Simultaneous bilateral reverse total shoulder arthroplasty for bilateral seizure-induced posterior shoulder fracture-dislocation complicated by severe postoperative anemia and hemorrhagic shock: a case report

Although proximal humerus fractures are the third most frequent fractures in the elderly patient after femoral neck fractures and distal radius fractures22Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. In: Clinical Orthopaedics and Related Research. Lippincott Williams and Wilkins; 2006. p. 87–92.doi:10.1097/01.blo.0000194672.79634.78Google Scholar, fracture-dislocations are rare6Cucchi D. Baumgartner T. Walter S.G. Menon A. Ossendorff R. Surges R. et al.Epidemiology and specific features of shoulder injuries in patients affected by epileptic seizures.Arch Orthop Trauma Surg. 2023 Apr 1; 143: 1999-2009https://doi.org/10.1007/s00402-022-04420-6Crossref PubMed Scopus (2) Google Scholar. Posterior fractures-dislocation are even rarer, amounting to 0.9% of the 1500 cases reported by Neer20Neer C.S. Displaced proximal humeral fractures. I. Classification and evaluation.J Bone Joint Surg Am. 1970; 52: 1077-1089Crossref PubMed Google Scholar,28Uppal H.S. Robinson P.W. Packham I. Crowther M. The management of bilateral posterior fracture dislocations of the shoulder: a case series illustrating management options.Shoulder Elbow. 2016 Apr 1; 8: 111-117https://doi.org/10.1177/1758573215626105Crossref PubMed Scopus (8) Google Scholar, and are associated almost exclusively with episodes of epilepsy: bilateral shoulder posterior fracture-luxation has been called "Triple-e syndrome" because it can only occur in case of extreme trauma, epilepsy or electrocution3Belvís R. Marlet V. Sanuy B. Robert J. Pagonabarraga J. Torrens C. et al.Triple E syndrome [7].Eur J Neurol. 2007 Nov; 14https://doi.org/10.1111/j.1468-1331.2007.01948.xCrossref PubMed Scopus (1) Google Scholar. Bilateral shoulder fracture-dislocations are so exceptional that they are only found in the literature in the form of case reports or case series1Azad A. Antonios J.K. Kang H.P. Omid R. Single-stage bilateral reverse total shoulder arthroplasty for bilateral posterior shoulder fracture-dislocation following seizure: A case report.Int J Surg Case Rep. 2020 Jan 1; 73: 298-302https://doi.org/10.1016/j.ijscr.2020.07.037Crossref PubMed Scopus (6) Google Scholar,17Langenbruch L. Rickert C. Gosheger G. Schorn D. Schliemann B. Brix T. et al.Seizure-induced shoulder dislocations – Case series and review of the literature.Seizure. 2019 Aug 1; 70: 38-42https://doi.org/10.1016/j.seizure.2019.06.025Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar,24Pushpakumara J. Sivathiran S. Roshan L. Gunatilake S. Bilateral posterior fracture-dislocation of the shoulders following epileptic seizures: A case report and review of the literature Case Reports.BMC Res Notes. 2015 Nov 23; 8https://doi.org/10.1186/s13104-015-1674-yCrossref Scopus (21) Google Scholar,25Sato K. Hatta T. Shinagawa K. Okuno H. Nobuta S. Simultaneous Reverse Shoulder Arthroplasty and Open Reduction With Internal Fixation for Bilateral Proximal Humerus Fractures in the Elderly: A Report of Two Cases.Cureus. 2022 Sep 4; https://doi.org/10.7759/cureus.28777Crossref Google Scholar,27Tokuhiro T. Urita A. Kameda Y. Motomiya M. Watanabe N. Iwasaki N. Simultaneous Bilateral Proximal Humerus Fractures Treated with Single-Stage Bilateral Reverse Shoulder Arthroplasty.Case Rep Orthop. 2022; (2022 Apr 20): 1-8https://doi.org/10.1155/2022/2162331Crossref Google Scholar, 28Uppal H.S. Robinson P.W. Packham I. Crowther M. The management of bilateral posterior fracture dislocations of the shoulder: a case series illustrating management options.Shoulder Elbow. 2016 Apr 1; 8: 111-117https://doi.org/10.1177/1758573215626105Crossref PubMed Scopus (8) Google Scholar, 29Vitali M. Bettinelli G. Montalbano F. Salini V. One-step Bilateral Reverse Shoulder Replacement for Posterior Fracture-dislocation in a Young Alcoholic.J Orthop Case Rep. 2022; 12: 11-14https://doi.org/10.13107/jocr.2022.v12.i05.2794Crossref PubMed Google Scholar. The treatment options for posterior shoulder fracture-dislocations, whether unilateral or bilateral, are manifold. Among them, proximal humerus osteosynthesis is the treatment of choice for young patients with good bone quality and high functional demand, but it is a treatment with difficultly predictable results and a high complication rate in the elderly patient. For this reason, with the progressive