Acute Axillary Artery Thrombosis Following Reverse Total Shoulder Arthroplasty for Complex Humeral Head Fracture: A Case Report

Several studies have reported an overall increase incidence
of proximal humeral fractures in the elderly with considerable
patient disability and increased public spending...


Introduction
Several studies have reported an overall increase incidence of proximal humeral fractures in the elderly with considerable patient disability and increased public spending [1,2]. Almost 80% of these fractures can be treated nonoperatively, being non or minimally displaced [3]. The gold standard surgical treatment for humeral complex fractures is still controversial. Numerous implants are available, including fixation devices (ORIF) and hemi, total or reverse arthroplasties. Reverse total shoulder arthroplasty (rTSA) was developed for treatment of cuff-tear arthropathy [4,5] but in the last decade has been used as a surgical solution for displaced proximal humeral fractures in the elderly [6]. It is a safe procedure with a very low in-hospital mortality rate [7]. However, many perioperative complications such as hematoma, deep venous thrombosis, cerebrovascular accident, blood transfusion, nerve injuries and postoperative infection [8] has been described. Axillary artery vascular thrombosis following shoulder trauma might be due to acute or iatrogenic, during open reduction techniques, anterior proximal dislocation [9,10]. However, this complication has been rarely described while performing RTSA [11,12]. According to our knowledge, this is the first case report of an early post-operative axillary artery thrombosis after rTSA for proximal humeral fracture in the elderly.

Case Report
A 79-year-old patient accidentally fell at home tripping over her shoes. She got in our emergency department with pain and functional limitation at her left shoulder. The patient was conscious, oriented with no headache, no nausea, no vomiting, no

ARTICLE INFO Summary
Reverse total shoulder arthroplasty (rTSA) is an expanding operative solution for complex proximal humeral fracture. Vascular thrombosis of the axillar artery is a rare but possible complication concomitant with RTSA. According to our knowledge, this is the first described early acute post-operative axillary artery occlusion after rTSA for proximal humerus fracture dislocation in the elderly. We describe the case of a 79-year-old female with a type 11 C-3 fracture according to the AO/OTA classification who underwent RTSA. Signs of acute ischemia of the left upper limb and axillary nerve stupor were detected clinically in the early post-operative. Prompt vascular surgery operation restored normal peripheral flow. At 1-year follow-up, patient resumed a normal life with complete restoration of circumflex nerve and residual dysesthesia of the median nerve. Probably, the intimal lesion caused by the trauma was worsened by the increased tension on the neurovascular structures during the procedure of fracture reduction and replacement. Moreover, rTSA places brachial plexus and axillary artery under longitudinal strain by lengthening the arm. This case report shows the importance of early clinical follow up after rTSA in displaced proximal humeral dislocated fractures. In these cases, combined vascular and orthopedic surgeons monitoring and careful post-operative physiotherapy is crucial for a good clinical and functional result. apparent motor or sensory deficits and valid bilateral radial pulses.
Hypertension, vascular encephalopathy, intestinal sub-occlusion, partial nephrectomy and chronic therapy with acetylsalicylic acid (ASA) and atenolol were part of patient's medical history. Barthel index premorbid was 90/100. Standard radiographs of her left shoulder were performed revealing a displaced, fracture-anteriordislocation of the proximal left humerus, described as type 11 C-3 fracture according to the AO/OTA classification ( Figure 1A-1B).
After two unsuccessful attempts of closed reduction of the humeral head, a Desault bandage was applied.

Discussion
Reverse total shoulder arthroplasty (RTSA) has been increasingly carried out during the past decade, and it is now widely preferred for treating displaced proximal humeral fractures in the elderly [6]. Furthermore, a recent multicentre randomized controlled trial has showed better clinical outcomes with rTSA than ORIF in the treatment of complex proximal humeral fractures of the elderly at a 2-year follow-up [13]. However, whatever type year. Furthermore no signs of prosthetic implant mobilization and chronic pain were shown. The occurrence of nerve complications following rTSA, relates to direct nerve damage, indirect traction, compression secondary to retractors use and post-operative hematoma formation [14]. Isolated axillary nerve stupor [15]. as well as persisting residual dysesthesia in the territory innervated by the median nerve, produced by an injury of the upper sensitive trunk have been described [16].

Conclusion
This early acute post-operative event of axillary thrombosis was correctly managed with the following vascular surgery procedure.
Furthermore, satisfactory long-term radiographic and clinical follow-up outcomes, without further complications, were obtained.
Care has to be given to early post-operative clinical evaluation after rTSA in displaced proximal humeral dislocated fractures, looking for trauma related or iatrogenic neurovascular damages. Posttraumatic injuries of the vessel innermost layer are fearful and unpredictable complications. A careful pre-operative planning, primarily focusing on both the choice of the surgical approach used and peripheral vascular status, is also fundamental while treating proximal humeral dislocated fractured with a reverse total shoulder prosthesis. Furthermore, careful post-operative physical therapy is important for a good clinical and functional outcomes as shown in this report. Further investigations of the incidence of arterial and deep vein thrombosis after rTSA for proximal humeral fractures might be helpful to evaluate also the benefits of prophylactic anticoagulant therapy in order to avoid the complication described.