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Polyethylene dissociation after reverse total shoulder arthroplasty: The use of diagnostic arthroscopy
Polyethylene dissociation after reverse total shoulder arthroplasty: The use of diagnostic arthroscopy Matthew J. Garberina, MD, and Gerald R. Williams, Jr, MD, Berkeley Heights, NJ, and Philadelphia, PA
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everse total shoulder arthroplasty can provide consistent pain relief and variable functional improvement in patients with glenohumeral arthropathy and irreparable rotator cuff insufficiency.1,3,5 Patients who complain of a sudden increase in pain and decrease in function after a reverse prosthesis warrant clinical and laboratory investigation for possible causes of failure. Reported complications include infection, dislocation, glenoid loosening, humeral loosening, acromial stress fracture, component fracture, or component failure (ie, unscrewing or dissociation).1,3,5 The workup includes laboratory studies, radiographic evaluation, nuclear imaging, and aspiration. Diagnostic arthroscopy has proven a useful adjunct in the diagnosis of glenoid loosening after total shoulder arthroplasty.2,6 We describe a case in which the cause of failure after reverse total shoulder arthroplasty was identified by diagnostic arthroscopy.
CASE REPORT A 69-year-old right hand–dominant woman was treated with a reverse total shoulder arthroplasty for cuff tear arthropathy at another hospital in January 2006. She reported that she did extremely well postoperatively, with immediate relief of pain and gradual restoration of function over the next 5 months. In June 2006, she noticed a gradual onset of pain that subsequently worsened over the next 2 months. Her surgeon moved from the area, and she was referred to our office for evaluation. In August 2006, the patient presented with severe pain in her left shoulder that she described as ‘‘worse than before surgery.’’ She kept her left elbow tucked gingerly at her side and was brought close to tears with any attempted passive elevation of her shoulder. She did have some active external and internal rotation at her side. She had no erythema or warmth about the shoulder. Her incision was healed. Clinically, her prosthesis appeared reduced. She could recall no From the University of Pennsylvania and Penn Presbyterian Medical Center. Reprint requests: Matthew J. Garberina, MD, Summit Medical Group, Berkeley Heights, NJ 07922 (E-mail: garbe003@ comcast.net). J Shoulder Elbow Surg 2008;17:e16-e18 Copyright ª 2008 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2008/$34.00 doi:10.1016/j.jse.2007.02.131
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history of documented temperature increase or chills but described often feeling subjectively feverish. Her oral temperature was 37 C. She had a history of type 2 diabetes. Our initial concern was infection. Plain radiographs revealed a reduced reverse total shoulder prosthesis without evidence of loosening (Figure 1). Under sterile conditions, aspiration was performed, and approximately 5 mL of blood-tinged synovial fluid was sent for cell count and differential, Gram stain, crystal evaluation, culture, and sensitivities (aerobic and anaerobic). She was given a prescription for blood work to include complete blood count, C-reactive protein level, and erythrocyte sedimentation rate. The patient’s white blood cell count was 4300. Her erythrocyte sedimentation rate and C-reactive protein level were also normal. Her synovial fluid aspirate was negative for bacteria on Gram stain, the cell count was 5000, and cultures were negative. Upon her return, the shoulder was still very painful, and she was distressed that her workup, thus far, revealed no abnormalities. She underwent a tagged white blood cell (indium) scan, the results of which were also negative. We discussed surgical and nonsurgical options including observation, revision arthroplasty, and diagnostic arthroscopy. At this point, the patient wanted some form of surgical intervention, as her pain was intolerable. We were hesitant to recommend outright revision without knowing the cause of pain. We believed that diagnostic arthroscopy could identify humeral or glenoid loosening and would also allow evaluation of wear and particulate debris. Although we have experience with arthroscopy after total shoulder arthroplasty for glenoid loosening and subacromial impingement, we had never used this technique after reverse total shoulder arthroplasty.4 At surgery, with the patient in the beach-chair position, a posterior portal was made. The goal was to enter the joint superior to the glenosphere, so as not to damage any wellfixed components. An anterior portal was established via an outside-in technique, and a rotary shaver cleared the arthroscopic view. The glenosphere and polyethylene and metaphyseal components were easily visualized (Figure 2). There was no evidence of gross infection. Because there was no rotator cuff superiorly, a lateral subacromial portal was established with an outside-in technique to evaluate the visible components for loosening. The shaver tip was gently used from the anterior and lateral portals to probe the components. There was no detectable motion of the glenosphere. However, there was obvious motion of the polyethylene component with gentle palpation (Figure 3). The metaphyseal component was not obviously loose. At this point, we felt confident that revision
Garberina and Williams
J Shoulder Elbow Surg Volume 17, Number 1
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Figure 2 View of polyethylene cup and glenosphere with camera in posterior portal.
