J Shoulder Elbow Surg (2017) 26, 3641

www.elsevier.com/locate/ymse

Does grafting of the tuberosities improve the

functional outcomes of proximal humeral fractures
treated with reverse shoulder arthroplasty?
Gokcer Uzer, MDa, Fatih Yildiz, MDa, Suat Batar, MDa, Ruwais Binlaksar, MDb,
Mehmet Elmadag, MDa, Gamze Kus, Msc Ptc, Kerem Bilsel, MD, FEBOTa,*
a

Department of Orthopedics and Traumatology, Bezmialem Vakif University School of Medicine, Istanbul, Turkey
Department of Orthopedics and Traumatology, Binzeela Modern Hospital, Sieyun, Hadramout, Yemen
c
Faculty of Health Science, Division of Physiotherapy and Rehabilitation, Istanbul University, Istanbul, Turkey
b

Background: Functional outcomes of reverse total shoulder arthroplasty (rTSA) can be improved by fixation of the tuberosities. This study compares clinical and radiologic results of patients with comminuted
proximal humeral fractures treated with rTSA, with and without autologous grafting.
Methods: Thirty-three patients with proximal humeral fractures were treated with rTSA and tuberosity
fixation. In 18 patients (group I; mean age, 75 years), tuberosity fixation was augmented with autografting;
in 15 patients (group II; mean age, 71 years), graft augmentation was not used. The mean follow-up was
16.7 (range, 12-24) months in group I and 16.8 (range, 12-25) months in group II.
Results: Radiologic tuberosity union was achieved in 14 of 18 (77.8%) patients who underwent autograft augmentation and in 6 of 15 (40.0%) patients treated without autografting. The mean American Shoulder
and Elbow Surgeons (ASES) score was 69.6 13.0 in group I and 51.0 20.0 in group II. The mean Disabilities of the Arm, Shoulder, and Hand (DASH) score was 31.9 24.0 in group I and 58.2 24.6 in group
II. A significant difference was detected between groups for ASES and DASH scores. Among shoulder
range of motion measures, only forward flexion differed significantly between groups I and II (124 23
vs. 98 30, respectively). External rotation muscle strength was significantly higher in group I
(3.36 1.46 kg) than in group II (2.39 2.00 kg).
Conclusion: In the treatment of complex proximal humeral fractures in elderly patients by rTSA, cancellous block autograft augmentation can increase the rate of tuberosity union and improve functional outcomes.
Level of evidence: Level III; Retrospective Cohort Design; Treatment Study
2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
Keywords: Three-four parts proximal humeral fracture; reverse total shoulder arthroplasty; tuberosity fixation;
autografting; tuberosity healing; graft

The Institutional Review Board of Bezmialem Vakif University, Department of Orthopedics and Traumatology, approved this study: 23.07.2015, 10-2.
*Reprint requests: Kerem Bilsel, MD, FEBOT, Bezmialem Vakif University, Department of Orthopedics and Traumatology, Vatan Cd. Fatih, 34093 Istanbul,
Turkey.
E-mail address: kbilsel@gmail.com (K. Bilsel).
1058-2746/$ - see front matter 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.
http://dx.doi.org/10.1016/j.jse.2016.05.005

Tuberosity grafting in reverse shoulder arthroplasty

Proximal humeral fractures (PHFs) account for about 7%
of all fractures and 80% of humeral fractures. In patients aged
>65 years, PHF is the second most common upper extremity fracture and the third most common nonvertebral
osteoporotic fracture, after proximal femoral and distal radial
fractures. PHFs account for about 10% of fractures in this
population of patients, with a male to female ratio of 1:2.
Overall, patients with PHFs are more fit than those with proximal femoral fractures but less fit than those with distal radial
fractures.21
The treatment of comminuted PHFs in older patients
remains difficult. Although hemiarthroplasty, which was first
proposed by Neer, seems to be a standard treatment method
for this fracture type, nonunion of the tuberosities may
result in dysfunction of the rotator cuff (RC), erosion of the
glenoid, and restriction of range of motion (ROM) in the
shoulder.3,4,7,11,14-17,20 Initially, reverse total shoulder arthroplasty (rTSA) was chosen by many authors as a good
alternative to hemiarthroplasty because its functional results
are not directly related to healing of the tuberosities or function of the RC, which is likely to be impaired because of
increased degeneration with advanced age.1,20 However, after
the treatment of a comminuted PHF with rTSA, the main clinical and functional problems were still the scapular notching
and the restriction of internal or external rotation motion and
strength and forward flexion due to the lack of tuberosity
healing.2,8,10 Although union of the tuberosities and function
of the RC are not as important in patients treated with rTSA
compared with patients who have undergone hemiarthroplasty,
any tuberosity healing improves external and internal rotation movement, external rotation muscle strength, and forward
flexion.2,13
The purpose of this retrospective study was to compare
the clinical and radiologic results in a cohort of patients aged
65 years with 3- and 4-part displacement PHFs treated with
rTSA with and without autologous bone block grafting. The
effects of bone grafting on tuberosity healing and outcomes
were also investigated.

