Shoulder Revisions: Why Are We Here?
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1 Shoulder Revisions: Why Are We Here? Indications for Revision to RSA Mark A. Frankle, MD Kaitlyn N. Christmas, BS Peter Simon, PhD DJO Revision Course 2017 June 2-3
2 Introduction Reverse shoulder arthroplasty(rsa) was FDA approved in 2003 for treatment of cuff tear arthropathy (CTA) Indications continue to expand CTA 4 part fracture Type B2 glenoid Revision of failed arthroplasty
3 Indications for RSA: Varied Pathological States & Disease 2012 Cuff et al. Mulieri et al Klein et al. Holcomb et al. 2010
4 Indications for Revision: Shoulder Arthroplasty on the Rise
5 Indications for Revision: Shoulder Arthroplasty on the Rise Utilized data for the Nationwide Inpatient Sample (NIS) Annual Growth in Procedure Rate for Revisions = 14% Projected 343% in revisions by 2015
6 Revisions on the Rise : shoulder arthroplasty revisions 29%
7 Revision Shoulder Arthroplasties Performed by MAF Revisions on the Rise: My Experience Jan - June 2017
8 Indications for Revision to Reverse :40-50% of all shoulder replacements performed were RSAs
9 Why is This Important? Aging & active population increasingly needs access to total joint arthroplasty High volume TSA surgeons have superior outcomes Distribution of these surgeons is unequal Access to high volume shoulder replacement surgeons is lacking in multiple major metropolitan areas in the US *Data from the 2014 Medicare Provider Utilization & Payment release
10 Why are We Here? TSA revisions are unique from other total joint revisions The humerus is often very thin, risking fracture during implant removal Soft tissue pathology can vary: Extremely scarred & stiff, risking nerve injury or limited functional improvement Hyperlax & patulous risking postoperative instability Glenoid bone loss associated with failed implants more complicated because preop imaging altered from implant artifact
11 Challenges of Revisions Preoperative Planning Intraoperative Complex Pathology Managing Complications Should I operate or not? Is the artifact/implant system convertible? Will I need nerve monitoring or fluoro? Will I need blood transfusions or graft? Surgical approach Altered anatomy Scar Humeral bone loss Glenoid bone loss Increased likelihood of having a complication Discuss with patients and be prepared to reoperate if necessary
12 Challenges of Revisions: Device-Specific Problems Anatomic RSA RSA RSA Failed HA for fx RSA Periprosthetic fracture Recurrent instability
13 Challenges of Revisions Infections Implant removal Reimplantation
14 Indications for Revision to RSA Failed HA Failed RSA Failed TSA PRIMARY INDICATIONS for RSA PERFORMED by M.A.F Cuff Tear Arthropathy 649 (45.8%) Failed Rotator Cuff Surgery 294 (20.7%) Failed Hemiarthroplasty 251 (17.7%) Failed Total Shoulder Arthroplasty 105 (7.4%) Fracture (acute/malunion) 79 (3.8%) Failed ORIF 14 (1%) Other 26 (1.8%) Total 1418
15 Indications for Revision to RSA Failed HA Failed RSA Failed TSA PRIMARY INDICATIONS for RSA PERFORMED by M.A.F Cuff Tear Arthropathy 649 (45.8%) Failed Rotator Cuff Surgery 294 (20.7%) Failed Hemiarthroplasty 251 (17.7%) Failed Total Shoulder Arthroplasty 105 (7.4%) Fracture (acute/malunion) 79 (3.8%) Failed ORIF 14 (1%) Other 26 (1.8%) Total 1418
16 Indications for Revision to RSA: Failed Hemiarthroplasty Case Example 75 year old male Chief Complaint: Increasing shoulder pain after HA for fracture after a fall. History: Anemia, RA, cancer, diabetes, & hypertension Physical Examination: Active elevation to 45, abduction 45, ER to 10, and IR to his side.
17 Indications for Revision to RSA: Failed Hemiarthroplasty Case Example
18
19 Indications for Revision to RSA: Failed Hemiarthroplasty Case Example
20 Indications for Revision to RSA Failed HA Failed RSA Failed TSA PRIMARY INDICATIONS for RSA PERFORMED by M.A.F Cuff Tear Arthropathy 649 (45.8%) Failed Rotator Cuff Surgery 294 (20.7%) Failed Hemiarthroplasty 251 (17.7%) Failed Total Shoulder Arthroplasty 105 (7.4%) Fracture (acute/malunion) 79 (3.8%) Failed ORIF 14 (1%) Other 26 (1.8%) Total 1418
21 Indications for Revision to RSA: Failed RSA Case Example 78 year old male Chief Complaint: Shoulder pain after ground level fall & recently moving boxes Previous Treatment: Treated with RSA 1 year prior to fall
22 Indications for Revision to RSA: Failed RSA Case Example Dislodged & dislocated glenoid component within the joint
23
24 Indications for Revision to RSA: Failed RSA Case Example Postop Radiograph
25 Indications for Revision to RSA: Failed TSA Case Example 55 year old male Chief Complaint: right shoulder pain after previous arthroplasty History: Right shoulder surgery performed approximately a year ago Physical Examination: Active elevation to 90 degrees, external rotation to 30 degrees, and IR to back pocket.
26 Indications for Revision to RSA: Failed TSA Case Example First postop visit Revision preop 1 year later
27 Surgical Information
28 Surgical Information
29 Indications for Revision to RSA: Failed TSA Case Example
30 Conclusion As the instance of shoulder arthroplasty continues to increase, so too will the need to revise these patients Revision surgery requires the development of specific techniques Analysis of failed implants will provide insight on how to improve implant design, surgical technique, and planning for eventual revision
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