Reverse total shoulder - why take x-rays in the recovery room?

 Clinical Utility of Immediate Postoperative Radiographs following Uncomplicated Primary Reverse Shoulder Arthroplasty

These authors reviewed the the recovery room (PACU) x-rays and other 90 postoperative films of 157 patients having uncomplicated primary reverse total shoulders. 

Immediate postoperative radiographs were read by the radiologist as normal/unremarkable for 100% of patients.  

13 patients had abnormal findings determined by the surgeon during the initial 3 month postoperative period.  

Ten out of 13 patients had radiographic findings at the first postoperative clinic visit that differed from the initial radiologist interpretation documented on the PACU radiograph.

The most common complication was instability and dislocation, which occurred in 9 patients. Additional complications included baseplate failure,  glenosphere dissociation, and humeral stem subsidence. Twelve of the 13 patients underwent revision surgery.

The authors concluded, "Based on our findings we see utility for an intra-operative or immediate postoperative radiograph following uncomplicated, primary reverse shoulder arthroplasty, especially when done as a salvage procedure for indications such as proximal humerus non-union. However, there is low utility for obtaining an immediate postoperative radiograph in the PACU when indications include osteoarthritis or rotator cuff tear arthropathy."

Comment: In contrast to these authors, we believe that it is important to obtain good quality postoperative x-rays in each case of reverse total shoulder arthroplasty, regardless of indication. The first reason is that these films provide the surgical team with immediate feedback on whether or not they realized their preoperative plan with respect to component positioning, screw placement, baseplate seating, humeral component positioning and humeral component fixation. 

Second, a "normal/unremarkable" reading by a radiologist may overlook abnormal findings of importance to the shoulder surgeon, such as the incomplete glenosphere seating shown below. Such a finding, even in a routine case may prompt a return to the OR from the PACU.

A third reason for taking a PACU x-ray is shown by the table from the article:

Case 5 (RSA for cuff tear arthropathy) was found to have baseplate failure 2 weeks after the procedure

Case 8 (RSA for massive cuff tear) was found to have a glenosphere dissociation a 3 weeks after the procedure.

Case 12 (RSA for massive cuff tear) was found to have a dislocation at two weeks after surgery

Case 13 (RSA for avascular necrosis) was found to have a greater tuberosity at 6 weeks after surgery.

In each of these cases of early failure it seems likely that there was a technical problem at surgery and that a careful examination of good quality PACU films might have identified the issue in a more timely manner.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).