J Shoulder Elbow Surg (2014) 23, e222
www.elsevier.com/locate/ymse
Author reply: Reverse total shoulder for acute proximal humeral fracture: comparison to open reduction–internal fixation and hemiarthroplasty In Reply: We thank you for the opportunity to reply to the comments on our paper entitled ‘‘Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction–internal fixation and hemiarthroplasty,’’1 and we are grateful to the authors of the letter for their interest in our study. We agree that further research is necessary with larger patient cohorts and longer follow-up, ideally in a prospective randomized fashion. As with any nonrandomized retrospective analysis, our study is subject to considerable bias, which is detailed in the limitations section of the article and which we believe precludes us from concluding on the basis of these findings with a high degree of certainty that reverse total shoulder arthroplasty (RTSA) is a better treatment for three- and four-part proximal humeral fractures than open reduction and internal fixation (ORIF) or hemiarthroplasty (HA). As the authors of the letter mention, one of the measured biases in our study is the difference in length of follow-up. However, despite the authors’ efforts to overcome bias with case-control matching, as this is a nonrandomized study, there are likely to be many other unmeasured biases. Even if length of follow-up had been identical between groups, selection bias would remain an issue. Without randomization, this issue will remain, and no study will be able to provide strong treatment recommendations. The second issue raised by the authors of the letter is the difference in rehabilitation protocols and physical therapy between the RTSA, HA, and ORIF cohorts. The differences in rehabilitation protocols are fundamental to each of these treatments and thus represent differences between RTSA, HA, and ORIF and not a bias between groups. Given that our goal in this study was to compare these treatments, this represents a difference in outcome due to the treatment and not a source of bias. Just as we would not have placed a proximal humeral locking plate on patients within the RTSA and HA groups to Please note that Nathan A. Mall, MD is currently associated with Regeneration Orthopaedics in St. Louis, MO, USA. The work for this manuscript was performed at Rush University Medical Center in Chicago, IL, USA.
avoid bias, we have not prescribed physical therapy to patients after RTSA to avoid bias. The authors have not prescribed physical therapy for patients after RTSA for other indications, such as rotator cuff tear arthropathy or osteoarthritis in the setting of a massive rotator cuff tear. As our study demonstrates, without physical therapy, patients who undergo RTSA for proximal humeral fractures achieve active forward elevation superior to that of patients who undergo ORIF and TSA for proximal humeral fractures. Final mean range of motion in our RTSA cohort was 133 20 active forward elevation, 41 19 active external rotation, and 46 15 active internal rotation. Prescribing physical therapy in this situation is thus unnecessary. As a result, in this small case-control study with shortterm follow-up, RTSA appears to provide range of motion superior to that of HA and ORIF, predictably restoring active elevation >90 in all patients within 4 months, without the need of formal outpatient therapy, and thus realizes significant cost savings to Medicare compared with ORIF and HA. Peter N. Chalmers, MD William Slikker III, MD Nathan A. Mall, MD Anil K. Gupta, MD Zain Rahman, MA Daniel Enriquez, MA Gregory P. Nicholson, MD Department of Orthopaedic Surgery Rush University Medical Center, Chicago, IL, USA E-mail: [email protected]
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.
Reference 1. Chalmers PN, Slikker W, Mall NA, Gupta AK, Rahman Z, Enriquez D, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg 2014;23:197-204. http://dx.doi.org/ 10.1016/j.jse.2013.07.044
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.05.014
www.elsevier.com/locate/ymse
Author reply: Reverse total shoulder for acute proximal humeral fracture: comparison to open reduction–internal fixation and hemiarthroplasty In Reply: We thank you for the opportunity to reply to the comments on our paper entitled ‘‘Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction–internal fixation and hemiarthroplasty,’’1 and we are grateful to the authors of the letter for their interest in our study. We agree that further research is necessary with larger patient cohorts and longer follow-up, ideally in a prospective randomized fashion. As with any nonrandomized retrospective analysis, our study is subject to considerable bias, which is detailed in the limitations section of the article and which we believe precludes us from concluding on the basis of these findings with a high degree of certainty that reverse total shoulder arthroplasty (RTSA) is a better treatment for three- and four-part proximal humeral fractures than open reduction and internal fixation (ORIF) or hemiarthroplasty (HA). As the authors of the letter mention, one of the measured biases in our study is the difference in length of follow-up. However, despite the authors’ efforts to overcome bias with case-control matching, as this is a nonrandomized study, there are likely to be many other unmeasured biases. Even if length of follow-up had been identical between groups, selection bias would remain an issue. Without randomization, this issue will remain, and no study will be able to provide strong treatment recommendations. The second issue raised by the authors of the letter is the difference in rehabilitation protocols and physical therapy between the RTSA, HA, and ORIF cohorts. The differences in rehabilitation protocols are fundamental to each of these treatments and thus represent differences between RTSA, HA, and ORIF and not a bias between groups. Given that our goal in this study was to compare these treatments, this represents a difference in outcome due to the treatment and not a source of bias. Just as we would not have placed a proximal humeral locking plate on patients within the RTSA and HA groups to Please note that Nathan A. Mall, MD is currently associated with Regeneration Orthopaedics in St. Louis, MO, USA. The work for this manuscript was performed at Rush University Medical Center in Chicago, IL, USA.
avoid bias, we have not prescribed physical therapy to patients after RTSA to avoid bias. The authors have not prescribed physical therapy for patients after RTSA for other indications, such as rotator cuff tear arthropathy or osteoarthritis in the setting of a massive rotator cuff tear. As our study demonstrates, without physical therapy, patients who undergo RTSA for proximal humeral fractures achieve active forward elevation superior to that of patients who undergo ORIF and TSA for proximal humeral fractures. Final mean range of motion in our RTSA cohort was 133 20 active forward elevation, 41 19 active external rotation, and 46 15 active internal rotation. Prescribing physical therapy in this situation is thus unnecessary. As a result, in this small case-control study with shortterm follow-up, RTSA appears to provide range of motion superior to that of HA and ORIF, predictably restoring active elevation >90 in all patients within 4 months, without the need of formal outpatient therapy, and thus realizes significant cost savings to Medicare compared with ORIF and HA. Peter N. Chalmers, MD William Slikker III, MD Nathan A. Mall, MD Anil K. Gupta, MD Zain Rahman, MA Daniel Enriquez, MA Gregory P. Nicholson, MD Department of Orthopaedic Surgery Rush University Medical Center, Chicago, IL, USA E-mail: [email protected]
Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.
Reference 1. Chalmers PN, Slikker W, Mall NA, Gupta AK, Rahman Z, Enriquez D, et al. Reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reduction-internal fixation and hemiarthroplasty. J Shoulder Elbow Surg 2014;23:197-204. http://dx.doi.org/ 10.1016/j.jse.2013.07.044
1058-2746/$ - see front matter Ó 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. http://dx.doi.org/10.1016/j.jse.2014.05.014
