[Revision of Failed Fracture Hemiarthroplasties to Reverse Total Shoulder Prosthesis Through the Transhumeral Approach : Method Incorporating a Pectoralis-major-pedicled Bone Window]

Objective: Alleviation of pain, restoration of function and active range of motion.

Indications: Failed posttraumatic shoulder prostheses with insufficient rotator cuff, pseudoparalysis, chronic instability, severe ankylosis.

Contraindications: Advanced glenoid destruction. Severe lesions of the deltoid muscle (> 50%) and axillary nerve palsy. Florid infections.

Surgical Technique: Deltopectoral approach. Exposure of the failed implant and explantation by fenestration of the humerus. Periarticular release with preservation of neurovascular structures. Exposure of the glenoid, cementless fixation of the glenoid base plate (metaglène) and application of the glenoid ball (glenosphere). Fenestration of the humeral shaft, removal of bone cement, placement of wire and suture loops, and cemented implantation of the humeral component (long revision stem) in 10-30 degrees retroversion related to the long axis of the forearm. Anatomic reconstruction of the soft tissues with preservation of the external rotators (reattachment of dislocated tubercles and, if necessary, transposition of latissimus dorsi and teres major as described by L'Episcopo).

Postoperative Management: For 6 weeks postoperatively, abduction brace and passive or active-assisted exercises including continuous passive motion (Ormed, Freiburg, Germany).

Results: From 2000 to 2005, a total of 84 shoulder replacement revisions were performed with the reverse prosthesis, of which 34 were revisions of failed fracture hemiarthroplasties (five men, 29 women) through a bone window in the humerus. 25 patients were followed prospectively for up to 59 months postoperatively; an additional nine patients were interviewed by telephone or in writing (n=34, average age 68 years [59-82 years], average follow-up 31.5 months [12-59 months]). The preoperative age- and gender-related Constant Score was 17.5% and improved to 63% postoperatively. Range of motion for active elevation and internal rotation was substantially improved (average elevation preoperatively 48 degrees , postoperatively 125 degrees ). Pain was relieved in every patient. Function correlated to the extent of soft-tissue damage. 14 patients were very satisfied with the surgical outcome, 16 were satisfied and four dissatisfied. There were eight complications in total.