Revision surgery for stiff total shoulder replacement arthroplasty - our approach, Part 7

The diagnosis of stiffness is made by the finding of reduced humeroscapular rotational laxity in flexion, cross body adduction, internal and external rotation with the arm at the side and internal and external rotation with the arm in 90 degrees of abduction.  As we saw from a previous post, some cases of stiff shoulder after arthroplasty can be managed with soft tissue releases alone. Often, however, soft tissue releases may be insufficient because of technical problems with the implants.  High quality anteroposterior and axillary radiographs are needed to determine the presence of unwanted bone,

 displaced tuberosities,

 or other ‘hard’ causes of restriction of motion. As shown previously all adhesions in the humeroscapular motion interface are lysed.  A 360-degree release of the subscapularis is performed, freeing it from the coracoid, the coracoid muscles, the axillary nerve and the glenoid lip.  The capsule is released around the periphery of the glenoid – 360 degrees unless there is posterior instability in which case the release is stopped at 190 degrees.

All unwanted bone, such as residual osteophytes between the medial humerus and inferior glenoid, is removed.  If the greater tuberosity is malunited posteriorly, it can block external rotation.  We prefer to avoid tuberosity osteotomy unless it is absolutely necessary because of the difficulties of mobilizing the tuberosity and of obtaining a secure tuberosity union to the shaft after a humeral arthroplasty.  For this reason we prefer to resect prominent tuberosity bone leaving the cuff intact if this is at all possible.

If the joint is overstuffed (the components consume too much of the joint volume) as shown below

the intraarticular prosthetic volume may be reduced by removing or revising the glenoid component, and by reducing the height (thickness) of the humeral component.

Varus positioning of the stem can also result in overstuffing (as shown below) and require component revision.

More often than not, a combination of soft tissue, bony, and component procedures are required to optimize the motion in a stiff arthroplasty.

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