Wednesday, October 21, 2015

Total shoulder arthroplasty - cementing, failure, revision

We are often referred patients with pain after a prior total shoulder. The x-rays below are of a 50 year old man who had a total shoulder elsewhere two years prior to consulting with us. His shoulder clicked when he used it. His Simple Shoulder Test score was 0 out of 12. He had been told 'everything was fine'.  His films show that at the time of his surgery, cement had been placed between the back of his glenoid component and his glenoid bone. This 'face cement' is something we avoid in performing a total shoulder arthroplasty for three reasons: (1) it should not be necessary if the glenoid bone was properly reamed to match the back of the component, (2) bone cement is not an adhesive, so that face cement does not improve the security of the component, and (3) this thin layer of cement is brittle and can loosen and crack as shown by the dark lines separating the cement an bone on the x-rays below.

The axillary view shows a substantial amount of cement posteriorly to make up for incomplete posterior reaming of the bone.

Two months ago we revised this shoulder to a ream and run procedure, removing his loose glenoiod and using an impaction grafted humeral component.  His intraoperative cultures were negative.

His two month followup films are shown below.

 At the time of his 6 week followup, he had 150 degrees of comfortable active elevation and minimal shoulder discomfort (and no clicking on movement). He was pleased with his progressive recovery.

Comment: Glenoid component failure continues to be the principal cause of revision after total shoulder arthroplasty. One approach to the failed glenoid component is conversion to a ream and run. One approach to eliminating the problem of glenoid component failure is to consider the ream and run as the primary arthroplasty in motivated young active patients such as this man.


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