Outcomes of operative and non-operative management of acromial and scapular spine fractures after reverse shoulder arthroplasty: a systematic review

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. 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.