ageing of the population, surgical treatment with shoulder arthroplasties (hemiarthroplasty or total reverse shoulder arthroplasty) is increasingly used, especially with regard to total reverse shoulder arthroplasty which, compared to anatomical hemiarthroplasty, has functional results that are more predictable and independent of rotator cuff integrity. In the specific case of bilateral shoulder fracture-dislocations, another treatment described is the osteosynthesis of the proximal humerus using an autologous graft from the contralateral shoulder on one side, and a prosthesis on the other side, to increase the chances of healing the treated humerus with osteosynthesis. This case report deals with simultaneous bilateral posterior shoulder fracture-dislocation in elderly woman, managed with one-step bilateral reverse total shoulder arthroplasty and complicated by severe postoperative anemia and hemorrhagic shock. The patient was informed that data concerning his case would be submitted for publication, and he provided written consent. On July 2023, a 73-year-old right-handed female patient with medical history of right lower lobar lung adenocarcinoma treated with right lung lobectomy in 2013 and chemo-radiotherapy until 2018, came to our Emergency Department (Riviera Chablais Hospital, Rennaz, Switzerland) following an episode of tonic-clonic seizure. The biological assessment revealed hyponatremia, which led the patient to be admitted to Intensive Care. The imaging evaluation (bilateral shoulder AP and Neer X-ray views and CT-scan, Fig. 1a, 1b, 2) showed the presence of a bilateral shoulder fracture-posterior dislocation. The patient stayed in Intensive Care Unit for two days to determine the cause of the hyponatremia, which is still unknown. Due to the clinical history of lung carcinoma and faced with the possibility that the hyponatremia was either a paraneoplastic phenomenon due to the progression of the carcinoma or the manifestation of brain metastases, colleagues in the Intensive Care Unit (ICU) organized a comprehensive assessment to be carried out in the preoperative period. Moreover, before proceeding to surgical treatment of the bilateral shoulder fracture-dislocation, it was in any case necessary to find a precise cause of the epilepsy in order to control it and minimize the risk of recurrence. The tests carried out in Intensive Care Unit had not shown any organic causes for the hyponatremia, and the patient had not had any other episodes of tonic-clonic seizures, so our colleagues retained a possible hypovolemic origin of hyponatremia and seizures. She was then admitted to the Department of Internal Medicine and referred to our Orthopedics and Traumatology Department for management of a bilateral shoulder fracture-posterior dislocation. Physical examination showed the presence of bilateral hematoma and swelling, and a bilaterally intact function of axillary nerve. Shoulder bilateral X-Ray and chest CT-scan (Fig. 1a, 1b, 2) performed at the emergency department clarified the fracture pattern: bilateral shoulder fracture-posterior dislocation with significant comminution, type four-part according to Neer classification20Neer C.S. Displaced proximal humeral fractures. I. Classification and evaluation.J Bone Joint Surg Am. 1970; 52: 1077-1089Crossref PubMed Google Scholar, 11-C3 according to AO/OTA classification18Marsh J.L. Slongo T.F. Agel J. Broderick J.S. Creevey W. DeCoster T.A. et al.Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association Classification, Database and Outcomes Committee.J Orthop Trauma. 2007; 21https://doi.org/10.1097/00005131-200711101-00001Crossref Scopus (1986) Google Scholar. The indications, risks and benefits of surgical management were therefore discussed with the patient. We proposed to the patient bilateral reverse total shoulder replacement for several reasons. First among them was the patient's age, functional requirements and low activity level. Secondly, the patient had occasional shoulder pain but no limitation of daily activities prior to the convulsive episode. Both sides were operated on the same day: first her right shoulder and then her left shoulder,14 days after injury. Since the patient was right-handed, we started with right shoulder. 