Imagine you're a professional under the age of
60, active, perhaps still years away from thinking
about retirement, and you've suffered a serious
proximal humeral fracture that's a break right
near the shoulder joint. A really nasty injury.
Exactly. And you've had surgery to fix it, maybe
what's called open reduction internal fixation,
using plates and screws, or perhaps even a hemiarthroplasty,
replacing just the ball part of the joint. Standard
approaches, often. But critically, that surgery
has failed. You're left with chronic, debilitating
pain, maybe severe stiffness, and your shoulder
just isn't working properly. It's not working
the way you need it to. A devastating situation.
So what do you do then? What are your options
when those initial standard treatments haven't
just not worked, but have arguably made things
even more complicated? Well. It's one of the
most challenging scenarios we actually face in
orthopedic surgery. It must be. It truly is a
difficult position for both the patient and,
well, for the surgeon too, unlike The more common
situations say treating degenerative arthritis
in an older person who's perhaps less active.
These are often younger, more demanding patients.
They've already endured significant trauma. And
then a subsequent surgical attempt that hasn't
succeeded. So they've been through a lot already.
A great deal. And their anatomy is often distorted.
There's frequently significant bone loss. And
the surrounding soft tissues, particularly the
crucial rotator cuff and deltoid muscles. they
might be quite compromised. So this isn't just
a simple revision surgery. It's often a complex
salvage procedure, and it's happening in a biological
environment that's much less forgiving. And today
on The Deep Dive, we're going to immerse ourselves
in exactly that complex scenario. We're doing
a deep dive into the treatment options for patients
younger than 60 who face these failed initial
surgeries, either that open reduction internal
fixation, which we'll call ORIF or a hemi arthroplasty
for these proximal humeral fractures. And specifically,
our focus today is on a procedure that's become
increasingly common for difficult shoulder problems
generally. But it carries quite unique considerations
in this younger sort of salvage context. Which
procedure is that? That's the reverse total shoulder
arthroplasty, or RTSA. Ah, yes, RTSA. As you
touched upon, this is where the traditional mechanics
are essentially flipped. The ball part of the
joint is fixed to the shoulder blade, the glenoid,
and the socket part is attached to the arm bone,
the humerus. OK. And this design, it can leverage
the deltoid muscle to provide function, effectively
bypassing a damaged or deficient rotator cuff.
Which is often the problem after these failed
fracture treatments. Precisely. It's very common
in this group. Exactly. So while RTSA has, well,
it's really revolutionized treatment for things
like rotator cuff terepathy in older populations.
Absolutely. Applying it as a salvage procedure
in younger patients after failed fracture fixation
or heme arthroplasty. Yeah. That's a different
proposition altogether, isn't it? It really is.
It's a much higher stakes game, you could say.
And the long term results, they haven't always
been clear. which is why we're focusing today
on this really critical long -term study. It
was published in the Journal of Shoulder and
Elbow Surgery, and this paper specifically examines
the outcomes of using the salvage RTSA in this
precise patient group under 60 failed previous
surgery for a proximal humeral fracture. And
you were involved in this research, weren't you?
That's right. Yes, this research represents a
significant effort to track these really challenging
cases over quite an extended period. So tell
us about the patients. Well, the study cohort,
it consisted of 30 patients who met these specific
criteria. Under the age of 60 at the time, they
had the salvage RTSA procedure. OK. Their mean
age was 52. And importantly, they had a substantial
mean follow up period of 11 years. that range
from eight right up to 18 years. 11 years mean
follow -up is significant. It is crucial because
the true durability and the potential long -term
issues of any joint replacement, but especially
in younger, more active patients, well, they
only really become apparent over many years,
don't they? Absolutely. You need that long view.
You do. So this study aimed to provide exactly
that necessary long -term perspective. And this
perspective is so vital because, as the paper's
background really lays out, whilst many proximal
humeral fractures can actually be managed non
-operatively... That's true for the majority.
...the severe or displaced ones often need surgery.
But when that ORE fails... Perhaps the screws
back out, or the bony bits the rotator cuff attaches
to, the tuberosities, they just don't heal. Or
when a hemiarthroplasty fails, maybe due to the
socket wearing away, the glenoid erosion, or
just persistent pain from those tuberosities
not healing. Well, you're left with a shoulder
that's often far worse than if the fracture hadn't
been operated on in the first place. That can
happen. You see pain, severe stiffness, dysfunction,
and often significant loss of bone or deformity.
