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Introduction
Although reverse total shoulder arthroplasty (RTSA) was
originally designed for rotator cuff tear arthropathy in elderly
patients, indications have been widened from osteoarthritis to
irreparable rotator cuff tears and three or four-part proximal
humeral fractures in recent years [1, 2]. Improvement of the
prosthesis design has let the surgeons to use RTSA more often in
different kinds of indications but as the number of operations
increased, a number of complications also followed this increase
meanwhile [3]. Herein, we report a very unusual case, a
mechanical failure of a RTSA at the humeral stem tray, which is a
rarely seen complication in the literature. A written consent was
obtained from the patient to publish his data.
Case Report
A 55-year-old male applied to our clinic with a sudden pain in his
right shoulder, 2 years after a reverse total shoulder arthroplasty
(RTSA) in another hospital due to rotator cuff arthropathy. He
was a gardener and returned to his work after 2 months of the
operation. His range of motion (ROM) was improved and had
no pain in his daily activities after several months. However,
almost 2 years from the initial surgery, he suddenly felt extreme
pain in his shoulder when he tried to operate a vacuum cleaner.
He applied to our clinic after trying painkillers for 3 weeks. A
sharp pain in the shoulder, restrained ROM, and a loosening-like
feeling were his major complaints at his admission with a normal
neurovascular examination and without any comorbidities. Plain
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DOI: https://doi.org/10.13107/jocr.2023.v13.i10.3956
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111
Dr. Furkan AralDr. Mehmet Kaymakoglu Dr. Gazi Huri
Case Report
Access this article online
Website:
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DOI:
https://doi.org/10.13107/jocr.2023.v13.i10.3956
1Department of Orthopaedics and Traumatology, Izmir University of Economics Faculty of Medicine, Izmir, Turkey,
²Department of Orthopaedics and Traumatology, Gazi University Faculty of Medicine, Ankara, Turkey,
³Department of Orthopaedics and Traumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
Address of Correspondence:
Dr. Gazi Huri, D
Department of Orthopaedics and Traumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey.
E-mail: gazihuri@yahoo.com
© 2023 Journal of Orthopaedic Case Reports Published by Indian Orthopaedic Research Group |
Submitted: 10/07/2023; Review: 18/08/2023; Accepted: Sep 2023; Published: October 2023
Journal of Or thopaedic Case Reports 2023 October:13(10):Page 111-114
Mehmet Kaymakoglu¹, Furkan Aral², Gazi Huri³
Introduction: The evolution of prosthesis design has increased the frequency of RTSA procedures across various indications. This rise in
surgeries has also led to a growing number of associated complications. This case report highlights an unusual occurrence: a mechanical failure of
a RTSA at the humeral stem tray.
Case Report: A 55-year-old male patient was admitted to our hospital with a sharp pain after 2 years of his initial reverse total shoulder
arthroplasty (RTSA) surgery. A broken humeral stem of the RTSA was diagnosed on the plain radiography and the patient underwent a one-
stage revision. Further complications have not arisen during his follow-up to date and the patient has a nearly full range of motion.
Conclusion: Although a humeral stem tray failure is a rarely seen complication for shoulder arthroplasty, surgeons who have used this model
prosthesis should be aware that they may encounter such a complication.
Keywords: Case report, humeral stem, revision, reverse total shoulder arthroplasty, implant failure.
Abstract
Learning Point of the Article:
This case report highlights the importance of recognizing and addressing mechanical complications associated with specific prosthesis
models in reverse total shoulder arthroplasty.
Failure of a Reverse Total Shoulder Arthroplasty with a Broken Humeral
Stem Tray: A Case Report
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radiographs of his shoulder were taken and a RTSA with a
broken humeral stem was determined (Fig. 1). Further
evaluation was done with a computed tomography of the right
shoulder to evaluate any occult fracture around the shoulder
girdle and bony fracture was excluded from the study.
A one-stage operation was planned for revision. We used the
previous incision line for the deltopectoral approach. After
reaching the glenohumeral joint, the prosthesis was found to be
dislocated and broken at the humeral tray of proximal stem. The
model itself was a modular stem and due to the suspicion of
infection, samples were taken from the surrounding synovium
and joint fluid. Metallosis and debris tissue were debrided. The
humeral stem and the glenoid hemisphere were removed with
its cement (Figs. 2 and 3)
an d a c emented long
humeral stem (S MR ,
Lima LTO, Udine, Italy)
was placed (Fig. 4). The
glenohumeral joint was
then reduced and the
layers were anatomically
closed. No post-operative
co mp li cat io ns we re
spotted. The synovial
culture which had been
taken for the suspicion of
an infection was reported
sterile. A frozen section
analysis revealed active
c h ro n i c s y n o v i ti s ,
fibrosis, and giant cell
re ac t io n o f f o re ig n
b o d i e s . S h o u l d e r
physiotherapy with ROM and strengthening exercises were
applied to the patient for 3-month postoperatively. No
complication has occurred during his 3-year follow-up after
surgery and the patient has nearly full ROM with only 20° of loss
in abduction and has neither pain nor complaints. The patient
was satisfied with result of the treatment and gained full
function of his right shoulder.
