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Haislup BD. CORR Insights®: Acquired Acromion Compromise, Including Thinning and Fragmentation, Is Not Associated With Poor Outcomes After Reverse Shoulder Arthroplasty. Clin Orthop Relat Res 2024; 482:2014-2016. [PMID: 39017172 PMCID: PMC11469879 DOI: 10.1097/corr.0000000000003182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 06/13/2024] [Indexed: 07/18/2024]
Affiliation(s)
- Brett D Haislup
- Resident, Orthopaedic Surgery Department, MedStar Union Memorial Hospital, Baltimore, MD, USA
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Kim SC, Park JH, Kim HG, Kim DY, Lee SM, Yoo JC. Acquired Acromion Compromise, Including Thinning and Fragmentation, Is Not Associated With Poor Outcomes After Reverse Shoulder Arthroplasty. Clin Orthop Relat Res 2024; 482:2001-2013. [PMID: 38843507 PMCID: PMC11469824 DOI: 10.1097/corr.0000000000003131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 05/03/2024] [Indexed: 10/13/2024]
Abstract
BACKGROUND Acquired acromial compromise, including thinning (less than 30% of the normal acromion) or fragmentation resulting from acromiohumeral impingement or previous acromioplasty, is a concern in reverse shoulder arthroplasty (RSA). This condition may lead to shoulder pain and difficulties in arm elevation because of acromial insufficiency fracture. QUESTIONS/PURPOSES (1) Do patients with acromial compromise (thinning less than 30% of normal acromion or fragmentation) have worse functional outcome scores, ROM, and strength after RSA compared with patients without acromial compromise? (2) Are patients with acromial compromise at a higher risk of complications such as acromial insufficiency fracture after RSA? (3) Do patients who develop acromial insufficiency fracture have predisposing associated factors and worse clinical outcomes? METHODS Between January 1, 2016, and December 31, 2020, we treated 398 patients with RSA, and all patients were considered potentially eligible for this study. Our clinic is part of the orthopaedic department within a tertiary general hospital, serving patients from across the country. Among them, 49% (197 of 398) of patients were excluded for the following reasons: 8% (31 of 398) because of proximal humerus fracture, 5% (19 of 398) because of osteonecrosis, 9% (35 of 398) because of previous infective arthritis, 5% (18 of 398) because of a deformed shoulder, 4% (14 of 398) because of poor general condition after surgery, 3% (12 of 398) because of death, and another 17% (68 of 398) were lost before the minimum study follow-up, leaving 51% (201 of 398) for analysis. A preoperative acromial compromise was defined as follows: (1) thinning of the acromion (< 3 mm), which means a thickness of less than 30% of the normal acromion thickness (8 to 9 mm), and (2) acromial fragmentation. Acromial thickness was measured using a CT scan. The middle portion of the anterolateral acromion, situated lateral to the distal end of the clavicle, was crosschecked using the axial view. Measurements were subsequently performed from both coronal and sagittal views. In all, 29 patients with acromion compromise and 172 without acromion compromise met the inclusion and exclusion criteria. There was no differential loss to follow-up before 2 years between patients with and without acromial compromise in this study (36% [16 of 45] versus 23% [52 of 224]; p = 0.12). We matched patients using propensity score, pairing them in a 1:3 ratio based on gender, age, bone mineral density, diagnosis, previous rotator cuff repair surgery, subscapularis repair or latissimus dorsi transfer performed during surgery, the type of prosthesis used, and follow-up duration. Twenty-three patients with acromial compromise (acromion compromised group) and 69 patients without acromial compromise (normal control group) were matched; the mean ± SD duration of follow-up was 40 ± 22 months in those with acromial compromise and 43 ± 19 months the in normal control group. Pre- and postoperative functional outcome scores, ROM, and shoulder strength were compared. Shoulder scaption refers to lifting the arm in the scapular plane, and scaption strength was measured by applying upward force with the arm at 90° while seated, pushing it as far as possible and measured using a handheld myometer. Complications, including acromial insufficiency fracture, scapular notching, dislocation, periprosthetic infection, and overall risk of complication, were analyzed. Acromial insufficiency fracture was diagnosed based on clinical and radiological findings. Clinically, sudden pain and tenderness at the acromion along with reduced shoulder elevation raised acromial insufficiency fracture suspicion. Radiologically, acromion tilt on plain radiograph or fracture line on coronal CT view confirmed diagnosis of acromial insufficiency fracture. RESULTS Comparing both groups, patients with a compromised acromion had no difference in American Shoulder and Elbow Surgeons scores (60 ± 12 versus 64 ± 12; mean difference -4 [95% CI -11 to 2]; p = 0.16), Constant scores (48 ± 10 versus 54 ± 12; mean difference -6 [95% CI -13 to 