Ream and run to salvage failed hemicap.

 A 35 year old physically active patient presented with a history of 6 prior surgical procedures culminating in a hemicap. Since that operation the shoulder was extremely stiff and painful. X-rays in the clinic showed a hemicap that had eroded into the glenoid bone.

The patient desired a revision to a ream and run performed under general anesthesia without a nerve block.  Surgical findings included a tightly contracted capsule and subscapularis, a medially eroded glenoid, several suture anchors on the face of the glenoid, no synovitis, a frozen section showing no neutrophils, and a well fixed humeral component.

The glenoid was reamed to a diameter of curvature of 54 mm, and a canal sparing stemmed implant was inserted with a 48 15 humeral head. Because of the history of multiple prior surgeries and the glenoid erosion, the patient was placed on the red protocol. The postoperative films are shown below.

Four hours after surgery the patient had this range of motion.

The patient was discharged home on the first post op day on mild analgesics.

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How you can support research in shoulder surgery Click on this link.

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.

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Failed shoulder arthroplasties

Revision of failed shoulder arthroplasty:epidemiology, etiology, and surgical options
These authors analyzed the epidemiology, etiologies, and revision options for 540 failed shoulder arthroplasties: 224 hemiarthroplasties (HAs), 237 anatomic total shoulder arthroplasties (TSAs) and 81 reverse total arthroplasties (RSAs) .

The indications for the initial arthroplasties differed by type of arthroplasty as shown below.

The indications for the first revision differed by type of arthroplasty as shown below.

Glenoid failure was a major indication for reoperation: erosion in HAs (29%) or loosening in TSAs (37%) and RSAs (24%). Instability was another major cause of reintervention: 32% in RSAs, 20% in TSAs, and 13% in HAs. Humeral implant loosening led to revision in 10% of RSAs, 6% of HAs, and 6% of TSAs.

An important finding of this study was the high rate of multiple revisions (21%) performed in the same patients, mainly attributable to unresolved soft-tissue insufficiency (26%) and/or infections (25%) as well as humeral bone loss; these may coexist with mechanical complications (glenoid or humeral loosening, instability).

The final implant was often an RSA, which has the potential to address combined bone and soft-tissue deficiencies.

Comment: The study of implant failure is vital to our understanding how we can do a better job of shoulder arthroplasty. The findings of this study need to be compared to those in three recent large studies, not included in the reference list:

Primary Shoulder Hemiarthroplasty: What Can Be Learned From 359 Cases That Were Surgically Revised? 

What can be learned from an analysis of 215 glenoid component failures?

Analysis of 4063 complications of shoulder arthroplasty reported to the US Food and Drug Administration from 2012 to 2016

The authors of the third of these articles point out that most of the literature on shoulder arthroplasty failure comes from high-volume centers and that these reports tend to exclude the experience of community orthopedic surgeons, who perform most of the shoulder joint replacements.

They analyzed the failure reports mandated by the US Food and Drug Administration for all hospitals. Each reported event from 2012 to 2016 was characterized by implant, failure mode, and year of surgery.

The percentage distribution among the different failure modes was relatively consistent over the years of this study. Thus the question, "are we learning anything from these failures?"

For the 1673 anatomic arthroplasties, the most common failure modes were glenoid component failure (20.4%), rotator cuff/subscapularis tear (15.4%), pain/stiffness (12.9%), dislocation/instability (11.8%), infection (9%), and humeral component loosening (5.1%).

For the 2390 reverse arthroplasties, the most common failure modes were dislocation/instability (32%), infection (13.8%), glenosphere-baseplate dissociation (12.2%), failed/loosened baseplate (10.4%), humeral component dissociation/tray fracture (5.5%), difficulty inserting the baseplate (4.8%), and difficulty inserting the glenosphere (4.2%).

The percentage distribution of the failure modes also differed substantially from those published in a recent review of the literature.

They concluded that the publicly available Food and Drug Administration database reveals modes of shoulder arthroplasty failure that are not emphasized in the published literature, such as rotator cuff tear, infection, and postoperative pain/stiffness for anatomic total shoulder arthroplasty and implant dissociation and baseplate failure for reverse shoulder arthroplasty.

This study points to the utility of the freely accessible FDA MAUDE database as a resource for identifying failure modes for shoulder arthroplasty not readily identified in the published literature. Some modes of failure appear in the MAUDE data base long before they appear in the published literature, such as the dissociation of the glenosphere from the the baseplate as shown below.

