import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Courses 5-7cm inferior to acromion, anteroinferior to subscapularis, exits quadrangular space **Protection**: Careful subscapularis mobilization, avoid inferior dissection beyond 5cm from coracoid, palpate during inferior retraction **Location**: Enters conjoint tendon 3-8cm distal to coracoid tip (variable) **Protection**: Limit medial retractor penetration depth to <2cm, avoid aggressive medial soft tissue stripping, visualize conjoint tendon **Location**: Scapular notch (superior) and spinoglenoid notch (posterior-superior) **Protection**: Avoid over-medialization of baseplate screws, careful with superior screw placement, limit posterior dissection **Location**: Medial to coracoid process and conjoint tendon (2-3cm medial to operative field) **Protection**: Controlled medial retraction, avoid overzealous soft tissue release medially, identify anatomical landmarks **Location**: Deltopectoral interval, variable anatomy with tributaries **Protection**: Preserve or carefully ligate (risk of venous congestion if disrupted), retract laterally with deltoid preferred ## Assessment and Decision Making ### Imaging Requirements - **AP, scapular Y, axillary views**: Implant position, bone loss, subluxation - **CT scan with metal artifact reduction**: Essential for bone stock assessment - Sirveaux classification of glenoid defects - Nerot-Sirveaux modification for central vs peripheral loss - Screw trajectory planning for revision fixation - **Consider advanced imaging**: - Labeled WBC scan if infection suspected - CRP/ESR - elevated suggests infection (threshold >10 CRP) - Aspiration with culture hold 48-72 hours minimum ### Failure Mode Classification ### Implant Inventory Planning - Previous operative notes (implant type, sizes, cementing) - Revision stem options (long stem, metaphyseal engaging) - Baseplate options (standard, augmented, custom) - Glenosphere options (various sizes, lateralization options) - Bone graft availability (allograft vs autograft iliac crest) - Subscapularis reconstruction materials if deficient ## Key Anatomical Considerations ### Deltopectoral Interval (Primary Approach) - **Landmarks**: Cephalic vein (lateral border of pectoralis major) - **Interval**: Between deltoid (axillary nerve) and pectoralis major (medial/lateral pectoral nerves) - **Advantage in revision**: Familiar anatomy, extensile, protects axillary nerve - **Disadvantage**: Subscapularis management challenging in revision setting ### Subscapularis Status Assessment - **Key revision consideration**: Often deficient, scarred, or previously sacrificed - **Anatomical relations**: - Axillary nerve: 5-7cm inferior to coracoid (exits inferior border) - Musculocutaneous nerve: 3-8cm into conjoint tendon from coracoid tip - Anterior humeral circumflex artery: Variable, often ligated in revision - **Preservation strategies**: Lesser tuberosity osteotomy if quality adequate ### Glenoid Bone Stock Architecture - **Subchondral bone**: Critical for baseplate support, often eroded in loosening - **Coracoid buttress**: Superior support, used for screw fixation - **Scapular spine**: Posterior support, guides baseplate version - **Vault**: Central bone stock, determines if BIO-RSA needed - **Scapular neck**: Must maintain integrity, fracture risk with over-reaming ### Neurovascular Danger Zones - **Anterior**: Musculocutaneous nerve entry into conjoint (variable) - **Inferior**: Axillary nerve and posterior humeral circumflex artery - **Medial**: Brachial plexus cords (2-3cm from joint) - **Superior**: Suprascapular nerve at scapular notch (screw trajectory risk) - **Posterior-superior**: Suprascapular nerve at spinoglenoid notch ## Step-by-Step Technique ### Step 1: Patient Positioning Beach chair position at 30-40 degrees, head supported in neutral, entire scapula free to manipulate **Positioning Pearl**: Ensure ability to extend arm off side of table for humeral exposure - inadequate setup leads to difficult humeral component extraction and increased fracture risk - Inadequate scapular mobility prevents proper glenoid visualization - Hypotension with steep beach chair (reduce angle if unstable) ### Step 2: Incision and Approach Use previous deltopectoral incision, extend if needed proximally toward clavicle or distally 1-2cm beyond deltoid insertion **Incision Strategy**: If multiple previous incisions present, use