Friday, February 3, 2017

Revision reverse total shoulder arthroplasty, a risky business

These authors performed revision reverse shoulder arthroplasty using long-stemmed cemented humeral components in 124 patients. The indication for revision surgery was
failed anatomic shoulder arthroplasty in 75
infection in 25,
aseptic stem loosening in 8,
periprosthetic fracture in 7,
and other causes in 9.

A minimum of 5 years followup was available for 50 of the 124 patients. Of these 50, 24 had progressive humeral radiolucency (6 had complete loosening), 18 had complications and 16 had re-revision surgery.

Comment: Even though followup was available for less than half of the cases, the high failure rate of revision reverse total shoulder arthroplasty in the hands of an experienced surgeon is sobering.

Review of some of the case examples indicates that proximal humeral bone loss was a common pre-revision issue in these cases.

It is important to preserve humeral bone stock in shoulder arthroplasty. Recognizing that there is a substantial rate of revision for anatomic and reverse shoulder arthroplasty, surgeons performing shoulder arthroplasty should consider using an arthroplasty technique that would not risk humeral bone stock should revision be necessary. For these reasons we try to avoid cement fixation or ingrowth humeral stems that can complicate revision

Instead we use impaction grafting for stem fixation. 

When revision is necessary, great care taken to avoid fracturing the proximal humerus so as not to compromise fixation of the revision component.

Any osteotomies required for component removal are carefully repaired.