Introduction Overview reverse shoulder arthroplasty (RSA) is a type of shoulder arthroplasty that uses a convex glenoid (hemispheric ball) and a concave humerus (articulating cup) to reconstruct the glenohumeral joint center of rotation (COR) is moved inferiorly and medialized allows the deltoid muscle to act on a longer fulcrum and have more mechanical advantage therefore, deltoid must be functional Epidemiology popularized in Europe and now increasingly used in North America since 1990 Outcomes results are dependent on indication, with cuff tear arthropathy (CTA) having the best results some cases series' have noted 10 year survivability is approximately 90% for implant retention radiographic results deteriorate after 6 years and clinical results after 8 years various studies have shown that complication rate amongst surgeons decrease after a surgeon has performed at least 18-45 cases Biomechanics The advantage of a reverse shoulder arthroplasty is that the center of rotation (COR) is moved inferiorly and medialized allows the deltoid muscle to act on a longer fulcrum and have more mechanical advantage to substitute for the deficient rotator cuff muscles to provide shoulder abduction allows increased (but not normal) shoulder abduction does not significantly help shoulder internal or external rotation Reverse shoulder arthroplasty can be combined with latissimus dorsi transfer to assist with external rotation Indications and Contraindications Indications clinical conditions cuff-tear arthropathy severe glenohumeral joint arthritis with superior escape in the setting of a massive rotator cuff tear pseudoparalysis an inability to actively elevate the arm in the presence of free passive ROM and in the absence of a neurologic lesion occurs secondary to irreparable rotator cuff tear in setting of glenohumeral arthritis antero-superior escape incompetent coracoacromial arch humeral "escape" in subcutaneous tissue with hemiarthroplasty proximal humerus fractures in the elderly 3 or 4-part fractures in patients age > 70 head-splitting fractures significant osteopenia or poor bone quality where GT has poor potential for healing rotator cuff insufficiency 'equivalent' non-union or mal-union of the tuberosity following trauma or prior arthroplasty failed arthroplasty when all other options have been exhausted rheumatoid arthritis only if glenoid bone stock is sufficient patient characteristics (in clinical conditions above) low functional demand patients physiological age >70 sufficient glenoid bone stock working deltoid muscle intact axillary nerve Contraindications permanent axillary nerve dysfunction global deltoid deficiency partial deltoid deficiency is a relative contraindication but RSA may give reasonable results bony acromion deficiency glenoid osteoporosis active infection Pre-operative Imaging Radiographs recommended views true AP (Grashey) determine extent of arthritis and look for superior migration of humerus axillary lateral look for posterior glenoid wear scapular-Y CT scan indications If unable to obtain an adequate axillary lateral, CT can be useful to determine glenoid version and glenoid bone stock estimate degree of osteopenia MRI indications evaluate rotator cuff integrity and fatty infiltration Approach deltopectoral advantages: preserves deltoid muscle exposure of the lower pole of the glenoid to facilitate glenoid implant positioning can extend inferiorly for increase exposure to proximal humerus if needed can perform a simutlatenous latissimus dorsi transfer if needed decreased risk of axillary nerve palsy disadvantages need to take-down subscapularis for adequate exposure need for extensive capsular release which may lead to instability lack of exposure to posterior glenoid potential for stiffness given immobilization required for subscapularis healing anterosuperior method the anterior deltoid is divided from the anterior edge of the acromioclavicular arch, allowing increased glenoid exposure. advantages increased glenoid exposure able to preserve subscapularis decreased post-operative instability due to preservation of anterior stabilizers ease of axial preparation of the humerus easier fixation of greater tuberosity for