Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Salvage Reverse Shoulder replacement for Humeral Fractures in Younger Patients

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Salvage Reverse Shoulder replacement for Humeral Fractures in Younger Patients · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

• 0:00
  Imagine you're a professional under the age of
• 0:02
  60, active, perhaps still years away from thinking
• 0:06
  about retirement, and you've suffered a serious
• 0:09
  proximal humeral fracture that's a break right
• 0:11
  near the shoulder joint. A really nasty injury.
• 0:13
  Exactly. And you've had surgery to fix it, maybe
• 0:16
  what's called open reduction internal fixation,
• 0:19
  using plates and screws, or perhaps even a hemiarthroplasty,
• 0:23
  replacing just the ball part of the joint. Standard
• 0:26
  approaches, often. But critically, that surgery
• 0:30
  has failed. You're left with chronic, debilitating
• 0:33
  pain, maybe severe stiffness, and your shoulder
• 0:36
  just isn't working properly. It's not working
• 0:38
  the way you need it to. A devastating situation.
• 0:40
  So what do you do then? What are your options
• 0:43
  when those initial standard treatments haven't
• 0:45
  just not worked, but have arguably made things
• 0:47
  even more complicated? Well. It's one of the
• 0:50
  most challenging scenarios we actually face in
• 0:52
  orthopedic surgery. It must be. It truly is a
• 0:54
  difficult position for both the patient and,
• 0:57
  well, for the surgeon too, unlike The more common
• 1:00
  situations say treating degenerative arthritis
• 1:03
  in an older person who's perhaps less active.
• 1:06
  These are often younger, more demanding patients.
• 1:08
  They've already endured significant trauma. And
• 1:11
  then a subsequent surgical attempt that hasn't
• 1:13
  succeeded. So they've been through a lot already.
• 1:15
  A great deal. And their anatomy is often distorted.
• 1:19
  There's frequently significant bone loss. And
• 1:22
  the surrounding soft tissues, particularly the
• 1:24
  crucial rotator cuff and deltoid muscles. they
• 1:27
  might be quite compromised. So this isn't just
• 1:31
  a simple revision surgery. It's often a complex
• 1:33
  salvage procedure, and it's happening in a biological
• 1:36
  environment that's much less forgiving. And today
• 1:38
  on The Deep Dive, we're going to immerse ourselves
• 1:40
  in exactly that complex scenario. We're doing
• 1:43
  a deep dive into the treatment options for patients
• 1:46
  younger than 60 who face these failed initial
• 1:49
  surgeries, either that open reduction internal
• 1:52
  fixation, which we'll call ORIF or a hemi arthroplasty
• 1:57
  for these proximal humeral fractures. And specifically,
• 2:00
  our focus today is on a procedure that's become
• 2:02
  increasingly common for difficult shoulder problems
• 2:05
  generally. But it carries quite unique considerations
• 2:09
  in this younger sort of salvage context. Which
• 2:12
  procedure is that? That's the reverse total shoulder
• 2:15
  arthroplasty, or RTSA. Ah, yes, RTSA. As you
• 2:18
  touched upon, this is where the traditional mechanics
• 2:21
  are essentially flipped. The ball part of the
• 2:23
  joint is fixed to the shoulder blade, the glenoid,
• 2:26
  and the socket part is attached to the arm bone,
• 2:29
  the humerus. OK. And this design, it can leverage
• 2:33
  the deltoid muscle to provide function, effectively
• 2:36
  bypassing a damaged or deficient rotator cuff.
• 2:39
  Which is often the problem after these failed
• 2:41
  fracture treatments. Precisely. It's very common
• 2:43
  in this group. Exactly. So while RTSA has, well,
• 2:47
  it's really revolutionized treatment for things
• 2:49
  like rotator cuff terepathy in older populations.
• 2:52
  Absolutely. Applying it as a salvage procedure
• 2:54
  in younger patients after failed fracture fixation
• 2:56
  or heme arthroplasty. Yeah. That's a different
• 3:00
  proposition altogether, isn't it? It really is.
• 3:01
  It's a much higher stakes game, you could say.
• 3:04
  And the long term results, they haven't always
• 3:06
  been clear. which is why we're focusing today
• 3:08
  on this really critical long -term study. It
• 3:11
  was published in the Journal of Shoulder and
• 3:13
  Elbow Surgery, and this paper specifically examines
• 3:16
  the outcomes of using the salvage RTSA in this
• 3:20
  precise patient group under 60 failed previous
• 3:23
  surgery for a proximal humeral fracture. And
• 3:25
  you were involved in this research, weren't you?
