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 after 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 anatomically healed GTs. Patients with GT malunion or nonunion were collectively categorized as nonhealed. 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 nonhealing. The plausible predictive factors for GT nonhealing (gender distribution, mean age, mean time from injury to surgery, dominant side distribution, and humeral inclination of the implanted prostheses) were analyzed by performing a metaregression. Any statistically significant difference in terms of ROM (active anterior elevation, abduction, and external rotation) between healed and nonhealed GT groups was detected by constructing individual forest plots. Results: A total of 21 studies were selected and included in the meta-analysis, with a sample of 1616 rTSAs in 1614 patients. The rate of GT nonhealing ranged from 15.0% to 63.2%, with a pooled rate of 31.9% (95% confidence interval, 25.6%-38.2%; I2 = 86.8%). The metaregression failed to individuate any plausible predictive factor among the evaluated elements. Anatomic GT healing provided improved ROM in active abduction (P = .002), anterior elevation (P < .00001), and external rotation (P < .0001). With regard to internal rotation, a statistically significant difference in favor of the GT healed group was reported in only 3 of 13 studies. Similarly, the random-effects meta-analysis demonstrated better functional scores in patients with healed GT according to 3 of 5 functional scores. Conclusion: GT healing after rTSA for proximal humerus fracture provides increased ROM and better functional outcomes. Moreover, this does not result in a 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.