Reverse Shoulder Research Articles

Reverse Total Shoulder Arthroplasty for Irreparable Rotator Cuff Tears

Multiple treatment options exist for treating massive rotator cuff tears without arthritis. In patients who have failed nonoperative treatments and have continued pain, anterior superior escape, static superior subluxation with acromial changes, pseudoparalysis, and decreased acromial humeral interval, reverse total shoulder arthroplasty (RTSA) becomes a viable solution. Favorable mid- and long-term results have demonstrated significant improvements in both patient-reported outcomes and functional outcome scores after RTSA for irreparable rotator cuff tears or failed cuff syndrome. Although there are significant risks associated with RTSA, with increasing biomechanical knowledge, improved implant design and surgeon experience have led to a decrease in complication rates. RTSA has become an outstanding procedure for the treatment of older patients with a massive rotator cuff tear or failed cuff syndrome.

Arthroscopic Latissimus Tendon Transfers for Irreparable Rotator Cuff Tears

Irreparable massive rotator cuff tears in the active population are a common cause of pain, loss of overhead hand positioning, and potentially pseudoparalysis in external rotation and forward elevation. After failure of conservative treatment, a wide variety of surgical techniques have been utilized for treatment including debridement and/or tenodesis, partial repair, superior capsular reconstruction, tendon transfers, as well as reverse total shoulder arthroplasty. The latissimus transfer was proposed to augment the diminished external rotation forces and to restore mechanical shoulder balance. This technique has now been utilized for nearly 3 decades with notable improvements in patient reported pain and outcome measures as well as increases in range of motion and strength. Arthroscopic assisted latissimus dorsi tendon transfer (A-LDTT) was subsequently described as a minimally invasive means to reduce iatrogenic deltoid injury and allow precise subscapularis repairs, when necessary. Multiple studies with ≥2 year follow-up have showed similar clinical outcomes to the open technique. A-LDTT is an effective, safe, and reliable treatment option for patients with irreparable posterosuperior rotator cuff repairs. This paper will describe our method and experience with the A-LDTT procedure.

Identification of Risk Factors for Abnormal Postoperative Chemistry Labs after Primary Shoulder Arthroplasty

The purpose of this study was to determine patient-specific risk factors and clinical intervention rates for abnormal postoperative Chem-7 panels in shoulder arthroplasty patients. Retrospectively, all primary anatomic total (aTSA) and reverse shoulder (RTSA) arthroplasties (between 2007-2013) performed at a single institution were identified. All patients underwent routine preoperative and postoperative day one (POD1) chemistry panels. Each clinically significant component of the Chem-7 panel was independently evaluated using a multivariate analysis to identify risk factors for abnormal results. Associated clinical intervention rates were also calculated. Data from 1,012 patients (248 RTSA; 764 aTSA) was analyzed. 5.4% of patients had at least one preoperative abnormal chemistry result. On multivariate analysis, patients with abnormal preoperative Chem-7 labs and a history of renal disease had significantly increased risk for abnormal POD1 labs (P<0.001). Although 25.6% (259/1,012) of patients had at least one abnormal POD1 lab result, the total postoperative clinical intervention rate was 15.1% (39/259). Renal disease and a preoperative abnormal chemistry result are important risk factors for abnormal postoperative Chem-7. Optimizing renal status and correcting abnormal blood chemistry results preoperatively may reduce the incidence of abnormal postoperative chemistry results.

