Outcomes following resection of a total shoulder prosthesis after a mean follow-up of 10 years: A case series

Akshar V. Patel; Benjamin D. Gross; Kenneth H. Levy; Bradford O. Parsons; Evan L. Flatow; Paul J. Cagle

doi:10.1016/j.jorep.2023.100273

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Research Article

2024

:3;

100273

doi:

10.1016/j.jorep.2023.100273

Outcomes following resection of a total shoulder prosthesis after a mean follow-up of 10 years: A case series

Akshar V. Patel, Benjamin D. Gross, Kenneth H. Levy, Bradford O. Parsons, Evan L. Flatow, Paul J. Cagle

Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York City, NY, USA

∗Corresponding author: Kenneth H. Levy. klevy000@citymail.cuny.edu

Received: 2023-8-1, Accepted: 2023-11-19, Published: 2023-11-23

The Authors

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Resection arthroplasty is an option for patients with multiple previous failed arthroplasties due to periprosthetic joint infection.

We report on 3 patients (4 shoulders) who were resected and followed for a decade on average. These patients had postoperative ASES scores in alignment with their preoperative baseline and a mean forward elevation of 155°. All patients reported being satisfied with their shoulder function at final follow-up.

Resection arthroplasty is an option for patients with risk factors for failed shoulder arthroplasty. While outcomes are moderate, they can be satisfactory if patients are counseled beforehand about realistic expectations.

Keywords

Infection

Prosthesis

Irrigation

Arthroplasty

Debridement

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1 Introduction

In contemporary practice, various approaches to shoulder replacement surgery have been developed to address patient-specific indications, including anatomic total shoulder arthroplasty (aTSA), reverse total shoulder arthroplasty (rTSA), and hemiarthroplasty.¹ Despite continued advancements in these techniques, there still exists notable risks of complications and subsequent need for revision surgery.²^,³ Common reasons for revision shoulder arthroplasty include glenoid or humeral component loosening, instability, pain, rotator cuff deficiency, or periprosthetic joint infection (PJI), with management being dependent on the specific cause of reoperation.⁴^,⁵

The management of PJI is particularly challenging due to the potential severity and lack of a clear consensus on the most optimal treatment.⁶ Current operative options include debridement with prosthesis retention,⁷ single-stage exchange,⁸ two-stage exchange with antibiotic spacers,⁹ arthrodesis,¹⁰ and resection arthroplasty.¹¹ In cases of chronic infection with soft tissue deficits, or elderly patients with increased comorbidities, resection arthroplasty may be indicated to provide immediate pain relief and to eradicate infection with a single, less exhausting procedure.¹² Conservative treatment is preferred in instances of acute infection to preserve functionality¹³; however, there is a high risk of persistent infection when the prosthesis is left in situ, which may eventually require resection arthroplasty as a last resort salvage procedure.¹⁴^,¹⁵ Indications for resection arthroplasty may also include others causes of primary arthroplasty failure, especially following rTSA due to significant bone loss making options for reconstruction limited.¹⁶

Currently there is a paucity of data available on resection arthroplasty, particularly for indications other than infection. Existing literature has reported variable rates of infection eradication, shoulder function, and performance on patient-reported outcomes measures (PROMs), with few studies reporting baseline values for comparison.¹²^,¹⁴^,¹⁵^,^17–21 Rispoli et al.’s series of 18 patients provides the longest mean follow-up available at 8.3 years.¹¹ With limited other studies reporting long-term data, it is difficult for surgeons to establish evidence-based expectations of outcomes to accurately counsel patients. In the present study we describe the indications and postoperative outcomes of a series of patients requiring resection arthroplasty at our institution, with the longest follow-up to date. We hypothesized patients to retain reasonable shoulder functionality with satisfactory improvements in pain.

2 Description of cases

2.1

2.1 Patient 1 (R and L shoulders)

The patient, a 57-year-old gentleman (at presentation) with a medical history of hypertension, type 2 diabetes, hyperlipidemia, and obesity, initially presented in June 2005 with persistent right and left shoulder pain that did not improve with conservative management and physical therapy. After further evaluation, he was diagnosed with left-sided cuff tear arthropathy and right-sided cuff deficient arthritis. In July 2005, the patient underwent uncomplicated LEFT reverse total shoulder arthroplasty. Several months later, in October 2005, the patient underwent a similar uncomplicated procedure on the right shoulder. In late August 2006, he developed a fever persisting for two weeks, and the source of infection was identified as the RIGHT shoulder prosthesis. Subsequently, on September 12th, 2006, the patient underwent surgery to remove the hardware, perform irrigation and debridement, and implant an antibiotic spacer along with a RIGHT humeral head replacement. One week following this procedure, he underwent further irrigation and debridement of the RIGHT shoulder. In late November 2006, the patient presented again with an infected LEFT reverse shoulder arthroplasty. On November 22nd, 2006, he underwent LEFT complicated hardware removal, irrigation and debridement, and the placement of an antibiotic cement spacer. On November 30th, he underwent LEFT irrigation and debridement, removal of antibiotic beads and RIGHT aspiration of the right shoulder, which appeared fluctuant and erythematous while in the operating room. On June 4th, 2007 he underwent additional deep irrigation and debridement, with application of antibiotic beads due to abscess of the RIGHT glenohumeral joint. On June 12th, 2007, he underwent RIGHT shoulder irrigation and debridement with removal of antibiotic beads, and subsequent placement of drains (Table 1). At final follow-up 13 years following resection, range of motion bilaterally was the following: forward elevation (FE) was 100°, external rotation was 10°, and internal rotation was not recorded (Table 2). Postoperative ASES score was 63 and VAS pain score was 2, both bilaterally (Table 3).

