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

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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.

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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.

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

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Authors and Affiliations

  1. Department of Orthopaedic Surgery and Traumatology, Ghent University Hospital, 10 C. Heymanslaan, Entrance 75, Route 740, 9000, Ghent, East Flanders, Belgium

    Bram P. Verhofste, Alexander C. G. Van Tongel, Julien Van Den Broucke, Laurent B. Willemot & Lieven F. De Wilde

Authors
  1. Bram P. Verhofste
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  2. Alexander C. G. Van Tongel
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  3. Julien Van Den Broucke
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  4. Laurent B. Willemot
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  5. Lieven F. De Wilde
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Correspondence to Lieven F. De Wilde.

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Conflict of interest

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

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

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

Approval number: B670201834933

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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

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