Failed total shoulder revised to a ream and run

Sixteen years ago an active man in his 70s presented with right shoulder arthritis

He had a total shoulder with a Hylamer glenoid (now discontinued because of degradation when radiated in air)

This total shoulder served him well for seven years at which time he had some increasing discomfort in his arm and these x-rays showing humeral subsidence and glenoid component wear.

He chose not to have additional surgery until 13 years after his index procedure at which time there was additional subsidence and glenoid deterioration.

He had a single stage revision to a ream and run with exchange of the humeral component. His cultures from surgery were strongly positive for Cutibacterium. He was placed on the red protocol with 6 weeks of IV antibiotics and 6 months of orals. 

His immediate postoperative films are shown below

Three years after his revision he returned for surgery on his opposite shoulder. He scored his right shoulder as 10 out of 12 on the Simple Shoulder Test. His three year post revision x-rays are shown below.

Comment: This is an instructive case illustrating delayed presentation of loosening associated with glenoid component failure and large amounts of Cutibacterium. A single stage revision without reimplantation of a glenoid component has served him well.

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Rocking horse loosening in a posteriorly unstable total shoulder

Recently we found this interesting axillary view that nicely demonstrates rocking horse glenoid component loosening associated with posterior instability after a total shoulder.
While no clinical information was available, the image is interesting in that it demonstrates the possible consequence when the humeral head is not centered in the prosthetic glenoid.

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Healing through joint replacement

Supporting progress in shoulder surgery

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Failed total shoulder - conservative management

A middle aged patient had a total shoulder for glenohumeral osteoarthritis.

Postoperative films are shown here

After a decade of excellent comfort and function, the patient experienced increased pain, stiffness and clunking on movement. X-rays at that time are shown here

At the time of revision, the loose and worn glenoid component was removed, no bone grafting was performed. The head diameter of curvature was upsized to 56. Cultures were negative. Assisted elevation exercises were started immediately after surgery.

Immediate post operative x-rays are shown here revealing the massive glenoid defect with the head perched on the rim.

This is like a large basketball sitting on a small hoop.

A one year after revision, the shoulder is comfortable and with 130 degrees of active elevation.

X-rays show filling in of the defect.

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Total shoulder failure - a 'natural' history.

A middle aged lady had a total shoulder for severe glenohumeral arthritis of the right shoulder.  Preoperatively, she could perform none of the 12 Simple Shoulder Test functions. Postoperative films show a good anatomical reconstruction and secure glenoid component fixation.

A one year after surgery she had excellent comfort and function. Her x-rays showed no lucent lines around her glenoid. She could perform all 12 of the SST functions.

Seven years after surgery, she returned complaining of some shoulder pain, but preserved function.

Her x-ray showed bone resorption around the glenoid fixation. She could perform 10 of the 12 SST functions. She elected non-operative management.

Here is her x-ray at 8 years.

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Here is her x-ray at 9 years.

Here is her x-ray at 10 years after her total shoulder at which time she elected a revision to a hemiarthroplasty.

At surgery the glenoid was grossly loose with massive osteolysis. There was only mild glenoid component wear. After thorough debridement a large diameter humeral head was placed on the residual glenoid bone surface which was smoothed by resecting the inferior prominences. There was no possibility of glenoid re-insertion. No bone graft was used. The rotator cuff was normal. The subscapularis was reconstructed. Multiple cultures showed no growth.

The day after surgery, she started assisted elevation of her arm, which she said was comfortable for her. Time will tell.

Comment: This case history shows the insidious manner in which bone can resorb around the glenoid component years after the index procedure. It also shows that patients with early glenoid component loosening can remain functional and may not recognize that there's an ongoing process in the shoulder.

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A case of glenoid component failure with a simple revision

A patient present to us recently with progressive pain and feelings of instability starting 13 years after a left total shoulder arthroplasty. On examination the shoulder was painful and clunking on any movement. Radiographs shown below demonstrate glenoid loosening as well as glenoid and humeral osteolysis.

At revision 44 21 humeral head was removed. The posterior aspect of the glenoid component was seen to be worn through. Joint fluid was clear and frozen section showed foreign body reaction and particulate debris without findings of acute inflammation. The glenoid bone was severely deficient.

After thorough removal of the reactive tissue from the humerus and glenoid bone, a 52 18 humeral head was inserted on the retained humeral stem and seen to be stable in the eroded glenoid cavity.

