Periprosthetic Fractures in Reverse Total Shoulder Arthroplasty: Current Concepts and Advances in Management

Abstract

Purpose of review: Expanded indications for reverse total shoulder arthroplasty (RSA) have raised awareness of associated complications, including periprosthetic fractures. The purpose of this article was to provide a comprehensive update on how, when, and why RSA-related periprosthetic fractures occur, as well as to describe the current treatment strategies.

Recent findings: Periprosthetic acromial and scapular spine fractures occur in up to 4.3% of cases and periprosthetic humeral fractures occur in approximately 3.5% of RSA procedures. Fractures of the coracoid process and clavicle have also been reported. Current literature has identified several risk factors for intraoperative or postoperative fracture, including underlying osteoporosis, revision arthroplasty, use of a superiorly placed screw during metaglene fixation, and disruption of the scapular ring by transection of the coracoacromial ligament. Periprosthetic fracture associated with RSA is a clinically significant event that warrants prolonged postoperative vigilance, timely diagnosis, and shared patient decision-making regarding treatment. Further research is needed to identify optimal treatment strategies and characterize long-term clinical outcomes following RSA-related periprosthetic fracture.

Keywords: Acromion; Clavicle; Coracoid process; Humeral fracture; Reverse shoulder arthroplasty; Scapular fracture.

Fig. 1

A post-RSA radiograph does not demonstrate evidence of fracture (a). However, an acromion base fracture is demonstrated on CT (b). (Reproduced from Neyton L, Erickson J, Ascione F, Bugelli G, Lunini E, Walch G. [••])

Fig. 2

Illustration of the scapular ring concept. The coracoacromial ligament (CAL) distributes strain patterns through the scapula. Transection of the CAL during reverse shoulder arthroplasty may result in increased strain seen at the scapular spine. (Reproduced from Taylor et al. [••])

Fig. 3

Illustration of the Levy classification of postoperative acromial fractures following reverse shoulder arthroplasty. Type 1 fractures involve the anterior and middle portions of the deltoid, type 2 fractures involve the middle and part of the posterior deltoid, and type 3 fractures involve the middle and entire posterior deltoid origin. (Reproduced from Levy et al. [•])

Fig. 4

Right shoulder anteroposterior radiograph of a 74-year old female 3 months status-post right reverse shoulder arthroplasty. Findings demonstrate a Levy III fracture. Patient was treated with 6 weeks of additional sling immobilization. Most recent follow-up demonstrated persistent chronic scapular spine fracture with persistent mild pain

Fig. 5

Campbell Classification of periprosthetic humeral fractures. a Type 1 involves the lesser or greater tuberosity, b type 2 involves the surgical neck, c type 3 the metadiaphyseal junction, and d type 4 the middle and distal humeral diaphysis. (Image reproduced from Campbell et al. [52])