most lateral to preserve medial skin bridge blood supply - parallel incisions <3cm apart risk skin necrosis - Thin scarred skin prone to necrosis - handle gently, minimal undermining - Previous infection history - consider plastic surgery consultation for flap coverage ### Step 3: Deltopectoral Interval Development Identify cephalic vein, develop interval, preserve vein with lateral retraction (or ligate if necessary), divide clavipectoral fascia **Revision Tip**: Dense scar tissue obliterates normal planes - identify coracoid tip first as landmark, work from known to unknown anatomy to protect musculocutaneous nerve - Axillary nerve vulnerable if dissection extends >5cm below coracoid tip - Cephalic vein disruption causes deltoid venous congestion ### Step 4: Subscapularis Assessment Identify subscapularis remnant or previous repair - often scarred to anterior capsule and humeral component **Critical Decision**: If subscapularis quality poor (<50% thickness), consider leaving detached and converting to latissimus dorsi transfer at completion for external rotation strength - Axillary nerve exits at inferior border - palpate and protect during inferior mobilization - Aggressive mobilization causes denervation even if nerve not transected ### Step 5: Capsulotomy and Joint Exposure Release anterior capsule from glenoid rim, inferior capsule from humeral neck - extensive release needed for component extraction **Exposure Pearl**: Circumferential capsular release around humeral component essential - incomplete release causes iatrogenic fracture during extraction attempts - Inferior release beyond 5cm from coracoid risks axillary nerve - Posterior-superior release risks suprascapular nerve at spinoglenoid notch ### Step 6: Component Dislocation Strategy If glenosphere removable: dislocate first then remove sphere. If glenosphere locked: may need to remove humeral tray first, then dislocate **Dislocation Technique**: External rotation and extension - if unable to dislocate, STOP and remove glenosphere first rather than forcing (fracture risk) - Forced dislocation causes humeral shaft fracture (especially osteoporotic bone) - Glenoid rim fracture if levering against glenosphere ### Step 7: Humeral Component Removal (if needed) Remove humeral polyethylene liner, dislocate (or remove glenosphere first), use extraction device on taper or cement if cemented **Extraction Pearl**: If well-fixed uncemented stem, create humeral window using oscillating saw 2cm distal to lesser tuberosity - preserve bone stock for revision stem fixation - Humeral shaft fracture during extraction (incidence 3-5% in revision) - Radial nerve injury with distal extension of dissection (posterior spiral groove) ### Step 8: Extended Humeral Exposure if Needed For well-fixed stem: humeral window (rectangular cortical window) or extended trochanteric osteotomy allows stem extraction without fracture **Window Technique**: Make window 2cm wide, length = 2x stem length, 2cm distal to lesser tuberosity starting point - secure with cerclage wires at closure - Window too proximal weakens metaphysis - stay 2cm below lesser tuberosity minimum - Incomplete osteotomy causes fracture propagation during stem extraction ### Step 9: Glenoid Exposure Retract humerus posteriorly and inferiorly, release soft tissue adhesions around baseplate, expose baseplate edge circumferentially **Glenoid Visualization**: Use bent Hohmann retractors: one inferior, one posterior, one superior - creates triangulated exposure essential for baseplate removal - Superior retractor risks suprascapular nerve at scapular notch - Aggressive posterior retraction risks spinoglenoid notch injury ### Step 10: Baseplate and Screw Removal Remove glenosphere (if not already done), remove locking screws sequentially, extract baseplate using dedicated removal tools or osteotomes carefully **Removal Sequence**: Remove peripheral screws first (superior, inferior, posterior), then central compression screw last - maintain some fixation during dissection to prevent spinning - Screw breakage leaves retained hardware - may need to drill out or leave if well-buried - Glenoid vault fracture if baseplate levered aggressively ### Step 11: Bone Stock Assessment Remove fibrous tissue and sclerotic bone, assess remaining bone stock with CT correlation, classify defect (Sirveaux or Nerot-Sirveaux) **Assessment Pearl**: Use curette to assess