0]; p = 0.06), forward flexion degree (125 ± 24 versus 130 ± 21; mean difference -5 [95% CI -16 to 6]; p = 0.36), and scaption strength (5 ± 3 versus 6 ± 3; mean difference -1 [95% CI -3 to 0]; p = 0.13). Having acromial compromise was not associated with increased risk of overall complications (30% [7 of 23] versus 19% [13 of 69], relative risk 2 [95% CI 1 to 4]; p = 0.26). However, the only complication that was higher in the acromial compromised group was infection (13% [3 of 23] versus 0% [0 of 69], relative risk not available; p = 0.01). Only the lateralized glenoid prosthesis demonstrated negative association with the acromial insufficiency fracture occurrence; no other factors showed an association. The use of lateralized glenoid prostheses was not observed in patients with acromial insufficiency fracture (0% [0 of 7] acromial insufficiency fracture versus 39% [33 of 85] no acromial insufficiency fracture, relative risk 0 [95% CI 0]; p = 0.047). CONCLUSION In patients with acquired acromial compromise-such as thinning or fragmented acromion because of advanced cuff tear arthropathy or previous acromioplasty-primary RSA resulted in no different functional outcome score, ROM, shoulder strength, and overall complications compared with patients without acromial compromise. Our findings suggest that a thin or fragmented acromion may not necessarily be exclusion criteria for RSA, potentially aiding surgeons in their decision-making process when treating these patients. However, one of the major complications, postoperative infection, is more frequently observed in patients with acquired acromial compromise. Pre- and postoperative caution would be necessary to prevent and detect infection even when short-term outcomes are favorable in this study. Further studies with large cohorts and long-term follow-up durations are needed. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Su Cheol Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jong Hun Park
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hyun Gon Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dae Yeung Kim
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang Min Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jae Chul Yoo
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Yu KE, Marigi EM, Austin DC, Tangtiphaiboontana J, Esper R, Barlow JD, Morrey ME, Sanchez-Sotelo J. Operative treatment of acromial and scapular spine fracture nonunions complicating reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2024:S1058-2746(24)00465-8. [PMID: 38992415 DOI: 10.1016/j.jse.2024.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND Fractures of the acromion and spine can have a major impact on the outcome of reverse shoulder arthroplasty (RSA) with respect to pain, motion, and function. Reports on internal fixation for these fractures are isolated to small series or case reports with variable outcomes. The purpose of this study was to report on the outcome of open reduction and internal fixation (ORIF) of acromion or spine fractures encountered before or after RSA and describes our evolution of fixation techniques. METHODS Between 2011 and 2023, 22 fractures or nonunions of the acromion or spine of the scapula underwent ORIF at a single institution and were followed for a minimum of 1 year. In 16 shoulders, fractures occurred after RSA, whereas 5 shoulders underwent ORIF prior to RSA. One shoulder had undergone prior failed ORIF elsewhere and revision ORIF was performed at our institution. There were 10 males and 12 females with a mean age of 67 (SD = 15.1) years. Fixation strategies included single (n = 11) and double plate fixation (n = 11). Kruskal-Wallis one-way analyses of variance were used to analyze continuous variables and Chi-square tests employed for categorical variables. RESULTS Of the 5 fractures treated with ORIF pre-RSA, 1 shoulder suffered an additional fracture medial to the hardware and 1 required additional bone grafting for incomplete union at the time of RSA. These 5 shoulders all underwent RSA uneventfully, but 1 fracture experienced late displacement of the scapular spine nonunion, leading to plate removal. Of the 16 post-RSA ORIF shoulders, radiographic union was confirmed in 14 and substantial residual inferior angulation identified in 3. New fractures occurred after ORIF in 5 shoulders. For patients who underwent ORIF after RSA, pain scores improved from a mean of 8 to 1.9 points, with more modest elevation gains (58.2°-91.3° pre and postoperatively, respectively). CONCLUSIONS ORIF of acromion and scapular spine fractures or nonunions in the setting of RSA have the potential to lead to union. When these fractures and nonunions are encountered prior to RSA, ORIF allows for uneventful RSA implantation, but secondary displacement may occur. ORIF seems to lead to improvements in pain, but more modest improvements in motion and function. Our fixation strategy has evolved to (1) dual plating, (2) spanning the whole length of the spine with 1 of the plates, (3) use of hook features under the acromion or os trigonum if possible, and (4) liberal use of bone graft.