fractures disadvantages increased risk of injury to distal branches of axillary nerve violates anterior deltoid muscle risk of excess height or superior tilt of glenoid Technical considerations Technique humeral preparation humeral head typically osteotomized anywhere between 0 and 30 degrees of retroversion (typically 20) more retroversion is gaining popularity as it may improve post-op external rotation humeral head can be saved for autograft if needed osteotomy generally not needed in setting of fracture long head of biceps is tenotomized or tenodesed ream and broach humerus similar to conventional TSA the humeral height and version typically judged by humeral calcar or tuberosity fragment if calcar missing in the setting of fracture, height can be judged by pectoralis insertion which resides 5.6 cm from top of fractured humeral head glenoid preparation labrum is excised and capsule is released circumferentially important to expose inferior glenoid by subperiosteally elevating tissue to ensure proper baseplate positioning accurate central guidewire placement is dictated by availability of the best bone stock for baseplate screw fixation place baseplate as inferiorly as possible with an inferior tilt shown to decrease implant loosening and scapular notching navigation systems increasingly used for accurate baseplate placement superior screw is generally aimed toward coracoid base and inferior screw aimed towards scapular body mount glenosphere onto baseplate size chosen based on patient size, motion and preservation of stability females/smaller pateints typically recieve a 36 mm and large men recieve a 40 mm. tuberosity repair anatomic repair of the greater tuberosity is associated with improved shoulder external rotation, function and patient satisfaction compared to tuberosity resection or malunion Rehabilitiation patient placed in sling post-op passive or active-assisted motion only during early rehab sling discontinued at 3 weeks if subscapularis is NOT repaired, and 6 weeks if subscapularis is repaired limit passive ER or active IR during this time avoid pushing out of chair during acute rehab subscapularis re-tear would lead to anterior shoulder instability treatement early exploration and repair Complications Scapular notching incidence occurs in 44%-96% of grammont style prosthesis decreased incidence with lateralization of baseplate related to impingement by the medial rim of the humeral cup during adduction risk factors superiorly placed glenoid component superior tilt of glenoid component medialization of center of rotation high BMI Dislocation incidence reported rate between 2% - 3.4% risk factors irreparable subscapularis (strongest risk) proximal humeral bone loss failed prior arthroplasty proximal humeral nonunion fixed pre-operative glenohumeral dislocation Glenoid Loosening incidence glenoid prosthetic loosening is most common mechanism of failure incidence significantly increases (~25% at 5-year followup) after revision RSA treatment treat using staged procedure to fill glenoid cavity with autogenous bone and await incorporation with a hemiarthroplasty prior to reimplantation of a new glenosphere Deep Infection incidence 1-2% risk of deep surgical cite infection following shoulder arthroplasty susceptible to infection due to large subacromial dead space created by reverse prosthesis most common organisms include c.acnes and staphylococci Risk Factors Younger age (less than 65) and male are the greatest risk factors Reverse Arthroplasty for traumatic reasons History of failed arthroplasty treatment 2-stage revision is considered gold standard most common antibiotic treatment of choice for c.acnes is vancomycin and clindamycin Acromial or scapular spine fractures incidence 4% after RSA treatment conservative management leads to 40-50% union rate operative management with ORIF or tension band wiring of acroimal fractures has increased union rates Neurapraxia of axillary nerve incidence 0.5-1% rate after RSA risk factors anterosuperior approach humerus lengthening treatment usually transient Sirveaux Classification of Scapular Notching Grade 1 limited to scapular pillar Grade 2 in contact with inferior screw of baseplate Grade 3 beyond the inferior screw Grade 4 extends under baseplate approaching central peg