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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

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Failed shoulder joint replacement - what is the role of arthroscopy?

Arthroscopy of the symptomatic shoulder arthroplasty

These authors retrospectively reviewed the records of 14 patients who underwent diagnostic
shoulder arthroscopy to evaluate symptoms of shoulder pain or stiffness after a shoulder arthroplasty without an obvious cause. Patients were excluded if they had any traditional symptoms of infection or had a raised serum white cell count or C-reactive protein level prior to diagnostic arthroscopy. Patients were also excluded if available preoperative imaging showed evidence of loosening, periprosthetic fracture, or superior or anterior migration of the humerus or showed any other finding suggestive of the cause of pain.

The mean interval between the joint replacement and arthroscopic evaluation was over five years.

Prophylactic antibiotics were administered at anesthetic induction to diminish the risk of iatrogenic infection. At arthroscopy five synovial tissue samples were taken from different positions within the joint. Each tissue biopsy specimen was taken with a separate, clean arthroscopic punch and was cultured on Columbia Agar with ‘‘Chocolated’’ Horse Blood (incubated in carbon dioxide) and Fastidious Anaerobic Agar with Horse Blood (incubated anaerobically). Extended cultures were interpreted at 15 days. Biopsy findings were considered positive if the same organism was cultured on 3 or more of the 5 samples.

Rotator cuff tears were noted in 8 patients (57%). Capsular contraction requiring release was noted in 2 patients (10%).

Arthroscopic biopsy specimens returned positive culture results in 3 patients (21%).

Of the patients who went on to definitive revision surgery, none had an unexpected positive microbiological result (defined as 3 positive samples from a further 5 samples) from samples taken at the time of revision surgery.

Of the 5 patients who underwent perioperative joint aspiration, only 2 had aspiration results that correlated with the biopsy results.

Other findings are summarized below

Comment: This study demonstrates the value of pre-revision shoulder arthroscopy in patients with failed arthroplasty for which a diagnosis cannot be made by clinical evaluation.

In contrast to some prior studies, these authors' technique includes harvesting five samples that were submitted for a culturing protocol specific for detecting Cutibacterium (Propionibacterium). It is of interest that the three cases with positive cultures, at least three of the specimens were culture positive. None of the cases had only one or two positive cultures.

These authors found that the findings at arthroscopy were helpful in guiding subsequent treatment of these patients.

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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

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Revision of failed hemiarthroplasty - it's complicated.

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

These authors identified 28 patients who underwent revision of a painful hemiarthroplasty to total shoulder arthroplasty over a 15-year period.  Complications were seen in 10 patients  and 6 patients required reoperation.

There were 3 intraoperative complications 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, 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%). Of these patients, 2 did not require revision of any components (irrigation and débridement in 1 and open subscapularis repair in 1). Reoperations involving component revision included humeral stem revision (2), arthroscopic glenoid excision (1), reverse shoulder arthroplasty (RSA) (1), and cement spacer placement (1). 

Of the 3 patients with rotator cuff tears at the time of aTSA, 2 had surviving implants at 84 and 40 months following surgery. The third patient underwent revision to RSA.

Comment: This article demonstrates the complications that can occur - even in experienced hands - when a failed hemiarthroplasty is revised. 

We need to learn how to prevent these failures by studying their cause. Interested readers should click on this link: Primary Shoulder Hemiarthroplasty: What Can Be Learned From 359 Cases That Were Surgically Revised? 

Some examples and the relative distribution of modes of failure are shown in this figure.

The rate of failure of hemiarthroplasty failure may be minimized by considering the knowledge gained from these failures: 

Prevention is obviously preferable to revision.

Fixing the humerus with impaction grafting (as shown above) may facilitate revision of a hemiarthroplasty, should it become 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

You may be interested in some of our most visited web pages arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Failed total shoulder: infected?

A patient presented to us one year after having had a left total shoulder using this prosthesis.

The patient experienced pain and stiffness since surgery. The patient has also had chronic swelling and a draining sinus. 

The patient had had two limited I&D's by the original surgeon to drain what was thought to be hematoma. All cultures were negative. The patient  was unable to use the arm for daily activities.

The patient had completed IV antibiotic for a short course of 5 days and an oral course of Keflex and doxycyline. At the time of presentation, the arm had the appearance shown below. CBC, sed rate and CRP were all normal.

