**3. Results**

Twenty-six patients (20 females, 6 males) with a mean age of 73.4 years were available for clinical and radiographic follow-up. The average postoperative follow-up occurred at 50 months (range: 12–142 months). A total of 19 patients dropped out of the study either because of death (*n* = 11), multimorbidity (*n* = 2) or severe dementia (*n* = 3) that hindered adequate examination of shoulder function; one patient suffered from paralysis following a severe stroke (*n* = 1), while two more dropped out either because of a SARS-COVID-19 infection (*n* = 1) or they were lost to follow-up (*n* = 1). There was no radiographic follow-up available for 3 of the 26 patients. Fracture morphologies and patient demographics are displayed in Table 1.

**Table 1.** Baseline patient demographics.


SD—standard deviation. \* according to Scheibel et al. [7].

## *3.1. Clinical Results*

Our patient cohort achieved excellent clinical results based on all measured shoulder function scores and ROM (Table 2, Figure 3). The average SSV was 82% (range: 50–100%) and the absolute CS was 80% (range: 58–97 points). Most patients were pain free and reached full points in ADLER score and satisfaction. Patients in our cohort reached on average a flexion of 148◦ (range 100–175), external rotation of 15◦ (range: −10–60) and internal rotation up to L3 vertebra (range: thigh–scapula). Compared to the healthy, unaffected shoulder, the RSA shoulder reached 92% (range: 67–141%) of the contralateral function on average.

**Table 2.** Final postoperative clinical scores and range of motion.


SD—standard deviation; CS—constant score; ASES—American shoulder and elbow surgeons assessment form; SSV—subjective shoulder score; SST—Simple Shoulder Test; ADLER—activities of daily living requiring active external rotation.

**Figure 3.** This 77-year-old woman sustained a type III fracture in preoperative radiographs (**upper two left**) after a fall onto her left shoulder while hiking. At 50 months post-RSA, the patient was very satisfied with excellent function (**lower bottom**) and a CS of 81 points, a relative CS of 99%, and a SSV of 95%. Both the greater and lesser tuberosities show healing and no scapular notching is visible on post-op (**upper two right**) images.

Patients who suffered a high-energy trauma performed significantly better and showed a greater absolute CS (79 vs. 69 points; *p* = 0.010), ASES (94 vs. 84 points; *p* = 0.044), ADLER score (30 vs. 26 points; *p* < 0.001) and SST score (87 vs. 68 points; *p* = 0.005) as well as abduction strength (5.0 vs. 2.9 kg; *p* = 0.005). With regard to ROM, patients after high-energy trauma reached greater anterior forward elevation (157◦ vs. 141◦; *p* = 0.011), abduction (151◦ vs. 139◦; *p* = 0.042) and external rotation (19◦ vs. 12◦; *p* = 0.047) at final follow-up.

A total of seven patients presented with a positive ERLS, two of which also presented with a positive Hornblower sign. The presence of a positive ERLS coincided with significantly worse outcomes for SSV (72% vs. 84%; *p* = 0.023), the ADLER score (29 vs. 24 points; *p* = 0.002) and external rotation (1◦ vs. 21◦; *p*= 0.002). Healing of both the greater (*p* = 0.02) and lesser tuberosities (*p* = 0.004) was observed when the ERLS was absent.
