Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Mark A. Frankle, MD*,
Florida Orthopedic Institute, Tampa, Florida
Posted January 2008
Patients in whom disabling shoulder pain and dysfunction develop
after previous shoulder arthroplasty have few reliable treatment options. In
situations in which the concurrent pathology of severe glenohumeral bone loss,
absent rotator cuff, and deltoid muscle dysfunction occurs, improvements are
unlikely with prosthetic reimplantation. In the paper by Scalise and Iannotti,
arthrodesis was used to treat seven individuals, six of whom had absence of a
functional rotator cuff and deltoid muscle as well as bone loss including a
portion of the proximal part of the humerus and glenoid vault. All of these
patients had undergone an average of five (range, two to fifteen) previous surgical
procedures prior to the attempted arthrodesis.
The article is a Level-IV case series and includes complete
preoperative and postoperative clinical and radiographic data. The patients had
an average follow-up of fifty months (range, eighteen to ninety-six months). The
selection of a particular surgical technique was related to the preoperative
assessment of the amount of bone loss requiring reconstitution. The options included
autologous iliac crest bone graft, fibular strut graft (with or without
microvascular anastomosis) and/or femoral head allograft. The surgical approach
was an extensile deltopectoral approach, and fixation involved large-fragment
pelvic reconstruction plates contoured to the spine of the scapula, the
acromion, and humeral shaft. Additional interference fixation of the fibular
strut was performed both to the glenoid vault and to the remaining proximal
part of the humerus. Postoperatively, the shoulder was immobilized in a spica
cast for a minimum of twelve weeks.
Outcome assessments included Penn shoulder scores as well as
evaluation for fusion, which was determined with use of serial radiographs. A
total of five patients achieved radiographic union at the time of final follow-up.
Three of these patients achieved union after the initial procedure, whereas two
patients required additional surgical bone-grafting procedures to achieve
union. The remaining two patients had persistent nonunion despite additional
attempts at bone-grafting. Five of the patients showed improvements in self-reported
outcome parameters.
The treatment for patients who have symptoms from a severe,
destructive pathologic condition of the shoulder, including bone and muscular
insufficiency, is difficult. It is critical that we, as the treating physicians,
communicate to our patients the challenges of surgical intervention in these situations
and discuss what can be realistically expected in terms of outcome. In this
study, each patient clearly believed that his or her shoulder had poor function
and was the cause of appreciable pain (average preoperative Penn Score, 17).
However, other conditions with lesser degrees of destructive pathology may elicit
similar preoperative ratings, but the prognosis for these patients carries a
greater likelihood of improvement. For example, patients who underwent primary
reverse shoulder arthroplasty1 had only slightly higher preoperative
ASES scores compared with a more recent series of patients who underwent
revision of a failed arthroplasty2 (thirty-four compared with twenty-nine,
respectively). However, the challenges that are posed to the surgeon and the
patient are much greater in the scenario of failed previous arthroplasty
because of the inherent extent of tissue destruction. An accurate and uniform
description of staging of the pathologic process and its effect on prognosis
helps the physician communicate realistic expectations and compare treatment
alternatives. Additionally, the characterization of the severity of the disorder
enables the surgeon to make meaningful comparisons between the success achieved
in this treatment group and the success of arthrodesis in other circumstances, such
as in situations in which bone loss is minimal and previous arthroplasty
implant removal has occurred.
Richards et al.3 reported the results of fifty-seven
arthrodeses, two of which were performed on patients with previous total shoulder
arthroplasty (for treatment of aseptic loosening of the prosthesis in one patient
and septic loosening in the other). When evaluated as a whole, the author
reported a 100% union rate with a 14% complication rate. The authors used two
to three screws through a plate to compress the humerus to the glenoid vault and
an additional screw across the acromiohumeral fusion site. The plate was fixed
to the humeral shaft as well as to the scapular spine. The patient with septic
loosening of a total shoulder prosthesis required revision surgery and bone-grafting
six months after the arthrodesis in order to achieve healing. Even though only
two of these were failed total shoulder arthroplasties, it is important to
understand that the nonunion may be related to the extent of bone loss associated
with the original disease process.
In the retrospective review by Scalise et al., vascularized free
fibular grafts were used in four patients. In the shoulder of one patient, the
anastomosis was compromised, so the graft was essentially a nonvascularized
autologous graft; the shoulder went on to achieve union. In the three other shoulders
in which a vascularized graft was used, union was not achieved initially. In
one of these shoulders, autologous iliac crest bone graft was subsequently
performed, which led to union. These results suggest that nonvascularized
grafts, which may be technically easier to use, may be effective as adjuncts in
achieving union. Recently, Crosby reported on the use of bulk allografts in
shoulder arthrodesis after the failure of twelve total shoulder prostheses4.
Four of five of the shoulders that were treated with a proximal humeral
allograft had allograft resorption and subsequent failure. The seven shoulders
that were treated with a proximal femoral bulk allograft maintained stability
and allowed incorporation of the graft. They recommended the use of a bulk
femoral allograft with augmentation and also suggested using iliac crest
autograft as the tissue of choice to avoid the morbidity that can be associated with harvesting fibular autografts4.
Fortunately, patients who have symptoms after shoulder
arthroplasty historically do not have severe muscle and bone loss requiring the
need for salvage procedures such as arthrodesis. Despite the extensive shoulder
arthroplasty experience of these authors, this treatment method was used in only
eight patients in a seven-year period during a time in which the use of
shoulder arthroplasty was becoming more prevalent5. An aging population and an increased awareness
and demand by the public for interventions that improve quality of life will
shape the future of arthroplasty. The introduction of reverse shoulder
arthroplasty will also add to the number of patients who will receive treatment
in the form of arthroplasty to treat shoulder dysfunction. Therefore, one
should expect that the need to treat shoulders that have mechanical failure after
shoulder arthroplasty will also increase. This article describes one such
option.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
References
1. Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: a minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am. 2005;87:1697-705. doi:10.2106/JBJS.D.02813
2. Levy JC, Virani N, Pupello D, Frankle M. Use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty in patients with glenohumeral arthritis and rotator cuff deficiency. J Bone Joint Surg Br. 2007;89:189-95. doi:10.1302/0301-620X.89B2
3. Richards RR, Beaton DE, Hudson AR. Shoulder arthrodesis with plate fixation: a functional outcome analysis. J Shoulder Elbow Surg. 1993;2:225-39.
4. Crosby L. Shoulder arthrodesis after failed shoulder arthroplasty. J Shoulder Elbow Surg. 2007;16:e24.
5. Adams JE, Sperling JW, Hoskin TL, Melton LJ 3rd, Cofield RH. Shoulder arthroplasty in Olmsted County, Minnesota, 1976-2000: a population-based study. J Shoulder Elbow Surg. 2006;15:50-5.
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