What Are Risk Factors for Intraoperative Humerus Fractures During Revision Reverse Shoulder Arthroplasty and Do They Influence Outcomes?

Abstract

Background With the increase in shoulder arthroplasty rates, the number of perioperative complications, such as periprosthetic fractures, continues to be a rise; however, the risk factors and incidence of intraoperative complications, such as fractures, during revision reverse shoulder arthroplasty are not well established. Questions/purposes We evaluated patients receiving a reverse shoulder arthroplasty to determine (1) the frequency and characteristics of intraoperative humerus fractures, (2) the risk factors for fracture, (3) the complications associated with treatment of fractures, and (4) clinical and functional outcomes after treatment. Methods Using one institution's total joint registry, we performed a retrospective analysis of medical records of 224 patients (230 shoulders) who underwent revision surgery to reverse shoulder arthroplasty, from 2005 to 2012, for failed total shoulder arthroplasty. Reverse shoulder arthroplasty was used when there was a deficient rotator cuff, prior instability, or deficient glenoid bone stock. Intraoperative periprosthetic humerus fractures occurred in 36 shoulders (16%) (36 patients). The clinical outcome analysis included 29 patients with a minimum 2-year clinical followup (mean followup, 3.1 years; range, 2.0À6.3 years). The control group consisted of 188 patients (194 shoulders), and it was used for risk-factor calculation; whereas only 150 patients (154 shoulders) in the control group had a minimum 2-year followup, and thus only 150 patients (154 shoulders) made up the comparators (controls) for outcome-analysis comparisons. Risk factors were assessed using univariate analysis with odds ratios (OR), whereas implant survival and complications were assessed using the Kaplan-Meier method. Results Three displaced and 33 nondisplaced fractures occurred during revision reverse total shoulder arthroplasties. Most of the fractures (81%) occurred during component removal of cemented (n = 11) and cementless (n = 25) components. Intraoperative fractures only were treated with stabilization of the prosthetic stem in 28 patients, while adjunctive internal fixation was used in eight patients. Risk of intraoperative periprosthetic fractures was increased by factors including female sex (n =18 women; OR, 2.41; range, 1.11À5.68; p = 0.03); history of instability (n = 27; OR, 2.65; range, 1.18À5.93; p = 0.02); and prior hemiarthroplasty (n = 22; OR, 2.34; range, 1.13À4.84; p = 0.03). There were two postoperative fractures in patients who had an intraoperative fracture and both were treated nonoperatively. Overall, three (8%) revision procedures were performed in patients with intraoperative fractures, with 2-and 5-year survivorship estimates of 94% and 85%, respectively, compared with 89% and 84%, respectively for patients without an intraoperative fracture (p = 0.45). At latest followup, patients

Complications of Shoulder Arthroplasty

“…Potential advantages with platform shoulder systems include reduced operative time, blood loss, cost, and length of hospitalization 11, 49,58,[203][204][205][206][207] . The most salient advantage involves reduction in the rate of periprosthetic humeral fracture during revision surgery (Figs.…”

Complications in reverse shoulder arthroplasty

“…24 Although most early RSA were initially designed for cemented fixation of the humeral component, cementless fixation has become very common. Excessive uncontrolled reaming for cementless fixation should be avoided, as it may produce a stress riser area at the end of the reaming area, and may increase the risk of periprosthetic fracture.…”

Risk factors for and timing of adverse events after revision total shoulder arthroplasty

“…Prior studies have focused on identifying risk factors for complications such as intraoperative humeral fracture, early dislocation, increased transfusion, infection, and nerve injury. 15 Specifically, Wagner et al 8 analyzed 230 RTSA cases and found risk of intraoperative periprosthetic fractures was increased by female gender (OR: 2.41, p ¼ 0.03), history of instability (OR: 2.65, p ¼ 0.02), and prior hemiarthroplasty (OR: 2.34, p ¼ 0.03). Two studies of 73 and 32 RTSA for glenoid loosening found that patients with a full-thickness rotator cuff tear at time of revision surgery had a higher risk of re-operation (p ¼ 0.03), and identified instability, rotator cuff tears, and malunion of the greater tuberosity as risk factors for poor outcomes.…”

“…He reported that component revision provides the best results while soft-tissue reconstruction provides worse results overall. Another study of 230 revisions of reverse TSA by Wagner et al 8 found that female gender, history of instability, and prior hemiarthroplasty increased risk for post-revision complications. Saltzman et al 9 compared complication rates for 111 primary and 26 RTSAs and found body mass index (BMI) to predict medical complications after primary and RTSA.…”