Abstract
Background
The incidence of closed proximal humerus fractures (CPHF) is steadily increasing worldwide. Open reduction internal fixation (ORIF) remains the most common surgical technique while reverse shoulder arthroplasty (RSA) is becoming a noteworthy approach. The optimal management of CPHF (ORIF vs. RSA) remains complex and continually evolving.
Methods
This retrospective cohort study utilized data from the National Inpatient Sample (2016–2019). Patients with proximal humerus fractures (PHF) treated with ORIF or RSA were included. Demographics, fracture characteristics, comorbidities, and complications were analyzed. Binary logistic regression identified risk factors for complications.
Results
A total of 11,667 patients with CPHF were included (ORIF, n = 2,657 vs. RSA, n = 1,932). Patients undergoing ORIF were younger and incurred lower hospital charges (P < 0.001). Female gender, elective admission rate, and Charlson comorbidity index were significantly higher in those who underwent RSA. Both groups differed in rates of major complications and postprocedural pain (P < 0.001). Implant-related complications (P = 0.046) and total complications (P = 0.157) showed no significant difference. For patients undergoing RSA, those with 3-part fractures (OR = 0.08, 95% CI 0.01–0.50, P = 0.006) and 4-part fractures (OR = 0.04, 95% CI 0.01–0.23, P < 0.001) had significantly lower odds of implant-related complications compared to those with 1-part fractures.
Conclusion
RSA may be a considered option for elderly patients with 3- or 4-part fractures and significant comorbidities, as it was associated with fewer major complications and served as a protective factor for implant-related issues. ORIF presents a viable option for 1- or 2-part fractures, given its association with lower postprocedural pain.
Level of evidence
Level III.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s13018-025-06639-6.
Keywords: Shoulder, Arthroplasty, Fracture, Complication, Database
Introduction
The incidence of proximal humerus fractures (PHF) is steadily increasing worldwide [1, 2]. Closed fractures are predominant in PHF [3], with various surgical or non-surgical management [2, 4]. While non-surgical treatment is preferred for non- or minimally displaced fractures, surgical intervention is often indicated for displaced, complex fractures to restore function and reduce complications like malunion or osteonecrosis [4–7]. However, the fundamental choice between surgical and non-surgical management for closed proximal humerus fractures (CPHF) remains a subject of active investigation in high-quality trials [8], reflecting a persistent evidence gap that early systematic reviews had already highlighted for complex fracture management [9].
The choice of surgical technique for CPHF, however, is a subject of ongoing debate. Open reduction internal fixation (ORIF) remains the most common surgical technique for CPHF [1, 2, 4]. However, its use in complex fractures has been associated with high reoperation rates than arthroplasty [10]. Reverse total shoulder arthroplasty (RSA) has been associated with improved radiographic and functional outcomes compared to ORIF and non-surgical management in selected cases of CPHF [11, 12]. Recent trends show a complex landscape, some studies report an increasing shift towards RSA, while others, note a trend towards more non-operative management or a decrease in certain surgeries like ORIF and hemiarthroplasty [13, 14]. Given this context, despite numerous studies, there is a paucity of large-scale, direct comparisons focusing on the short-term complications of ORIF versus RSA for CPHF, particularly within the context of evolving treatment trends.
This study aims to retrospectively compare the demographics, hospital and fracture characteristics, comorbidities and short-term in-hospital complications of patients undergoing ORIF versus RSA for CPHF. We seek to identify risk factors associated with complications for each procedure to better inform surgical decision-making.
Methods
Data source
This retrospective study utilized the National Inpatient Sample (NIS) from the Healthcare Cost and Utilization Project (HCUP). The International Classification of Diseases-10-Clinical Modification (ICD-10-CM) codes were used for identifying diseases and surgical procedures. The NIS data of patients were deidentified and complied with the Health Insurance Portability and Accountability Act (HIPAA).
Study population
The study identified patients who had PHF and various procedures (including ORIF with plate fixation, RSA, hemi or total shoulder arthroplasty, intramedullary nailing, closed reduction percutaneous fixation, and external fixation) from 2016 to 2019. The ICD-10-CM codes were attached to the supplementary materials.
Inclusion process
Including 12,113 patients who have initial occurrence of acute PHF from 2016 to 2019 in the study, 559 patients who have any missing valuables, such as specified fracture types, demographics, or hospital characteristics, were excluded. Excluding 101 of those diagnosed as open proximal humerus fractures (OPHF), patients who have bilateral upper limb injuries, multiple procedure codes, and pathological fractures were also excluded, leaving 11,667 CPHF patients. Among them, 6,493 patients received conservative treatment, and 5,174 patients underwent surgical treatment, including 2,657 patients undergoing ORIF and 1,932 undergoing RSA (Fig. 1).
Fig. 1.
Flow diagram of the study population
Study design
Descriptive analysis was used to characterize the CPHF population. Patients were stratified with the ORIF and RSA groups. Mann-Whitney U tests were used to analyze quantitative data, including age, Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index (ECI), length of stay (LOS), and total charges. A Chi-square test was used to evaluate the potential association between gender, race, elective admission, death, and fracture characteristics including complete rotator cuff tear or rupture (CRCT), primary osteoarthritis, osteoporosis, and fracture types. In analyzing comorbidities (including all comorbidities in CCI and ECI) and complications among patients who underwent ORIF or RSA, Chi-square tests were employed to assess differences among the population. Binary logistic regression models and forward selection were used to control for valuables of demographics, hospital and fracture characteristics, and comorbidities, determining independent predictors of complications separately. Postoperative cardiovascular complications (including postprocedural cardiac arrest, postprocedural cardiac insufficiency, postprocedural heart failure), pulmonary embolism, postoperative stroke, sepsis, postoperative shock, deep vein thrombosis, and bacterial pneumonia were classified as major complications, Mechanical complications of implants (including breakdown of implants, dislocation of implants, mechanical loosening of implants, implant osteolysis, wear of implants), implant infection, and preimplant fracture were classified as implant-related complications. Lastly, total complications included any of the following: major complications, postprocedural pain, implant-related, or death. A more conservative P-value of < 0.01 was set as the threshold for statistical significance for univariate analyses to account for multiple comparisons and the large sample size. IBM SPSS Statistics 26 was used for all analyses.
Results
Population demographics
As shown in Fig. 2, non-surgical treatment accounted for 55.7% of all treatment options overall, but the number of surgical treatments steadily increased between 2016 and 2019. The number of patients undergoing ORIF remained stable, while RSA showed conspicuous growth.
Fig. 2.
