Review Question - QID 214118

Compared to a primary RSA, revision RSA significantly increases the risk of glenoid component loosening and fracture with rates approaching ~25% at 5-year follow-up.

Revision RSA can be a salvage procedure performed for a failed shoulder hemiarthroplasty, failed anatomic total shoulder arthroplasty and failed primary RSA. The most frequent complications noted following a revision RSA is loosening or fracture of the glenoid. Other commonly seen complications are dislocation and recurrent instability. The increased risk of glenoid loosening and fracture is thought to be due to the relatively high ratio of metal within the confines of a small glenoid bone stock, leading to significant stress rise.

Walch et al. evaluated the clinical and radiographic outcomes of 240 RSAs with a minimum 2-year follow-up performed by a single surgeon from 2003-2007 and compared the results to 240 RSAs performed by the same surgeon between 1995-2003. The authors noted that the postoperative complication rate decreased with increased experience (from 19% to 10.8%), with dislocations reducing (from 7% to 3.2%), and infections reducing (from 4% to 0.9%). The overall revision rate decreased from 7.5% to 5%. The authors concluded that experience significantly modified results and complications.

Wagner et al. reviewed 27 cases of revision RSAs performed for a failed primary RSA with a followup of 4.4 years. The authors noted 6 patients developing complications requiring further revision surgery (22%). Overall, the 5-year survival free of further revision was 85%. At the most recent follow-up, six patients (23%) had glenoid lucency with smokers having a significantly higher risk. The authors concluded that revision RSA, when used to salvage a failed primary RSA, can be a successful procedure but dislocation and glenoid lucency remain a concern, particularly in smokers.

Incorrect Answers:
Answer 1: This patient has no evidence of an axillary nerve palsy currently 6 months out from revision RSA. There would be no expected cause of axillary nerve palsy going forward.
Answer 2: Acromial stress fractures most often occur during implantation of the RSA and can be a cause of persistent acute shoulder pain after RSA.
Answer 3: Pseudoparalysis is generally caused by severe rotator cuff deficiency, which RSA compensates for.
Answer 4: Periprosthetic glenoid, not humerus, fractures are the most common complication following revision RSA.