• 3:27
  That's right. Yes, this research represents a
• 3:29
  significant effort to track these really challenging
• 3:32
  cases over quite an extended period. So tell
• 3:35
  us about the patients. Well, the study cohort,
• 3:37
  it consisted of 30 patients who met these specific
• 3:40
  criteria. Under the age of 60 at the time, they
• 3:43
  had the salvage RTSA procedure. OK. Their mean
• 3:46
  age was 52. And importantly, they had a substantial
• 3:50
  mean follow up period of 11 years. that range
• 3:53
  from eight right up to 18 years. 11 years mean
• 3:56
  follow -up is significant. It is crucial because
• 3:59
  the true durability and the potential long -term
• 4:02
  issues of any joint replacement, but especially
• 4:04
  in younger, more active patients, well, they
• 4:07
  only really become apparent over many years,
• 4:09
  don't they? Absolutely. You need that long view.
• 4:10
  You do. So this study aimed to provide exactly
• 4:13
  that necessary long -term perspective. And this
• 4:15
  perspective is so vital because, as the paper's
• 4:18
  background really lays out, whilst many proximal
• 4:21
  humeral fractures can actually be managed non
• 4:23
  -operatively... That's true for the majority.
• 4:25
  ...the severe or displaced ones often need surgery.
• 4:28
  But when that ORE fails... Perhaps the screws
• 4:31
  back out, or the bony bits the rotator cuff attaches
• 4:35
  to, the tuberosities, they just don't heal. Or
• 4:39
  when a hemiarthroplasty fails, maybe due to the
• 4:42
  socket wearing away, the glenoid erosion, or
• 4:44
  just persistent pain from those tuberosities
• 4:46
  not healing. Well, you're left with a shoulder
• 4:49
  that's often far worse than if the fracture hadn't
• 4:52
  been operated on in the first place. That can
• 4:55
  happen. You see pain, severe stiffness, dysfunction,
• 4:59
  and often significant loss of bone or deformity.
• 5:02
  That's the reality, isn't it? It is. It's a grim
• 5:04
  landscape. And RTSA is considered here because,
• 5:07
  frankly, the other options are even less predictable.
• 5:09
  What sort of other options? Well, traditional
• 5:12
  things like trying to revise the ORIF, do it
• 5:14
  again, that's often just not feasible because
• 5:16
  of the bone loss. Or if you try it, it carries
• 5:19
  equally high failure rates in this setting. Revision
• 5:22
  hemi arthroplasty, replacing the hemi again.
• 5:24
  That's often contraindicated if there's significant
• 5:27
  glenoid wear. Or if the rotator cuff is clearly
• 5:30
  non -functional because those two porosities
• 5:32
  haven't healed or are gone. So the options are
• 5:35
  really limited. Very limited. So RTSA emerges
• 5:37
  as this potential solution. It uses the deltoid
• 5:40
  muscle as the primary motor for the shoulder,
• 5:43
  even though the underlying anatomy is highly
• 5:45
  compromised by the previous surgery and the original
• 5:48
  injury itself. So the key question this study
• 5:51
  really sought to answer was, what are the long
• 5:54
  -term consequences and indeed the benefits of
• 5:57
  applying RTSA in this specific highly challenging
• 6:00
  younger group? And the central tension, the sort
• 6:03
  of headline finding of the paper, it's quite
• 6:05
  stark, isn't it? It presents a real paradox for
• 6:08
  clinicians and patients who are considering this
• 6:10
  path. It is very much so. The study's primary
• 6:12
  conclusion is, well, it's unequivocal. Salvage
• 6:16
  RTSA in this younger cohort is associated with
• 6:18
  a very high complication rate. You simply cannot
• 6:20
  look at this data and ignore that reality. There
• 6:23
  is. And it's an important but. The equally important
• 6:27
  part of the conclusion, the part that offers
• 6:30
  maybe a glimmer of hope in a very difficult situation,
• 6:34
  is that despite this high rate of complications,
• 6:38
  the procedure can lead to worthwhile and durable
• 6:41
  long -term improvement in pain and function if,
• 6:44
  and it's a big if, if those complications could
• 6:46
  be successfully managed without having to remove
• 6:49
  the implant entirely. Okay, let's really unpack
• 6:51
  that because that's a statement that requires
• 6:53
  some careful thought, high risk, but potentially
• 6:56
  high reward if the implant stays in. Let's start
• 6:59
  with the reward side, the potential upside. What
• 7:02
  did the study find? In terms of the functional
• 7:04
  improvements, the subjective improvements for
• 7:06
  those patients where the RTSA was actually retained.
