Clavicular osteotomy in complicated revision of total shoulder arthroplasty: indications, surgical technique, and outcomes

Abstract

Purpose

Adequate exposure in revision of total shoulder arthroplasty (TSA) is important for optimal prosthesis placement and functional results. A clavicular osteotomy in difficult cases of revision TSA is a useful surgical technique that increases the superior exposure area, provides safer dissection, minimizes damage to the anterior deltoid muscle, improves glenoid access, and allows for superior dislocation of the humeral component. There is a paucity of literature analyzing the clavicular osteotomy during challenging cases of revision TSA. The aims of this study were to describe the application, surgical technique, and outcomes of revision TSA with a clavicular osteotomy.

Methods

This was a retrospective study of consecutive patients who underwent revision TSA with a clavicle osteotomy at a single institution (2004–2016). A curved longitudinal clavicular osteotomy is created parallel to the origin of the anterior deltoid muscle. This allows for lateral reflection of the osteotomy and anterior deltoid muscle to significantly increase superior exposure and reduce damage to remaining deltoid muscle fibres. Osteotomy closure is simple with four or five Nice knot osteosutures. The Constant-Murley score and osteotomy healing were assessed at every follow-up. All complications were reviewed.

Results

Forty patients who had a mean age of 63.8 years (range 37–87) at time of surgery and mean follow-up duration of 34 months (range 12–88) were analyzed. Pre-operative Constant-Murley scores improved significantly from 32 ± 19.0 to 58 ± 15.0 (p < 0.001) at one year and 65 ± 13.1 (p < 0.001) at two years. Primary osteotomy healing and callus formation were evident in 95% of cases by three months. Five patients developed post-operative complications (13%) related to the clavicular osteotomy: three mid-diaphyseal clavicular fractures sustained after trauma (8%), one clavicular stress fracture (3%), and case of one loosening (3%). Three patients (8%) required surgical revision of the osteotomy (two internal fixation and one revision osteosuturing). No neurovascular injuries or scapular fractures were encountered.

Conclusion

A curved longitudinal clavicular osteotomy is beneficial in difficult revision TSA and is another tool in the arsenal of experienced shoulder surgeons who manage these challenging cases. This surgical technique increases glenoid exposure, facilitates superior dislocation of the humeral component, minimizes anterior deltoid damage, and reduces the risk of neurovascular injuries. All clavicular complications occurred within four months prior to osteotomy union, with many sustained due to trauma. However, patients who developed a complication had comparable shoulder function as those without.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4

References

  1. 1.

    Beekman PD, Katusic D, Berghs BM, Karelse A, De Wilde L (2010) One-stage revision for patients with a chronically infected reverse total shoulder replacement. J Bone Joint Surg Br 92:817–822. https://doi.org/10.1302/0301-620X.92B6.23045

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Middernacht B, Van Tongel A, De Wilde L (2014) Reversed revised: what to do when it goes wrong? Acta Orthop Belg 80:314–321

    CAS  PubMed  Google Scholar 

  3. 3.

    Verhofste B, Decock T, Van Tongel A, De Wilde L (2016) Heterotopic ossification after reverse total shoulder arthroplasty. Bone Joint J 98-B:1215–1221. https://doi.org/10.1302/0301-620X.98B9.37761

    CAS  Article  PubMed  Google Scholar 

  4. 4.

    Familiari F, Rojas J, Nedim Doral M, Huri G, McFarland EG (2018) Reverse total shoulder arthroplasty. EFORT Open Rev 3:58–69. https://doi.org/10.1302/2058-5241.3.170044

    Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    King JJ, Dalton SS, Gulotta LV, Wright TW, Schoch BS (2019) How common are acromial and scapular spine fractures after reverse shoulder arthroplasty?: a systematic review. Bone Joint J 101-B:627–634. https://doi.org/10.1302/0301-620X.101B6.BJJ-2018-1187.R1

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Joyce CD, Seidl AJ (2019) Managing acromial fractures: prevention and treatment, both nonoperative and operative. Ann Joint 4:1–1. https://doi.org/10.21037/aoj.2018.12.03

    Article  Google Scholar 

  7. 7.

