This study was

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J Shoulder Elbow Surg (2012) 21, 514-522

1058-2746/$ - s

doi:10.1016/j.jse

www.elsevier.com/locate/ymse

The use of the reverse shoulder arthroplasty fortreatment of failed total shoulder arthroplasty

Matthew Walker, MDa, Matthew P. Willis, MDa, Jordan P. Brooks, BSb,Derek Pupello, MBAb, Philip J. Mulieri, MD, PhDa, Mark A. Frankle, MDa,*

aFlorida Orthopaedic Institute, Tampa, FL, USAbFoundation for Orthopaedic Research and Education, Tampa, FL, USA

Background: This study evaluated the outcomes of patients with failed total shoulder arthroplasty (TSA)who were treated with conversion to reverse shoulder arthroplasty (RSA).Materials and methods: We performed a retrospective case series of 24 consecutive patients with failedTSA who were treated with conversion to RSA. Twenty-two patients (16 women, 6 men) had a minimum2-year clinical and radiographic follow-up. The average age at the time of revision was 68 years (range, 51-84 years). Indications for conversion to RSA included failure of TSA from glenohumeral instability in 19,mechanical failure of the humeral or glenoid component in 10, and infection in 2.Results: The median total American Shoulder and Elbow Surgeons score improved from 38.5 preopera-tively to 67.5 (P < .001). Visual analog scale pain scores decreased from 5 to 1.5 (P < .001), and functionimproved from 2 to 6.5 (P < .001). The median Simple Shoulder Test improved from 1 to 5 (P ¼ .006).Forward flexion improved from 50� to 130� (P < .001), abduction from 45� to 100� (P < .001), andexternal rotation from 12.5� to 49.5� (P ¼ .056). Internal rotation improved from a spinal level of S2 toL3 (P ¼ .064). Fourteen patients rated their outcome as excellent, 3 as good, 3 as satisfactory, and 2 asunsatisfactory. The overall complication rate was 22.7% (5 of 22).Conclusion: RSA can be an effective treatment for failed TSA by decreasing pain and improving shoulderfunction. However, RSA in the revision setting is associated with a higher complication rate.Level of evidence: Level IV, Case Series, Treatment Study.� 2012 Journal of Shoulder and Elbow Surgery Board of Trustees.

Keywords: Reverse shoulder arthroplasty; failed total shoulder arthroplasty; glenohumeral instability

Management of the failed total shoulder arthroplasty(TSA) continues to be a difficult problem for the orthopedicsurgeon. In addition to the challenges inherent in revisionsurgery, loss of both humeral and glenoid bone stock, softtissue compromise, and complications related to the failed

approved by Western Institutional Review Board (WIRB

uests: Mark A. Frankle, MD, Florida Orthopaedic Institute,

Parkway N, Tampa, FL 33637, USA.

ss: frankle@pol.net (M.A. Frankle).

ee front matter � 2012 Journal of Shoulder and Elbow Surgery

.2011.03.006

prosthesis make the restoration of a stable, functional jointdifficult. Among the salvage procedures that can be per-formed are resection arthroplasty, conversion to hemi-arthroplasty, and arthrodesis; however, these alternatives donot reliably decrease pain and restore function to theaffected shoulder.4,6,15

As an alternative, reverse shoulder arthroplasty (RSA)has been considered as another treatment option for failedTSA. RSA has been shown to be an effective treatment forother complex shoulder problems, including rotator cuff

Board of Trustees.

Table I Patient information

Variable No. or average(range)

Total population 22Male 6

Reverse shoulder arthroplasty for failed TSA 515

arthropathy,21,23 failed hemiarthroplasty,12 and proximalhumerus fractures.8,9 However, information regarding theoutcomes of RSA for the treatment of failed TSA islimited.16-18 In this retrospective cohort study, we evaluatedthe clinical and radiographic outcomes of patients withfailed TSA who were treated by conversion to RSA.

Female 16Age at surgery, years 68.6 (51-84)Surgical sideRight 11Left 11

Follow-up, months 39.6 (25-72)Reasons for revisionInstability without mechanical failure 10Instability and mechanical failure 9Mechanical failure alone 1Infection 2

Materials and methods

This study was a retrospective case series of prospectivelycollected data. Between January 2004 and March 2008, 24consecutive patients underwent revision of a failed TSA to RSA atour institution. Each procedure was performed by a singlesurgeon, the senior author of this study (M.F.). The study included22 patients (16 women, 6 men) with preoperative data anda minimum 2-year clinical and radiographic follow-up (average,40 months; range, 29-72 months; Table I). Excluded were 2patients who died before the 2-year follow-up assessment. Thestudy patients were an average age of 68 years (range, 51-84years). Reasons for revision to an RSA included instabilitywithout mechanical failure in 10, instability with mechanicalfailure of either the glenoid or humeral component in 9, compo-nent failure without instability in 1, and infection in 2.