• 7:09
  OK, so for the 24 patients who still had their
• 7:12
  RTSA implant in place at the final follow -up,
• 7:14
  and remember, this is a mean of 11 years after
• 7:16
  the surgery. Right, long term. The functional
• 7:18
  gains were substantial, really quite substantial.
• 7:20
  Looking at objective measures like the constant
• 7:22
  score, which is a widely accepted functional
• 7:25
  assessment for the shoulder. Yeah, the mean relative
• 7:27
  constant score improved dramatically. It went
• 7:30
  from a very low preoperative baseline of just
• 7:32
  25 % up to 58%. Wow, a constant score of 25%.
• 7:38
  That suggests a shoulder that's barely functional,
• 7:41
  doesn't it? Causing significant disability. Absolutely.
• 7:43
  It's very low. So jumping to 58%, that's a really
• 7:47
  clinically significant improvement. It doesn't
• 7:49
  necessarily mean, I suppose, a return to a completely
• 7:52
  normal pain -free shoulder, like before the injury?
• 7:55
  No, generally not. But it suggests a move away
• 7:57
  from severe disability towards a level that might
• 8:00
  allow for many activities of daily living, perhaps
• 8:03
  even some light work. That's exactly right. That
• 8:06
  magnitude of improvement really indicates just
• 8:08
  how severely compromised these patients were
• 8:10
  before the RTSA. And what about how the patients
• 8:13
  themselves felt, the subjective view? Yes, the
• 8:16
  subjective shoulder value, the SSV. This captures
• 8:19
  the patient's own perception of their shoulders
• 8:21
  function, usually as a percentage compared to
• 8:23
  a normal shoulder. That also saw mirroring. improvement.
• 8:26
  It rose from a mean of only 20 % preoperatively
• 8:29
  up to 56%. So they felt a marked improvement
• 8:32
  in how useful their shoulder actually was to
• 8:35
  them day to day. They did. A very significant
• 8:37
  perceived improvement. And range of motion. That's
• 8:40
  often terribly limited after failed fracture
• 8:42
  fixation, isn't it? Especially lifting the arm
• 8:44
  up. Yes, and significant improvements were seen
• 8:47
  here too. Active anterior elevation, so lifting
• 8:50
  the arm forward, increased from a mean of just
• 8:53
  45 degrees preoperatively. Very restricted. Very.
• 8:57
  Up to 106 degrees at follow -up. Okay. That's
• 9:00
  over the horizontal. It is. An active abduction
• 9:02
  lifting the arm out to the side went from 42
• 9:05
  degrees up to 99 degrees. Again, functionally
• 9:08
  important gains. Crucial gains, especially getting
• 9:11
  over that 90 degree mark for elevation and abduction
• 9:13
  that's so important for reaching and performing
• 9:15
  many basic tasks. And pain. Pain scores also
• 9:19
  saw significant reductions and perhaps surprisingly
• 9:21
  even strength improved notably. Really? Strength
• 9:24
  improved too. Yes. The study highlights that
• 9:27
  all of these functional and subjective improvements
• 9:29
  were statistically highly significant. We're
• 9:32
  talking p values less than 0 .0001. So very unlikely
• 9:37
  to be due to chance. Extremely unlikely. Less
• 9:40
  than a 1 in 1000 chance that these observed improvements
• 9:44
  were just random variation. That level of statistical
• 9:47
  significance really underscores the robustness
• 9:50
  of the finding, at least for those patients with
• 9:52
  retained implants. And you mentioned the follow
• 9:55
  -up was long -term, a mean of 11 years. Did the
• 9:58
  paper comment on whether these functional gains
• 10:01
  held up over that extended period? Did they last?
• 10:03
  Yes. And that's a really key point about the
• 10:06
  durability, isn't it? The study specifically
• 10:08
  looked at the outcomes over time, and it confirmed
• 10:11
  that the functional gains achieved at earlier
• 10:13
  time points, they were largely maintained. even
• 10:16
  beyond 10 years postoperatively for the patients
• 10:18
  whose implants remain in place. That's encouraging.
• 10:21
  It is. It suggests that when salvage RTSA works
• 10:24
  in this population, it could provide a lasting
• 10:26
  improvement, which is crucial given the younger
• 10:28
  age of these patients. They need something that
• 10:30
  lasts. OK. So the potential upside is clear.
• 10:34
  Significant, durable functional recovery possible
• 10:37
  for a severely damaged shoulder. But now, now
• 10:42
  we must confront the other side of the quail.
