Saturday, June 2, 2018

Revision of hemiarthroplasty to total shoulder can be complicated

Revision of failed hemiarthroplasty for painful glenoid arthrosis to anatomic total shoulder arthroplasty

These authors identified 28 patients who underwent revision of painful hemiarthroplasty to total shoulder arthroplasty and had a minimum of 2 years’ follow-up after revision surgery.

The 2- and 5-year implant survival rates were 93% and 86%, respectively. Functional outcomes were obtained from 21 patients with surviving implants: mean American Shoulder and Elbow Surgeons score 78 ± 20, visual analog scale score for pain 2.3 ± 2.6,, and Single Assessment Numerical Evaluation score 71 ± 24.

There were 3 intraoperative complications (11%) at the time of conversion from failed HA to aTSA, including fracture (humeral shaft in 1 and greater tuberosity in 1) and iatrogenic rotator cuff tear (1). There were 10 postoperative complications (36%), including subscapularis failure (3), infection (1), humeral component loosening (1), hemarthrosis (1), lesser tuberosity nonunion (1), brachial plexus injury (1), glenoid loosening (1), and posterior-superior rotator cuff tear (1). Thus, in total, 13 intraoperative and postoperative complications occurred, giving an overall complication rate of 46%.

Following revision to aTSA, reoperation was required in 6 patients (21.4%). Reoperations involving component revision included humeral stem revision (2), arthroscopic glenoid excision (1), reverse shoulder arthroplasty (RSA) (1), and cement spacer placement (1).

Comment: This article points out that revision of a failed arthroplasty carries substantial risk of intraoperative and postoperative complications. Thus it is important to recognize and, when possible, avoid the need for revision as discussed in a recent article, "Primary Shoulder Hemiarthroplasty: What Can Be Learned From 359 Cases That Were Surgically Revised?" It is not always easy to determine the cause of a painful hemiarthroplasty. While it is tempting to attribute a hemiarthroplasty failure to "glenoid arthrosis",  a painful hemiarthroplasty can also result from instability, stiffness, component malposition, subscapularis failure, cuff disease, and low grade infection. Each of these failure modes calls for different management strategies, so a careful preoperative assessment is essential to a successful revision.

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