1.5g of intravenous Cefuroxime was administered 30 minutes before the surgery for prophylactic purposes, and 1g of Tranexamic Acid was administered to decrease intraoperative bleeding. The surgical procedure was performed under general anesthesia and in semi-sitting position. The deltopectoral approach was used. Intraoperative assessment of the right shoulder was consistent with a 4-part fracture-dislocation according to Neer classification20Neer C.S. Displaced proximal humeral fractures. I. Classification and evaluation.J Bone Joint Surg Am. 1970; 52: 1077-1089Crossref PubMed Google Scholar, with preserved insertion of the subscapularis tendon on the lesser tuberosity, preserved insertion of the supraspinatus and infraspinatus tendons on the greater tuberosity, and the teres minor tendon intact. The humeral head was dislocated posteriorly and the glenoid was intact. After releasing the fractured humeral head, the tendon of the subscapularis muscle was tagged with a FiberWire (Arthrex, Naples, FL, USA) for later repair. We then isolated the greater tuberosity and tagged the supraspinatus and infraspinatus tendons with two FiberWire (Arthrex, Naples, FL, USA). The humeral head was unimpacted and removed. The glenoid was carefully prepared and the definitive implants placed. Glenoid components included a Trabecular Metal baseplate with 15mm central plot (Zimmer Biomet, Warsaw, IN, USA), fixed with one 42mm 4.5 locking screw and one 36mm 4.5 locking screw, and a 36mm of diameter Trabecular Metal Reverse Glenoid Head (Zimmer Biomet, Warsaw, IN, USA) centered glenosphere. Humeral components were a 130mm long Trabecular Metal Reverse Humeral Stem (Zimmer Biomet, Warsaw, IN, USA), implanted with 20° of retroversion. A 36 mm of diameter and 0 mm of thickness (inlay) Trabecular Metal Reverse Poly Liner (Zimmer Biomet, Warsaw, IN, USA) was impacted. The FiberWire (Arthrex, Naples, FL, USA) sutures were used to fix the tuberosities to the humeral stem. Superior rotator cuff was fixed with transosseous sutures to proximal humerus, then the tuberosities were repaired to each other with a FiberWire (Arthrex, Naples, FL, USA) circumferential to humeral stem. For the left shoulder, the deltopectoral approach was used. Intraoperative assessment of the left shoulder was consistent with a 4-part fracture-dislocation according to Neer classification20Neer C.S. Displaced proximal humeral fractures. I. Classification and evaluation.J Bone Joint Surg Am. 1970; 52: 1077-1089Crossref PubMed Google Scholar, with preserved insertion of the subscapularis tendon on the lesser tuberosity, preserved insertion of the supraspinatus and infraspinatus tendons on the greater tuberosity, and the teres minor tendon intact. The humeral head was dislocated posteriorly with associated long longitudinal metaphyseal fracture, and the glenoid was intact. It was decided to use the same implants used for the right Reverse Total Shoulder Arthroplasty for the left one. Tuberosity fixation was also performed. Intraoperative testing showed bilateral excellent stability and a range of motion of 135° of forward flexion, 90° of abduction, 45° of external rotation and 45° of internal rotation. The patient was immobilized for 6 weeks in a shoulder immobilizer in internal rotation position. Active assisted mobilization was allowed for the left shoulder from the first postoperative day, and pendulum exercise was allowed for the right shoulder from the first postoperative day. After the procedure, the patient was kept in intensive care unit for 48 hours postoperatively for surveillance purposes. The hemoglobin check in the immediate postoperative showed a normochromic normocytic anemia with hemoglobin at 92g/L (102 g/L in the immediate preoperative, with 500 ml estimated blood loss during surgery). The next morning at 8am, our patient suffered severe anemia according to National Cancer Institute definition (the hemoglobin had dropped to 79g/L and at 12 noon to 70g/L), so the patient received 1 unit of packed red blood cells. Two days after the operation, Hemoglobin was found to be 76g/L and she was then transferred to the orthopedic department. Once transferred to the orthopedic department, the patient began to experience symptoms of acute anemia, such as weakness, fatigue, pallor, tachycardia, hypotension, and shortness of breath. Hemoglobin was measured 63 g/L and the patient went into hemorrhagic shock, necessitating a transfer to intensive care unit and the transfusion of 2 unit of packed red blood cells. She stayed three days in the Intensive Care Unit, with progressive improvement of vital parameters and hemoglobin, and finally returned to the orthopedic department five days after the operation. No other