• 10:44
  The side that makes this procedure such a complex
• 10:47
  clinical decision, that very high complication
• 10:50
  rate you mentioned earlier. Yes. What were the
• 10:52
  numbers the study reported there? Well, this
• 10:54
  is where the challenge really lies. The study
• 10:56
  found that 18 out of the 30 patients in the cohort.
• 10:59
  That's a substantial 60 percent. 60 percent.
• 11:02
  Experienced one or more postoperative complications
• 11:04
  following their salvage RTSA. 60 percent. Wow.
• 11:09
  More than half of the patients undergoing this
• 11:11
  specific procedure in the study experienced a
• 11:13
  problem afterwards. And how did these complications
• 11:16
  then translate into needing more surgery or,
• 11:18
  you know, worst case scenario, failure of the
• 11:21
  implant itself? Well, the rate of revision surgery
• 11:23
  was also high. The paper reported that 11 open
• 11:26
  revisions were either performed or planned to
• 11:28
  be performed in 10 of the patients. 10 out of
• 11:30
  30. Yes, representing 36 % of the original cohort.
• 11:35
  And these revisions, they often occurred relatively
• 11:38
  late. The average time for the index salvage
• 11:40
  RTSA to the revision procedure was 71 months.
• 11:44
  71 months. That's nearly six years later. Almost
• 11:47
  six years on average. So over a third of patients
• 11:50
  needed another significant operation to try and
• 11:53
  deal with issues arising from the RTSA itself.
• 11:56
  And what about the ultimate failure rate where
• 11:58
  the implant just couldn't be salvaged and had
• 12:01
  to come out? The study defined failure quite
• 12:02
  stringently actually. It included explantation
• 12:04
  of the RTSA that's removing the implant entirely.
• 12:07
  Right. conversion back to a hemiarthroplasty,
• 12:10
  which is a rare and often problematic step, or
• 12:13
  insertion of a cement spacer, which is typically
• 12:15
  a temporary measure, often used to manage deep
• 12:18
  infection. So by that definition, six patients
• 12:20
  out of the 30, that's 20 % of the cohort, were
• 12:23
  classified as failures. One in five. One in five.
• 12:26
  This is a significant number. It represents one
• 12:28
  in five patients where the salvage RTSA just
• 12:31
  did not provide a lasting solution and the implant
• 12:34
  ultimately had to be abandoned. So let me just
• 12:36
  recap that. for a younger patient under 60. With
• 12:40
  a failed fracture fixation or heme arthroplasty,
• 12:43
  considering a salvage RTSA, they face roughly
• 12:46
  a 60 % chance of some kind of complication. Correct.
• 12:49
  A 36 % chance of needing another revision surgery
• 12:52
  down the line, possibly years later. Yes. And
• 12:55
  a 20 % chance that the whole procedure will ultimately
• 12:57
  fail, requiring removal of the implant. Those
• 13:00
  are the figures from this study, yes. Those are
• 13:02
  really sobering statistics. They absolutely highlight
• 13:05
  the high -risk nature of this specific procedure
• 13:08
  in this. specific patient group. Now, given these
• 13:11
  risks, the paper also looked at factors that
• 13:14
  might predict who is more likely to have these
• 13:16
  complications or perhaps less successful outcomes.
• 13:18
  What were the key associations they identified?
• 13:21
  Yes, this is critical, isn't it? For informing
• 13:24
  patient selection and, indeed, surgical planning,
• 13:27
  the study found a strong association between
• 13:29
  the number of previous surgical procedures on
• 13:31
  that shoulder and the likelihood of postoperative
• 13:34
  complications. That makes sense. It does. Patients
• 13:36
  with more prior surgeries were significantly
• 13:38
  more likely to experience issues. The p -value
• 13:41
  was 0 .005. So, highly significant statistically.
• 13:45
  Yes. It really underscores the cumulative damage
• 13:48
  that happens with each operation. You get scar
• 13:50
  tissue, altered anatomy, potential compromise
• 13:52
  of blood supply, the soft tissues. It just creates
• 13:55
  a much more hostile environment for further implant
• 13:57
  surgery. Right. The more times you've been in
• 13:59
  there, the harder it gets to achieve a good result
• 14:01
  the next time. What else significantly increased
• 14:05
  the risk? A documented history of infection prior
• 14:08
  to the salvage RTSA. That was another major predictor
• 14:11
  of complications, and this was striking. All
• 14:14
  seven patients in the study who had a history
• 14:16
  of infection experienced post -operative complications
• 14:19
  after the RTSA. All of them. Every single one.
