Saturday, February 25, 2017

Revision reverse shoulder arthroplasty

Cement-within-cement technique in revision reverse shoulder arthroplasty

These authors reviewed 38 shoulders in which a cemented humeral component was revised to a cemented reverse humeral component fixed by cementing within the existing cement mantle.

The primary indications for revision surgery were instability or subluxation (21), glenoid  disease (wear or component loosening) (16) , and humeral component loosening within the cement mantle (1). Of those revised for instability, 7 had prior anatomic arthroplasties with rotator cuff tears leading to anterior (n = 2) or posterosuperior (n = 5) instability, 5 had instability associated with a reverse arthroplasty, and 9 had failed hemiarthroplasties associated with rotator cuff tears and superior escape.

There were 7 (18%) nondisplaced intraoperative fractures involving the greater tuberosity that occurred on implant removal; all healed at last follow-up. A second revision surgery was performed in 3 (8%) patients who underwent cement-in-cement humeral component revision for glenoid loosening (n = 1), periprosthetic instability associated with glenoid loosening (n = 1), and periprosthetic humerus fracture (n = 1). There was 1 “at-risk” humeral component (grade 4 or higher humeral lucency, moderate subsidence) that did not undergo revision surgery. There were 2 other humeral components with grade 3 humeral lucency, no subsidence.

The overall implant revision-free survival at 2 and 5 years was 95% and 91%, respectively. 

Of note, 3 of the 17 cases revised for loosening had positive intraoperative cultures.

Comment: From this report one can see that (1) the primary reasons for revision to a reverse were instability and glenoid failure, (2) revision carries the risk of intraperative fracture, and (3) failed arthroplasties can be associated with positive cultures - a potential concern because of the retained cement.

Recementing in an extant cement mantle usually requires the use of a smaller stem.


One of the advantages of humeral stem fixation with impaction grafting is the ease of revision as shown by a recent case of a patient with arthritis after multiple failed attempts at cuff repair but who retained active elevation. 

This patient elected to have an impaction-autografted CTA prosthesis which provided good comfort and function for seven years

A recent fall rendered this shoulder pseudo paralytic and the patient elected to have a revision to a reverse. The CTA prosthesis was removed without difficulty or fracture and the reverse stem was fixed securely with impaction allografting without down-sizing the stem. This approached optimized bone preservation.

When applicable, the impaction grafting approach may help reduce the risk of periprosthetic fractures after revision reverse arthroplasty.