Reverse Total Shoulder Arthroplasty for Proximal Humeral Fracture Sequelae: Outcome, Challenges and Designs

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (31 October 2022) | Viewed by 11587

Special Issue Editors


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Guest Editor
Department of Orthopaedic Surgery, University of Zurich, Uniklinik Balgrist, 8006 Zurich, Switzerland
Interests: orthopaedic trauma; upper limb trauma; proximal humerus fracture; shoulder arthroplasty; ORIF; upper limb biomechanics
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Guest Editor
Department of Orthopaedic Surgery, University of Zurich, Uniklinik Balgrist, 8006 Zurich, Switzerland
Interests: shoulder; elbow; biomechanics; tendon pathologies

Special Issue Information

Dear Colleagues,

The surgical management of complex proximal humeral fractures can be challenging. While hemiarthroplasty is still considered for young patients with head-split fractures or if open reduction and internal fixation is not feasible, treatment with reverse total shoulder arthroplasty (RTSA) has gained popularity over the recent years, and its indication has been extended to young patients. The importance of proper tuberosity fixation was previously underestimated, but recent studies have highlighted the influence of successful tuberosity repair on satisfying outcomes. Several tuberosity fixation techniques have been described, with new techniques outperforming the traditional ones. Fracture stems were introduced to facilitate the refixation of the greater and lesser tuberosities to their anatomic locations. This Special Issue aims to discuss indications for RTSA in the case of a fracture of the proximal humerus, describe different stem designs and tuberosity fixation techniques, and review the literature on mid- to long-term results of RTSA for proximal humeral fractures.

Dr. Lukas Ernstbrunner
Dr. Paul Borbas
Guest Editors

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Keywords

  • reverse total shoulder arthroplasty (RTSA)
  • proximal humeral fracture
  • fracture stem
  • tuberosities
  • malunion
  • non-union
  • fixation technique
  • long-term results
  • complications

Published Papers (6 papers)

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Research

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10 pages, 257 KiB  
Article
Reverse Total Shoulder Arthroplasty for Proximal Humeral Fractures and Sequalae Compared to Non-Fracture Indications: A Matched Cohort Analysis of Outcome and Complications
by Alexander Paszicsnyek, Philipp Kriechling, Sam Razaeian, Lukas Ernstbrunner, Karl Wieser and Paul Borbas
J. Clin. Med. 2023, 12(6), 2097; https://doi.org/10.3390/jcm12062097 - 07 Mar 2023
Cited by 2 | Viewed by 1017
Abstract
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 [...] Read more.
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. Full article
12 pages, 3879 KiB  
Article
Reverse Total Shoulder Arthroplasty with a Cementless and Metaphyseal Stem Fixation Is a Viable Option for the Treatment of Proximal Humeral Fractures with Calcar Involvement
by Raffaele Garofalo, Alberto Fontanarosa, Nunzio Lassandro and Angelo De Crescenzo
J. Clin. Med. 2023, 12(4), 1443; https://doi.org/10.3390/jcm12041443 - 11 Feb 2023
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Abstract
Background: The purpose of the study was to evaluate the suitability of reverse total shoulder arthroplasty (RTSA) with a cementless and metaphyseal stem fixation as a treatment for complex proximal humeral fractures (PHFs) with a calcar fragment when this may be fixed with [...] Read more.
Background: The purpose of the study was to evaluate the suitability of reverse total shoulder arthroplasty (RTSA) with a cementless and metaphyseal stem fixation as a treatment for complex proximal humeral fractures (PHFs) with a calcar fragment when this may be fixed with a steel wire cerclage. Clinical and radiographic outcomes were compared with the same RTSA for PHFs without a calcar fragment at a minimum of five-year follow-up. Methods: A retrospective analysis was performed on acute PHFs “with a medial calcar fragment” (group A) and “without a calcar fragment” (group B) treated with a RTSA and cementless metaphyseal stem fixation. Results: At an average follow-up of 6.7 years (5–7.8 years), no statistical difference was observed comparing group A (18 patients) to group B (50 patients) for active anterior elevation (141 ± 15° vs. 145 ± 10°, p = 0.67), active external rotation ER1 (49 ± 15° vs. 53 ± 13°, p = 0.55), and active internal rotation (5 ± 2 vs. 6 ± 2, p = 0.97). Similarly, a comparison of ASES score (89.2 ± 10 vs. 91.6 ± 9, p = 0.23) and Simple Shoulder Test score (91.1 ± 11 vs. 90.4 ± 10, p = 0.49) revealed no significant difference. Conclusion: RTSA with a cementless and metaphyseal stem fixation represents a safe and feasible treatment for complex PHFs with a medial calcar fragment when this may be fixed with a steel wire cerclage. Full article
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10 pages, 1296 KiB  
Article
Greater Tuberosity Fractures after RTSA: A Matched Group Analysis
by Farah Selman, Philipp Kriechling, Lukas Ernstbrunner, Karl Wieser and Paul Borbas
J. Clin. Med. 2023, 12(3), 1153; https://doi.org/10.3390/jcm12031153 - 01 Feb 2023
Viewed by 1304
Abstract
Periprosthetic fractures, such as acromial and spine fractures, are known complications following implantation of reverse shoulder arthroplasty (RTSA). The entity of greater tuberosity fractures (GTF) has rarely been studied in the literature. The purpose of this study was to analyze the outcome of [...] Read more.
Periprosthetic fractures, such as acromial and spine fractures, are known complications following implantation of reverse shoulder arthroplasty (RTSA). The entity of greater tuberosity fractures (GTF) has rarely been studied in the literature. The purpose of this study was to analyze the outcome of postoperative greater tuberosity fractures after RTSA compared to a matched control group. The main findings of this study are that a GTF after RTSA is associated with worse clinical outcome scores (mean absolute CS 50 ± 19 (p = 0.032); SSV 63% ± 26 (p = 0.022); mean force 1 kg ± 2 kg (p = 0.044)) compared with the control group (mean absolute CS 62 ± 21; SSV 77% ± 29; mean force 2 kg ± 2 kg). In terms of postoperative range of motion, the fracture group was significantly worse in terms of external rotation (17° ± 19° vs. 30° ± 19° (p = 0.029)). Internal rotation, flexion, as well as abduction of the shoulder appear to be unaffected (internal rotation GTF 4 ± 2, control group 5 ± 3 (p = 0.138); flexion GTF 102° ± 28°, control group 114° ± 27° (p = 0.160); abduction GTF 109° ± 42°, control group 120° ± 39° (p = 0.317)). Full article
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0 pages, 2117 KiB  
Article
Single or Double Plating for Acromial Type III Fractures: Biomechanical Comparison of Load to Failure and Fragment Motion
by Marianne Hollensteiner, Sabrina Sandriesser, Felix Rittenschober, Josef Hochreiter, Peter Augat, Lukas Ernstbrunner and Reinhold Ortmaier
J. Clin. Med. 2022, 11(11), 3130; https://doi.org/10.3390/jcm11113130 - 31 May 2022
Cited by 4 | Viewed by 1943
Abstract
Background: Acromial Levy III fractures after inverse shoulder arthroplasty occur in up to 7% of patients. To date, it is not clear how these fractures should be treated as clinical outcomes remain unsatisfactory. The aim of this study was to evaluate the biomechanical [...] Read more.
Background: Acromial Levy III fractures after inverse shoulder arthroplasty occur in up to 7% of patients. To date, it is not clear how these fractures should be treated as clinical outcomes remain unsatisfactory. The aim of this study was to evaluate the biomechanical performance of three different plating methods of type III acromion fractures. Methods: Levy III fractures in synthetic scapulae were fixed with three different methods. Angular stable locking plates were placed on the spina scapula to bridge the fracture either dorsally, caudally, or on both aspects by double plating. In a biomechanical experiment, the pull of the deltoid muscle at 40° abduction of the arm was simulated by cyclic loading with increasing load levels until failure. Failure load, cycles to failure, and fragment motions were evaluated. Results: The results showed that double plating (350 ± 63 N) withstood the highest loads until failure, followed by dorsal (292 ± 20 N) and caudal (217 ± 49 N) plating. Similarly, double plating showed significantly smaller fragment movement than the other two groups. Conclusions: Double plating appeared to provide the largest biomechanical stability in type III acromion fracture under arm abduction. Caudal plating in contract resulted in insufficient fracture stability and early failure and can thus not be recommended from a biomechanical point of view. Full article
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Review

