Alberto Rivera, MD
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The number of shoulder arthroplasty procedures is rapidly increasing. Therefore, shoulder revision is becoming a commonly performed procedure. Historically revising a hemiarthroplasty or total shoulder replacement ended up in a hemiarthoplasty, resection arthroplasty, arthrodesis or more recently reverse arthroplasty. This type of revision usually required stem removal, which could potentially lead to humeral fracture with or without the need of an osteotomy, increasing surgical time, bleeding and neural damage. Also, late complications, such as osteotomy nonunion and malunion could develop. Another important factor to take into consideration is the added cost of using additional implants such as a new stem, cement, cables or allograft in the setting of humeral stem revision. Modular implants using a platform system allows for a faster revision with fewer complications and potentially less cost.
I believe the use of modular platform in primary shoulder arthroplasty either hemi or total should be the standard of care.
In my experience, revising TSA to RSA has evolved to a more straightforward procedure with the use of modular components of the platform shoulder type. I believe the use of modular platform in primary shoulder arthroplasty either hemi or total should be the standard of care.
This is a case of a 60 year-old male with a TSA presenting with inability to lift his shoulder two years out of TSA, and rotator cuff failure. In my practice, rotator cuff has been the most common presenting symptom and indication for short term revision shoulder arthroplasty.
Revision to RSA starts with the removal of the humeral head. Next a 360 degree capsular release is performed and the glenoid component and scar tissue are removed in a systematic manner. Limited reaming and glenoid grafting is performed as needed, to place the reverse shoulder metaglene and screws. The glenosphere is then placed and secured with a locking screw or a morse taper. Attention is then turned toward the placement of the humeral platform tray and reverse polyethylene. The majority of the time there is no need to sink the stem further.
In seven years doing shoulder arthroplasty and five of them using convertible stems I may have near 100% of convertability using a platform system when the cause of revision does not involve a loose stem. It takes 30-60 minutes off my revision time decreasing complications. To achieve an effective reverse reduction without excessive tension one should pay attention to the soft tissue capsule release and to the level of anesthesia relaxation achieved.
An exception for a well-fixed stem revision can be considered when the patient aims for a specific more functional rotation arc.
The important question to ask today is how to identify those patients who may need stem revision and demonstrate a well-fixed and positioned stem. Identifying this patient may reduce excessive deltoid tension and perhaps a sooner decline in shoulder function.
Alberto Rivera, MD, is an AAOS board-certified orthopaedic surgeon and founder of Rivera Orthopedics and Sports Medicine in Bayamon, Puerto Rico. Dr. Rivera received his medical degree, with honors, from the Ponce Health Sciences University and completed his residency at the University of Puerto Rico in San Juan. He then completed a sports medicine fellowship at Plancher Orthopaedics & Sports Medicine in Cos Cob, Conn. Dr. Rivera specializes in sports medicine, arthroscopic surgery, joint replacement, and ligament reconstruction for the hip, knee and shoulder.