Case Reports

Coracoid Fracture After Reverse Total Shoulder Arthroplasty: A Report of 2 Cases

Am J Orthop. 2015 November;44(11):E469-E472

Although reverse total shoulder arthroplasty is largely successful, there are still complications that require appropriate diagnostic workup and treatment. These 2 cases of patients with a coracoid fracture were encountered at 3 months and 15 months after reverse total shoulder arthroplasty. One patient presented with new-onset pain in the coracoid region without significant functional deficit, and the other presented with functional deficit and complaint of a strange noise at the anterior aspect of the operative shoulder. While standard radiographs did not detect the fracture, computed tomography imaging was sufficient to establish the diagnosis. Ultimately, nonoperative management led to resolution of these symptoms.

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References

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Reverse total shoulder arthroplasty (RTSA) performed in carefully selected patients often leads to satisfactory outcomes.^1,2 In recent years, its indications and the number performed per year have expanded. Subsequently, there has been a concomitant rise in reported complications,^2,3 with a rate ranging from 19% to 68%.^2,3 Some common complications include scapular notching,^2-4fracture,^2,3,5-7 dislocation,^2,3,7 and infection.^2,3,7

In this series, we describe 2 cases of coracoid fracture after RTSA. The patients provided written informed consent for print and electronic publication of these case reports.

Case Series

Case 1

An independently functioning 81-year-old right hand–dominant woman (BMI, 22.1 [height, 160 cm; weight, 56.7 kg]) presented with increasing left shoulder pain and dysfunction after a motor vehicle accident 2 months earlier. She had reported vague chronic left shoulder pain in the past, but after the accident her pain was significantly worse. A subacromial corticosteroid injection by her primary care physician provided temporary symptomatic relief, but her symptoms recurred.

On presentation, there was obvious anterior superior escape of the humeral head, which was accentuated by shoulder shrug. Her deltoid motor function was found to be intact, and her active shoulder range of motion was severely limited (pseudoparesis). There was notable crepitation as well as significant weakness and pain with abduction and external rotation strength testing.

Radiographic imaging showed anterior superior escape of the humeral head with some early degenerative changes (Seebauer type IIB⁸ [Figure 1A]). Magnetic resonance imaging confirmed a full-thickness retracted massive rotator cuff tear with complete involvement of the supraspinatus, infraspinatus, and most of the subscapularis muscles. Significant glenohumeral degenerative changes consistent with cuff tear arthropathy were also seen without any evidence of fracture.

After thorough discussion of options, risks, and benefits, the decision was made to proceed with RTSA. The patient underwent the procedure without complications. A DePuy Delta Xtend prosthesis was used with a cemented humeral stem, polyethylene, and glenosphere, sizes of 12, +3, and 38, respectively. The glenosphere component, positioned inferiorly to avoid scapular notching, was secured with 3 screws, and the stem was placed in neutral version. The patient’s shoulder was reduced, ranged, and noted to be stable, allowing for supple passive range of motion without evidence of excessive tightness. She was placed in a sling with the shoulder positioned in neutral alignment. Her postoperative radiograph (Figure 1B) showed satisfactory implantation of the reverse total shoulder prosthesis. Her postoperative course was uneventful, and rehabilitation consisted of 6 weeks of sling protection, with advancing passive and active range of motion. Strengthening exercises were initiated 6 weeks after surgery.

At the patient’s 6-week postoperative visit, she demonstrated pain-free passive elevation to 80° and active forward elevation to 70°. At her 3-month postoperative visit, she reported a 1-week onset of anterior shoulder pain accompanied by a strange noise at the anterior aspect of the operative shoulder. She denied any recent trauma. She continued to have minimal shoulder pain with passive forward flexion of 80°; however, her active forward elevation was very limited because of pain in the anterior aspect of her shoulder. Active external rotation was noted to be 20° and internal rotation was to her buttock. She had pain to palpation of the coracoid process. Radiographs were unchanged from immediate postoperative radiographs. Computed tomography (CT), which was ordered to ensure that the implant was stable with no loosening, showed satisfactory alignment of the prosthesis and no loosening. However, CT was notable for a nondisplaced fracture through the base of the coracoid (Figures 2A-2D). The patient stopped formal physical therapy, and sling immobilization was initiated. After 3 weeks, the sling was discontinued and physical therapy was begun again. She responded satisfactorily to this treatment approach, and, at her 6-month postoperative follow-up, she was without pain, instability, or crepitation. Her range of motion had improved with pain-free active forward flexion, external rotation, and abduction of 100°, 15°, and 90°, respectively. At 28-month postoperative follow-up, her visual analog scale, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score were 3, 73, and 67, respectively.

Case 2

A 68-year-old, right-handed woman (BMI, 22.5 [height, 160 cm; weight, 57.6 kg]) presented with right shoulder pain and dysfunction of 3 years’ duration. She had undergone an open rotator cuff repair at an outside facility 4 years ago that was unsuccessful. At the time of her presentation to our institution, she had already undergone a failed course of physical therapy. A trial of corticosteroid subacromial injections did not adequately manage her symptoms.