Tuesday, August 4, 2015

Reverse total shoulder for failed internal fixation of fractures - a cautionary tale

Reverse shoulder arthroplasty as a salvage procedure after failed internal fixation of fractures of the proximal humerus: outcomes and complications.

These authors evaluated the clinical outcomes of reverse shoulder arthroplasty for failed fracture surgery in 19 patients (15 women and four men, mean age 66 years; 52 to 82 at a mean follow-up of 36 months (25 to 60).

The mean American Shoulder and Elbow Score improved from 27.8 to 50.1.
The mean Simple Shoulder Test score improved from 0.7 to 3.2.
The mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). 

A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures) as well as one nerve palsy.

Comment: A normal ASES score is 100, so the score of 50 achieved is only half of that. A normal Simple Shoulder Test score is 12, so the score of 3 achieved is only a quarter of that.

Two lessons can be learned: 
(1) Fracture surgery must be done well - the first operation needs to be the best operation, so that we don't wind up in the situation shown below.

Fixing proximal humeral fractures is a specialty in itself and the surgery is usually not an emergency. If a surgeon is not experienced in this specialty, the patient may be best served by a referral to someone who is.

(2) Salvage of failed fracture surgery is hazardous and the results of a reverse total shoulder are often not as good as the patient or the surgeon would like. These outcomes need to be discussed before embarking.


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