Sunday, January 8, 2012

revision of painful hemiarthroplasty to total shoulder - Dec 2011 - JSES

The topic of painful hemiarthoplasty is always interesting. Is the problem "glenoid arthrosis", stiffness, infection, instability or some combination of the above?

Rhee et al reported on 34 shoulders revised from hemiarthroplasty to total shoulder because of pain. While patients experienced reduction of pain. 61% of the patients felt they were 'better' or 'much better'. 38% were the same or worse.  22 shoulders had unsatisfactory results on the modified Neer scale.

Of note is that in this series the humeral head replacement surgeries were performed for complex fractures - a situation much more complex and more prone to stiffness, cuff issues, humeral component positioning difficulties and tuberosity problems than when a hemiarthroplasty is used for non-traumatic conditions. Some had had prior attempts at internal fixation of their fractures.

These revisions involved substantial surgery: in 21 cases the humeral body was removed and replaced, some required tuberosity osteotomy and / or rotator cuff surgery in addition to lysis of adhesions. Poorer outcomes were noted in those cases needing rotator cuff surgery, greater tuberosity management or capsular tension adjustment. No mention is made of results of cultures taken at the time of these revisions.

These index surgeries and the revision surgeries were performed by Bob Cofield, one of the world's experts in shoulder reconstruction. This series points to the challenges posed by the unsatisfactory humeral hemiarthroplasty performed for trauma, even in the best of hands. While the title suggests that the revisions were performed for 'painful glenoid arthrosis', these patients had truly complex pathologies involving not only the glenoid surface, but also glenohumeral subluxation,  tuberosity malunion or nonunion, cuff tears and soft tissue contractures. These revisions are not for the faint of heart!


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