Operative technique

The humeral stem removal was performed in a stepwise fashion.Once the stem was dislodged from the cortical bone (15 patients)or cement mantle (7 patients), the arm was placed into fulladduction and the extraction was completed. When present, and incases where infection was not a concern, the cement mantle wasleft intact and the humeral component was cemented into theremaining mantle; however, modification of the component wassometimes necessary. The cement mantle was removed in itsentirety in patients with known infection and when intraoperativefrozen section analysis revealed more than 5 polymorphonuclearneutrophils per high-power field.

Sequential handheld diaphyseal reamers were used prepare theintramedullary canal and a trial broach was introduced. For stemremoval, proximal release using osteotomes and burs to free thehumeral stem from the metaphyseal bone was all that wasnecessary in 20 patients, and a linear corticotomy was needed in 2.

Glenoid removal was performed so that as much remainingglenoid bone stock as possible was preserved. Loose glenoidswere easily removed (7 in this series), but the well-fixed glenoidswere removed by amputating the component from the pegs orkeels. This step was performed using osteotomes or small oscil-lating saws. Remaining pegs and keels were curetted out of theglenoid bone stock with the remaining cement mantle. Removal ofglenoid components, especially metal-backed components, can beassociated with increased glenoid bone loss, so this should bedone in a manner that preserves as much glenoid bone as possible.

Bone defects were graded intraoperatively according to theclassification system of Antuna et al.1 Occasionally, glenoid bonedefects must be addressed to obtain secure baseplate fixation withthe reverse baseplate. The technique for addressing glenoid bonedefects has been previously reported.10 In this series, securebaseplate insertion required structural allograft in 10 patients.

Postoperative protocol

A shoulder immobilizer was worn for 6 weeks while pendulumexercises and elbow, wrist, and hand range of motion (ROM)exercises were performed, as previously described.12 After thefirst 6 weeks, supine active-assisted forward elevation ROMexercises were initiated. The patients were also encouraged tobegin active forward flexion beginning at 6 weeks, as comfortallowed. Resistive exercises for gentle strengthening were initiatedat 12 weeks. At 6 months, the patient could use the arm for anyactivity that comfort and confidence allowed.

Clinical and radiographic assessment

Clinical outcomes were prospectively measured before and afterthe operation via patient questionnaires. Patient-completed formsincluded the American Shoulder and Elbow Surgeon (ASES)assessment for pain and function,19 Simple Shoulder Test(SST),2,14 the visual analog scale (VAS) for pain and function, anda rating scale for overall patient satisfaction with the outcome ofsurgery (excellent, good, satisfactory, or unsatisfactory). ROMwas determined by evaluation of digital videos of each patientobtained preoperatively and postoperatively, as previouslydescribed.5

All patients were evaluated with a standard radiographic series,including an anteroposterior (AP) in internal and external rotation,a Y lateral, a true AP (Grashey) view,13 and axillary radiographs.Preoperative radiographs were evaluated for evidence of humeralor glenoid component loosening or glenohumeral instability(Table II). Humeral component loosening was graded according tothe system described by Sperling et al,22 and glenoid looseningwas graded by the system described by Lazarus et al.11

Glenohumeral stability was graded according to the methodof Rispoli et al20: grade 0 represented no instability; grade 1(mild)dup to 25% subluxation; grade 2 (moderate)d25% to 50%subluxation; grade 3 (severe)dgreater than 50% subluxation; andgrade 4ddislocation. The direction of any instability was alsonoted.

