import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Exits quadrilateral space posteriorly, crosses inferior glenohumeral joint capsule at 6 o'clock position, runs on deep surface of deltoid 5-7cm below acromion. **Protection**: Identify early during inferior capsular release, use nerve stimulator in scarred tissue, limit inferior retraction force and duration, protect during glenoid exposure **Location**: Enters conjoint tendon 3-8cm distal to coracoid tip (mean 5-6cm). Location distorted by scarring from previous deltopectoral approach. **Protection**: Identify conjoint tendon early, limit medial retraction on conjoint, avoid dissection >8cm distal to coracoid, use nerve stimulator if anatomy unclear **Location**: Spirals around posterior humeral shaft in spiral groove, 10-14cm proximal to lateral epicondyle, 15-18cm distal to humeral head. At risk with extended approach or long stem revision. **Protection**: Limit distal humeral dissection, stay anterior when extending exposure, identify nerve before humeral window osteotomy if extended approach, use image intensification to confirm stem length **Location**: Anterior and medial to surgical field, protected by pectoralis minor and conjoint tendon. Risk increased in revision due to scarring and distorted anatomy. **Protection**: Stay lateral to conjoint tendon, avoid aggressive medial retraction, identify anatomical landmarks early before extensive dissection **Location**: Passes through suprascapular notch beneath superior transverse scapular ligament, then around lateral scapular spine to innervate infraspinatus. At risk with superior glenoid screws in RSA conversion. **Protection**: Superior baseplate screws directed anterosuperior toward coracoid (not posterosuperior), confirm screw length with fluoroscopy, use CT planning to assess bone corridors ## Indications for Revision Shoulder Arthroplasty ### Primary Failure Modes **Aseptic Glenoid Loosening (Most Common)** - Progressive radiolucent lines around glenoid component (>2mm, progressive) - Component migration or tilt on serial radiographs - Pain with activity (especially overhead use) - CT confirms bone loss pattern and extent **Aseptic Humeral Loosening (Less Common)** - Radiolucent lines around humeral stem (complete circumferential) - Stem subsidence or varus/valgus tilt - Pain with arm rotation or loading - More common with uncemented stems in osteoporotic bone **Instability and Dislocation** - Recurrent subluxation or dislocation episodes - Subscapularis failure (anterior instability most common) - Component malposition (excessive retroversion, superior tilt) - Glenoid bone loss creating rim instability - Rotator cuff failure (superior migration, anterior-superior escape) **Infection (Rule Out in All Cases)** - Acute postoperative: wound drainage, fever, pain - Chronic low-grade: indolent pain, stiffness, minimal inflammation - Propionibacterium acnes (25-30% of infected revisions): slow-growing, minimal signs - Elevated inflammatory markers (ESR, CRP) - low sensitivity - Joint aspiration MANDATORY if any suspicion **Periprosthetic Fracture** - Traumatic (fall) or atraumatic (stress fracture in osteoporotic bone) - Proximal humerus most common (metaphyseal bone loss) - Glenoid fracture rare but catastrophic - May occur intraoperatively during index procedure **Rotator Cuff Failure** - Progressive superior migration (loss of acromiohumeral interval) - Subscapularis rupture (anterior instability, internal rotation loss) - Rotator cuff arthropathy pattern (Hamada classification progression) - Pseudoparalysis (inability to elevate arm) **Unexplained Pain with Well-Fixed Components** - Most difficult indication - careful patient selection - Rule out: infection (aspiration, inflammatory markers), nerve injury (EMG), cervical spine pathology (MRI neck), complex regional pain syndrome, psychiatric factors - Poor outcomes if no mechanical etiology identified - Consider non-operative