Detritic Synovitis With Osteolysis Leading to Pathologic Fracture and Deltoid Avulsion Following Total Shoulder Arthroplasty

Abstract

To report a unique case of detritic synovitis with associated lytic lesion leading to pathologic fracture of the acromion and deltoid avulsion following total shoulder arthroplasty (TSA). Methods: An institutional review board-approved retrospective case analysis was performed using Electronic Medical Records (EMR) sourced pathology and radiology results, clinic notes, and surgical reports. Case Description: We present the case of a 79-year-old woman with a surgical history significant for TSA who presented with new onset of shoulder pain. The patient was found to have a lytic lesion in the acromion secondary to an inflammatory reaction to polyethylene wear debris. The lytic lesion led to fracture of the acromion and avulsion of the deltoid muscle. The patient was treated with an open biopsy, culture, and repair of the deltoid avulsion. Discussion: This is a previously unreported complication of TSA resulting from detritic synovitis, a destructive inflammatory reaction to polyethylene wear debris within an artificial joint. The differential diagnosis includes periprosthetic infection with osteomyelitis and metastatic disease. This patient presented with extensive osteolysis, pathologic fracture of the acromion and deltoid avulsion that was successfully treated with debridement and surgical repair of the deltoid. Conclusion: As the prevalence of TSA rises, orthopedic surgeons should be aware of the possibility of detritic synovitis in patients who present with pain after shoulder arthroplasty with imaging studies demonstrating periarticular osteolysis.

Pathogenesis, Evaluation, and Management of Osteolysis After Total Shoulder Arthroplasty

“…In one analysis of 42 patients with symptomatic glenoid loosening following a primary anatomical TSA who underwent an isolated glenoid exchange, 67% of patients had recurrence of glenoid loosening, and 17% required reoperation at approximately year 6 of follow-up [63]. Sheth et al [64] corroborated the disappointing results of revision anatomical TSA in a cohort of 20…”

“…Known to cause implant failure in hip, hand, and foot arthroplasty, detritic synovitis leading to osteolysis after anatomical TSA was first described in 2018 [17][18][19]. Guild et al [20] described an inflammatory foreign body reaction to polyethylene implant wear resulting in osteolysis; histopathologic analysis found multinucleated giant cell and histiocyte infiltrates and polarizable debris resulting from the destruction of bone and joint tissue. Detritic synovitis and periprosthetic osteolysis share many histological characteristics; however, the scope of their consequences differs given the relative lack of geographic limitation seen in detritic synovitis.…”