EVIDENCE-BASED REVIEWS & RECOMMENDATIONS FROM THE BRAZILIAN SOCIETY OF SHOULDER AND ELBOW SURGERY: REVERSE ARTHROPLASTY FOR COMPLEX PROXIMAL HUMERAL FRACTURES IN ELDERLY PATIENTS.

Introduction: Complex (Neer 3- or 4-part) proximal humeral fractures in elderly patients are associated with high complication and failure rates after open reduction and internal fixation with locking plates (ORIF-LP). Reverse shoulder arthroplasty (RSA) has emerged as an alternative, but its comparative effectiveness remains debated. Methods: We conducted an evidence-based review of systematic reviews and randomized controlled trials including elderly patients with Neer 3- or 4-part fractures, identified through PubMed, Embase, Cochrane Library, and BVS (search to August 2025). High-quality systematic reviews were prioritized, and individual RCTs were added when necessary. Risk of bias and certainty of evidence were assessed using Cochrane methods and the GRADE approach. Results: Four systematic reviews and three RCTs met the inclusion criteria. Across network meta-analyses and direct comparisons, RSA provided superior shoulder function, with higher Constant and Oxford scores at 2 and 5 years than ORIF-LP. RSA also tended to reduce complication and reoperation rates, although event numbers were small and confidence intervals were wide. Overall certainty was low for function and very low for complications and reoperations. Conclusions: In elderly patients with complex proximal humeral fractures requiring surgery, RSA appears to yield better functional outcomes and fewer reoperations than ORIF-LP, supporting its use as the preferred surgical option, while acknowledging the low certainty of evidence.