Table 1 Preoperative details at time of each procedure.

	Patient	Date of Procedure	Age (years)	Preoperative Diagnosis	Operation
Initial Operation	Patient 1L	July 2005	57	Cuff tear	Left rTSA
	Patient 1R	Oct 2005	57	Cuff deficient	Right rTSA
	Patient 2	Dec 1998	60	4-pt fracture of left proximal humerus	Left HHR
	Patient 3	1995	51	Humerus Fracture	Right HHR
1st Removal Encounter	Patient 1L	Nov 2006	58	Infected left rTSA	Deep, complicated hardware removal-irrigation and debridement-placement of antibiotic cement humeral head replacement spacer
	Patient 1R	Sep 2006	58	Infected right rTSA	Right shoulder hardware removal (deep and complicated)-irrigation and debridement-implantation of antibiotic cement spacer and humeral head replacement-Further irrigation and debridement 1 week later
	Patient 2	Sep 2015	77	Loose left proximal humeral replacement with cuff failure	Left Hardware removal-reverse TSA
	Patient 3	Aug 2006	62	Failed humeral head replacement	Hardware removal-irrigation and debridement-antibiotic cement spacer and humeral head replacement arthroplasty
2nd Removal Encounter	Patient 1L	N/A	N/A	N/A	N/A
	Patient 1R	June 2007	59	Infection (Abscess)	Deep irrigation and debridement-application of antibiotic beads
	Patient 2	Mar 2019	81	Humerus loose and Pain	Harwdware removal (reverse TSR)-removal of antibiotic spacer beads-debridement
	Patient 3	Nov 2006	62	Infection and Continued pain	Hardware removal-Removal of spacer-Arthrotomy-revision rTSA
3rd Removal Encounter	Patient 1L	N/A	N/A	N/A	N/A
	Patient 1R	June 2007	59	Infection	Right shoulder irrigation-Debridement with hardware removal
	Patient 2	N/A	N/A	N/A	N/A
	Patient 3	Nov 2006	62	Infection, status post revision rTSA	Removal of hardware-irrigation and debridement-placement of antibiotic spacer

Table 2 Pre- and post-operative range of motion throughout follow-up.

	Patient	Date of Visit	Forward Elevation (degrees)	External Rotation (degrees)	Internal Rotation (level)
Preoperative Visit	Patient 1L	June 2005	120	45	L3
	Patient 1R	June 205	90	N/A	N/A
	Patient 2	Oct 2001	N/A	N/A	N/A
	Patient 3	June 1995	170	60	T7
Initial Postoperative Visit	Patient 1L	Aug 2005	160	20	L4
	Patient 1R	Aug 2005	110	20	Glut
	Patient 2	Feb 2015	130	50	N/A
	Patient 3	Feb 2006	150	60	L2
1st Post-Explant Visit	Patient 1L	N/A	N/A	N/A	N/A
	Patient 1R	N/A	N/A	N/A	N/A
	Patient 2	Oct 2018	120	40	N/A
	Patient 3	N/A	N/A	N/A	N/A
2nd Post-Explant Visit	Patient 1L	Nov 2019	100	10	N/A
	Patient 1R	Nov 2019	100	10	N/A
	Patient 2	Mar 2021	180	45	N/A
	Patient 3	Jul 2015	130	10	N/A

Table 3 Postoperative patient reported outcome measures.

	Patient	Date of Visit	ASES score	Pain Score
Earliest recorded measures	Patient 1L	Dec 2008	70	0
	Patient 1R	Dec 2008	68	0
	Patient 2	Dec 2002	65	10
	Patient 3	Sep 2007	75	2
Latest records measures	Patient 1L	Apr 2014	63	2
	Patient 1R	Apr 2014	63	2
	Patient 2	Jan 2014	52	8
	Patient 3	July 2015	73	6