That's the reality, isn't it? It is. It's a grim
landscape. And RTSA is considered here because,
frankly, the other options are even less predictable.
What sort of other options? Well, traditional
things like trying to revise the ORIF, do it
again, that's often just not feasible because
of the bone loss. Or if you try it, it carries
equally high failure rates in this setting. Revision
hemi arthroplasty, replacing the hemi again.
That's often contraindicated if there's significant
glenoid wear. Or if the rotator cuff is clearly
non -functional because those two porosities
haven't healed or are gone. So the options are
really limited. Very limited. So RTSA emerges
as this potential solution. It uses the deltoid
muscle as the primary motor for the shoulder,
even though the underlying anatomy is highly
compromised by the previous surgery and the original
injury itself. So the key question this study
really sought to answer was, what are the long
-term consequences and indeed the benefits of
applying RTSA in this specific highly challenging
younger group? And the central tension, the sort
of headline finding of the paper, it's quite
stark, isn't it? It presents a real paradox for
clinicians and patients who are considering this
path. It is very much so. The study's primary
conclusion is, well, it's unequivocal. Salvage
RTSA in this younger cohort is associated with
a very high complication rate. You simply cannot
look at this data and ignore that reality. There
is. And it's an important but. The equally important
part of the conclusion, the part that offers
maybe a glimmer of hope in a very difficult situation,
is that despite this high rate of complications,
the procedure can lead to worthwhile and durable
long -term improvement in pain and function if,
and it's a big if, if those complications could
be successfully managed without having to remove
the implant entirely. Okay, let's really unpack
that because that's a statement that requires
some careful thought, high risk, but potentially
high reward if the implant stays in. Let's start
with the reward side, the potential upside. What
did the study find? In terms of the functional
improvements, the subjective improvements for
those patients where the RTSA was actually retained.
OK, so for the 24 patients who still had their
RTSA implant in place at the final follow -up,
and remember, this is a mean of 11 years after
the surgery. Right, long term. The functional
gains were substantial, really quite substantial.
Looking at objective measures like the constant
score, which is a widely accepted functional
assessment for the shoulder. Yeah, the mean relative
constant score improved dramatically. It went
from a very low preoperative baseline of just
25 % up to 58%. Wow, a constant score of 25%.
That suggests a shoulder that's barely functional,
doesn't it? Causing significant disability. Absolutely.
It's very low. So jumping to 58%, that's a really
clinically significant improvement. It doesn't
necessarily mean, I suppose, a return to a completely
normal pain -free shoulder, like before the injury?
No, generally not. But it suggests a move away
from severe disability towards a level that might
allow for many activities of daily living, perhaps
even some light work. That's exactly right. That
magnitude of improvement really indicates just
how severely compromised these patients were
before the RTSA. And what about how the patients
themselves felt, the subjective view? Yes, the
subjective shoulder value, the SSV. This captures
the patient's own perception of their shoulders
function, usually as a percentage compared to
a normal shoulder. That also saw mirroring. improvement.
It rose from a mean of only 20 % preoperatively
up to 56%. So they felt a marked improvement
in how useful their shoulder actually was to
them day to day. They did. A very significant
perceived improvement. And range of motion. That's
often terribly limited after failed fracture
fixation, isn't it? Especially lifting the arm
up. Yes, and significant improvements were seen
here too. Active anterior elevation, so lifting
the arm forward, increased from a mean of just
45 degrees preoperatively. Very restricted. Very.
Up to 106 degrees at follow -up. Okay. That's
over the horizontal. It is. An active abduction
lifting the arm out to the side went from 42
degrees up to 99 degrees. Again, functionally
important gains. Crucial gains, especially getting
over that 90 degree mark for elevation and abduction
that's so important for reaching and performing
many basic tasks. And pain. Pain scores also
saw significant reductions and perhaps surprisingly
even strength improved notably. Really? Strength
improved too. Yes. The study highlights that
all of these functional and subjective improvements
were statistically highly significant. We're
talking p values less than 0 .0001. So very unlikely
to be due to chance. Extremely unlikely. Less
than a 1 in 1000 chance that these observed improvements
were just random variation. That level of statistical
significance really underscores the robustness
of the finding, at least for those patients with
retained implants. And you mentioned the follow
-up was long -term, a mean of 11 years. Did the
paper comment on whether these functional gains
held up over that extended period? Did they last?
