Aims. It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery. Methods. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review was performed to identify clinical data for patients undergoing revision shoulder arthroplasty. Data were extracted from the literature and pooled for analysis. Complication and reoperation rates were analyzed using a meta-analysis of proportion, and continuous variables underwent comparative subgroup analysis. Results. A total of 112 studies (5,379 shoulders) were eligible for inclusion, although complete clinical data was not ubiquitous. Indications for revision included component loosening 20% (601/3,041), instability 19% (577/3,041), rotator cuff failure 17% (528/3,041), and infection 16% (490/3,041). Intraoperative complication and postoperative complication and reoperation rates were 8% (230/2,915), 22% (825/3,843), and 13% (584/3,843) respectively. Intraoperative and postoperative complications included iatrogenic humeral fractures (91/230, 40%) and instability (215/825, 26%). Revision to reverse total shoulder arthroplasty (TSA), rather than revision to anatomical TSA from any index prosthesis, resulted in lower complication rates and superior Constant scores, although there was no difference in American Shoulder and Elbow Surgeons scores. Conclusion. Satisfactory improvement in patient-reported outcome measures are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse TSA. Cite this article: Bone Jt Open 2021;2(8):618–630

Aims. A number of methods have been described to remove a well-fixed humeral implant as part of revision shoulder arthroplasty. These include the use of cortical windows and humeral osteotomies. The router bit extraction technique uses a high-speed router bit to disrupt the bone-implant interface. The implant is then struck in a retrograde fashion with a square-tip impactor and mallet. The purpose of this study was to determine the characteristics and frequency of the different techniques needed for the removal of a well-fixed humeral stem in revision shoulder arthroplasty. Patients and Methods. Between 2010 and 2018, 288 revision shoulder arthroplasty procedures requiring removal of a well-fixed humeral component were carried out at a tertiary referral centre by a single surgeon. The patient demographics, indications for surgery, and method of extraction were collected. Results. Of the 288 revisions, 284 humeral stems (98.6%) were removed using the router bit extraction technique alone. Four humeral stems (1.39%) required an additional cortical window. Humeral osteotomy was not necessary in any procedure. Most of the humeral stems removed (78.8%) were cementless. Of the four humeral stems that required a cortical window, three involved removal of a hemiarthroplasty. Two were cemented and two were cementless. Conclusion. The router bit extraction technique removed a well-fixed humeral component in a very high proportion of patients (98.6%). This method allows surgeons to avoid more invasive approaches involving a cortical window or humeral osteotomy, and their associated complications. Cite this article: Bone Joint J 2019;101-B:1280–1284

Complications such as implant loosening, infection, periprosthetic fracture or instability may lead to revision arthroplasty procedures. There is limited literature comparing single-stage and two-stage revision shoulder arthroplasty. This study aims to compare clinical outcomes and cost benefit between single-stage and two-stage revision procedures. Thirty-one revision procedures (mean age 72+/-7, 15 males and 16 females) performed between 2016 and 2021 were included (27 revision RSA, 2 revision TSA, 2 failed ORIFs). Two-stage procedures were carried out 4-6 weeks apart. Single-stage procedures included debridement, implant removal and washout, followed by re-prep, re-drape and reconstruction with new instrumentations. Clinical parameters including length of stay, VAS, patient satisfaction was recorded preoperatively and at mean 12-months follow up. Cost benefit analysis were performed. Seven revisions were two-stage procedures and 24 were single-stage procedures. There were 5 infections in the two-stage group vs 14 in the single-stage group. We noted two cases of unstable RSA and 8 other causes for single-stage revision. Majority of the revisions were complex procedures requiring significant glenoid and/or humeral allografts and tendon transfers to compensate for soft tissue loss. No custom implants were used in our series. Hospital stay was reduced from 41+/-29 days for 2-stage procedures to 16+/-13 days for single-stage (p<0.05). VAS improved from 9+/-1 to 2+/-4 for two-stage procedures and from 5+/-3 to 1+/-2 for single-stages. The average total cost of hospital and patient was reduced by two-thirds. Patient satisfaction in the single-stage group was 43% which was comparable to the two-stage group. All infections were successfully treated with no recurrence of infection in our cohort of 31 patients. There was no instability postoperatively. 3 patients had postoperative neural symptoms which resolved within 6 months. Single-stage procedures for revision shoulder arthroplasty significantly decrease hospital stay, improve patients’ satisfaction, and reduced surgical costs