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Affiliation(s)
- Kristin E Yu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Erick M Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Ronda Esper
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Glener J, Vegas A, Schodlbauer DF, Levy JC. Acromion fractures after reverse shoulder arthroplasty occur in predictable clusters. J Shoulder Elbow Surg 2024; 33:1150-1156. [PMID: 37944744 DOI: 10.1016/j.jse.2023.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/10/2023] [Accepted: 09/24/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Acromion and scapular spine fractures (ASFs) following reverse total shoulder arthroplasty (RSA) have been reported at a rate of 3.9%. The location of the fracture has been shown to be an important factor in determining the outcomes of nonoperative treatment, with medial fractures having worse outcomes than lateral fractures. As the debate between operative and nonoperative treatment continues, a more precise understanding of the location of the fracture is necessary for effective management. The purpose of this study was to use 3-dimensional computed tomography (CT) reconstruction to characterize the exact location of ASFs after RSA. METHODS A retrospective review of 2 separate institutional shoulder and elbow repositories was performed. Patients with post-RSA ASFs documented by post-fracture CT scans were included. The query identified 48 patients who sustained postoperative ASFs after RSA between July 2008 and September 2021. CT scans of patients with ASFs were segmented using Mimics software. Eight patients were excluded because of poor image quality. Each bone model was manipulated using 3-Matic Medical software to align the individual scapula with an idealized bone model to create a view of scapular fracture locations on a normalized bone model. This model was used to classify the fractures using the modified Levy classification. RESULTS The study cohort consisted of 40 patients with a diagnosis of postoperative ASF after RSA. The median age at the time of surgery was 76 years (interquartile range, 73-79 years). The cohort comprised 32 women (80%) and 8 men (20%), with a median body mass index of 27.8. Only 10 patients (25%) had a previous diagnosis of osteoporosis and 6 (13%) had a diagnosis of inflammatory arthritis; 53% of patients underwent RSA owing to rotator cuff tear arthropathy. The distribution of fracture locations was similar within the cohort. However, lateral fractures were slightly more prevalent. The most common fracture location was the type I zone, with 12 fracture lines (29%). There were 11 fracture lines (26%) in the type IIa zone, 10 (23%) in the type IIb zone, 0 in the type IIc zone, and 9 (21%) in the type III zone. CONCLUSION ASFs after RSA occur in 4 predictable clusters. No fractures appeared to distinctly cluster in the type IIc zone, which may not represent a true fracture zone. Understanding the distribution of these fractures will help to enable the future design of implants and devices to stabilize the fractures that require fixation.
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Affiliation(s)
- Julie Glener
- Holy Cross Orthopedic Institute, Fort Lauderdale, FL, USA
| | - Austin Vegas
- Department of Orthopedic Surgery, Larkin Community Hospital, South Miami, FL, USA
| | | | - Jonathan C Levy
- Levy Shoulder Center at Paley Orthopedic & Spine Institute, Boca Raton, FL, USA.
