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RE ST ORAT I ON OF E XT E RNAL ROT AT I ON AF T E R RE VE RSE SHOUL DE R ART HROPL AST Y WI T HOUT L AT I SSI MUS DORSI T RANSF E R De re k D. Be rg lund, MD Sa mue l Ro sa s, MD; Ja c o b J. T riple t, MD; Je

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SLIDE 1

RE ST ORAT I ON OF E XT E RNAL ROT AT I ON AF T E R RE VE RSE SHOUL DE R ART HROPL AST Y WI T HOUT L AT I SSI MUS DORSI T RANSF E R

De re k D. Be rg lund, MD

Sa mue l Ro sa s, MD; Ja c o b J. T riple t, MD; Je nnife r K uro wic ki, MD; Bra ndo n Ho rn, DO; Jo na tha n C. L e vy, MD Ho ly Cro ss Ortho pe dic Re se a rc h I nstitute F

  • rt L

a ude rda le , F L

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SLIDE 2

I (a nd/ or my c o- a uthors) ha ve some thing to disc lose .

De taile d disc losur e infor mation is available via: T he c our se syllabus, or AAOS Disc losur e Pr

  • gr

am on the AAOS we bsite at http:/ / www.aaos.or g/ disc losur e

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SLIDE 3

BACK GROUND

  • E

a rly Gra mmo nt de sig n did no t impro ve E R.

  • I

na b ility o f hume ra l c up to ro ta te a ro und g le no sphe re .

  • L
  • ss o f po ste rio r de lto id re c ruitme nt.
  • De c re a se d E

R musc le te nsio n.

  • Pre -o p infra spina tus a nd/ o r te re s mino r

a tro phy a ffe c te d E R re c o ve ry.

  • So lutio n fo r pa tie nts with CL

E E R:

  • RSA + la tissimus do rsi tra nsfe r

impro ve d E R.

Bo ile a u, CORR, 2008 Bo ile a u, JSE S, 2005

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SLIDE 4

BACK GROUND

  • T

he o re tic a l Ra tio na le fo r L a te ra lize d RSA

  • Re -te nsio ns re ma ining ro ta to r c uff

(Gre ine r e t a l, CORR, 2013)

  • Re c ruits Po ste rio r De lto id (Bo ile a u e t

a l, JSE S, 2005)

  • Gre a te r I

mping e me nt-fre e Mo tio n Ava ila b le (Vira ni e t a l, JSE S, 2013)

F ra nkle , JBJS, 2008

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SLIDE 5

PURPOSE

  • Study purpo se : T
  • a sse ss the e ffe c tive ne ss o f a RSA

syste m tha t la te ra lize s the c e nte r o f ro ta tio n in re sto ring a c tive E R witho ut the use o f la tissimus do rsi tra nsfe r in a sub se t o f pa tie nts with a pre o pe ra tive E R de fic it (E R< 0⁰).

  • Se c o nda ry purpo se : T
  • de te rmine if the fo llo wing

ha ve a n impa c t o n E R:

  • F

a tty infiltra tio n o f E R musc le s.

  • Gle no sphe re la te ra liza tio n.
  • T
  • ta l pro sthe tic la te ra liza tio n.
slide-6
SLIDE 6

ME T HODS

  • Re tro spe c tive re vie w o f I

nstitutio na l Sho ulde r a nd E lb o w Da ta b a se .

  • I

nc lusio n c rite ria

  • Pre -o pe ra tive E

R de fic it (E R< 0⁰)

  • At le a st 2 ye a r fo llo w-up
  • E

xc lusio n c rite ria

  • Simulta ne o us la tissimus do rsi tra nsfe r
  • Re visio n a rthro pla sty
  • Co mb ine d lo ss o f e le va tio n a nd

e xte rna l ro ta tio n (CL E E R)

  • Ro ta to r c uff a rthro pa thy + E

R de fic it

  • No n-CL

E E R

  • E

R de fic it due to po st-tra uma tic e tio lo g ie s

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SLIDE 7

ME T HODS

  • Pre -o pe ra tive va ria b le s
  • Ac tive E

R

  • Pre se nc e o f E

R la g sig n

  • “Ca n yo u pla c e yo ur ha nd b e hind yo ur he a d with

the e lb o w stra ig ht o ut to the side ? ”

  • F

a tty infiltra tio n o f infra spina tus a nd te re s mino r using Go uta llie r c la ssific a tio n