Purpose of the study: Revision shoulder arthroplasty is generally considered to be a difficult procedure yielding modest improvement. Material and methods: We report a prospective study of 45 patients, aged 69.8 years (range 49–85 years). Thirty-two patients had a simple humeral prosthesis and thirteen a total prosthesis. A reversed prosthesis was used for all revisions. The reasons for the revisions were classified into five groups: failure of prosthesis implanted for fracture (36%), glenoid problems of a total shoulder arthroplasty (24%), prosthetic instability (18%), failure of a hemiarthroplasty implanted for rotator cuff tear (11%), failure of a hemiarhtroplasty implanted for post-traumatic osteoarthritis (11%). The revision consisted in replacement with a reversed prosthesis. Patients were assessed pre and postoperatively using the Constant score for the clinical assessment and plain x-rays for the radiological assessment. Results: Forty-one patients were reviewed at mean follow-up of 42.1 months (range 24–92). The four other patients died during the first two postoperative years. Subjectively, 73% of patients were satisfied. The Constant score improved from 187.7 to 55.6 on average. The best gain was obtained for the pain and daily activities scores. Discussion: Revision shoulder arthroplasty provides only moderate improvement. Neer called a limited goal surgery. Results published on revision shoulder arthroplasty using a non-constrained prosthesis show that the functional gain is moderate. Revisio with a reversed total prosthesis gives better results because of the lesser impact of the cuff deficiency. The rate of complications after revision is greater than with first intention implantations. Conclusion: Use of a reversed total shoulder prosthesis for revision shoulder arthroplasty provides encouraging results in terms of the mid-term functional outcome

We report our experience of revision shoulder arthroplasty at Wrightington Hospital. Thirty-Nine patients had undergone revision surgery and followed up for a minimum of two years. Patients were scored using the Constant score and the ASES score pre-operatively and post operatively. All patients had X-ray evaluation for loosening and migration. Of the thirty-nine patients, 16 were failed humeral head replacement (HHR) and 16 were failed total shoulder replacement (TSR). All but two of the HHR were revised for glenoid erosion to a TSR, there was an equal proportion of patients with rheumatoid arthritis and osteoarthritis. Of the 16 patients undergoing revision surgery for failed TSR 6 were rheumatoid, 4 had osteoarthritis and 5 had posttraumatic arthritis. The main reasons for revision include glenoid loosening (7) instability (4) and peri-prosthetic fracture (2). The average constant scores post operatively for HHR and TSR were 35.5 (sd+/− 21.1) and 29.1 (sd+/− 12.1) respectively. The average ASES scores for HHR and TSR were 60.5(sd +/ 27.8) and 50.1(sd +/− 22.0) respectively. There was no statistical difference between the two groups in respect to the constant scores (p value 0.18) or ASES scores (p value 0.16). Overall, the pain relief was good post operatively following both HHR and TSR. The mean visual analogue score for pain following HHR was 3.2 and following TSR 3.5. Range of movement, function and strength was poor following both HHR and TSR. HHR fail in a predictable way and can be revised with conversion to a TSR. TSR fail in a variety of ways and there revision surgery is demanding and complex. Both types of revision offer good pain relief but poor function

