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Complications of Shoulder Arthroplasty

- Hematoma:
    - Infection associated with hematoma formation after shoulder arthroplasty   

- Fractures
    - fractures may occur at the tip of the prosthesis;
    - long oblique and spiral fractures can be treated non operatively as long as good alignment is maintained;
    - transverse or short oblique fractures may not heal with non operative treatment and operative intervention shold be consideed;
    - references:
           - Humeral fractures after shoulder arthroplasty.
           - Humeral fracture following shoulder arthroplasty.   


- Loss of Tuberosity Fixation:
         - when the lesser and greater tuberosity fragments have been quatered (as is necessarily in 4 part frx), it is essential that a secure repair be re-established;
         - when fixation fails, only a poor postoperative result can be expected;

- Instability:
    - instability following shoulder arthroplasty should be divided into early and late;
         - early dislocations:
                - dislocations which occur in early post op period may be due to malposition of implant, soft tissue imbalance or due to inadequate postop protection;
                - treatment involves reduction (if possible) and immobilization;
         - late dislocation:
                - consider rotator cuff tear, component loosenig, or glenoid wear;
    - superior instability:
         - most often due to supraspinatus/infraspinatus tear;
    - inferior instability:
         - this is avoided by noting whether the deltoid, superior cuff and capsule are adequately tensioned w/ the arm at the side;
         - in some cases, unexpected inferior subluxation will be seen postoperatively;
                 - this may be due to loss of deltoid muscle tone, and once deltoid strength is re-established, the subluxation may improve;
    - anterior instability:
         - deficiency/tear of the subscapularis;
                 - most common reason for instability;
                 - anterior instability may result from avulsion of the tendon from the repair site;
                 - "over-stuffing the shoulder" with placement of a glenoid component will lateralize the humeral component and will place subscapularis tendon under increased tension and risk rupture;
                 - when diagnosed early may be amenable to surgical repair (consider Achilles tendon allograft for augmentation);
         - failure to restore proper length (= proper deltoid tension);
         - correct amount of retroversion (normally 30-35 mm);
                 - malrotation of the humeral component: retroversion less than 20 deg may lead to anterior dislocation;
         - previous anterior acromioplasty and excision of the CA ligament: may allow antero-superior dislocation;
         - may result from previous contracture of the posterior capsule;
         - anterior deltoid dysfunction;
    - posterior instability:
         - may occur when the humeral component is placed in more than 45 deg of retroversion;
         - may occur from posterior glenoid erosion;
         - may occur from over-tightening the anterior capsule and subscapularis;
    - references:
         - Instability of the shoulder after arthroplasty.
         - Complications of total shoulder arthroplasty.                     
         - Complications of total shoulder-replacement arthroplasty.                                             
         - Instability After Shoulder Arthroplasty: Results of Surgical Treatment. 

- Shoulder Stiffness:
       - soft tissue release: subscapularis adhessions require circumferential release 
       - over stuffed replacement: 
                - consider modular downsizing of the components (reduction of humeral head diameter and offset) 
       - arthroscopic release:
                - references:
                       - Long head of the biceps pathology as a cause of anterior shoulder pain after shoulder arthroplasty.
                       - Arthroscopic capsular release after hemiarthroplasty of the shoulder for fracture: a new treatment paradigm.
                       - The role of arthroscopy for the problem shoulder arthroplasty.

- Glenoid Loosening:
    - Radiographic and Computed Tomography Analysis of Cemented Pegged Polyethylene Glenoid Components in Total Shoulder Replacement.

Complications of total shoulder arthroplasty: Are they fewer or different?

Rotator cuff repair after shoulder replacement.

The complex characteristics of 282 unsatisfactory shoulder arthroplasties

The outcome of resection shoulder arthroplasty for recalcitrant shoulder infections.