Incidence of patients undergoing different interventions for closed proximal humerus fracture from 2016 to 2019. (RSA reverse shoulder arthroplasty, ORIF open reduction internal fixation)
Demographics and hospital characteristics between ORIF and RSA
The two groups substantially differed in demographics and hospital characteristics (Table 1). Patients undergoing ORIF (n = 2,657) were younger (64[51,73] vs. 74[67,80], P < 0.001), had longer hospital stays (3 [2, 6] vs. 2 [1, 4], P < 0.001), and incurred lower hospital charges (73,555[47,429, 116,789] vs. 84,600[60,530, 124,042], P < 0.001) compared to the RSA group. Regarding gender, both ORIF and RSA groups were predominantly performed on women, with obviously more women undergoing RSA (63.60% vs. 83.00%, P < 0.001). Non-elective surgeries were predominant in the ORIF group, while the RSA group showed the opposite trend (73.10% vs. 37.50%, P < 0.001). There were significant differences in race between the two groups (P < 0.001), with the majority being White race (80.8% vs. 90.5%) and Black race showing obvious variation between the two groups, with the ORIF group being more common (5.8% vs. 1.3%). There was a significant difference in CCI between ORIF and RSA groups (0[0,1] vs. 1[0,2], P < 0.001). However, no significant difference was found in ECI (0[0,5] vs. 0[0,5], P = 0.081) and mortality (0.2% vs. 0.3% P = 1).
Table 1.
Demographics and hospital characteristics of patients undergoing open reduction internal fixation (ORIF) or reverse shoulder arthroplasty (RSA)
| ORIF | RSA | P value | |
|---|---|---|---|
| Median age | 64(51 to 73) | 74(67 to 80) | < 0.001 |
| Age group (%) | < 0.001 | ||
| < 60 | 1,065(40.1%) | 113(5.8%) | |
| 60 to 74 | 993(37.4%) | 909(47.0%) | |
| ≥ 75 | 599(22.5%) | 910(47.1%) | |
| Female (%) | 1,690(63.6%) | 1,604(83.0%) | < 0.001 |
| Elective admission (%) | 715(26.9%) | 1,207(62.5%) | < 0.001 |
| Race (%) | < 0.001 | ||
| White | 2,147 (80.8%) | 1,748(90.5%) | |
| Black | 154(5.8%) | 25(1.3%) | |
| Hispanic | 231(8.7%) | 100(5.2%) | |
| Asian or Pacific Islander | 37(1.4%) | 12(0.6%) | |
| Native American | 9(0.3%) | 5(0.3%) | |
| Other | 79(3.0%) | 42(2.2%) | |
| Elixhauser Comorbidity Index | 0(0 to 5) | 0(0 to 5) | 0.085 |
| Charlson Comorbidity Index | 0(0 to 1) | 1(0 to 2) | < 0.001 |
| Length of stay | 3(2 to 6) | 2(1 to 4) | < 0.001 |
| Total charges | 73,555(47,429 to 116,789) | 84,600(60,530 to 124,042) | < 0.001 |
| Mortality (%) | 6(0.2%) | 11(0.3%) | 1 |
Fracture characteristics between ORIF and RSA
Visible differences exist in the fracture characteristics between the two groups (Table 2). Patients undergoing ORIF had less CRCT (0.3% vs. 0.8%, P = 0.007), primary osteoarthritis (0.6% vs. 6.3%, P < 0.001), and osteoporosis (9.0% vs. 13.7%, P < 0.001). More patients who had 4-part fractures underwent RSA (12.2% vs. 55.1%), while the condition of patients who had 1, 2, or 3-part fractures was the opposite.
Table 2.
Fracture characteristics of patients undergoing open reduction internal fixation (ORIF) or reverse shoulder arthroplasty (RSA)
| ORIF | RSA | P value | |
|---|---|---|---|
|
Complete Rotator cuff tear or rupture (%) |
7(0.3%) | 16(0.8%) | 0.007 |
| Primary osteoarthritis (%) | 17(0.6%) | 121(6.3%) | < 0.001 |
| Osteoporosis (%) | 238(9.0%) | 264(13.7%) | < 0.001 |
| Fracture type (%) | < 0.001 | ||
| 1-part fracture | 95(3.6%) | 29(1.5%) | |
| 2-part fracture | 1,587(59.7%) | 566(29.3%) | |
| 3-part fracture | 651(24.5%) | 273(14.1%) | |
| 4-part fracture | 324(12.2%) | 1,064(55.1%) |
Comorbidities between ORIF and RSA
ORIF and RSA patients exhibited distinctly different comorbidity profiles (Table 3). Patients undergoing RSA had more comorbidities, including hypertension (72.0% vs. 55.0%, P < 0.001), uncomplicated diabetes (22.3% vs. 17.2%, P < 0.001), chronic pulmonary disease (20.5% vs. 16.4%, P < 0.001), hypothyroidism (20.2% vs. 13.3%, P < 0.001), obesity (19.7% vs. 15.9%, P = 0.001), renal disease (11.5% vs. 7.8%, P < 0.001), dementia (6.4% vs. 4.6%, P = 0.007). Conversely, Patients undergoing ORIF were characterized by fluid and electronic disorders (21.1% vs. 17.0%, P = 0.001), neurological disorders (11.8% vs. 6.8%, P < 0.001), alcohol abuse (9.4% vs. 3.3%, P < 0.001), cerebrovascular disease (3.2% vs. 1.7%, P < 0.001), and drug abuse (2.2% vs. 1.2%, P = 0.009).
Table 3.