37

Surgical technique
All patients underwent surgery on a standard operative table in the
beach chair position under general anesthesia. Each fracture was approached through a deltopectoral incision, and the humeral head was
resected between the tuberosities. The glenoid and humerus were
reamed and prepared for implant fixation using appropriate surgical instruments. After cementless fixation of the glenoid component,
a humeral component (Delta Xtend; DePuy Synthes, Warsaw, IN,
USA) of the appropriate size was fixed using cement with about 20
retroversion. In group I, the chondral surface of the resected humeral
head was removed to create a cancellous autologous block graft
(Fig. 1). Its fractured surface was deepened to improve its placement on the proximal ridge of the humeral component, and 1 hole
on each end was created using a 2.7-mm drill bit (Fig. 2, A). A No.
5 Ethibond suture (Ethicon, Somerville, NJ, USA) was passed through
these holes to fix the graft to the tuberosities and the component
(Fig. 2, B). The intramedullary canal was reamed to create the best
dimensions for the humeral component. Before insertion of the
humeral component, three 2.7-mm holes were created on the anterior and lateral cortices, about 2 cm distal to the fracture, and a No.
5 Ethibond suture was passed through each hole. After insertion of
a distal plaque and bone cement into the canal, the humeral component was placed with about 20 retroversion. Excess bone cement
was removed from the cortical holes using a Kirschner wire to allow
movement of the Ethibond sutures, and cement near the fracture line
was removed to prevent interposition and thermal damage, which
can increase the risk of nonunion of the tuberosities. The cancellous block autograft was placed over the posterior portion of the
humeral component, and the tuberosities were placed over the graft.
The tuberosities were fixed to the humeral component and the proximal humerus through the previously created holes using Ethibond
sutures and the vertical and horizontal cerclage techniques (Fig. 2,
C). In group II, no graft was used. The tuberosities were fixed to
the stem and the metaphysis or proximal diaphysis of the humerus.
For the first 2 postoperative weeks, patients were allowed to
perform only isometric deltoid exercises using a 30 abduction sling.

Materials and methods

Between November 2013 and January 2015, 59 patients aged
65 years with 3- and 4-part PHFs were treated surgically in our
clinic. Patients files and the hospitals digital database were reviewed retrospectively, and patients with neoplastic pathologic
fractures, rheumatoid comorbidity, or cognitive dysfunction as well
as those who had been treated with primary fixation or
hemiarthroplasty were excluded. In total, 33 patients who had undergone rTSA and been observed for at least 12 months were included
in the study. According to Neers system, PHFs in 7 patients were
classified as type 3 and those in 26 patients were classified as type
4. The mechanism of fracture was a simple fall in all patients. Eighteen patients (7 men and 11 women) with a mean age of 75 (range,
65-82) years who were treated with tuberosity fixation using
autografting were included in group I, and 15 patients (5 men and
10 women) with a mean age of 71 (range, 65-82) years who were
treated without autografting were included in group II.

Figure 1

Preparation of the autograft from the humeral head.

38

G. Uzer et al.

Figure 2 Inner side of the graft was deepened for better fit to the stem and templating before implantation (A), the graft was attached
after the humeral stem insertion (B), and the tuberosities were placed over the graft and fixed using horizontal and vertical cerclage suturing
technique (C).
At 2 to 4 weeks postoperatively, passive ROM and pendulum exercises were initiated. After 4 weeks, active ROM was permitted.
Radiographic examinations were performed using direct radiography and computed tomography, which was performed at the 12month follow-up to evaluate union of the tuberosities, scapular
notching, loosening of the components, and component positions
by 2 shoulder surgeons. Functional results were evaluated using the
Constant score; Disabilities of the Arm, Shoulder, and Hand (DASH)
score; American Shoulder and Elbow Surgeons (ASES) score; and
active and passive ROM, measured with a goniometer. Muscle
strength of the shoulder in forward flexion, abduction, and internal
and external rotation was also measured using a dynamometer
(Manual Muscle Testing System; Lafayette Instrument Co, Lafayette, IN, USA).
The results in groups I and II were compared using the 2 test
and the Mann-Whitney U test. The level of significance was defined
as P = .05.

