Friday, May 31, 2013

Glenoid component failure, is it worth a second try at implantation?

Aseptic glenoid loosening or failure in total shoulder arthroplasty: revision with glenoid reimplantation

Glenoid component failure remains one of the most common, serious complications of total shoulder arthroplasty. These authors report on  42 TSAs with symptomatic failed glenoids revised by reimplantation of an all-polyethylene (PE), cemented glenoid component with a mean follow-up of 74 months.
Interestingly 32 of the failed glenoids were metal backed and only 10 were all polyethylene. 19 (46%) were loose and 23 (54%) had PE wear or dissociation. Associated complications were very frequent, including rotator cuff tears, subscapularis insufficiency, and prosthesis instability. 
At last follow-up, 7 patients (17%) had already been re-revised because of symptomatic recurrent glenoid loosening. The overall rate of recurrent glenoid loosening (re-revision plus radiologic loosening) was 67%. In this study, 21% of patients who had already undergone revision required further surgery, mainly for recurrent glenoid failure. Soft-tissue problems and prosthetic instability were significantly associated with recurrent loosening. Of the 10 associated bone grafts performed during the revision procedure, all were partially or totally lysed. 

One of the issues with reimplanting a glenoid component is the problem of filling the defect in the glenoid bone. Neither cementing nor bone grafting appear to be dependable solutions.

Comment: this study is consistent with our practice: once a glenoid component fails, we do not perform a primary exchange. We have often been pleasantly surprised at how much patients are improved by glenoid component removal, smoothing of the residual glenoid bone surface and insertion of a humeral head component with a large radius of curvature to spread out the load. Our post operative management is the same as that after a primary shoulder arthroplasty. For our approach see this post.

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