DISCLOSURES The following rela.onships exist: 1. Royal.es and stock - - PowerPoint PPT Presentation
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
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
The following rela.onships exist:
DJO Surgical Lippinco?, Williams & Wilkins
DJO Surgical Cayenne (Zimmer-Biomet)
DJO Surgical Cayenne (Zimmer-Biomet)
Mahure et al, submitted
Kim et al, 2011
Hemiarthroplasty
a TSA 5%
r TSA 17%
Revision 14%
severe arthropathy
rotator cuff shoulder joint
v Patients must have a functional deltoid muscle
➢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
➢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
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.
ØJ Shoulder Elbow Surg. 2016
> Armstrong AD, et al. Penn State - Hershey
ØPE; U/S; EMG - 30 patients Ø6 - + liftoff test Ø2 - rupture by U/S Ø15 chronic denervation (30% subscap)
Ø1600 patients - 15-91 yrs old - 6 mo re-tear rate Ø < 50 yo = 5% Ø 50 - 59 yo = 10% Ø 60 - 69 yo = 15% Ø 70 - 79 yo = 25% Ø > 80 yo = 34%
Ø Results generally poor - best to avoid Ø Sanchez-Sotelo et al. (JBJS ’03); Subscapularis repair, component revision, and humeral head exchange - 5/9 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.
➢ 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
➢ J Shoulder Elbow Surg. 2016 Jun ➢ Sports after shoulder arthroplasty: a comparative analysis
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
➢ 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,
➢51 RC Arthropathy; 15 Severe OA ➢ 99% 2yr and 91% 5yr survival ➢No difference in complications ➢18% Notching; 3% Instability; No loosening
➢ 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
Ø42/95 Original 5 yr Patients Ø91% Survivorship Ø2 revisions Ø1 Periprosthetic Fx Ø1 Dislocation ØNo Diminishment in ASES, ASES pain, SST
➢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
➢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
➢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
➢2013 - 99 rTSA 13 aTSA ➢2014 - 125 rTSA 12 aTSA ➢2015 - 146 rTSA 5 aTSA ➢2016 - 192 rTSA 2 aTSA
6 Months Postop
➢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
➢rTSA
arthropathy
cuff shoulder joint
➢aTSA ➢Indication - OA with excellent RC fx - min glenoid deformity
➢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!
REVERSE IS KING!