Technique Guide CPT Codes: 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC. Reverse Total Shoulder Arthroplasty Orthobullets Team Shoulder & Elbow - Rotator Cuff Arthropathy
QUESTIONS 1 of 27 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE13BS.52) Reverse total shoulder arthroplasty improves kinematics in the rotator cuff deficient joint by what directional change to the center of rotation? Tested Concept QID: 8289 Type & Select Correct Answer 1 Medial 75% (293/389) 2 Lateral 23% (91/389) 3 Posterior 1% (3/389) 4 Proximal 1% (2/389) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ13.166) A 55-year-old male returns for followup 3 months after reverse shoulder arthroplasty. He reports limited function of his right shoulder but no antecedent trauma. A radiograph of his shoulder is shown in Figure A. All of the following variables are associated with this complication EXCEPT: Tested Concept QID: 4801 FIGURES: A Type & Select Correct Answer 1 History of malunited proximal humerus fracture 17% (671/3874) 2 Proximal humeral bone loss 8% (301/3874) 3 Failed primary arthroplasty 8% (319/3874) 4 Rheumatoid arthritis 60% (2308/3874) 5 Fixed preoperative glenohumeral dislocation 6% (250/3874) L 4 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.102) A 75-year-old male with 2 previous rotator cuff repairs has persistent shoulder pain and active forward elevation to 60 degrees. He has normal deltoid function with a positive lift-off test. Radiographs and coronal MRI of his shoulder are found in Figures A through C. Which of the following treatment options is most appropriate? Tested Concept QID: 3525 FIGURES: A B C D Type & Select Correct Answer 1 Revision supraspinatus repair 1% (15/2287) 2 Shoulder hemiarthroplasty 2% (46/2287) 3 Total shoulder arthroplasty 3% (62/2287) 4 Reverse total shoulder arthroplasty 92% (2107/2287) 5 Latissimus transfer 2% (49/2287) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ11.231) An 79-year-old male presents with longstanding left shoulder pain and difficulty with raising his arm over his head. His exam shows wasting of the deltoid and obvious scapular dysrhythmia on the left side. He lacks the ability to do any forward flexion or external rotation in his left shoulder. He can internally rotate without difficulty. His radiograph and MRI images are seen in figures A and B respectively. He wants to know if he is a candidate for a reverse shoulder arthroplasty (RSA). Which of the following answer choices is the MOST appropriate response? Tested Concept QID: 3654 FIGURES: A B Type & Select Correct Answer 1 He is a candidate for RSA due to rotator cuff tear arthropathy 11% (308/2858) 2 He is a candidate for RSA due to ability to internally rotate 1% (22/2858) 3 He is not a candidate for RSA due to deltoid dysfunction 86% (2468/2858) 4 He is not a candidate for RSA due to massive rotator cuff tear 1% (40/2858) 5 He is not a candidate for RSA due to his age 0% (4/2858) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (OBQ11.87) Superior placement of the baseplate during reverse shoulder arthroplasty is a known technical risk factor for which of the following complications? Tested Concept QID: 3510 Type & Select Correct Answer 1 Inferior acromial erosion 7% (319/4492) 2 Humeral component loosening 2% (90/4492) 3 Infection 0% (12/4492) 4 Inferior scapular notching 82% (3681/4492) 5 Superior scapular notching 8% (371/4492) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ10.274) Deltoid denervation is a contraindication to which of the following procedures? Tested Concept QID: 3362 Type & Select Correct Answer 1 C5-6 anterior cervical diskectomy and fusion 1% (16/2463) 2 Reverse total shoulder arthroplasty 98% (2402/2463) 3 Shoulder arthrodesis 0% (11/2463) 4 Biceps tenodesis 0% (10/2463) 5 Arthroscopic subacromial decompression 1% (17/2463) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review tested concept (OBQ09.9) What technical error leads to scapular notching after reverse total shoulder arthroplasty? Tested Concept QID: 2822 Type & Select Correct Answer 1 Superior placement of the glenoid component 69% (460/666) 