Revision Shoulder Arthroplasty

Abstract

HISTORICAL PERSPECTIVE During the past decade the number of shoulder arthroplasties performed around the world has increased greatly, with approximately 10,000 performed per year. Cofield's survivorship analysis of unconstrained total shoulder replacements projected 96% survivorship at 2 years, 92% at 5 years, and 88% at 10 years (1). Based on the parallel experience with hip and knee arthroplasty, with increased numbers of cases, one can expect increased numbers of complications that often require revision surgery (1–8). Arthroplasty failures can be categorized based on soft tissue or bony deformities, component malpositioning, component loosening, and mechanical failure such as component dissociation and joint instabilities (Fig. 1). Functional improvement is directly related to the condition of the soft tissues, which in many cases are severely compromised. Scar tissue, musculotendinous contractures and deficiencies, nerve injury, and bone loss are challenging to the revision surgeon. Successful, stable outcomes of revision shoulder arthroplasty depend on recognizing and addressing these problematic issues and for this reason a variety of surgical techniques may be necessary to treat a specific underlying pathology.FIG. 1.: Axillary view demonstrating posterior instability of a total shoulder arthroplasty due to excessive glenoid retroversion.It is the purpose of this report to outline the indications, preoperative assessment and technical considerations necessary to carry out a comprehensive total shoulder revision. INDICATIONS AND CONTRAINDICATIONS The primary goal of revision surgery is pain relief. Often severe bone and soft tissue deficiencies preclude surgical restoration of full range of motion and function. The individual surgeon's ability to recognize and appropriately address the degree of bone loss and soft tissue contracture determines the outcome. In some cases of severe soft tissue and bony deformity acceptable goals include relief of pain and limited restoration of function. Patients with severe pain, restricted range of motion, and poor function after primary shoulder arthroplasty, especially in cases with initially good results that deteriorated over time, should be considered for revision. The procedure should only be considered after a thorough history, physical examination, and appropriate laboratory studies and imaging have been carried out to delineate the possible causes of failure. Because the causes are often multifactorial, meticulous preoperative evaluation is paramount for success of revision arthroplasty. Revision shoulder arthroplasty is contraindicated in patients whose medical status puts them at risk in the prospect of such complex surgery. Profound neurologic disorders, psychological impairment, and inability to undergo extensive rehabilitation program because of physical or emotional issues are also contraindications. PREOPERATIVE PLANNING History A careful history is critical in establishing causes for failure after shoulder arthroplasty. The primary diagnosis and any surgery that preceded the index arthroplasty are very important in establishing a cause of implant failure. For example, failure after total shoulder arthroplasty may be the result of component loosening, instability, rotator cuff insufficiency, or mechanical failure(1,2,4,5,9–18). However, failures in hemiarthroplasty for fractures have been most commonly reported to be related to tuberosity fixation failure, component malposition, or secondary glenoid arthrosis (16–25) (Figs. 2 and 3).FIG. 2.: A loose glenoid component that has become displaced superiorly.FIG. 3.: Glenoid arthrosis in a patient who had previously undergone successful hemiarthroplasty for fracture and experienced late pain symptoms.Postoperative rehabilitation programs and any new trauma must also be documented. A history of fever, chills, erythema, or warmth at the incision are indicators of possible infection. Infection should be considered and ruled out in all cases of failed arthroplasty. In suspicious cases aspiration should be carried out before revision surgery. Night pain and weakness may indicate soft tissue or rotator cuff failure and a history of delayed onset of pain and loss of motion with crepitus or clicking may be highly suggestive of an acute glenoid loosening. A complete history and physical examination evaluating the patient's generalized well-being must be considered before any further surgical intervention. Physical Examination A thorough examination of the shoulder, upper extremity, cervical spine, and ipsilateral thorax is mandatory. Referral patterns for cervical spine and even pulmonary findings must be ruled out as a cause of pain. Range of motion, strength, and stability are carefully evaluated and soft tissue contractures and scars are noted. The stability of the joint must be carefully assessed. This involves anterior, posterior, and inferior translation of the humerus