Outcomes of operative and non-operative management of acromial and scapular spine fractures after reverse shoulder arthroplasty: a systematic review
TL;DR
Surgical fixation demonstrates higher union, but functional outcomes are comparable to non-operative management and surgery carries notable complication burden, and treatment should be individualized, and prospective comparative studies using standardized classifications/outcomes are required.
Abstract
Background Reverse total shoulder arthroplasty (rTSA) use is rising. Acromial stress fractures (ASFs) are infrequent but significant complication associated with pain and functional limitation. Optimal management remains uncertain. This review compared union, functional outcomes, and complication between non-operative and operative management of ASF post-rTSA. Methods Systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library were searched. Randomized controlled trials, observational studies, and case series including ≥3 adult patients with post-rTSA ASFs reporting management and outcomes were eligible. A descriptive quantitative synthesis was undertaken. Results Fourteen studies (376 fractures in 374 patients; mean age 72.9 years; 78% female) were included. ASF incidence (from 4 studies) ranged from 3.1 to 7.2%. Seventy percent of fractures occurred atraumatically; mean time to diagnosis was 11.3 months; mean follow-up was 41.1 months. Levy type II predominated. Management was non-operative (73.9%) or operative (26.1%). Overall union was 68%, higher after fixation (78% vs. 59.8%; P = .004). Patient-reported outcomes differed modestly: visual analog scale 1.7 versus 2.4, American Shoulder and Elbow Surgeons 66.9 versus 60.2, Constant score 37.9 versus 46.0, and Subjective Shoulder Value 63.5 versus 60.7 (operative vs. non-operative). External rotation trended higher after surgery. Operative complications occurred in 28.2%, with 91% requiring reoperation, most hardware irritation or fixation failure. Conclusion ASFs post-rTSA remains challenging. Surgical fixation demonstrates higher union, but functional outcomes are comparable to non-operative management and surgery carries notable complication burden. Given the descriptive, Level IV evidence, findings are hypothesis-generating; treatment should be individualized, and prospective comparative studies using standardized classifications/outcomes are required.