management, pain psychology ### Preoperative Workup (MANDATORY Components) **Infection Evaluation (ALL Cases)** 1. Serum inflammatory markers: ESR, CRP (low sensitivity - normal does not exclude infection) 2. Joint aspiration: cell count (>1,100 WBC/mm³ concerning, >3,000 likely septic), differential (>70% PMN concerning), Gram stain (low sensitivity), culture aerobic/anaerobic 14 days for P. acnes 3. Consider: synovial alpha-defensin, leukocyte esterase if aspiration equivocal 4. Review prior operative notes for infection history **Bone Stock Assessment (CT Mandatory)** 1. CT shoulder with 3D reconstruction (thin cuts <2mm) 2. Assess glenoid bone loss pattern (central, peripheral, combined) 3. Classify glenoid deficiency: mild (<10mm depth), moderate (10-15mm), severe (>15mm or medial wall breach) 4. Evaluate humeral canal: diameter, cortical thickness, prior cement mantle 5. Plan component sizes and bone grafting strategy **Soft Tissue Evaluation** 1. MRI or ultrasound: rotator cuff integrity (subscapularis, supraspinatus, infraspinatus) 2. Cuff tears indicate need for conversion to RSA in most cases 3. Deltoid function assessment (axillary nerve integrity essential) 4. Assess for adhesive capsulitis (passive ROM under anesthesia) **Previous Operative Records** 1. Request all prior operative notes 2. Document: previous approach, component types/sizes, complications, infection history 3. Obtain implant stickers/details for planning extraction strategy 4. Review previous imaging to understand progression **Medical Optimization** 1. Optimize bone health: calcium, vitamin D supplementation, consider DEXA scan 2. Smoking cessation mandatory (wound healing, infection risk) 3. Diabetic control (HbA1c <7%) 4. Nutritional status (albumin >3.5 g/dL, lymphocyte count >1,500) 5. Cardiac risk stratification if elderly or comorbid ## Approach Selection and Technique ### Extended Deltopectoral Approach (Standard) **Indications** - All revision shoulder arthroplasty (primary approach) - Extensile exposure: can extend proximally to clavicle or distally to mid-humerus - Preserves deltoid origin (critical for function) - Familiar anatomy despite scarring **Positioning** - Beach chair position: 30-45° upright - Head secured in headrest, avoid excessive extension - Arm free drape to allow manipulation - Mark bony landmarks: acromion, clavicle, coracoid, deltopectoral groove **Incision Planning** - Use previous scar if possible (minimize skin bridges, necrosis risk) - Extend previous incision proximally and/or distally as needed - Standard length: clavicle to deltoid insertion (15-18cm) - May extend to mid-humerus for stem extraction or long stem insertion **Deep Dissection** 1. Develop subcutaneous flaps maintaining full-thickness skin (minimize necrosis) 2. Identify deltopectoral interval (cephalic vein is landmark) 3. Cephalic vein: take laterally with deltoid (preserves venous drainage) or medially with pectoralis (easier exposure) 4. In revision, vein often thrombosed or scarred - may need to ligate **Key Structures Identification** - Conjoint tendon (medial border): identify early, contains musculocutaneous nerve - Pectoralis major insertion (medial): can partially release for exposure - Deltoid (lateral): protect origin on clavicle/acromion, avoid detachment - Axillary nerve (inferior): at risk during inferior capsular release **Exposure Enhancement Techniques** 1. Pectoralis major tenotomy: release 1-2cm from humeral insertion, tag for repair 2. Conjoint tendon retraction: carefully medialize (protect musculocutaneous nerve) 3. Superior extension: can extend along clavicle for clavipectoral fascia release 4. Inferior extension: to mid-humerus for long stem insertion ### Subscapularis Management in Revision **Assessment** - Subscapularis often deficient, scarred, or fatty infiltrated from prior failure - Assess quality: tissue thickness, vascularity, Goutallier grade on MRI - May be absent in multiply revised shoulders **Technique Options** **(1) Lesser Tuberosity Osteotomy** (Preferred if Bone Stock Adequate) - Mark osteotomy site: 3-5mm medial to bicipital groove - Oscillating saw or osteotome: 10-15mm thickness, 25-30mm width - Elevate with subscapularis attached - Repair at closure: transosseous sutures or suture anchors - Advantages: anatomic repair, improves healing - Disadvantages: nonunion risk (5-10%), requires protected rehabilitation **(2) Subscapularis Peel** (If Osteotomy Not Feasible) - Release subscapularis from lesser tuberosity staying on bone - Elevate capsule and subscapularis as one layer - Place stay sutures for later repair - Repair to bone at closure with transosseous or anchor fixation **(3) Subscapularis Slide** (If Severe Scarring/Contracture) - Release subscapularis from scapular neck (slide anteriorly) - Allows mobilization of contracted tissue - Repair to bone at closure (may be under tension) **(4) Accept Deficiency** (If Converting to RSA) - Subscapularis less critical for RSA than anatomic TSA - Attempt repair if tissue adequate - Accept deficiency if tissue poor quality (document, inform patient) - Consider pectoralis major transfer if young/active patient ### Capsular Release **Indications** - Extensive adhesions in all revisions - Required for component exposure and dislocation - Inadequate release risks: fracture during dislocation, inadequate exposure **Technique** 1. Release rotator interval (superior): between subscapularis and supraspinatus 2. Release inferior capsule: protect axillary nerve (identify, retract inferiorly) 3. Release posterior capsule: external rotation with gentle retraction 4. Often require 360° capsulectomy for adequate exposure 5. Remove all scar tissue and adhesions **Specific Considerations** - Deltoid adhesions to proximal humerus common - free carefully - Coracohumeral ligament release may be needed - Assess passive ROM after complete release (goal: full passive motion) ## Component Removal Techniques ### Humeral Component Extraction **Critical Concept**: Fracture during component extraction is common (5-15% intraoperative fractures in revision). Prevention: adequate soft tissue release, gentle technique, low threshold for humeral window osteotomy with well-fixed cemented stems. **Uncemented Stem Removal** 1. **Adequate Exposure First** - Complete capsular release (360°) - Free all adhesions - Achieve atraumatic dislocation before extraction attempts 2. **Extraction Tools** - Universal extractor (Synthes, Zimmer systems) - Slap hammer attachment - Progressive extraction guides 3. **Technique** - Attach extractor to Morse taper - Apply steady axial force with slap hammer - Avoid eccentric force (causes fracture) - If well-fixed: flexible osteotomes around proximal stem - Ultrasonic tools may help disrupt bone-implant interface 4. **If Resistant** - Extended trochanteric osteotomy (see below) - Controlled longitudinal split with repair - DO NOT force (fracture risk) **Cemented Stem Removal** **Challenge**: Well-fixed cement difficult to remove without fracture **Options**: **(1) Direct Cement Removal** (Poorly Fixed Cement Only) - High-speed burr (long carbide or diamond) - Narrow flexible osteotomes - Work circumferentially around stem-cement interface - Time-consuming (1-2 hours possible) - High fracture risk if cement well-fixed **(2) Humeral Window Osteotomy** (Preferred for Well-Fixed Cement) Indications: - Well-fixed cemented stem - Allows direct visualization of cement - Safer than blind extraction Technique: 1. Mark window on anterior humeral shaft - Start: 2-3cm distal to pectoralis major insertion - Length: 8-12cm (depends on cement extent on CT) - Width: 2-3cm (one-third circumference) 2. Create osteotomy with oscillating saw - Stay in anterior cortex - Complete four sides of rectangular window - Remove as free bone piece (save for later grafting) 3. Remove cement under direct vision - High-speed burr to disrupt cement - Osteotomes to lever