• 14:22
  The p -value there was .048. Just a powerful
• 14:26
  reminder that eradicating infection, especially
• 14:28
  around orthopedic implants, is incredibly difficult,
• 14:31
  and a history of infection significantly escalates
• 14:33
  the risk of it recurring or other related complications
• 14:36
  happening with the next surgery. So if infection
• 14:38
  was part of the reason the initial surgery failed
• 14:40
  in the first place, carrying that history into
• 14:42
  the RTSA setting, it almost guarantees future
• 14:45
  problems based on this data. It carries a very,
• 14:48
  very high risk, yes. The nature of the previous
• 14:50
  failed surgery also seemed to matter. How so?
• 14:53
  Well, salvage RTSA performed for a failed heme
• 14:55
  arthroplasty was associated with a higher overall
• 14:58
  complication rate compared to salvage RTSA performed
• 15:01
  after a failed ORF. OK. Specifically. 19 out
• 15:05
  of the 23 patients who had a failed hemiarthroplasty
• 15:08
  went on to have complications after their RTSA.
• 15:12
  That p -value was 0 .014. That's interesting.
• 15:15
  Why might that be? Well, it's an interesting
• 15:17
  finding. It might suggest that the reasons why
• 15:19
  the hemiarthroplasty failed in this particular
• 15:22
  cohort, perhaps severe tuberosity resorption
• 15:25
  or significant glenoid erosion, were on the socket
• 15:28
  side. Right. Did these create a more complex
• 15:30
  biomechanical and soft tissue challenge for a
• 15:33
  subsequent RTSA? compared to the issues you typically
• 15:36
  see after a failed ORF, like screw cut out or
• 15:39
  simple non -union. That resonates clinically.
• 15:42
  Dealing with poor bone stock on both sides of
• 15:44
  the joint? Potentially significant soft tissue
• 15:46
  deficiency after a failed hemi? That does sound
• 15:49
  much more challenging than revising a failed
• 15:51
  plate and screw construct, generally speaking.
• 15:53
  It often is, yes. Did the study also look at
• 15:56
  implant -specific factors? Did the type of RTSA
• 15:59
  used matter? Yes, they did. They found an association
• 16:03
  between the use of older generation implants
• 16:05
  specifically. They mentioned the Delta III RTSA
• 16:08
  design and a higher complication rate. OK. 17
• 16:11
  out of the 20 patients who received that specific
• 16:13
  Delta implant experienced complications. The
• 16:17
  p -value was 0 .018. Now, the authors rightly
• 16:21
  acknowledge the limitations of a retrospective
• 16:23
  study, and obviously surgical techniques evolve
• 16:25
  over time. Of course. But this finding does hint
• 16:28
  that advancements in implant design and perhaps
• 16:31
  the surgical protocols associated with newer
• 16:33
  implants might well influence the outcomes. That's
• 16:35
  a crucial point for clinicians, isn't it? Being
• 16:38
  aware that the results reported might be influenced
• 16:40
  by the specific generation of the prosthesis
• 16:42
  used and the techniques that were contemporary
• 16:44
  at that time. The paper also noted a particularly
• 16:47
  high infection rate within the study cohort itself
• 16:49
  after the RTSA. Yes, the overall rate of infection
• 16:52
  post -salvage RTSA was noted as 27 % across the
• 16:56
  whole cohort. 27 %? That seems very high compared
• 17:00
  to primary RTSA for other reasons like arthritis.
• 17:03
  It is high. And it further highlights the compromised
• 17:06
  state of these revision shoulders. Hmm. Consistent
• 17:09
  with the other findings, factors significantly
• 17:11
  associated with this post -operative infection
• 17:13
  included, again, the number of previous surgeries
• 17:16
  and obviously a prior documented infection. The
• 17:20
  study did note, however, that their management
• 17:22
  protocol for dealing with infection before performing
• 17:25
  the RTSA, typically a staged approach using antibiotic
• 17:28
  -laden cement spacers, that appeared effective
• 17:31
  in controlling the infection before the RTSA
• 17:34
  was put in, which aligns with other research
• 17:36
  in the field. But controlling the infection beforehand
• 17:39
  doesn't eliminate the risk of it recurring or
• 17:42
  other complications cropping up once a large
• 17:44
  foreign body, the implant, is placed back into
• 17:46
  that environment. So even doing everything right,
• 17:49
  using staged procedures with spacers to clear
• 17:51
  a pre -existing infection, it doesn't wipe the
• 17:54
  slate clean. There's still a high risk of complications,
• 17:57
  including infection, after the RTSA in these
• 17:59
  complex cases. That's what this data suggests,
• 18:02
  yes. Yes. The risk remains elevated. OK. Beyond
• 18:05
  just complications, were there specific factors
• 18:07
  linked to inferior functional outcomes? So even
• 18:10
  if the implant remained in place, did some patients
• 18:13
  do less well functionally? Yes. The type of prior
• 18:16
  failed surgery also seemed to impact the level
• 18:19
  of functional recovery achieved. The study found
• 18:21
  that salvage RTSA performed for a failed secondary
• 18:25
  hemiarthroplasty. What does secondary mean here?
