Failed Reverse Shoulder Arthroplasty and Recommendations for Revision.

Abstract

The most common complications warranting revision consideration in reverse shoulder arthroplasty (RSA) include instability and its associated causes: infection, periprosthetic fracture, and glenoid baseplate loosening. Management of complications can be challenging and the nuances of treatment are still being elucidated. The focus of this paper is to review the treatment of the failed RSA and discuss evidence-based recommendations for revision. The most common complications requiring revision RSA are instability and infection. The causes for instability can be subdivided into three main subcategories: loss of compression, loss of containment, and impingement. Loss of compression is further broken down into 6 subcategories revolving around abnormal prosthesis positioning, undersized prostheses, or intrinsic soft-tissue tension loss leading to instability. Periprosthetic infection can also lead to instability, yet the most appropriate management for infected RSA remains controversial. Restoring stability by maximizing deltoid and soft tissue tension while avoiding impingement revolves around three basic methods: (1) lateralizing and/or upsizing the glenosphere to an inferior position on the glenoid, (2) use of a more constrained polyethylene insert, and (3) distalizing the humerus by increasing the polyethylene thickness and/or the thickness of the humeral tray. Management of periprosthetic joint infection can be performed in one-stage, two-stage, or "three-stage" procedures all showing good outcomes with two-stage procedures being the most commonly performed. However, persistent positive culture with propriobacterium acnes can occur in up to 25% of cases. In order to limit the associated morbidity from failed revision reverse shoulder arthroplasty, continued research on best management of associated complications is warranted.