Additively manufactured implant components for imaging validation studies

Radiographic imaging is the current standard for evaluating postoperative joint replacements. Prior to application, such imaging methods need to be validated to determine the lower limits of performance under ideal conditions, using either a phantom or cadaver setup. Conventionally manufactured orthopedic implants for use in such studies are not always accessible and may be cost-prohibitive to purchase. We propose the use of additively manufactured implants as a cheaper, more accessible alternative for use in radiographic imaging validation studies. Bias and repeatability were compared between conventionally manufactured and additively manufactured reverse total shoulder implant sets under a standard model-based radiostereometric analysis phantom study environment. Measurements were compared using the humeral stem or glenosphere model relative to reference bone beads, and the humeral stem relative to the glenosphere model to measure implant relative displacement. Compared to the conventionally manufactured implants, the additively manufactured implants had less bias along the internal-external rotation axis (p < 0.001), but greater bias along the abduction-adduction and flexion-extension rotation axes (p = 0.005, 0.011). Additively manufactured implants had greater repeatability along the internal-external rotation axis (p < 0.001), but worse repeatability along the medial-lateral translation axis (p = 0.001) and the abduction-adduction rotation axis (p < 0.001). Differences were on the orders of 0.01 mm and 0.5°. For the purpose of validating two-dimensional-three-dimensional radiographic imaging techniques of orthopedic implants, additively manufactured implants can be used in place of conventionally manufactured implants, assuming they are fabricated to the manufacturer's specifications. Observed differences were within the errors of the measurement technique and not clinically meaningful.

CORR Insights®: Superior Baseplate Inclination Is Associated With Instability After Reverse Total Shoulder Arthroplasty.

CORR Insights®: Superior Baseplate Inclination Is Associated With Instability After Reverse Total Shoulder Arthroplasty.

Outcomes of shoulder arthroplasty in diabetic patients as assessed by peri-operative A1C.

Although diabetes mellitus (DM) has an adverse effect on complication rates in orthopaedic surgery, neither the effect of DM nor the association between haemoglobin A1C (HbA1C) and outcomes after shoulder arthroplasty (SA) has been studied. A retrospective review of 406 SAs (70 HAs, 188 total shoulder arthroplasties [TSAs], 148 reverse total shoulder arthroplasties [RSAs]) with HbA1Cs within 90days of surgery was conducted. The average age was 70years (range 27-97) and 55% were female. The average peri-operative HbA1C was 6.4% (range 4.7-9.8%), with 104 (26%) having a HbA1C of 7.0% or greater. Kaplan-Meier curves were constructed to determine complication, re-operation, and revision rates at two, five and tenyears post-operatively. At mean follow-up of fouryears, 58 (16.5%) SAs were associated with post-operative complications including six (1.5%) infections. Kaplan-Meier two and fiveyear survivorship free of any complication was 87.3 and 82.6% and of infection was 95.8 and 90.9%, respectively. Thirty-two (7.9%) SAs required reoperation with 26 (6.4%) of these being revisions. Survivorship at two and fiveyears post-operatively was 97.1 and 92.7% for re-operation and 98.6 and 98.2% for revision, respectively. No increased risk of complications, re-operation, revision, or infection was seen with increased HbA1C analyzed as a continuous variable (hazard ratio = 0.97-1.11, 95% CI = 0.28-3.94, p = 0.5882-0.9445) or as a dichotomous variable with a cutoff of 7.0% (hazard ratio = 1.02-1.47, 95% CI = 0.20-7.48, p = 0.3253-0.9544). A collaborative and comprehensive approach to the pre-operative medical evaluation of patients with DM is critical, as is future investigation into alternative methods associated with outcomes after shoulder arthroplasty in patients with DM. Level IV.

Reverse Total Shoulder Arthroplasty in Proximal Humeral Fractures

Primary reverse total shoulder arthroplasty was performed in 13 patients, aged 65 – 83 years, with three- and four-part (by Neer classification) proximal humeral fractures. Rotator cuff injuries and shoulder contractures of various degrees were present in all patients. Surgical technique and postoperative rehabilitation program were described in details. Treatment results were assessed roentgenologically by Constant-Murley score in 6 months, 1, 2 and 3 years after intervention. Reverse total shoulder arthroplasty enabled to achieve good functional outcomes and considerable pain relief even in elderly patients with compound fractures and rotator cuff injuries.

Bony Increased Offset-Reversed Shoulder Arthroplasty (BIO-RSA).