Table II Pre-operative radiographic findings

Pt Side Glenoid type Radiolucency Humeralcement

Instability Dislocated Intra-op findings

Glenoid Humeral Degree Direction Cuff Glenoid bone defect1

1 Left Keel Grade 3 1 e Mild Anterior-superior e Small supra tear Severe central bone loss2 Left Keel Grade 5 0 e Severe Anterior-superior e No data No data3 Right Metal backed Grade 0 0 Yes Severe Anterior-superior Anterior-

superiorNo data No data

4 Right Peg Grade 5 0 e Severe Anterior-superior Anterior-superior

Irreparable supra andsubscap tear

Severe central bone loss

5 Right Peg Grade 5 0 Yes Severe Anterior Anterior Irreparable supra andsubscap tear

Moderate central bone loss

6 Left Metal backed Grade 0 0 (headdissociated)

Yes Severe Anterior Anterior Moderate supra tear;subscap intact

Moderate central bone loss

7 Right Peg Grade 5 0 Yes Severe Superior Superior No data No data8 Right Peg Grade 4 0 Yes Severe Posterior Posterior Irreparable supra and

subscap tearModerate central bone loss

9 Left Peg Grade 5 0 e Severe Anterior-superior Anterior-superior

Irreparable supra, infraand subscap

Mild central bone loss

10 Right Peg Grade 1 0 e Severe Posterior Posterior Irreparable supra andsubscap

Moderate central bone loss

11 Left Peg Grade 3 0 e Severe Anterior-superior Anterior-superior

Irreparable supra, infra,and subscap

Moderate central bone loss

12 Left Peg Grade 3 1 e Severe Anterior-superior – No data No data13 Right Peg Grade 2 0 e Severe Superior – Irreparable supra, infra,

and subscapSevere combined boneloss e ‘‘potato chip’’

14 Right Peg Grade 1 0 e Severe Anterior-superior Anterior-superior

Supra and subscap tear Moderate central tear

15 Right Keel Grade 5 0 e Severe Anterior-superior Anterior-superior

Irreparable subscap Severe central loss

16 Left Metal backed Grade 3(peg andbaseplate)

0 e Moderate Anterior-superior e No data No data

17 Left All hardwareremoved

N/A N/A Yes Moderate Superior e Supra and subscap torn Moderate combined boneloss

18 Right Peg Grade 4 1 e Mild Superior e Irreparable supra andsubscap

Severe posterior bone loss

19 Left Peg Grade 4 1 No Severe Superior Superior Irreparable Supra, infraand subscap

Severe central bone loss

20 Right Peg Grade 3 1 e Severe Superior Superior Irreparable supra, infra,and subscap

Severe central bone loss

21 Left Metal backed Grade 4 e e Severe Anterior-superior Anterior-superior

No data No data

22 Left Metal backed Grade 5 e Yes Moderate Superior e Irreparable subscap Moderate central bone loss

516

M.Walker

etal.

Table III Clinical outcomes of 22 patients with failed totalshoulder arthroplasty treated with reverse shoulderarthroplasty

Variable Evaluation, mean (range) P

Pre-op Last follow-up

ASESTotal 35.8 (5-76.7) 67.5 (38-97) <.001Pain 25 (0-50) 42.5 (20-50) <.001Function 12.5 (0-36.7) 25.8 (7-47) <.001

VASPain 5 (0-10) 1.5 (0-6) <.001Function 2 (0-8) 6.5 (1-10) <.001

SST 1 (0-41) 5 (0-11) .006Forward flexion,� 50 (0-120) 130 (35-180) <.001Abduction,� 45 (0-90) 100 (60-180) <.001External rotation,� 12.5 (�25-65) 49.5 (�60-90) .056Internal rotation S2 (GT-L2) L3 (GT-T6) .064

ASES, American Shoulder and Elbow Surgeons; SST, Simple Shoulder

Test; VAS, visual analog scale.

Reverse shoulder arthroplasty for failed TSA 517

Initial postoperative radiographs were compared with the mostrecent postoperative radiographs to assess for humeral componentloosening by the system of Sperling et al22 and glenoid baseplateloosening (radiolucency around the baseplate screws). Theradiographs were also evaluated for evidence of scapular notching,which was graded according to Sirveaux et al).21 Finally, theradiographs were evaluated for any evidence of hardware failureand the presence or absence of a healed allograft, where appro-priate. Allograft incorporation was based on radiographs showinghealing at the junction of the allograft and native glenoid bone;however, because this is often difficult to determine, intact base-plates with no change in position over time were assumed to haveincorporated the allograft bone.

All radiographicmeasurementsweremade at 2 separate times by3 fellowship-trained orthopedic surgeonswho specialize in shoulderreconstruction. Twoof thesewere authors of this report (X.X.,M.F.),and the third was a surgeon not involved in this study.

