Reverse Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly
Authors: Fraser Alexander Nilsskog , Bjørdal Jonas , Wagle Tone Mehlum , Karlberg Anna Cecilia , Lien Odd Arve , Eilertsen Lars , Mader Konrad , Apold Hilde , Larsen Leif Børge , Madsen Jan Erik , Fjalestad Tore 
Published: January 2020

Update
This article was updated on May 20, 2020, because of a previous error. On page 482, in the legend for Figure 5, the sentence that had read “The Oxford Shoulder Score consists of 12 questions concerning shoulder pain, shoulder function, and activities of daily living and ranges from 12 points (worst) to 60 points (best)” now reads “The Oxford Shoulder Score consists of 12 questions concerning shoulder pain, shoulder function, and activities of daily living and ranges from 0 points (worst) to 48 points (best).”
An erratum has been published: J Bone Joint Surg Am. 2020 June 17;102(12):e63.

Background:
Almost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate.

Methods:
The DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients.

Results:
There were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, −3.8 to 19.1 points; p = 0.19).

Conclusions:
At a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients.

Level of Evidence:
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.