Yes. And that's a really key point about the
durability, isn't it? The study specifically
looked at the outcomes over time, and it confirmed
that the functional gains achieved at earlier
time points, they were largely maintained. even
beyond 10 years postoperatively for the patients
whose implants remain in place. That's encouraging.
It is. It suggests that when salvage RTSA works
in this population, it could provide a lasting
improvement, which is crucial given the younger
age of these patients. They need something that
lasts. OK. So the potential upside is clear.
Significant, durable functional recovery possible
for a severely damaged shoulder. But now, now
we must confront the other side of the quail.
The side that makes this procedure such a complex
clinical decision, that very high complication
rate you mentioned earlier. Yes. What were the
numbers the study reported there? Well, this
is where the challenge really lies. The study
found that 18 out of the 30 patients in the cohort.
That's a substantial 60 percent. 60 percent.
Experienced one or more postoperative complications
following their salvage RTSA. 60 percent. Wow.
More than half of the patients undergoing this
specific procedure in the study experienced a
problem afterwards. And how did these complications
then translate into needing more surgery or,
you know, worst case scenario, failure of the
implant itself? Well, the rate of revision surgery
was also high. The paper reported that 11 open
revisions were either performed or planned to
be performed in 10 of the patients. 10 out of
30. Yes, representing 36 % of the original cohort.
And these revisions, they often occurred relatively
late. The average time for the index salvage
RTSA to the revision procedure was 71 months.
71 months. That's nearly six years later. Almost
six years on average. So over a third of patients
needed another significant operation to try and
deal with issues arising from the RTSA itself.
And what about the ultimate failure rate where
the implant just couldn't be salvaged and had
to come out? The study defined failure quite
stringently actually. It included explantation
of the RTSA that's removing the implant entirely.
Right. conversion back to a hemiarthroplasty,
which is a rare and often problematic step, or
insertion of a cement spacer, which is typically
a temporary measure, often used to manage deep
infection. So by that definition, six patients
out of the 30, that's 20 % of the cohort, were
classified as failures. One in five. One in five.
This is a significant number. It represents one
in five patients where the salvage RTSA just
did not provide a lasting solution and the implant
ultimately had to be abandoned. So let me just
recap that. for a younger patient under 60. With
a failed fracture fixation or heme arthroplasty,
considering a salvage RTSA, they face roughly
a 60 % chance of some kind of complication. Correct.
A 36 % chance of needing another revision surgery
down the line, possibly years later. Yes. And
a 20 % chance that the whole procedure will ultimately
fail, requiring removal of the implant. Those
are the figures from this study, yes. Those are
really sobering statistics. They absolutely highlight
the high -risk nature of this specific procedure
in this. specific patient group. Now, given these
risks, the paper also looked at factors that
might predict who is more likely to have these
complications or perhaps less successful outcomes.
What were the key associations they identified?
Yes, this is critical, isn't it? For informing
patient selection and, indeed, surgical planning,
the study found a strong association between
the number of previous surgical procedures on
that shoulder and the likelihood of postoperative
complications. That makes sense. It does. Patients
with more prior surgeries were significantly
more likely to experience issues. The p -value
was 0 .005. So, highly significant statistically.
Yes. It really underscores the cumulative damage
that happens with each operation. You get scar
tissue, altered anatomy, potential compromise
of blood supply, the soft tissues. It just creates
a much more hostile environment for further implant
surgery. Right. The more times you've been in
there, the harder it gets to achieve a good result
the next time. What else significantly increased
the risk? A documented history of infection prior
to the salvage RTSA. That was another major predictor
of complications, and this was striking. All
seven patients in the study who had a history
of infection experienced post -operative complications
after the RTSA. All of them. Every single one.