Statistical analysis

Data obtained from preoperative and postoperative questionnairesand ROM analysis based on digital video measurements werecompared using a Wilcoxon signed rank test. Owing to a nonnormaldistribution of data, the results were calculated according to themedian scores of these assessments, and themedianvalues and rangesare reported. The level of statistical significance was set at 0.05.

Results

The median total ASES score improved from 38.5 preop-eratively to 67.5 (P < .001). VAS pain scores decreasedfrom 5 to 1.5 (P < .001), and function improved from 2 to6.5 (P < .001). The median SST score improved from 1 to 5(P ¼ .006). Forward flexion improved from 50� to 130�

(P < .001), abduction from 45� to 100� (P < .001), andexternal rotation from 12.5� to 49.5� (P ¼ .056). Internalrotation improved from a spinal level of S2 to L3 (P ¼.064). Overall, 14 patients rated their outcomes as excellent(64%), 3 as good (14%), 3 as satisfactory (14%), and 2 asunsatisfactory (9%). The clinical results, including theASES and SST scores as well as the ROM measurements,are summarized in Table III.

A subgroup analysis, using the Bonferroni adjustment tocorrect for multiple variables, was performed to determinedifferences in outcomes between the patients who receiveda structural allograft to the glenoid and those who hadnonstructural or no allograft bone. No statistically signifi-cant difference was observed for any of the outcomesmeasures or ranges of motion.

Radiographic analysis

Preoperative radiographic findings are listed in Table II.Instability was noted in 19 patients overall (86%); of those,14 had frank dislocations (64% overall). Of the patientswith instability, 10 had no obvious mechanical failure of

the components (45% overall) and 9 had failure of one orboth components (41% overall). Seven glenoids weregrossly loose (32%). One humeral component failure(4.5%) occurred in a patient with a chronic anterior dislo-cation in which the humeral head was disassociated fromthe stem. Loosening of the humeral and glenoid compo-nents was documented in 1 patient (Fig. 1), 4 patients hadevidence of radiolucency around the humeral stem, and theother patients had no evidence of humeral loosening.

Findings on the postoperative radiographs are listed inTable IV. Bone graft was used in 15 patients (68%), ofwhich 10 grafts were structural femoral head allografts. Allbut 1 of the structural allografts showed evidence ofincorporation on final radiographs, and all 5 nonstructuralallografts were incorporated. The patient noted above hadradiolucencies around the revised humeral and glenoidcomponents (Fig. 1), which ultimately led to revision toa long stem component. Her rerevised components did notshow any lucency at the most recent follow-up. Two otherpatients (9%) had nonprogressive radiolucency proximallyon the humerus, without evidence of component loosening.Reactive bone formation without bone loss was seen on theinferior scapular pillar in 8 patients (36%). Overall, post-operative radiographs for 2 patients (9%) had evidence ofnotching: 1 patient had a grade 1 inferior notch and theother had a grade 4 notch and baseplate loosening (Fig. 2).This patient had a structural allograft of the glenoid andwas the only patient in whom the graft did not incorporate.One other patient had lucency around the baseplate screwsbut had no clinical evidence of loosening (no pain).

Complications

The overall complication rate in this series was 22.7% (5 of22). One patient sustained a scapular spine fracture after

Figure 1 This patient underwent initial conversion from total shoulder arthroplasty to reverse shoulder arthroplasty (RSA), but requiredrerevision to a long stem component for persistent humeral and glenoid sided loosening. (A) Initial preoperative radiographs show lucenciesaround the glenoid component. (B) Initial revision to a long stem RSA. (C) Lucencies around baseplate screws are noted 3 months after theinitial revision. (D) Final rerevised components. It was noted at the time of rerevision that there remained cement in the glenoid vault. It islikely that this cement prevented boney ingrowth of the initial revision baseplate and lead to the lucencies seen in Figure 1, C.

518 M. Walker et al.

a fall that was treated nonoperatively. A postoperativedislocation of the reverse prosthesis occurred at 5 weeksfrom surgery that required closed reduction in the emer-gency department. The patient was placed back intoa shoulder immobilizer for an additional 6 weeks and didnot have any further dislocations. One patient had persistentglenoid-sided loosening, but declined further surgery.

The follow-up radiographs for another patient, whoseintraoperative frozen sections were positive at the initialrevision surgery, showed evidence of humeral and glenoid-sided loosening and was ultimately treated with a rerevisionto a long stem prosthesis. At the rerevision procedure,retained cement was seen at the glenoidebone interface,preventing any boney ingrowth of the baseplate. It is likelythat the humeral-sided loosening was related to infection,whereas the baseplate loosening could have resulted froma combination of infection and poor cement removaltechnique at the initial revision.