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Hsiue PP, Chiou D, Shi B, Ahlquist S, Jensen AR, Cheung EC. Acromion fracture associated with traumatic first time anterior shoulder dislocation: a case report. JSES REVIEWS, REPORTS, AND TECHNIQUES 2024; 4:284-290. [PMID: 38706667 PMCID: PMC11065664 DOI: 10.1016/j.xrrt.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Affiliation(s)
- Peter P. Hsiue
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel Chiou
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Brendan Shi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Seth Ahlquist
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Andrew R. Jensen
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
| | - Edward C. Cheung
- Department of Orthopaedic Surgery, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA, USA
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Cui H, Cheong J, McKenzie D, Gould D, Rele S, Patel M. Outcomes of conservative treatment of acromial and scapular spine stress fracture post reverse shoulder arthroplasty: a systematic review with meta-analysis. J Shoulder Elbow Surg 2023; 32:2613-2630. [PMID: 37573934 DOI: 10.1016/j.jse.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/25/2023] [Accepted: 07/09/2023] [Indexed: 08/15/2023]
Abstract
INTRODUCTION Acromial and scapular spine stress fractures are common complications post reverse shoulder arthroplasty. A systematic review with meta-analysis was conducted to evaluate the clinical outcomes of conservatively treated acromial and scapular spine stress fractures post reverse shoulder arthroplasty in comparison to nonfracture control. METHODS Embase, MEDLINE, and Web of Science were searched on September 9, 2022, using various terms related to fracture, acromion, scapula, and reverse shoulder arthroplasty. Meta-analysis using a random effects model was performed on common outcome scores. Risk of bias was assessed using the Joanna Briggs Institute tools for case-controlled studies. Sensitivity analysis was performed for imputed standard deviations and studies with <20 participants. RESULTS Thirteen studies with a total of 339 fracture and 3142 control patients were included in the systematic review. Meta-analysis was performed on 12 studies assessing active forward flexion, abduction, external rotation, Constant-Murley score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, pain score, Simple Shoulder Test, and Single Assessment Numeric Evaluation. Fracture patients experienced significantly poorer functional outcome compared with control patients when the fractures were managed conservatively. Levy III fractures tend to experience worse outcomes. Pain score did not demonstrate a statistically significant difference between the fracture and nonfracture cohort. DISCUSSION Currently, literature regarding surgical management is lacking, partially because of a dearth of high-quality literature but also hindered by a lack of standardized techniques. This review was limited by inclusion of studies of low evidence, small sample sizes, and inconsistency in outcome measurement and follow-up period. Overall, patients with acromial and scapular spine stress fractures treated conservatively are expected to have reduced shoulder function compared to nonfracture patients, with the spine of scapula fracture patients suffering the poorest outcomes. Future studies should aim to use the same sets of outcomes parameters to assess the patients at fixed time intervals and report outcomes stratified by Levy classification. This will enable interinstitutional collaboration and pooling of results.
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Affiliation(s)
- Haoze Cui
- Department of Surgery, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia; Epworth Clinical School, Epworth HealthCare, Melbourne, VIC, Australia.
| | - Joel Cheong
- Department of Surgery, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia; Epworth Clinical School, Epworth HealthCare, Melbourne, VIC, Australia
| | - Dean McKenzie
- Research Development and Governance, Epworth HealthCare, Melbourne, VIC, Australia; Health Sciences and Biostatistics, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Daniel Gould
- Department of Surgery, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia; Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Siddharth Rele
- Department of Surgery, St Vincent's Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Minoo Patel
- Musculoskeletal Institute, Epworth HealthCare, Melbourne, VIC, Australia; Faculty of Health and Engineering, Royal Melbourne Institute of Technology University, Melbourne, VIC, Australia