bone quality - if curette penetrates easily, insufficient bone stock for screw purchase, requires grafting or augmentation strategy - Over-resection of sclerotic bone causes unnecessary bone loss - Failure to recognize defect extent leads to inadequate reconstruction ### Step 12: Minor Defect Management For peripheral defects <5mm: use larger diameter baseplate (covers defect), or use augmented baseplate with built-in wedge **Augment Strategy**: Place augment on defect side to restore glenoid anatomy - typically inferior for wear pattern, provides structural support and corrects version - Augment overhang risks impingement and instability - Inadequate augment seating causes micromotion and early loosening ### Step 13: Major Defect Management (BIO-RSA) For central or major defects >5mm: prepare graft (autograft iliac crest or structural allograft), place under baseplate, fix with screws through baseplate **BIO-RSA Technique**: Graft must be >10mm thick, shaped to fill defect, central screw penetrates graft into native bone - incorporation occurs at 6-12 months, delay full activity - Graft resorption if inadequate vascularity (>20% volume loss expected) - Baseplate subsidence if graft not compressed adequately during fixation ### Step 14: Severe Bone Loss - Custom Implants For massive defects with glenoid vault compromise: patient-specific custom baseplate with scapular body engagement (coracoid, spine, scapular pillar) **Custom Implant Pearl**: Requires preoperative CT-based planning, 6-8 week manufacturing time - interim surgery with graft compaction and delayed reconstruction alternative approach - Scapular fracture during insertion if fit too tight - Limited screw trajectory options - may compromise nerve safety margins ### Step 15: Baseplate Positioning Position baseplate with 10-15 degrees inferior tilt, neutral or slight anteversion, flush with inferior glenoid rim - avoid superior placement **Positioning Pearl**: Inferior tilt critical to prevent scapular notching - use glenoid vault as reference (perpendicular to vault = neutral, then tilt inferiorly) - Superior tilt causes scapular notching and accelerated loosening - Excessive retroversion limits external rotation and causes posterior instability ### Step 16: Screw Fixation Strategy Central compression screw first (into vault), then peripheral locking screws - aim for bicortical purchase, divergent trajectories for maximum fixation **Screw Pearl**: Superior screw directed toward coracoid base (strong bone), inferior screws toward scapular pillar, posterior screw toward spine - avoid convergence - Anterior screws risk brachial plexus (stay lateral to coracoid base) - Superior-medial screws risk suprascapular nerve at scapular notch - Over-torquing causes screw breakage or bone fracture ### Step 17: Glenosphere Attachment Select appropriate glenosphere size (36mm standard, 42mm for lateralization), ensure proper locking mechanism engagement, check stability manually **Lateralization Pearl**: Lateralized glenosphere (+10mm) improves deltoid moment arm and reduces scapular notching but increases shear forces on baseplate - use selectively for instability cases - Incomplete locking causes dissociation (check for gap between sphere and baseplate) - Oversized sphere limits motion and causes impingement on acromion ### Step 18: Humeral Component Revision If humeral loosening present: remove old stem, ream to fit new revision stem (2mm larger diameter or 20mm longer minimum), cement if poor bone quality **Humeral Revision Pearl**: Long stem revision (120-150mm) bypasses stress risers from previous screw holes and cement - ensure 2 cortical diameters below any defect - Underfilling humeral canal risks subsidence and instability - Oversizing during reaming causes fracture (especially revision osteopenic bone) ### Step 19: Trial Reduction Testing Insert trial components, reduce, test stability in full range: forward flexion, abduction, rotation - should be stable to 90 degrees flexion and 30 degrees external rotation **Stability Assessment**: "Shuck test" - apply inferior traction force; <1cm translation acceptable, >1cm indicates inadequate tensioning - consider thicker polyethylene or more lateralized glenosphere - Forced reduction during trialing causes iatrogenic fracture - Instability recognized but not addressed leads to early revision for dislocation ### Step 20: Final Component Implantation