2 Retroverted placement of the glenoid component 8% (52/666) 3 Inferior placement of the glenoid component 15% (97/666) 4 Overtensioning of the soft tissue envelope 1% (7/666) 5 Inferior tilt of the glenoid component 6% (41/666) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ08.199) A 76-year-old man has a two-year history of shoulder pain which no longer responds to non-operative treatments. A radiograph is shown in Figure A. He has forward flexion to 80 degrees and abduction to 70 degrees. An example of his belly push examination is shown in Figure B. What is the most appropriate surgical procedure? Tested Concept QID: 585 FIGURES: A B Type & Select Correct Answer 1 Arthroscopic debridement and subacromial decompression 3% (35/1156) 2 Open rotator cuff repair 1% (9/1156) 3 Total shoulder arthroplasty 14% (165/1156) 4 Reverse shoulder arthroplasty 81% (936/1156) 5 Shoulder arthrodesis 0% (2/1156) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept (OBQ08.231) Which of the following patients would be the most appropriate candidate for a reverse total shoulder replacement? Tested Concept QID: 617 Type & Select Correct Answer 1 A 71-year-old man with a massive rotator cuff tear, glenohumeral arthritis, and forward elevation to 40 degrees 82% (740/906) 2 A 45-year-old man who has failed 3 rotator cuff repairs and has glenohumeral arthritis 9% (78/906) 3 A 65-year-old man with glenoid wear and pain 10 years following a hemiarthroplasty 4% (33/906) 4 A 72-year-old man with severe glenohumeral arthritis and an intact rotator cuff 6% (50/906) 5 A 30-year-old man with a locked posterior shoulder dislocation 0% (1/906) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review tested concept (OBQ08.73) Early reverse total shoulder designs (before the development of the Grammont-style prosthesis) had a high failure rate due to early loosening of the glenoid component. What biomechanical feature accounted for this problem? Tested Concept QID: 459 Type & Select Correct Answer 1 Glenoid component did not have a neck 9% (69/732) 2 Humeral component too horizontal 5% (39/732) 3 Center of rotation too lateral 61% (443/732) 4 Center of rotation too anterior 8% (57/732) 5 Center of rotation too inferior 16% (118/732) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review tested concept (OBQ06.31) Which of the following patient scenarios is most appropriate for reverse total shoulder arthroplasty? Tested Concept QID: 142 Type & Select Correct Answer 1 A 40-year-old laborer severe glenohumeral arthritis and irrepairable rotator cuff tear. 3% (50/1694) 2 A 40-year-old with a painful proximal humerus malunion. 0% (6/1694) 3 A 75-year-old woman with severe arthritis and active overhead motion. 3% (45/1694) 4 A 75-year-old man with painful arthritis and a massive irrepairable rotator cuff tear 93% (1576/1694) 5 Failed hemiarthroplasty due to significant glenoid wear. 1% (14/1694) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review tested concept
All Videos (36) Podcasts (3) Biomechanical Summary of Reverse Shoulder Arthroplasty Shoulder & Elbow - Reverse Shoulder Arthroplasty 2/23/2020 969 views (4) Login to View Community Videos Login to View Community Videos 2018 Orthopaedic Summit Evolving Techniques Emerging Techniques: How I revise a TSA to RSA - Lawrence V. Gulotta, MD (OSET 2018) Lawrence Gulotta Shoulder & Elbow - Reverse Shoulder Arthroplasty 10/14/2019 154 views (1) 2018 Orthopaedic Summit Evolving Techniques Reverse TSA For Complex Proximal Humeral Fractures - Sumant "Butch" Kirshnan, MD (OSET 2018) Shoulder & Elbow - Reverse Shoulder Arthroplasty 10/14/2019 830 views (2) Question Session⎪Reverse Shoulder Arthroplasty & THA Revision Orthobullets Team Shoulder & Elbow - Reverse Shoulder Arthroplasty Listen Now 26:27 min 11/5/2019 31 plays (0) Shoulder & Elbow ⎜ Reverse Total Shoulder Arthroplasty Team Orthobullets (AF) Shoulder & Elbow - Reverse Shoulder Arthroplasty Listen Now 9:48 min 10/16/2019 43 plays (0) Shoulder & Elbow⎪Reverse Shoulder Arthroplasty Team Orthobullets 4 Shoulder & Elbow - Reverse Shoulder Arthroplasty Listen Now 8:58 min 10/15/2019 222 plays (3) See More See Less
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