixation was tenuous, extend sling protection to 8 weeks and delay active rotation until there is radiographic evidence of healing. In poor bone quality, expect to have used a cemented stem and an augmented baseplate, and keep cerclage cables available for an intraoperative fracture. For staged bilateral cases, separate the procedures by 3 to 6 months and only operate the second side once the first has reliable elevation. Complications
- Incidence
- 10 to 30 percent (lower with modern lateralised designs)
- Recognition
- Progressive bone loss on the inferior scapular neck on AP radiographs; may be asymptomatic or cause pain and crepitus
- Prevention and management
- Prevention: inferior glenosphere placement with 2 to 4 mm overhang, 5 to 10 degrees inferior baseplate tilt, lateralised designs. Management: observe if asymptomatic; revise to a lateralised component or bone graft if symptomatic and progressive
- Incidence
- 2 to 5 percent
- Recognition
- Sudden loss of elevation, visible deformity, pain; radiographs confirm dislocation
- Prevention and management
- Prevention: correct component version, adequate soft-tissue tension, repair subscapularis when possible. Management: closed reduction if early; revision for component malposition or inadequate tension if recurrent
- Incidence
- 5 to 10 percent
- Recognition
- Sudden acromial pain 4 to 12 weeks postoperatively with loss of active elevation; may be missed on plain films — CT confirms
- Prevention and management
- Prevention: avoid excessive humeral lengthening, sling for 4 to 6 weeks, delay aggressive deltoid strengthening. Management: non-operative in most (sling, activity modification); ORIF rarely for displaced fractures
- Incidence
- 15 to 40 percent (lower with meticulous technique)
- Recognition
- Limited external and internal rotation despite good elevation; radiographs show displaced or resorbed tuberosities
- Prevention and management
- Prevention: anatomic reduction, generous autograft, secure suture fixation through bone tunnels. Management: revision reconstruction if symptomatic; accept limited rotation if elevation is functional
- Incidence
- 1 to 3 percent
- Recognition
- Deltoid weakness, sensory loss over the lateral shoulder; EMG confirms if unclear
- Prevention and management
- Prevention: identify and protect the nerve during approach and humeral work; limit retraction time. Management: observation (most neuropraxias recover); exploration and repair if no recovery by 3 to 6 months
- Incidence
- 1 to 3 percent
- Recognition
- Persistent pain, swelling, raised CRP or ESR; sinus tract if chronic
- Prevention and management
- Prevention: prophylactic antibiotics, meticulous haemostasis, minimise operative time. Management: debridement and implant retention if acute; two-stage revision if chronic or components are loose
- Incidence
- 2 to 5 percent at 5 years
- Recognition
- Progressive radiolucent lines around the baseplate; pain and loss of function
- Prevention and management
- Prevention: adequate bone stock, correct version, inferior placement. Management: revision glenoid reconstruction with augments or bone graft
Viva & Exam Focus
INDICATEINDICATE — when to choose primary reverse TSA for a proximal humerus fracture
DELTOPECTORALDELTOPECTORAL — the operative sequence
Clinical Decision Scenarios
Practise clinical reasoning and management decisions out loud
“A 78-year-old woman with low functional demand presents with a comminuted 4-part proximal humerus fracture after a fall. CT shows greater tuberosity comminution involving greater than 60 percent of the fragment and a head-split component. The rotator cuff appears intact on imaging. What is your recommended treatment and why?”
“Six weeks after reverse TSA for a 4-part fracture, a 75-year-old man reports sudden pain over the acromion and loss of active elevation. Radiographs show a transverse acromial fracture. How do you manage this?”
“You are planning reverse TSA for a 72-year-old woman with a 4-part proximal humerus fracture. Preoperative CT shows 25 degrees of glenoid retroversion. How do you address glenoid version during surgery and what are the consequences of leaving it uncorrected?”
