A 69-year-old female presented to our clinic with a longstanding history of symptomatic right shoulder rotator cuff tear arthropathy. She exhausted non-operative management including activity modification, oral anti-inflammatories, physiotherapy and multiple corticosteroid injections (Figure 1). Her physical exam demonstrated significantly limited pre-operative active range of motion: 40 degrees of forward elevation, 20 degrees of abduction, 0 degrees of external rotation (with arm adducted to the side) and internal rotation to the buttock. X-ray and CT scan imaging studies demonstrated superior migration of the humeral head, an acromiohumeral interval <6 mm and acetabularization of the acromion, consistent with grade 3 Hamada rotator cuff tear arthropathy. Due to persistent pain and dysfunction negatively impacting on her quality of life, it was recommended that her most reliable surgical option would be a RTSA. After a thorough discussion regarding the risk and benefits, she elected to move forward with the procedure.
In October 2013, a RTSA procedure was completed (Biomet Comprehensive Reverse Shoulder prosthesis (Biomet Inc, Warsaw, Indiana, USA) with a 6-mm mini cemented stem, 28-mm glenoid baseplate, 36-mm standard glenosphere (Versa-Dial between position B and C providing a 2 mm inferior offset) and a standard 44-mm humeral tray with a 36-mm polyethylene humeral cup was implanted (Figure 2). The procedure was uncomplicated. She was provided a routine rehabilitation protocol that consisted of an abduction sling and non-weightbearing in the right upper extremity for 6 weeks followed by active physiotherapy treatment to increase range of motion and gradual strengthening.
She did not return for additional assessments after the 6-week clinical and radiographic check as she lived a significant distance from our hospital. Thus, her preference was to follow-up on an as needed basis and objective measures of motion and strength subsequently were not available. However, she stated she did well during this time returning to all her normal activities of daily living of self-care and house-hold tasks both at and above shoulder level maintaining independent function.
In November 2018, she sustained a mechanical fall onto her right shoulder. Repeat radiographs demonstrated an isolated mid-to-distal one-third clavicle shaft fracture without any evidence of prosthetic loosening or change in position of her RTSA implants (Figure 3). Her initial physical exam demonstrated no significant clinical deformity consisting of an ipsilateral shoulder droop, significant clavicular shortening, or an anterior rotational deformity with shoulder ptosis and/or scapular winging. Radiographically, the clavicle fracture had minimal shortening of <1cm and mild angulation. Therefore, non-operative treatment was recommended and a sling was applied for comfort with therapy to be initiated after 2 weeks to maintain motion.
On serial reassessments, the fracture failed to demonstrate healing on standard clinical and radiographic examinations and she subsequently developed a chronic symptomatic non-union of her right clavicle fracture (Figure 4). She had no history of bone metabolic abnormalities. At 6 months post-injury, she continued to have pain localized to the right clavicle, motion at the fracture site, as well as significantly reduced active range of motion. Her forward elevation was 60 degrees, abduction was 50 degrees, external rotation was 0 degrees, and internal rotation was limited to the greater trochanter. X-rays revealed an oligotrophic non-union of the clavicle fracture. The scapula had a notable increase in superior tilt, as demonstrated with increasing upward rotation angle with scapular measurements taken according to Endo et al.   and shoulder AP radiographs (Figure 5), in addition to scapular notching and exposure of the inferior base plate screw compared to her initial postoperative imaging (Figure 6). While the glenoid base plate was still noted to be stable on CT imaging, given the potential of further notching and impingement leading to progressive glenoid loosening and persistent symptoms, the decision was made to proceed with operative fixation of her clavicle fracture.
In May 2019, the patient underwent open reduction and internal fixation of her clavicle fracture. Her pseudoarthrosis was excised and a 3.5-mm precontoured clavicular lateral locking plate (DePuy Synthes, West Chester, PA) was used to anatomically reduce and stabilize the clavicle fracture with local autograft. Her surgery was uncomplicated.
At her 4 month post-operative follow-up, her fracture had healed, both clinically and radiographically (Figure 7). There was no further progression of her superior scapular tilt or scapular notching (Figure 8). Her active range of motion improved, such that she was able to forward elevate and abduct to 100 degrees, externally rotate to 20 degrees and internally rotate to the sacrum.