Revision of total shoulder arthroplasty.

Orthopaedic and Trauma Surgery, François Rabelais University, 10, boulevard Tonnellé, 37032 Tours, France. Electronic address: .
Orthopaedics & Traumatology Surgery & Research (Impact Factor: 1.17). 01/2013; DOI: 10.1016/j.otsr.2012.11.010
Source: PubMed

ABSTRACT In France, the number of revisions for total shoulder arthroplasty (TSA) has increased by 29% between 2006 and 2010. Published studies have reported a revision rate of approximately 11% for hemi-arthroplasty and total anatomical implants, and 10% for reversed implants. The decision to revise or not revise a TSA requires that a rigorous, clinical, laboratory and imaging initial assessment be done in order to answer five questions. Is it infected? Is it unstable? Is it worn? Is it loosened? How is the rotator cuff? This assessment and an evaluation of the bone stock are required to decide whether or not to revise. If the problem is infection, the best solution is not always complete removal of the implant, which results in very poor shoulder function. In such a situation, a multidisciplinary consultation is essential in the decision-making. If the problem is instability, the cause must be identified and rectified. Instability is often caused by insufficient restoration of the humerus length. If the problem is loosening, the type of revision must take into account the patient's age, the rotator cuff status and the available bone stock. The possibilities to reimplant an anatomical glenoid are scarce, and only for cases with minor bone loss and an intact cuff. If a bone graft without reimplantation of a glenoid component is preferred, it should be a tricortical graft to resist wear and medialisation. In the other cases, a reversed shoulder implant with an autograft is preferable. Whether or not the humeral stem is loose, it must often be removed. However, its removal is very difficult, risky and it often causes complications, with humerus fracture being the most common. The possibility of reconstruction depends on the quality of the remaining bone stock. In all these risky situations, the patient should be duly informed and should take part in the decision-making process.