    Crosby LA, Hamilton A, Twiss T (2011) Scapula fractures after reverse total shoulder arthroplasty: classification and treatment. Clin Orthop Relat Res 469:2544–2549. https://doi.org/10.1007/s11999-011-1881-3

    Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Farshad M, Gerber C (2010) Reverse total shoulder arthroplasty-from the most to the least common complication. Int Orthop 34:1075–1082. https://doi.org/10.1007/s00264-010-1125-2

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Werthel J-D, Schoch BS, van Veen SC, Elhassan BT, An K-N, Cofield RH, Sperling JW (2018) Acromial fractures in reverse shoulder arthroplasty: a clinical and radiographic analysis. J Shoulder Elbow Arthroplast 2. https://doi.org/10.1177/2471549218777628

  10. 10.

    Zumstein MA, Pinedo M, Old J, Boileau P (2011) Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elb Surg 20:146–157. https://doi.org/10.1016/j.jse.2010.08.001

    Article  Google Scholar 

  11. 11.

    Redfern TR, Wallace WA, Beddow FH (1989) Clavicular osteotomy in shoulder arthroplasty. Int Orthop 13:61–63. https://doi.org/10.1007/bf00266725

    CAS  Article  PubMed  Google Scholar 

  12. 12.

    Bateman E, Donald SM (2012) Reconstruction of massive uncontained glenoid defects using a combined autograft-allograft construct with reverse shoulder arthroplasty: preliminary results. J Shoulder Elb Surg 21:925–934. https://doi.org/10.1016/j.jse.2011.07.009

    Article  Google Scholar 

  13. 13.

    Eraly K, Stoffelen D, Vander Sloten J, Jonkers I, Debeer P (2016) A patient-specific guide for optimizing custom-made glenoid implantation in cases of severe glenoid defects: an in vitro study. J Shoulder Elb Surg 25:837–845. https://doi.org/10.1016/j.jse.2015.09.034

    Article  Google Scholar 

  14. 14.

    Boileau P, Watkinson DJ, Hatzidakis AM, Balg F (2005) Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elb Surg 14:147S–161S. https://doi.org/10.1016/j.jse.2004.10.006

    Article  Google Scholar 

  15. 15.

    De Wilde L, Mombert M, Van Petegem P, Verdonk R (2001) Revision of shoulder replacement with a reversed shoulder prosthesis (Delta III): report of five cases. Acta Orthop Belg 67:348–353

    PubMed  Google Scholar 

  16. 16.

    Hansen ML, Routman H (2019) The biomechanics of current reverse shoulder replacement options. Ann Joint 4:17. https://doi.org/10.21037/aoj.2019.01.06

    Article  Google Scholar 

  17. 17.

    Mole D, Favard L (2007) Excentered scapulohumeral osteoarthritis. Rev Chir Orthop Reparatrice Appar Mot 93:37–94. https://doi.org/10.1016/s0035-1040(07)92708-7

    CAS  Article  PubMed  Google Scholar 

  18. 18.

    Wiater BP, Koueiter DM, Maerz T, Moravek JE Jr, Yonan S, Marcantonio DR, Wiater JM (2015) Preoperative deltoid size and fatty infiltration of the deltoid and rotator cuff correlate to outcomes after reverse total shoulder arthroplasty. Clin Orthop Relat Res 473:663–673. https://doi.org/10.1007/s11999-014-4047-2

    Article  PubMed  Google Scholar 

  19. 19.

    De Wilde L, Boileau P, Van der Bracht H (2011) Does reverse shoulder arthroplasty for tumors of the proximal humerus reduce i mpairment? Clin Orthop Relat Res 469:2489–2495. https://doi.org/10.1007/s11999-010-1758-x

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Boehm TD, Wallace WA, Neumann L (2005) Heterotopic ossification after primary shoulder arthroplasty. J Shoulder Elb Surg 14:6–10. https://doi.org/10.1016/j.jse.2004.04.007

    Article  Google Scholar 

  21. 21.

    Constant CR, Murley AH (1987) A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 160–164

  22. 22.

    Gohlke F, Rolf O (2007) Revision of failed fracture hemiarthroplasties to reverse total shoulder prosthesis through the transhumeral approach: method incorporating a pectoralis-major-pedicled bone window. Oper Orthop Traumatol 19:185–208. https://doi.org/10.1007/s00064-007-1202-x

    Article  PubMed  Google Scholar 

  23. 23.

    Van Thiel GS, Halloran JP, Twigg S, Romeo AA, Nicholson GP (2011) The vertical humeral osteotomy for stem removal in revision shoulder arthroplasty: results and technique. J Shoulder Elb Surg 20:1248–1254. https://doi.org/10.1016/j.jse.2010.12.013

    Article  Google Scholar 

  24. 24.

