Introduction Use of a convex glenoid (hemispheric ball) and 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 History popularized in Europe and now increasingly used in North America Indications Indications clinical conditions CTA 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 acute 3 or 4-part proximal humerus fractures in the elderly where GT has poor potential for healing and bone quality is poor for primary repair rotator cuff insufficiency 'equvialent' 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 deltoid deficiency (axillary nerve palsy) bony acromion deficiency glenoid osteoporosis active infection Biomechanics 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 Surgical Technique Approaches superolateral lower incidence of postoperative instability lower risk of intraoperative scapular spine and acromion fractures deltopectoral better preservation of active external rotation better orientation of glenoid component decreased risk of glenoid loosening and scapular notching often used for revision surgery Technique humeral preparation humeral head typically osteotomized anywhere between 0 and 30 degrees of retroversion more retroversion is gaining popularity as it may improve post-op external rotation long head of biceps is tenotomized ream and broach humerus similar to conventional TSA glenoid preparation labrum is excised and capsule is released circumferentially 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 mount glenosphere onto baseplate 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 Postoperative Care patient placed in sling post-op may allow use of arm for light ADLs (brushing teeth and eating) sling discontinued at 3 weeks if subscapularis is NOT repaired, and 6 weeks if subscapularis is repaired Outcomes There are no high quality long-term outcome studies present in literature 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 Complications Scapular notching common related to impingement by the medial rim of the humeral cup during adduction increased risk with superiorly placed glenoid component, or insufficient inferior tilt of glenoid component on the native glenoid Dislocation reported rate between 2% - 3.4% usually anterior instability increased risk with irreparable subscapularis (strongest risk) proximal humeral bone loss failed prior arthroplasty proximal humeral nonunion fixed glenohumeral dislocation preop NOT related to condition of rotator cuff Glenoid Loosening glenoid prosthetic loosening is most common mechanism of failure 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 susceptible to infection due to large subacromial dead space created by reverse prosthesis most common organisms include propionibacterium acnes and staphylococci Acromion and Scapular Spine Fractures Neurapraxia 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 23 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 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 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? Review Topic QID: 3525 FIGURES: A B C D 1 Revision supraspinatus repair 1% (12/1662) 2 Shoulder hemiarthroplasty 2% (39/1662) 3 Total shoulder arthroplasty 3% (46/1662) 4 Reverse total shoulder arthroplasty 92% (1522/1662) 5 Latissimus transfer 2% (38/1662) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ10.274) Deltoid denervation is a contraindication to which of the following procedures? Review Topic QID: 3362 1 C5-6 anterior cervical diskectomy and fusion 0% (10/2059) 2 Reverse total shoulder arthroplasty 98% (2013/2059) 3 Shoulder arthrodesis 0% (8/2059) 4 Biceps tenodesis 0% (9/2059) 5 Arthroscopic subacromial decompression 1% (12/2059) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (OBQ06.31) Which of the following patient scenarios is most appropriate for reverse total shoulder arthroplasty? Review Topic QID: 142 1 A 40-year-old laborer severe glenohumeral arthritis and irrepairable rotator cuff tear. 4% (42/1096) 2 A 40-year-old with a painful proximal humerus malunion. 1% (6/1096) 3 A 75-year-old woman with severe arthritis and active overhead motion. 