Bony increased offset-reversed shoulder arthroplasty (BIO-RSA) is an effective and safe means of achieving lateralization of the prosthetic center of rotation in reverse shoulder arthroplasty. Confirm the indication for surgery and obtain radiographs and 3-dimensional (3D) imaging (computed tomography [CT] or magnetic resonance imaging [MRI] scans) to confirm the suitability for a BIO-RSA. With the patient in the beach-chair position, approach the shoulder via a standard deltopectoral approach. Dislocate the humeral head anteriorly and use the instrumentation to harvest a 29-mm fully cancellous graft of desired thickness from the humeral head. Carefully and meticulously expose and prepare the glenoid for prosthetic implantation. Prepare and implant the humeral prosthesis as per the standard surgical technique described for implantation of the Aequalis Reversed prosthesis10. Postoperative management is the same as that for a nonlateralized reverse prosthesis, with no alteration in rehabilitation required. In our original series of 42 patients with a minimum follow-up of 2 years (mean, 28 months), the glenoid bone graft incorporated completely in 41 patients and partially in 1 patient (Fig. 5)6.

Reverse total shoulder arthroplasty in proximal humeral fractures

Primary reverse total shoulder arthroplasty was performed in 13 patients, aged 65 - 83 years, with three- and four-part (by Neer classification) proximal humeral fractures. Rotator cuff injuries and shoulder contractures of various degrees were present in all patients. Surgical technique and postoperative rehabilitation program were described in details. Treatment results were assessed roentgenologically by Constant-Murley score in 6 months, 1, 2 and 3 years after intervention. Reverse total shoulder arthroplasty enabled to achieve good functional outcomes and considerable pain relief even in elderly patients with compound fractures and rotator cuff injuries.

Irreparable Tears: The Role for Debridement or Partial Rotator Cuff Repair

Management of massive, retracted rotator cuff tear repair is a difficult task without a consensus algorithm for treatment. Although nonoperative management is appropriate in certain patients, surgical treatment is advocated for younger, more active patients or those with persistent pain. Aggressive surgical options such as rotator cuff repair with patch augmentation, tendon transfers, and reverse total shoulder arthroplasty are options for many patients in which complete anatomical repair of the massive rotator cuff tear is not always surgically possible because of poor tissue quality, tendon loss, severe retraction, or increased tension of the repair. Debridement of the rotator cuff or partial rotator cuff repair offer viable options for patients with goals of pain relief and improvement in range of motion. Although partial repair often does not restore full strength, most patients are satisfied with their overall improvement in function.

Reverse shoulder arthroplastyの術後成績不良例の検討

Reverse shoulder arthroplastyの術後成績不良例の検討

Subscapularis tendon management during anatomic and reverse total shoulder arthroplasty

Subscapularis tendon management during anatomic and reverse total shoulder arthroplasty

Arthroplasty treatment of proximal humerus fractures: 14-year trends in the United States

ABSTRACTObjectives: Proximal humerus fractures are a common injury in the elderly population that can usually be managed non-operatively. However, arthroplasty has become increasingly utilized for complex fractures and poor bone quality. We evaluated national trends in treatment, specifically looking at the adoption of reverse total shoulder arthroplasty.Methods: The incidence of proximal humerus fractures was calculated from the Nationwide Emergency Department Database (NEDD) from 2006 to 2012. The Nationwide Inpatient Sample (NIS) was used to select patients from 2000 to 2013 with proximal humerus fractures treated with open reduction and internal fixation (ORIF), total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), and hemiarthroplasty (HSA). RSA and TSA shared the same ICD-9 code until 2010.Results: The incidence of proximal humerus fracture was stable from 2006 to 2012. Hemiarthroplasty was the majority treatment choice for arthroplasty in the early 2000’s. However, in 2008, there was a large decrease in utilization, to 51.3% in 2013. During this period, utilization of TSA greatly increased, coinciding with a large increase of RSA. By 2013, RSA made up 45.1% of arthroplasty procedures.Conclusion: The rate of proximal humerus fracture appears stable, while we observed both an overall increase in operative intervention. RSA appears to be increasingly chosen over HSA for arthroplasty treatment of proximal humerus fractures, an observation more pronounced in older patients. While clinical results appear promising, it is important to remember that most proximal humerus fractures may be treated successfully with conservative management, and rapid adoption of new technology should be watched carefully to ensure appropriate use.

