Anterior sling with hamstring autograft for recalcitrant reverse shoulder arthroplasty instability

Reverse total shoulder arthroplasty (RTSA) has significantly advanced the treatment of a wide range of shoulder disorders, expanding its indications from rotator cuff arthropathy to include irreparable rotator cuff tears, complex fractures, and inflammatory arthritis. However, the rapid increase in RTSA procedures has been accompanied by a corresponding rise in complications, with dislocation being one of the most prevalent early postoperative complications.

This case report presents a 74-year-old, right-hand dominant female patient with a periprosthetic fracture of the right shoulder. She underwent revision surgery involving glenoid lateralization and the use of a thicker, restrictive polyethylene insert. Postoperatively, the patient experienced pain and instability, eventually leading to an atraumatic anterior dislocation. A re-revision surgery was performed, incorporating an anterior sling using a hamstring autograft to address subscapularis deficiency caused by recurrent dislocations, and an increased humeral tray size for improved containment. Approximately 2 years after the re-revision surgery, the patient demonstrated restored stability, improved range of motion, and reported satisfaction with the outcome.

Numerous recommendations for addressing instability or dislocation following RTSA have been discussed in the literature. Dislocation may be influenced by several biomechanical factors, including humeral shortening, excessive medialization, implant version, socket constraint, soft-tissue tensioning, and nerve dysfunction. Subscapularis deficiency is a potential contributor to recurrent dislocations. Few techniques have been described to manage and enhance soft tissue tension in cases of subscapularis insufficiency.

This case report highlights the challenges of managing recurrent anterior dislocation following RTSA. It demonstrates the successful use of an anterior hamstring autograft sling as a salvage procedure to restore stability in cases of persistent anterior dislocation after RTSA. However, further clinical studies are needed to better define the role of such interventions in addressing complications associated with RTSA.