    Boileau P, Alami G, Rumian A, Schwartz DG, Trojani C, Seidl AJ (2017) The doubled-suture Nice knot. Orthopedics 40:e382–e386. https://doi.org/10.3928/01477447-20161202-05

    Article  PubMed  Google Scholar 

  25. 25.

    Levigne C, Boileau P, Favard L, Garaud P, Mole D, Sirveaux F, Walch G (2008) Scapular notching in reverse shoulder arthroplasty. J Shoulder Elb Surg 17:925–935. https://doi.org/10.1016/j.jse.2008.02.010

    Article  Google Scholar 

  26. 26.

    Gutierrez S, Greiwe RM, Frankle MA, Siegal S, Lee WE 3rd (2007) Biomechanical comparison of component position and hardware failure in the reverse shoulder prosthesis. J Shoulder Elb Surg 16:S9–S12. https://doi.org/10.1016/j.jse.2005.11.008

    Article  Google Scholar 

  27. 27.

    Rosenberg N, Neumann L, Modi A, Mersich IJ, Wallace AW (2007) Improvements in survival of the uncemented Nottingham total shoulder prosthesis: a prospective comparative study. BMC Musculoskelet Disord 8:76. https://doi.org/10.1186/1471-2474-8-76

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Rozing PM, Brand R (1998) Rotator cuff repair during shoulder arthroplasty in rheumatoid arthritis. J Arthroplast 13:311–319. https://doi.org/10.1016/s0883-5403(98)90177-2

    CAS  Article  Google Scholar 

  29. 29.

    Pastor MF, Ferle M, Hagenah J, Ellwein A, Wellmann M, Smith T (2019) The stabilization effect of the conjoint tendon in reverse total shoulder arthroplasty. Clin Biomech (Bristol, Avon) 63:179–184. https://doi.org/10.1016/j.clinbiomech.2019.03.009

    Article  Google Scholar 

  30. 30.

    Matsen FA (1994) Practical evaluation and management of the shoulder. Saunders, Philadelphia

    Google Scholar 

  31. 31.

    Yung SW, Lazarus MD, Harryman DT 2nd (1996) Practical guidelines to safe surgery about the subscapularis. J Shoulder Elb Surg 5:467–470. https://doi.org/10.1016/s1058-2746(96)80019-x

    CAS  Article  Google Scholar 

  32. 32.

    Dubrow S, Streit JJ, Muh S, Shishani Y, Gobezie R (2014) Acromial stress fractures: correlation with acromioclavicular osteoarthritis and acromiohumeral distance. Orthopedics 37:e1074–e1079. https://doi.org/10.3928/01477447-20141124-54

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

We would like to acknowledge Lisa E. Ramaut, MD for her skill in creating the beautiful illustrations.

Disclaimer

Lieven De Wilde is a DePuy-Synthes paid consultant, receives royalties from DeltaXtend, Johnson & Johnson for presenting and speaking.

IRB

Commission for Medical Ethics, Ghent University Hospital, Ghent, Belgium (Approval number: B670201834933). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration.

and its later amendments or comparable ethical standards.

Funding

No funding, grants, or financial compensation were received for the creation of this study.

Author information

Affiliations

Authors

Corresponding author

Correspondence to Lieven F. De Wilde.

Ethics declarations

Conflict of interest

Lieven De Wilde is a DePuy-Synthes paid consultant, receives royalties from DeltaXtend, Johnson & Johnson for presenting and speaking.

Ethics board approval

This study received IRB approval prior to the start of this study.

Commission for Medical Ethics, Ghent University Hospital, Ghent, Belgium.

Approval number: B670201834933

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

ESM 1

(DOCX 12 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Verhofste, B.P., Van Tongel, A.C.G., Van Den Broucke, J. et al. Clavicular osteotomy in complicated revision of total shoulder arthroplasty: indications, surgical technique, and outcomes. International Orthopaedics (SICOT) 44, 1341–1352 (2020). https://doi.org/10.1007/s00264-020-04573-2

Download citation

Keywords

  • Total shoulder arthroplasty
  • Revision total shoulder arthroplasty
  • Reverse total shoulder arthroplasty
  • Clavicular osteotomy
  • Constant-Murley score
  • Outcomes
  • Complications