Impact of Shoulder Sonography on Clinical Decision Making.

To assess the impact of musculoskeletal shoulder sonography (US) on clinical decision making. This Health Insurance Portability and Accountability Act-compliant retrospective study received Institutional Review Board approval with a waiver of informed consent. Consecutive musculoskeletal shoulder US examinations ordered over a 12-month period were retrospectively reviewed. The medical records of each patient were analyzed, recording immediate pre- and post-US treatment plans. Treatment plans were categorized as follows: 1, no further treatment; 2, conservative management/physical therapy; 3, therapeutic injection; 4, surgical intervention; 5, change in diagnosis; and 6, need additional imaging. Data were analyzed by nonparametric statistical methods. A total of 935 patient examinations met inclusion criteria. Of 935 patients, 591 (63.2%) had a post-US treatment plan that differed from pre-US treatment, showing a statistically significant impact on patient treatment (P < .001). In 744 of the 935 examinations (79.6%), the treating physician initially prescribed conservative therapy as a treatment plan; 423 of those 744 patients (56.9%) were subsequently prescribed a more invasive form of treatment. Of the remaining 191 of 935 patients (20.4%) initially treated with invasive treatment, 101 (52.9%) received a change in the treatment plan after the US examinations, with 46 patients (24.1%) relegated to noninvasive treatment. Sonography also played a role in surgical planning, with 25 studies (2.7%) specifically performed to evaluate rotator cuff integrity when deciding between conventional and reverse shoulder arthroplasty. Musculoskeletal shoulder US has a substantial impact on clinical decision making and patient treatment.

2017

Complex proximal humerus fractures in elderly patients represent a difficult problem for orthopaedic surgeons. Classically, treatment methods have included nonoperative management, open reduction and internal fixation, and hemiarthroplasty. Outcomes of nonoperative management for these complex fractures have been poor, and results of traditional operative techniques are variable at best. Over the past several years, reverse total shoulder arthroplasty (RTSA) has been increasingly employed in these injuries with encouraging results. RTSA may represent a valuable treatment option for select patients. This article reviews the existing data on RTSA in the treatment of complex proximal humerus fractures in the elderly population as well as the authors' experience with this technique.

Custom Reverse Total Shoulder Arthroplasty

Reverse total shoulder arthroplasty (rTSA) initially faltered because of glenoid component failure. Modern design utilizes a large glenosphere component and relies upon a functional deltoid for arm elevation. We report novel use of rTSA to revise a chronically dislocating TSA. The patient underwent proximal humeral resection for chondrosarcoma, requiring sacrifice of the deltoid and all proximal insertions including the latissimus dorsi. Twoyears post-operatively, he had good stability, no pain, and was using his arm more than he had in years. rTSA is a salvage option for failed TSA, even with absent deltoid function and lack of a latissimus.

In vivo fracture of a reverse total shoulder replacement humeral tray: A case report

Failure analysis was performed for two humeral tray components which fractured in vivo after only 6 and 9 months. Implant retrieval analysis indicated that the components failed due to fatigue failure initiating from a small radius fillet at the interface of the trunnion and tray regions. Finite element simulations revealed the small radius fillet to have resulted in a large stress concentration and confirmed the possibility for fatigue failure in 6 months. The stress concentration caused by both the small radius fillet and the insufficient tray thickness contributed to the premature fatigue failure of the humeral trays.

Changes in Driving Performance Following Shoulder Arthroplasty.

