Sunday, June 15, 2014

Reverse total shoulder - glenoid and scapular complications

Reverse shoulder arthroplasty in 41 patients with cuff tear arthropathy with a mean follow-up period of 5 years.

These authors present 41 consecutive Delta III reverse total shoulders performed through an anterosuperior approach in 37 patients with pseudoparalysis due to cuff tear arthropathy. The patients' mean age was 79 years with an average follow-up of 5 years. None were lost to follow-up.

The authors observed scapular notching in 68% of the patients. 

Four shoulders had complications, with 1 undergoing revision surgery. Two patients had post-traumatic glenoid component failure. One patient fell 6 weeks postoperatively, causing the glenoid component to migrate superiorly requiring revision to a hemiarthroplasty. Another glenoid component failure occurred in an 88-year-old low-demand patient from a nursing home, who fell and sustained superior migration of the glenoid component. One patient fell 5 months after surgery and sustained a minimally displaced fracture of the acromion. One patient had a broken superior glenoid screw at 18 months after initial surgery without any history of trauma. 

A total of 9 patients were either unsure or unhappy about the outcome of their procedures, 4 were the patients who had complications. Of the remaining 5 patients, all complained of persistent pain, but no cause was identified.

Comment: It is of note that these patients had the most benign of 'indications' for a reverse: cuff tear arthropathy- none of these cases were performed for failed prior arthroplasty or fracture. Nevertheless the problem rate was high. 

The prosthesis used here medializes the medial edge of the humeral component so that it can contact the bone of the scapula resulting in notching that approaches the inferior screw as shown below. Other designs and techniques enable the surgeon to increase the lateralization of the medial edge of the humeral component.

It is of note that these elderly patients demonstrated a high rate of falls - something the reverse total shoulder tolerates poorly - often resulting in glenoid component failure or humeral shaft fracture. In patients with a high fall risk, it may be reasonable to consider either non-operative management or a CTA arthroplasty, either of which are more fall tolerant than a reverse total shoulder.


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