Aims: The modes of failure of bipolar arthroplasty and outcomes following revision surgery have not been described. Methods: 7 patients (2f, 5m) who previously underwent bipolar arthroplasty were treated with revision surgery. Patient self-assessment was obtained pre- and postoperatively with a satisfaction survey, SF-36, SST, ASES scores, and preoperative/postoperative x-rays. Results: Modes of failure included rotator cuff failure 6/7, superior arch deficiency (4/7) and glenoid erosion (3/7). Revision surgery was performed to reconstruct instability, resurface eroded bone and repair available rotator cuff tissue. Anterior superior arch deficiencies were all revised to a semiconstrained reverse prosthesis. Other patients (3/7) were revised to unconstrained TSA. In this group, additionally soft tissue reconstructions were performed. ASES scores improved from 33 preoperatively to 55.5 postoperatively (P < 0.05). The mean SF 36 domains for PHC improved from 33.9 to 38.4 (P < 0.05). The mean VAS score for pain improved from 5.9 to 2.9 (p< 0.05). Mean active elevation increased from 60° to 78°. External rotation improved from 45° to 60°. 80% reported excellent/good, 20% reported satisfactory and none reported unsatisfactory outcome. Complications included 2 patients with recurrent instability. Conclusion: Revision shoulder arthroplasty following failure of a bipolar prosthesis requires reconstructive options of a semiconstrained prosthesis and conventional TSA with complex soft tissue reconstructions. Soft tissue problems such as superior arch deficiency and rotator cuff tears are the most common mode of failure. Patients may be improved from pain but limited improvement of shoulder function is to be expected

Aim: Revision of shoulder replacements in patients with irreparably damaged rotator cuffs and disintegrated coracoacromial arch are typical indications for the Delta-III-prosthesis. The aim of this study was to evaluate the results of one-stage exchange procedures with and without reconstruction of the glenoid (n =21) and compare them with the preoperative status. Methods: Eighty-four patients who had undergone one-stage prosthesis exchange were included in the prospective analysis. Pain and functional results were recorded using our own specifically compiled follow-up questionnaire and evaluated according to the Constant/Murley Shoulder Score. The indications for exchange surgery were impingement and pain due to cranial dislocation of the prosthesis head in fifty-four cases, cranio-ventral dislocation in nineteen, periprosthetic infection in six, aseptic loosening in four, and postoperative ankylosis of the shoulder with heterotopic ossifications in one case. Results: The mean age of the patients was 68.1 years (49–82). Prior to our exchange surgery sixteen patients had already undergone one and five patients two exchange procedures with implantation of a standard prosthesis. Thirty-eight patients had had several non-arthroplasty revision operations. After exchange for a Delta prosthesis eighty-three of the patients were pain-free or experienced tolerable pain only when the joint was subjected to a longer period of strain. The Constant/Murley Shoulder Score improved from a mean preoperative value of 27 to 58 points within 36–48 months. The overall complication rate was 13.1%. Bony reconstruction of the glenoid did not appear to have any significant influence on the outcome of the exchange procedure. Conclusion: Patients’ satisfaction with the result of one-stage exchange of shoulder replacements using inverse implants is high due to the reliable and fast alleviation of pain, the satisfactory function of the joint and the fact that the need for nursing care can be avoided. The almost maximum functional result is already achieved after three months and with continued physiotherapy further gradual improvement is possible up to one year after surgery due to an increase in muscle strength. The outcome may be impaired by impingement at the lower glenoid rim leading to erosion and possible loosening of the component

If a modular convertible total shoulder system is used as a primary implant for an anatomical total shoulder arthroplasty, failure of the prosthesis or the rotator cuff can be addressed by converting it to a reverse shoulder arthroplasty (RSA), with retention of the humeral stem and glenoid baseplate. This has the potential to reduce morbidity and improve the results.

In a retrospective study of 14 patients (15 shoulders) with a mean age of 70 years (47 to 83) we reviewed the clinical and radiological outcome of converting an anatomical shoulder arthroplasty (ASA) to a RSA using a convertible prosthetic system (SMR system, Lima, San Daniele, Italy).

The mean operating time was 64 minutes (45 to 75). All humeral stems and glenoid baseplates were found to be well-fixed and could be retained. There were no intra-operative or early post-operative complications and no post-operative infection.

