Purpose of Review The incidence of shoulder arthroplasty is increasing dramatically for primary arthroplasty but also for revision arthroplasty. Revision to reverse total shoulder arthroplasty is increasingly the salvage operation for failed primary arthroplasty. The purpose of this review is to explore the indications for and results of revision reverse total shoulder arthroplasty. Recent Findings Despite relatively high complication and reoperation rates with revision shoulder replacement, revision of failed hemiarthroplasty or total shoulder arthroplasty to reverse total shoulder arthroplasty improves outcomes for many patients. A failed hemiarthroplasty or total shoulder arthroplasty is frequently disabling for the patient and because the surgical revision options are often limited only to reverse total shoulder arthroplasty, the potential improvement is often worth the higher surgical complication or reoperation rate. Summary Due to the challenges inherent in revision arthroplasty, revision of primary arthroplasty to reverse total shoulder arthroplasty, outcomes are poorer than primary reverse total shoulder arthroplasty. Despite these limitations, patient postoperative pain and function do increase from preoperative levels making conversion of hemiarthroplasty or anatomic total shoulder to reverse total shoulder arthroplasty an important option for a challenging problem.

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This case illustrates the natural history of catastrophic failure in a metal-on-polyethylene total hip arthroplasty design. If recognized earlier, this patient may have been a candidate for isolated liner and head exchange. Additionally, this case represents a unique complication in using mixed metals in total hip arthroplasty, where the harder cobalt-chrome femoral head wore completely through the much softer titanium component.

Background: The lesser tuberosity osteotomy (LTO) is a commonly employed technique for mobilizing the subscapularis tendon during anatomic total shoulder arthroplasty that is performed through a deltopectoral approach. During this procedure, the lesser tuberosity is osteotomized from the proximal aspect of the humerus while maintaining the strong tendon-to-bone attachment of the subscapularis tendon insertion. After the shoulder arthroplasty is performed, the lesser tuberosity osseous fragment is then resecured to the proximal aspect of the humerus with heavy nonabsorbable suture, which allows for direct bone-to-bone compression and healing of the fragment to the proximal aspect of the humerus. This technique may be utilized for subscapularis tendon mobilization in any primary and some revision anatomic total shoulder arthroplasty procedures. Description: The procedure is performed as follows. (1) Preoperative planning is performed. (2) The patient is positioned in the semi-upright beach-chair position, and the shoulder girdle and the upper arm are prepared and draped. (3) A standard deltopectoral approach is utilized. (4) A tenotomy of the long head of the biceps tendon is performed, exposing the bicipital groove. (5) An LTO is made from lateral to medial with an oscillating saw and is completed with use of an osteotome. (6) The remaining inferior portion of the subscapularis and capsule are released off of the humerus. (7) The total shoulder arthroplasty is completed up to the point of implantation of the final humeral component. (8) Four drill-holes are made lateral to the bicipital groove and osteotomy site. (9) Heavy nonabsorbable sutures, with or without cerclage wires, are passed from lateral to medial around the humeral stem and passed medial to the osteotomy fragment through the insertion of the subscapularis tendon. (10) The sutures are then tensioned and tied with the arm in 30° of external rotation. (11) The wound is irrigated, dried, and closed in layered fashion. Alternatives: The most commonly accepted alternative approaches include the subscapularis tenotomy and subscapularis peel techniques. Rationale: The LTO approach technique was developed to take advantage of bone-to-bone healing and to address concerns regarding poor tendon-to-tendon or tendon-to-bone healing in the subscapularis tenotomy and subscapularis peel exposure techniques, respectively. Expected Outcomes: Based on numerous published studies, excellent clinical results are achieved with anatomic total shoulder arthroplasty. When comparing surgical techniques involving the subscapularis in Level-I, randomized controlled trials, no significant differences exist among clinical outcomes, range of motion, or strength between the different techniques. Important Tips: Three-dimensional preoperative templating software allows for the anticipation of potential operative challenges, the prediction of implant limitations, and more accurate assessment of abnormal glenoid morphology and wear patterns.An articulating arm positioner can be helpful in controlling the arm position without the need for an extra surgical assistant.The goal thickness of the LTO is 10 mm. If the osteotomy is made too thin, there is a risk that the repair sutures cut through the lesser tuberosity fragment, leading to subscapularis repair failure.Releasing the capsule from the subscapularis is a critical step to ensure adequate tendon excursion for later repair and restoration of external rotation in arthritic shoulders. However, careful attention must be directed to the position and orientation of the axillary nerve in order to avoid iatrogenic injury during this critical step.Creating the drill-holes lateral to the bicipital groove takes advantage of the very strong and dense bone in that area of the proximal aspect of the humerus, enhancing the integrity of the repair.The tension band suture is critical to aid in further compression of the LTO fragment when the arm is brought into external rotation.Closing the rotator interval substantially increases the strength of the subscapularis repair; however, the closure of the interval must be made with the arm in at least 30° of external rotation in order to avoid iatrogenic motion restriction.Using interrupted nonabsorbable sutures to close the deltopectoral interval at the conclusion of the procedure is helpful in the event that any revision procedure is needed because these sutures will guide the revision surgeon toward making the deltopectoral approach in the correct interval. Acronyms and Abbreviations: LTO = lesser tuberosity osteotomyROM = range of motionASES = American Shoulder and Elbow SurgeonsWOOS = Western Ontario Osteoarthritis of the Shoulder indexVAS = visual analog scaleSF-36 = 36-Item Short Form Health SurveySST = Simple Shoulder TestDVT = deep-vein thrombosis