The p -value there was .048. Just a powerful
reminder that eradicating infection, especially
around orthopedic implants, is incredibly difficult,
and a history of infection significantly escalates
the risk of it recurring or other related complications
happening with the next surgery. So if infection
was part of the reason the initial surgery failed
in the first place, carrying that history into
the RTSA setting, it almost guarantees future
problems based on this data. It carries a very,
very high risk, yes. The nature of the previous
failed surgery also seemed to matter. How so?
Well, salvage RTSA performed for a failed heme
arthroplasty was associated with a higher overall
complication rate compared to salvage RTSA performed
after a failed ORF. OK. Specifically. 19 out
of the 23 patients who had a failed hemiarthroplasty
went on to have complications after their RTSA.
That p -value was 0 .014. That's interesting.
Why might that be? Well, it's an interesting
finding. It might suggest that the reasons why
the hemiarthroplasty failed in this particular
cohort, perhaps severe tuberosity resorption
or significant glenoid erosion, were on the socket
side. Right. Did these create a more complex
biomechanical and soft tissue challenge for a
subsequent RTSA? compared to the issues you typically
see after a failed ORF, like screw cut out or
simple non -union. That resonates clinically.
Dealing with poor bone stock on both sides of
the joint? Potentially significant soft tissue
deficiency after a failed hemi? That does sound
much more challenging than revising a failed
plate and screw construct, generally speaking.
It often is, yes. Did the study also look at
implant -specific factors? Did the type of RTSA
used matter? Yes, they did. They found an association
between the use of older generation implants
specifically. They mentioned the Delta III RTSA
design and a higher complication rate. OK. 17
out of the 20 patients who received that specific
Delta implant experienced complications. The
p -value was 0 .018. Now, the authors rightly
acknowledge the limitations of a retrospective
study, and obviously surgical techniques evolve
over time. Of course. But this finding does hint
that advancements in implant design and perhaps
the surgical protocols associated with newer
implants might well influence the outcomes. That's
a crucial point for clinicians, isn't it? Being
aware that the results reported might be influenced
by the specific generation of the prosthesis
used and the techniques that were contemporary
at that time. The paper also noted a particularly
high infection rate within the study cohort itself
after the RTSA. Yes, the overall rate of infection
post -salvage RTSA was noted as 27 % across the
whole cohort. 27 %? That seems very high compared
to primary RTSA for other reasons like arthritis.
It is high. And it further highlights the compromised
state of these revision shoulders. Hmm. Consistent
with the other findings, factors significantly
associated with this post -operative infection
included, again, the number of previous surgeries
and obviously a prior documented infection. The
study did note, however, that their management
protocol for dealing with infection before performing
the RTSA, typically a staged approach using antibiotic
-laden cement spacers, that appeared effective
in controlling the infection before the RTSA
was put in, which aligns with other research
in the field. But controlling the infection beforehand
doesn't eliminate the risk of it recurring or
other complications cropping up once a large
foreign body, the implant, is placed back into
that environment. So even doing everything right,
using staged procedures with spacers to clear
a pre -existing infection, it doesn't wipe the
slate clean. There's still a high risk of complications,
including infection, after the RTSA in these
complex cases. That's what this data suggests,
yes. Yes. The risk remains elevated. OK. Beyond
just complications, were there specific factors
linked to inferior functional outcomes? So even
if the implant remained in place, did some patients
do less well functionally? Yes. The type of prior
failed surgery also seemed to impact the level
of functional recovery achieved. The study found
that salvage RTSA performed for a failed secondary
hemiarthroplasty. What does secondary mean here?
It means the patient had already had at least
two previous surgeries before the RTSA was even
considered. So perhaps ORIF then HEMI, or HEMI
then revision HEMI, before the RTSA. Okay, multiple
prior surgeries. Exactly. And in those cases,
the salvage RTSA resulted in significantly inferior
active abduction, lifting the arm out sideways
compared to salvage RTSA for a failed ORIF. How
much inferior? The mean abduction was just 77
degrees after failed secondary HEMI versus 116
degrees after failed ORIF. That difference was
statistically significant. P equals marrow point
zero two three. Okay, so multiple previous surgeries
And then, specifically, a failed hemiarthroplasty
before the RTSA seems to result in significantly
less ability to lift the arm out to the side
compared to someone who maybe just had a single
failed aura half as their only prior surgery.
