Abstract
Purpose
While treating fracture sequelae (FS) with unconstrained prostheses has been shown to give inferior or unpredictable outcomes, the literature is still scant regarding their treatment with reverse shoulder arthroplasty (RSA). This study was performed to determine the suitability of RSA as a solution for FS with severe tuberosity malunion/nonunion and rotator cuff dysfunction, and to identify any useful preoperative prognostic factors.
Method
Between 1997 and 2007, RSA was performed in 26 cases for FS of type 4 according to the classification of Boileau et al., previously treated either operatively or nonoperatively. Prior treatment with hemiarthroplasty was an exclusion criteria, as was follow-up of less than two years, leaving 20 patients who had undergone an average of one surgery prior to the index RSA (range, 1–3) and were followed up for a mean of 4.8 years. Preoperatively, the mean global fatty degeneration index (GFDI) was 1.8 (range, 0.7–2.9), and almost half the patients had an atrophic or ruptured teres minor. The mean age at surgery was 70 years (range, 50–91). Clinical evaluation was performed by two independent observers with the help of the Constant score (CS) and Subjective Shoulder Value (SSV).
Results
Three patients (15%) had five complications, all of which were treated with reoperation. No infections and only one case of instability occurred. Overall, 82% were satisfied or very satisfied, and the mean relative CS improved by 45% (from 35% to 80%). The best range-of-motion gains were made in active anterior elevation, which improved by 53 (from 62 to 115), although gains were generally variable. Teres minor and subscapularis insufficiency was observed in many patients. Worse clinical outcomes were associated with these preoperative variables: prior surgical treatment, medical comorbidity, a lack of active external rotation, and a GFDI of 2.0 or more. However, the numbers available did not produce statistically significant correlations. Radiographic humeral-component loosening was seen in one patient (5%), and either the humeral or the glenoid component was considered at-risk in three patients (15%), although no revisions were performed for loosening.
Conclusion
These results show that in the medium term, RSA is a very good treatment option for elderly patients with severe FS and rotator cuff dysfunction. They are better than previously published results of RSA performed for FS but not as good as those of RSA for CTA. High satisfaction rates may be related to the severity of preoperative disability and good patient education. The association of prior surgical treatment with worse results may be related to the negative effect of surgery on the rotator cuff and anterior deltoid. Much can be learned from the reported complications, and outcomes will probably improve with improved prosthetic design and surgical techniques, as well as with better surgeon and patient awareness of the surgical pitfalls and variable clinical gains, especially in rotation.
