Saturday, April 12, 2014

Reverse total shoulder - proximal humeral bone loss is associated with poorer results

The metaphyseal bone defect predicts outcome in reverse shoulder arthroplasty for proximal humerus fracture sequelae.

These authors reviewed 50 cases of reverse shoulder arthroplasty used to treat sequelae of proximal humerus fractures.The patients had a mean age of 69 (range 44-89) and a mean followup of 34 months.

Shoulders with proximal humeral metaphyseal bone loss of more than 3 cm had significantly lower clinical outcomes. In addition degenerative changes of the teres minor muscle and the number if prior surgeries also had significant negative influences on clinical results.

There were five revisions (10%) for infection (3 cases), instability (1 case), and stiffness (1 case).

Comment: The best results with reverse total shoulders are obtained when the pathology is simple, for example in cases of previously unoperated rotator cuff tear arthropathy. The results are poorer when  the pathology is complicated, for example in failed prior arthroplasty or in cases of post traumatic bone loss as pointed out in this paper. This information informs our discussions with patients considering reverse total shoulder and points to the need for careful stratification of preoperative pathology when outcomes of reverse total shoulder are compared.

It is of note that the most common complication was infection in this series.

One of the particular challenges in performing reverse total shoulders in the presence of proximal bone loss is fixation of the humeral component. As shown in the x-ray below, the stems of reverse total shoulder humeral components are essentially circular in cross section - thus the fixation is at risk for failure when torque is applied to the humeral component.

In such cases, securing humeral component fixation is critical to the success of the procedure.

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