case presentations: failed and revision rsa

Case presentations

Amit KapoorUpper Limb Fellow

Case 1

72 year old Retired consultant pathologist 10 month old # proximal humerus Managed conservatively Non union

Reverse shoulder replacement aug’12

6/52 check

Revision insert with pec major transfer

Case 2

67 year old female

# dislocation left shoulder feb 2012

ORIF Feb 2012

2/52 f/u

Open stabilisation mar 2012

Redislocation, Re ORIF

Reverse shoulder arthroplasty Oct 2012

Closed reduction

Open Reduction Pec Major transfer

Instability most common complication, 4.7%

Reoperations required in 87%, most commonly exchange of liners

9/57 cases of instability Within 6/12 of primary surgery All needing revision Only 3 had satisfactory results

6/44 prosthetic dislocation (13.6%)

Workup

Rule out infection Non infectious instability

Inadequate deltoid tensioning impingement of

components

insufficiency of subscapularis

Inadequate deltoid tension

Grammont ‘ Global Decoaptation’ – lack of sufficient deltoid

tension forms a space between ball and socket

Tension within conjoint tendon Surgeons experience Contralateral limb

Global coaptation

increase offset

Increase glenosphere diameter

Neck extension beneath the poly

Increase thickness of poly

Impingement of components

Impingement of implant with scapular neck in adduction

To reduce Component placement flush or extending beyond

the inferior glenoid rim 150 downward tilt of component

Subscapularis

Subscap sparing approch 4 published series Total of 50 patients No dislocations

RSA with deltopectoral approach

55 without subscap repair 65 with subscap repair

3 dislocations 2 dislocations

Summary

Multifactorial causation

Increased incidence in #, revision cases Adequate tensioning of deltoid important Avoid impingement of components Subscap repair if possible