This surgical video, narrated and performed by Dr. Anthony A. Romeo, documents a complex revision procedure on a 54-year-old female patient.

Patient History & Clinical Presentation

The patient sustained a left proximal humerus fracture more than a year prior, which was initially treated with an open reduction and internal fixation (ORIF) using a plate, screws, and sutures. Following that surgery, the humeral head collapsed, leading to a malunion of the tuberosities. Consequently, the patient presented with persistent pain, highly restricted shoulder mobility, and screws that had begun eroding into the glenoid surface.

Surgical Plan & Challenges

The objective was to remove the failed internal fixation hardware and perform a reverse total shoulder arthroplasty to restore stable, low-to-mid-level arm function and alleviate pain.

The procedure presented several challenges due to the revision environment:

• Altered Anatomy & Scarring: Dense scar tissue from the previous surgery distorted natural planes, making the initial dissection and identification of the deltopectoral interval highly difficult.
• Elevated BMI: The patient's anatomy required careful lateral-to-medial adjustment to localize the cephalic vein and protect the anterior deltoid fibers.
• Hardware Removal: A total of ten screws and a proximal humerus locking plate had to be meticulously extracted from hard, sclerotic bone.
• Tissue Stiffness: Marked contracture and tight closures from the previous ORIF significantly resisted external rotation, requiring extensive soft-tissue releases—including partial release of the pectoralis tendon and complete circumferential release of the glenoid capsule.

Component Placement & Reconstruction

• Glenoid Side: Using advanced virtual implant planning (VIP), the team achieved full structural exposure. They corrected a superior inclination deformity back to zero degrees and placed a lateralized baseplate and glenosphere to optimize internal rotation and mitigate the risk of scapular notching.
• Humeral Side: Due to the malunion and a tight proximal canal, a shorter stem brooch was introduced to prevent posterior cortical blowout. Dr. Romeo opted for a specialized implant configured at a classic inclination angle to manage the structural bone variations and match the lateralized glenoid geometry. A constrained polyethylene cup was utilized to provide additional structural stability against potential levering forces, especially given the patient's body habitus.
• Biologics & Closure: Autologous bone graft harvested during the humeral preparation was packed into structural defects along the posterior and medial aspects of the humerus. Because the subscapularis was severely compromised and non-viable, it was left unrepaired, relying entirely on the reverse geometry for stability.

Prophylaxis & Prognosis

To counteract the elevated risk of infection inherent to revision arthroplasty, the surgical site was copiously irrigated via pulsatile lavage, sterilized with a diluted betadine solution for three minutes, and treated with topical vancomycin powder prior to layered closure.

Postoperatively, the patient is projected to achieve a substantial reduction in daily and nocturnal pain (dropping from a pre-operative 7–10 down to a manageable 0–2). While high-elevation or strenuous activities may remain limited due to previous deltoid trauma, the reconstruction provides a stable foundation for the patient to regain independent living and functional range of motion for daily tabletop and shoulder-level activities.