That's a finding, yes. That reinforces the idea,
doesn't it, that the cumulative negative effect
of prior interventions really impacts the final
functional result you can expect. Absolutely.
And furthermore, salvage RTSA performed after
that failed secondary hemiarthroplasty also yielded
significantly inferior mean active abduction
compared to RTSA following a failed primary hemiarthroplasty.
So worse than just one failed hemi. Yes. 77 degrees
versus 107 degrees. P value 0 .049. So again,
it points to the compounding difficulty introduced
by multiple previous procedures, particularly
when a failed hemiarthroplasty is part of that
patient's history. And what about external rotation?
The ability to turn the arm outwards, that's
notoriously difficult to recover after these
proximal humeral fractures, isn't it? Especially
if those tuberosities, the rotator cuff attachments,
don't heal properly. Yes, and this study confirmed
that observation. Even with an RTSA place. They
found significantly better active external rotation
when the greater tuberosity had healed properly
prior to the RTSA or was successfully incorporated
into the reconstruction. Okay. Compared to when
it was resorbed, essentially dissolved away or
had been resected during previous surgeries.
What was the difference? A mean of 21 degrees
of external rotation if the tuberosity was healed
versus a very limited three degrees if it was
resorbed or resected. That p -value is .025.
Only three degrees. That's very little outward
rotation. Very little. And it highlights that
while RTSA is often described as bypassing the
need for a functional rotator cuff for elevation,
the state of those tuberosities still plays a
crucial role in trying to restore external rotation,
which is often poor in these failed fracture
cases, precisely because tuberosity healing is
so problematic. And did the paper link that poor
tuberosity status to the failed hemi group? Yes.
It specifically notes that in seven out of the
eight patients who had failed secondary hemiarthroplasty,
the tuberosities were either resorbed or resected.
And that strongly contributes to their poor abduction
rotation results compared to the other groups
in the study. That lobbage is really important,
isn't it? It's not just about the implant mechanics.
The residual anatomy and the biological situation
resulting from the previous failures significantly
influenced the outcome, even for a complex procedure
like RTSA. Let's briefly touch on implant survival
itself and maybe what they saw on imaging on
the x -rays. Sure. The study provided survival
estimates using Kaplan -Meier analysis, which
is a standard statistical method to estimate
the probability of an event like revision or
failure happening over time. Okay. They reported
an overall survival rate of the RTSA without
needing a revision of 69 % at 10 years. 69 %
free of revision at 10 years. Correct. Now, if
you define survival more strictly using failure
as the endpoint, remember that was explantation,
conversion, or spacer insertion. Right, the really
bad outcomes. Then the survival rate was higher,
79 % at 10 years. OK, so roughly four out of
five implants were still in place at 10 years,
even if some had needed revisions along the way.
That's right. Now, whilst these rates are certainly
lower than often reported for primary RTSA performed
for, say, degenerative conditions in older patients.
Sure. They do provide a realistic benchmark for
this specific, highly challenging salvage indication
in a younger population. That's important context.
And what did the x -rays show over the long term?
Any common findings? Yes, a very common finding
on the radiographic side was inferior scapular
notching. Ah, yes, notching. This is where the
metal component on the arm bone, the humeral
component, can rub against the lower edge of
the shoulder blade socket, the glenoid. It was
present in a very high proportion, actually 92
percent of patients with retained implants in
this study. 92 percent. That's almost everyone.
Almost everyone showed some degree of it. However,
and this was quite a key finding, the study found
that the presence or even the severity of the
scapular notching was not statistically associated
with inferior functional or subjective outcomes
in this specific cohort over the observed period.
That's surprising because notching is often cited
as a Potential concern for RTSA longevity and
outcomes, isn't it? It is often discussed, yes.
Yeah. But in this difficult salvage setting in
these younger patients, this paper suggests it
wasn't the primary driver of poor results, at
least not within the time frame studied. Interesting.
Anything else on the x -rays? They also noted
radiographic lucent lines around the humeral
component, the part in the arm bone, in about
25 % of patients. And what do those lines mean?
