SECEC Grammont Award 2017: the prejudicial effect of greater tuberosity osteotomy or excision in reverse shoulder arthroplasty for fracture sequelae

Abstract

Hypothesis: The aim was to evaluate risk factors for complications, revision, and mid-to long-term outcomes after reverse shoulder arthroplasty (RSA) implanted for proximal humeral fracture sequelae (PHFS). Methods: The radiographs of 98 patients (mean age, 68 years) who underwent RSA for the treatment of PHFS were reviewed at a minimum 5-year follow-up. PHFS were divided into 4 types according to the Boileau classification: type 1 (46 cases), type 2 (6 cases), type 3 (12 cases), and type 4 (34 cases). The tuberosities underwent osteotomy in 28 cases and excision in 12 (all type 3 or 4 PHFS). The mean follow-up period was 8.4 years (range, 5-14 years). Results: The functional results and rate of RSA survival without revision (85% vs. 100% at 10 years, P ¼ .007) were significantly lower for types 3 and 4 vs. types 1 and 2. Overall, our findings showed that RSA for PHFS is not the panacea that surgeons once believed: At a mean follow-up of 8.5 years (range, 5-14 years), 59% of the patients in our series had fair or poor results. Patients who underwent tuberosity osteotomy or excision had lower functional results (adjusted Constant score, 69% vs. 88%; P < .001), more postoperative complications (32% vs. 9%, P ¼ .003), and a higher revision rate (15% vs. 2%, P ¼ .017). Patients who underwent tuberosity osteotomy or excision at the time of RSA were at risk of postoperative prosthetic instability and humeral stem loosening. The absence of the greater tuberosity at last radiographic follow-up was predictive of higher rates of complications and revisions, as well as a poorer final outcome. Previous fracture fixation was associated with a higher rate of complete tuberosity resorption (56% vs. 33%, P ¼ .026) and with higher rates of postoperative complications (27% vs. 13%, P ¼ .099) and reinterventions (17% vs. 2%, P ¼ .018). Conclusion: The functional results and rates of complications and revision depend on the type of fracture sequelae and tuberosity management. Patients with more severe (type 3 and 4) fracture sequelae who undergo tuberosity osteotomy or excision are at risk of having a poorer functional result and higher rates of complications and revision with lower survival. Previous fracture fixation is also a prejudicial factor.

Proximal humerus fracture sequelae: are corrective osteotomies still a taboo? The role of three-dimensional preoperative planning and patient-specific surgical guides for proximal humerus corrective osteotomy in combination with reverse shoulder arthroplasty

“… 14 In this latter case, should the patient undergo rTSA, an accurate placement of the stem could be technically difficult with a high rate of complications. 6 , 8 , 18 , 22 In order to correct humeral deformities without performing an osteotomy of the greater tuberosity, Neer recommended to ream eccentrically the medullary canal and to use an undersized humeral stem placed in a nonanatomic position. 21 Conversely, other authors have proposed to use stemless or onlay stem prostheses.…”

“…Previous studies reported an intraoperative fracture rate between 6.8% and 33%. 6 , 19 , 25 , 26 In a review including 9 studies and 234 patients affected by PHFS (without any distinction about subtype) treated with rTSA, Holton et al reported a 29% rate of severe complication (dislocation in 16.7%, infection in 6.8%, periprosthetic fracture in 3%, and nerve injury in 2.6% of cases) . 14 In 2020, Boileau et al reported the results achieved in 98 patients presenting with PHFS, undergone rTSA and followed at a minimum of 5 y.…”

“…In order to avoid an excessive humeral shortening, a cuneiform resection was not considered. Once the osteotomy had been completed, the humeral prosthetic stem was handled as a nail (“shish-kebab” technique 6 ). The metaphyseal fragment was fixed to the prosthetic stem and to the humeral diaphysis using non-resorbable, number 2, transosseous sutures.…”

“… 4 , 8 , 10 , 18 This may be explained by the longer delay between trauma and surgery, the amount of tuberosity displacement, the chronic soft tissue retraction, the metaphyseal bone loss, the complexity of revision surgery after failed osteosynthesis, and the patient functional expectations. 6 , 11 , 13 , 23 , 35 …”

“…Interestingly, many authors have advised against performing greater tuberosity osteotomies in the setting of prosthetic replacement of the shoulder due to the poor clinical outcome and the high complication rate. 6 On the other side, during the last years, three-dimensional (3D) virtual preoperative planning and custom-made surgical guides have been made available and proven as valuable aids in this kind of surgery, 12 29 42 enabling surgeons to evaluate post-traumatic deformities in a 3D environment and to plan osteotomies with greater accuracy. 43 , 44 …”