source of bleeding apart from bilateral posterior shoulder fractures-dislocations and the surgery was found to be the cause for the hemorrhagic shock. In retrospect, we could have performed an injected CT scan of both shoulders looking for active bleeding. This (or other complementary tests) were not considered necessary, as the scars were calm, there was no large hematoma, and the clinical evolution was good. As the clinical evolution was favorable and the hemoglobin was 102 g/L, the patient was discharged 14 days after surgery. When the patient was discharged, the postoperative clinical examination showed the absence of axillary and suprascapular nerve lesions. Given the shoulder immobilizer on both sides, and especially on the dominant arm, the patient's age and the complications experienced postoperatively, a period of stay in a readaptation center was necessary. The patient remained in the readaptation center for 37 days, which added to the 14 days spent in hospital makes 51 days in a hospital facility away from home. Day 45 X-ray (Fig. 3a, 3b, 3c, 3d ) showed correct positioning of reverse total shoulder arthroplasty and tuberosities on both sides, and the patient stated her SSV was 10% for right shoulder and 20% for left shoulder. Constant score was 25 for the right shoulder and 35 for the left shoulder. At physical examination right shoulder/left shoulder active forward flexion was 45°/90°, abduction was 45°/75°, external rotation 1 (ER1) was 0°/10° and internal rotation 1 (IR1) was to buttock/L4. After the six-week check-up, the patient contracted a SARS-Cov-2 infection, which was the reason why she was not able to perform all the physical therapy sessions scheduled prior to the 3-month postoperative check-up. Good clinical evolution was observed at 3 months postoperative follow-up, with Subjective Shoulder Value (SSV) 60% for right shoulder and 70% for left shoulder. Constant score was 59 for right shoulder and 61 for left shoulder. At physical examination right shoulder/left shoulder active forward flexion was 90°/110°, abduction was 90°/90°, external rotation 1 (ER1) was 10°/20° and internal rotation 1 (IR1) was to L1/L1, with bilateral 4/5 muscular strength according to Medical Research Council (MRC) scale for resisted active forward flexion, abduction, IR1 and ER1. Rotator cuff testing was painless and force was 4/5 bilaterally. Three-months follow-up X-ray (4a, 4b, 4c, 4d) showed correct positioning of reverse total shoulder arthroplasty and healed tuberosities on both sides. At 6 months postoperative follow-up Subjective Shoulder Value (SSV) was 90% for both shoulders. Constant score was 89 for both shoulders. Physical exam showed muscular force M5/M5 and the following active range of motion: forward flexion 135°/135° (Fig. 5a, 5b), abduction 160°/160° (Fig. 5c, 5d), external rotation 45°/45° (Fig. 5e) and internal rotation 1 L1/L1 (Fig. 5f, 5g). Subjective Shoulder Value (SSV) was 90% for both shoulders. Constant score was 89 for both shoulders. Six-months follow-up X-ray (Fig. 6a, 6b, 6c, 6d, 6e, 6f) showed no postoperative complications on both sides. In view of the clinical and radiological evolution, no further controls were planned at the senior author's consultation.Fig. 2CT-scan (axial view) of bilateral shoulders performed in Emergency Department, showing bilateral posterior fracture-dislocationView Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 3X-ray (AP, Neer views) 6 weeks postoperative of right (3a, 3b) shoulder and left, (3c, 3d) shoulder, showing correct positioning of reverse total shoulder arthroplasty on both sidesView Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 4X-ray (AP, Neer views) 3 months postoperative of right (4a, 4b) shoulder and left (4c, 4d) shoulder, showing correct positioning of reverse total shoulder arthroplasty and healed tuberosities on both sidesView Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 5Range of Motion (ROM) at 6 months postoperative (5a and 5b : Forward Flexion, 5c and 5d: Abduction, 5e External Rotation at 0° of Abduction, 5f Internal Rotation of Left Shoulder at 0° of abduction, 5g Internal Rotation of Left Shoulder at 0° of abduction).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig. 6X-ray (AP, Neer, axial views) 6 months postoperative of right (6a, 6b, 6c), shoulder and left (6d, 6e, 6f) shoulder, showing correct positioning of reverse total shoulder arthroplasty and healed tuberosities on both sides.