3% (30/1096) 4 A 75-year-old man with painful arthritis and a massive irrepairable rotator cuff tear 92% (1003/1096) 5 Failed hemiarthroplasty due to significant glenoid wear. 1% (13/1096) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (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? Review Topic QID: 3654 FIGURES: A B 1 He is a candidate for RSA due to rotator cuff tear arthropathy 11% (277/2529) 2 He is a candidate for RSA due to ability to internally rotate 1% (18/2529) 3 He is not a candidate for RSA due to deltoid dysfunction 86% (2183/2529) 4 He is not a candidate for RSA due to massive rotator cuff tear 1% (35/2529) 5 He is not a candidate for RSA due to his age 0% (3/2529) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (OBQ11.87) Superior placement of the baseplate during reverse shoulder arthroplasty is a known technical risk factor for which of the following complications? Review Topic QID: 3510 1 Inferior acromial erosion 7% (287/3978) 2 Humeral component loosening 2% (80/3978) 3 Infection 0% (11/3978) 4 Inferior scapular notching 82% (3257/3978) 5 Superior scapular notching 8% (326/3978) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ09.9) What technical error leads to scapular notching after reverse total shoulder arthroplasty? Review Topic QID: 2822 1 Superior placement of the glenoid component 65% (298/458) 2 Retroverted placement of the glenoid component 10% (44/458) 3 Inferior placement of the glenoid component 16% (74/458) 4 Overtensioning of the soft tissue envelope 1% (5/458) 5 Inferior tilt of the glenoid component 7% (31/458) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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? Review Topic QID: 585 FIGURES: A B 1 Arthroscopic debridement and subacromial decompression 4% (33/837) 2 Open rotator cuff repair 1% (8/837) 3 Total shoulder arthroplasty 15% (126/837) 4 Reverse shoulder arthroplasty 79% (663/837) 5 Shoulder arthrodesis 0% (2/837) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (OBQ08.231) Which of the following patients would be the most appropriate candidate for a reverse total shoulder replacement? Review Topic QID: 617 1 A 71-year-old man with a massive rotator cuff tear, glenohumeral arthritis, and forward elevation to 40 degrees 82% (457/555) 2 A 45-year-old man who has failed 3 rotator cuff repairs and has glenohumeral arthritis 7% (41/555) 3 A 65-year-old man with glenoid wear and pain 10 years following a hemiarthroplasty 3% (18/555) 4 A 72-year-old man with severe glenohumeral arthritis and an intact rotator cuff 6% (36/555) 5 A 30-year-old man with a locked posterior shoulder dislocation 0% (1/555) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 1 (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? Review Topic QID: 459 1 Glenoid component did not have a neck 8% (33/439) 2 Humeral component too horizontal 4% (16/439) 3 Center of rotation too lateral 62% (274/439) 4 Center of rotation too anterior 7% (29/439) 5 Center of rotation too inferior 19% (82/439) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
Login to View Community Videos Login to View Community Videos 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine Video Spotlight: Reverse Total Shoulder Arthroplasty for Irreparable Rotator Cuff - Evan Lederman, MD (1.33, 2018 Winter SKS) Evan Lederman Shoulder & Elbow - Reverse Shoulder Arthroplasty 7/11/2018 304 views Login to View Community Videos Login to View Community Videos 2018 Winter SKS Meeting: Shoulder, Knee, & Sports Medicine When is Reverse Total Shoulder Arthroplasty the Only Option? - Anthony Romeo, MD (1.32, 2018 Winter SKS) Anthony Romeo Shoulder & Elbow - Reverse Shoulder Arthroplasty 7/11/2018 230 views Login to View Community Videos Login to View Community Videos 2017 Orthopaedic Summit Evolving Techniques Brad Parsons, MD - Spotlight Session non-CME Shoulder & Elbow - Reverse Shoulder Arthroplasty 5/2/2018 104 views See More See Less
P acnes infected shoulder after ORIF and cuff repair (C1410) Shoulder & Elbow - Reverse Shoulder Arthroplasty HPI - 69 male complicated r shoulder hx. Initial proximal humerus fx. Had ORIF. Did ok but developed impingement. Eventually had removal of hardware and rotator cuff repair. Then had p acnes infection. Was treated with IV abx protocol and shoulder wash out twice. Now presents to me with shoulder pain. MRI shows large cysts in humeral head. Aspiration showed continued p acnes infection. I elected to perform two staged reverse tsa. Placed abx spacer. Pain has improved significantly. Infection labs have always been normal. Now do I: Re aspirate? Plan for placement of reverse while obtaining frozen, but will p acnes show up? Place reverse along with calcium sulfate abx beads? How to determine if p acnes infection has been irradicated? 2/12/2013 113 1 5