The mean follow-up was 43 months (21 to 83), by which time the mean visual analogue scale for pain had decreased from 8 pre-operatively to 1, the mean American Shoulder and Elbow Surgeons Score from 12 to 76, the mean Oxford shoulder score from 3 to 39, the mean Western Ontario Osteoarthritis of the Shoulder Score from 1618 to 418 and the mean Subjective shoulder value from 15 to 61.

On radiological review, one patient had a lucency around the humeral stem, two had stress shielding. There were no fatigue fractures of the acromion but four cases of grade 1 scapular notching.

The use of a convertible prosthetic system to revise a failed ASA reduces morbidity and minimises the rate of complications. The mid-term clinical and radiological results of this technique are promising.

Cite this article: Bone Joint J 2015;97-B:1662–7.

Aims

To report the rate of early revision (within two years) after shoulder arthroplasty and identify any patient, disease or prosthesis factors that may be associated with these early failures.

The diagnosis of infection following shoulder arthroplasty is notoriously difficult. The prevalence of prosthetic shoulder infection after arthroplasty ranges from 3.9 – 15.4% and the most common infective organism is Cutibacterium acnes. Current preoperative diagnostic tests fail to provide a reliable means of diagnosis including WBC, ESR, CRP and joint aspiration. Fluoroscopic-guided percutaneous synovial biopsy (PSB) has previously been reported in the context of a pilot study and demonstrated promising results. The purpose of this study was to determine the diagnostic accuracy of percutaneous synovial biopsy compared with open culture results (gold standard). This was a multicenter prospective cohort study involving four sites and 98 patients who underwent revision shoulder arthroplasty. The cohort was 60% female with a mean age was 65 years (range 36-83 years). Enrollment occurred between June 2014 and November 2021. Pre-operative fluoroscopy-guided synovial biopsies were carried out by musculoskeletal radiologists prior to revision surgery. A minimum of five synovial capsular tissue biopsies were obtained from five separate regions in the shoulder. Revision shoulder arthroplasty was performed by fellowship-trained shoulder surgeons. Intraoperative tissue samples were taken from five regions of the joint capsule during revision surgery. Of 98 patients who underwent revision surgery, 71 patients underwent both the synovial biopsy and open biopsy at time of revision surgery. Nineteen percent had positive infection based on PSB, and 22% had confirmed culture positive infections based on intra-operative tissue sampling. The diagnostic accuracy of PSB compared with open biopsy results were as follows: sensitivity 0.37 (95%CI 0.13-0.61), specificity 0.81 (95%CI 0.7-0.91), positive predictive value 0.37 (95%CI 0.13 – 0.61), negative predictive value 0.81 (95%CI 0.70-0.91), positive likelihood ratio 1.98 and negative likelihood ratio 0.77. A patient with a positive pre-operative PSB undergoing revision surgery had an 37% probability of having true positive infection. A patient with a negative pre-operative PSB has an 81% chance of being infection-free. PSB appears to be of value mainly in ruling out the presence of peri-prosthetic infection. However, poor likelihood ratios suggest that other ancillary tests are required in the pre-operative workup of the potentially infected patient

