Higher primary stability of tuberosity fixation in reverse fracture arthroplasty with 135° than with 155° humeral inclination

Background: Proximal humeral fractures in elderly patients are frequently treated with reverse total shoulder arthroplasty, and tuberosity healing improves clinical outcome and patient satisfaction. So far reverse prostheses with different humeral inclination (HI) angles have been used. However, it has not been investigated yet if the HI angle affects the primary stability of the tuberosity fixation in primary reverse total shoulder arthroplasty for proximal humeral fractures in a biomechanical setting. Methods: A 4-part fracture was created in 7-paired human cadaver proximal humeri after preceding power analysis. After randomization in a pairwise fashion, reverse prostheses with either 135 degrees (n = 7) or 155 degrees (n = 7) were implanted. The tuberosities were reduced anatomically to the metaphysic of the prostheses and were fixed with 3 suture cerclages in a standardized technique. Tightening was performed with a cerclage tension device with 50 Newton meter (N m). Before biomechanical testing, the initial vertical and horizontal gap formation was measured. The humeri were placed in a custom-made test setup enabling internal and external rotation. Cyclic loading with a gradually increasing load magnitude was applied with a material testing machine starting with 20 N in and increasing by 5 N m after each 100th cycle until failure (>15 degrees rotation of the tuberosities). Any motion of the tuberosities was measured with a 3-dimensional camera system. Results: Overall, the 155 degrees group reached an average of 1460 +/- 270 cycles and the 135 degrees group of 1900 +/- 271 cycles (P = .048) . In contrast to the 135 degrees group, in the 155' group, a mean initial vertical (03 +/- 0.7 mm) and horizontal (2.7 +/- 3.3 mm) gap formation could be observed before cyclic loading. After 1100 cycles, the 155 degrees group showed increased rotation of both lesser and greater tuberosities in all 3 axes around the humeral shaft compared with the 135 degrees group. Conclusion: Primary stability of the reattached tuberosities is significantly increased, whereas rotational movements are decreased in prostheses with an anatomic HI of 135 degrees compared with a 155 degrees HI according to the original Grammont design. In addition, a 135 degrees HI allows an exact anatomic reposition of the tuberosities, whereas this was not possible for the 155 degrees design. However, transferability and clinical relevance of these biomechanical results have to be verified with clinical studies. (C) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.