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Posterior shoulder fracture-dislocation is a rare entity, but it is also quite typical injury for young, male patient at their first or second episode of seizure4Bühler M. Gerber C. Shoulder instability related to epileptic seizures.J Shoulder Elbow Surg. 2002; 11: 339-344https://doi.org/10.1067/mse.2002.124524Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar,7Cucchi D. Baumgartner T. Walter S.G. Menon A. Ossendorff R. Surges R. et al.Epidemiology and specific features of shoulder injuries in patients affected by epileptic seizures.Arch Orthop Trauma Surg. 2023 Apr 1; 143: 1999-2009https://doi.org/10.1007/s00402-022-04420-6Crossref PubMed Scopus (2) Google Scholar. We managed a bilateral shoulder fracture-dislocation in a female elderly patient with poor bone quality (deltoid tuberosity index 1.3526), which is not typical. In our case pure humeral osteosynthesis was not indicated for the high risk of complications, first of all humeral head necrosis because of the fracture pattern according to Hertel's criteria15Hertel R. Hempfing A. Stiehler M. Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus.J Shoulder Elbow Surg. 2004 Jul; 13: 427-433https://doi.org/10.1016/j.jse.2004.01.034Abstract Full Text Full Text PDF PubMed Scopus (553) Google Scholar (comminuted fracture of the greater and lesser tuberosities, dislocation of the humeral head without medial calcar support) and second humeral osteosynthesis failure because of the poor bone quality26Spross C. Kaestle N. Benninger E. Fornaro J. Erhardt J. Zdravkovic V. et al.Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures.Clin Orthop Relat Res. 2015 Sep 5; 473: 3038-3045https://doi.org/10.1007/s11999-015-4322-xCrossref PubMed Scopus (86) Google Scholar, nor shoulder hemiarthroplasty for the high risk of rotator cuff deficiency, complications such as tuberosities non-union or resorption, and worst functional outcomes (forward elevation, abduction) compared to total reverse shoulder arthroplasty. For the surgical approach, we chose a deltopectoral approach. There are several reasons for this choice: first, the senior surgeon is more accustomed to the deltopectoral approach than to the superolateral approach. Our patient was a fragile patient with a bilateral fracture-dislocation, and the most logical choice was to use the most practical surgical approach for the surgeon to reduce operative time and complications. This is an a-traumatic surgical approach with a well-defined internervous and intramuscular plane12Gillespie R.J. Garrigues G.E. Chang E.S. Namdari S. Williams G.R. Surgical Exposure for Reverse Total Shoulder Arthroplasty. Differences in Approaches and Outcomes.Orthopedic Clinics of North America. 2015 Jan 1; 46: 49-56https://doi.org/10.1016/j.ocl.2014.09.015Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar. The deltoid muscle, which is the main player in shoulder mobility after RTSA, is spared in this approach. In contrast, although it provides better exposure to the glenoid especially in the case of prosthesis-fracture, in the superolateral approach the origin and muscle bellies of the deltoid are violated. Since it was a poor-quality bone, if we had intraoperative fractures we could have extended the deltopectoral approach with the anterior approach to the humerus. We used a fracture designed humeral stem to improve anatomic healing and consolidation of tuberosities21Onggo J.R. Nambiar M. Onggo J.D. Hau R. Pennington R. Wang K.K. Improved functional outcome and tuberosity healing in patients treated with fracture stems than nonfracture stems during shoulder arthroplasty for proximal humeral fracture: a meta-analysis and systematic review.J Shoulder Elbow Surg. 2021 Mar 1; 30: 695-705https://doi.org/10.1016/j.jse.2020.09.044Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, and we didn't allow passive nor assisted-active right shoulder movement for 6 weeks to allow tuberosities healing. This choice was made on the basis of the evidence that in the case of reverse total shoulder arthroplasty following a fracture the most important prognostic factor for functional outcomes (improving in internal and external rotation) is the correct positioning of the tuberosities10Gallinet D. Adam A. Gasse N. Rochet S. Obert L. Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty.J Shoulder Elbow Surg. 2013 Jan; 22: 38-44https://doi.org/10.1016/j.jse.2012.03.011Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar: the tuberosities were reinserted on both sides but we preferred to protect the right shoulder for 6 weeks because it was the dominant shoulder. We could have performed an autologous bone graft augmented osteosynthesis for dominant side and contralateral total reverse shoulder arthroplasty in order to improve shoulder function, as described in Uppal et al28Uppal H.S. Robinson P.W. Packham I. Crowther M. The management of bilateral posterior fracture dislocations of the shoulder: a case series illustrating management options.Shoulder Elbow. 2016 Apr 1; 8: 111-117https://doi.org/10.1177/1758573215626105Crossref PubMed Scopus (8) Google Scholar case series, but patient in their case series were on average more than 10 years younger than our patient, and we decided to perform a bilateral reverse total shoulder arthroplasty for more predictable results. However, in our case, we proposed directly to the patient a one-step bilateral reverse total shoulder arthroplasty because, as explained earlier, the functional results of a fracture prosthesis lie largely in the anatomical reduction of the tuberosities, which would have been much more difficult for the second prosthesis if this had been done at a distance from the first (especially considering that we would have waited 3 months to start getting results). In addition, according to recent literature, post-fracture RTSA have better functional outcomes when operated on acutely2Barger J. Stenquist D.S. Mohamadi A. Weaver M.J. Dyer G.S.M. von Keudell A. Acute versus delayed reverse total shoulder Arthroplasty for the management of Proximal Humerus Fractures.Injury. 2021 Aug 1; 52: 2272-2278https://doi.org/10.1016/j.injury.2021.05.040Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, and recovery times are shorter than with delayed RTSA23Panagopoulos G.N. Pugliese M. Leonidou A. Butt F. Jaibaji M. Megaloikonomos P.D. et al.Acute versus delayed reverse total shoulder arthroplasty for proximal humeral fractures: a consecutive cohort study.J Shoulder Elbow Surg. 2022 Feb 1; 31: 276-285https://doi.org/10.1016/j.jse.2021.07.003Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar. For a 73-year-old patient, moreover, having one of the two shoulders immobilized for a long period (3 months waiting for 'surgery) would have resulted in significant atrophy of the rotator cuff muscles. Our patient suffered postoperative hemorrhagic shock, requiring the transfusion of 3 packed blood cells, and for this reason she remained hospitalized for 51 postoperative days. This finding is in line with the results of the study conducted by Gerber et al11Gerber C, Lingenfelter EJ, Reischl N, Sukthankar A, Ed F, of Orthopaedics J Lingenfelter PE, et al. Single-stage bilateral total shoulder arthroplasty A PRELIMINARY STUDY. 2006;88(6). doi:10.1302/0301-620X.88B6Google Scholar, who compared the outcomes and complications of bilateral reverse total shoulder arthroplasty for primary glenohumeral osteoarthritis implanted in a single-stage or two-stage procedure. According to their study, in fact, postoperative anemia requiring transfusion is more frequent in the group of patients with bilateral shoulder prosthesis in one time (statistically significant result). Severe anemia, although a common complication of total shoulder replacements, is a predictive factor for increasing in length of stay (in our case the patient spent 51 days in a hospital facility) and poorer 30-days outcomes9Doan M.K. Pollock J.R. Moore M.L. Hassebrock J.D. Makovicka J.L. Tokish J.M. et al.Increasing severity of anemia is associated with poorer 30-day outcomes for total shoulder arthroplasty.JSES Int. 2021 May 1; 5: 360-364https://doi.org/10.1016/j.jseint.2021.02.001Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar and should be avoided, if possible, with bleeding control, postoperative blood test, packed red blood cells transfusion if needed. Other factors that negatively influence the length of the hospital stay are ageing, female gender, the presence of preparatory anemia, congestive heart failure or renal failure19Menendez M.E. Baker D.K. Fryberger C.T. Ponce B.A. Predictors of extended length of stay after elective shoulder arthroplasty.J Shoulder Elbow Surg. 2015 Oct 1; 24: 1527-1533https://doi.org/10.1016/j.jse.2015.02.014Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar. In light of the postoperative anemia, we could have used a Cell saver (Cell Saver Elite; Haemonetics, Boston, MA, USA) during surgery to perform an autotransfusion. In