Well, lucent lines can sometimes indicate loosening
of the implant or stress at the bone implant
interface, and these lines were significantly
associated with using that older Delta III implant
model, and also with the need for subsequent
revision surgery. So that further supports the
idea that implant design and achieving stable
fixation at the bone implant interface really
does play a role in the long -term outcome. Right.
Now before we wrap up, it's always important,
as the authors themselves noted, to consider
the limitations of any study. What were the key
caveats they highlighted for this research? Well,
they pointed out quite rightly that it was a
retrospective study. That means they looked back
at data that was collected over time, which can
introduce certain biases compared to a prospective
study where you follow patients forward under
a very strict protocol. There was also inevitably
in a long -term study like this a percentage
of patients who were lost to follow up about
11 % in this case. And sadly another 11 % died
during the study period, which is expected given
the time frame but can affect the overall power
and completeness of the analysis. They also acknowledged
the relatively limited sample size 30 patients
in total. which meant they had limited statistical
power for doing very detailed subgroup analyses.
And finally, they noted that there might be inherent
differences between the patient groups who initially
had ORIF versus those who initially had hemiarthroplasty,
perhaps related to the original injury severity
or bone quality that weren't fully captured or
adjusted for in the analysis. Those are standard
but important limitations to bear in mind when
we interpret the findings of a study like this
one. Taking all of this information together
now, the significant potential for functional
improvement on the one hand, contrasted with
that very high risk of complications and failure
on the other hand, particularly in the context
of previous surgeries and prior infection. How
does this paper really frame the overall clinical
decision making for this challenging group of
younger patients? Well, I think the paper strongly
reinforces that salvage RTSA in this population
is absolutely not a straightforward procedure
with any guaranteed success. It is clearly associated
with substantial risks. And those risks are particularly
influenced by the patient's prior surgical history
and any history of infection. However, the buddy
again. The study also presents quite compelling
evidence that for those patients where the implant
can be retained, it does offer a level of pain
relief and functional recovery that may simply
not be achievable with the other available salvage
options. If there are any other options left.
Precisely. It underscores the fact that in these
severely compromised younger shoulders, all the
options are difficult. None are without significant
drawbacks. RTSA, despite that high complication
rate, emerges as a procedure that can work. But
it demands really careful patient selection and
a preparedness, both from the surgeon and the
patient, for managing the potential issues that
are quite likely to arise. It really sounds like
it's often a procedure of last resort, then,
chosen perhaps out of necessity when other options
have failed or aren't viable, accepting that
high likelihood of future problems in exchange
for the potential for significant, albeit maybe
imperfect, improvement in a shoulder that is
otherwise debilitatingly painful and dysfunctional.
I think that's a fair summary. It forces a very
difficult conversation, doesn't it, about managing
expectations and accepting a significant level
of risk. Exactly. The improvements shown in the
study are real, and they are meaningful for patients
starting from such a low baseline with severely
failed shoulders. But they come at a cost, frequently
requiring further surgical intervention down
the line to manage complications, and with that
non -trivial chance around 1 in 5 of ultimate
failure requiring implant removal. Well, this
deep dive has certainly illuminated the complexities
and the critical data surrounding salvage RTSA
in this very challenging patient group. If this
discussion sparked some insights for you, or
perhaps clarified this difficult clinical scenario,
please do consider leaving us a rating and perhaps
sharing this deep dive with a colleague who might
find it valuable. Yes, we appreciate you joining
us for this in -depth look at a complex problem.
And finally, a thought to perhaps mull over,
drawing directly from the factors identified
in this paper. we've discussed. Given that the
study found things like a higher number of previous
surgeries and prior infection were so strongly
linked to complications, and that factors like
tuberosity healing and the specific type of failed
prior surgery impacted the functional outcomes,
how much of the ultimate success of salvage RTSA
in these challenging younger patients is actually
determined not just by the technical execution
of the RTSA surgery itself. Right. but perhaps
even more so by the surgeon's ability to meticulously
select the right patients in the first place,
to rigorously optimize their condition preoperatively,
especially managing any hint of infection, and
then possess the experience and the infrastructure
to effectively anticipate and manage the almost
inevitable complications when they do arise.
It suggests the outcome might be less about the
implant or the index procedure in isolation,
and much more about the comprehensive long -term
management of a complex previously operated and
often compromised shoulder.