External fixation versus reverse shoulder arthroplasty for proximal humerus fractures in the elderly: a retrospective comparative study

The optimal management of displaced proximal humerus fractures (PHFs) in the elderly remains a subject of ongoing debate. This study aims to compare the clinical and functional outcomes of biologically driven external fixation (EF) versus functional joint replacement via reverse shoulder arthroplasty (RSA) in patients aged 65-80 years. A retrospective comparative study was conducted on patients with displaced Neer two- or three-part PHFs treated between 2015 and 2022. The final analysis included 67 patients: Group A (EF; n=34) and Group B (RSA; n=33). Clinical and functional outcomes were quantified using the Constant-Murley Score (CMS), Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder and Hand (Quick-DASH) score, and Range of Motion (ROM) assessment. Patient satisfaction was evaluated via a 5-point Likert scale. Both cohorts were homogeneous regarding mean age (72.2 ± 3.5 vs. 73.4 ± 3.8 years). Group A demonstrated significantly shorter mean operative times (48.2 ± 10.5 vs. 92.4 ± 15.2 min; p < 0.001) and a lower requirement for blood transfusions (0% vs. 12.1%; p < 0.05). At the final follow-up, both cohorts achieved comparable CMS (58.4 ± 8.2 vs. 55.2 ± 10.1; p = 0.42), SST (7.6 ± 1.5 vs. 7.0 ± 1.4; p = 0.38), and ASES scores (69 ± 7.8 vs. 65 ± 9.4; p = 0.51). Group A exhibited significantly superior external rotation (60.9° ± 9.2° vs. 46.5° ± 10.1°; p < 0.01) and a trend toward better internal rotation (49° ± 16.2° vs. 42° ± 17.1°; p = 0.09). Subjective satisfaction was comparable (Likert score: 3.2 ± 0.8 vs. 2.9 ± 0.9; p = 0.16). The overall complication rate was 20.6% in Group A and 12.1% in Group B (p = 0.51). Both EF and RSA are effective for managing PHFs in the elderly, yielding similar functional outcomes. However, EF represents a significantly less invasive, "bio-friendly" alternative, offering shorter surgical duration, no transfusion risk, and superior restoration of physiological rotations. The preservation of native anatomy and high patient satisfaction support EF as a viable treatment option in the geriatric population. Level III, Retrospective Comparative Study.