• 18:27
  It means the patient had already had at least
• 18:29
  two previous surgeries before the RTSA was even
• 18:32
  considered. So perhaps ORIF then HEMI, or HEMI
• 18:35
  then revision HEMI, before the RTSA. Okay, multiple
• 18:38
  prior surgeries. Exactly. And in those cases,
• 18:41
  the salvage RTSA resulted in significantly inferior
• 18:43
  active abduction, lifting the arm out sideways
• 18:46
  compared to salvage RTSA for a failed ORIF. How
• 18:48
  much inferior? The mean abduction was just 77
• 18:50
  degrees after failed secondary HEMI versus 116
• 18:53
  degrees after failed ORIF. That difference was
• 18:56
  statistically significant. P equals marrow point
• 18:59
  zero two three. Okay, so multiple previous surgeries
• 19:02
  And then, specifically, a failed hemiarthroplasty
• 19:05
  before the RTSA seems to result in significantly
• 19:09
  less ability to lift the arm out to the side
• 19:11
  compared to someone who maybe just had a single
• 19:14
  failed aura half as their only prior surgery.
• 19:17
  That's a finding, yes. That reinforces the idea,
• 19:19
  doesn't it, that the cumulative negative effect
• 19:22
  of prior interventions really impacts the final
• 19:24
  functional result you can expect. Absolutely.
• 19:27
  And furthermore, salvage RTSA performed after
• 19:29
  that failed secondary hemiarthroplasty also yielded
• 19:33
  significantly inferior mean active abduction
• 19:35
  compared to RTSA following a failed primary hemiarthroplasty.
• 19:39
  So worse than just one failed hemi. Yes. 77 degrees
• 19:43
  versus 107 degrees. P value 0 .049. So again,
• 19:47
  it points to the compounding difficulty introduced
• 19:49
  by multiple previous procedures, particularly
• 19:52
  when a failed hemiarthroplasty is part of that
• 19:54
  patient's history. And what about external rotation?
• 19:57
  The ability to turn the arm outwards, that's
• 19:59
  notoriously difficult to recover after these
• 20:00
  proximal humeral fractures, isn't it? Especially
• 20:03
  if those tuberosities, the rotator cuff attachments,
• 20:06
  don't heal properly. Yes, and this study confirmed
• 20:09
  that observation. Even with an RTSA place. They
• 20:13
  found significantly better active external rotation
• 20:16
  when the greater tuberosity had healed properly
• 20:19
  prior to the RTSA or was successfully incorporated
• 20:22
  into the reconstruction. Okay. Compared to when
• 20:24
  it was resorbed, essentially dissolved away or
• 20:27
  had been resected during previous surgeries.
• 20:29
  What was the difference? A mean of 21 degrees
• 20:31
  of external rotation if the tuberosity was healed
• 20:34
  versus a very limited three degrees if it was
• 20:36
  resorbed or resected. That p -value is .025.
• 20:40
  Only three degrees. That's very little outward
• 20:42
  rotation. Very little. And it highlights that
• 20:45
  while RTSA is often described as bypassing the
• 20:47
  need for a functional rotator cuff for elevation,
• 20:50
  the state of those tuberosities still plays a
• 20:52
  crucial role in trying to restore external rotation,
• 20:56
  which is often poor in these failed fracture
• 20:57
  cases, precisely because tuberosity healing is
• 21:00
  so problematic. And did the paper link that poor
• 21:03
  tuberosity status to the failed hemi group? Yes.
• 21:06
  It specifically notes that in seven out of the
• 21:08
  eight patients who had failed secondary hemiarthroplasty,
• 21:12
  the tuberosities were either resorbed or resected.
• 21:15
  And that strongly contributes to their poor abduction
• 21:17
  rotation results compared to the other groups
• 21:20
  in the study. That lobbage is really important,
• 21:22
  isn't it? It's not just about the implant mechanics.