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Buchanan TR, Bindi VE, Caban-Klepac E, Hones KM, Wright TW, Schoch BS, King JJ, Hao KA. Mitigating Fracture of the Acromion and Scapular Spine After Reverse Shoulder Arthroplasty: A Critical Analysis Review of Patient and Surgical Risk Factors. JBJS Rev 2023; 11:01874474-202312000-00004. [PMID: 38079495 DOI: 10.2106/jbjs.rvw.23.00175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
LEVEL OF EVIDENCE Level V. Narrative Review. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Victoria E Bindi
- College of Medicine, University of Florida, Gainesville, Florida
| | | | - Keegan M Hones
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, Florida
| | - Thomas W Wright
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, Florida
| | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Joseph J King
- Department of Orthopaedic Surgery & Sports Medicine, University of Florida, Gainesville, Florida
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, Florida
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Lee JH, Kim SH, Baek G, Nakla A, Kwak D, McGarry M, Lee TQ, Shin SJ. The biomechanical effects of acromial fracture angulation in reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2023; 32:2382-2388. [PMID: 37379965 DOI: 10.1016/j.jse.2023.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/01/2023] [Accepted: 05/13/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND The biomechanical changes and treatment guidelines on acromial fracture after reverse shoulder arthroplasty (RSA) are still not well understood. The purpose of our study was to analyze the biomechanical changes with respect to acromial fracture angulation in RSA. METHODS RSA was performed on 9 fresh-frozen cadaveric shoulders. An acromial osteotomy was performed on the plane extending from the glenoid surface to simulate an acromion fracture. Four conditions of acromial fracture inferior angulation were evaluated (0°, 10°, 20°, and 30° angulation). The middle deltoid muscle loading origin position was adjusted based on the position of each acromial fracture. The impingement-free angle and capability of the deltoid to produce movement in the abduction and forward flexion planes were measured. The length of the anterior, middle, and posterior deltoid was also analyzed for each acromial fracture angulation. RESULTS There was no significant difference in the abduction impingement angle between 0° (61.8° ± 2.9°) and 10° angulation (55.9° ± 2.8°); however, the abduction impingement angle of 20° (49.3° ± 2.9°) significantly decreased from 0° and 30° angulation (44.2° ± 4.6°), and 30° angulation significantly differed from 0° and 10° (P < .01). On forward flexion, 10° (75.6° ± 2.7°), 20° (67.9° ± 3.2°), and 30° angulation (59.8° ± 4.0°) had a significantly decreased impingement-free angle than 0° (84.2° ± 4.3°; P < .01), and 30° angulation had a significantly decreased impingement-free angle than 10°. On analysis of glenohumeral abduction capability, 0° significantly differed (at 12.5, 15.0, 17.5, and 20.0N) from 20° and 30°. For forward flexion capability, 30° angulation showed a significantly smaller value than 0° (15N vs. 20N). As acromial fracture angulation increased, the middle and posterior deltoid muscles of 10°, 20°, and 30° became shorter than those of 0°; however, no significant change was found in the anterior deltoid length. CONCLUSIONS In acromial fractures at the plane of glenoid surface, 10° inferior angulation of the acromion did not interfere with abduction and abduction capability. However, 20° and 30° of inferior angulation caused prominent impingement in abduction and forward flexion and reduced abduction capability. In addition, there was a significant difference between 20° and 30°, suggesting that not only the location of the acromion fracture after RSA but also the degree of angulation are important factors for shoulder biomechanics.
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Affiliation(s)
- Jae-Hoo Lee
- Department of Orthopaedic Surgery, Inje University, Ilsan Paik Hospital, Goyang-si, Republic of Korea
| | - Seong Hun Kim
- Department of Orthopaedic Surgery, Ilsan Hospital, National Health Insurance Service, Goyang-si, Republic of Korea
| | - Gyurim Baek
- Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Andrew Nakla
- Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Daniel Kwak
- Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Michelle McGarry
- Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Thay Q Lee
- Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Sang-Jin Shin
- Department of Orthopaedic Surgery, Ewha Shoulder Disease Center, Seoul Hospital, Ewha Womans University School of Medicine, Seoul, Republic of Korea.