Key indications
- Age older than 70 years with low functional demand and a comminuted 3- or 4-part fracture
- Head-split fracture or greater than 50 percent tuberosity comminution precludes reliable ORIF or hemiarthroplasty
- Rotator cuff deficiency or fracture-dislocation with poor bone quality
- Primary reverse TSA is preferred over staged reconstruction in selected elderly patients
Critical anatomy
- Axillary nerve lies 5 to 7 cm distal to the acromion on the deep deltoid surface — identify and protect
- Greater and lesser tuberosities must be tagged before humeral head removal for later reconstruction
- Glenoid version averages 5 to 10 degrees retroversion — correct to less than 10 degrees
- The pectoralis major insertion is the landmark for stem height (about 5.5 cm)
- Deltoid tension must restore but not exceed native length to avoid an acromial fracture
Operative sequence
- Deltopectoral approach; protect the cephalic vein and axillary nerve
- Tag the greater and lesser tuberosities with heavy sutures before head removal
- Glenoid preparation: low baseplate, inferior tilt 5 to 10 degrees, 2 to 4 mm glenosphere overhang
- Humeral stem height set for anatomic greater tuberosity reduction; version 20 to 30 degrees
- Tuberosity reconstruction with autograft and multiple heavy sutures through bone tunnels
- Verify anatomic reduction and stability with fluoroscopy before closure
Danger zones
- Axillary nerve injury: excessive deltoid retraction or aggressive inferior capsular release
- Scapular notching: superior glenosphere placement or lack of inferior tilt or overhang
- Acromial stress fracture: excessive humeral lengthening or early aggressive deltoid strengthening
- Tuberosity nonunion: a gap greater than 2 mm, inadequate graft, or insecure fixation
- Glenoid loosening: uncorrected retroversion greater than 15 degrees or vault penetration
Complications
- Scapular notching 10 to 30 percent — prevented by inferior glenosphere placement
- Acromial stress fracture 5 to 10 percent — non-operative sling treatment in most cases
- Tuberosity nonunion 15 to 40 percent — anatomic reduction and autograft reduce it dramatically
- Instability 2 to 5 percent — correct version and soft-tissue tension are key
- Infection 1 to 3 percent — standard prophylaxis and meticulous technique
Post-operative protocol
- Abduction sling for 4 to 6 weeks; passive elevation only for the first 4 weeks
- Active elevation and rotation begin at 6 weeks
- Deltoid and periscapular strengthening from 6 to 8 weeks
- Full elevation expected by 3 to 6 months; rotation may improve up to 12 months
- Tuberosity healing on radiographs at 3 months guides progression of activity
Evidence thresholds
- Primary reverse TSA in patients older than 70 years with complex fractures shows a lower reoperation rate than ORIF
- Elevation of 120 to 140 degrees is typical even with tuberosity nonunion
- Rotation recovery requires tuberosity healing — nonunion converts the shoulder to pure deltoid elevation
- Modern lateralised glenosphere designs reduce notching rates versus Grammont-style prostheses
Background & Evidence
Epidemiology. Proximal humerus fractures are among the most common fragility fractures of the elderly, with a strong female predominance and a peak incidence in the eighth decade. The large majority follow a low-energy fall onto the outstretched arm in an osteoporotic patient. Three- and four-part fractures, head-split injuries and fracture-dislocations are the patterns that threaten tuberosity and humeral head vascularity and drive the decision toward arthroplasty in older patients. Classification. Management and the arthroplasty decision turn on the Neer parts system, where a fragment counts as a separate part only if it is displaced more than 1 cm or angulated more than 45 degrees.