• 21:25
  The residual anatomy and the biological situation
• 21:27
  resulting from the previous failures significantly
• 21:30
  influenced the outcome, even for a complex procedure
• 21:33
  like RTSA. Let's briefly touch on implant survival
• 21:36
  itself and maybe what they saw on imaging on
• 21:39
  the x -rays. Sure. The study provided survival
• 21:41
  estimates using Kaplan -Meier analysis, which
• 21:44
  is a standard statistical method to estimate
• 21:46
  the probability of an event like revision or
• 21:48
  failure happening over time. Okay. They reported
• 21:51
  an overall survival rate of the RTSA without
• 21:53
  needing a revision of 69 % at 10 years. 69 %
• 21:57
  free of revision at 10 years. Correct. Now, if
• 21:59
  you define survival more strictly using failure
• 22:01
  as the endpoint, remember that was explantation,
• 22:04
  conversion, or spacer insertion. Right, the really
• 22:06
  bad outcomes. Then the survival rate was higher,
• 22:09
  79 % at 10 years. OK, so roughly four out of
• 22:12
  five implants were still in place at 10 years,
• 22:15
  even if some had needed revisions along the way.
• 22:17
  That's right. Now, whilst these rates are certainly
• 22:20
  lower than often reported for primary RTSA performed
• 22:24
  for, say, degenerative conditions in older patients.
• 22:27
  Sure. They do provide a realistic benchmark for
• 22:31
  this specific, highly challenging salvage indication
• 22:34
  in a younger population. That's important context.
• 22:38
  And what did the x -rays show over the long term?
• 22:40
  Any common findings? Yes, a very common finding
• 22:42
  on the radiographic side was inferior scapular
• 22:45
  notching. Ah, yes, notching. This is where the
• 22:48
  metal component on the arm bone, the humeral
• 22:50
  component, can rub against the lower edge of
• 22:52
  the shoulder blade socket, the glenoid. It was
• 22:55
  present in a very high proportion, actually 92
• 22:57
  percent of patients with retained implants in
• 22:59
  this study. 92 percent. That's almost everyone.
• 23:02
  Almost everyone showed some degree of it. However,
• 23:05
  and this was quite a key finding, the study found
• 23:08
  that the presence or even the severity of the
• 23:10
  scapular notching was not statistically associated
• 23:13
  with inferior functional or subjective outcomes
• 23:16
  in this specific cohort over the observed period.
• 23:19
  That's surprising because notching is often cited
• 23:22
  as a Potential concern for RTSA longevity and
• 23:25
  outcomes, isn't it? It is often discussed, yes.
• 23:27
  Yeah. But in this difficult salvage setting in
• 23:30
  these younger patients, this paper suggests it
• 23:32
  wasn't the primary driver of poor results, at
• 23:35
  least not within the time frame studied. Interesting.
• 23:38
  Anything else on the x -rays? They also noted
• 23:40
  radiographic lucent lines around the humeral
• 23:42
  component, the part in the arm bone, in about
• 23:45
  25 % of patients. And what do those lines mean?
• 23:47
  Well, lucent lines can sometimes indicate loosening
• 23:50
  of the implant or stress at the bone implant
• 23:53
  interface, and these lines were significantly
• 23:55
  associated with using that older Delta III implant
• 23:58
  model, and also with the need for subsequent
• 24:02
  revision surgery. So that further supports the
• 24:04
  idea that implant design and achieving stable
• 24:08
  fixation at the bone implant interface really
• 24:10
  does play a role in the long -term outcome. Right.
• 24:13
  Now before we wrap up, it's always important,
• 24:16
  as the authors themselves noted, to consider
• 24:18
  the limitations of any study. What were the key
• 24:21
  caveats they highlighted for this research? Well,
• 24:24
  they pointed out quite rightly that it was a
• 24:25
  retrospective study. That means they looked back
• 24:28
  at data that was collected over time, which can
• 24:31
  introduce certain biases compared to a prospective
• 24:34
  study where you follow patients forward under
• 24:36
  a very strict protocol. There was also inevitably
• 24:39
  in a long -term study like this a percentage
• 24:41
  of patients who were lost to follow up about
• 24:43
  11 % in this case. And sadly another 11 % died
• 24:47
  during the study period, which is expected given
• 24:49
  the time frame but can affect the overall power
• 24:51
  and completeness of the analysis. They also acknowledged
• 24:54
  the relatively limited sample size 30 patients
• 24:57
  in total. which meant they had limited statistical
• 24:59
  power for doing very detailed subgroup analyses.