With this study, we sought to quantify perioperative changes in driving performance among patients who underwent anatomic or reverse shoulder arthroplasty. Using a driving simulator, 30 patients (20 anatomic and 10 reverse total shoulder arthroplasties) were tested preoperatively and at 2 weeks (PO2), 6 weeks (PO6), and 12 weeks (PO12) postoperatively. The total number of collisions, centerline crossings, and off-road excursions (when the vehicle traversed the lateral road edge), and scores on a visual analog scale (VAS) for pain and the Shoulder Pain and Disability Index (SPADI) were recorded at each driving trial. The mean number of collisions increased from 5.9 preoperatively to 7.4 at PO2 and subsequently decreased to 5.6 at PO6 and 4.0 at PO12 (p = 0.0149). In addition, the number of centerline crossings decreased from 21.4 preoperatively to 16.3 at PO12 (p < 0.05). Multivariate analysis of the data demonstrated that increased VAS for pain scores, older age, and less driving experience had a negative impact on driving performance. Driving performance returned to preoperative levels at 6 weeks after shoulder arthroplasty. By 12 weeks postoperatively, patients demonstrated improved driving performance compared with preoperative performance. On the basis of our findings, clinicians can suggest a window of 6 to 12 weeks postoperatively for the gradual return to driving. However, for patients of older age, with less driving experience, or with greater pain, a return to driving at closer to 12 weeks postoperatively should be recommended. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

ASSESMENT OF KEY PARAMETERS ON THE PERFORMANCE OF THE DELTOID MUSCLE IN REVERSE SHOULDER ARTHROPLASTY — A MODELING AND SIMULATION-BASED STUDY

Reverse shoulder arthroplasty (RSA), in which anatomic concavities of glenohumeral (GH) joint are inverted, is a popular treatment of arthritic shoulders with deficient rotator cuff. The correct positioning of the glenohumeral center of rotation and initial setting of the deltoid length (Deltoid Tension) plays an important role in the outcome of the RSA. A study of the key literature has shown that despite common use of RSA, its biomechanical characteristics during motion are not fully understood. This study investigates the influence of some of the key parameters on the intensity of the moment in a shoulder after RSA during abduction in scapular plane. The kinematics after RSA are then compared with the anatomic shoulder kinematics and differences are discussed. Mathematical models of both the anatomical and reverse shoulder (RS) were developed in MATLAB and in MSC ADAMS. The anatomical and RSA geometries were defined using measurements obtained from X-ray and magnetic resonance imaging (MRI) images of the shoulder girdle. The results show that in RSA, the intensity of the moment generated in the GH joint improves. However, this improvement does not show a constant trend and its intensity can dramatically decrease in higher GH joint abduction.

Current Controversies in Reverse Total Shoulder Arthroplasty.

Reverse total shoulder arthroplasty can restore forward elevation in pseudoparalytic shoulders, can reduce pain, and can increase quality of life for patients; however, there are a number of issues with regard to the design and ideal implantation technique of reverse total shoulder arthroplasties that remain controversial. Glenospheres with a Grammont, medialized center of rotation and designs with a more lateralized center of rotation have specific pros and cons. Medialized designs have historically decreased glenosphere loosening but increase scapular notching, and lateralized designs decrease notching and improve range of motion but historically have resulted in increased baseplate failure. As such, a concrete conclusion with regard to medialization or lateralization of the glenosphere cannot be made at this time. Caudal, inferior placement of the glenosphere increases internal rotation, external rotation, abduction, and adduction while reducing notching. Superior baseplate positioning and tilt are correlated with baseplate failure and therefore should be avoided. It remains unclear whether neutral or slightly inferior tilt is preferred. The ideal humerosocket inclination angle remains unclear. The 135[degrees] designs appear to have a lower rate of scapular notching than the Grammont-style 155[degrees] humerosockets. The implications of this angle for instability remain unclear as, to our knowledge, there have been no randomized comparisons and the largest meta-analysis was confounded by other implant variables.