Results
The mean ages of patients in groups I and II were similar (74
and 71 years, respectively; P = .138). The mean postoperative follow-up periods were 16.7 (range, 12-24) months in
group I and 16.8 (range, 12-25) months in group II, with no
significant difference between groups (P = .961). Radiologic tuberosity union was achieved in 14 of 18 patients treated

with autograft augmentation and 6 of 15 patients treated

without autografts (Fig. 3). The rate of tuberosity union was
significantly higher in group I than in group II (P = .048). The
mean ASES score was significantly higher in group I
(69.6 13.0 [range, 43.3-83.3]) than in group II (51.0 20.0
[range, 11.6-85.0]; P = .008). The mean DASH scores were
31.9 24.0 (range, 4.0-88.0) in group I and 58.2 24.6 (range,
12.0-60.0) in group II (P = .005). Mean Constant scores did
not differ significantly between group I (44.0 20.8 [range,
12.0-78.0]) and group II (34.5 16.8 [range, 12.0-60.0];
P = .309). Among shoulder ROM measures, only forward
flexion differed significantly between groups I and II
(125 23 vs. 99 31, respectively; P = .015; Table I;
Fig. 4). External rotation muscle strength was significantly
greater in group I (3.36 1.46 kg) than in group II
(2.39 2.00 kg; P = .027) Forward flexion and abduction
muscle strength did not differ significantly between groups
(P = .080 and P = .089, respectively).
Superficial surgical site infection was observed and treated
with antibiotherapy in 1 patient in group I. In group II, asymptomatic Sirveaux type III scapular notching was observed
in 1 patient; periprosthetic fracture at the level of the distal
tip of the humeral stem occurred in 1 patient and was treated
with fibular strut autograft augmentation and fixation with a
4.5-mm limited-contact dynamic compression plate; and

Figure 3 Preoperative anteroposterior radiograph of a comminuted proximal humeral fracture of an 82-year-old woman (A). Complete
unions of the tuberosities are shown on the radiograph (B) and computed tomography scan (C) of the same patient 1 year postoperatively.

Tuberosity grafting in reverse shoulder arthroplasty

Table I

39

Patient demographics and clinical results in both groups

Variable

Group I

Age (years)
Sex
Male
Female
Comorbidities (No. of patients)
Operated shoulders
Right
Left
Follow-up (months)
Tuberosity healing
Range of motion
Forward flexion
Abduction
Active external rotation
Active internal rotation
Forward flexion strength (kg)
External rotation strength (kg)
ASES score
DASH score
Constant score

Group II

74 (range, 65-82)

71 (range, 65-82)

P value
.138

7 (39%)
11 (61%)
S (2), DM (8), CVD (9), HT (18), HL (4)

5 (33%)
10 (67%)
S (1), DM (9), CVD (6), HT (11), HL (2)

11 (61%)
7 (39%)
16.7 4.8
14/18 (77.8%)

5 (49%)
10 (51%)
16.8 5.3
6/15 (40%)

.758
.048

125 23
96 24
49 23
44 15
2.7 1.5
3.3 1.4
69.6 12.9
31.9 24
44 20.8

99 31
85 21
34 27
37 18
1.9 2.1
2.3 2
51 20
58.2 24.6
34.5 16.8

.015
.118
.119
.237
.080
.027
.008
.005
.309

S, smoking; DM, diabetes mellitus; CVD, cardiovascular disease; HT, hypertension; HL, hyperlipidemia; ASES, American Shoulder and Elbow Surgeons; DASH,
Disabilities of the Arm, Shoulder, and Hand.
Bold values indicate stastical significance of P < .05.

periprosthetic infection with isolated methicillin-resistant

Staphylococcus aureus occurred in 1 patient who had undergone 2-stage revision. Early aseptic humeral stem loosening
in 1 patient in group II was treated with humeral component revision.

Discussion
In the treatment of PHFs in patients aged >65 years with rTSA,
the main goals are to obtain increased forward flexion and
to relieve pain. Forward flexion range and functional results
are independent of tuberosity healing, but the results of rTSA

Figure 4

are reportedly superior to those of hemiarthroplasty when tuberosity union is achieved.9,15

The appropriate fixation of the tuberosities in their anatomic positions and tuberosity union are thought to be
predictors of postoperative RC function and the functional
results of surgical treatment.9,12 Gallinet et al9 reported that
anatomic fixation of the tuberosities over the prosthesis
significantly improved rotational functions of the shoulder
and, conversely, that nonunion worsens the functional results.
Although the reported tuberosity healing rates of grafted
and nongrafted rTSA for the treatment of PHFs range from
47% to 100% (overall 72%),8-10,13,20 in a prospective review
of Bufquin et al,5 43 patients were treated with the same

Clinical results of the patient in Fig. 3 1 year after the surgery.

