Friday, May 31, 2013

Revision of failed shoulder arthroplasty with reverse total shoulder - allograft needed?

Reverse total shoulder arthroplasty for the management of failed shoulder arthroplasty with proximal humeral bone loss: is allograft augmentation necessary?

It is well known that one of the highest complication rates in reverse total shoulder is when this procedure is used for failed prior arthroplasty. These patients often have complex problems, including instability, glenoid bone deficiency, humeral bone deficiency, subscapularis deficiency and possibly low grade infection. This study reports the results of RTSA without proximal humeral allograft in 15 patients with proximal humeral bone loss after failed shoulder arthroplasty. Average bone loss measured 38.4 mm (range, 26-72 mm). Patients were followed up for a minimum of 2 years. Overall function was improved. Radiographs demonstrated notching in 3 patients (20%), no humeral subsidence or loosening, and prosthetic fracture in 1 modular humeral stem.

The authors do point out that when a modular humeral stem is used in patients with bone deficiency, the addition of proximal humeral allograft may increase the stability of the construct and prevent fracture at the modular stem–cup junction.

The key things to consider is that (1) reverse total shoulders apply a greater rotational moment to the humeral fixation than a standard total shoulder and (2) that there is less resistance to this rotational moment when the tuberosities are deficient (as is often the case in revision of a prior arthroplasty). Humeral component fixation in the shaft becomes very important. Conceivably, a secure allograft might further increase the resistance to torque. 

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