Saturday, April 15, 2017

Total shoulder failure - a 'natural' history.

A middle aged lady had a total shoulder for severe glenohumeral arthritis of the right shoulder.  Preoperatively, she could perform none of the 12 Simple Shoulder Test functions. Postoperative films show a good anatomical reconstruction and secure glenoid component fixation.

A one year after surgery she had excellent comfort and function. Her x-rays showed no lucent lines around her glenoid. She could perform all 12 of the SST functions.

Seven years after surgery, she returned complaining of some shoulder pain, but preserved function.
Her x-ray showed bone resorption around the glenoid fixation. She could perform 10 of the 12 SST functions. She elected non-operative management.

Here is her x-ray at 8 years.

Here is her x-ray at 9 years.

Here is her x-ray at 10 years after her total shoulder at which time she elected a revision to a hemiarthroplasty.

At surgery the glenoid was grossly loose with massive osteolysis. There was only mild glenoid component wear. After thorough debridement a large diameter humeral head was placed on the residual glenoid bone surface which was smoothed by resecting the inferior prominences. There was no possibility of glenoid re-insertion. No bone graft was used. The rotator cuff was normal. The subscapularis was reconstructed. Multiple cultures showed no growth.

The day after surgery, she started assisted elevation of her arm, which she said was comfortable for her. Time will tell.

Comment: This case history shows the insidious manner in which bone can resorb around the glenoid component years after the index procedure. It also shows that patients with early glenoid component loosening can remain functional and may not recognize that there's an ongoing process in the shoulder.