And this x-ray showing a fractured central metal peg with surrounding osteolysis. 

We revised this prosthesis by removing all components. The retrieved glenoid showed a fractured peg

The portion of the peg remaining in the glenoid had to be removed with a trephine.

Removal of the humeral component was difficult because of the tight diaphysial fit, the proximal ingrowth surface, and the fragile osteopenic metaphyseal bone.

A cement spacer was inserted with a plan 6 weeks of IV Ceftriaxone followed by oral Augmentin. The pathology report from surgery was as follows: 

Left shoulder capsule, excision: - Fibro-connective tissue with focal fibrin deposition, chronic inflammation, giant cell reaction, and rare neutrophils focally present.  Very few (<5/HPF) neutrophils are identified in one focal area directly underlying surface fibrin deposition. On retrospective review of the frozen section slides, these neutrophils are present, but do not reach numbers above 5/HPF.

At the time of the revision, 8 specimens were submitted for culture. The humeral stem had one colony only of coagulase negative Staph (SpCV 0.1), and one of three capsule specimens grew one colony only of Propionibacterium (SpPV 0.1). The rest showed no growth at 3 weeks.

Four months later, we removed the spacer and inserted a reverse total shoulder. In spite of the glenoid bone deficiency, robust fixation of the baseplate was achieved without bone grafting.

 Comment: When a shoulder arthroplasty fails, we consider
(1) removal/revision of loose components
(2) single stage removal/revision of all components
(3) insertion of an antibiotic spacer, possibly as the first step in a two-stage revision
(4) removal of all components without re-insertion

The decision among these options needs to be based on the information available before and at surgery. Often, as shown in this case, the history, the physical examination, and plain radiographs provide most of the needed information. The results of cultures obtained at the time of revision surgery does not become available in time to inform the surgical decision-making.

This case demonstrates (1) the ever present risk of infection in shoulder arthroplasty, (2) the susceptibility of fatigue fracture of a metal post, (3) the problems created by a tight press-fit bone ingrowth stem should prosthesis removal become necessary.

The potential for fatigue fracture of a hybrid post has been shown in a recent article

Five-year minimum clinical and radiographic outcomes of total shoulder arthroplasty using a hybrid glenoid component with a central porous titanium post.

Here is a radiograph from that article.

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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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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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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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How should we evaluate and treat the microbiologic aspects of a patient with a failed arthroplasty?

Diagnosis of Periprosthetic Joint Infection: The Potential of Next-Generation Sequencing

These authors sought to evaluate the accuracy of next-generation sequencing in identifying the causative organism(s) in patients with periprosthetic joint infection.

Samples were collected from 65 revision arthroplasties (39 knees and 26 hips) and 17 primary arthroplasties (9 hips and 8 knees). Synovial fluid, deep tissue, and swabs were obtained at the time of the surgical procedure and were submitted for next-generation sequencing. Deep-tissue specimens were also sent to the institutional laboratory for culture.

Sensitivity and specificity were calculated for next-generation sequencing using the Musculoskeletal Infection Society (MSIS) definition of periprosthetic joint infection as the standard.

28 of the 65 revisions met the authors' criteria for infection. 17 of these were cultures positive and 25 were next-generation sequencing positive. There was concordance between next-generation sequencing and culture in 15 cases. Among the 11 cases of culture-negative periprosthetic joint infection, next-generation sequencing was able to identify an organism in 9 cases.

Next-generation sequencing identified microbes in 9 of 36 "aseptic" revisions with negative cultures and in 6 of 17 primary total joint arthroplasties. 

Next-generation sequencing detected several organisms in most positive samples. However, in the majority of patients who were infected, 1 or 2 organisms were dominant. These findings suggest that some cases of monomicrobial periprosthetic joint infection may have additional organisms that escape detection when culture is used. 

Comment: In their introduction the authors state "in up to 50% of periprosthetic joint infection cases, cultures fail to isolate the infecting organism". In the realm of revision shoulder arthroplasty, we and others have pointed out that "culture negativity", especially with regard to Propionibacterium, is often due to inadequate culture techniques: failure to obtain at least 5 deep tissue or explant samples, failure to culture on aerobic and anaerobic media and broth, and failure to observe the cultures for 17 days. Thus, unless the details of the approach to culturing are appropriate for Propionibacterium, the phrase "culture negative" must be used with caution. On the other hand, if specimen harvesting and culturing methods are appropriate and standardized, one can generate a semiquantitative picture of the culture results for the joint in question, estimating the load of bacteria in the joint rather than stating that the culture result as simply "positive" or "negative" - see this link.