on the glenoid and a careful assessment of any gross instability. Clicking, whether painful or not, during translation of the glenohumeral joint may indicate overt loosening of the glenoid component. Rotator cuff strength and impingement signs are assessed to determine rotator cuff function. Biceps tests are also performed to document any pathology associated with the long head of the biceps tendon (26). Finally, a careful neurovascular evaluation is mandatory to document any loss in either motor or sensory function or vascular injury before any further surgical intervention. If necessary, appropriate neurologic studies should be considered. Radiologic Evaluation Evaluation of serial plain radiographs, true anteroposterior, axillary, and outlet views can be helpful in assessing component malposition, instability, and component loosening. Plain radiographs may also be used to evaluate bone loss and to assess the subacromial space for outlet impingement secondary to bone spurs of the acromion or acromioclavicular joint. With the use of serial plain radiographs the diagnosis of prosthetic loosening is confirmed when a shift in radiographic position is identified. A radiolucent line of 2 mm or more that completely surrounds the implant is also suspicious for component loosening. However, a number of authors have shown that radiolucency does not always correlate with clinical loosening (1,6,16,20,27). Axillary views are helpful in documenting glenoid bone loss, deformity, and excessive component version. It can also be helpful in the diagnosis of glenohumeral instability. Computed tomography scans with implant subtraction can be a further help when an axillary view is ambiguous. Careful evaluation of component position, bone quality, cement mantel, and concomitant ipsilateral elbow replacement are also critically important in the preoperative planning. Diagnostic Arthroscopy Diagnostic arthroscopy can be helpful in identifying and treating patients with rotator cuff insufficiency, outlet impingement, acromioclavicular joint problems, loose bodies, and even gross glenoid component loosening (28,29). The arthroscope should be directed away from the humeral head component to avoid the “mirror effect.” A probe through an anterior portal is used to test for gross glenoid stability (Fig. 4). Biceps lesions can be treated with arthroscopic release or tenodesis (26). Finally, arthroscopy can assist rotator cuff repair performed with a mini-open technique.FIG. 4.: Arthroscopic photograph demonstrating the “mirror effect” and probe of the glenoid component to check for loosening.Laboratory Data Because most patients who undergo a revision procedure are older, a complete work-up should be considered to rule out underlying metabolic bone disease. Erythrocyte sedimentation rate, complete white blood cell count with differential, and C-reactive protein should be evaluated to help rule out sepsis. If sepsis is suspected, a diagnostic arthrogram and aspiration may confirm infection and obtain the offending organism. An arthrogram may also confirm aseptic loosening if dye leaks around the implant at the bone cement interface; however, arthrographic findings may be negative in the face of loosening. Radionuclear scanning, including three-phase bone scans and indium-labeled leukocyte scans, may also indicate indolent sepsis. If nerve injury is suspected, a complete electromyographic study, including nerve conduction studies, is mandatory to document existing neurologic lesions before attempting any revision surgery. TECHNIQUE Patient Positioning Great care should be taken to ensure proper patient positioning at the time of revision surgery. The patient should be placed in the semi-Fowler's position with the feet elevated. The patient should be placed laterally on the table with proper restraint to prevent dangerous movement during traction of the arm. Lateral positioning should allow room for the arm to be extended fully off the table toward the floor. Exposure At exposure it is critical to utilize old incisions if possible. Subcutaneous contractures should be released at this time. An extended anterior incision from above the clavicle over the coracoid process and distally following the anterior portion of the deltoid is carried out. In some cases in which there is a gross posterior displacement of the glenoid component, a posterior approach should be considered. Great care should be used in handling the deltoid muscle. Preservation of deltoid function is critical for successful outcome. Preservation of the deltoid origin when possible is the best choice. In cases when the deltoid is detached for repair of a large rotator cuff tear or for other reasons, a stable reattachment through bone is mandatory. Once the deltopectoral interval has been exposed, a complete release and excision of the subdeltoid and subacromial adhesions should be carried out. In cases in which the rotator cuff is intact, or if a repairable tear is