Fractures of the acromion and the scapular spine are established complications of reverse shoulder arthroplasty (RSA), and when they occur, the continuous strain by the deltoid along the bony fragments makes healing difficult. Evidence on treatment specific outcomes is poor, making the definition of a gold standard fixation technique difficult. The purpose of this systematic review is to assess whether any particular fixation construct offers improved clinical and/or radiographic outcomes. A systematic review of the literature on fixation of acromial and scapular spine fractures following RSA was carried out based on the guidelines of PRISMA. The search was conducted on PubMed, Embase, OVID Medline, and CENTRAL databases with strict inclusion and exclusion criteria applied. Methodological quality assessment of each included study was done using the modified Coleman methodology score to asses MQOE. Selection of the studies, data extraction and methodological quality assessment was carried out by two of the authors independently. Only clinical studies reporting on fixation of the aforementioned fractures were considered. Fixation construct, fracture union and time to union, shoulder function and complications were investigated. Nine studies reported on fixation strategies for acromial and scapular spine fractures and were therefore included. The 18 reported results related to fractures in 17 patients; 1 was classified as a Levy Type I fracture, 10 as a Levy Type II fracture and the remaining 7 fractures were defined as Levy Type III. The most frequent fixation construct in type II scapular spine fractures was a single plate (used in 6 of the 10 cases), whereas dual platin was the most used fixation for Levy Type III fractures (5 out of 7). Radiographic union was reported in 15 out of 18 fractures, whereas 1 patient (6.7%) had a confirmed non-union of a Levy Type III scapular spine fracture, requiring revision fixation. There were 5 complications reported, with 2 patients undergoing removal of metal and 1 patient undergoing revision fixation. The Subjective Shoulder Value and Visual Analogue Scale pain score averaged 75% and 2.6 points, respectively. The absolute Constant Score and the ASES score averaged 48.2 and 78.3 points, respectively. With the available data, it is not possible to define a gold standard surgical fixation but it seems that even when fracture union can be achieved, functional outcomes are moderate and there is an increased complication rate. Future studies are required to establish a gold standard fixation technique.
Background: With the increase in utility and popularity of the reverse total shoulder arthroplasty (RTSA) within the last decades, indications for RTSA have expanded. As well as the established indications such as cuff tear arthropathy and massive irreparable rotator cuff tears, RTSA for complex proximal humeral fractures in elderly patients has been proven to be a reliable treatment option. Methods: A prospectively enrolled RTSA database of 1457 RTSAs implanted between September 2005 and November 2020 was reviewed. Patients treated with RTSA for a complex proximal humerus fracture and fracture sequalae (F-RTSA) were 1:1 matched with a group of patients who were treated electively with RTSA for indications other than a fracture (E-RTSA). Matching criteria included sex, age, length of follow-up and body mass index. Evaluation after a minimum of 2 years follow-up included evaluation of the absolute and relative Constant–Murley score (aCS; rCS), subjective shoulder value (SSV), range of motion (ROM) assessment and complications. Results: Each of the matched cohorts comprised 134 patients with a mean follow-up of 58 ± 41 months for the fracture group and 58 ± 36 months for the elective group. The mean age for both groups was 69 ± 11 years in the F-RTSA and 70 ± 9 years for the E-RTSA group. There were no significant differences in clinical outcome measures including aCS, rCS and SSV (p > 0.05). There was a significant difference in mean active external rotation with 20° ± 18° in the F-RTSA group compared with 25° ± 19° in the E-RTSA group (p = 0.017). The complication rate was not significantly different, with 41 complications in 36 shoulders in the F-RTSA and 40 complications in 32 shoulders in the E-RTSA group (p = 0.73). The main complication for the F-RTSA group was dislocation of the greater tuberosity (6%), whereas acromial fractures (9%) were the leading complication in the E-RTSA group. There was also no significant difference in revision rate comparing F-RTSA with E-RTSA (10% vs. 14%; p = 0.25). Conclusions: RTSA for complex proximal humeral fractures and its sequalae leads to a comparable clinical outcome as that for patients treated electively with RTSA for indications other than fracture. There was, however, a significant difference in active external rotation, with inferior rotation in patients undergoing RTSA for fracture. This valuable information can help in requesting informed consent of patients with proximal humeral fractures.
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