After confirming satisfactory trial, implant final baseplate with glenosphere and humeral stem with chosen polyethylene thickness **Final Implantation Pearl**: Do not alter plan during final implantation - if instability concern, return to trials and reassess all variables (glenosphere size/lateralization, polyethylene thickness, humeral version) - Cross-threading of locking screws or glenosphere causes inadequate fixation - Soft tissue interposition prevents seating - must be clear before final impaction ### Step 21: Subscapularis Management If subscapularis quality adequate: repair to lesser tuberosity with transosseous sutures or suture anchors. If deficient: consider leaving unrepaired or tendon transfer **Repair Pearl**: Reverse TSA function deltoid-dependent, subscapularis repair less critical than anatomic TSA - some surgeons leave unrepaired intentionally in revision setting to preserve external rotation - Over-tensioned repair limits external rotation and causes stiffness - Axillary nerve injury during inferior suture passage (most common nerve injury in shoulder arthroplasty) ### Step 22: Final Stability Check Test stability through full passive range of motion on table - should achieve 140+ degrees flexion, 40+ degrees external rotation without dislocation **Final Check Pearl**: If unstable, most common error is inadequate soft tissue tensioning - thicker polyethylene liner solves most instability issues (8mm, 10mm, 12mm options) - Unrecognized instability leads to early dislocation (20% of revision complications) - Overstuffing joint causes stiffness and potential stress fracture ## Postoperative Management ### Immediate Postoperative (0-6 weeks) - **Immobilization**: Sling with shoulder immobilized in adduction and neutral rotation - Higher risk of complications than primary RTSA - If subscapularis repaired: maintain immobilization for 6 weeks - If subscapularis not repaired: begin gentle pendulums at 2 weeks - **Pain control**: Multimodal analgesia (avoid excessive narcotics) - Regional anesthesia (interscalene block) duration 12-24 hours - Scheduled NSAIDs unless contraindicated - Ice therapy 20 minutes every 2 hours while awake - **Wound care**: Inspect at 2 weeks, remove sutures at 14 days - Monitor for infection signs (increased warmth, drainage, fever) - Revision surgery higher infection risk (3-5% vs 1-2% primary) - **Radiographs**: AP, scapular Y, axillary lateral at 2 weeks - Confirm component position unchanged - Assess for early periprosthetic fracture - Baseplate seating and screw position ### Intermediate Phase (6-12 weeks) - **Physical therapy initiation**: - Week 6-8: Passive forward flexion to 90 degrees, passive external rotation to neutral - Week 8-10: Increase passive ROM to 120 degrees flexion, 20 degrees ER - Week 10-12: Begin active-assisted ROM, gentle strengthening (no resistance) - **Activity restrictions**: - No lifting >1kg with operative arm until 12 weeks - No reaching behind back until 12 weeks (subscapularis protection) - No driving until 8 weeks minimum (pain-free and off narcotics) - **Radiographic monitoring**: 6-week X-rays - Confirm no component migration - If BIO-RSA performed: assess graft position (resorption common, acceptable if <20%) ### Advanced Rehabilitation (3-6 months) - **Progressive strengthening**: - Month 3-4: Active ROM exercises, light resistance bands (deltoid strengthening) - Month 4-5: Progressive resistance 1-3kg, functional activities - Month 5-6: Return to full activities of daily living - **Expected outcomes** (generally lower than primary RTSA): - Forward flexion: 100-120 degrees (vs 140 primary) - Abduction: 90-110 degrees (vs 130 primary) - External rotation: Variable (0-30 degrees, depends on subscapularis status) - Internal rotation: Limited (typically hand to lateral thigh only) - **Radiographs**: 3-month and 6-month follow-up - Assess graft incorporation if BIO-RSA (progressive sclerosis indicates incorporation) - Monitor for scapular notching (Grade 1-2 acceptable, Grade 3-4 concerning) - Evaluate for radiolucent lines (any progressive lucency >2mm concerning for loosening) ### Long-term Surveillance (6+ months) - **Annual radiographs** for first 5 years, then biennial - **Activity modifications**: Permanent restrictions recommended - Avoid overhead sports (tennis, volleyball) - Avoid heavy lifting >10kg overhead - Golf and swimming acceptable after 6 