  • Ba se d o n pre -o p CT

sc a n

  • I

ntra -o pe ra tive va ria b le s

  • Gle no sphe re la te ra liza tio n
  • T
  • ta l pro sthe tic la te ra liza tio n = g le no sphe re

la te ra liza tio n + hume ra l a ug me nt la te ra liza tio n + va ria b le thic kne sse s o f the po lye thyle ne c o mpo ne nts

  • Po st-o pe ra tive va ria b le s
  • Ac tive E

R

  • “Ca n yo u pla c e yo ur ha nd b e hind yo ur he a d with

the e lb o w stra ig ht o ut to the side ? ”

  • Sa tisfa c tio n

Wa lc h, JBJS-Br, 1998 F ra nkle , JBJS, 2006

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SLIDE 8

RE SUL T S

  • 33 pa tie nts me t inc lusio n c rite ria
  • All a nswe re d “No ” to “Ca n yo u

pla c e yo ur ha nd b e hind yo ur he a d with the e lb o w stra ig ht o ut to yo ur side ? ”

  • 24 with CL

E E R

  • All ha d E

R la g sig n.

  • 9 No n-CL

E E R

  • 5 ha d E

R la g sig n.

  • Me a n a g e = 74.6 ± 7.2 ye a rs
  • Me a n fo llo w-up = 43.4 ± 15.5 mo nths
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SLIDE 9

RE SUL T S

T able III: Go uta llie r c la ssific a tio n fo r CL

E E R a nd no n-CL E E R pa tie nts.

Va r ia ble

Gro up Numb e r o f Pa tie nts Me a n Go uta llie r Gra de Gra de Gra de 1 Gra de 2 Gra de 3 Gra de 4

Gouta llie r c la ssific a tion for infr a spina tus

CL E E R 2 4 15

3.6 ± 0.7

No n-CL E E R 1 3 3 2

2.6 ± 1.3

Gouta llie r c la ssific a tion for te r e s minor

CL E E R 3 3 6 4 5

2.2 ± 1.4

No n-CL E E R 6 2 1

0.6 ± 1.0

  • CL

E E R g ro up

  • 100% ha d a t le a st Go uta llie r g ra de 2 fo r infra spina tus
  • 71.4% ha d a t le a st Go uta llie r g ra de 2 fo r te re s mino r
  • No n-CL

E E R g ro up

  • 88.9% ha d a t le a st Go uta llie r g ra de 2 fo r infra spina tus
  • 11.1% ha d a t le a st Go uta llie r g ra de 2 fo r te re s mino r
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SLIDE 10

RE SUL T S

E R impro ve me nt

  • Ove ra ll g ro up: -20⁰ to 27⁰
  • CL

E E R g ro up: -21⁰ to 28⁰

  • No n-CL

E E R g ro up: -19⁰ to 26⁰

  • 22 pa tie nts (66.67%) re po rte d

re sto ring a b ility to pla c e ha nd b e hind b a c k with e lb o w to the side .

  • Only 2 pa tie nts ha d a n E

R de fic it po st-o pe ra tive ly.

  • 93.9% o f pa tie nts we re sa tisfie d

with surg e ry.

slide-11
SLIDE 11

RE SUL T S

T able IV: Co rre la tio n b e twe e n Go uta llie r c la ssific a tio n,

g le no sphe re la te ra liza tio n, a nd to ta l pro sthe tic la te ra liza tio n a nd E R impro ve me nt fo r pa tie nts with CL E E R a nd no n-CL E E R pa tie nts.

Va r ia ble

Gro up r p-va lue

Gouta llie r c la ssific a tion for infr a spina tus

CL E E R 0.018 0.938 No n-CL E E R

  • 0.087

0.823

Gouta llie r c la ssific a tion for te r e s minor

CL E E R 0.032 0.891 No n-CL E E R

  • 0.207

0.593

Gle nosphe r e la te r a lization

CL E E R

  • 0.055

0.800 No n-CL E E R 0.621 0.074

T

  • ta l pr
  • sthe tic

la te r a lization

CL E E R

  • 0.188

0.380 No n-CL E E R 0.480 0.191

Multiva ria te a na lysis

  • Ag e
  • Pre -o p E

R

  • I

nfra spina tus Go uta llie r g ra de

  • T

e re s mino r Go uta llie r g ra de

  • Gle no sphe re la te ra liza tio n
  • T
  • ta l pro sthe tic la te ra liza tio n
  • No sig nific a nt pre dic to rs o f E

R impro ve me nt fo r CL E E R (p=0.963) o r No n-CL E E R (p=0.753)

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SLIDE 12

CONCL USI ON

  • RSA with a la te ra lize d c e nte r o f ro ta tio n c a n

e ffe c tive ly re sto re e xte rna l ro ta tio n witho ut the use

  • f la tissimus do rsi tra nsfe rs in pa tie nts with a pre -
  • pe ra tive E

R de fic it.