present, release of the coracoacromial ligament or acromioplasty, or both, can be considered for better exposure. For patients with overt rotator cuff insufficiency or irreparable rotator cuff disease, it is best to leave the coracoacromial ligament to prevent further anterosuperior instability secondary to the loss of the coracoacromial arch (4,8,28,30,31). At this time care should be used in re-establishing the plane deep to the conjoint tendon to expose the subscapularis tendon. After all the subdeltoid adhesions have been removed, the shoulder should again be examined for range of motion with the patient under anesthesia to assess external rotation. If there is less than 30° of external rotation, one can consider one of many options for lengthening the subscapularis tendon and carrying out any appropriate capsular releases. This must be planned before closure so that enough tendon length remains to carry out appropriate soft tissue balance and repair. Soft Tissue Contractures and Deformities Recreation of the optimal soft tissue balance is critical for restoration of function after a primary or revision shoulder arthroplasty. Soft tissue balance depends on proper release of the contractures, appropriate lengthening of tendons, and repair or reconstruction of the rotator cuff when possible. At the same time the origin and function of the deltoid must be maintained. Preoperative assessment and examination under anesthesia give the surgeon important information about the quality and function of the soft tissues. In cases of severe contracture the releases begin with lysis and excision of the subacromial, subdeltoid, and subcoracoid adhesions. Reestablishing the space below the conjoint tendon is critically important for subscapularis lengthening and exposure. Often an incision along the lateral border of the conjoint tendon will facilitate clearing a space to visualize the subscapularis tendon. Great care must be taken to avoid injury to the musculocutaneous nerve deep to the conjoint tendon and the axillary nerve inferior medially to the subscapularis tendon. In many cases exploration and retraction of the axillary nerve facilitate further exposure. At this time, if external rotation is less than a subscapularis tendon lengthening should be considered. The subscapularis tendon is often It should be off the tuberosity to length and to the of the humeral through In this to of length can be rotation to 30° or more (Fig. The subscapularis length can be a of the tendon off the tuberosity and repair through bone at the of the with from Glenoid replacement in total shoulder arthroplasty. the subscapularis has been the tendon can be further a release from the and lysis of adhesions in the rotator subcoracoid and at the inferior of the subscapularis tendon (Fig. length is necessary, the subscapularis may be from the glenoid a Once it has been subscapularis tendon should be released in a from the rotator and inferior subscapularis adhesions. with from and The contractures must be released for soft tissue balance and for proper exposure of the the contractures and scars are released from the glenoid and from below the of the long head of the biceps if it remains to the must be taken to prevent injury to the axillary which may be in the In these cases it is best to expose the nerve before The posterior can be released and the from the position to approximately the position The inferior is best released off the of the humerus to avoid any injury to the axillary which in some cases may be very to The inferior may also be released directly the below the subscapularis tendon and it and to release the posterior inferior glenohumeral or this is the axillary This will allow restoration of arm In some cases motion loss may be due to use of large a humeral head component. In these cases the humeral component will help range of restoration of rotator cuff function and is critical for optimal rotator cuff should be and to the tuberosity appropriate fixation In some cases of severe of the tendon or cases of irreparable rotator cuff should be Preservation of the coracoacromial arch is critical to prevent anterior and of the humeral It is best to avoid glenoid replacement in most of these patients in to avoid the of the glenoid to and glenoid component loosening In cases in which there is good anterior and posterior stability total shoulder arthroplasty can be considered as long as the humeral head remains stable and Glenoid and Revision due to primary or secondary to bone loss after glenoid loosening are bone is mandatory for proper glenoid can be or a complex of After a of the glenoid of the of the glenoid a number of excision of the anterior or posterior and in cases of severe bone loss, a bone can be considered (Fig. glenoid bone loss or can be treated in one of the following or excision of the in severe cases, bone with from Glenoid replacement in total shoulder arthroplasty. reported on a for with glenoid bone the anterior or posterior