The most recent follow-up radiographs for 1 patientshowed a grade 4 scapular notch that was related to loos-ening of the glenoid component (Fig. 2). This patient doesnot wish to undergo any further surgical interventionbecause she is pleased with her functional result.

Two patients rated their satisfaction with the procedureas poor: one was the patient who fell postoperatively and

sustained a scapular spine fracture, and the other patientcomplained of persistent pain postoperatively and was thusunsatisfied with her result.

Discussion

The use of RSA has been described for rotator cuff teararthropathy, failed hemiarthroplasty, and proximal humerusfracture.8,9,12,21,23 Use of RSA in these clinical situationsrequires thorough consideration of the preexisting softtissue and bony anatomy, patient age and function level,and presence of infection. These factors ultimately deter-mine the viability, success, and survival of the RSA.

Likewise, the use of RSA for failed TSA requires thor-ough consideration of these factors. As a revision surgeryfor failed TSA, the outcomes of RSA have not been thor-oughly evaluated. However, Wall et al23 showed thatpatients who were managed with a reverse TSA for thetreatment of posttraumatic arthritis or for a revisionarthroplasty fared worse than patients with cuff teararthropathy, primary osteoarthritis associated witha massive rotator cuff tear, or a massive rotator cuff tearalone. Similarly, studies by Werner et al24 and Boileauet al3 indicated that the results of reverse TSA as a revision

Table IV Postoperative radiographic findings)

Pt Lucency Hardwarefailure

Fracture Reactive boneformation

Notching Glenoid bonegraftHumeral zone Baseplate

1 e e e e e e Structural2 e e e e Present e e3 e e e e Present e e4 5 and 6

(after revision)e e e e e Structural

5 e e e e Present e –6 e e e e Present e Nonstructural7 e Yes Yes e Grade 4 Nonstructural8 e e e e Grade 2 Structural9 e e e e e e

10 1, 7, 8 e e e e Structural11 e Yes e Acromial Present e Structural12 1, 7, 8 e e e e Structural13 e e e e Present e Structural14 e e e e e e15 e e e e Present e Structural16 e e e e e Nonstructural17 e e e e e e18 e e e e Present e Structural19 e e e Scapula

(after fall)e Structural

20 e e e e e Nonstructural21 e e e e Grade 1 Nonstructural22 e e e e e e

) No patient presented with instability on the radiographs.

Reverse shoulder arthroplasty for failed TSA 519

procedure are less predictable than those of reverse TSA asa primary procedure.

Only a few published studies address conversion of TSAto RSA. Neyton et al17,18 evaluated a series of patientsrequiring revision of TSA to RSA with bone grafting to theglenoid defects and noted improvements in pain andfunction. Melis et al16 conducted a retrospective multi-center study of 37 patients who underwent conversion ofTSA to RSA for glenoid loosening, dissociation, and wear.They noted a 22% rerevision rate for persistent glenoidloosening and an overall 30% complication rate (includingglenoid loosening, instability, and infection). At the latestfollow-up, the RSA was in place in 35 of the original 37patients, and the authors noted significant improvements inConstant score, forward elevation, and pain scores.16 Wenoted a higher satisfaction rate with conversion to RSA aswell as a lower rerevision rate and complication rate(22.7%).

Alternatively, procedures other than RSA can beconsidered to address the failed TSA. Antuna et al1 eval-uated the results of glenoid revision in 48 patients withloosening, failure, or wear. They noted mean improvementsin forward elevation of 96� to 112� and in external rotationof 36� to 49�. They reported that results were excellent in10, satisfactory in 14, and unsatisfactory in 19 and notedthat most of the unsatisfied patients had forward elevation

of less than 90�. Their complication rate was 25%, with 12patients requiring rerevision surgery. The high number ofcomplications, rerevisions, and dissatisfaction speaks to thefact that revision arthroplasty is a difficult procedure withless predictable outcomes than primary TSA.

Similarly, Dines et al7 evaluated a heterogeneous cohortof patients who underwent various revision procedures fordiffering modes of failure of previous shoulder arthroplastyprocedures. Using the University of California, LosAngeles score, they noted 24 excellent outcomes, 15 goodoutcomes, 24 fair outcomes, and 15 poor outcomes; thisamounts to a 50% rate of fair or poor results.