Therefore, we made the decision to remove the humeral component and cement a new humeral component with a fresh polyethylene implant. The patient’s humeral component was easily removed. Some proximal cement was removed to allow placement of a trial prosthesis. Trial reduction with a 6-mm stem and 36-mm metaphyseal +6 polyethylene components produced a stable configuration. The final components were placed, and the incision was closed over a drain. The arm was placed in a sling with an abduction pillow. Postoperatively, the patient had excellent pain relief at early follow-up. Radiographs revealed reduction of the prosthesis (Figure 4). The patient is currently in the early phases of her rehabilitation.
DISCUSSION
Figure 1 Anteroposterior (A) and axillary lateral (B) views of the painful reverse prosthesis preoperatively show no gross evidence of loosening.
arthroplasty was indicated. The prior deltopectoral incision was used. The prosthesis was dislocated, and the polyethylene component was grossly loose and eccentrically worn anteriorly. Both the glenosphere and humeral components appeared well fixed. The humeral component appeared to have proper, neutral version. The prosthesis was different from the one available at our institution. Pairing the retrieved polyethylene and a trial glenosphere from our set, there appeared to be excellent conformity between the components.
Reverse total shoulder arthroplasty is an effective treatment for rotator cuff arthropathy. The prosthesis enhances shoulder elevation by medializing the joint line and lengthening the deltoid by reversing the ball-socket articulation. This allows the deltoid to flex the shoulder more effectively and compensate for large, irreparable rotator cuff tears. This prosthesis has been used with success in Europe for over 2 decades but has only recently been approved for implantation in the United States. Frankle et al3 reported a minimum 2-year follow-up in 60 patients after reverse total shoulder arthroplasty. Complications occurred in 13 patients (17%), and the revision rate at a mean of 33 months postoperatively was 12%. At revision surgery, all patients were found to lack bony ingrowth at the glenoid baseplate. One patient had humeral dissociation, but it is not clear whether that meant polyethylene dissociation or an uncoupling between the metaphyseal and diaphyseal components. A recent study by Guery et al5 evaluated outcomes for reverse prostheses 5 to 10 years after implantation. Survival rates were greater than 90% after 10 years, with 16% showing some evidence of glenoid loosening. The authors recommended selective indications for the reverse prosthesis:
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Garberina and Williams
J Shoulder Elbow Surg January/February 2008
Figure 4 Postoperative radiograph after humeral revision.
cause of pain. In retrospect, an arthrogram is another reasonable diagnostic modality for this problem. Arthroscopy was easy to perform, as the lack of a rotator cuff and distally located humerus make joint entry above the articulation easy. Similarly, anterior and lateral portals were easily placed and helpful in the diagnosis of polyethylene dissociation. At the conclusion of the arthroscopy, we could confidently perform the revision surgery. Therefore, we feel that diagnostic arthroscopy is a useful adjunct in identifying causes of failure in patients with painful reverse total shoulder arthroplasty, especially when the cause of failure is unclear. Figure 3 Posterior view shows loose polyethylene cup before (A) and after (B) palpation by use of the shaver tip as a probe.