2.2

2.2 Patient 2

The patient, a 60-year-old female (at time of presentation) with a history of hypertension, hyperlipidemia, hepatitis C, and atrial fibrillation, underwent a LEFT hemiarthroplasty in 1998 for a proximal humerus fracture. In October 2001, she presented with a fracture in the mid diaphyseal region of the LEFT humerus (distal to the tip of the stem of a previous humeral hemiarthroplasty [HHX]) and a distal radius fracture following a fall. While conservative management was initially considered for the humerus fracture, the patient elected surgical treatment. Open reduction internal fixation and iliac crest bone grafting were performed. In January 2014, the patient reported persistent pain and limited LEFT shoulder motion. It was believed this was due to a loose LEFT proximal humeral replacement and rotator cuff failure, therefore it was recommended that she undergo a reverse shoulder arthroplasty. On September 29, 2015, the patient underwent LEFT hardware removal of HHX, brachial plexus exploration, axillary nerve neurolysis, and reverse total shoulder replacement arthroplasty. On March 26, 2019, the patient underwent hardware removal, antibiotic spacer bead placement, and debridement due to a loose humerus component and clear fluid in the joint (Table 1). At final follow-up 3 years following resection, range of motion bilaterally was the following: forward elevation (FE) was 180°, external rotation was 45°, and internal rotation was not recorded (Table 2). Postoperative ASES score was 52 and VAS pain score was 8 (Table 3).

2.3

2.3 Patient 3

The patient, a 51-year-old male (at time of presentation) with a history of obesity, esophageal reflux, and major depressive-affective disorder, underwent RIGHT humeral head replacement following a humerus fracture in 1995. On August 1st, 2006, due to the failure of the initial humeral head replacement, the patient underwent hardware removal, irrigation, debridement, and antibiotic cement spacer placement. However, on October 24th, 2006, the patient presented with continued pain, infection indicators (elevated WBC, ESR, CRP), and multiple dislocations in the RIGHT shoulder. As a result, the patient underwent hardware removal, incision and drainage, and placement of an antibiotic spacer. On November 28th, 2006 the patient underwent a final revision RIGHT reverse total shoulder replacement. The procedure was complex, involving the assistance of a hand specialist, and this patient was ultimately discharged on postoperative day 2 (Table 1). At final follow-up 10 years following resection, range of motion bilaterally was the following: forward elevation (FE) was 130°, external rotation was 10°, and internal rotation was not recorded (Table 2). Postoperative ASES score was 73 and VAS pain score was 6 (Table 3).

3 Discussion

The objective of this study is to contribute to the existing literature surrounding patients who had their shoulder prostheses removed. Previous studies have highlighted surgical indications and risk factors for resection, and our findings are in accordance.⁸^,¹⁷^,²¹ We aim to discuss the function of our patients a decade after surgery.

Range of motion is of principal concern in any patient with a shoulder pathology. In our cohort, the mean forward elevation was 155°, external rotation was 10° in 3/4 patients and 45° in the last patient, and internal rotation was not recorded. The excellent forward elevation following a shoulder resection provides patients with opportunities for moderate shoulder function in the right setting. In our study, there was no significant difference in preoperative and postoperative ASES scores (p = 0.72). Considering that mean ASES scores were 69.5 preoperatively on average and 62.8 postoperatively, this suggests that shoulder function was not harmed following resection. Patients were able to return to their preoperative baseline values after the resection arthroplasty, and a decline in shoulder function was avoided even a decade after surgery.

Resection arthroplasty is a last-resort option when patients may not be candidates for further surgical interventions.¹⁷ Previous studies have documented that risk factors for adverse outcomes following arthroplasty include prior periprosthetic joint infections and obesity.⁷^,¹⁷^,¹⁸ Our patients had a history of both of these risk factors, and with multiple failed arthroplasties, resection was deemed an option to maintain shoulder function and avoid future complications. By managing patient expectations before resection, we were able to achieve patient satisfaction in all four cases. While the prosthesis was explanted, patients went on to achieve their preoperative shoulder function and were ultimately satisfied with the level of care received. Thus, resection arthroplasty is an option for patients receptive to tempered expectations, and those who are also at high-risk for subsequent complications following another shoulder arthroplasty.

4 Conclusion

In patients with failed shoulder arthroplasty, resection arthroplasty is a viable treatment option, particularly in patients with recurrent infection of their prosthesis. Surgeons should be aware of the varying indications for resection arthroplasty and their projected outcomes at long-term follow-up. Prior to undergoing resection arthroplasty, patients should be counseled on the risks of range of motion deficits and reduced patient-reported outcomes, so that realistic expectations may be set.

Declaration of interest statement

The authors, their immediate families, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of this article.

Conflict of interest

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Patient consent

The patients and/or their families were informed that data from the research would be submitted for publication, and gave their consent.

Institutional ethical committee approval

This study was approved by our institution’s ethical committee review board (IRB-17-00684-CR002).

Author contributions

All authors contributed to (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be submitted.

Declaration of competing interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Bradford O. Parsons reports a relationship with Arthrex Inc that includes: funding grants. Evan L. Flatow reports a relationship with Innomed Inc that includes: consulting or advisory. Evan L. Flatow reports a relationship with Zimmer Inc that includes: consulting or advisory. Paul J. Cagle reports a relationship with Stryker that includes: consulting or advisory. Paul J. Cagle reports a relationship with Johnson & Johnson Services Inc that includes: consulting or advisory.

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