Comorbidities of patients undergoing open reduction internal fixation (ORIF) or reverse shoulder arthroplasty (RSA)
| ORIF | RSA | P value | |
|---|---|---|---|
| AIDSa (%) | 6(0.2%) | 0(0%) | 0.094 |
| Alcohol abuse (%) | 249(9.4%) | 64(3.3%) | < 0.001 |
| Cardiac arrhythmias (%) | 396(14.9%) | 314(16.3%) | 0.212 |
| Cerebrovascular disease (%) | 84(3.2%) | 32(1.7%) | 0.001 |
| Chronic blood loss anemia (%) | 29(1.1%) | 22(1.1%) | 0.880 |
| Chronic pulmonary disease (%) | 436(16.4%) | 397(20.5%) | < 0.001 |
| Coagulopathy (%) | 37(1.4%) | 23(1.2%) | 0.552 |
| Congestive heart failure (%) | 189(7.1%) | 138(7.1%) | 0.969 |
| Deficiency anemia (%) | 91(3.4%) | 77(4.0%) | 0.318 |
| Dementia (%) | 121(4.6%) | 123(6.4%) | 0.007 |
| Depression (%) | 380(14.3%) | 313(16.2%) | 0.076 |
| Diabetes (uncomplicated) (%) | 457(17.2%) | 431(22.3%) | < 0.001 |
| Diabetes with chronic complication (%) | 189(7.1%) | 170(8.8%) | 0.036 |
| Drug abuse (%) | 59(2.2%) | 23(1.2%) | 0.009 |
| Fluid and electrolyte disorders (%) | 560(21.1%) | 329(17.0%) | 0.001 |
| Hypertension (%) | 1,462(55.0%) | 1,392(72.0%) | < 0.001 |
| Hypothyroidism (%) | 354(13.3%) | 390(20.2%) | < 0.001 |
| Leukemia (%) | 6(0.2%) | 10(0.5%) | 0.098 |
| Lymphoma (%) | 5(0.2%) | 4(0.2%) | 0.887 |
| Metastatic solid tumor (%) | 12(0.5%) | 6(0.3%) | 0.450 |
| Mild liver disease (%) | 113(4.3%) | 61(3.2%) | 0.055 |
| Moderate or severe liver disease (%) | 19(0.7%) | 13(0.7%) | 0.865 |
| Myocardial infarction (%) | 110(4.1%) | 80(4.1%) | 0.999 |
| Obesity (%) | 422(15.9%) | 381(19.7%) | 0.001 |
| Other neurological disorders (%) | 314(11.8%) | 131(6.8%) | < 0.001 |
| Paralysis (%) | 12(0.5%) | 3(0.2%) | 0.082 |
| Peptic ulcer disease (%) | 13(0.5%) | 5(0.3%) | 0.217 |
| Peripheral vascular disease (%) | 67(2.5%) | 47(2.4%) | 0.848 |
| Psychoses (%) | 39(1.5%) | 14(0.7%) | 0.020 |
| Pulmonary circulation disorders (%) | 73(2.7%) | 40(2.1%) | 0.144 |
| RA or CVb (%) | 89(3.3%) | 87(4.5%) | 0.045 |
| Renal disease (%) | 207(7.8%) | 222(11.5%) | < 0.001 |
| Solid tumor without metastasis (%) | 34(1.3%) | 31(1.6%) | 0.358 |
| Valvular disease (%) | 105(4.0%) | 97(5.0%) | 0.081 |
| Weight loss (%) | 75(2.8%) | 34(1.8%) | 0.020 |
a: acquired immune deficiency syndrome. b: rheumatoid arthritis or collagen vascular diseases
Complications between ORIF and RSA
Figure 3 details the counts of complications. Among ORIF patients, major complications accounted for the greatest number of cases. Among RSA patients, postprocedural pain accounted for the highest count. The incidence of major complications was significantly lower in the RSA group than in the ORIF group (1.2% vs. 2.7%, P < 0.001). Conversely, the incidence of postprocedural pain was significantly lower in the ORIF group (3.4% vs. 1.7%, P < 0.001). No significant differences were observed in the incidence of implant-related complications (0.8% vs. 1.3%, P = 0.046) and total complications (6.1% vs. 7.1%, P = 0.157).
Fig. 3.
The proportion of major complications, postprocedural pain, and implant-related complications of patients. (RSA reverse shoulder arthroplasty, ORIF open reduction internal fixation)
The regression analysis results were presented separately (Tables 4 and 5; Fig. 4). For patients undergoing ORIF, pulmonary circulatory disorders (OR = 18.77, 95% CI 9.74–36.15, P < 0.001), coagulopathy (OR = 6.16, 95% CI 2.31–16.45, P < 0.001), fluid and electrolyte disorders (OR = 3.58, 95% CI 2.11–6.07, P < 0.001), and weight loss (OR = 2.93, 95% CI 1.31–6.55, P = 0.009) were identified as risk factors in major complications. Chronic blood loss anemia (OR = 8.64, 95% CI 1.88–39.73, P = 0.006), Black race (OR = 4.40, 95% CI 1.98–9.78, P < 0.001), elective admission (OR = 2.67, 95% CI 1.42–5.03, P = 0.002), and depression (OR = 2.65, 95% CI 1.29–5.45, P = 0.008), were considered as risk factors in postprocedural pain. However, women served as protective factors in major complications (OR = 0.42, 95% CI 0.25–0.71, P = 0.001) and postprocedural pain (OR = 0.36, 95% CI 0.19–0.68, P = 0.002). Coagulopathy (OR = 8.84, 95% CI 1.89–41.36, P = 0.006) and depression (OR = 3.90, 95% CI 1.54–9.87, P = 0.004) were identified as risk factors in implant-related complications. For patients undergoing RSA, pulmonary circulatory disorder (OR = 18.70, 95% CI 6.35–55.05, P < 0.001), and fluid and electrolyte disorders (OR = 5.74, 95% CI 2.35–14.02, P < 0.001) present as risk factors in major complications. Chronic blood loss anemia (OR = 6.15, 95% CI 1.71–22.20, P = 0.006) served as a risk factor in postprocedural pain. Congestive heart failure (OR = 6.49, 95% CI 2.45–17.21, P < 0.001) was considered a risk factor in implant-related complications. However, 3-part fracture (OR = 0.08, 95% CI 0.01–0.50, P = 0.006), and 4-part fracture (OR = 0.04, 95% CI 0.01–0.23, P < 0.001) were identified as protective factors in implant-related complications.
Table 4.
