Revising a Failed Primary Shoulder Arthroplasty to rTSA
Revision of a failed primary shoulder arthroplasty to a reverse total shoulder arthroplasty (rTSA) is an increasingly common choice, but according to a study from The Rothman Institute, surgeons should counsel patients that functional outcomes will be more modest than with a primary rTSA and that they will be at a higher risk for complications.
These findings were presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons. The study has also been published by the Journal of Shoulder and Elbow Surgery. 
The researchers reviewed data – including functional outcomes scores, reoperations, and implant survival – for 110 patients who had undergone rTSA for a failed anatomic total shoulder arthroplasty or hemiarthroplasty at their tertiary healthcare system over a 15-year period. Primary procedures had been performed for:
- Acute fracture
- Rotator cuff tear arthropathy
- Fracture sequelae
- Inflammatory arthritis
- Osteonecrosis of the humeral head
The reasons for revision procedures included:
- Isolated cuff failure
- Cuff failure with instability
- Cuff and component failure
- Fracture sequelae
At 2 years after revision to rTSA, implant survival (retention of glenoid baseplate and humeral stem) was 92%. By 5 years, it had dropped to 74%. The reoperation rate was 11%.
Patient-reported functional outcome scores were not what the study authors had expected: Mean ASES score of 63 ± 24 (5-97), mean SANE score of 60 ± 25 (0-100), and mean pain visual analog scale score of 2.9 ± 2.9 (0-10).
“We were surprised to see the relatively mediocre functional results of revision to rTSA,” said Surena Namdari, MD, one of the study authors. “Though rTSA remains the best option for patients with soft-tissue deficiency as a source of failure after anatomic arthroplasty, the functional improvements are modest.”
A higher risk of complications is to be expected with any revision procedure, and that was the case with this study. “The complication rates are higher than most reports for primary rTSA,” Dr. Namdari said. “We reported a 19% mid-term complication rate, [while] recent studies on primary rTSA report complication rates under 10%.”
These complications included:
- Scapular stress fracture
- Periprosthetic fracture
- Baseplate loosening
- Glenosphere dissociation
- Painful hardware
- Greater tuberosity nonunion
“Patient satisfaction was also lower in our revision population compared to other studies on primary rTSA patients,” Dr. Namdari said. “In our study, 70% of patients were ‘very satisfied’ or ‘satisfied’ with their outcome, compared to most studies on primary rTSA reporting approximately 90% satisfaction.”
Dr. Namdari and his colleagues were unable to determine specific factors that predict a successful or unsuccessful outcome of revision from failed primary shoulder arthroplasty to rTSA. “We believe that this was due to the heterogenous patient population and variable indications for revision surgery,” he said.
“Anecdotally, we believe that the most successful revisions are those without substantial bone loss, without preoperative stiffness, and without a history of infection.”
Reverse total shoulder arthroplasty is a technically demanding procedure, especially when revising from a failed primary arthroplasty, so “surgeons should be prepared for surgical complexity,” Dr. Namdari said. “Surgeons should prepare [for] a corticotomy for stem removal and bone grafts or augmented components to address bone defects on the glenoid.”
The results of this study highlight how important it is for surgeons to set realistic expectations with their patients.
“Patients can be counseled that revision to rTSA has a high complication and reoperation risk,” Dr. Namdari said. “While 70% of our patients were satisfied with their outcome, mean functional outcome and pain scores are modest and there is a wide range of results.”
Sheth MM, Sholder D, Abboud JA, Lazarus MD, Ramsey ML, Williams GR, Namdari S. Revision of a Failed Anatomic Arthroplasty to Reverse Total Shoulder Arthroplasty (Paper 390). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.
- Sheth MM, Sholder D, Getz CL, Williams GR, Namdari S. Revision of failed hemiarthroplasty and anatomic total shoulder arthroplasty to reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2019 Feb 1. pii: S1058-2746(18)30784-5. doi: 10.1016/j.jse.2018.10.026. [Epub ahead of print]