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

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

Disclosures Consulting and speaking fees from Zimmer-Biomet, Inc

Great Advances for Mankind

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

Shoulder Biomechanics 101 Courtesy of Andreas Kontaxis, PhD

Shoulder Biomechanics 101 Courtesy of Andreas Kontaxis, PhD

Cuff Deficient Shoulder  Escape

NEED STABILITY!! RSA works because it is semi-constrained -> STABLE Courtesy of Andreas Kontaxis, PhD

Cuff Deficient Shoulder  Charles Neer’s Experience Anatomic Arthroplasty in Cuff Deficient S houlder - Reduced Pain - Did not Improve Function - “ Limited Goals”

Cuff Deficient Shoulder  Need more constraint to improve function Mark I Mark III • High Glenoid Failure Rates • Large moment arm created shear • Poor fixation Neer. S houlder Reconstruction. 1990

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

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

Expanding Use of Shoulder Arthroplasty • Kim et al. JBJS 2011

Expanding Use of Shoulder Arthroplasty Worldwide: 50% Reverse Europe: >50% Reverse

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

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

Expanding Use of Shoulder Arthroplasty 6 Weeks Post-op RS A

Results

Outcomes of RSA French Tampa 93% S atisfied AS ES 33.3 -> 75.4 Constant 23 -> 60 Boston 90% S atisfied S S V 26% -> 77% Primary, 62% Revision

Outcomes of RSA - Take home from several studies: - Validated shoulder scores in the 70’s - Effective for pain relief - ROM - FF – 140 Constraint Allows for S tability - ER – 10 But Limits Motion - IR – Back pocket - Satisfaction in 90% of patients - These are not normal shoulders - Complications…...

Complications Some reports as high as 50% (Gerber, HSS) – Hematoma – Notching – Acromion stress fracture – Baseplate failure – Periprosthetic fractures – Neurologic injury – Deltoid origin pain – Infection

Complications Primary: 13.4% Revision: 33.3%

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

My Experience Complications by Year 30% 25% 50 RS A ’s 20% 15% 10% 5% 0% Year 1 Year 2 Year 3 Year 4 Year 5 Year 6

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????

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

Outcomes of RSA After RS A - 85% went back to recreational activities - Average of 5 months post - op - #1 Complaint: Can’ t put arm behind back

Clinical Studies Can We Predict Outcomes Following RSA?

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

Clinical Studies Predictors of Poor Outcomes - Men - Intact RC - High Baseline AS ES Final AS ES 75 S ame for both groups

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

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

Thank You