out cement pieces - Extract stem through window 4. Reconstruct window - Replace bone window - Fix with cerclage cables (2-3 cables) - May add plate for additional stability - Consider strut allograft if cortex thin **(3) Extended Trochanteric Osteotomy (ETO)** Indications: - Well-fixed long cemented stem - Prefer to window if stem extends beyond deltoid insertion Technique: 1. Mark osteotomy - Anterior cortex starting just lateral to bicipital groove - Length: extends distal to cement (typically 10-18cm) - Width: 1/3 circumference 2. Create longitudinal osteotomy - Oscillating saw for proximal and distal transverse cuts - Multiple drill holes for longitudinal extent - Complete with osteotomes - Hinge laterally maintaining soft tissue attachment 3. Reflect osteotomy fragment - Lever laterally maintaining lateral soft tissue - Provides direct view of cement and canal 4. Extract cement and stem under vision 5. Reconstruct osteotomy - Reduce fragment to anatomic position - Fix with cerclage cables (3-4 cables) - May add strut allografts if cortex thin - Protected postoperative rehabilitation ### Glenoid Component Extraction **Polyethylene Component Removal** 1. **Curved Osteotomes** - Work around periphery of component - Angle toward keel/pegs (not toward joint line) - Loosen cement mantle circumferentially 2. **Central Peg/Keel Removal** - High-speed burr along keel/peg - Thin remaining bone bridge - Osteotome to complete removal - Avoid aggressive techniques (glenoid fracture risk) 3. **Cement Removal** - Curettes and small osteotomes - High-speed burr for bulk cement - Remove to bleeding bone - Preserve bone stock (avoid deep reaming) **Metal-Backed Component Removal** 1. **Screw Removal** (If Accessible) - Identify screw heads - Remove with appropriate screwdriver - If stripped: burr head, remove baseplate, extract screw remnant 2. **Baseplate Removal** - Curved osteotomes around periphery - Disimpact from bone - May need to fragment component (high-speed burr) 3. **Central Post Removal** - Burr down if well-fixed - Trephine around post - Preserve bone stock **Reverse Shoulder Arthroplasty Component Removal** 1. **Remove Humeral Polyethylene Liner** - Disassemble per manufacturer technique - Usually snap-out or screw-out design 2. **Remove Glenosphere** - Morse taper: extractor and slap hammer - Screw-in: appropriate screwdriver - Avoid damaging baseplate if preserving 3. **Remove Baseplate** (If Revising) - Remove peripheral screws (may be difficult to access) - Use specific extraction tools for central screw - Osteotomes to disimpact baseplate - High fracture risk (communicate with patient preoperatively) - Glenoid fracture during component removal (2-5% incidence) - Excessive bone loss from aggressive cement removal - Medial wall perforation (axillary nerve, suprascapular vessels at risk) - Fragment retention causing synovitis or wear ### Intraoperative Tissue Sampling **Critical for Infection Detection** 1. **Timing**: After component removal, before irrigation 2. **Technique** - 5-6 separate tissue samples from different sites - Interface membrane around components - Glenoid bone bed - Humeral canal - Capsular tissue 3. **Processing** - Sterile containers (not formalin) - Aerobic and anaerobic culture - Extended culture: 14 days (for Propionibacterium acnes) - Consider fungal culture if immunocompromised 4. **Additional Samples** - Frozen section (polymorphonuclear cells >5 per high-power field suggests infection) - Permanent histology (>5 PMN/HPF or >10 in single field) ## Bone Deficiency Management and Reconstruction ### Glenoid Bone Loss Assessment **Classification Systems** **Antuna Classification** (Commonly Used) - Type 1: Minimal bone loss, central erosion <10mm depth - Type 2: Moderate bone loss, central erosion 10-15mm depth - Type 3: Severe bone loss, >15mm depth or medial wall compromise **Walch Classification** (For Glenoid Morphology) - A1: Centered humeral head, minor erosion - A2: Centered humeral head, major central erosion - B1: Posterior subluxation, biconcave glenoid - B2: Posterior subluxation, posterior erosion >70% - B3: Posterior subluxation, >25° retroversion - C: Dysplastic (glenoid retroversion >25°) **Exam Key**: Preoperative CT with 3D reconstruction is MANDATORY for revision glenoid assessment. Cannot accurately classify bone loss or plan reconstruction from radiographs alone. Always mention CT planning in viva scenarios. ### Glenoid Reconstruction Strategies **(1) Minor Defects (<10mm Central Erosion)** Technique: - Ream to healthy bleeding bone - May ream eccentrically to correct version - Standard glenoid component - Cemented fixation for immediate stability Outcomes: - Good results similar to primary arthroplasty - Low failure risk if adequate bone stock achieved **(2) Moderate Defects (10-15mm Central Erosion)** Options: **A. Eccentric Reaming** - Ream posteriorly or inferiorly to fill defect - Corrects version to neutral - Limit: cannot ream >10° correction (component malposition risk) **B. Augmented/Stepped Components** - Glenoid with built-in augmentation (wedge design) - Fills asymmetric defects - Maintains version and joint line - Various manufacturers offer stepped/wedge designs **C. Structural Bone Graft** - Fresh-frozen allograft (distal tibia, femoral head) - Shape to defect with burr/rongeur - Fix with 2-3 screws perpendicular to graft - May stage: graft incorporation 4-6 months, then implant - May proceed single-stage if graft stable **(3) Severe Defects (>15mm Erosion or Medial Wall Loss)** Options: **A. Structural Allograft with Staging** - Large structural graft (distal tibia or hemipelvis) - Fix securely with multiple screws - Stage procedure: 4-6 month graft incorporation - Second stage: component implantation into incorporated graft - Best outcomes for severe bone loss **B. Reverse Shoulder Arthroplasty with Augmented Baseplate** - RSA more forgiving of bone loss than anatomic TSA - Medialized center of rotation reduces shear stress - Augmented baseplates or bone graft to fill defects - Long screws into coracoid and scapular spine - Increasingly preferred over anatomic reconstruction for severe loss **C. Hemiarthroplasty Alone** - If glenoid bone stock inadequate for component fixation - Pain relief less predictable than TSA/RSA - Avoid in young/active patients (glenoid erosion progression) **D. Resection Arthroplasty** - Salvage option for multiply failed revisions - Remove all components, thorough debridement - Maintain humeral head (do not remove bone) - Outcomes: pain improvement variable, limited function - Preserves bone stock for potential future reconstruction ### Humeral Bone Deficiency Management **Assessment** - Cortical thickness on CT (normal >4mm) - Canal diameter (osteoporosis, prior stress shielding) - Cavitary vs cortical defects - Previous cement mantle extent **Cavitary Defects** (Cancellous Bone Loss in Metaphysis) Treatment: - Impaction bone grafting - Morselized allograft or autograft - Impact into metaphyseal defects - Cement stem over impacted graft - Provides immediate stability and biologic reconstruction **Cortical Defects** (Thinned Cortex, Fracture, Osteotomy) Treatment: - Strut allografts (femoral cortical strut) - Position over defect - Fix with cerclage cables or cables + screws - Long stem cemented through strut - Provides cortical augmentation and stress sharing **Humeral Stem Selection** Principles: - Long stem: bypass defects and previous cement by 2 cortical diameters - Typical revision stem: 150-200mm length - Cortical contact in humeral isthmus for rotational stability - Cemented fixation preferred (immediate stability for early motion) Options: - Fully cemented long stem (most common) - Modular stems for independent length/offset adjustment - Allograft-prosthesis composite for massive bone loss (rare) ### Conversion to Reverse Shoulder Arthroplasty **Indications** (Most Common Revision Strategy) 