Monday, March 7, 2016

Reverse total shoulder - is it a good choice for wheelchair-dependent patients?

These authors reviewed 16 of 19 wheelchair-dependent patients who had a reverse total shoulder arthroplasty (RTSA) for symptomatic arthritis or rotator cuff pathology.

While most patients were satisfied and had improved shoulder comfort and function, the complication rate was 25%; baseplate failure and dislocation occurred early, and periprosthetic humeral fracture secondary to infection occurred late. The notching rate was 42%.

Comment: It may be more appropriate to refer to these individuals as "arm-dependent" in that they must use their upper extremities for all transfers and for getting around. As such, they are (1) at greater risk for wearing out their shoulder joint and rotator cuff,  (2) incapacitated if they are not allowed to use their arms after surgery, (3) at greater risk for complications from shoulder surgery, and (4) can be permanently debilitated should shoulder reconstruction fail. Again we must remember that we're operating on a patient, not a shoulder.

The case below shows (A) preoperative cuff tear arthopathy, (B) postoperative humeral loosening and fracture and glenoid baseplate failure and (C) a spacer placed for infection with loss of the proximal 40% of the humerus - a situation that is likely to result in permanent loss of function of the arm in this arm-dependent patient. 

 The case below shows another case of cuff tear arthropathy treated with a cemented humeral implant that creates a stress-riser at the distal end of the cement which may increase the risk of fracture should the patient fall as well as glenosphere that depends on bone ingrowth for fixation.

Our approach to the arm dependent individual with rotator cuff arthropathy is more conservative.
Unless the patient has preoperative anterosuperior escape, we use a cuff tear arthropathy prosthesis fixed with impaction autografting. This approach avoids the risk of glenoid baseplate fixation failure and allows immediate postoperative load bearing on the reconstructed arm.

Note the absence of cement or cortical contact of the humeral stem, avoiding a distal diaphyseal stress riser.

A critical element of the surgical technique is the preservation of the "CA+" to maintain stability. In exposing the humeral head, we retain as much as possible of the clavipectoral fascia attached to the coracoacromial ligament (the “CA+”) as a barrier to anterosuperior instability. 

The technical details are described in this post.

Should the patient have preoperative anterosuperior escape, we use a reverse total shoulder technique that (1) provides immediate secure baseplate screw fixation without needing to wait for bone ingrowth and (2) has an impaction grafted stem that avoids a diaphyseal stress riser as shown below.


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