Wednesday, August 26, 2015

Total shoulder - options if at surgery the shoulder is posteriorly unstable

Outcome and value of reverse shoulder arthroplasty for treatment of glenohumeral osteoarthritis: a matched cohort.

These authors evaluated 24 patients with glenohumeral osteoarthritis scheduled to have total shoulder (TSA) but who were changed to a reverse total shoulder (RSA) because of intraoperative difficulties with the glenoid component or instability; these were compared with a cohort of 96 in which the preoperative plan for a TSA was carried through. RSA was performed when persistent posterior subluxation occurred during TSA trialing or when the glenoid trial demonstrated rocking after glenoid reaming. If the glenoid could not be reamed to a symmetric surface or if the subchondral plate was significantly violated, an RSA was placed. During the study time frame, 112 patients were identified as having undergone RSA with an intact rotator cuff.

Preoperative retroversion was approximately 7 degrees greater in the RSA group compared with the TSA group (20.8  ±  13 and 13.7  ± 11.3; P .018). Sixteen percent of patients (4 of 24) in the RSA group and 10% of patients (10 of 96) in the TSA group had preoperative retroversion > 30 degrees. However, review of the preoperative CT scans of the RSA group did not provide any guidance for the need to intraoperatively change the strategy from TSA to RSA.

Five TSA patients had radiographic glenoid loosening, whereas no RSA patients did. Neither group required a revision. One RSA patient required surgery for treatment of a periprosthetic fracture. RSA was $7274 more costly than TSA, related mainly to implant cost.

Comment: These authors present a strategy for managing the cases where the preoperative plan was to perform a total shoulder, but intraoperative problems of instability or inability to properly seat the anatomic glenoid component led to their decision to convert to a reverse total shoulder. Those patients had somewhat more retroversion than those that were managed with TSA, but preoperative CT scans were not helpful in distinguishing the two groups preoperatively (the shoulder on the left received a reverse and the shoulder on the right an anatomic TSA.

The preoperative workup did not include a standardized axillary view to evaluate functional decentering. The operative technique for an anatomic total shoulder did not include the use of anteriorly eccentric humeral heads or rotator interval plication for managing intraoperative posterior instabillity. Using these techniques, we have not had to convert from a preoperative plan for a total shoulder to the more costly reverse total shoulder.


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