Saturday, December 1, 2012

Managing glenoid bone deficiency after a failed total shoulder

Shown below are the x-rays of a man who had a right total shoulder performed in California six years earlier. They show massive osteolysis and loosening of the glenoid component and osteolysis around the humeral stem.

Before our revision surgery he answered 'yes' to five of the 12 Simple Shoulder Test questions.

The revision surgery went according to our standard protocol: 
"The shoulder was doubly prepped and draped in the usual manner. Antibiotics were withheld until cultures could be obtained from the soft tissue and fluid, then were administered and will be discontinued at 24 hours unless infectious disease believes that there is a strong possibility of infection, in which case antibiotics will be sustained.
The abundant scar of the humeroscapular motion interface was lysed. The subscapularis was identified and lengthened. The humerus was exposed by gentle external rotation. The previous humeral head component was removed. There was massive osteolysis of the proximal humerus. A fragment of glenoid was noted lodged inferior to the humeral head on the neck in a massive osteolytic area. After the head was removed, the humeral stem was seen to be securely fixed to the shaft so no shaft revision was required. 
Attention was then directed to the glenoid where multiple small fragments of the glenoid component were removed. The glenoid vault was carefully curetted. There was deep erosion of the glenoid bone. There was a relatively tall anterior glenoid residual lip. This was resected to that it was relatively flush with the eroded glenoid base. No bone grafting was performed
All the specimens were sent to the laboratory for culture and for histological examination. Histological examination did not show evidence of acute inflammation.
A re-stabilization of the tuberosity was required to the stem because of the severe degree of osteolysis. This was performed using 4 sutures of #2 Tevdek. The definitive humeral prosthesis was selected as the 54, 23, Tornier eccentric. This was placed with the eccentricity down and created a reasonable articulation with the residual glenoid bone. The wound was sterilely irrigated. The subscapularis was then reconstructed to the drill holes placed at the anterior neck cut.
The wound was sterilely irrigated and closed in layers. Dry sterile dressings were applied. The patient was returned to the recovery room in satisfactory condition with his arm in continuous passive motion.
Our postoperative plan calls for the 140-degree assisted elevation program. "

By 21 months after his surgery, his Simple Shoulder Test score was 10 of twelve.

We saw him recently, over four years after our revision. His shoulder function has remained excellent. His radiographs showed robust glenoid bone supporting his prosthetic humeral head. 
As shown here, we do not try to reimplant a glenoid component when revising a shoulder with a loose glenoid component and do not use bone graft to fill in the defect.


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