Management of the Failed Arthroplasty for Proximal Humerus Fracture

Djuro Petkovic, MD; David Kovacevic, MD; William N. Levine, MD; Charles M. Jobin, MD

Disclosures

J Am Acad Orthop Surg. 2019;27(2):39-49. 

In This Article

Abstract and Introduction

Abstract

A variety of reasons exist for failure of arthroplasty performed for management of proximal humerus fracture. Revision surgery for these failures is complex and has a high likelihood of inferior outcomes compared with primary arthroplasty. Successful management requires consideration of various modes of failure including tuberosity malunion or resorption, rotator cuff deficiency, glenoid arthritis, bone loss, component loosening, stiffness, or infection. Although revision to a reverse shoulder arthroplasty is an appealing option to address instability, rotator cuff dysfunction, and glenoid arthritis, there are concerns with higher complication rates and inferior results compared with primary reverse replacement. Any treatment plan should appropriately address the cause for failure to optimize outcomes.

Introduction

Failure of shoulder arthroplasty for proximal humerus fracture is a challenging clinical entity and can require revision in up to 20% of patients.[1] Hemiarthroplasty and reverse total shoulder arthroplasty (RTSA) are the most common types of arthroplasty for these fractures. Hemiarthroplasty for fracture has inconsistent outcomes and is technically difficult, leading many surgeons to adopt RTSA for irreparable fractures, especially in elderly patients.[2–4] Outcomes of revision arthroplasty are consistently inferior to those of primary arthroplasty, and success is dependent on the reason for the primary arthroplasty failure.[5] Many revision arthroplasties are performed for combined modes of failure.

Identifying the mode of failure requires a thorough history, detailed physical examination, radiographic imaging, laboratory testing, and a joint aspiration and biopsy to rule out deep infection. Revision for osseous or component-related problems usually results in good or excellent outcomes, whereas revision for soft-tissue reconstruction often has poor outcomes.[5] Revision arthroplasty is especially challenging because of tissue loss, distorted tissue planes, implant debris, associated proximal humerus and glenoid bone loss, possible need to explant a well-fixed stem, and occasionally infection. Appropriate soft-tissue management, especially the subscapularis, during revision arthroplasty affects patient satisfaction and long-term implant survival.

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