To Repair, or Not to Repair, That is the Question…

Kaveh Sajadi, MD

Read complete study: The effect of subscapularis repair on dislocation rates in reverse shoulder arthroplasty: a meta-analysis and systematic review

Whether ‘tis nobler in the mind to bear the slings and arrows of our colleagues…

The role of the subscapularis in reverse total shoulder arthroplasty (rTSA) continues to be debated. Reverse TSA is most commonly performed via a deltopectoral approach, which often requires takedown of an intact, though possibly degenerated or atrophic, subscapularis tendon. Surgeons debate the importance of its repair at the conclusion of the surgery. This debate centers on the importance and role of the subscapularis in stability of the prosthesis, range of motion (both internal and external rotation), and outcomes. Those in favor of repair cite studies indicating lower dislocation rates with repair and better internal rotation; those opposed express concern about it potentially limiting external rotation and possibly opposing the deltoid in elevating the arm.1 This meta-analysis and systematic review sought to compare the dislocation rates and outcomes in rTSA with and without subscapularis tendon repair using the highest level of data available.

This meta-analysis and systematic review sought to compare the dislocation rates and outcomes in rTSA with and without subscapularis tendon repair using the highest level of data available.

It is important to clarify some descriptions used in the study. Since the introduction of the original Grammont style reverse prosthesis in the late 1980s and early 1990s, many different design modifications have been introduced.2 The primary differentiating characteristic between implant designs is the location of the center of rotation (COR) of the new glenohumeral articulation. By their very nature, all reverse designs medialize the COR compared with the native shoulder. However, systems with the COR at the glenoid face, as the original Grammont design, are considered medialized and those with the COR lateral to the glenoid are referred to in this paper as lateralized designs. Furthermore, the implant can have a medialized humerus (Grammont) or a lateralized humerus. Routman HD, et al, proposed a classification to standardize the nomenclature, dividing implants into the medial glenoid/medial humerus (Grammont), lateral glenoid/medial humerus, and medial glenoid/lateral humerus.2,3 Some of the implants in this study, classified as lateralized glenoids by the authors, are classified as medial glenoid/lateral humerus by Routman.

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What Options Are Available for Extensive Proximal Humeral Bone Loss?

Stephanie Muh, MD

Read complete study:  Radiographic changes and clinical outcomes associated with an adjustable diaphyseal press-fit humeral stem in primary reverse shoulder arthroplasty

The use of press-fit humeral components for reverse shoulder arthroplasty has become more common in shoulder replacement surgery.  Historically, humeral fixation was achieved with cementation techniques.  However, due to increased operating time for cementation and added difficulty with higher complications in revisions during humeral component removal, surgeons have increasingly transitioned to press-fit humeral stems.

This article is a retrospective review of primary reverse shoulder replacements implanted with a modular diaphyseal press-fit humeral stem.  Total hip literature has shown that distal press-fit stems obtain control through the medullary canal.  The torsional stress is then transferred to proximal fixation and leads to increased stress shielding proximally with corresponding bone loss.  This seems to be demonstrated in this study as well.  With only a short-term follow-up, the authors found minimal radiolucent lines around distal fixation.  However, 97% of radiographs demonstrated radiolucent lines around the smooth metaphyseal component. Additionally, the authors found progression of these radiolucent lines during the first two years.  The authors claim the radiolucent line progression stabilizes after two years, however their mean follow up was 42 months (three and a half years).  I do not believe this is sufficient time to truly access whether evidence of radiolucent lines has stabilized.

The evidence of proximal humeral bone loss is concerning and brings up an interesting clinical question. How do we revise shoulders with massive proximal bone loss? Continue reading

What is the Difference in Post-Op Activity Level Between Older and Younger rTSA Patients?

Ryan Simovitch, MD

Read complete study: Younger patients report similar activity levels to older patients after reverse total shoulder arthroplasty

The authors conducted a study to measure a subjective questionnaire that reported type of activities, range of motion, pain and strength. The authors looked at patients younger and older than 65 to determine if there was a difference in activity levels and what the functional differences were in these patient populations. They broke activity level down into low, medium and high demand.

Literature Review:

The authors bring up a good point for surgeons to think about. Older patients are not necessarily inactive patients. The patient population at my practice in South Florida is older demographically, but those patients still enjoy golfing, swimming, lifting weights, cycling, hunting and other similar  activities that place high stresses on shoulder implants.

In my practice, I tend to view physiological age as a more important indicator than chronological age because my experience confirms what the study has above has found. Continue reading

Is rTSA the Solution to Every Patient’s Problem?

Howard Routman, DO

Read the complete study: Causes of poor postoperative improvement after reverse total shoulder arthroplasty

This study reviewed comorbidities and results for higher baseline American Shoulder and Elbow Surgeons (ASES) scores that are correlated with poor post-operative improvement. The study collected data from a total of 150 patients who underwent reverse total shoulder arthroplasty (rTSA) from 2007-2013. A minimum of two-year post-operative ASES scores were included, and poor post-op improvement was defined as a change of ASES score of less than 12 points. Out of the 150 patients, male gender, presence of an intact rotator cuff at the time of surgery, depression, a higher baseline ASES score and higher total number of medical comorbidities were associated with poor post-operative improvement after rTSA. Neither patient age, nor indication for surgery, was found to correlate with poor improvement after rTSA. In general, the study population was older, with an average age of 71.6 +/- 8.8, and the majority of patients were female.

Literature Review:

It should be noted that as the number of rTSAs continues to grow rapidly—due to its success in improving pain and function in most patients—some patients fail to improve clinically. Interestingly, the article also mentioned that patient satisfaction is now frequently linked to hospital and physician reimbursements. This study emphasizes reasons for poor post-operative improvement throughout with baseline pulled  from ASES scores and patient data. Physical examination findings were not a focused component of the analysis.

The temptation to view the rTSA as a panacea that can fix everything is high.  We need to temper our enthusiasm and ensure that we select our patients wisely.

When managing expectations with higher pre-operative ASES scores, I don’t really look at an ASES score pre-operatively as a screening tool, but I appreciate the concept of the ‘delta’ of improvement before surgery.  If a patient’s radiograph shows a classic cuff tear arthropathy, and the patient has maintained overhead elevation and mild pain, the change in function and pain that can be provided with a perfect reverse is minimal.  Ideally, patient selection can help us identify who best benefits from rTSA.  By limiting the indications to patients who cannot elevate beyond 90⁰, and who identify themselves has having quality-of-life-altering pain, we can skew our delta favorably.  The article referenced a study by Wall et al that noted patients who underwent rTSA for primary osteoarthritis had much smaller improvements in range of motion compared with patients who underwent rTSA for rotator cuff tear arthropathy or massive tears. Current expectations for improving post-operative function versus outcomes in patients with high levels of pre-operative function are to be noted.

In a cohort of 31 of my rTSA patients, the average post op ASES score was 82.68 (+/- 18.4), compared to 76 +/- 16.7 as mentioned in the study. Continue reading

Can Sufficient Internal Rotation Be Achieved with Bilateral rTSA?

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.

Literature Review:

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.

Figure_1

79 year old male, cuff tear arthropathy on the right side, 3 months post op

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