Reverse Total Shoulder Arthroplasty : The Only Answer for Most Indications and Most Surgeons Patrick St. Pierre, M.D. Director, Shoulder and Elbow Service and Orthopedic Research
DISCLOSURES The following rela.onships exist: 1. Royal.es and stock op.ons DJO Surgical Lippinco?, Williams & Wilkins 2. Consultant DJO Surgical Cayenne (Zimmer-Biomet) 3. Speaker Panels DJO Surgical Cayenne (Zimmer-Biomet)
Shoulder Arthroplasty Utilization increasing 8x Mahure et al, submitted
Arthroplasty and in particular rTSA volumes increasing Kim et al, 2011
UTILIZATION Hemiarthroplasty -15%
UTILIZATION a TSA 5%
UTILIZATION r TSA 17%
UTILIZATION Revision 14%
Indications for Reverse Arthroplasty • Grossly deficient rotator cuff shoulder joint with severe arthropathy • Failed joint replacement with a grossly deficient rotator cuff shoulder joint • Displaced Proximal Humerus Fractures • Rheumatoid Arthritis • Massive Rotator Cuff Tears • OA with B2 glenoid and posterior wear - Walch • Glenoid bone deficiency • Elderly patients with Osteoarthritis v Patients must have a functional deltoid muscle
Anatomic Shoulder Arthroplasty ➢ Why are we talking about Reverse Shoulders for Osteoarthritis? #1 rTSA Outcomes better than expected #2 aTSA Outcomes not always as good as expected > Rotator cuff dysfunction - poorer healing potential > Subscapularis failure > Glenoid loosening
Rotator Cuff Failure ➢ Good result with aTSA — RC heals and functions well ➢ Glenoid wear often leads to fixed posterior subluxation and soft-tissue imbalance ➢ We know that all cuff repairs do not heal — even in the best of circumstances
Subscapularis Failure following aTSA Ø Reported Incidence 1-2 % Late failures….. Ø Critical to do a good repair, but failure can still occur. Ø Successful repairs - some degree of weakness and inability to perform liftoff or belly press test. Ø Underestimated - need to critically look at subscapularis function postoperatively.
Rotator Cuff Function after TSA Ø J Shoulder Elbow Surg. 2016 > Armstrong AD, et al. Penn State - Hershey Ø PE; U/S; EMG - 30 patients Ø 6 - + liftoff test Ø 2 - rupture by U/S Ø 15 chronic denervation (30% subscap)
Ø 1600 patients - 15-91 yrs old - 6 mo re-tear rate < 50 yo = 5% Ø Ø 50 - 59 yo = 10% Ø 60 - 69 yo = 15% 70 - 79 yo = 25% Ø Ø > 80 yo = 34%
Subsequent Repair 50% Ø Results generally poor - best to avoid Ø Sanchez-Sotelo et al. (JBJS ’03); Subscapularis repair, component revision, and humeral head exchange - 5/9 Reverse Shoulder Arthroplasty Success rate. Ø Ahrens, Boileau, Walch (Sauramps Medical ‘01): Repaired the subscapularis, transferred the pectoralis major tendon, and reoriented the humeral and glenoid components in thirty-five shoulders. Less than 50% effective.
➢ Excellent results w rTSA ➢ rTSA is only way to control soft-tissue imbalance and continued fixed posterior subluxation and wear. ➢ Avoid aTSA with B2 glenoid.