Our study noted a greater improvement in forwardelevation compared with Antuna et al (50� preoperativelyto 130� postoperatively) and a greater improvement inexternal rotation (12.5� to 49.5�), although this did notreach statistical significance. Our patient satisfaction rateswere higher than those in the Dines et al7 study, with 77%reporting good or excellent results.

The most common reason for failure of TSA requiringrevision in this series was refractory instability (10 patientshad instability alone and 19 patients had a combination ofinstability and mechanical failure). Instability usuallyresults from deficiencies of various portions of the rotatorcuff.25 One advantage of using a reverse prosthesis in thesetting of instability is the ability of the prosthesis to

Figure 3 (A) Photograph of a SawBones model (Pacific Research Laboratories, Inc. Vashon, WA, USA) illustrates a central cavitarydefect and the ideal trajectory of central screw of the baseplate. (B) An overhead view illustrating the ideal trajectory of the central screw.(C) The technique for placing structural allograft involves fashioning femoral head allograft to the shape of the glenoid bone defect usingsaws and burs. The graft should be supported over 70% to 75% of its area by the native glenoid vault. (D) After reaming, the central screwof the reverse shoulder arthroplasty design used in this study compresses the graft into the base of the glenoid vault.

Figure 2 The most recent anterior-posterior radiographs show a grade 4 notch with associated loosening of the glenoid component.However, the patient is happy with her result and has refused further surgery. (A) Initial postoperative films. (B) Most recent follow-upfilms.

520 M. Walker et al.

provide a stable construct and restore the glenohumeralcenter of rotation.

In addition to instability and mechanical failure ofcomponents, failed TSA can be associated with variousdegrees of bone loss. Glenoid bone grafting was required in15 patients, including structural in 10 and nonstructuralin 5. Although no generally accepted guidelines exist,

a one-stage revision can be performed if the overall bonequality is good, a portion of the central peg/screw for theglenoid component is contained within the native bone, andthe glenoid allograft is supported through 70% to 75% of itscircumference by the native glenoid vault (Fig. 3).10 Ifthese criteria are not fulfilled, glenoid reconstructionwith allograft in a 3-month staged protocol may be

subject of this article.

Reverse shoulder arthroplasty for failed TSA 521

warranted.25 In this series, a staged procedure was notnecessary.

Component extraction can be difficult in convertinga failed TSA to an RSA, and can be a source of compli-cations. In this series, 1 humeral-sided fracture was notedduring the approach. The availability of newer, convertibledevices may help decrease component extraction-relatedcomplications.

During humeral stem extraction, partial or completeremoval of cement previously used for the TSA may berequired, and complete removal is particularly important inthe setting of infection. However, removal of the cementmantle may lead to humeral bone loss. Therefore, in theabsence of infection, we do not attempt to remove any morecement than is necessary to properly seat the new implant.

On the glenoid side, removal of cement to achieve viablebleeding glenoid bone is critical. All current reversedesigns require bone ingrowth for durable fixation, in thepatient who required re-revision (Fig. 1), inadequateremoval of cement likely led to component loosening fromfailure of bony ingrowth.

Finally, when presenting patients with the option ofrevision of failed TSA to RSA, the discussion must notethat the benefits of this surgery are more modest than withprimary procedures in improvements in pain relief andfunction. In addition, at least one-third of patients mayencounter a complication. Two patients in this series wereunsatisfied: one was not satisfied with the degree ofimprovement that she achieved and the other developeda postoperative complication and therefore was no better. Inmost patients though, this study showed that revision offailed TSA with an RSA can improve pain, function, andROM.

Conclusion

Failure of TSA can result from multiple etiologies,including infection, aseptic loosening of the compo-nents, and mechanical instability. This study showed thatsignificant improvements in shoulder comfort andfunction can be achieved by revising these failed TSAswith RSAs. During the revision surgery, careful attentionto minimizing bone loss and achieving stable componentfixation can help minimize complications. The compli-cation rate was higher than primary procedures;however, patients were generally very satisfied with theirresults.

Disclaimer

This study received funding from DJO Surgical,a designer and manufacturer of orthopedic surgicalproducts related to the subject of this work.

Dr Mark A. Frankle receives royalties and is a paidconsultant for DJO Surgical, and his affiliated researchfoundation has also received support from DJO Surgical.Jordan P. Brooks received research support from DJOSurgical. The other authors, their immediate families,and any research foundations with which they are affil-iated have not received any financial payments or otherbenefits from any commercial entity related to the

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