Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston Shoulder Institute, Boston, MA, USA.
Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA.
J Shoulder Elbow Surg. 2023 Dec;32(12):2483-2492. doi: 10.1016/j.jse.2023.05.015. Epub 2023 Jun 15.
Both patient and implant related variables have been implicated in the incidence of acromial (ASF) and scapular spine fractures (SSF) following reverse shoulder arthroplasty (RSA); however, previous studies have not characterized nor differentiated risk profiles for varying indications including primary glenohumeral arthritis with intact rotator cuff (GHOA), rotator cuff arthropathy (CTA), and massive irreparable rotator cuff tear (MCT). The purpose of this study was to determine patient factors predictive of cumulative ASF/SSF risk for varying preoperative diagnosis and rotator cuff status.
Patients consecutively receiving RSA between January 2013 and June 2019 from 15 institutions comprising 24 members of the American Shoulder and Elbow Surgeons (ASES) with primary, preoperative diagnoses of GHOA, CTA and MCT were included for study. Inclusion criteria, definitions, and inclusion of patient factors in a multivariate model to predict cumulative risk of ASF/SSF were determined through an iterative Delphi process. The CTA and MCT groups were combined for analysis. Consensus was defined as greater than 75% agreement amongst contributors. Only ASF/SSF confirmed by clinical and radiographic correlation were included for analysis.
Our study cohort included 4764 patients with preoperative diagnoses of GHOA, CTA, or MCT with minimum follow-up of 3 months (range: 3-84). The incidence of cumulative stress fracture was 4.1% (n = 196). The incidence of stress fracture in the GHOA cohort was 2.1% (n = 34/1637) compared to 5.2% (n = 162/3127) (P < .001) in the CTA/MCT cohort. Presence of inflammatory arthritis (odds ratio [OR] 2.90, 95% confidence interval [CI] 1.08-7.78; P = .035) was the sole predictive factor of stress fractures in GHOA, compared with inflammatory arthritis (OR 1.86, 95% CI 1.19-2.89; P = .016), female sex (OR 1.81, 95% CI 1.20-2.72; P = .007), and osteoporosis (OR 1.56, 95% CI 1.02-2.37; P = .003) in the CTA/MCT cohort.
Preoperative diagnosis of GHOA has a different risk profile for developing stress fractures after RSA than patients with CTA/MCT. Though rotator cuff integrity is likely protective against ASF/SSF, approximately 1/46 patients receiving RSA with primary GHOA will have this complication, primarily influenced by a history of inflammatory arthritis. Understanding risk profiles of patients undergoing RSA by varying diagnosis is important in counseling, expectation management, and treatment by surgeons.
患者和植入物相关因素都与反肩关节置换（RSA）后肩峰（ASF）和肩胛脊柱骨折（SSF）的发生有关；然而，先前的研究尚未对不同适应证的风险特征进行描述和区分，包括原发性肩盂肱关节炎伴完整肩袖（GHOA）、肩袖关节炎（CTA）和巨大不可修复肩袖撕裂（MCT）。本研究旨在确定不同术前诊断和肩袖状态下与累积 ASF/SSF 风险相关的患者因素。
本研究纳入了 2013 年 1 月至 2019 年 6 月期间来自 15 个机构的 24 名美国肩肘外科医生（ASES）的 RSA 患者，这些患者术前诊断为原发性 GHOA、CTA 和 MCT。通过迭代德尔菲法确定了包括患者因素在内的多变量模型来预测累积 ASF/SSF 风险的纳入标准、定义和纳入。CTA 和 MCT 组被合并进行分析。共识定义为贡献者之间的大于 75%的一致性。仅包括通过临床和影像学相关性证实的 ASF/SSF 进行分析。
我们的研究队列包括了 4764 名术前诊断为 GHOA、CTA 或 MCT 的患者，最短随访时间为 3 个月（范围：3-84 个月）。累积应力骨折的发生率为 4.1%（n=196）。GHOA 组的应力骨折发生率为 2.1%（n=34/1637），而 CTA/MCT 组为 5.2%（n=162/3127）（P<.001）。炎性关节炎（比值比[OR]2.90，95%置信区间[CI]1.08-7.78；P=.035）是 GHOA 患者应力骨折的唯一预测因素，而炎性关节炎（OR 1.86，95% CI 1.19-2.89；P=.016）、女性（OR 1.81，95% CI 1.20-2.72；P=.007）和骨质疏松症（OR 1.56，95% CI 1.02-2.37；P=.003）是 CTA/MCT 组的预测因素。
与 CTA/MCT 患者相比，GHOA 的 RSA 后应力骨折风险的术前诊断有不同的风险特征。尽管肩袖完整性可能对 ASF/SSF 有保护作用，但大约每 46 例接受 RSA 治疗的原发性 GHOA 患者中就会出现这种并发症，主要受炎性关节炎病史的影响。了解不同诊断下 RSA 患者的风险特征对于外科医生的咨询、期望管理和治疗很重要。
