Thursday, November 19, 2015

Reverse total shoulders - how they fail

Failure after reverse total shoulder arthroplasty: what is the success of component revision?

These authors note that complication rates after  reverse total shoulder arthroplasty (RTSA) are high, including instability, component loosening or failure, fractures, and infection. The most common complications are reported to be instability (4.7%), infection (3.8%), aseptic glenoid loosening (3.5%), and acromial fractures, glenoid disassembly, and humeral disassembly (each 1.5%).  This is likely to be only the tip of the iceberg we will be encountering over the next decade.

They present 16 patients requiring component revision and reimplantation after a prior failed RTSA for baseplate failure (7 patients, 43.8%), instability (6 patients, 37.5%), infection (2 patients, 12.5%), and humeral loosening (1 patient, 6.3%). While overall these patients were improved, 9 suffered major complications (56%), and 6 of these ultimately underwent further procedures (38% of cohort).

Comment: It is apparent that reverse total shoulder arthroplasty failures may relate to surgical technique, component design, and the severity of the pathology being treated. We can learn a lot by analyzing each failure in some detail. It is easier to prevent failure that to treat it.

The arthroplasty below left failed after only 4 months of implantation and failed again after revision.

With an implant of this type one can see that the initial fixation depends on the superior and inferior screws. If, as may have been the situation in this case, the inferior screw is not in secure bone, the baseplate may fail before ingrowth into the central peg can occur.
By contrast, other designs may offer more robust initial fixation (as shown in the case shown below, where the base plate was inserted in a glenoid with four previously inserted suture anchors).


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