Wednesday, September 9, 2015

Revision total shoulder - single stage exchange with impaction grafting.

The management of a painful shoulder arthroplasty is always a challenge. Here are the films of a man in his mid fifties who had an injury to his shoulder, then an 'elsewhere' debridement followed by an 'elsewhere' total shoulder. Following this surgery he continued to have shoulder pain and then a month prior to seeing us he developed a painful 'pop' when he moved his shoulder. At the time of presentation he was two years after his arthroplasty.

Take a minute to look at these films to see what you think might be problematic.

What we see is (1) a bone ingrowth humeral component incarcerated in the diaphysis preventing full seating and leaving the humeral component somewhat high and (2) a glenoid component inserted with cement interposed between the bone and the back of the component with subsequent radiolucency between the cement and the bone. This can be seen a bit better on a coned down axillary view showing that cement had been used to fill in the posterior gap between the back of the glenoid component and the flat glenoid bone.

We suspected that his painful popping was due to rocking of his glenoid component.

After detailed discussion with the patient and spouse, it was elected to perform a single stage exchange to an impaction grafted humeral component followed by the red protocol. We recognized that a humeral osteotomy would be required to loosen the proximal bone ingrowth aspect of the humeral component.

We removed his components; as expected a proximal medial osteotomy of the humerus was required.
His glenoid peg was secure, but the glenoid component toggled with eccentric loading. A new humeral component was inserted at the proper level using impaction allografting with Vancomycin-soaked cancellous allograft. The glenoid bone surface was smooth after removing the component.

Here are his immediate post operative films 

While it is very early he has comfortable shoulder elevation to 150 degrees passively without the 'pop'. 

Comment: This case points out the issues related to a press fit bone ingrowth stem: a challenge to seat properly and difficult to remove in case revision is needed. It also points out the importance of avoiding cement between the glenoid component and the glenoid bone to compensate for incomplete glenoid reaming.


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