Aim. Diagnosis of periprosthetic shoulder infections (PSI) is difficult as they are mostly caused by low-virulent bacteria and patients do not show typical infection signs, such as elevated blood markers, wound leakage, or red and swollen skin. Ultrasound-guided biopsies for culture may therefore be an alternative for mini-open biopsies as less costly and invasive method. The aim of this study was to determine the diagnostic value and reliability of ultrasound-guided biopsies for cultures alone and in combination polymerase chain reaction (PCR), and/or synovial markers for preoperative diagnosis of PSI in patients undergoing revision shoulder surgery. Method. A prospective explorative diagnostic cohort study was performed including patients undergoing revision shoulder replacement surgery. A shoulder puncture was taken preoperatively before incision to collect synovial fluid for interleukin-6 (IL-6), calprotectin, WBC, polymorphonuclear cells determination. Prior to revision surgery, six ultrasound-guided synovial tissue biopsies were collected for culture and two additional for PCR analysis. Six routine care tissue biopsies were taken during revision surgery and served as reference standard. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV; primary outcome measure), and accuracy were calculated for ultrasound-guided biopsies, and synovial markers, and combinations of these. Results. Fifty-five patients were included. In 24 patients, routine tissue cultures were positive for infection. Cultures from ultrasound-guided biopsies diagnosed an infection in 7 of these patients, yielding a sensitivity, specificity, PPV, NPV, and accuracy of 29.2%, 93.5%, 77.8%, 63.0%, and 65.6%, respectively. Ultrasound-guided biopsies in combination with synovial WBC increased the NPV to 76.7% and accuracy to 73.8%. When synovial WBC and calprotectin were combined with ultrasound-guided biopsies, it resulted in a better diagnostic value: sensitivity 69.2%, specificity 80.0%, PPV 69.2%, NPV 80.0%, and accuracy 75.8%. Ultrasound-guided biopsies in combination with calprotectin and ESR yielded a sensitivity of 50.0%, specificity of 93.8%, PPV of 80.0%, NPV of 78.9%, and accuracy of 79.2%. Synovial fluid was obtained in 42 patients. Sensitivities of WBC, PMN, IL-6, and calprotectin were between 25.0% and 35.7%, specificities between 89.5% and 95.0%, PPVs between 60.0% and 83.3%, NPVs between 65.4% and 69.4%, and accuracies between 64.5% and 70.6%. Conclusions. In this prospective study we showed that ultrasound-guided biopsies for cultures alone and in combination with PCR and/or synovial markers are not reliable enough to use in clinical practice for the preoperative diagnosis of low grade PSI

Removal of a well-fixed humeral component during revision shoulder arthroplasty presents a challenging problem. If the humeral component cannot be extracted simply from above, an alternate approach must be taken that may include compromising bone architecture to remove the implant. Two potential solutions to this problem that allow removal of the well-fixed prosthesis are making a humeral window or creating a longitudinal split in the humerus. A retrospective review was performed at the Mayo Clinic to determine the complications associated with performing humeral windows and longitudinal splits during the course of revision shoulder arthroplasty. This study included 427 patients from 1994–2010 at Mayo Clinic undergoing revision shoulder arthroplasty. From this cohort, those who required a humeral window or a longitudinal split to assist removal of a well-fixed humeral component were identified. Twenty-seven patients had a humeral window produced to remove a well-fixed humeral component. Six intra-operative fractures were reported from this group: 5 were in the greater tuberosity and 1 was in the distal humeral shaft. At the latest radiographic follow-up, 24 of 27 windows healed, 2 patients had limited inconclusive radiographic follow-up (1 and 2 months), and 1 did not have follow-up at our institution. Twenty-four patients underwent longitudinal osteotomy to extract a well-fixed humeral component. From this group, 1 had intra-operative fracture in the greater tuberosity. At most recent radiographic follow-up, 22 of 24 longitudinal splits healed, 1 had short follow-up (1 ½ months) with demonstrated signs of healing, and 1 did not have follow-up at our institution. In both groups, there were no cases of window malunion and no components have developed clinical loosening. Data from this study suggests humeral windows and longitudinal splits can assist with controlled removal of well-fixed humeral components with a high rate of union and a low rate of intra-operative and post-operative sequelae