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11 pages, 20296 KiB  
Review
Prosthesis Designs and Tuberosity Fixation Techniques in Reverse Total Shoulder Arthroplasty: Influence on Tuberosity Healing in Proximal Humerus Fractures
by Olivia Jo, Paul Borbas, Florian Grubhofer, Eugene T. Ek, Christopher Pullen, Thomas Treseder and Lukas Ernstbrunner
J. Clin. Med. 2021, 10(18), 4146; https://doi.org/10.3390/jcm10184146 - 14 Sep 2021
Cited by 10 | Viewed by 3225
Abstract
Reverse total shoulder arthroplasty (RTSA) is increasingly used for the treatment of complex proximal humerus fractures and fracture sequelae. In 2021, half a dozen models of fracture stems are commercially available, reflecting its growing utility for fracture management. Prosthesis designs, bone grafting and [...] Read more.
Reverse total shoulder arthroplasty (RTSA) is increasingly used for the treatment of complex proximal humerus fractures and fracture sequelae. In 2021, half a dozen models of fracture stems are commercially available, reflecting its growing utility for fracture management. Prosthesis designs, bone grafting and tuberosity fixation techniques have evolved to allow better and more reliable fixation of tuberosities and bony ingrowth. Patients with anatomical tuberosity healing not only have an increased range of active anterior elevation and external rotation, but also experience fewer complications and longer prosthesis survival. This review provides an overview of recent evidence on basic and fracture-specific RTSA design features as well as tuberosity fixation techniques that can influence tuberosity healing. Full article
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Other

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14 pages, 668 KiB  
Systematic Review
Acromial and Scapular Spine Fractures following Reverse Total Shoulder Arthroplasty—A Systematic Review of Fixation Constructs and Techniques
by J. Tristan Cassidy, Alexander Paszicsnyek, Lukas Ernstbrunner and Eugene T. Ek
J. Clin. Med. 2022, 11(23), 7025; https://doi.org/10.3390/jcm11237025 - 28 Nov 2022
Cited by 4 | Viewed by 1929
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 [...] Read more.
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. Full article
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