Tuesday, July 17, 2012

The reverse total shoulder for prior failed shoulder surgery

Recently we have had the chance to use the reverse total shoulder to manage some challenging shoulder problems. Some recent cases are illustrative.

The first is a patient who fell and sustained a fracture of the proximal humerus. Ten years ago the fracture was internally fixed, but the patient experienced ongoing severe pain and loss of function.

When she first met us, the shoulder looked like this.

After a detailed discussion of the alternatives we decided to offer her a reverse total shoulder. The key step in the procedure was transecting the head from the shaft before attempting to dislocate the proximal humerus - it turns out that the displaced humeral head was tightly scarred to the brachial plexus. The post operative x-rays look like this. We will eagerly await her functional outcome.

The second case was a shoulder that had had a standard arthroplasty a decade ago with an outstanding functional result. 

Recently, however the patient took a fall landing on the arm, losing the ability to actively elevate the arm due to a massive cuff tear.
We converted this to a reverse. The key step here was preserving the quality of the glenoid bone by cutting through the polyethylene pegs with an osteotome, rather than trying to dig the pegs and cement out of the glenoid bone. The base plate was then placed over the prepared glenoid surface.

Again, we eagerly await the result.
Stay tuned.

A third case presented with a rotationally unstable humeral component inserted for treatment of a four part fracture.

Because of concern about infection, this was revised to a spacer. Happily, there was no significant growth from the cultures taken at surgery.

Two years ago we revised the spacer to a reverse. Today she has a comfortable shoulder with 110 degrees of active elevation.


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