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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Failed prosthesis for fracture - salvaged by a reverse total shoulder

Here are some CT scan images of a 73 year old lady with a proximal humeral fracture

Her surgeon attempted a reconstruction with a massive cemented humeral implant. Note the greater tuberosity applied to the metal prosthesis laterally.

She presented to us a year later with pseudo paralysis and with resorption of the tuberosity as shown in the film below.

With difficulty in removing the cemented stem, we were able to convert to a reverse total shoulder.

We saw her yesterday in the office - she said she had no shoulder pain and had active elevation to 150 degrees. Her films are shown below.

Comment: Complex fractures such as this may be best managed by an initial reverse total shoulder rather than attempting an anatomic prosthesis. In cases where a prosthesis was previously cemented, a reverse can be cemented within the existing cement mantle. 

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Use the "Search" box to the right to find other topics of interest to you.


You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.