Updated: 7/14/2019

Reverse Shoulder Arthroplasty

Topic
Review Topic
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Questions
23
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Evidence
21
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Videos
33
Cases
1
Techniques
1
https://upload.orthobullets.com/topic/3076/images/reverse ball.jpg
https://upload.orthobullets.com/topic/3076/images/scapularnotching.jpg
https://upload.orthobullets.com/topic/3076/images/scapno.jpg
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 '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
    • 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

 

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Technique Guides (1)
Questions (23)
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(SAE13BS.52) Reverse total shoulder arthroplasty improves kinematics in the rotator cuff deficient joint by what directional change to the center of rotation? Review Topic

QID: 8289
1

Medial

77%

(103/133)

2

Lateral

21%

(28/133)

3

Posterior

0%

(0/133)

4

Proximal

1%

(1/133)

ML 2

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PREFERRED RESPONSE 1
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(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:
1

Revision supraspinatus repair

1%

(13/1789)

2

Shoulder hemiarthroplasty

2%

(43/1789)

3

Total shoulder arthroplasty

3%

(49/1789)

4

Reverse total shoulder arthroplasty

92%

(1641/1789)

5

Latissimus transfer

2%

(38/1789)

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

1%

(12/2149)

2

Reverse total shoulder arthroplasty

98%

(2099/2149)

3

Shoulder arthrodesis

0%

(9/2149)

4

Biceps tenodesis

0%

(9/2149)

5

Arthroscopic subacromial decompression

1%

(13/2149)

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.

3%

(43/1248)

2

A 40-year-old with a painful proximal humerus malunion.

0%

(6/1248)

3

A 75-year-old woman with severe arthritis and active overhead motion.

3%

(33/1248)

4

A 75-year-old man with painful arthritis and a massive irrepairable rotator cuff tear

92%

(1151/1248)

5

Failed hemiarthroplasty due to significant glenoid wear.

1%

(13/1248)

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:
1

He is a candidate for RSA due to rotator cuff tear arthropathy

11%

(281/2617)

2

He is a candidate for RSA due to ability to internally rotate

1%

(18/2617)

3

He is not a candidate for RSA due to deltoid dysfunction

87%

(2267/2617)

4

He is not a candidate for RSA due to massive rotator cuff tear

1%

(35/2617)

5

He is not a candidate for RSA due to his age

0%

(3/2617)

ML 1

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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%

(291/4099)

2

Humeral component loosening

2%

(84/4099)

3

Infection

0%

(11/4099)

4

Inferior scapular notching

82%

(3364/4099)

5

Superior scapular notching

8%

(332/4099)

ML 2

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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

68%

(339/501)

2

Retroverted placement of the glenoid component

9%

(44/501)

3

Inferior placement of the glenoid component

15%

(74/501)

4

Overtensioning of the soft tissue envelope

1%

(5/501)

5

Inferior tilt of the glenoid component

6%

(32/501)

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:
1

Arthroscopic debridement and subacromial decompression

4%

(33/865)

2

Open rotator cuff repair

1%

(8/865)

3

Total shoulder arthroplasty

15%

(130/865)

4

Reverse shoulder arthroplasty

79%

(687/865)

5

Shoulder arthrodesis

0%

(2/865)

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%

(470/570)

2

A 45-year-old man who has failed 3 rotator cuff repairs and has glenohumeral arthritis

7%

(41/570)

3

A 65-year-old man with glenoid wear and pain 10 years following a hemiarthroplasty

3%

(19/570)

4

A 72-year-old man with severe glenohumeral arthritis and an intact rotator cuff

6%

(37/570)

5

A 30-year-old man with a locked posterior shoulder dislocation

0%

(1/570)

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%

(36/469)

2

Humeral component too horizontal

4%

(19/469)

3

Center of rotation too lateral

63%

(294/469)

4

Center of rotation too anterior

6%

(28/469)

5

Center of rotation too inferior

19%

(87/469)

ML 3

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PREFERRED RESPONSE 3
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