The Reverse Shoulder Replacement: Let Me Show You The Results - - PowerPoint PPT Presentation

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The Reverse Shoulder Replacement: Let Me Show You The Results - - PowerPoint PPT Presentation

Dec 04, 2023 141 likes •486 views

The Reverse Shoulder Replacement: Let Me Show You The Results Lawrence V. Gulotta, MD Director of Research, Sports Medicine and Shoulder Service Co-Medical Director, Leon Root Motion Analysis Laboratory Attending Surgeon, Sports Medicine and

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The Reverse Shoulder Replacement: Let Me Show You The Results

Lawrence V. Gulotta, MD

Director of Research, Sports Medicine and Shoulder Service Co-Medical Director, Leon Root Motion Analysis Laboratory Attending Surgeon, Sports Medicine and Shoulder Service Hospital for Special Surgery New York, NY

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Disclosures

Consulting and speaking fees from Zimmer-Biomet, Inc

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Great Advances for Mankind

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What is a Reverse Shoulder Replacement? Why Does it Work? Most People Would Consider Putting Something in Ass Backwards a Mistake, Not a Revolution

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Shoulder Biomechanics 101

Courtesy of Andreas Kontaxis, PhD

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Shoulder Biomechanics 101

Courtesy of Andreas Kontaxis, PhD

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Cuff Deficient Shoulder

  • Escape
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NEED STABILITY!!

RSA works because it is semi-constrained -> STABLE

Courtesy of Andreas Kontaxis, PhD

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Cuff Deficient Shoulder

  • Charles Neer’s Experience

Anatomic Arthroplasty in Cuff Deficient S houlder

  • Reduced Pain
  • Did not Improve Function
  • “ Limited Goals”
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Cuff Deficient Shoulder

  • Need more constraint to improve function

Mark III Mark I

  • Neer. S

houlder Reconstruction. 1990

  • High Glenoid Failure Rates
  • Large moment arm created shear
  • Poor fixation
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Birth of the Modern RSA

  • Paul Grammont, Lyon France, 1980’s
  • Constrained shoulder with medialized center of rotation
  • Converts shear forces to compressive forces across glenoid

implant – bone interface

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Birth of the Modern RSA

  • 1. It works because it is

more constrained, stable.

  • 2. Clinically viable

because reversing the anatomy allowed medializing the COR which limited glenoid failures

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Expanding Use of Shoulder Arthroplasty

  • Kim et al. JBJS

2011

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Expanding Use of Shoulder Arthroplasty

Worldwide: 50% Reverse Europe: >50% Reverse

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Expanding Use of Shoulder Arthroplasty

  • Cuff Tear Arthropathy
  • Fractures
  • Nonunion, malunions
  • Revisions
  • Irreparable Rotator Cuff Tears
  • OA with “Dysfunctional Cuff”
  • OA with Glenoid Bone Loss
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Expanding Use of Shoulder Arthroplasty

Cuff Tear Arthropathy - #1 Indication

  • 73 y/o RHD female with right shoulder pain.
  • FF 70, ER neutral, IR to back pocket
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Expanding Use of Shoulder Arthroplasty

6 Weeks Post-op RS A

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Results

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Outcomes of RSA

93% S atisfied Constant 23 -> 60 French Boston 90% S atisfied S S V 26%

  • > 77%

Primary, 62% Revision Tampa AS ES 33.3 -> 75.4

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Outcomes of RSA

  • Take home from several studies:
  • Validated shoulder scores in the 70’s
  • Effective for pain relief
  • ROM
  • FF – 140
  • ER – 10
  • IR – Back pocket
  • Satisfaction in 90% of patients
  • These are not normal shoulders
  • Complications…...

Constraint Allows for S tability But Limits Motion

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Complications

Some reports as high as 50% (Gerber, HSS)

– Hematoma – Notching – Acromion stress fracture – Baseplate failure – Periprosthetic fractures – Neurologic injury – Deltoid origin pain – Infection

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Complications

Primary: 13.4% Revision: 33.3%

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Complications – My Experience First 500 RSA’s Overall Complication Rate: 9.0% (45) –Revision Arthroplasty: 16% –Primary Arthroplasty: 6.6%

  • Persistent Pain/Stiffness – No Obvious Cause (31)
  • Instability (5)
  • Nerve Injury (3)
  • Acromial Stress Fracture (3)
  • Infection (3)

Comparable to Anatomic TS A

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My Experience

0% 5% 10% 15% 20% 25% 30% Year 1 Year 2 Year 3 Year 4 Year 5 Year 6

Complications by Year

50 RS A ’s

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Outcomes of RSA

We know that about 90% of patients will be satisfied What does it mean to have a shoulder that is 70-75% of normal????

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Outcomes of RSA

  • Doc, after surgery, can I:
  • Golf?
  • Swim?
  • Perform my ADL’s?
  • Go back to work?
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Outcomes of RSA

After RS A

  • 85%

went back to recreational activities

  • Average of 5 months post -
  • p
  • #1 Complaint: Can’ t put

arm behind back

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Clinical Studies

Can We Predict Outcomes Following RSA?

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Clinical Studies

Can We Predict Functional Outcomes?

  • PROMS - Registries

MCID for TS A and RS A was 9 points for AS ES score S CB for RS A was 23 points on AS ES

  • Patients who failed to reach MCID
  • Higher baseline MCID
  • RS

A not as likely to reach MCID as TS A

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Clinical Studies

Predictors of Poor Outcomes

  • Men
  • Intact RC
  • High Baseline AS

ES Final AS ES 75 S ame for both groups

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Relativity

There is a ceiling effect with RSA RSA tops out at:

  • FF 140
  • Functional scores 70’s
  • Constraint a blessing

and a curse

Reality (Outcome Scores) – Expectations = Satisfaction

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Conclusions RSA indications and utilization continue to expand Solution to a problem that vexed surgeons for decades Only reliable solution to true mechanical pseudoparalysis Constraint provides stability, but also prohibits normal motion There is a ceiling effect with outcomes Rotation is particularly limited

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Thank You