REFERENCES
patients aged greater than 70 years with rotator cuff arthropathy are ideal. It was also noted that most failures occur within 36 months, with predictable deterioration of function after 6 years. Complications included infection, dislocation, and glenoid dissociation. Another study, by Boileau et al,1 confirmed that the best indication for a reverse prosthesis is cuff tear arthropathy, when compared with fracture sequelae and revision arthroplasty. Complication rates were much higher in the latter patient groups. Diagnostic arthroscopy has been used for identifying glenoid loosening, and arthroscopic techniques have been used to excise loose glenoid components.2,6 We have also reported the use of arthroscopy to treat impingement syndrome after total shoulder arthroplasty.4 We are aware of no reports of using arthroscopy in the diagnosis of component loosening after reverse total shoulder arthroplasty. The patient in this case report provided a diagnostic dilemma that was easily resolved by use of arthroscopy. There was no obvious radiographic abnormality to identify the
1. Boileau P, Watkinson D, Hatzidakis A, Hovorka I. Neer Award 2005: the Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg 2006;15:527-40. 2. Bonutti PM, Hawkins RJ, Saddemi S. Arthroscopic assessment of glenoid component loosening after total shoulder arthroplasty. Arthroscopy 1993;9:272-6. 3. Frankle M, Siegal S, Pupello D, Siegal S, Saleem A, Mighell M, et al. The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum twoyear follow-up study of sixty patients. J Bone Joint Surg Am 2005; 87:1697-705. 4. Freedman KB, Williams GR, Iannotti JP. Impingement syndrome following total shoulder arthroplasty and humeral hemiarthroplasty: treatment with arthroscopic acromioplasty. Arthroscopy 1998;14: 665-70. 5. Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am 2006; 88:1742-7. 6. O’Driscoll SW, Petrie RS, Torchia ME. Arthroscopic removal of the glenoid component for failed total shoulder arthroplasty: a report of five cases. J Bone Joint Surg Am 2005;87:858-63.
R
everse total shoulder arthroplasty can provide consistent pain relief and variable functional improvement in patients with glenohumeral arthropathy and irreparable rotator cuff insufficiency.1,3,5 Patients who complain of a sudden increase in pain and decrease in function after a reverse prosthesis warrant clinical and laboratory investigation for possible causes of failure. Reported complications include infection, dislocation, glenoid loosening, humeral loosening, acromial stress fracture, component fracture, or component failure (ie, unscrewing or dissociation).1,3,5 The workup includes laboratory studies, radiographic evaluation, nuclear imaging, and aspiration. Diagnostic arthroscopy has proven a useful adjunct in the diagnosis of glenoid loosening after total shoulder arthroplasty.2,6 We describe a case in which the cause of failure after reverse total shoulder arthroplasty was identified by diagnostic arthroscopy.