1. **Rotator Cuff Deficiency** (Most Common) - Subscapularis failure (cannot repair) - Superior cuff failure (irreparable tears) - Pseudoparalysis from cuff deficiency - Fatty infiltration Goutallier grade 3-4 2. **Severe Glenoid Bone Loss** - RSA more forgiving than anatomic TSA - Baseplate fixation possible with augments - Medialized design reduces shear stress 3. **Multiple Prior Revisions** - More predictable outcomes than anatomic re-revision - Does not require intact cuff or optimal bone stock 4. **Elderly/Low-Demand Patients** - Simpler reconstruction - More predictable pain relief - Lower revision rate than anatomic TSA revision **Contraindications** Absolute: - Deltoid dysfunction (axillary nerve palsy) - Active infection (requires staging) - Inadequate glenoid bone for baseplate fixation Relative: - Young age (<65 years) - wear concerns long-term - High activity demands - loosening risk - Severe glenoid bone loss - may need staging with bone graft **Technique Considerations** 1. **Glenoid Baseplate Placement** - Medialized position at glenoid vault (best bone) - Neutral or slight inferior tilt (avoid superior tilt) - Central screw into vault (primary fixation point) - Peripheral screws: - Superior: into coracoid base or scapular spine (strongest) - Inferior: into scapular pillar - Anterior/posterior: into scapular body - Minimum 3 screws, 4 preferred - Augments for bone deficiency (wedge or step designs) 2. **Humeral Component** - Long stem (150-200mm) for revision setting - Humeral offset/lateralization to tension deltoid - Appropriate neck-shaft angle (135-155° options) - Version: 20-30° retroversion 3. **Stability Optimization** - Appropriate glenosphere size (36-42mm typical) - Lateralized or medialized design per bone stock - Humeral component position for deltoid tensioning - Assess stability: no anterior translation in adduction and internal rotation ## Complications Management ## References 1. **Bonnevialle N, Melis B, Neyton L, et al.** Aseptic glenoid loosening or failure in total shoulder arthroplasty: revision with glenoid reimplantation. *J Shoulder Elbow Surg.* 2013;22(6):745-751. doi:10.1016/j.jse.2012.07.011 2. **Holschen M, Siemes MK, Witt KA, et al.** Two-stage revision shoulder arthroplasty for periprosthetic joint infection: tackling the challenges. *Int Orthop.* 2020;44(2):295-304. doi:10.1007/s00264-019-04461-x 3. **Patel DN, Young B, Onyekwelu I, et al.** Reverse total shoulder arthroplasty for failed shoulder arthroplasty. *J Shoulder Elbow Surg.* 2012;21(11):1478-1483. doi:10.1016/j.jse.2011.11.011 4. **Zumstein MA, Pinedo M, Old J, Boileau P.** Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. *J Shoulder Elbow Surg.* 2011;20(1):146-157. doi:10.1016/j.jse.2010.08.001 5. **Boileau P, Melis B, Duperron D, et al.** Revision surgery of reverse shoulder arthroplasty. *J Shoulder Elbow Surg.* 2013;22(10):1359-1370. doi:10.1016/j.jse.2013.02.004 6. **Antuna SA, Sperling JW, Cofield RH, Rowland CM.** Glenoid revision surgery after total shoulder arthroplasty. *J Shoulder Elbow Surg.* 2001;10(3):217-224. doi:10.1067/mse.2001.113961 7. **Wagner ER, Houdek MT, Schleck C, et al.** Increasing rates of bone grafting in revision shoulder arthroplasty: an analysis of 4,657 cases. *J Bone Joint Surg Am.* 2018;100(24):e162. doi:10.2106/JBJS.18.00356 8. **Kiet TK, Feeley BT, Naimark M, et al.** Outcomes after shoulder replacement: comparison between reverse and anatomic total shoulder arthroplasty. *J Shoulder Elbow Surg.* 2015;24(2):179-185. doi:10.1016/j.jse.2014.06.039 9. **Cofield RH, Edgerton BC.** Total shoulder arthroplasty: complications and revision surgery. *Instr Course Lect.* 1990;39:449-462. PMID: 2186138 10. **Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR).** Hip, Knee & Shoulder Arthroplasty: 2022 Annual Report. Adelaide: AOA; 2022. Available at: https://aoanjrr.sahmri.com/annual-reports-2022

Shoulder Arthroplasty Revision

Shoulder Arthroplasty Revision