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Kriechling P, Weber F, Karczewski D, Borbas P, Wieser K. Predictive factors of acromial fractures following reverse total shoulder arthroplasty: a subgroup analysis of 860 shoulders. JSES Int 2023; 7:812-818. [PMID: 37719815 PMCID: PMC10499654 DOI: 10.1016/j.jseint.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background Acromion stress fractures (ASF) or scapular spine fractures (SSF) following reverse total shoulder arthroplasty (RTSA) are common complications with impaired clinical outcome. The underlying biomechanical factors remain unclear. The aim of this study was to evaluate basic demographic and radiographic parameters predicting occurrence of different types of ASF/SSF in a large single-center study cohort. Methods A total of 860 RTSA (805 patients) with available minimum follow-up of 2 years were implanted between 2005 and 2018 at a tertiary academic center. All RTSA with subsequent ASF/SSF (n = 45 in 43 shoulders [42 patients, 5%]) were identified and classified as Levy I to III. Predictive demographic, surgical, and radiographic factors were evaluated for each subtype and compared to the control group (817 RTSA, 763 patients). The radiographic analysis included critical shoulder angle, lateralization shoulder angle (LSA), distalization shoulder angle (DSA), acromio-humeral distance (ACHD), acromial thickness, deltoid tuberosity index, deltoid length, and center of rotation. Results Of the 45 ASF/SSF in 42 patients, 8 were classified as Levy I, 21 as Levy II, and 16 as Levy III. Demographic analysis revealed indication as risk factor for Levy I fractures, higher American Society of Anesthesiologists score as risk for Levy type II fractures and higher age as risk factor for Levy type III fractures. None of the measured radiographic parameters were predictive for occurrence of Levy type I and Levy type II ASF. However, analysis of Levy III SSF revealed a higher postoperative LSA (89° ± 10° vs. 83° ± 9°, P = .015), a lower postoperative DSA (45° ± 8° vs. 53° ± 12°, P = .002), less distalization (ACHD of 33 ± 8 mm vs. 38 ± 10 mm, P = .049), and a more medial center of rotation preoperatively (COR-LA 16 ± 8 mm vs. 12 ± 7 mm, P = .048) as predictive radiographic factors. Conclusion The present analysis showed a significant association of higher postoperative LSA, lower DSA, a lower ACHD, and higher age as predictive factor only for Levy type III fractures. Some of these factors can be surgically influenced and this knowledge can be of value for preoperative planning and surgical execution to avoid these complications.
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Affiliation(s)
- Philipp Kriechling
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
| | - Florian Weber
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
| | - Daniel Karczewski
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
| | - Paul Borbas
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
| | - Karl Wieser
- Department of Orthopedics, Balgrist University Hospital, Zurich, Switzerland
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Garcia JR, Cannon D, Rodriguez HC, Grewal G, Lewis S, Lapica H, Levy JC. Comparison of reverse shoulder arthroplasty and total shoulder arthroplasty for patients with inflammatory arthritis. J Shoulder Elbow Surg 2023; 32:573-580. [PMID: 36206983 DOI: 10.1016/j.jse.2022.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/07/2022] [Accepted: 08/27/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND End-stage glenohumeral joint arthritis is common in patients with inflammatory arthritis. Reverse shoulder arthroplasty (RSA) and anatomic total shoulder arthroplasty (TSA) are both indicated in this setting. RSA is often considered based on the impacts of long-standing inflammatory arthritis including glenoid and humeral bone erosion and rotator cuff insufficiency. However, acromial and scapular spine fractures following RSA have been reported more commonly in these patients, which can have a significant impact on outcomes. Currently, no study has directly compared the efficacy and complication rates of RSA vs. TSA in patients with inflammatory arthritis. This study aimed to investigate differences in clinical outcomes and complications in patients undergoing RSA vs. TSA with glenohumeral inflammatory arthritis. METHODS We performed a retrospective review of 86 patients with inflammatory arthritis treated with primary RSA (n = 43) or TSA (n = 43) with a minimum of 2 years' follow-up. American Shoulder and Elbow Surgeons scores, Simple Shoulder Test scores, visual analog scale scores for pain and function, active range of motion, and patient self-ratings of upper-extremity normality (Subjective Assessment of Normal Evaluation [SANE]) were collected preoperatively and at minimum 2-year follow-up. Radiographic classification of preoperative glenoid and humeral bone loss was performed, and postoperative complications were observed. Revision and complication details were compared. RESULTS The study cohort had an average age of 72.1 years (range, 31-92 years) and average follow-up period of 51.6 months (range, 22-159 months). Both the RSA and TSA cohorts demonstrated improvements in patient-reported outcome measures and ranges of motion; however, patients treated with TSA showed a greater postoperative final Simple Shoulder Test score (P < .001), visual analog scale score for function (P = .0347), active elevation (P = .0331), active external rotation (P < .001), active internal rotation (P = .005), and Single Assessment Numeric Evaluation (SANE) score (P = .0161). Analysis of complication rates demonstrated no statistically significant difference between cohorts. Four acromial fractures occurred in the RSA group. When RSA patients who sustained acromial fractures were removed from the analysis, there were minimal differences in outcomes between the RSA and TSA cohorts. CONCLUSION TSA in patients with inflammatory arthritis leads to improved clinical outcomes but higher early revision rates when compared with RSA. RSA outcomes are negatively impacted by a high rate of postoperative acromial fractures.
