Friday, July 3, 2015

Reverse total shoulder for failed anatomic shoulder joint replacement arthroplasty

The effect of proximal humeral bone loss on revision reverse total shoulder arthroplasty.

These authors reviewed 32 shoulders that were revised to reverse total shoulder arthroplasty (RTSA) for failed shoulder hemiarthroplasty. Proximal humeral bone loss was found in 16 patients, with an average loss of 36.3 mm (range, 17.2-66 mm). The authors did not use allograft for cases of bone deficiency, preferring instead a cemented long-stem monoblock humeral prosthesis. 
A humeral osteotomy was necessary in 12 patients to retrieve the humeral stem.

The patients demonstrated significant improvement in the average American Shoulder and Elbow Surgeons score (30.7 to 66.8), the Simple Shoulder Test score (1.6 to 5.3), the visual analog scale score (6.0 to 2.6), and in forward flexion (51° to 100°). They detected no difference in functional or subjective outcomes in comparing shoulders with and without proximal bone loss. However, three of the patients with proximal bone loss demonstrated humeral-sided loosening and five had complications (periprosthetic fractures, component loosening, instability, nerve palsy, and acromial fracture) attesting to the severity of the pathology and the complexity of the reconstruction.

Comment: Experience around the world has shown that the use of the reverse total shoulder in the revision of anatomic shoulder arthroplasty is difficult and has a high rate of complications. In some cases authors have advocated the use of allograft as a part of the reconstruction to manage the bony defects that are commonly present. Our practice is to use a monoblock  - but usually not a long stem - commonly fixed with cement in the prior cement mantle for hight and version control as shown below in a case with a 3 cm proximal humeral bone defect.  We prefer a glenoid component with firm initial fixation to the glenoid bone (i.e. not depending on bone ingrowth) and that allows East-West tensioning for stability.


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