Acromial and Scapular Spine Fractures following Reverse Total Shoulder Arthroplasty—A Systematic Review of Fixation Constructs and Techniques

Abstract

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.

Scapular spine fracture, presentation of two cases and novel surgical treatment

“…Cassidy 3 concluded that double-plating has the highest chance of achieving union and biomechanically strong enough to withstand the extra strain of the acromion-spine of scapular region in setting of RSA confirmed by Katthagen 8 biomechanical study. Among the various possible plate positions (superiorly supraspinatus fossa, spine of scapula-posterior position, and caudally-infraspinatus fossa); they 3 concluded single plate has potential highest strength in posterior position and dual plating when combine posterior and caudal position which was the position of choice in author’s cases.…”

“…In 2 other studies, Morella 13 and Ascione 1 came to a very similar conclusion (0% of inlay vs. 7.9% of onlay and 4.3% in onlay compared to 1.3% reported literature on Grammont style, respectively). Cassidy 3 did not report the type of implant been used among their pooled data of SSF. Sußiek 17 reported pooled result of 11 studies reporting SSF after RSA; among the 50 cases, 2 did not report the type of implant, 21 used Grammont style RSA (mainly Delta III, Depuy Synthes, Raynham, MA, USA), and 27 lateralized implants (mainly Ascend flex; Tornier, Bloomington, MN, USA following by DJO surgical, Lewisville, TX, USA).…”

“…In Cassidy study, 3 they identified 18 reported SSFs treated surgically. Ten of them Levy II and 7 Levy III.…”

“…Also planned to use a fibular strut allograft (Australian Biotechnologies Pty Ltd.), divided longitudinally in the operating room and bevelled the lateral tip to be clear of suprascapular nerve, and supports the undersurface of acromion. After reduction and holding fracture with precontour plate over the top of spine (known as posterior position), 3 the fibular strut allograft was positioned in the supraspinatus fossa with another small joint plate (Minifragment T 2.4 profile plate, variax Stryker, Schönkirchen, Germany) coming from infraspinatus fossa, 90/90 figure, capturing spine of scapula, acromion and compressed cancellous bone graft in the space between allograft and supraspinatus border of spine of scapula which gently decorticated to encourage healing, and cancellous allograft packed in that space. At 3 months, once the fracture united ( Fig.…”

Mitigating Fracture of the Acromion and Scapular Spine After Reverse Shoulder Arthroplasty

“…While the ideal treatment is unclear, a period of nonoperative immobilization in an abduction sling is common 6 . Fractures amenable to surgical management (Levy types IIb-III) are often single or dual-plated with variable results 24,25 . The optimal management of acromion and SS fractures, including indications for prophylactic plating, is evolving, and limited treatment series are currently available.…”