Review and clinical presentation in reverse shoulder arthroplasty in deltoid palsy

Reverse Shoulder Arthroplasty for Irreparable Rotator Cuff Tear After Radial to Axillary End-to-Side Transfer: A Case Report

CASE

A 60-year-old man sustained a massive irreparable rotator cuff tear and axillary nerve palsy with deltoid dysfunction after an anterior shoulder dislocation. He underwent staged reverse end-to-side radial-to-axillary nerve transfer with return of deltoid function allowing for subsequent reverse shoulder arthroplasty. At 1 year postoperatively, he returned to full activity.

CONCLUSION

Irreparable rotator cuff tears complicated by axillary nerve palsy can be effectively treated with a staged approach of nerve transfer followed by reverse shoulder arthroplasty.

The humeral suspension technique: a novel operation for deltoid paralysis

Isolated deltoid paralysis is a rare pathology that can occur after axillary nerve injury due to shoulder trauma or infection. This condition leads to loss of deltoid function that can cause glenohumeral instability and inferior subluxation, resulting in rotator cuff muscle fatigue and pain. To establish dynamic glenohumeral stability, a novel technique was invented. Humeral suspension is achieved using a double button implant with non-resorbable high strength cords between the acromion and humeral head. This novel technique was used in two patients with isolated deltoid paralysis due to axillary nerve injury. The results indicate that the humeral suspension technique is a method that supports centralizing the humeral head and simultaneously dynamically stabilizes the glenohumeral joint. This approach yielded high patient satisfaction and reduced pain. Glenohumeral alignment was improved and remained intact 5 years postoperative. The humeral suspension technique is a promising surgical method for subluxated glenohumeral joint instability due to isolated deltoid paralysis.

Revision Reverse Total Shoulder Arthroplasty With Pectoralis Major Transfer for Anterior Deltoid Deficiency: A Case Report

CASE

A 70-year-old male patient presented with anterior deltoid weakness from Parsonage-Turner neuropathy status post failed nerve transfer and a failed total shoulder arthroplasty with pseudoparalysis. The patient underwent revision to a reverse total shoulder arthroplasty with concomitant pectoralis major transfer to substitute for the anterior deltoid. An excellent functional result was attained as early as 6 weeks after surgery.

CONCLUSION

Pectoralis major transfer can be an effective treatment option for isolated anterior deltoid insufficiency, even in the setting of a reverse total shoulder arthroplasty.

Poor results after pyrocarbon interpositional shoulder arthroplasty

BACKGROUND

This study aimed to describe the clinical outcomes and complications of 10 cases of pyrocarbon interposition shoulder arthroplasty (PISA).

METHODS

The clinical and radiographic records of 10 patients who underwent PISA using the InSpyre shoulder prosthesis (Tornier-Wright) between July 2012 and March 2017 were reviewed. The mean age at surgery was 55 years. Surgical indications included patients aged <60 years with Walch type B glenoid glenohumeral osteoarthritis (n = 7), avascular necrosis (AVN) of the humeral head (n = 1), or secondary severe glenohumeral osteoarthritis with axillary nerve dysfunction (n = 2). Outcomes of interest were postoperative complications and need for revision surgery, preoperative and postoperative patient-reported outcomes (Constant score [CS] and Subjective Shoulder Value [SSV]), and range of motion. The radiographic characteristics of the implants were evaluated.

RESULTS

Among the 10 patients, 5 underwent revision to reverse shoulder arthroplasty during the study period owing to poor clinical outcomes based on the CS and SSV. All 5 revised patients had Walch type B glenoid morphology at the time of the index procedure. The mean time to revision surgery in this subset of patients was 60 months. The remaining 5 patients who did not undergo any revision procedure had significant improvement in mean CS and SSV from 30-65 points and 32%-87%, respectively, but at a shorter duration of follow-up of 35 months.

CONCLUSION

High clinical failure rate and poor results at mean 5-year follow-up were found in younger PISA patients with baseline Walch B glenohumeral osteoarthritis. We would caution against use of PISA in this challenging patient population. PISA yielded more favorable short-term outcomes in patients with humeral-sided deformity or severe secondary glenohumeral osteoarthritis with axillary nerve dysfunction; however, longevity of the implant in this population remains unclear.

Shoulder Arthrodesis in the Management of Glenohumeral Pathologies

Background

In an era of advanced shoulder stabilization procedures, arthroplasty implants and techniques, shoulder arthrodesis is considered an end-stage salvage procedure with negative connotations. However, in correctly selected patients, arthrodesis can alleviate pain, provide acceptable and stable motion, with a resultant functional shoulder.

Methods

The current literature on shoulder arthrodesis was reviewed to determine the indications, surgical technique, post-operative rehabilitation, complications and outcomes.

Results

Indications for shoulder arthrodesis include brachial plexus injuries, paralytic disorders, pseudo paralysis from combined severe/irreparable rotator cuff and deltoid injuries, inflammatory arthritis with severe rotator cuff pathology, persistent refractory instability, and tumor resection. Shoulder arthrodesis generally involves compression screws with or without plate fixation and bone graft. The arthrodesis is positioned to optimize the function of the extremity, primarily for activities of daily living. Postoperatively, most patients are immobilized for 8 to 10 weeks, dependent on the completeness of radiological fusion. Complications include nonunion, shoulder girdle muscle atrophy, painful hardware, periprosthetic fractures, and infection.

Discussion

With the use of recent biological innovations, the nonunion rate has declined, and rehabilitation technologies have allowed maintenance of muscle mass for future conversion to shoulder arthroplasty. Hence, in carefully selected patients, shoulder arthrodesis provides a valuable option for a stable, functional, and pain-free shoulder and should be retained as part of the treatment algorithm for complex shoulder pathology.