CASE REPORT A 69-year-old right hand–dominant woman was treated with a reverse total shoulder arthroplasty for cuff tear arthropathy at another hospital in January 2006. She reported that she did extremely well postoperatively, with immediate relief of pain and gradual restoration of function over the next 5 months. In June 2006, she noticed a gradual onset of pain that subsequently worsened over the next 2 months. Her surgeon moved from the area, and she was referred to our office for evaluation. In August 2006, the patient presented with severe pain in her left shoulder that she described as ‘‘worse than before surgery.’’ She kept her left elbow tucked gingerly at her side and was brought close to tears with any attempted passive elevation of her shoulder. She did have some active external and internal rotation at her side. She had no erythema or warmth about the shoulder. Her incision was healed. Clinically, her prosthesis appeared reduced. She could recall no From the University of Pennsylvania and Penn Presbyterian Medical Center. Reprint requests: Matthew J. Garberina, MD, Summit Medical Group, Berkeley Heights, NJ 07922 (E-mail: garbe003@ comcast.net). J Shoulder Elbow Surg 2008;17:e16-e18 Copyright ª 2008 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2008/$34.00 doi:10.1016/j.jse.2007.02.131
e16
history of documented temperature increase or chills but described often feeling subjectively feverish. Her oral temperature was 37 C. She had a history of type 2 diabetes. Our initial concern was infection. Plain radiographs revealed a reduced reverse total shoulder prosthesis without evidence of loosening (Figure 1). Under sterile conditions, aspiration was performed, and approximately 5 mL of blood-tinged synovial fluid was sent for cell count and differential, Gram stain, crystal evaluation, culture, and sensitivities (aerobic and anaerobic). She was given a prescription for blood work to include complete blood count, C-reactive protein level, and erythrocyte sedimentation rate. The patient’s white blood cell count was 4300. Her erythrocyte sedimentation rate and C-reactive protein level were also normal. Her synovial fluid aspirate was negative for bacteria on Gram stain, the cell count was 5000, and cultures were negative. Upon her return, the shoulder was still very painful, and she was distressed that her workup, thus far, revealed no abnormalities. She underwent a tagged white blood cell (indium) scan, the results of which were also negative. We discussed surgical and nonsurgical options including observation, revision arthroplasty, and diagnostic arthroscopy. At this point, the patient wanted some form of surgical intervention, as her pain was intolerable. We were hesitant to recommend outright revision without knowing the cause of pain. We believed that diagnostic arthroscopy could identify humeral or glenoid loosening and would also allow evaluation of wear and particulate debris. Although we have experience with arthroscopy after total shoulder arthroplasty for glenoid loosening and subacromial impingement, we had never used this technique after reverse total shoulder arthroplasty.4 At surgery, with the patient in the beach-chair position, a posterior portal was made. The goal was to enter the joint superior to the glenosphere, so as not to damage any wellfixed components. An anterior portal was established via an outside-in technique, and a rotary shaver cleared the arthroscopic view. The glenosphere and polyethylene and metaphyseal components were easily visualized (Figure 2). There was no evidence of gross infection. Because there was no rotator cuff superiorly, a lateral subacromial portal was established with an outside-in technique to evaluate the visible components for loosening. The shaver tip was gently used from the anterior and lateral portals to probe the components. There was no detectable motion of the glenosphere. However, there was obvious motion of the polyethylene component with gentle palpation (Figure 3). The metaphyseal component was not obviously loose. At this point, we felt confident that revision
Garberina and Williams
J Shoulder Elbow Surg Volume 17, Number 1
e17
Figure 2 View of polyethylene cup and glenosphere with camera in posterior portal.
Therefore, we made the decision to remove the humeral component and cement a new humeral component with a fresh polyethylene implant. The patient’s humeral component was easily removed. Some proximal cement was removed to allow placement of a trial prosthesis. Trial reduction with a 6-mm stem and 36-mm metaphyseal +6 polyethylene components produced a stable configuration. The final components were placed, and the incision was closed over a drain. The arm was placed in a sling with an abduction pillow. Postoperatively, the patient had excellent pain relief at early follow-up. Radiographs revealed reduction of the prosthesis (Figure 4). The patient is currently in the early phases of her rehabilitation.
DISCUSSION
Figure 1 Anteroposterior (A) and axillary lateral (B) views of the painful reverse prosthesis preoperatively show no gross evidence of loosening.
arthroplasty was indicated. The prior deltopectoral incision was used. The prosthesis was dislocated, and the polyethylene component was grossly loose and eccentrically worn anteriorly. Both the glenosphere and humeral components appeared well fixed. The humeral component appeared to have proper, neutral version. The prosthesis was different from the one available at our institution. Pairing the retrieved polyethylene and a trial glenosphere from our set, there appeared to be excellent conformity between the components.