Logistic regression analysis of patient and hospital predictors, fracture characteristics predictors, and comorbidity predictors of those undergoing ORIF with major complications, postprocedural pain, or implant-related complications
| Major Complications | Postprocedural Pain | Prosthesis–related Complications | |||||||
|---|---|---|---|---|---|---|---|---|---|
| OR | 95%CI | P value | OR | 95%CI | P value | OR | 95%CI | P value | |
| Age group | – | – | – | ||||||
| < 60 | – | – | – | ||||||
| 60 to 74 | – | – | – | ||||||
| ≥ 75 | – | – | – | ||||||
| Female | 0.42 | 0.25 to 0.71 | 0.001 | 0.36 | 0.19 to 0.68 | 0.002 | 0.35 | 0.14 to 0.87 | 0.024 |
| Elective admission | 0.34 | 0.13 to 0.89 | 0.027 | 2.67 | 1.42 to 5.03 | 0.002 | – | ||
| Race | – | 0.012 | – | ||||||
| White | – | – | – | ||||||
| Black | – | 4.40 | 1.98 to 9.78 | < 0.001 | – | ||||
| Hispanic | – | 0.62 | 0.14 to 2.63 | 0.513 | – | ||||
| Asian or Pacific Islander | – | 0.00 | 0.00 to Inf | 0.998 | – | ||||
| Native American | – | 0.00 | 0.00 to Inf | 0.999 | – | ||||
| Other | – | 1.85 | 0.43 to 8.00 | 0.409 | – | ||||
| Complete rotator cuff tear or rupture | – | – | – | ||||||
| Primary osteoarthritis | – | – | – | ||||||
| Osteoporosis | – | – | – | ||||||
| Fracture type | – | – | – | ||||||
| 1-part fracture | – | – | – | ||||||
| 2-part fracture | – | – | – | ||||||
| 3-part fracture | – | – | – | ||||||
| 4-part fracture | – | – | – | ||||||
| AIDSa | – | – | – | ||||||
| Alcohol abuse | – | – | – | ||||||
| Cardiac arrhythmias | – | – | – | ||||||
| Cerebrovascular disease | – | – | – | ||||||
| Chronic blood loss anemia | – | 8.64 | 1.88 to 39.73 | 0.006 | – | ||||
| Chronic pulmonary disease | – | – | 3.30 | 1.31 to 8.35 | 0.012 | ||||
| Coagulopathy | 6.16 | 2.31 to 16.45 | < 0.001 | – | 8.84 | 1.89 to 41.36 | 0.006 | ||
| Congestive heart failure | – | – | – | ||||||
| Deficiency anemia | – | – | – | ||||||
| Dementia | – | – | – | ||||||
| Depression | – | 2.65 | 1.29 to 5.45 | 0.008 | 3.90 | 1.54 to 9.87 | 0.004 | ||
| Diabetes (uncomplicated) | – | – | – | ||||||
| Diabetes with chronic complications | – | – | – | ||||||
| Drug abuse | – | – | – | ||||||
| Fluid and electronic disorders | 3.58 | 2.11 to 6.07 | < 0.001 | – | – | ||||
| Hypertension | – | – | – | ||||||
| Hypothyroidism | – | – | – | ||||||
| Leukemia | – | – | – | ||||||
| Lymphoma | – | – | – | ||||||
| Metastatic cancer | – | – | – | ||||||
| Mild liver disease | – | – | – | ||||||
| Moderate or severe liver disease | – | – | – | ||||||
| Myocardial infarction | – | – | – | ||||||
| Obesity | – | – | – | ||||||
| Other neurological disorders | – | 2.05 | 1.00 to 4.21 | 0.050 | – | ||||
| Paralysis | – | – | – | ||||||
| Peptic ulcer disease | – | – | – | ||||||
| Peripheral vascular disorders | – | – | – | ||||||
| Psychoses | 3.17 | 0.97 to 10.34 | 0.055 | – | – | ||||
| Pulmonary circulation disorders | 18.77 | 9.74 to 36.15 | < 0.001 | – | – | ||||
| RA or CVb | – | – | – | ||||||
| Renal disease | – | – | – | ||||||
| Solid tumor without metastasis | – | – | – | ||||||
| Valvular disease | – | – | – | ||||||
| Weight loss | 2.93 | 1.31 to 6.55 | 0.009 | – | – | ||||
a: acquired immune deficiency syndrome. b: rheumatoid arthritis or collagen vascular diseases. –: Excluded variables by the forward selection of binary logistic regression models
Table 5.
Logistic regression analysis of patient and hospital predictors, fracture characteristics predictors, and comorbidity predictors of those undergoing RSA with major complications, postprocedural pain, or implant–related complications
| Major Complications | Postprocedural Pain | Prosthesis–related Complications | |||||||
|---|---|---|---|---|---|---|---|---|---|
| OR | 95%CI | P value | OR | 95%CI | P value | OR | 95%CI | P value | |
| Age group | – | 0.024 | 0.065 | ||||||
| < 60 | – | – | – | ||||||
| 60 to 74 | – | 1.19 | 0.39 to 3.21 | 0.836 | 26,911,193 | 0.00 to Inf | 0.996 | ||
| ≥ 75 | – | 0.52 | 0.17 to 1.57 | 0.246 | 9,175,139 | 0.00 to Inf | 0.996 | ||
| Female | 0.30 | 0.12 to 0.77 | 0.012 | 3.60 | 0.99 to 10.04 | 0.014 | 0.41 | 0.17 to 0.95 | 0.039 |
| Elective admission | – | 1.87 | 1.04 to 3.34 | 0.036 | – | ||||
| Race | – | – | 0.365 | ||||||
| White | – | – | – | ||||||
| Black | – | – | 0.00 | 0.00 to Inf | 0.998 | ||||
| Hispanic | – | – | 0.00 | 0.00 to Inf | 0.997 | ||||
| Asian or Pacific Islander | – | – | 0.00 | 0.00 to Inf | 0.999 | ||||
| Native American | – | – | 17.77 | 1.58 to 199.70 | 0.020 | ||||
| Other | – | – | 0.00 | 0.00 to Inf | 0.998 | ||||
| Complete rotator cuff tear or rupture | – | – | – | ||||||
| Primary osteoarthritis | – | – | – | ||||||
| Osteoporosis | – | – | – | ||||||
| Fracture type | – | – | 0.001 | ||||||
| 1-part fracture | – | – | – | ||||||
| 2-part fracture | – | – | 0.19 | 0.05 to 0.83 | 0.027 | ||||
| 3-part fracture | – | – | 0.08 | 0.01 to 0.50 | 0.006 | ||||
| 4-part fracture | – | – | 0.05 | 0.01 to 0.23 | < 0.001 | ||||
| AIDSa | – | – | – | ||||||
| Alcohol abuse | – | – | – | ||||||
| Cardiac arrhythmias | – | – | – | ||||||
| Cerebrovascular disease | – | 3.60 | 0.99 to 13.10 | 0.052 | – | ||||
| Chronic blood loss anemia | – | 6.15 | 1.71 to 22.20 | 0.006 | – | ||||
| Chronic pulmonary disease | – | – | – | ||||||
| Coagulopathy | – | – | – | ||||||
| Congestive heart failure | – | – | 6.94 | 2.45 to 17.21 | < 0.001 | ||||
| Deficiency anemia | 3.36 | 1.02 to 11.15 | 0.047 | – | – | ||||
| Dementia | – | – | – | ||||||
| Depression | – | – | – | ||||||
| Diabetes (uncomplicated) | – | – | – | ||||||
| Diabetes with chronic complications | – | – | – | ||||||
| Drug abuse | – | – | – | ||||||
| Fluid and electronic disorders | 5.74 | 2.35 to 14.02 | < 0.001 | – | – | ||||
| Hypertension | – | – | – | ||||||
| Hypothyroidism | – | – | – | ||||||
| Leukemia | – | – | – | ||||||
| Lymphoma | – | – | – | ||||||
| Metastatic cancer | – | – | – | ||||||
| Mild liver disease | – | – | – | ||||||
| Moderate or severe liver disease | – | 5.03 | 0.98 to 25.78 | 0.053 | – | ||||
| Myocardial infarction | – | – | – | ||||||
| Obesity | – | – | – | ||||||
| Other neurological disorders | – | – | – | ||||||
| Paralysis | – | – | – | ||||||
| Peptic ulcer disease | 18.42 | 1.58 to 214.92 | 0.020 | – | – | ||||
| Peripheral vascular disorders | – | – | – | ||||||
| Psychoses | – | – | – | ||||||
| Pulmonary circulation disorders | 18.70 | 6.35 to 55.05 | < 0.001 | – | – | ||||
| RA or CVb | – | – | – | ||||||
| Renal disease | – | – | – | ||||||
| Solid tumor without metastasis | – | – | – | ||||||
| Valvular disease | – | – | – | ||||||
| Weight loss | 4.82 | 1.26 to 18.49 | 0.022 | – | – | ||||
a: acquired immune deficiency syndrome. b: rheumatoid arthritis or collagen vascular diseases. -: Excluded variables by the forward selection of binary logistic regression models
Fig. 4.