Comparison aTSA vs rTSA ➢ J Shoulder Elbow Surg. 2015 Feb ➢ Outcomes after shoulder replacement: comparison between reverse and anatomic total shoulder arthroplasty. Kiet TK, Feeley BT, Naimark M, Gajiu T, Hall SL, Chung TT, Ma CB. ➢ 2 yr f/u - 53 RCA - rTSA; 47 OA - TSA ➢ Complications: 15% TSA; 13% rTSA ➢ Revisions: 11% TSA; 9 % rTSA
Sports after Hemi vs. rTSA ➢ J Shoulder Elbow Surg. 2016 Jun ➢ Sports after shoulder arthroplasty: a comparative analysis of hemiarthroplasty and reverse total shoulder replacement. Liu JN, Garcia GH, Mahony G, Wu HH, Dines DM, Warren RF, Gulotta LV ➢ 102 rTSA - 71 Hemi; 1 yr; questionnaire ➢ RTSports - 85.9% r TSA; 66.7% Hemi ➢ Complaints - 29% rTSA; 63% Hemi
Reverse under 65 ➢ J Shoulder Elbow Surg. 2016 Aug ➢ Primary reverse shoulder arthroplasty in patients aged 65 years or younger. Samuelsen BT, Wagner ER, Houdek MT, Elhassan BT, Sánchez-Sotelo J, Cofield R, Sperling JW. ➢ 51 RC Arthropathy; 15 Severe OA ➢ 99% 2yr and 91% 5yr survival ➢ No difference in complications ➢ 18% Notching; 3% Instability; No loosening
Activity Level following rTSA ➢ J Shoulder Elbow Surg. 2016; ➢ Younger patients report similar activity levels to older patients after rTSA. Walters JD, Barkoh K, Smith RA, Azar FM, Throckmorton, TW. ➢ 17 patients- 58 y/o; 29 patients - 75 y/o questionnaire ➢ 47% vs. 44% maintained high demand activities ➢ Concern about activity level with rTSA may be unwarranted ➢ Patients self-regulate activity
Ø 42/95 Original 5 yr Patients Ø 91% Survivorship Ø 2 revisions Ø 1 Periprosthetic Fx Ø 1 Dislocation Ø No Diminishment in ASES, ASES pain, SST
My Results rTSA results > = aTSA results ➢ Faster Recovery ➢ Equal Activity level: Golf, Tennis, Swimming ➢ No Radiographic or Clinical Failures at 8 years ➢ More revisions of aTSA than rTSA patients over same time period
rTSA for Primary OA ➢ Sep 2011 - Sep 2013 ➢ 165 rTSA; ➢ 58 primary OA ➢ 107 - (Other) RCA, Revision arthroplasty, massive RCT, fractures, fracture sequela ➢ 2 yr f/u — 35 OA/ 61 Other patients; ➢ Age: 65 yo /73 yo ➢ Modified Constant Score: 83/77 ➢ DASH: 6.2/5.7 ➢ FF: 156 deg / 150 deg
rTSA for Primary OA ➢ Complications (OA / Other) ➢ 2 / 1 Acromial Stress Fx ➢ 1 / 2 Instability - 2 reduction - 1 revision ➢ 1 / 0 Glenosphere dissociation - revision ➢ 0 / 0 Deep infections ➢ 78% OA/ 65% able to participate with high demand activity - golf, swimming, tennis, weight lifting
Personal Transition to Reverse Arthroplasty ➢ 2013 - 99 rTSA 13 aTSA ➢ 2014 - 125 rTSA 12 aTSA ➢ 2015 - 146 rTSA 5 aTSA ➢ 2016 - 192 rTSA 2 aTSA
Radiographic Results
6 Months Postop
Shoulder Arthroplasty ➢ Still 70% done by surgeons doing < 12/yr ➢ aTSA more difficult operation to do well ➢ Results based on more variables ➢ Subscapularis and RC healing and fx ➢ Glenoid fixation and wear
Which Shoulder Arthroplasty? ➢ aTSA ➢ Indication - OA with excellent RC fx - min glenoid deformity ➢ rTSA • Grossly deficient rotator cuff shoulder joint with severe arthropathy • Failed joint replacement with a grossly deficient rotator cuff shoulder joint • Displaced Proximal Humerus Fractures • Rheumatoid Arthritis • Massive Rotator Cuff Tears • OA with B2 glenoid and posterior wear • OA
Shoulder Arthroplasty ➢ Reverse shoulder arthroplasty, if done well, can give equal or better results compared with anatomic arthroplasty ➢ Most surgeons should get really good at one arthroplasty ➢ Reverse shoulder - way more versatile!
BATTLE between rTSA and aTSA REVERSE IS KING!
Thank You
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