Abstract. Shoulder replacements have evolved and current 4th generation implants allow intraoperative flexibility to perform anatomic, reverse, trauma, and revision shoulder arthroplasty. Despite high success rates with shoulder arthroplasty, complication rates high as 10–15% have been reported and progressive glenoid loosening remains a concern. Objectives. To report medium term outcomes following 4th generation VAIOS® shoulder replacement. Methods. We retrospectively analysed prospectively collected data following VAIOS® shoulder arthroplasty performed by the senior author between 2014–2020. This included anatomical (TSR), reverse(rTSR), revision and trauma shoulder replacements. The primary outcome was implant survival (Kaplan-Meier analysis). Secondary outcomes were Oxford Shoulder Scores (OSS), radiological outcomes and complications. Results. 172 patients met our inclusion criteria with 114 rTSR, 38 anatomical TSR, and 20 hemiarthroplasty. Reverse TSR- 55 primary, 31 revision, 28 for trauma. Primary rTSR- 0 revisions, average 3.35-year follow-up. Revision rTSR-1 revision (4.17%), average 3.52-year follow-up. Trauma rTSR- 1 revision (3.57%), average 4.56-year follow-up OSS: Average OSS improved from 15.39 to 33.8 (Primary rTSR) and from 15.11 to 29.1 (Revision rTSR). Trauma rTSR-Average post-operative OSS was 31.4 Anatomical TSR38 patients underwent primary anatomical TSR, 8 were revisions following hemiarthroplasty. In 16/38 patients, glenoid bone loss was addressed by bone grafting before implantation of the metal back glenoid component. Mean age at time of surgery was 68.3 years (53 – 81 years). Mean follow-up was 34 months (12 – 62 months). The average Oxford shoulder score improved from 14 (7–30) to 30 (9–48). There were 3 revisions (7.8%); two following subscapularis failure requiring revision conversion to reverse shoulder replacement and one for glenoid graft failure. Conclusions. The medium-term results of the VAIOS® system suggest much lower revision rates across multiple configurations of the system than previously reported, as well as a low incidence of scapular notching. This system allows conversion to rTSR during primary and revision surgery

Introduction and Objective. The aim of this study was to evaluate whether CT-based pre-operative planning, integrated with intra-operative navigation could improve glenoid baseplate fixation and positioning by increasing screw length, reducing number of screws required to obtain fixation and increasing the use of augmented baseplate to gain the desired positioning. Reverse total shoulder arthroplasty (RSA) successfully restores shoulder function in different conditions. Glenoid baseplate fixation and positioning seem to be the most important factors influencing RSA survival. When scapular anatomy is distorted (primitive or secondary), optimal baseplate positioning and secure screw purchase can be challenging. Materials and Methods. Twenty patients who underwent navigated RSA (oct 2018 and feb 2019) were compared retrospectively with twenty patients operated on with a conventional technique. All the procedures were performed by the same surgeon, using the same implant in cases of eccentric osteoarthritis or complete cuff tear. Exclusion criteria were: other diagnosis as proximal humeral fractures, post-traumatic OA previously treated operatively with hardware retention, revision shoulder arthroplasty. Results. The NAV procedure required mean 11 (range 7–16) minutes more to performed than the conventional procedure. Mean screw length was significantly longer in the navigation group (35.5+4.4 mm vs 29.9+3.6 mm; p . .001). Significant higher rate of optimal fixation using 2 screws only (17 vs 3 cases, p . .019) and higher rate of augmented baseplate usage (13 vs 4 cases, p . .009) was also present in the navigation group. Signficant difference there is all in function outcomes, DASH score is 15.7 vs 29.4 and constant scale 78.1 vs 69.8. Conclusions. The glenoid component positioning in RSA is crucial to prevent failure, loosening and biomechanical mismatch, coverage by the baseplate of the glenoid surface, version, inclination and offset are all essential for implant survival. This study showed how useful 3D CT-based planning helps in identifying the best position of the metaglena and the usefulness of receiving directly in the operation theater real-time feedback on the change in position. This study shows promising results, suggesting that improved baseplate and screw positioning and fixation is possible when computer-assisted implantation is used in RSA comparing to a conventional procedure