glenoid is bone a out of the and a of a with a fixation (Fig. authors have the use of bone in cases of than of glenoid (Fig. In either the glenoid must be to the from the glenoid component. In cases of severe bone loss, glenoid fixation may be and hemiarthroplasty should be carried out. when the complex bone loss is hemiarthroplasty may be a more A for anterior or posterior bone a placed after of the and with a with from The of glenoid in total shoulder arthroplasty. Axillary view of revision of a glenoid (Fig. a posterior bone with component in bone in with of instability of shoulder bone loss from the glenoid may be treated with a The may be bone and a hemiarthroplasty may be carried out in the that the bone will be and allow for glenoid reconstruction (Fig. In most patients have enough pain relief from the hemiarthroplasty that not for glenoid component revision of the glenoid may be treated in procedure with excision of the glenoid and excision of the glenoid and bone or of the glenoid glenoid component may to posterior instability (Fig. revision. The glenoid component must be and the bony deformity and glenoid bone must be as In most cases of glenoid there is also an of soft tissue contracture that must be in to the shoulder arthroplasty. In cases of glenoid that are placed in an position the best glenoid are and may be considered if bone The glenoid should be to the of the cement should be used to a or because cement and loosening are possible. Revision component loosening is a cause of arthroplasty component is more (Fig. is the cause of tuberosity failures after hemiarthroplasty for trauma A can cause placed to loss of the and deltoid and rotator cuff failure as as secondary impingement from the a loss of humeral and tuberosity to further rotator cuff insufficiency and failure. humeral may also to for fracture that has been placed out of the humeral the patient severe pain and humeral bone loss, after acute or often to of the humeral component at an which to instability. of the humeral component is the most cause of inferior instability. it is increased in the of the deltoid or rotator cuff to a painful impingement or instability. require revision of the humeral component and to a more Preoperative are often necessary to and assess the for such humeral require at the time of revision. In cases of or the humeral component may and a or revision head component may be used if to or (Fig. In cases of a or humeral component can be and in some cases The very posterior humeral is to fracture and during revision appropriate including appropriate and for of with these meticulous exposure and very careful techniques are to avoid or fracture of the humeral exposure and of the humerus are mandatory and require a complete of the soft tissue from the and This is carried to approximately the and humerus (Fig. Once the humerus should be the and the arm. with this in some cases a or may be necessary to a humeral component severe bone trauma (Fig. In cases of humeral or are necessary to through cement or bony At this that for of the humeral component is used If the surgeon that the fixation is the or above should be component cement or are used to the implant after the humerus has been release of tissue or In cases of humeral component a can be in the anterior of the humerus to facilitate exposure of the humeral component and humeral fracture or after revision of the humeral component with fixation of the the component has been removed, the revision should be placed in the proper and appropriate fixation a component previously it may be considered again if there is bone In other cases the appropriate cement should be carried out. there has been a humeral bone loss, primary or humeral prosthetic can be used in with bone or to a stable humeral for Revision of and have instability as the most revision after shoulder arthroplasty after arthroplasty a careful and thorough assessment of the and causes to any revision surgery. Soft tissue insufficiency, component and component are the most causes for such instability. a of these causes the overt injury and loose such as a loose glenoid component are less causes of instability after shoulder arthroplasty (Fig. The surgical repair or revision of a component in the with proper and as as appropriate soft tissue repair and In some cases soft tissue reconstruction may be and posterior instability is the result of soft tissue contracture in the of the instability or soft tissue failure in the of instability subscapularis in acute anterior the most instability patterns after shoulder arthroplasty is a anterosuperior instability through the coracoacromial arch in cases in which arthroplasty has been carried out in the face of rotator cuff insufficiency and a or coracoacromial ligament patients can become severely pain and of function and this instability is to an tendon with fixation of the bone portion to the coracoid process a and The tendon is to the full of the which has been