Forest plot for regression analysis in complications including major complications (A), postprocedural pain (B), and implant-related complications (C) of patients. (RSA reverse shoulder arthroplasty, ORIF open reduction internal fixation)
Discussion
We conducted a large-scale database study specifically examining the risks associated with treatments of CPHF. A rising trend in the number of annual surgical procedures was observed. Particularly with the widespread use of RSA, ORIF, hemiarthroplasty, and Anatomic total shoulder arthroplasty (ATSA) were partly replaced [1, 2, 4]. Moreover, our study found that RSA was primarily chosen for women elderly who had 4-part fractures. Those patients often underwent elective admissions and had shorter LOS compared to ORIF.
Patients undergoing RSA were older and had a narrower age-bracket than ORIF. This is similar to the research results of Papalia et al. [15]. Given the association of the elderly with more complex displacement CPHF [16], ORIF was more suitable for younger patients who had better bone quality [2]. Passaretti et al. [17] reported that in adults, women commonly experience low-energy fractures following falls due to decreased muscle strength, balance, and gait disorders, with a higher occurrence of 3 or 4-part fractures. Attributed to the higher cost of joint prosthetics and perioperative management, total charges of RSA were higher. However, there was no significant difference in mortality rates despite higher CCI observed in patients undergoing RSA. Moreover, recent studies have indicated that RSA is associated with the lowest revision rate, offering superior shoulder joint function and enhanced cost-effectiveness, thereby establishing it as a valuable option for elderly patients with complex displacement fractures [18–21].
Patients undergoing RSA were more prone to postoperative pain and fewer major complications than ORIF. Significant differences cannot be observed in implant-related complications. Surgical treatments appeared to influence the occurrence of short-term complications, primarily due to the comorbidities [22]. Noguera et al. reported that higher ASA scores in RSA were associated with prosthetic complications, especially in patients who had comorbidities such as rheumatoid arthritis, neurological diseases, or those receiving anticoagulant therapy [23]. Our study found that the RSA group had more elderly with more comorbidities, such as rheumatic disease, neurological disorders, endocrine disease, chronic pulmonary disease, renal disease, and hypertension. Additionally, congestive heart failure (CHF) was a risk factor for implant-related complications in the RSA group. In arthroplasty, CHF patients usually had a high comorbidity index and were more prone to wound dehiscence, periprosthetic joint infection, aseptic loosening, dislocation, and revision [24–26]. Rysinska et al. [27] reported that vascular calcification caused by cardiovascular disease may be related to osteolysis. Compared to 1-part fractures, 3 and 4-part fractures were protective factors for implant-related complications in RSA patients. This revealed one of the important reasons why RSA was more suitable for 3 or 4-part fracture patients, and ORIF was recommended for 1or 2-part fracture patients. Osteoporosis did not seem to increase the incidence of implant-related complications, which is different from the previous belief that osteoporosis in elderly women affects prosthesis-related complications in arthroplasty [28]. Perhaps it is because the shoulder joint was not an entire load-bearing joint such as the hip or knee [29]. Furthermore, Casp et al. [30] reported that osteoporosis was associated with only an increased risk of periprosthetic fracture, and no increased risk of loosening or osteolysis. However, it cannot be inferred higher long-term incidence of implant-related complications with RSA. There was ample evidence that patients undergoing RSA had the lowest revision rate [14, 18, 31], while the revision rate of ORIF was the highest among common surgical treatments for CPHF [32–35]. Also, there is currently no accurate conclusion on postoperative pain. High-quality evidence suggested that ORIF had the poorest control of pain levels compared to other treatments [20]. However, Robinson et al. [36] found satisfactory pain level satisfaction in the long-term outcomes of ORIF patients. Moreover, previous literature suggested that shoulder joint scores of ORIF including the pain and range of motion were significantly better than RSA [31, 34]. Our study found that patients undergoing ORIF had less postoperative pain than RSA during hospitalization. The regression analysis results of postoperative pain showed that elective admission, Black race, and depression were identified as risk factors for patients undergoing ORIF. This can be explained Black race had worse economic situations, nutritional status, and compliance that caused even sharper pain [37, 38]. Selective admission may represent delayed surgery related to ineffective conservative treatment, while depressed patients were more sensitive [39]. We found that chronic blood loss anemia was considered as a risk factor for both groups. Causing chronic pain, prolonged hemorrhage is notable during perioperative management. No more factors were found in RSA, possibly the unique non-anatomical surgical approach resulting in a higher prevalence of postoperative pain [40]. Besides, women served as a protective factor for major complications and postoperative pain, only in ORIF patients. It can be inferred that men undergoing ORIF had more comorbidities such as alcohol abuse, drug abuse, and psychological disorders, which were often associated with more severe traumatic events [41, 42]. We found that coagulopathy and weight loss were considered as risk factors in ORIF. At the same time, fluid and electronic disorders, and pulmonary circulation disorders were identified as risk factors for the major complications in both groups. These findings highlight that elderly patients with CPHF, who often present with multiple comorbidities, are particularly vulnerable to systemic complications following trauma and surgery. For instance, post-traumatic hemorrhage and aggressive fluid resuscitation can exacerbate coagulopathy and electrolyte imbalances, especially in those with pre-existing cardiopulmonary compromise or sarcopenia [43, 44]. Moreover, major trauma induces endothelial injury and prolongs hospitalization, further elevating the risks of deep vein thrombosis and pneumonia [45, 46]. The confluence of these risk factors underscores that the management of CPHF in this frail population extends beyond the surgical technique itself. To mitigate these systemic complications and optimize outcomes for patients undergoing either ORIF or RSA, a proactive, multidisciplinary team approach is warranted. This should involve perioperative optimization by anesthesiologists, comprehensive medical management by geriatricians, and early, coordinated rehabilitation by allied health professionals to provide holistic care throughout the patient’s journey.