- Definition
- Fragments displaced less than 1 cm and angulated less than 45 degrees
- Relevance to the reverse-TSA decision
- Managed non-operatively or with ORIF; not a reverse-TSA indication
- Definition
- One fragment (anatomic neck, surgical neck, greater or lesser tuberosity, or a fracture-dislocation) displaced beyond the threshold
- Relevance to the reverse-TSA decision
- ORIF if displaced; reverse TSA only in the elderly with cuff deficiency or unreconstructable anatomy
- Definition
- Two fragments displaced beyond the threshold
- Relevance to the reverse-TSA decision
- ORIF in good bone; reverse TSA in the elderly low-demand patient or with a head-split component
- Definition
- Head, shaft and both tuberosities displaced; high avascular-necrosis risk
- Relevance to the reverse-TSA decision
- Elderly low-demand: primary reverse TSA is the operation of choice
- Definition
- The articular surface of the head is split (often a 4-part pattern)
- Relevance to the reverse-TSA decision
- Anatomic reconstruction is impossible; reverse TSA is favoured in the elderly
- Definition
- Dislocation combined with a tuberosity or head fracture
- Relevance to the reverse-TSA decision
- Reverse TSA when tuberosity or cuff injury precludes a stable reduction
Biomechanics. Reverse geometry reverses the ball and socket — the glenosphere sits on the glenoid and the cup on the humerus — which medialises the centre of rotation and lengthens the deltoid lever arm. The deltoid can therefore power elevation even when the rotator cuff is absent or the tuberosities fail to heal, the property that makes it so effective in the fractured, cuff-deficient elderly shoulder. The trade-off is the loss of the native restraint to superior migration, so component position and deltoid tension must be exact. Comparative evidence. Primary reverse TSA in selected elderly patients delivers reliable forward elevation of about 120 to 140 degrees even when the tuberosities do not unite. Hemiarthroplasty is exquisitely dependent on tuberosity healing — nonunion rates of 30 to 50 percent after hemiarthroplasty translate into poor elevation and rotation. ORIF of osteoporotic four-part fractures carries high reoperation rates from screw cut-out and avascular necrosis. Against that background, primary reverse TSA shows a lower reoperation rate than ORIF in patients older than 70 years with complex patterns, and better elevation than hemiarthroplasty where tuberosity healing is unreliable. Rotation never fully recovers to anatomic standards, but patient satisfaction is high because elevation is functional for daily living.
References
Primary reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humerus fractures in elderly patients
Level II prospective comparison of reverse TSA and hemiarthroplasty in patients older than 70 years with 3- or 4-part fractures. Reverse TSA gave superior elevation and patient-reported outcomes at 2 years when tuberosity healing was unreliable, with a lower reoperation rate than hemiarthroplasty or staged reconstruction. Primary reverse TSA is a reasonable choice in selected elderly low-demand patients with complex fractures where tuberosity healing is unlikely.
Reverse shoulder arthroplasty for acute proximal humerus fractures: a systematic review
Level III systematic review of 15 studies and 385 shoulders treated with primary reverse TSA for fracture. Mean elevation was 122 degrees and mean external rotation 25 degrees, with a tuberosity healing rate of about 70 percent. The complication rate was 15 to 20 percent (notching and instability most common) and the reoperation rate 5 to 8 percent. Reverse TSA provides reliable elevation in elderly fracture patients; tuberosity reconstruction improves rotation but is not required for functional elevation.
Scapular notching in reverse shoulder arthroplasty: the effect of glenosphere position and design
Level II retrospective radiographic review correlating glenosphere position with notching. Inferior glenosphere overhang of 2 mm or greater with inferior tilt reduced notching from about 60 percent to 12 percent, and notching correlated with poorer clinical outcomes and higher revision rates. Meticulous baseplate positioning with inferior tilt and overhang is mandatory to minimise scapular notching.
Tuberosity healing after reverse shoulder arthroplasty for proximal humerus fracture: factors influencing outcome
Level III prospective series of 45 patients having primary reverse TSA for a 4-part fracture. Anatomic tuberosity reduction and bone grafting achieved an 80 percent healing rate, and nonunion led to significantly poorer rotation — though satisfaction remained high because elevation was functional. Tuberosity reconstruction should be attempted in every case; meticulous technique and autograft improve healing and rotation recovery.
Acromial stress fractures after reverse total shoulder arthroplasty: incidence, risk factors and management
Level IV retrospective review of 400 reverse TSA cases; an acromial fracture occurred in 5.5 percent. Risk factors included excessive humeral lengthening and aggressive early physiotherapy. Non-operative treatment succeeded in 85 percent of cases and revision was rarely required. Protect the acromion with a sling for 4 to 6 weeks and avoid over-lengthening the humerus to minimise this complication.