Revision Shoulder Arthroplasty

Issues

 

Rule out infection

 

Assess rotator cuff

 

Assess bone stock

- can you re-implant glenoid

- do you need bone graft

 

Removal of prosthesis

- glenoid typically simple

Revise to

- aTSA

- rTSA

- hemiarthroplasty

 

Outcomes

 

Ravi et al. Bone Joint Open 2021

- systematic review of 5379 revision aTSA

- multiple indications including loosening (20%), instability (19%), rotator cuff failure (17%) and infection (16%)

- 22% complication rate

- 8% reoperation rate

- revision to rTSA rather than aTSA resulted in fewer complications, better Constant score, but not ASES scores

 

Otte et al. JSES 2020

- revision aTSA to rTSA in 75 patients

- multiple indications for surgery

- major complications in 28% and reoperation in 12%

- improvements in patient reported outcome measures but did not reach that of primary aTSA

 

Sheth et al. JSES 2019

- revision of 110 failed hemiarthroplasties and aTSA to rTSA

- 92% 2 year survival

- 74% 5 year survival

 

Investigations

 

Rule out infection

- CRP / ESR

- ultrasound or xray guided aspiration

- arthroscopy for fluid and tissue sampling

 

Ultrasound

- good for cuff integrity

- MRI often not useful due to large amount of metal artefact

 

CT scan

- glenoid bone stock

 

Approach

 

Verhoste et al. Int Orthop 2020

- clavicular osteotomy in revision TSA

- curved longitudinal osteotomy parallel to deltoid insertion, sutured back on at end of case

- improves exposure and preserves deltoid

- 40 patients, with 95% healed by 3 months

- 3 post op clavicle fractures after a fall, one loosening

- 3 surgical revisions required

 

Implant Removal

 

Glenoid

- often very loose

- easy to remove

 

Revision TSR Loose GlenoidRevision TSR Loose Glenoid

 

Humeral component

- most uncemented stems only proximally coated

- flexible osteotomes

 

Revision TSR

 

Glenoid bone stock restoration

 

1.  Cortical ring allograft

- napkin ring type

- take from calcar of a femoral neck

- cut so is thicker posteriorly to reconstitute the glenoid

- place onto freshened glenoid surface

 

2.  Bulk posterior allograft

 

 Revision Reverse TSR Glenoid Bulk Posterior Allograft

 

Technique

- use femoral head

- reconstitute posterior aspect of glenoid

- fix with 2 x cannulated 4mm screws via stab incisions posteriorly

- need to be able to fix glenoid component with screws still

 

Revision Humeral Component

 

Technique

- often need long stem

- often use cement in revision circumstance

 

Revision TSR Long Stem Cemented Humeral Component

 

May need proximal humerus allograft

 

Revision TSA proximal humerus allograft

 

Sanchez - Sotelo et al. JBJS Am 2017

- 26 patients undergoing revision to reverse with bulk proximal allograft

- average time to union 7 months

- one patient required bone grafting to obtain union