We found that RSA patients were elderly who had high CCI, suffering more CRCT, primary osteoarthritis, and osteoporosis. Unexpectedly, CRCT, primary osteoarthritis, and osteoporosis were not considered as risk factors for any short-term complication. Presumably, it is because those factors act on long-term prognosis and improvement in joint function. Previous studies reported that patients undergoing RSA had more complications and adverse events than ORIF [22, 47]. However, there was no significant difference in total complications, indicating better management for RSA with those patients. Furthermore, revision surgeries directly lead to complications. While the present study did not investigate revision rates, it is important to consider their clinical significance, as revision surgeries are associated with substantial patient burden and healthcare costs. Published literature indicates that revision RSA is linked to lower patient satisfaction regarding pain relief, poorer shoulder functional outcomes, shorter implant survivorship, and higher risks of complications compared to primary procedures, alongside increased total hospital costs, more thromboembolic events, and higher mortality rates [48–50]. Given that other studies have reported a higher revision rate for ORIF compared to RSA [51], the potential for RSA to reduce the incidence of revision surgery and its associated sequelae may represent an important consideration in surgical decision-making for specific patient populations.
This study has limitations related to its retrospective design and reliance on administrative data, including the lack of long-term outcomes, potential selection bias, and absence of radiographic details. Nevertheless, the use of a large national sample and recent four-year data enhances the robustness of our findings. Furthermore, our results regarding patient selection patterns and short-term complication profiles appear to align with observations from several contemporary studies, lending support to the clinical relevance of our conclusions within the acknowledged methodological constraints.
Conclusion
Our study provides recommendations for treating CPHF, elucidating indications and differences between ORIF and RSA. RSA may be a considered option for elderly patients with 3- or 4-part fractures and significant comorbidities, as it was associated with fewer major complications and served as a protective factor for implant-related issues. ORIF presents a viable option for 1- or 2-part fractures, given its association with lower postprocedural pain. Appropriate treatment for CPHF patients is needed to reduce complications.
Supplementary Information
Below is the link to the electronic supplementary material.
Acknowledgements
Not applicable.
Abbreviations
- ATSA
Anatomic total shoulder arthroplasty
- CCI
Charlson Comorbidity Index
- CHF
Congestive heart failure
- CPHF
Closed proximal humerus fractures
- CRCT
Complete rotator cuff tear or rupture
- ECI
Elixhauser Comorbidity Index
- HCUP
Healthcare Cost and Utilization Project
- HIPAA
Health Insurance Portability and Accountability Act
- ICD-10-CM
The International Classification of Diseases-10-Clinical Modification
- LOS
Length of stay
- NIS
National Inpatient Sample
- OPHF
Open proximal humerus fractures
- ORIF
Open reduction internal fixation
- PHF
Proximal humerus fractures
- RSA
Reverse shoulder arthroplasty
Author contributions
RK. T., XD. L., MY. K., and YH. C. performed this study, analyzed and interpreted data; RK. T., Y. C., and J. W. designed the study; WQ. T. and MY. K. carried out data collection; RK. T. and YH. C. wrote the manuscript. All authors read and approved the final manuscript.
Funding
Not applicable.
Data availability
Administrative permissions were required to access the raw data employed in this study, and the affiliation of co-author (Jian Wang, Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, Guangdong, 510515, China.) has already granted permission from the Agency for Healthcare Research and Quality (AHRQ) to access Healthcare Cost and Utilization Project (HUCP) Nationwide Databases.The data that support the findings of this study are available from Healthcare Cost and Utilization Project (HUCP) Nationwide Databases but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Healthcare Cost and Utilization Project (HUCP) Nationwide Databases.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rikuan Tong, Xiaodan Li, and Weiquan Tan have contributed equally to this work.
Yuhang Chen, Manyuan Kuang, Yang Chen and Jian Wang contributed equally to this work.
References
- 1.McLean AS, Price N, Graves S, Hatton A, Taylor FJ. Nationwide trends in management of proximal humeral fractures: an analysis of 77,966 cases from 2008 to 2017. J Shoulder Elbow Surg. 2019;28(11):2072–8. 10.1016/j.jse.2019.03.034. [DOI] [PubMed] [Google Scholar]
- 2.Klug A, Gramlich Y, Wincheringer D, Schmidt-Horlohe K, Hoffmann R. Trends in surgical management of proximal humeral fractures in adults: a nationwide study of records in Germany from 2007 to 2016. Arch Orthop Trauma Surg. 2019;139(12):1713–21. 10.1007/s00402-019-03252-1. [DOI] [PubMed] [Google Scholar]
- 3.Dixit A, Cautela FS, Cooper CS, et al. ORIF versus arthroplasty for open proximal humerus fractures: nationwide inpatient sample data between 1998 and 2013. J Orthop Traumatol. 2018;19(1):12. 10.1186/s10195-018-0503-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Brorson S, Viberg B, Gundtoft P, Jalal B, Ohrt-Nissen S. Epidemiology and trends in management of acute proximal humeral fractures in adults: an observational study of 137,436 cases from the Danish National patient Register, 1996–2018. Acta Orthop. 2022;93:750–5. 10.2340/17453674.2022.4578. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Martinez-Catalan N. Conservative treatment of proximal humerus fractures: when, how, and what to expect. Curr Rev Musculoskelet Med. 2023;16(2):75–84. 10.1007/s12178-022-09817-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Soler-Peiro M, Garcia-Martinez L, Aguilella L, Perez-Bermejo M. Conservative treatment of 3-part and 4-part proximal humeral fractures: a systematic review. J Orthop Surg Res. 2020;15(1):347. 10.1186/s13018-020-01880-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Lowry V, Bureau NJ, Desmeules F, Roy JS, Rouleau DM. Acute proximal humeral fractures in adults. J Hand Ther. 2017;30(2):158–66. 10.1016/j.jht.2017.05.005. [DOI] [PubMed] [Google Scholar]
