Wednesday, March 21, 2018

Reverse overkill?

An active handball enthusiast with rotator cuff tear arthropathy, but retained active elevation (see x-rays below)

was treated with a reverse total shoulder arthroplasty with a large, cemented humeral stem. After 6 weeks of PT the patient returned to the surgeon who took these x-rays showing a dissociation of the glenosphere from the baseplate

The patient then underwent a revision reverse total shoulder arthroplasty, but two weeks after that surgery the reverse total shoulder had dislocated.

The patient then had a revision, removing the base plate and replacing the humeral cup with a humeral head prosthesis at which time a fracture necessitated insertion of a circlage wire.

He now has pseudoparalysis and anterosuperior instability, and worse function than before his first surgery.

Comment: For active individuals with cuff tear arthropathy and retained active elevation, we consider an impaction grafted small stem CTA prosthesis inserted with care to preserve all the anterior stabilizers.  See this link and this link. This approach preserves bone stock, avoids the complications of a reverse total shoulder (such as the two experienced by this patient), and allows for straightforward revision should it fail to deliver the desired shoulder function. By contrast, a large stem cemented reverse with a "platform" stem can be difficult to revise as shown in this case.

The reader may also be interested in these posts:

Information about shoulder exercises can be found at this link.

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