Stephanie Muh, MD
Read complete study: Clinical Outcomes after Reverse Shoulder Arthroplasty with and without subscapularis repair: The Importance of considering glenosphere lateralization
There continues to be significant debate on whether subscapularis repair is necessary during reverse total shoulder arthroplasty. Historically subscapularis repair was felt to be necessary to provide anterior soft tissue stability and help prevent post-operative dislocation. There have been multiple articles written on both the advantages and disadvantages of subscapularis repair. It should be noted that most previous articles that strongly advocated subscapularis repair included the traditional Grammont-style prosthesis with a medialized glenosphere and valgus medialized humeral stem (155 degrees).
This article retrospectively reviews patients who underwent reverse total shoulder arthroplasty (RTSA). They first stratified the subscapularis repair group versus no repair. The authors then looked at the effects of glenosphere lateralization (0mm lateralization vs +3 or +6mm) in both groups to determine if this played a significant role. The humeral stem used in the study has a neck shaft angle of 147 degrees but a humeral stem with no lateralization. ASES score from baseline was the primary outcome measured with a minimum of two-year follow-up.
The study demonstrated patients with no subscapularis repair and lateralization had the most overall improvement in ASES scores. This supports the design rationale of the Equinoxe® reverse shoulder system.
Overall, the authors found no difference in ASES scores when comparing subscapularis repair versus no repair. The authors also reported that subscapularis management and lateralized glenosphere individually did not have significant effect on ASES scores. However, analysis did find that patients with subscapularis repair with a lateralized glenosphere did worse compared to subscapularis repair with medialized glenosphere and no repair with lateralized glenosphere.
This article demonstrates the impact of the combined effect of subscapularis management with glenosphere lateralization on clinical outcomes. The study demonstrated patients with no subscapularis repair and lateralization had the most overall improvement in ASES scores. This supports the design rationale of the Equinoxe® reverse shoulder system. Continue reading
Alberto Rivera, MD
Read complete studies:
Conversion to reverse shoulder arthroplasty: humeral stem retention versus revision
Platform shoulder arthroplasty: a systematic review
The number of shoulder arthroplasty procedures is rapidly increasing. Therefore, shoulder revision is becoming a commonly performed procedure. Historically revising a hemiarthroplasty or total shoulder replacement ended up in a hemiarthoplasty, resection arthroplasty, arthrodesis or more recently reverse arthroplasty. This type of revision usually required stem removal, which could potentially lead to humeral fracture with or without the need of an osteotomy, increasing surgical time, bleeding and neural damage. Also, late complications, such as osteotomy nonunion and malunion could develop. Another important factor to take into consideration is the added cost of using additional implants such as a new stem, cement, cables or allograft in the setting of humeral stem revision. Modular implants using a platform system allows for a faster revision with fewer complications and potentially less cost.
“Recent publication by Williams and Colleagues (1) reported on 17 patients who underwent modular conversion and nine who had revision of humeral stem. Pain, stability and ASES scores improved significantly.”
I believe the use of modular platform in primary shoulder arthroplasty either hemi or total should be the standard of care.
In my experience, revising TSA to RSA has evolved to a more straightforward procedure with the use of modular components of the platform shoulder type. I believe the use of modular platform in primary shoulder arthroplasty either hemi or total should be the standard of care.
Thomas Wright, MD
Read complete study: Risk of insufficient internal rotation after bilateral reverse shoulder arthroplasty: clinical and patient reported outcome in 57 patients.
This study focused on the effects and risks of bilateral reverse shoulder arthroplasty (rTSA) on internal rotation (IR) in 57 patients. Data was recorded up to two years after the second surgery. The study found that only 15 percent of patients had insufficient IR in both shoulders after 12 months and 5 percent after 24 months. Patients who had insufficient baseline IR in their second shoulder and insufficient IR 12 month post op after their first shoulder had a 100 percent risk of having insufficient IR in both shoulders. The conclusion of this article is a recommendation to use staged bilateral rTSA over the use of a hemiathroplasty. The authors found that the majority of patients would undergo the surgery again, as it does provide benefits, like reduction in pain, regardless of the issues with IR.
The authors of this study focused on the risks of staged bilateral rTSA on internal rotation. I agree with their concern, as bilateral decreased IR could result in difficulties with toileting. In my practice, I stage my bilateral cases; however the timing is up to the patient. I will proceed with the second surgery no sooner than 12 weeks, but I do not recommend waiting as long as a year. In 2014, we published an article on bilateral rTSA1 in which we found all patients eventually had enough IR to allow toileting with at least one shoulder. I agree with the authors and do not recommend using a hemiarthroplasty in the second shoulder, based on the positive results that we had with rTSA.
Although the article showed a 100 percent failure rate in achieving sufficient IR in the second shoulder when it comes to patients who have both insufficient baseline IR and insufficient IR 12 months post op in their first shoulder, we have not noted that to be a problem.
One example is a 79 year old male with symptomatic cuff tear arthropathy on the right and a failed total shoulder arthroplasty (TSA) on the left due to rotator cuff insufficiency.Because of the predictable nature of performing an rTSA as a primary, the right side was addressed first. At three months post-op he had IR to L5.
79 year old male, cuff tear arthropathy on the right side, 3 months post op