Complications in reverse shoulder arthroplasty

Abstract

The reported rate of complications of reverse shoulder arthroplasty (RSA) seems to be higher than the complication rate of anatomical total shoulder arthroplasty.The reported overall complication rate of primary RSA is approximately 15%; when RSA is used in the revision setting, the complication rate may approach 40%.The most common complications of RSA include instability, infection, notching, loosening, nerve injury, acromial and scapular spine fractures, intra-operative fractures and component disengagement.Careful attention to implant design and surgical technique, including implantation of components in the correct version and height, selection of the best glenosphere-humeral bearing match, avoidance of impingement, and adequate management of the soft tissues will hopefully translate in a decreasing number of complications in the future. Cite this article: Barco R, Savvidou OD, Sperling JW, Sanchez-Sotelo J, Cofield RH. Complications in reverse shoulder arthroplasty. EFORT Open Rev 2016;1:72-80. DOI: 10.1302/2058-5241.1.160003.

Keywords: Complications; fracture; instability; loosening; notching; reverse shoulder arthroplasty.

Fig. 1

This figure shows the case of a patient with an intra-operative fracture. An anteroposterior radiograph of the right shoulder of a female patient operated for revision arthroplasty of a cemented hemiarthroplasty for post-traumatic sequelae of a proximal humerus fracture is shown (left column). Revision arthroplasty is at greater risk of suffering intra-operative fractures when compared to primary arthroplasty. When the fracture is proximal to the tip of the stem, most may be treated successfully by circumferential cerclage. In this case a long stem was used in addition to bypass a cortical window needed for cement extraction of the previous implant (middle and right columns).

Fig. 2

This figure demonstrates a patient with a right uncemented RSA with a short stem (left column) suffering a post-operative episode of anterior shoulder dislocation (middle column) after an initial satisfactory outcome. The patient underwent revision surgery and stability was achieved using an increased glenosphere size (right column). Further options may include lateralisation/distalisation of the glenosphere, the use of more constrained liners and correcting the height and version of the humeral stem, if anomalous.

Fig. 3

This figure shows an anteroposterior radiograph of a patient that had suffered a revision arthroplasty for failure of a hemiarthroplasty for fracture. A cement-in-cement fixation was used along with preventive cerclage due to the high risk of intra-operative fracture (left column). After 1.5 years the patient was diagnosed with a periprosthetic joint infection and underwent a two-stage revision arthroplasty. During the first surgery all the components were removed and an antibiotic-cemented spacer was used along with specific intravenous antibiotics targeting the intra-operative cultures (Staph. epidermidis)(middle column). After normalisation of PCR and ESR counts and a successful clinical course, the patient was revised to another cemented reverse shoulder arthroplasty. Intra-operative unexpected cultures grew (P. acnes) and antibiotic suppression was initiated (lateral column).

Fig. 4

AP radiograph of a right shoulder in a patient with a RSA for rotator cuff arthropathy two years after implantation showing grade III scapular notching. The exact degree of scapular notching may be underdiagnosed if true AP views are not obtained. High-degree notching may be at risk for implant loosening and the patient must be closely monitored for evolving notching and advised of the possibility of component revision and bone grafting. Distalisation of the glenoid component with an eccentric component, along with the use of a humeral component with a more vertical joint line with or without humeral lateralisation may be advantageous in these situations.

Fig. 5

This figure shows the case of a patient that four months after uneventful RSA for rotator cuff arthropathy (left column) suffered a fall with acute onset of pain on the top of his right shoulder. Advanced imaging techniques are helpful in the diagnosis of acromial and scapular spine fractures (middle column). Subsequent evaluation of these patients shows a displaced acromion without functional impairment and a satisfied patient (right column). This may not be the case in patients with fractures of the scapular spine and it is yet not clear which patients may benefit from internal fixation.