fact, when analyzing the literature retrospectively, our patient had all the recognized risk factors for postoperative anemia requiring postoperative transfusion of packed red cells: blood transfusion rates after total shoulder arthroplasty vary between 4.5% et 43%, and the main proven risk factors are preoperative anemia with Hb < 109 g/L (for our patient the ICU assessment showed a hemoglobin of 108 g/L), and a total intraoperative blood loss (right and left shoulder together) >300 ml (for our patient estimated blood loss was 500 ml). The above two factors, together with a history of anemia, have been shown to be predictive of the need for postoperative transfusion with a sensitivity of 80.0% and specificity of 99.6%5Burns K.A. Robbins L.M. LeMarr A.R. Childress A.L. Morton D.J. Wilson M.L. Estimated blood loss and anemia predict transfusion after total shoulder arthroplasty: a retrospective cohort study.JSES Open Access. 2019 Dec 1; 3: 311-315https://doi.org/10.1016/j.jses.2019.08.003Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar. According to another study, the indication for which a shoulder prosthesis surgery is performed makes a difference in terms of the postoperative need for transfusion: the indications most at risk are fracture-arthroplasties and revisions of arthroplasties due to infection, and since ours was a fracture prosthesis, this increases the risk of the postoperative need for transfusion. In terms of prosthesis design, reverse shoulder arthroplasties are more at risk than anatomical ones16Kopechek K.J. Frantz T.L. Everhart J.S. Samade R. Bishop J.Y. Neviaser A.S. et al.Risk factors for postoperative blood transfusion after shoulder arthroplasty.Shoulder Elbow. 2022 Jun 1; 14: 254-262https://doi.org/10.1177/1758573220982253Crossref PubMed Scopus (3) Google Scholar. Finally, factors negatively influencing the need to transfuse postoperatively for a shoulder prosthesis are age over 65 and female gender13Grier A.J. Bala A. Penrose C.T. Seyler T.M. Bolognesi M.P. Garrigues G.E. Analysis of complication rates following perioperative transfusion in shoulder arthroplasty.J Shoulder Elbow Surg. 2017 Jul 1; 26: 1203-1209https://doi.org/10.1016/j.jse.2016.11.039Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar,14Gruson K.I. Accousti K.J. Parsons B.O. Pillai G. Flatow E.L. Transfusion after shoulder arthroplasty: An analysis of rates and risk factors.J Shoulder Elbow Surg. 2009 Mar; 18: 225-230https://doi.org/10.1016/j.jse.2008.08.005Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar. All of the above factors are independent risk factors for the need for postoperative transfusion for a single shoulder replacement. Our patient had all or almost all of the identified factors, so it was not difficult to assume that she would almost certainly develop severe postoperative anemia. Even further, as we had done the same surgery on both shoulders at the same time, it is not surprising that the patient went into hemorrhagic shock. In spite of this, we did not reason in terms of postoperative anemia because we were misled by the fact that this was a relatively healthy patient and because of her condition of extreme discomfort dictated by the presence of the bilateral dislocation fracture and her will to get well as soon as possible. We administered 1 g of tranexamic acid to the patient, which has been shown to reduce intraoperative bleeding in RTSA, but at the same time has no effect on postoperative complications, particularly the need for transfusions8Cunningham G. Hughes J. Borner B. Mattern O. Taha M.E. Smith M.M. et al.A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial.J Shoulder Elbow Surg. 2021 Jul 1; 30: 1553-1560https://doi.org/10.1016/j.jse.2020.11.022Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar. Anyway, to the best of our knowledge, postoperative anemia does not influence mid- and long-term functional outcomes. In conclusion, in our opinion, simultaneous bilateral shoulder replacement is a good option for a bilateral dislocation fracture in elderly patients, provided that due care and precautions are taken in the management of any postoperative anemia. Single-stage bilateral RTSA is a valid option for the treatment of bilateral shoulder fractures-dislocations in elderly patients, but a preoperative assessment and appropriate precautions must be included for the possible complication of postoperative anemia, and postoperative anemia risk factors should not be neglected.