- 8.Handoll H, Brealey S, Rangan A, et al. Protocol for the profher (PROximal fracture of the humerus: evaluation by randomisation) trial: a pragmatic multi-centre randomised controlled trial of surgical versus non-surgical treatment for proximal fracture of the humerus in adults. BMC Musculoskelet Disord. 2009;10:140. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Misra A, Kapur R, Maffulli N. Complex proximal humeral fractures in adults–a systematic review of management. Injury. 2001;32(5):363–72. 10.1016/s0020-1383(00)00242-4. [DOI] [PubMed] [Google Scholar]
- 10.Sinkler MA, Moyal AJ, Adelstein JM, et al. Acute reverse total shoulder arthroplasty versus internal fixation for 3- and 4- part proximal humerus fractures: a propensity matched analysis of 5466 elderly patients. Injury. 2025;56(10):112624. 10.1016/j.injury.2025.112624. [DOI] [PubMed] [Google Scholar]
- 11.Miquel J, Cassart E, Santana F, et al. Reverse shoulder arthroplasty or nothing for patients with displaced proximal humeral fractures: a randomized controlled trial. J Shoulder Elb Surg. 2024;33(10):2187–95. 10.1016/j.jse.2024.02.023. [DOI] [PubMed] [Google Scholar]
- 12.Fraser AN, Bjørdal J, Wagle TM, et al. Reverse shoulder arthroplasty is superior to plate fixation at 2 years for displaced proximal humeral fractures in the elderly: a multicenter randomized controlled trial. J Bone Joint Surg Am. 2020;102(6):477–85. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Joshi T, Calem D, Ogilvie D, et al. Proximal humerus fractures: National treatment trends with associated 30- and 90-day readmission rates. Injury. 2025;56(11):112690. 10.1016/j.injury.2025.112690. [DOI] [PubMed] [Google Scholar]
- 14.Critchley O, McLean A, Page R, et al. Reverse total shoulder arthroplasty compared to stemmed hemiarthroplasty for proximal humeral fractures: a registry analysis of 5946 patients. J Shoulder Elb Surg. 2020;29(12):2538–47. 10.1016/j.jse.2020.04.005. [DOI] [PubMed] [Google Scholar]
- 15.Papalia AG, Romeo PV, Kingery MT, et al. Trends in the treatment of proximal humerus fractures from 2010 to 2020. J Shoulder Elb Surg. 2024;33(2):e49–57. 10.1016/j.jse.2023.07.038. [DOI] [PubMed] [Google Scholar]
- 16.Boadi BI, Belayneh R, Littlefield CP, Egol KA. Patient obesity is associated with severity of proximal humerus fractures, not outcomes. Arch Orthop Trauma Surg. 2022;143(1):373–9. 10.1007/s00402-022-04338-z. [DOI] [PubMed] [Google Scholar]
- 17.Passaretti D, Candela V, Sessa P, Gumina S. Epidemiology of proximal humeral fractures: a detailed survey of 711 patients in a metropolitan area. J Shoulder Elb Surg. 2017;26(12):2117–24. 10.1016/j.jse.2017.05.029. [DOI] [PubMed] [Google Scholar]
- 18.Jonsson EÖ, Ekholm C, Salomonsson B, et al. Reverse total shoulder arthroplasty provides better shoulder function than hemiarthroplasty for displaced 3- and 4-part proximal humeral fractures in patients aged 70 years or older: a multicenter randomized controlled trial. J Shoulder Elbow Surg. 2021;30(5):994–1006. 10.1016/j.jse.2020.10.037. [DOI] [PubMed] [Google Scholar]
- 19.Osterhoff G, O’Hara NN, D’Cruz J, et al. A cost-effectiveness analysis of reverse total shoulder arthroplasty versus hemiarthroplasty for the management of complex proximal humeral fractures in the elderly. Value Health. 2017;20(3):404–11. 10.1016/j.jval.2016.10.017. [DOI] [PubMed] [Google Scholar]
- 20.Du S, Ye J, Chen H, Li X, Lin Q. Interventions for treating 3- or 4-part proximal humeral fractures in elderly patient: a network meta-analysis of randomized controlled trials. Int J Surg. 2017;48:240–6. 10.1016/j.ijsu.2017.09.002. [DOI] [PubMed] [Google Scholar]
- 21.Migliorini F, Sammaria G, Schäfer L, Memminger M, Simeone F, Maffulli N. Reverse arthroplasty compared to hemiarthroplasty and open reduction and internal fixation for displaced proximal humerus fracture in patients above 60: a bayesian network meta-analysis. Arch Orthop Trauma Surg. 2025;145(1):481. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Cvetanovich GL, Chalmers PN, Verma NN, Nicholson GP, Romeo AA. Open reduction internal fixation has fewer short-term complications than shoulder arthroplasty for proximal humeral fractures. J Shoulder Elb Surg. 2016;25(4):624–e313. 10.1016/j.jse.2015.09.011. [DOI] [PubMed] [Google Scholar]
- 23.Noguera L, Trigo L, Melero V, Santana F, Torrens C. Reverse shoulder arthroplasty for acute proximal humeral fractures: postoperative complications at 7 days, 90 days and 1 year. Injury. 2019;50(2):371–5. 10.1016/j.injury.2019.01.002. [DOI] [PubMed] [Google Scholar]
- 24.Curtis GL, Newman JM, George J, Klika AK, Barsoum WK, Higuera CA. Perioperative outcomes and complications in patients with heart failure following total knee arthroplasty. J Arthroplasty. 2018;33(1):36–40. 10.1016/j.arth.2017.07.043. [DOI] [PubMed] [Google Scholar]
- 25.Rodriguez-Merchan EC, Delgado-Martinez AD. Risk factors for periprosthetic joint infection after primary total knee arthroplasty. J Clin Med. 2022;11(20). 10.3390/jcm11206128. [DOI] [PMC free article] [PubMed]
- 26.Sequeira SB, Boucher HR. Heart failure is associated with early medical and surgery-related complications following total hip arthroplasty: a propensity-scored analysis. J Arthroplasty. 2023;38(5):868–72. 10.1016/j.arth.2022.11.009. e4. [DOI] [PubMed] [Google Scholar]
- 27.Rysinska A, Skoldenberg O, Garland A, et al. Aseptic loosening after total hip arthroplasty and the risk of cardiovascular disease: a nested case-control study. PLoS ONE. 2018;13(11):e0204391. 10.1371/journal.pone.0204391. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Harris AB, Lantieri MA, Agarwal AR, Golladay GJ, Thakkar SC. Osteoporosis and total knee arthroplasty: higher 5-year implant-related complications. J Arthroplasty. 2024;39(4):948 – 53 e1. 10.1016/j.arth.2023.10.045 [DOI] [PubMed]
- 29.Hollensteiner M, Sandriesser S, Bliven E, von Rüden C, Augat P. Biomechanics of osteoporotic fracture fixation. Curr Osteoporos Rep. 2019;17(6):363–74. 10.1007/s11914-019-00535-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Casp AJ, Montgomery SR Jr., Cancienne JM, Brockmeier SF, Werner BC. Osteoporosis and Implant-Related complications after anatomic and reverse total shoulder arthroplasty. J Am Acad Orthop Surg. 2020;28(3):121–7. 10.5435/JAAOS-D-18-00537. [DOI] [PubMed] [Google Scholar]