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SLIDE 13

RE F E RE NCE S

1. Bo ile a u P, Chuina rd C, Ro ussa nne Y, Ne yto n L , T ro ja ni C. Mo d ifie d la tissimus d o rsi a nd te re s ma jo r tra nsfe r thro ug h a sing le d e lto -pe c to ra l a ppro a c h fo r e xte rna l ro ta tio n d e fic it o f the sho uld e r: a s a n iso la te d pro c e d ure o r with a re ve rse a rthro pla sty. J Sho uld e r E lbo w Surg 2007 No v-De c ;16(6):671-82. 2. Bo ile a u P, Rumia n AP, Zumste in MA. Re ve rse d sho uld e r a rthro pla sty with mo d ifie d L 'E pisc o po fo r c o mb ine d lo ss o f a c tive e le va tio n a nd e xte rna l ro ta tio n. Jo urna l o f Sho uld e r & E lbo w Surg e ry 2010 Ma r;19(2 Suppl):20-30. 3. Bo ile a u P, Wa tkinso n DJ, Ha tzid a kis AM, Ba lg F . Gra mmo nt re ve rse pro sthe sis: d e sig n, ra tio na le , a nd b io me c ha nic s. J Sho uld e r E lb o w Surg 2005 Ja n-F e b ;14(1 Suppl S):147S-61S. 4. F ra nkle M, Sie g a l S, Pupe llo D, Sa le e m A, Mig he ll M, Va se y M. T he Re ve rse Sho uld e r Pro sthe sis fo r g le no hume ra l a rthritis a sso c ia te d with se ve re ro ta to r c uff d e fic ie nc y. A minimum two -ye a r fo llo w-up stud y o f sixty pa tie nts. J Bo ne Jo int Surg Am 2005 Aug ;87(8):1697-705. 5. Gre ine r S, Sc hmid t C, K

  • nig C, Pe rka C, He rrma nn S. L

a te ra lize d re ve rse sho uld e r a rthro pla sty ma inta ins ro ta tio na l func tio n o f the re ma ining ro ta to r c uff. Clin Ortho p Re la t Re s 2013 Ma r;471(3):940-6. 6. Puska s GJ, Ca ta nza ro S, Ge rb e r C. Clinic a l o utc o me o f re ve rse to ta l sho uld e r a rthro pla sty c o mb ine d with la tissimus d o rsi tra nsfe r fo r the tre a tme nt o f c hro nic c o mb ine d pse ud o pa re sis o f e le va tio n a nd e xte rna l ro ta tio n o f the sho uld e r. J Sho uld e r E lb o w Surg 2014 Ja n;23(1):49- 57. 7. Simo vitc h RW, He lmy N, Zumste in MA, Ge rb e r C. Impa c t o f fa tty infiltra tio n o f the te re s mino r musc le o n the o utc o me o f re ve rse to ta l sho uld e r a rthro pla sty. J Bo ne Jo int Surg Am 2007 Ma y;89(5):934-9. 8. Va le nti P, Sa uzie re s P, K a tz D, K a lo uc he I, K ilinc AS. Do le ss me d ia lize d re ve rse sho uld e r pro sthe se s inc re a se mo tio n a nd re d uc e no tc hing ? Clin Ortho p Re la t Re s 2011 Se p;469(9):2550-7. 9. Vira ni NA, Ca b e za s A, Gutie rre z S, Sa nto ni BG, Otto R, F ra nkle M. Re ve rse sho uld e r a rthro pla sty c o mpo ne nts a nd surg ic a l te c hniq ue s tha t re sto re g le no hume ra l mo tio n. J Sho uld e r E lb o w Surg 2013 F e b ;22(2):179-87.

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SLIDE 14

T HANK YOU