Comparative analysis of the improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty compared to open reduction and internal fixation: a systematic review and meta-analysis

PURPOSE: To compare the clinical and functional outcomes of open reduction and internal fixation (ORIF) and reverse shoulder arthroplasty (RSA) in patients aged ≥ 65 years with complex proximal humeral fractures (PHFs). METHODS: A systematic review and meta-analysis was conducted according to the PRISMA guidelines. PubMed, Web of Science, ScienceDirect, EBSCO, and the Cochrane Library were searched for randomized controlled trials (RCTs) and cohort studies published in English without date restrictions. Eligible studies compared RSA and ORIF in elderly patients with PHFs and reported functional, radiographic, or complication outcomes. Pooled data were analyzed using a random-effects model. RESULTS: Twenty-two studies involving > 34,000 patients were included. RSA was associated with greater forward flexion and a trend toward improved abduction, whereas internal rotation favored ORIF without reaching significance. No significant differences were observed in external rotation. The functional scores (Constant-Murley, Oxford Shoulder Score) were similar, and the complication and reoperation rates did not differ significantly between the groups. CONCLUSION: RSA offers modest advantages in forward flexion compared with ORIF but does not consistently improve overall functional scores or reduce complications. RSA may be preferred in elderly patients with poor bone stock or rotator cuff pathology, whereas ORIF remains appropriate for patients in whom joint preservation is feasible. High-quality RCTs with standardized outcome reporting are needed to clarify the optimal surgical management.