Reverse total shoulder arthroplasty is an effective treatment for rotator cuff arthropathy. The prosthesis enhances shoulder elevation by medializing the joint line and lengthening the deltoid by reversing the ball-socket articulation. This allows the deltoid to flex the shoulder more effectively and compensate for large, irreparable rotator cuff tears. This prosthesis has been used with success in Europe for over 2 decades but has only recently been approved for implantation in the United States. Frankle et al3 reported a minimum 2-year follow-up in 60 patients after reverse total shoulder arthroplasty. Complications occurred in 13 patients (17%), and the revision rate at a mean of 33 months postoperatively was 12%. At revision surgery, all patients were found to lack bony ingrowth at the glenoid baseplate. One patient had humeral dissociation, but it is not clear whether that meant polyethylene dissociation or an uncoupling between the metaphyseal and diaphyseal components. A recent study by Guery et al5 evaluated outcomes for reverse prostheses 5 to 10 years after implantation. Survival rates were greater than 90% after 10 years, with 16% showing some evidence of glenoid loosening. The authors recommended selective indications for the reverse prosthesis:
e18
Garberina and Williams
J Shoulder Elbow Surg January/February 2008
Figure 4 Postoperative radiograph after humeral revision.
cause of pain. In retrospect, an arthrogram is another reasonable diagnostic modality for this problem. Arthroscopy was easy to perform, as the lack of a rotator cuff and distally located humerus make joint entry above the articulation easy. Similarly, anterior and lateral portals were easily placed and helpful in the diagnosis of polyethylene dissociation. At the conclusion of the arthroscopy, we could confidently perform the revision surgery. Therefore, we feel that diagnostic arthroscopy is a useful adjunct in identifying causes of failure in patients with painful reverse total shoulder arthroplasty, especially when the cause of failure is unclear. Figure 3 Posterior view shows loose polyethylene cup before (A) and after (B) palpation by use of the shaver tip as a probe.
REFERENCES
patients aged greater than 70 years with rotator cuff arthropathy are ideal. It was also noted that most failures occur within 36 months, with predictable deterioration of function after 6 years. Complications included infection, dislocation, and glenoid dissociation. Another study, by Boileau et al,1 confirmed that the best indication for a reverse prosthesis is cuff tear arthropathy, when compared with fracture sequelae and revision arthroplasty. Complication rates were much higher in the latter patient groups. Diagnostic arthroscopy has been used for identifying glenoid loosening, and arthroscopic techniques have been used to excise loose glenoid components.2,6 We have also reported the use of arthroscopy to treat impingement syndrome after total shoulder arthroplasty.4 We are aware of no reports of using arthroscopy in the diagnosis of component loosening after reverse total shoulder arthroplasty. The patient in this case report provided a diagnostic dilemma that was easily resolved by use of arthroscopy. There was no obvious radiographic abnormality to identify the
1. Boileau P, Watkinson D, Hatzidakis A, Hovorka I. Neer Award 2005: the Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg 2006;15:527-40. 2. Bonutti PM, Hawkins RJ, Saddemi S. Arthroscopic assessment of glenoid component loosening after total shoulder arthroplasty. Arthroscopy 1993;9:272-6. 3. Frankle M, Siegal S, Pupello D, Siegal S, Saleem A, Mighell M, et al. The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum twoyear follow-up study of sixty patients. J Bone Joint Surg Am 2005; 87:1697-705. 4. Freedman KB, Williams GR, Iannotti JP. Impingement syndrome following total shoulder arthroplasty and humeral hemiarthroplasty: treatment with arthroscopic acromioplasty. Arthroscopy 1998;14: 665-70. 5. Guery J, Favard L, Sirveaux F, Oudet D, Mole D, Walch G. Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am 2006; 88:1742-7. 6. O’Driscoll SW, Petrie RS, Torchia ME. Arthroscopic removal of the glenoid component for failed total shoulder arthroplasty: a report of five cases. J Bone Joint Surg Am 2005;87:858-63.