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    ABSTRACT: The increasing number of primary shoulder arthroplasty operations is correlated to an increasing revision rate of up to 11.2 % for anatomical shoulder arthroplasty and 13.4 % for reverse shoulder arthroplasty. To reduce the risk of implant revision the surgeon has to take the possibility of late complications into account for the index operation and to choose a modular implant system. Indications for revision arthroplasty are secondary glenoid wear, aseptic loosening, infections, rotator cuff deficiency, instability, implant malpositioning, mechanical complications and periprosthetic fractures. Due to the high rate of humeral fractures during revision surgery of anatomical stemmed implants (12 %) and reverse implants (30 %) osteotomy of the humerus is of particular importance. Osteotomy of the humeral shaft with a distal window or transhumeral shaft osteotomy as described by Gohlke can be used. The most demanding step during implantation of the revision implant is the accurate reconstruction of the prosthetic height because the stability, strength of the deltoid muscle and in unfavourable situations the degree of stiffness in the glenohumeral joint all depend on the prosthetic height. The result of anatomical glenoid revision surgery totally depends on the bony defect. Revision glenoid components showed better results compared to glenoid reconstruction using a corticocancellous bone graft but resulted in a higher rate of secondary loosening of the glenoid implant. Cementless glenoid revision implants seem to achieve a higher stability of bony fixation than cemented implants. Due to a better form closure with the reverse humeral implant and a mechanically more favorable loading of the glenoid bone stock, the glenosphere should be implanted with an inferior tilt in revision surgery.
    Der Orthopäde 06/2013; · 0.67 Impact Factor
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    ABSTRACT: Background and purpose - Glenoid reconstruction and inverted glenoid re-implantation is strongly advocated in revisions of failed reverse shoulder arthroplasty (RSA). Nevertheless, severe glenoid deficiency may preclude glenoid reconstruction and may dictate less favorable solutions, such as conversion to hemiarthropasty or resection arthropasty. The CAD/CAM shoulder (Stanmore Implants, Elstree, UK), a hip arthroplasty-inspired implant, may facilitate glenoid component fixation in these challenging revisions where glenoid reconstruction is not feasible. We questioned (1) whether revision arthroplasty with the CAD/CAM shoulder would alleviate pain and improve shoulder function in patients with failed RSA, not amenable to glenoid reconstruction, (2) whether the CAD/CAM hip-inspired glenoid shell would enable secure and durable glenoid component fixation in these challenging revisions. Patients and methods - 11 patients with failed RSAs and unreconstructable glenoids underwent revision with the CAD/CAM shoulder and were followed-up for mean 35 (28-42) months. Clinical outcomes included the Oxford shoulder score, subjective shoulder value, pain rating, physical examination, and shoulder radiographs. Results - The average Oxford shoulder score and subjective shoulder value improved statistically significantly after the revision from 50 to 33 points and from 17% to 48% respectively. Pain rating at rest and during activity improved significantly from 5.3 to 2.3 and from 8.1 to 3.8 respectively. Active forward flexion increased from 25 to 54 degrees and external rotation increased from 9 to 21 degrees. 4 patients required reoperation for postoperative complications. No cases of glenoid loosening occurred. Interpretation - The CAD/CAM shoulder offers an alternative solution for the treatment of failed RSA that is not amenable to glenoid reconstruction.
    Acta Orthopaedica 04/2014; 85(2):171-6. DOI:10.3109/17453674.2014.899850 · 2.45 Impact Factor
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    ABSTRACT: Mit der steigenden Zahl primär implantierter Schulterendoprothesen erhöht sich auch die Revisionsrate, die nach Auswertung von Metaanalysen 11,2 % bei anatomischen und 13,4 % bei inversen Implantaten beträgt. Um die Wechseloperationszahl zu senken, muss man bereits bei der Indexoperation etwaige langfristige Komplikationsmöglichkeiten bedenken und ein Implantat wählen, das modular auswechselbar ist, ohne zukünftigen Schaftausbau oder Wechsel der glenoidalen Basisplatte. Für einen Endoprothesenwechsel gibt es eine ganze Reihe von Indikationen: sekundärer Pfannenverbrauch, aseptische Lockerung, Infektionen, Rotatorenmanschettendefekt, Instabilität, Prothesenfehlstellung, mechanische Komplikationen und periprothetische Frakturen. Da die Rate von Humerusfrakturen beim Wechsel von anatomischen Prothesen bei 12 % und von inversen Prothesen bei 30 % liegt, kommt der Humerusosteotomie ein besonderer Stellenwert zu. Unterschieden wird zwischen einfacher Schaftosteotomie, distalem Knochenfenster und transhumeraler Schaftosteotomie nach Gohlke. Die größte Schwierigkeit bei der Implantation des Revisionsschafts liegt in der passgenauen Einstellung der Prothesenhöhe, weil davon die Stabilität, Kraftentfaltung des M. deltoideus und im ungünstigsten Fall die Ausbildung einer Schultersteife abhängt. Beim Wechsel einer anatomischen Pfanne hängt das Ergebnis ganz vom Knochendefekt ab. Zwar weisen Revisionspfannen bessere Ergebnisse als ein alleiniger Pfannenaufbau mit kortikospongiösen Spänen auf, gehen aber auch mit hohen sekundären Lockerungsraten einher. Im Revisionsfall scheinen zementfreie Revisionspfannen eine bessere Verankerungsqualität aufzuweisen als zementierte Pfannen. Beim Wechsel von Glenosphären sollte bei jeder Rekonstruktion versucht werden, die Glenosphäre mit einem inferioren Tilt, d. h. in leichter Varusstellung einzubauen, weil damit ein größerer Formschluss mit der Humeruspfanne bei mechanisch günstigerer Belastung des glenoidalen „bone stock“ resultiert.
    Der Orthopäde 07/2013; 42(7). DOI:10.1007/s00132-012-2025-5 · 0.67 Impact Factor