Thus, it is of interest that in this study, only 60% of the lower extremity joints meeting the MSIS criteria for infection were "culture positive".

Defining and standardizing the culture practice is essential to the application of the MSIS criteria for infection, which are critically dependent on the number of specimens that are culture positive. The smaller number of specimens submitted, the fewer media used, and the shorter the period of culture observation, the less likely that bacteria will be recovered by culture and the less likely the case is to meet the criteria.

To build on this point, the authors state, "in approximately one-third of supposedly noninfected revision cases in this study, next-generation sequencing had detected bacteria. In many of these cases, Propionibacterium acnes was the predominant organism." Thus it would be important to know whether Propionibacterium-specific culturing techniques were used in the those cases; if not, it is unlikely that standard culturing techniques would have been positive for this organism. Furthermore, the detection of Propionibacterium in failed / revised hip and knee arthroplasty cases raises the concern that cases failing to meet the MSIS criteria for infection (because of the low level of inflammatory response and the difficulty of culturing Propionibacterium) may actually harbor this organism. Of note, none of the hip and knee cases in this series were culture positive for Propionibacterium. This is  in marked contrast to the results of some other studies of revised hip and knee arthroplasty in which Propionibacterium were prominent (see this link).

There is a well know saying, "absence of evidence is not evidence of absence," suggesting we be cautious in using the term 'aseptic'. We could take a number of samples of this lawn and not find any that show a poisonous mushroom, but that doesn't mean Amanita phalloides are not really there.

Finally, these authors found that next-generation sequencing was positive in approximately 35% of primary arthroplasties and 25% of revision of arthroplasties, in which the patients were presumed to be noninfected. In these cases we must wonder if these results were spurious, or (more likely in our view) that these cases actually had bacteria present, but that the presence of the bacteria (often Propionibacterium) had not manifested itself in a manner that was otherwise evident.

These authors are to be congratulated on a robust study that challenges current thinking regarding how to define a "periprosthetic infection". It prompts us to ask what may be the more important question, "what preoperative and intraoperative data do we need to select the appropriate surgical and antibiotic treatment of a patient having a revision of a failed arthroplasty?"

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Mechanical failure of reverse shoulder arthroplasty

We recently consulted on an active man who had surgery for cuff tear arthroplasty three years ago.
His preoperative films are shown below.

He had a reverse total shoulder which failed shortly after surgery. As shown below, the cause of the failure was dissociation of the glenosphere from the baseplate

This surgery was revised to a "hemiarthroplasty" as shown below, but the 'roof' of the joint has been compromised. The shoulder is now pseudoparalytic.

One wonders how this patient might have done with a CTA arthroplasty.

Many of our patients with classical cuff tear arthropathy want to lead active lives. They wish to avoid a reverse total shoulder because of concerns about activity limitations, dissociation of the components, dislocation, screw breakage or humeral shaft fracture should they fall. If these individuals have active elevation > 90 degrees and have no evidence of anterior superior instability, we discuss the option of a CTA prosthesis.

Here's the example of a lady in her mid sixties with a failed cuff repair. Two years after that surgery she presented to us with a weak and painful shoulder. She was taking prednisone, methotrexate and Humira for her rheumatoid arthritis. She had active elevation to 110 and passive elevation to 160 degrees. Her x-rays at this time are shown below.

She elected a CTA arthroplasty. At surgery she had an irreparable cuff defect involving her supraspinatus and infraspinatus.

She dropped by to see us nine years after surgery. Her films at that time are shown below.

Her shoulder was painless. Her active elevation is shown below.

As another example we recently we saw an active physician-rancher who had had bilateral CTA prostheses performed after failed cuff repairs. Because he recognized that his ranching was demanding on his shoulders and carried the risk of falls, he preferred the CTA over the reverse total shoulder.

Before his left shoulder surgery his films were as shown below and he reported the ability to perform only 5 of the 12 Simple Shoulder Test functions. He was able to elevate his arm to over 90 degrees and had no anterosuperior instability.

At the time of surgery he had no supraspinatus, no infraspinatus and a detached subscapularis.
We were able to reattach his subscapularis.

At four years after surgery, he could perform 8 of the 12 SST functions and had the radiographs shown below. Note the impaction grafted humeral stem and the articulation of the prosthesis with the undersurface of the coracoacromial arch.

