Tuesday, January 24, 2017

Total shoulder arthroplasty failure

Optimizing follow-up after anatomic total shoulder arthroplasty

These authors sought to establish a data-based follow-up schedule minimizing unnecessary patient and health care system costs without sacrificing the quality of patient care. They reviewed 2786 consecutive anatomic total shoulder replacements to identify the common modes of failure and times to failure.

208 shoulders (7.5%) required reoperation. Early failure mechanisms included instability, rotator cuff tears, and infection, with 63% of these reoperations occurring within 2 years.  The most common failure mechanism was instability, resulting in 89 reoperations (3.2%). Later failures included mechanical failures (including component loosening) and periprosthetic fractures, with no identifiable peak occurrence. After 2 years, TSA failed at an average rate 1.1% per year.

Comment: In this large study total shoulder arthroplasties continued to fail at an almost linear rate as long as 20 years after surgery. In examining the chart below, the primary cause of failure in the first year was instability (green dots) (left arrow). It would be of interest to know more about the 89 cases with instability, in that this is not usually a common indication for revision.  Component failure (teal dashes) was not a prominent cause of failure until after five years, but then accounted for an progressively increasing percentage of the failures after that)(right arrow). 

"It's not over until it's over." As emphasized in this article, Glenoid Component Failure in Total Shoulder Arthroplasty is the long term issue in the survival of total shoulder arthroplasty.

The importance of long term followup is illustrated by this case.

The patient presented with this x-ray and a Simple Shoulder Test Score of 1/12

She had a total shoulder as shown below.

Two years after surgery, her SST was 12/12 with the x-ray shown below.

Thirteen years after surgery, her SST dropped to 2/12 and she presented with glenoid component failure as shown below.

We have found that asking patients to complete the Simple Shoulder Test annually provides an inexpensive, sensitive, convenient and practical method for the necessary long term followup after shoulder arthroplasty as demonstrated in this article:

Patient functional self-assessment in late glenoid component failure at three to eleven years after total shoulder arthroplasty The routine use of SST as a patient reported outcome may enable the early identification of component failure without having the patient return to the office.

Here's another recent case example
x-ray at 2.5 years after shoulder arthroplasty showing glenoid loosening and osteolysis

x-ray at 3 years after arthroplasty showing increased osteolysis and progressive loosening. SST at the time of presentation to us was 5/12.


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