These authors reviewed 30 patients (mean age 52, range 30-59 year) having reverse total shoulder arthroplasty after failed open reduction (7) or failed hemiarthroplasty (23) for proximal humeral fracture.
The follow-up period averaged 11 years (range, 8-18 years). At final follow-up, the mean relative Constant score had improved from 25% (12%) to 58% (21%, P <.001). Significant improvements were seen in the mean Subjective Shoulder Value (20% to 56%), active elevation (45 to 106), abduction (42 to 99), pain scores, and strength (P <.001). Clinical outcomes did not significantly deteriorate over a period of 10 years.
The number of previous surgical procedures (P .005), infection prior to salvage RTSA (7 of 7 shoulders, P .048), failed hemiarthroplasty (19 of 23 shoulders, P .014), and Delta III RTSA (17 of 20 shoulders, P .018) were significantly associated with postoperative complications.
8 patients (27%, all with hemiarthroplasty) had a history of infection, which was significantly associated with the number of previous surgical procedures (P .013).
Periprosthetic infections developed in 4 patients who had had a documented infection prior to salvage RTSA and in 1 patient owing to revision surgery or a periprosthetic fracture. Three patients underwent conservative treatment for a low-grade Cutibacterium acnes infection.
One or more complications occurred in 18 shoulders (60%), and 6 (20%) resulted in explantation of the RTSA.
The number of previous surgical procedures (P .005), infection prior to salvage RTSA (7 of 7 shoulders, P .048), failed hemiarthroplasty (19 of 23 shoulders, P .014), and Delta III RTSA (17 of 20 shoulders, P .018) were significantly associated with postoperative complications.
8 patients (27%, all with hemiarthroplasty) had a history of infection, which was significantly associated with the number of previous surgical procedures (P .013).
Periprosthetic infections developed in 4 patients who had had a documented infection prior to salvage RTSA and in 1 patient owing to revision surgery or a periprosthetic fracture. Three patients underwent conservative treatment for a low-grade Cutibacterium acnes infection.
Inferior shoulder function was associated with greater tuberosity resorption or resection and with the diagnosis of failed secondary hemiarthroplasty.
Comment: These authors give us an important "heads up" about the challenges they encountered in managing failed prior surgeries for fracture. One of the key messages is that surgeons need to be alert to the possibility of infection in revising shoulders with prior surgery. Our practice is obtain cultures at the time of revision, even if signs of infection are not obvious (a frequent feature of Cutibacterium infections) and to keep the patient on post operative antibiotics until the culture results are finalized.
Comment: These authors give us an important "heads up" about the challenges they encountered in managing failed prior surgeries for fracture. One of the key messages is that surgeons need to be alert to the possibility of infection in revising shoulders with prior surgery. Our practice is obtain cultures at the time of revision, even if signs of infection are not obvious (a frequent feature of Cutibacterium infections) and to keep the patient on post operative antibiotics until the culture results are finalized.
Problems encountered in revising prior surgeries for fracture to a reverse total shoulder also include periprosthetic fractures, bone loss, instability, and soft tissue deficiency. In addition the surgeon needs to consider patient factors that may have contributed to the initial fracture in this young population (30 to 59 years of age): is the patient at risk for additional accidents, is the patient a smoker or a heavy drinker) and if there are patient factors that may have contributed to the failure of the initial surgery: co morbidities, problems with compliance?
The point being that in approaching these cases, we need to consider both patient and shoulder factors before jumping in. Revising a failed surgery is rarely an emergency. A failed prior surgery is not always an indication for yet another surgery.
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