• 25:02
  And finally, they noted that there might be inherent
• 25:05
  differences between the patient groups who initially
• 25:07
  had ORIF versus those who initially had hemiarthroplasty,
• 25:12
  perhaps related to the original injury severity
• 25:15
  or bone quality that weren't fully captured or
• 25:17
  adjusted for in the analysis. Those are standard
• 25:20
  but important limitations to bear in mind when
• 25:23
  we interpret the findings of a study like this
• 25:25
  one. Taking all of this information together
• 25:28
  now, the significant potential for functional
• 25:31
  improvement on the one hand, contrasted with
• 25:35
  that very high risk of complications and failure
• 25:37
  on the other hand, particularly in the context
• 25:39
  of previous surgeries and prior infection. How
• 25:42
  does this paper really frame the overall clinical
• 25:45
  decision making for this challenging group of
• 25:48
  younger patients? Well, I think the paper strongly
• 25:50
  reinforces that salvage RTSA in this population
• 25:53
  is absolutely not a straightforward procedure
• 25:55
  with any guaranteed success. It is clearly associated
• 25:57
  with substantial risks. And those risks are particularly
• 26:00
  influenced by the patient's prior surgical history
• 26:02
  and any history of infection. However, the buddy
• 26:06
  again. The study also presents quite compelling
• 26:09
  evidence that for those patients where the implant
• 26:11
  can be retained, it does offer a level of pain
• 26:14
  relief and functional recovery that may simply
• 26:17
  not be achievable with the other available salvage
• 26:19
  options. If there are any other options left.
• 26:22
  Precisely. It underscores the fact that in these
• 26:25
  severely compromised younger shoulders, all the
• 26:28
  options are difficult. None are without significant
• 26:31
  drawbacks. RTSA, despite that high complication
• 26:35
  rate, emerges as a procedure that can work. But
• 26:38
  it demands really careful patient selection and
• 26:41
  a preparedness, both from the surgeon and the
• 26:43
  patient, for managing the potential issues that
• 26:45
  are quite likely to arise. It really sounds like
• 26:48
  it's often a procedure of last resort, then,
• 26:50
  chosen perhaps out of necessity when other options
• 26:53
  have failed or aren't viable, accepting that
• 26:55
  high likelihood of future problems in exchange
• 26:57
  for the potential for significant, albeit maybe
• 27:00
  imperfect, improvement in a shoulder that is
• 27:03
  otherwise debilitatingly painful and dysfunctional.
• 27:06
  I think that's a fair summary. It forces a very
• 27:08
  difficult conversation, doesn't it, about managing
• 27:11
  expectations and accepting a significant level
• 27:13
  of risk. Exactly. The improvements shown in the
• 27:16
  study are real, and they are meaningful for patients
• 27:19
  starting from such a low baseline with severely
• 27:21
  failed shoulders. But they come at a cost, frequently
• 27:25
  requiring further surgical intervention down
• 27:27
  the line to manage complications, and with that
• 27:30
  non -trivial chance around 1 in 5 of ultimate
• 27:33
  failure requiring implant removal. Well, this
• 27:36
  deep dive has certainly illuminated the complexities
• 27:39
  and the critical data surrounding salvage RTSA
• 27:42
  in this very challenging patient group. If this
• 27:45
  discussion sparked some insights for you, or
• 27:47
  perhaps clarified this difficult clinical scenario,
• 27:50
  please do consider leaving us a rating and perhaps
• 27:53
  sharing this deep dive with a colleague who might
• 27:54
  find it valuable. Yes, we appreciate you joining
• 27:57
  us for this in -depth look at a complex problem.
• 27:59
  And finally, a thought to perhaps mull over,
• 28:02
  drawing directly from the factors identified
• 28:04
  in this paper. we've discussed. Given that the
• 28:06
  study found things like a higher number of previous
• 28:09
  surgeries and prior infection were so strongly
• 28:12
  linked to complications, and that factors like
• 28:16
  tuberosity healing and the specific type of failed
• 28:18
  prior surgery impacted the functional outcomes,
• 28:22
  how much of the ultimate success of salvage RTSA
• 28:25
  in these challenging younger patients is actually
• 28:28
  determined not just by the technical execution
• 28:30
  of the RTSA surgery itself. Right. but perhaps
• 28:33
  even more so by the surgeon's ability to meticulously
• 28:36
  select the right patients in the first place,
• 28:38
  to rigorously optimize their condition preoperatively,
• 28:41
  especially managing any hint of infection, and
• 28:44
  then possess the experience and the infrastructure
• 28:46
  to effectively anticipate and manage the almost
• 28:49
  inevitable complications when they do arise.
• 28:52
  It suggests the outcome might be less about the
• 28:54
  implant or the index procedure in isolation,
• 28:56
  and much more about the comprehensive long -term
• 28:59
  management of a complex previously operated and
• 29:01
  often compromised shoulder.