The number of shoulder arthroplasty procedures performed in the United States continues to rise. Currently, the number of procedures performed per year ranges from 55,000–80,000 and is expected to increase more than 300% in the coming years. Periprosthetic joint infection (PJI) is one of the most serious complications associated with arthroplasty surgery, leading to poor outcomes, increased cost, and technically difficult revision surgery. The incidence of infection following primary shoulder arthroplasty has been reported between 0.7% and 4%, representing 2.9–4.6% of all complications. Prosthetic shoulder joint infections are unlike prosthetic joint infections of the hip and knee. Shoulder PJIs are primarily indolent in nature and difficult to diagnose using traditional methods that have been shown to be accurate for periprosthetic infections of the hip and knee. The majority of infected revision shoulder arthroplasties are associated with growth of Propionibacterium acnes (P. Acnes). This slow-growing, anaerobic organism requires longer than normal incubation times for culture (7–21 days), and typically demonstrates a subtle, non-specific clinical presentation that can make the presence of infection difficult to identify. In the reported literature, P. Acnes accounts for about 70% of cases with positive cultures associated with revision for treatment of a painful shoulder arthroplasty and due to the bacteria's slow growing nature and virulence profile, the rate of infection following shoulder arthroplasty may often be underestimated. A more recent and promising tool for evaluation of periprosthetic infection has been analysis of synovial fluid. Synovial fluid biomarkers have been identified as part of the innate response to pathogens, and include pro-inflammatory cytokines and anti-microbial peptides, and marker levels have shown promise for improved diagnostic efficacy in hip and knee PJI. Currently, no highly predictive clinical test for diagnosis of PJI in the shoulder exists, however, several of these synovial biomarkers have recently been analyzed for their diagnostic capacity in the setting of periprosthetic shoulder infection. Synovial fluid cytokine analysis shows the potential to improve diagnosis of infection in revision shoulder arthroplasty. This information can help to guide decision-making in the management of PJI of the shoulder, including the decision to perform a single- vs. two-stage revision surgery, and the need for post-operative antibiotics following an unexpected positive culture result after revision surgery. However, there are still challenges to broader use of these synovial biomarkers. Synovial α-defensin (Synovsure, CD Diagnostic) is the only marker currently available as a commercial test, and no point-of-care test is currently available for any of the biomarkers to allow for intraoperative decision-making. While a preoperative synovial aspirate is possible to send for α-defensin analysis currently, with results back in approximately 24 hours, dry fluid aspirations are frequent in the shoulder because of the predominance of indolent pathogens and may limit utility of the test. In summary, indolent infection associated with P. acnes is a common cause for the painful total shoulder arthroplasty. Pre-operative diagnosis of infection is difficult as a result of the poor diagnostic accuracy of traditional methods of testing. Synovial biomarker testing may ultimately improve our ability to more accurately diagnosis and treat prosthetic shoulder joint infections

Aim: To reduce the amount of blood wastage in our unit. Method: In 72 patients, the number of blood units cross-matched and the haemoglobin/haematocrit fall were audited for primary total shoulder replacement (n=44), primary hemiarthroplasty (n=21), and revision shoulder replacement (n=7) over twelve months (January 2008 to December 2008). The amount of crossmatched blood was compared to the amount of blood transfused, pre-operative haemoglobin and fall in haemoglobin/haematocrit. Results: 23 of 44 primary total shoulder replacements and 5 of 21 hemiarthroplasties were crossmatched 55 units preoperatively. 4 of the 7 revision arthroplasties were crossmatched 7 units preoperatively. No units were transfused. 4 patients were later transfused 2 units each for symptomatic low haemoglobin at day 3–5 postoperatively from postoperatively crossmatched blood. No correlation existed between preoperative haemoglobin and number of units blood ordered. A haemoglobin reduction of ~2.5 g/dl was seen for both primary and revision surgery. There was significant correlation between low preoperative haemoglobin and need for transfusion (p< 0.05). Nearly all patients in whom blood was crossmatched rather than group and saved, belonged to one consultant. No patients had an adverse outcome due to a lack of immediately available cross-matched blood. Conclusion: A large amount of blood was crossmatched and no units used in primary and revision shoulder replacement surgery. We recommend group and save only in primary shoulder arthroplasty and crossmatch of 2 units for revision shoulder surgery. Providing pre-operative haemoglobin is > 11.5 g/dl, group and save is safe even for revision shoulder arthroplasty. Wastage of blood could be reduced to zero in our unit. We recommend regular audit as a tool to ensure compliance with guidelines, and for clinical governance purposes ensuring guidelines remain best practice