40
type of prosthesis without grafting that was used in our
series, and the union rate was found to be 47%, similar to
our rate of 40% for the nongrafting group. To increase the
tuberosity union rate, the use of biologic (autografts) and
nonbiologic (patient-specific implants and trabecular metals)
materials has been suggested.8,13,19 A bone graft can act as a
shield to prevent cement-related thermal necrosis effects on
the tuberosity, and it can also enhance bone healing.8 Levy
and Badman13 used a similar autografting technique in their
series, and they reported that autografts increased the tuberosity union rate (union occurred in 86% of patients) by
increasing the surface contact area for the tuberosities. They
reported a mean forward flexion of 117 (range, 95-150),
mean external rotation of 19 (range, 0-30), and mean
external rotation strength of 5/5. Formaini et al8 used the
black-and-tan technique for rTSA and detected tuberosity
union in 88% of patients; mean follow-up forward flexion
was 117 23, external rotation was 29 18, and external rotation strength was 4.9 0.2 points by Oxford scale.
Russo et al19 compared the use of allografts (placed using
Breems technique) and autografts (placed using the bone
collar and tie technique) for bone grafting and tuberosity
fixation in rTSA and found that the autograft group had
greater mean forward flexion (160 vs. 125) and external
rotation (55 vs. 25). In our study, tuberosity union was
observed in 14 of 18 patients in group I and 6 of 15 patients
in group II. The lower union rate in patients treated without
grafting is likely due to tuberosity osteolysis. The range of
forward flexion was greater in group I (125 23) than in
group II (99 31). The range of flexion in the graft group
was higher than reported in 2 similar articles but lower than
that reported by Russo et al.18 Our patients treated without
grafting had less forward flexion than reported previously
(122).2
The mean active external rotation range in our patients
treated with grafts (49 23) was similar to that reported
by Russo et al18 and greater than that observed in group II
(34 27) and reported in the literature (32).2,19 Mean external rotation strength was greater in group I (3.36 1.40 kg)
than in group II (2.39 2.00 kg). We measured muscle strength
using a dynamometer to obtain objective results, whereas different methods (eg, 5-point Oxford scale) have been used in
other studies of grafting and muscle strength, which may affect
the comparability of the results.
In this study, the DASH and ASES scores improved significantly in group I compared with group II. The mean ASES
score in group I (69.6) was similar to that reported by Formaini
et al8 (71.0) but lower than that reported by Levy and Badman13
(86.3), who used a similar grafting technique. Although this
difference is minimal, it may be due to the inclusion of fewer
patients in the previous study.
The most common complications related to rTSA are
scapular notching (32%), heterotopic ossification, dislocation, periprosthetic infection, humeral bone loss, and
loosening of the glenoid component.2,6 Asymptomatic Sirveaux
grade III scapular notching without glenoid component

G. Uzer et al.
loosening was observed in 1 patient in group II in this
study. Patients advanced age and sedentary lifestyles as
well as short follow-up durations may explain the low frequency of scapular notching in our study. The reported
rates of periprosthetic infection after rTSA and revision for
this reason are 2.9% and 1.2%, respectively.2 In our series,
1 patient underwent 2-stage revision because of infection,
and 1 patient underwent this procedure because of aseptic
loosening of the humeral component. No dislocation or
heterotopic ossification was observed in our patients. Although there was a significant difference in the number of
complications between the 2 groups, which may have an
effect on the outcomes, there were still significant differences in the mean forward flexion (P = .029), external rotation
strength (P = .050), ASES score (P = .025), and DASH score
(P = .018) in comparing the 2 groups without the patients
with complications.
The limitations of this study are the inclusion of a small
number of patients, the relatively short follow-up duration,
the retrospective study design, and not using the fracture
humeral stem.

Conclusion
In the treatment of comminuted PHFs in patients aged >65
years, cancellous block autograft augmentation using the
resected humeral head can increase the rate of tuberosity
union and improve the functional results. Further prospective randomized studies are warranted to investigate
the effect of grafting and tuberosity healing on the functional outcomes.

Disclaimer
The authors, their immediate families, and any research
foundations with which they are affiliated have not received any financial payments or other benefits from
any commercial entity related to the subject of this
article.

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