Saturday, June 2, 2018

Shoulder arthroplasty failure - one complication gives rise to another - l’abîme appelle l’abîme

Cutaneous metallosis following reverse total shoulder arthroplasty

A woman with a medical history of obesity, gout, non–insulin-dependent type 2 diabetes mellitus, hypertension, and hypercholesterolemia had 
(1) an anatomic total shoulder arthroplasty (TSA) for end-stage glenohumeral arthritis. This was complicated by glenoid loosening. 
(2) a revision was performed at which time an intraoperative gram stain revealed gram-positive cocci in clusters and gram-negative bacilli; both the glenoid and humeral components were explanted and replaced with a hemiarthroplasty with an antibiotic-impregnated cement spacer.
(3) Approximately a year later, a revision TSA was performed.  
(4) A year later a resection arthroplasty was performed for a loose glenoid component and persistent pain.
(5) Several years later she underwent a revision to an RTSA to improve function and pain.
(6) Three months postoperatively the shoulder was found to be unstable as shown below

She had dark pigmentation surrounding the incision on the anterior shoulder and chest wall .

(7) Approximately eight years after her index procedure she underwent explantation and resection arthroplasty. At nearly 2 years after the second resection arthroplasty, the patient remained dissatisfied with her shoulder.

Comment: The French have a saying, "l’abîme appelle l’abîme", meaning one problem brings on another. Here we see a patient with comorbidities that experienced septic glenoid loosening after a total shoulder and several operations later was left with a flail shoulder.  It is not uncommon to see such situations where revisions of revisions fail, creating a costly outcome for the patient.

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