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Dear Editor, dear Authors:
We read the case report of Wendling et al  with interest. We thank the Authors for sharing their experience, and we would like to congratulate with them. Even if with low-energy trauma in elderly patients, these cases are of interest because of the frequently multiple injuries and medical comorbidities that make the case difficult to treat, for the orthopedic surgeons as well as for our colleagues the anesthesiologists. We had a similar experience with a bilateral four-part fracture of the proximal humerus in a female in her late 70s, and we were able to carry out a simultaneous bilateral reverse shoulder arthroplasty (RSA) thanks to stability of vital parameters during the first procedure. Our patient was barely younger than yours, had no major medical comorbidities, and had no concomitant hip fracture: that’s the reason why we could managed a simultaneous bilateral RSA, and we published it as the first case described, to our knowledge, in Literature , a few weeks before you did.
Pathology was quite similar: bilateral four-part fracture over gleno-humeral eccentric osteoarthritis in our case and left four-part posterior fracture-dislocation and right three-part posterior fracture-dislocation associated to a glenoid fracture in your case. As for indication to RSA, the correct treatment of proximal humeral fractures is still not clear, with recent meta-analysis  confirming prior reviews  about no super...
Pathology was quite similar: bilateral four-part fracture over gleno-humeral eccentric osteoarthritis in our case and left four-part posterior fracture-dislocation and right three-part posterior fracture-dislocation associated to a glenoid fracture in your case. As for indication to RSA, the correct treatment of proximal humeral fractures is still not clear, with recent meta-analysis  confirming prior reviews  about no superior results of operative versus nonoperative treatment, especially in the elderly. Given the choice for surgical treatment, pre-operative planning should take into account Hertel’s criteria  to predict the risk of humeral head avascular necrosis to reduce the risk for patient to undergo revision surgery.  Increasing evidence presently in the literature that RSA is a valid option for the treatment of displaced fractures of humeral head in the elderly.  In the rare case of simultaneous bilateral traumatic disease, the treatment of choice is more controversial. Simultaneous bilateral three-part or four-part fractures of the proximal humerus are even more rare, and in our opinion, their treatment should rely on the same principles as for monolateral injury, even if concerns about post-operative care and rehabilitation exist.
We believe the issue is not the simultaneous or the near-simultaneous procedure from the surgical point of view, because it is a matter of anesthesiologic feasibility (better: of patient’s medical condition) and not of orthopedic expertise. In our opinion the real challenge is physical rehabilitation and personal care because of the complete temporary disability. That’s the reason why major bilateral upper limb surgery is not proposed to patients in case of elective surgery, but it can be done “by necessity” in traumatic diseases.
Again, we congratulate with the Authors for the case, and we would appreciate more challenging cases like this.
 Wendling A, Vopat ML, Yang S-Y, Saunders B. Near-simultaneous bilateral reverse total shoulder arthroplasty for the treatment of bilateral fracture dislocations of the shoulder. BMJ Case Rep 2019;12:e230212. doi:10.1136/bcr-2019-230212
 Ceri L, Mondanelli N, Sangaletti R, Bottai V, Muratori F, Giannotti S. Simultaneous bilateral reverse shoulder arthroplasty for bilateral four-part fracture of the proximal humerus in an elderly patient: A case report. Trauma Case Rep. 2019;23:100242. Published 2019 Aug 19. doi:10.1016/j.tcr.2019.100242
 Beks R.B., Ochen Y., Frima H., Smeeing D.P.J., van der Meijden O., Timmers T.K. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J. Shoulder Elb. Surg. 2018;27:1526–1534.
 Handoll H.H., Gibson J.N., Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst. Rev. 2003;4:CD000434.
 Hertel R., Hempfing A., Stiehler M., Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J. Shoulder Elb. Surg. 2004;13:427–433.
 Jost B, Spross C, Grehn H, et al. Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. J Shoulder Elbow Surg 2013;22:542–9.
 Jawa A., Burnikel D. Treatment of proximal humeral fractures. JBJS Reviews. 2016;4:e31–e39.