On the morning after surgery the patient had assisted elevation of 150 degrees without clunking or sensation of instabilty. 

Comment: While the eventual clinical outcome remains to be determined, we were pleasantly surprised that a stable shoulder could be achieved with this simple conversion, especially since we were prepared to perform a reverse total shoulder had this approach not been successful.

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Failed glenoid components - bad and good news.

We recently had the opportunity to revise two total shoulders for failed glenoid components. That's the bad news. The good news is that the glenoid components had been in place for a long time.

The first case had a total shoulder in 1995 with a great functional result. Eleven years later it started to become somewhat less comfortable; the x-ray appearance at that time is shown below.

22 years after the total shoulder pain had increased to the point that the patient desired a revision; the x-ray appearance at that time is shown below: glenoid component loosening and osteolysis.

At revision surgery the glenoid component was loose and showed concentric wear.

There was a large osteolytic defect in the glenoid bone and no possibility of component reinsertion. After thorough curettage of the defect, a large diameter humeral head prosthesis was inserted to sit on top of the defect.

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In the second case a total shoulder had been performed in 2004,

In 2008 the shoulder was functioning well; the x-ray appearance at that time is shown below.

In 2017 the shoulder had become painful; the x-ray appearance at that time is shown below: glenoid component failure with major osteolysis of the glenoid and humerus

At revision surgery the glenoid component was loose and showed severe wear.

 There was a large chronic inflammatory mass attached to the back of the component that had eroded into the glenoid bone.

There was a large osteolytic defect in the glenoid bone and no possibility of component reinsertion. After thorough curettage of the defect, a large diameter humeral head prosthesis was inserted to sit on top of the defect.

In both cases early assisted range of motion was started on postop day 1.

Comment: This may represent examples of the best case scenario for prosthetic glenoids. In both cases the patient had enjoyed a long time of shoulder comfort and function. But in both cases the failed glenoid components left large cavitary defects. 

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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.

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Total shoulder arthroplasty failure

Optimizing follow-up after anatomic total shoulder arthroplasty

These authors sought to establish a data-based follow-up schedule minimizing unnecessary patient and health care system costs without sacrificing the quality of patient care. They reviewed 2786 consecutive anatomic total shoulder replacements to identify the common modes of failure and times to failure.

208 shoulders (7.5%) required reoperation. Early failure mechanisms included instability, rotator cuff tears, and infection, with 63% of these reoperations occurring within 2 years.  The most common failure mechanism was instability, resulting in 89 reoperations (3.2%). Later failures included mechanical failures (including component loosening) and periprosthetic fractures, with no identifiable peak occurrence. After 2 years, TSA failed at an average rate 1.1% per year.

Comment: In this large study total shoulder arthroplasties continued to fail at an almost linear rate as long as 20 years after surgery. In examining the chart below, the primary cause of failure in the first year was instability (green dots) (left arrow). It would be of interest to know more about the 89 cases with instability, in that this is not usually a common indication for revision.  Component failure (teal dashes) was not a prominent cause of failure until after five years, but then accounted for an progressively increasing percentage of the failures after that)(right arrow). 

"It's not over until it's over." As emphasized in this article, Glenoid Component Failure in Total Shoulder Arthroplasty is the long term issue in the survival of total shoulder arthroplasty.

The importance of long term followup is illustrated by this case.

The patient presented with this x-ray and a Simple Shoulder Test Score of 1/12

She had a total shoulder as shown below.

Two years after surgery, her SST was 12/12 with the x-ray shown below.

Thirteen years after surgery, her SST dropped to 2/12 and she presented with glenoid component failure as shown below.

We have found that asking patients to complete the Simple Shoulder Test annually provides an inexpensive, sensitive, convenient and practical method for the necessary long term followup after shoulder arthroplasty as demonstrated in this article:

Patient functional self-assessment in late glenoid component failure at three to eleven years after total shoulder arthroplasty The routine use of SST as a patient reported outcome may enable the early identification of component failure without having the patient return to the office.

Here's another recent case example
x-ray at 2.5 years after shoulder arthroplasty showing glenoid loosening and osteolysis

x-ray at 3 years after arthroplasty showing increased osteolysis and progressive loosening. SST at the time of presentation to us was 5/12.

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Click here to see the new Shoulder Arthritis Book

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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'