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Affiliation(s)
- Jose Rafael Garcia
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Dylan Cannon
- Holy Cross Orthopedic Institute, Fort Lauderdale, FL, USA
| | | | - Gagan Grewal
- Department of Orthopedic Surgery, Larkin Community Hospital, South Miami, FL, USA
| | - Steven Lewis
- Holy Cross Orthopedic Institute, Fort Lauderdale, FL, USA
| | - Hans Lapica
- Holy Cross Orthopedic Institute, Fort Lauderdale, FL, USA
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Evaluation of the Painful Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2023; 31:440-449. [PMID: 36853881 DOI: 10.5435/jaaos-d-22-01006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 01/29/2023] [Indexed: 03/01/2023] Open
Abstract
Despite the overall success of anatomic and reverse total shoulder arthroplasties (aTSA and rTSA), some patients continue to have or develop pain postoperatively. As the number of shoulder arthroplasties continues to increase in the United States, it is important that surgeons are able to recognize, diagnose, and treat the various pathologies. Some painful etiologies are specific to either aTSA or rTSA, and others can occur with both implant types. Infections, stiffness, neurologic syndromes, polyethylene wear, aseptic implant loosening, and metal allergies occur, regardless of implant choice. However, after an aTSA, subscapularis repair failure, superior rotator cuff tear, and joint overstuffing can result in shoulder pain. After a rTSA, specific causes of postoperative pain include instability, scapular notching, acromial or scapular spine fractures, subcoracoid pain, and neurologic injury. Regardless of the diagnosis, the surgeon must be methodical in the evaluation and, when appropriate, use blood work, advanced imaging studies, joint aspirations, shoulder arthroscopy, and nerve studies. Once diagnosed, appropriate treatment should be undertaken to resolve the cause of the pain or at least minimize the effect of the pain on the patient's outcome.
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Friedrichs J, Ellwein A, Lill H, Hanhoff M. Akromionfrakturen und Deltamuskelverletzungen. ARTHROSKOPIE 2022. [DOI: 10.1007/s00142-022-00576-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hartzler RU, Ardebol J, Denard PJ. Arthroscopic Excision for Painful Acromial Fracture Nonunion After Reverse Total Shoulder Replacement. Arthrosc Tech 2022; 11:e2097-e2102. [PMID: 36457409 PMCID: PMC9706133 DOI: 10.1016/j.eats.2022.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 08/05/2022] [Indexed: 11/19/2022] Open
Abstract
Acromial stress fracture is a well-known complication after reverse shoulder arthroplasty. Although some patients are asymptomatic, others may present with reproducible pain to palpation and signs of impingement. Generally, the initial mode of treatment is conservative; however, surgical intervention is considered in patients with painful nonunion and displaced fragments. Although open reduction techniques are most common, Levy type I fragments may be amenable to excision. This technical note provides a stepwise approach to arthroscopic excision for painful nonunited acromial stress fractures after reverse shoulder arthroplasty.
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Affiliation(s)
- Robert U. Hartzler
- San Antonio Orthopaedic Group (TSAOG), Burkhart Research Institute for Orthopaedics (BRIO), San Antonio, Texas, U.S.A.,Address correspondence to Robert U. Hartzler, M.D., M.S., The San Antonio Orthopaedic Group, 19138 US Hwy 281 N, San Antonio, TX 78258, U.S.A.
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