What is the optimal management plan for a patient undergoing reverse total shoulder arthroplasty?

Optimal Management Plan for Reverse Total Shoulder Arthroplasty

Radiographic imaging should be performed at 3-6 weeks post-surgery and annually thereafter to monitor for complications such as scapular notching, loosening, and periprosthetic fractures, as these can significantly impact patient morbidity and mortality. 1

Preoperative Considerations

• Evaluate for risk factors that may increase complication rates:
  • Medical comorbidities (assessed using Deyo-Charlson index) increase risk of periprosthetic fractures 1
  • Male gender and younger age are associated with higher infection rates (0.7-2.9% prevalence) 1
  • History of rheumatoid arthritis, corticosteroid use, diabetes, repeated intra-articular steroid injections, or prior shoulder surgery increases infection risk 1

Immediate Postoperative Care

• Obtain immediate postoperative radiographs to confirm proper component positioning, though their benefit without specific indications has been questioned 1
• Standard radiographic views include:
  • Anterior-posterior
  • Anterior-posterior Grashey
  • Scapular Y
  • Axillary views 1

Rehabilitation Protocol

• Sling immobilization for 4-6 weeks 2
• Progressive rehabilitation phases:
  1. Passive range of motion exercises
  2. Active-assisted exercises
  3. Progressive strengthening exercises 2
• Early deltoid isometric exercises are recommended 3
• Monitor for common complications unique to reverse total shoulder arthroplasty:
  • Neurologic injury
  • Periprosthetic fracture
  • Hematoma
  • Infection
  • Scapular notching
  • Dislocation
  • Mechanical baseplate failure
  • Acromial fracture 4

Follow-up Imaging Schedule

• First follow-up radiographs: 3-6 weeks post-surgery 1
• Additional imaging: Between 3 months and 1 year post-surgery 1
• Long-term: Annual radiographic examinations to assess for:
  • Interval changes in bone surrounding the prosthesis 1
  • Scapular notching (associated with poor clinical outcomes) 1
  • Component loosening (risk increases over time, with notable changes at least 5 years after surgery, most commonly involving the glenoid component) 1

Management of Symptomatic Patients

• For patients presenting with pain or decreased function:
  1. Begin with radiographs to evaluate for:
     • Loosening
     • Infection
     • Periprosthetic fracture
     • Rotator cuff tear 1
  2. If radiographs are negative but clinical suspicion remains high:
     • CT with metal reduction protocol for suspected fractures (particularly useful for acromial stress fractures) 1
     • MRI for soft tissue abnormalities, infection, or occult fractures 1
     • Ultrasound for rotator cuff integrity assessment 1

Special Considerations for Infection

• Higher infection rates in reverse total shoulder arthroplasty (0.8-10%) compared to anatomic total shoulder arthroplasty 1
• If infection is suspected:
  • In-111-labeled WBC with Tc-99m sulfur colloid bone marrow study provides high sensitivity and specificity for acute osteomyelitis 1
  • Discordant activity of increased labeled WBC and photopenic bone marrow is consistent with acute osteomyelitis 1

Long-term Monitoring

• Continue annual radiographic follow-up for at least 15 years, as late complications requiring revision surgery can occur up to 15 years postoperatively 1
• Monitor particularly for:
  • Loosening
  • Infection
  • Fracture 1

This management plan prioritizes early detection of complications through appropriate imaging protocols to reduce morbidity and mortality associated with reverse total shoulder arthroplasty.