Peri-prosthetic joint infection (PJI) can be both a diagnostic and therapeutic challenge in shoulder arthroplasty, due to the indolent nature of the common infecting organisms. Proprionobacterium acnes (P. acnes) is the most common pathogen cultured in revision shoulder arthroplasty. It is a slow growing, anaerobic organism – requires longer incubation period (7–21 days). Coagulase-negative Staphylococcus species (CNSS) is also a common organism responsible for PJI. Established diagnostic tests for hip and knee PJI are often negative in the shoulder despite post-operative growth of intra-operative cultures. Pre-operative synovial aspiration often low volume due to indolent pathogens and successful aspiration is often reported to be 50% or less with Dilisio et al, JBJS 2014: reporting 16.7% sensitivity, 100% specificity. Variable culture length for P. acnes culture protocols are reported from 7–28 days with most groups recommending 14 days. From our research, we demonstrated time to culture growth was significantly shorter in probable true positive culture group (median, 5 vs. 9 days, p=0.002). Frozen section analysis may help intra-operative decision-making (one- vs. two-stage reimplantation) yet the reported sensitivity and specificity in shoulder arthroplasty is far less than in hip and knee arthroplasty. Synovial fluid biomarkers have been identified as part of the innate response to pathogens include pro-inflammatory cytokines and antimicrobial peptides. In a series of prospective studies of revision shoulder arthroplasty, synovial fluid analysis reported by Frangiamore et al, JBJS 2015: IL-6, Frangiamore et al, JSES 2015: α-defensin (Synovasure. TM. ), Frangiamore et al, AAOS 2015: Broader cytokine analysis it was demonstrated that these markers are much more predictive of infection than synovial fluid cultures, frozen section or serum markers

Introduction The aim of this study was to investigate the potential of impaction bone grafting for the restoration of glenoid bone stock in revision shoulder arthroplasty. Methods There was significant osteolysis around the glenoid component in four rheumatoid patients who underwent revision shoulder arthroplasty using this technique. The criteria was a contained or containable defect. Femoral head allograft and iliac crest autograft harvested at the time of revision were used. Pre and post-operative radiographs, tomograms and fluoroscopic views aided in bone-stock analysis. Images were analysed for osteolysis, graft survival, incorporation and component loosening. Patients were followed using Constant-Murley scoring pre-operatively, and at a minimum of 12 months. The average patient age was 56 years (range 42 to 76), with three females and one male patient. Results Glenoid component survivorship pre-revision averaged 9.5 years (range 8 to 12). The pre-operative Constant-Murley average was 11 (range 4 to 20) versus 64 post-operatively, a significant improvement over an average follow-up of 19.5 months (range 12 to 40). Radiological assessment demonstrated all grafts had incorporated with minimal subsidence and no radio-lucency at the graft-bone interface. Two of the glenoid components demonstrated static lucency at the component-graft interface, but no component movement on serial x-rays. In both patients the significant improvement in functional was maintained. Conclusions To our knowledge this technique has not been described in glenoid component revision. It successfully provided bone for glenoid component insertion. This would not have been possible using standard techniques. The early results for this technique are encouraging and justify the continued application and follow-up of glenoid impaction grafting

Aims

The aim of this study is to evaluate the change in incidence rate of shoulder arthroplasty, indications, and surgeon volume trends associated with these procedures between January 2003 and April 2021 in the province of Nova Scotia, Canada.

Aims

Proximal humeral fractures are the third most common fracture among the elderly. Complications associated with fixation include screw perforation, varus collapse, and avascular necrosis of the humeral head. To address these challenges, various augmentation techniques to increase medial column support have been developed. There are currently no recent studies that definitively establish the superiority of augmented fixation over non-augmented implants in the surgical treatment of proximal humeral fractures. The aim of this systematic review and meta-analysis was to compare the outcomes of patients who underwent locking-plate fixation with cement augmentation or bone-graft augmentation versus those who underwent locking-plate fixation without augmentation for proximal humeral fractures.