These authors report the results of 73 patients were treated with a reverse shoulder allograft composite for failed prior arthroplasty. A typical preoperative defect is shown below
Press-fit stems were removed using a combination of burrs and osteotomes to separate the bone-implant interface, followed by impaction devices and mallets to remove the stem. For cemented stems, if the previous cement mantle was stable and there was no concern for infection, the cement was left intact and a cement-within-cement technique was performed.
If the degree of bone loss compromised the stability of the revision prosthetic stem, a fresh-frozen allograft was shaped using an oscillating saw and a step-cut technique.
The prepared allograft was then cabled to the host bone using multiple 1.7-mm cables, and the definitive humeral component was cemented into the final construct.
Patients were significantly improved and were usually satisfied, but the self-assessed function remained limited: the Simple Shoulder Test score improved from 1.3 to 3.5. Range of flexion improved from 49° to 75°. Revision was required in 14 patients (19%) for periprosthetic fracture (n = 6), instability (n = 2), glenosphere dissociation (n = 2), humeral loosening (n = 2), and infection (n = 2) at a mean of 38 months postoperatively.
The reoperation-free survival rate of all reconstructions was 88% (30 of 34) at 5 years, 78% (21 of 27) at 10 years, and 67% (8 of 12) beyond 10 years.
Ten patients had radiographic evidence of humeral loosening at final follow-up.
Comment: Failed reverse total shoulders often have associated loss of proximal bone with poor remaining bone quality - factors that complicate surgical revision.
The authors of this paper have extensive experience with these revisions. As they point out, infection, host bone quality that is insufficient for circlage, and massive amounts of bone loss present additional challenges. Finding an appropriately sized proximal humeral allograft of the desired side can also be a major problem. Hand crafting the humerus using struts and a long stem prosthesis may be necessary.
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We have a new set of shoulder youtubes about the shoulder, check them out at this link.
Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link
Use the "Search" box to the right to find other topics of interest to you.
How you can support progress in shoulder surgery
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