 

Two years ago he presented with a similar situation in his right shoulder. His SST score was 3/12. He had active elevation of 100 degrees without anterosuperior escape. His preoperative x-rays shown below.

Two years after his right shoulder arthroplasty he could perform 8/12 SST functions and was back at work on his ranch. His 2 year films are shown below.

 

Here is his active motion at present

Here is a video of a lady two years after her CTA arthroplasty

Here are the x-rays and the shoulder function of a man one year out from his CTA arthroplasty

Here is his function at one year.

Comment:  From our standpoint, the CTA arthroplasty is a most attractive option for consideration by active individuals with cuff tear arthropathy and the ability to actively elevate the arm above 90 degrees without manifesting anterosuperior instability.  Inserting the prosthesis with impaction grafting makes for an easy conversion to a reverse should that be necessary, fortunately this is rarely the case. The cuff tear arthropathy prosthesis is considered for individuals with active elevation of 90 or more degrees without anterosuperior escape – especially those who desire higher levels of physical activity or those who are at increased risk of falls. It is important to realize that this prosthesis has an extended lateral joint surface for articulation with the undersurface of the coracoacromial arch, thus it is distinct from the usual hemiarthroplasty prosthesis. The implant system should allow selection of the appropriate diameter of curvature and should enable fixation by impaction grafting.

 

The surgical keys to a successful CTA arthroplasty are (1) optimizing stability and (2) matching the prosthetic diameter of curvature to that of the resected humeral head. The patient positioning, anesthetic, prophylactic antibiotics, skin preparation, and skin incision are identical to that for an anatomic arthroplasty. 

 

In exposing the humeral head, we retain as much as possible of the clavipectoral fascia attached to the coracoacromial ligament (the “CA+”) as an additional barrier to anterosuperior instability. 

The subscapularis is carefully incised from the lesser tuberosity taking care to keep the subjacent capsule attached to its deep side. The humerus is exposed by gentle external rotation allowing for debridement of cuff tendon remnants and osteophytes as well as sectioning of the long head tendon of the biceps if it remains intact. The humeral head height and diameter of curvature are measured, ideally before the head is resected.

The medullary canal is entered and progressively larger reamers inserted as sizers until the diaphyseal endosteal cortex is encountered at a depth corresponding to the length of the prosthetic stem (‘love at first bite’); this reamer defines the orthopaedic axis. The humeral head is resected at an angle of 45 degrees with the orthopaedic axis; the proximal humerus is prepared as for a standard humeral arthroplasty. The lateral tuberosity is resected. The humeral head diameter of curvature is chosen to match that of the resected head. Trial reduction is carried out. The height of the prosthesis is selected so that the deltoid is under mild-moderate tension when the arm is adducted. Impaction grafting is carried out using bone from the resected humeral head. If the biceps tendon is available, an in-and-out biceps tenodesis is performed. Drill holes are placed for reattachment of the subscapularis. The is prosthesis assembled and inserted and the subscapularis is securely repaired.

 


Additional relevant posts can be found here and here and here

We first described our approach over two decades ago in a publication, Prosthetic replacement of the shoulder for the treatment of defects in the rotator cuff and the surface of the glenohumeral joint, which reported on twenty-one shoulders in nineteen patients, fifty-four to eighty-four years old, who had disabling pain attributable to a massive tear of the rotator cuff, accompanied by loss of the surface of the glenohumeral joint. These patients were not candidates for total shoulder replacement because of the massive deficiency in the cuff and the fixed upward displacement of the humeral head. At that time reverse total shoulder was not an option. A prerequisite for hemiarthroplasty was a functionally intact coracoacromial arch to provide superior secondary stability for the prosthesis. One important aspect of the operative technique was the selection of a sufficiently small prosthesis so that excessive tightness of the posterior aspect of the capsule could be avoided. Eighteen shoulders in sixteen patients were available for follow-up, which ranged from twenty-five to 122 months. Pain decreased from marked or disabling in fourteen shoulders preoperatively to none or slight in ten and to pain only after unusual activity in four. Active forward elevation improved from an average of 66 degrees preoperatively to an average of 109 degrees postoperatively. One patient, who had had an excellent result, fell and sustained an acromial fracture, so the functional result changed to poor. Three patients had persistent, substantial pain in the shoulder that led to a revision. Neither infection nor prosthetic loosening nor instability developed in any shoulder.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.