Discussion
The overall complication rate of primary RTSA has been
reported at between 5% and 25% and even higher in revision
cases, up to 60% [4, 5]. Due to extended indications, patients
and orthopedic surgeons are facing complications more often in
the recent years [6]. Instability, implant loosening,
intraoperative or post-operative periprosthetic fracture, deltoid
weakness, neurological injuries, and infection are the main
complications. Among them, instability is the most common
complication seen in the primary RTSA and an increasing
periprosthetic fracture incidence was also observed with the
aging population [7]. Among patient-related factors, smoking
and male gender seem to increase risk of complications such as
infection and dislocation [4]. Some studies claim that the type
of prosthesis originally used may have an impact on the rates of
subsequent operations [8]. Prostheses with longer stems are
viable options when faced with a lack of proximal humeral bone
stock and short stem or stemless designs provide shorter
operative time, less blood loss, bone preservation, ease of
revision, and the potential to reduce both periprosthetic
fractures and stress shielding [9].
112
Journal of Orthopaedic Case Reports Volume 13 Issue 10 October 2023 Page 111-114 | | | |
Kaymakoglu M, et al
Figure 1: Plain radiographs of the right shoulder. Figure 2: Intraoperative photo removal of proximal
broken part of the humeral stem.
Figure 3: Glenosphere was intact and due to the suspicion of infection,
samples were taken from the surrounding synovium and joint fluid.
113
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Journal of Orthopaedic Case Reports Volume 13 Issue 10 October 2023 Page 111-114 | | | |
In this case, we reported a very uncommon cause of post-
operative complication in RTSA with a specific prosthesis
model. According to the best of our knowledge, humeral stem
failure at humeral tray is a very rare complication in RTSA
literature. The humeral stem failures in the literature have been
reported from a particular modular reverse shoulder system
manufactured by Biomet (Comprehensive Reverse Shoulder
System) in 2010. The failure was caused by a problem at the
design and production stage of humeral tray and this specific
model of reverse shoulder arthroplasty recalled by Zimmer-
Biomet in 2017 [10]. First, Lewicki et al. published an article
about in vivo fatigue cracks in models whose humeral trays were
produced with titanium alloy [11]. An electron microscopic
analysis and a finite element simulation revealed high-stress
concentration at the titanium humeral tray with a possible
failure less than a year in vivo [12]. These findings were also
clinically proven with the case series published by McDonald et
al. Five patients with six humeral tray failures were reported
from 300 patients operated by this specific RTSA model. One
patient underwent a second revision for the same humeral stem
failure. Although a finite element analysis by McDonald et al.
revealed that the mechanical failure usually occurs in the 1st
year after RTSA surgery [13].
The reported case in this paper underwent one-stage revision
surgery, during which the dislocated and broken prosthesis was
removed, and a cemented long humeral stem was implanted.
The occurrence of stem fractures in the shoulder joint is
uncommon, as the shoulder does not bear heavy cyclic loads
like the hip and knee but may have been accelerated by the
patient’s occupation as a gardener, which involved frequent use
of the upper extremity and higher cyclic loads compared to
elderly patients. Although previous studies have identified risk
factors for stem failures in joint arthroplasty, such as patient age,
gender, implant design, and material quality; advances in
technology and material sciences have reduced the incidence of
such failures, but rare cases still occur [14, 15]. It underscores
the need for ongoing research and improvements in implant
design, material selection, and surgical techniques to optimize
patient outcomes and minimize the risk of mechanical failures
in shoulder arthroplasty procedures. Since the patient’s primary
reverse shoulder prosthesis was performed by another center,
we have no information about the intraoperative situation and
the accuracy and inaccuracy of the surgical technique, which is
the weakness of the study. There was neither any biomechanical
study nor reported similar case reports of this specific
prosthesis model. It could not be concluded whether the failure
was due to the design of the prosthesis or the technique used in
the first surgical intervention. We reported the failure and sent
the broken humeral stem to the manufacturer for examination.
Knowing the brand model of the prosthesis and being able to
remove all the parts completely during surgery are among the
strengths of our report.
Conclusion
The patient had a successful outcome, with no post-operative
complications, nearly full range of motion, minimal loss in
abduction, and no pain or complaints during a 3-year follow-up
period. This specific model is not under production anymore,
but it is known that it was used in many patients during the 2010.
The investigation will reveal whether it is a one-time event or if
all the same model prosthesis is at risk. Shoulder surgeons
should be aware of this very rare complication, especially when
using modular prostheses which have trays to connect the stem
and modular head. This case report highlights the importance
of recognizing and addressing mechanical complications
associated with specific prosthesis models in RTSA.
Kaymakoglu M, et al
Figure 4: Post-operative radiograph of the revised reverse total
shoulder arthroplasty with cemented long humeral stem.
Clinical Message
Although the shoulder joint does not carry heavy cyclic loads as hip
or knee joints do, implant failure can rarely be seen in conjunction
with design/material problems. Orthopedic surgeons should be
aware of improper design or manufacturing of the modular RTSA
designs, which can lead to mechanical complications in shoulder
arthroplasty patients.
www.jocr.co.in
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Journal of Orthopaedic Case Reports Volume 13 Issue 10 October 2023 Page 111-114 | | | |
Kaymakoglu M, et al
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References
Declaration of patient consent: The authors certify that they have obtained all appropriate patient consent forms. In the form,
the patient has given the consent for his/ her images and other clinical information to be reported in the journal. The patient
understands that his/ her names and initials will not be published and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Conflict of interest: Nil Source of support: None
How to Cite this Article
Kaymakoglu M, Aral F, Huri G. Failure of a Reverse Total Shoulder
Arthroplasty with a Broken Humeral Stem Tray: A Case Report. Journal of
Orthopaedic Case Reports 2023 October;13(10): 111-114.
Conflict of Interest: Nil
Source of Support: Nil
______________________________________________
Consent: The authors confirm that informed consent was
obtained from the patient for publication of this case report
