Revision Strategies in Reverse Total Shoulder Arthroplasty

Abstract

Background: While initially developed to improve function in patients with chronic rotator cuff deficiency, the success of reverse total shoulder arthroplasty (RTSA) has led to expanding indications including fracture sequelae and revision of failed hemi-or total shoulder arthroplasty. While primary RTSA carries complication and revision rates of up to 75% and 2%-10%, respectively, these rates are higher in RTSA performed in a revision setting. Methods: The current literature on RTSA and revision RTSA was reviewed to determine the most common complications and treatment strategies to address these complications. Results: The most common complications leading to revision of RTSA are instability, infection, humeral implant loosening, and glenoid implant loosening. Each of these presents unique technical challenges for the surgeon. Retention or replacement of a reverse prosthesis affords high patient satisfaction and better functional outcomes than resection, but may require several additional surgeries. In cases in which reverse components cannot be implanted, salvage options, including resection arthroplasty and conversion to hemiarthroplasty, provide satisfactory pain relief but limited function. Discussion: As the number of RTSA performed increase, so will the number of revisions. In this article, current treatment strategies for addressing the challenges of revision reverse shoulder arthroplasty are discussed.

Management of Revision Reverse Shoulder Arthroplasty

“…If bone graft is needed, the choice of autograft versus allograft should be discussed with the patient. 8 Finally, to rule out infectious etiologies, studies such as complete blood count, erythrocyte sedimentation rate, C-reactive protein, bone scan, and joint aspiration may be helpful, but biopsy remains the gold standard. 2,10,11…”

“…Glenoid bone loss may stem from scapular notching, osteolysis around a loose glenoid component, arthritis, osteoporosis, or altered kinematics following surgery. 3,5,8 This is particularly true for larger patients in which using a small glenoid implant decreases deltoid coaptation and increases humeral medialization, ultimately impairing stability and increasing risk for bone loss. 12 It follows, then, that glenoid medialization can be caused by bone loss due to excessive reaming and/or osteolysis.…”

“…21 For small peripheral glenoid-contained defects that require less than 15 of correction, eccentric reaming can be used to create a flat surface for the baseplate to be implanted. 8,22 In cases of large peripheral defects, grafting options include autograft from the ipsilateral iliac crest or freshfrozen femoral head allograft to match the glenoid defect. 8,22 Iannotti and Frangiamore utilized a polymethyl methacrylate mold to shape fresh-frozen femoral head allograft with a burr and saw.…”

“…8,22 In cases of large peripheral defects, grafting options include autograft from the ipsilateral iliac crest or freshfrozen femoral head allograft to match the glenoid defect. 8,22 Iannotti and Frangiamore utilized a polymethyl methacrylate mold to shape fresh-frozen femoral head allograft with a burr and saw. 23 The results of this method were variable which lead to concern that excessive graft was being reabsorbed or inadequate graft was being incorporated.…”

“…7 Furthermore, up to 22% of revision procedures require additional revision, and these procedures generally result in lower functional outcome scores and decreased range of motion. 8 This review summarizes the most relevant advances in the field of revision RTSA. This includes the factors that predispose to failure including infection, glenoid bone loss, proximal humoral bone loss, and soft tissue deficiency.…”