a of through bone (Fig. In some cases this procedure carried out with humeral head that more of the humeral more In of cases outcomes tendon from the coracoid process to the of the acromion to the coracoacromial ligament in a patient who has anterosuperior instability after arthroplasty. Lateral instability is the result of a soft tissue failure or closure of the subscapularis tendon. This can be injury or poor repair and in some cases the use of large a humeral component. If the glenoid component is not on plain radiographs, an arthrogram or imaging may be necessary to a subscapularis If the subscapularis may be repairable through bone or In some cases, releases that have been above may be necessary to the tendon for proper In cases of subscapularis insufficiency, have the use of an tendon to the anterior soft tissue insufficiency An tendon to the glenoid of a and to the humerus of or has been previously This an anterior and tenodesis to prevent anterior translation (Fig. tendon used to a subscapularis insufficiency after shoulder arthroplasty. of the shoulder after arthroplasty. with instability is most commonly associated with increased humeral head posterior glenoid or excessive glenoid component capsular is a in most cases of posterior instability. In most cases revision of the glenoid component, posterior capsular and a of the humeral head or will this is as in the above on component The goal should be of the humeral head and the glenoid component of 30° and can be carried out after the component revision has been and before the humeral head component has been A incision is in the and a of is placed to the The humeral head component is and the the are in such a as to avoid excessive of the posterior better soft tissue The of total shoulder revision is in the patient or is necessary to any soft tissue or bone techniques that have been carried out. The rehabilitation program at the time of surgery. The surgeon must range of motion during surgery that can be in the rehabilitation of motion can be used in an range of motion program directed the and the physical If soft tissue reconstruction has been carried and motion is delayed in the these have In range of motion in a is and Once soft tissue or bone has been motion can be and other are at the appropriate time. The rehabilitation program is important for successful revision arthroplasty. Patient to this program is If a patient is to undergo this should be as to whether revision surgery is revision have been reported to in unconstrained total shoulder arthroplasties and has reported an failure in survivorship of to at 10 years, there is in the on the results of revision arthroplasty studies as or of and are results of a number of that have been carried out for causes of arthroplasty failure. of these is and to the In a of including that of the patients had however, had outcomes in this evaluated patients revision from patients had outcomes and 5 patients had outcomes after revision surgery. In patients revision for aseptic glenoid loosening or humeral arthrosis after primary hemiarthroplasty had the best Patients revision for soft tissue deficiencies, and severe bone loss had the In cases of hemiarthroplasty for patients with tuberosity failure had the evaluated glenoid component failure in patients and results in and results in the other one in results in patients with glenoid revision or glenoid evaluated patients with causes of shoulder arthroplasty failure patients had failures due to instability or bone tuberosity failure after hemiarthroplasty for in other patients with aseptic loosening the in study, of humeral to complications or poor results in of and reported on patients component revision for failed shoulder arthroplasty. a for pain relief in all cases of component or Finally, and reported on glenoid excision in cases of aseptic loosening in 10 cases with pain relief and of shoulder motion and a improvement in the ability to of the number of revision more of results and survivorship will give a better of the true of revision in shoulder arthroplasty. Revision total shoulder arthroplasty remains one of the most about the shoulder even in the of an experienced shoulder surgeon. The which revision necessary, are often to document completely in a preoperative For this reason the surgeon must be with surgical and techniques that are necessary to address the and that are at the time of surgery. This a careful preoperative assessment including evaluation of the soft tissue, bone and component must be ruled out before any revision. revision surgery depends on proper and soft tissue and appropriate component and for exposure and component is mandatory. The surgeon must have all the necessary primary and that may be necessary during the The surgical procedure meticulous to surgical with a on deltoid function. A careful rehabilitation program is also mandatory for With these successful outcomes in revision shoulder arthroplasty have been in more than of