Updated: 7/5/2020

Reverse Shoulder Arthroplasty

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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
  • 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

 

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Questions (26)
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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 | Tested Concept

QID: 8289
1

Medial

76%

(229/302)

2

Lateral

23%

(69/302)

3

Posterior

1%

(2/302)

4

Proximal

1%

(2/302)

L 2 D

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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 | Tested Concept

QID: 3525
FIGURES:
1

Revision supraspinatus repair

1%

(14/2125)

2

Shoulder hemiarthroplasty

2%

(45/2125)

3

Total shoulder arthroplasty

3%

(60/2125)

4

Reverse total shoulder arthroplasty

92%

(1953/2125)

5

Latissimus transfer

2%

(46/2125)

L 1 A

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(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 | Tested Concept

QID: 3654
FIGURES:
1

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

11%

(300/2802)

2

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

1%

(21/2802)

3

He is not a candidate for RSA due to deltoid dysfunction

87%

(2425/2802)

4

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

1%

(39/2802)

5

He is not a candidate for RSA due to his age

0%

(4/2802)

L 1 B

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(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 | Tested Concept

QID: 3510
1

Inferior acromial erosion

7%

(312/4394)

2

Humeral component loosening

2%

(89/4394)

3

Infection

0%

(12/4394)

4

Inferior scapular notching

82%

(3600/4394)

5

Superior scapular notching

8%

(363/4394)

L 2 B

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(OBQ10.274) Deltoid denervation is a contraindication to which of the following procedures? Review Topic | Tested Concept

QID: 3362
1

C5-6 anterior cervical diskectomy and fusion

1%

(16/2372)

2

Reverse total shoulder arthroplasty

97%

(2312/2372)

3

Shoulder arthrodesis

0%

(11/2372)

4

Biceps tenodesis

0%

(10/2372)

5

Arthroscopic subacromial decompression

1%

(16/2372)

L 1 B

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(OBQ09.9) What technical error leads to scapular notching after reverse total shoulder arthroplasty? Review Topic | Tested Concept

QID: 2822
1

Superior placement of the glenoid component

69%

(411/597)

2

Retroverted placement of the glenoid component

8%

(49/597)

3

Inferior placement of the glenoid component

14%

(86/597)

4

Overtensioning of the soft tissue envelope

1%

(6/597)

5

Inferior tilt of the glenoid component

6%

(38/597)

L 2 B

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(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 | Tested Concept

QID: 585
FIGURES:
1

Arthroscopic debridement and subacromial decompression

3%

(34/1105)

2

Open rotator cuff repair

1%

(9/1105)

3

Total shoulder arthroplasty

14%

(156/1105)

4

Reverse shoulder arthroplasty

81%

(895/1105)

5

Shoulder arthrodesis

0%

(2/1105)

L 1 A

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(OBQ08.231) Which of the following patients would be the most appropriate candidate for a reverse total shoulder replacement? Review Topic | Tested Concept

QID: 617
1

A 71-year-old man with a massive rotator cuff tear, glenohumeral arthritis, and forward elevation to 40 degrees

82%

(660/806)

2

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

8%

(66/806)

3

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

4%

(30/806)

4

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

6%

(45/806)

5

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

0%

(1/806)

L 1 A

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(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 | Tested Concept

QID: 459
1

Glenoid component did not have a neck

9%

(59/647)

2

Humeral component too horizontal

5%

(34/647)

3

Center of rotation too lateral

61%

(395/647)

4

Center of rotation too anterior

8%

(49/647)

5

Center of rotation too inferior

16%

(105/647)

L 3 C

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(OBQ06.31) Which of the following patient scenarios is most appropriate for reverse total shoulder arthroplasty? Review Topic | Tested Concept

QID: 142
1

A 40-year-old laborer severe glenohumeral arthritis and irrepairable rotator cuff tear.

3%

(47/1539)

2

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

0%

(6/1539)

3

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

2%

(37/1539)

4

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

93%

(1434/1539)

5

Failed hemiarthroplasty due to significant glenoid wear.

1%

(13/1539)

L 1 B

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