Saturday, March 4, 2017

The failed reverse total shoulder

Revision Strategies in Reverse Total Shoulder Arthroplasty (RTSA)

These authors state that "primary RTSA carries complication and revision rates of up to 75% and 2%–10%, respectively, these rates are higher in RTSA performed in a revision setting."

They reviewed the current literature on RTSA and revision RTSA was reviewed to determine the most common complications and treatment strategies to address these complications.

They found that the most common complications leading to revision of RTSA were instability, infection, humeral implant loosening, and glenoid implant loosening. 

Some of the cases they present are of interest (see figure below the text)

Case 1:A 62-year-old man s/p humeral head replacement arthroplasty for fracture with pain and inability to raise the arm. AP (A) and lateral (B) radiographs showing tuberosity resorption in a well-fixed cemented humeral prosthesis. AP (C) and lateral (D) radiographs after staged resection and removal of the prosthesis by humeral osteotomy and cerclage wiring. After infection was ruled out and osteotomy healed, reimplantation of a reverse total shoulder arthroplasty was performed. Immediate postoperative AP radiograph shows stable prosthesis (E). Subsequent AP radiograph (F) shows dislocation of the humeral prosthesis. Revision was performed with soft tissue repair, retention of the prosthesis, the addition of a metal spacer, and prosthetic lengthening. Final AP (G) and lateral (H) radiographs 6 months postoperatively show stable revision RTSA reconstruction.

Comment: This case points to (1) the importance of securing the tuberosities when a prosthesis is performed for fracture, (2) the challenges in safely revising a cemented humeral implant, (3) the difficulty in excluding infection in a failed arthroplasty, (4) the challenge of achieving stability when a failed arthroplasty is revised to a RTSA.

Case 2: A 68-year-old man s/p anatomic total shoulder arthroplasty with persistent anterior shoulder pain and subscapularis deficiency. AP (A) and axillary (B) radiographs show stable total shoulder arthroplasty with an uncemented humeral prosthesis and a cemented pegged glenoid component. Revision RTSA was performed with removal of both components and reimplantation of a long-stem humeral component.

Comment: By contrast with case 1, this case shows the ease and safety with which an uncemented, non-ingrowth humeral stem can be revised without the use of a platform stem.

Case 3: A 80-year-old man s/p RTSA for rotator cuff arthropathy. Two-week postoperative radiographs demonstrated dislocation of the prosthesis and closed reduction was performed. Subsequent 6 week postoperative AP (A) and lateral (B) radiographs show persistent anterior dislocation of the prosthesis. Revision surgery was performed and excessive retroversion (60) of the humeral prosthesis was noted leading to anterior impingement of the humeral cup on the anterior glenoid neck. The humeral prosthesis was retained and the position of the cup revised to 10 of retroversion. Postrevision RTSA radiographs (C, D) show stable prosthesis and restoration of stability and function.

Comment: In this case the fact that the original humeral component was modular enabled the surgeon to change the version and height of the humeral cup without removing the cemented stem.

As the number of reverse shoulder arthroplasties performed per year increase and as the indications for this procedure are extended, we will encounter a growing variety of complications that will challenge our management skills.


To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and runreverse total shoulderCTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'