Anatomic healing of greater tuberosity improves range of motion and functional outcomes after reverse total shoulder arthroplasty for proximal humerus fractures. An updated systematic review and meta-analysis on 21 studies.

Background: Reverse shoulder arthroplasty (rTSA) is increasingly being used to treat complex proximal humerus fractures, especially in the senior population. The question of whether it is worthwhile to repair the greater tuberosity (GT) after rTSA for proximal humerus fractures still needs to be answered.

Methods: A systematic review was performed on PubMed, Scopus, Cochrane library and EMBASE, for studies available up to February 2024 focused on tuberosity repair following rTSA for proximal humerus fracture and reporting clinical outcomes and range of motion (ROM) between patients with anatomic GT healing and patients with malunion or nonunion of GT. The primary outcome was the rate of anatomical healed GTs. Patients with GT malunion or non-union were collectively categorized as non-healed. The secondary outcomes were active ROM and functional scores. A random-effects proportion meta-analysis (weighted for individual study size) was generated for calculation of the pooled rate of GT non-healing. The plausible predictive factors for GT non-healing (gender distribution, mean age, mean time from injury to surgery, dominant side distribution, humeral inclination of the implanted prostheses) were analyzed by performing a meta-regression. Any statistically significant difference in terms of ROM (active anterior elevation, abduction and external rotation) between healed and non-healed GT groups was detected by constructing individual forest plots.

Results: A total of 21 studies was selected and included in the meta-analysis, with a sample of 1616 rTSAs in 1614 patients. The rate of GT non-healing ranged from 15.0% to 63.2%, with a pooled rate of 31.9% (95% CI, 25.6%-38.2%; I = 86.8%). The meta-regression failed to individuate any plausible predictive factor among the evaluated elements. Anatomic GT healing provided improved ROM in active abduction (p=0.002), anterior elevation (p<0.00001) as well as external rotation (p<0.0001). With regard to internal rotation, a statistically significant difference in favor of GT healed group was reported in only 3 out of 13 studies. Similarly, the random-effect meta-analysis demonstrated better functional scores in patients with healed GT according to 3 out of 5 functional scores.

Conclusion: GT healing following rTSA for proximal humerus fracture provides increased ROM and better functional outcomes. Moreover, this does not result in higher level of pain for patients. Future prospective studies with more rigorous selection criteria are welcome to increase the level of evidence on this topic.