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Shoulder Arthritis / Rotator Cuff Tears / Shoulder Pain : Acromion and spine fractures after reverse total shoulder arthroplasty


The authors of Clinical results of conservative versus operative treatment of acromial and scapular spine fractures following reverse total shoulder arthroplasty reviewed their experience with operative and non-operative treatment of patients with acromial or scapular spine fractures after reverse total shoulders (RTSA). These fractures were recognized 30 of 1146 RTSAs, although there was no prospective study of these patients to determine the actual prevalence of this complication. 23 had acromial fractures, and 7 had a scapular spine fracture.

While the indications for internal fixation were not described, 7 had surgery and 23 did not. 

The authors could not relate the healing rate to the type of fracture or type of treatment. Neither method of treatment yielded better outcomes and neither successfully restored shoulder comfort and function to the levels achieved by patients without these fractures. 

These poor outcomes from a major medical center prompted a literature review to see what we know about this disabling complication. In the presentation below, supporting references can be accessed by clicking on the pub med links. 

I. Overview

These fractures occur after about 4% of RTSAs, often within the first year. Many – sometimes conflicting – risk factors for these have been suggested, including advanced age, female sex, osteoporosis, rheumatoid arthritis, rotator cuff tear arthropathy, revision arthroplasty, falls, prior surgery, thin acromion, high glenoid inclination, medialized preoperative center of rotation, use of a long superiorly placed screw during baseplate fixation, increased deltoid length > 1 inch, contact of the acromion with the greater tuberosity, disruption of the scapular ring by transection of the coracoacromial ligament, lower distalization of the humerus, medialization of the center of rotation, and use of a lateralized glenoid.













II. Non operative treatment

    A. Fractures that occur at or medial to the glenoid face demonstrate high rates of unsatisfactory results and worse clinical outcomes with nonoperative management.


    B. Immobilization with an abduction splint frequently resulted in nonunion or malunion


    C. Nonoperative management was chosen due to a concern that stable fixation would not be obtained with surgery.


III. Operative treatment

    A. Most of the studies comparing surgical methods were carried out in in vitro using models that do no replicate the osteoporotic bone commonly encountered clinically.

        1. Double plating better in comparison of fixation methods in synthetic scapulae


        2. Dorsal plate with lateral hook performed better in cadaver study of fixation methods


        3. Locking compression plate was the best of three plating techniques in sawbones


    B. Most clinical reports of surgical treatment consist of case reports with only a few patients

        1. Single case using locked double plating of scapular spine fracture


        2. Single case using plate and screws


        3. 7 type II fractures and 4 type III were treated surgically 



        4. Plate and screws used in three cases


        5. Plate in a single case of bilateral fractures


        6. 4 fractures with 50% union rate after internal fixation 


        7. Single case of internal fixation


    C. Clinical comparison of operative and non-operative treatment

        1. Open reduction-internal fixation was not shown to be clinically superior


        2. Operative treatment was not superior to conservative treatment



        3. 3 surgical and 3 nonoperative – clinically unsatisfactory results



        4. The healing rate was shown to be much higher with a surgical approach. Nevertheless, fracture consolidation did not result in better clinical outcomes compared with nonunion.



Comment: Acromial and scapular spine fractures complicating reverse total shoulder are not uncommon (occurring in 1 out of 25 cases), and usually lead to major loss in shoulder comfort and function. Currently we do not know either how to prevent or how to treat these fractures.

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