- 31.Davey MS, Hurley ET, Anil U, et al. Management options for proximal humerus fractures - a systematic review and network meta-analysis of randomized control trials. Injury. 2022;53(2):244–9. 10.1016/j.injury.2021.12.022. [DOI] [PubMed] [Google Scholar]
- 32.Yahuaca BI, Simon P, Christmas KN, et al. Acute surgical management of proximal humerus fractures: ORIF vs. hemiarthroplasty vs. reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2020;29(7):S32–40. 10.1016/j.jse.2019.10.012. [DOI] [PubMed] [Google Scholar]
- 33.Nazarian A, Chen L, Xing F, Xiang Z. Effectiveness and safety of interventions for treating adults with displaced proximal humeral fracture: A network Meta-Analysis and systematic review. PLoS ONE. 2016;11(11). 10.1371/journal.pone.0166801. [DOI] [PMC free article] [PubMed]
- 34.Pizzo RA, Gianakos AL, Haring RS, et al. Are arthroplasty procedures really better in the treatment of complex proximal humerus fractures? A comprehensive meta-analysis and systematic review. J Orthop Trauma. 2021;35(3):111–9. 10.1097/bot.0000000000001926. [DOI] [PubMed] [Google Scholar]
- 35.Gupta AK, Harris JD, Erickson BJ, et al. Surgical management of complex proximal humerus fractures-a systematic review of 92 studies including 4500 patients. J Orthop Trauma. 2015;29(1):54–9. 10.1097/bot.0000000000000229. [DOI] [PubMed] [Google Scholar]
- 36.Robinson CM, Stirling PHC, Goudie EB, MacDonald DJ, Strelzow JA. Complications and long-term outcomes of open reduction and plate fixation of proximal humeral fractures. J Bone Joint Surg Am. 2019;101(23):2129–39. 10.2106/JBJS.19.00595. [DOI] [PubMed] [Google Scholar]
- 37.Jella TK, Cwalina TB, Schmidt JE, Wu VS, Yong TM, Vallier HA. Do patients reporting fractures experience food insecurity more frequently than the general population? Clin Orthop Relat Res. 2023;481(5):849–58. 10.1097/CORR.0000000000002514. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Root KT, Burnett AJ, Kakalecik J, et al. The association between race and extended length of stay in Low-energy proximal humerus fractures in elderly patients. J Am Acad Orthop Surg. 2024. 10.5435/jaaos-d-23-00925. [DOI] [PubMed] [Google Scholar]
- 39.Al Salman A, Shah R, Thomas JE, et al. Symptoms of depression and catastrophic thinking attenuate the relationship of pain intensity and magnitude of incapability with fracture severity. J Psychosom Res. 2022;158:110915. 10.1016/j.jpsychores.2022.110915. [DOI] [PubMed] [Google Scholar]
- 40.Goetti P, Denard PJ, Collin P, Ibrahim M, Mazzolari A, Ladermann A. Biomechanics of anatomic and reverse shoulder arthroplasty. EFORT Open Rev. 2021;6(10):918–31. 10.1302/2058-5241.6.210014. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Els C, Jackson TD, Milen MT, et al. Random drug and alcohol testing for preventing injury in workers. Cochrane Database Syst Rev. 2020;12(12):CD012921. 10.1002/14651858.CD012921.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.De La Vega D, Giner L, Courtet P. Suicidality in subjects with anxiety or obsessive-compulsive and related disorders: recent advances. Curr Psychiatry Rep. 2018;20(4):26. 10.1007/s11920-018-0885-z. [DOI] [PubMed] [Google Scholar]
- 43.Padrón-Monedero A, López-Cuadrado T, Galán I, Martínez-Sánchez EV, Martin P, Fernández-Cuenca R. Effect of comorbidities on the association between age and hospital mortality after fall-related hip fracture in elderly patients. Osteoporos Int. 2017;28(5):1559–68. 10.1007/s00198-017-3926-2. [DOI] [PubMed] [Google Scholar]
- 44.Eneroth M, Olsson UB, Thorngren KG. Nutritional supplementation decreases hip fracture-related complications. Clin Orthop Relat Res. 2006;451:212–7. 10.1097/01.blo.0000224054.86625.06. [DOI] [PubMed] [Google Scholar]
- 45.Pastori D, Cormaci VM, Marucci S, et al. A comprehensive review of risk factors for venous thromboembolism: from epidemiology to pathophysiology. Int J Mol Sci. 2023;24(4). 10.3390/ijms24043169. [DOI] [PMC free article] [PubMed]
- 46.Zang K, Chen B, Wang M, et al. The effect of early mobilization in critically ill patients: a meta-analysis. Nurs Crit Care. 2020;25(6):360–7. 10.1111/nicc.12455. [DOI] [PubMed] [Google Scholar]
- 47.Köppe J, Stolberg-Stolberg J, Rischen R, Faldum A, Raschke MJ, Katthagen JC. In-hospital complications are more likely to occur after reverse shoulder arthroplasty than after locked plating for proximal humeral fractures. Clin Orthop Relat Res. 2021;479(10):2284–92. 10.1097/corr.0000000000001776. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48.Chalmers PN, Boileau P, Romeo AA, Tashjian RZ. Revision reverse shoulder arthroplasty. J Am Acad Orthop Surg. 2019;27(12):426–36. doi:10.5435/JAAOS-D-17-00535. [DOI] [PubMed] [Google Scholar]
- 49.Colasanti CA, Anil U, Adams J, et al. Primary versus conversion reverse total shoulder arthroplasty for complex proximal humeral fractures in elderly patients: a retrospective comparative study. J Shoulder Elb Surg. 2023;32(8):e396–407. 10.1016/j.jse.2023.01.019. [DOI] [PubMed] [Google Scholar]
- 50.Koeppe J, Stolberg-Stolberg J, Rischen R, et al. Increased complication rates of salvage reverse total shoulder arthroplasty (RTSA) after failed locked plate fixation compared with primary RTSA in the treatment of proximal humeral fractures in elderly patients. J Shoulder Elb Surg. 2023;32(8):1574–83. 10.1016/j.jse.2022.12.020. [DOI] [PubMed] [Google Scholar]
- 51.Nowak LL, Hall J, McKee MD, Schemitsch EH. A higher reoperation rate following arthroplasty for failed fixation versus primary arthroplasty for the treatment of proximal humeral fractures: a retrospective population-based study. Bone Joint J. 2019;101–B(10):1272–9. 10.1302/0301-620x.101b10.Bjj-2019-0142.R2. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Administrative permissions were required to access the raw data employed in this study, and the affiliation of co-author (Jian Wang, Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue, Guangzhou, Guangdong, 510515, China.) has already granted permission from the Agency for Healthcare Research and Quality (AHRQ) to access Healthcare Cost and Utilization Project (HUCP) Nationwide Databases.The data that support the findings of this study are available from Healthcare Cost and Utilization Project (HUCP) Nationwide Databases but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Healthcare Cost and Utilization Project (HUCP) Nationwide Databases.