months - **Complication vigilance**: - Late instability (can occur years later with soft tissue attenuation) - Progressive scapular notching (Grade 3-4 may require revision) - Late infection (dental procedures require antibiotic prophylaxis lifetime) - Baseplate loosening (progressive pain and function loss) ## Clinical Outcomes and Evidence ### Survival and Revision Rates - **5-year survival**: 85-90% (compared to 93-95% for primary RTSA) - **10-year survival**: 75-80% (limited long-term data) - **Re-revision rate**: 15-25% at 5 years - Most common causes: instability (40%), infection (25%), loosening (20%) - Higher failure rate for revision of instability vs. revision of anatomic TSA to reverse ### Functional Outcomes - **Forward flexion improvement**: Average 30-40 degrees (from 60-70 to 100-110) - Less improvement than primary RTSA (typical 60-degree improvement) - Limited by soft tissue deficiency and scarring - **Pain relief**: Significant improvement in 70-80% of patients - VAS improvement from 7-8 to 2-4 on average - Infection-related revisions have less predictable pain relief - **Patient satisfaction**: 70-75% satisfied or very satisfied - Lower than primary RTSA (85-90% satisfaction) - Realistic expectations crucial for preoperative counseling ### Complication Rates (Higher than Primary) - **Instability/dislocation**: 10-15% (most common complication) - Higher with subscapularis deficiency - Soft tissue tensioning critical - **Infection**: 3-5% (vs 1-2% in primary) - Two-stage revision successful in 85% of infected revisions - **Nerve injury**: 2-4% (vs <1% in primary) - Axillary nerve most commonly affected (neurapraxia usually temporary) - **Periprosthetic fracture**: 5-8% (intraoperative and postoperative) - Humeral shaft fractures most common - Scapular fractures associated with screw fixation - **Baseplate failure**: 5-10% at 5 years - Higher with inadequate bone stock reconstruction - BIO-RSA shows 90% graft incorporation but 15% subsidence ### Prognostic Factors **Favorable outcomes associated with:** - Revision for anatomic TSA failure (better than revision for failed primary reverse) - Good bone stock preservation or successful bone grafting - Stable soft tissue envelope - Absence of infection - Patient age <75 years **Poor outcomes associated with:** - Multiple prior surgeries (3+ procedures) - Severe glenoid bone loss (Nerot-Sirveaux Grade 4) - Subscapularis deficiency or insufficiency - Active infection or incomplete infection eradication - Poor bone quality (osteoporosis, rheumatoid arthritis) ## References 1. Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg. 2005;14(1 Suppl S):147S-161S. doi:10.1016/j.jse.2004.10.006 2. Favard L, Levigne C, Nerot C, Gerber C, De Wilde L, Mole D. Reverse prostheses in arthropathies with cuff tear: are survivorship and function maintained over time? Clin Orthop Relat Res. 2011;469(9):2469-2475. doi:10.1007/s11999-011-1833-y 3. Neyton L, Erickson J, Ascione F, Bugelli G, Lunini E, Walch G. Grammont Award 2018: Scapular fractures in reverse shoulder arthroplasty (RSA): risk factors, outcome, and prevention strategies. J Shoulder Elbow Surg. 2019;28(6):1119-1127. doi:10.1016/j.jse.2018.11.066 4. 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(2):189-195. doi:10.1302/0301-620X.89B2.18161 5. Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty. 1999;14(6):756-760. doi:10.1016/s0883-5403(99)90232-2 6. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br. 2004;86(3):388-395. doi:10.1302/0301-620x.86b3.14024 7. Flatow EL, Harrison AK. A history of reverse total shoulder arthroplasty. Clin Orthop Relat Res. 2011;469(9):2432-2439. doi:10.1007/s11999-010-1733-6 8. Klein SM, Dunning P, Mulieri P, Pupello D, Downes K, Frankle MA. Effects of acquired glenoid bone defects on surgical technique and clinical outcomes in reverse shoulder arthroplasty. J Bone Joint Surg Am. 2010;92(5):1144-1154. doi:10.2106/JBJS.I.00778 9. Boileau P, Moineau G, Roussanne Y, O'Shea K. Bony increased-offset reversed shoulder arthroplasty: minimizing scapular impingement while maximizing glenoid fixation. Clin Orthop Relat Res. 2011;469(9):2558-2567. doi:10.1007/s11999-011-1775-4 10. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Hip, Knee & Shoulder Arthroplasty: 2023 Annual Report. Adelaide: AOA; 2023. Available at: https://aoanjrr.sahmri.com/annual-reports-2023

Reverse TSA Revision

Reverse TSA Revision