Reverse total shoulder for everything? How about for cuff tear arthropathy?

Cuff tear arthropathy (CTA) can be defined as the combination of a large, irreparable rotator cuff tear and glenohumeral arthritis. In this condition, the humeral head is typically superiorly decentered with respect to the scapula

The lack of the centering effect of the normal rotator cuff puts a prosthetic glenoid component at risk for rocking horse loosening 

in which the superiorly decentered humeral head differentially loads the superior aspect of the glenoid component, prying it away from the bone

(see Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency).

The prosthetic options for managing disabling cuff tear arthropathy include a reverse total shoulder arthroplasty (RSA, below left, see this link) and, for selected patients, a cuff tear arthropathy hemiarthroplasty (CTAH, below right, see this link).

    

The CTAH can be a good option for the active patient with cuff tear arthropathy and the ability to actively elevate the arm above the horizontal. See this case for example (link). 

The CTAH cannot be effectively used in a patient with pseudoparalysis (inability to actively raise the arm) or anterosuperior escape as shown below

The authors of Managing rotator cuff tear arthropathy: A role for cuff tear arthropathy hemiarthroplasty as well as reverse total shoulder arthroplasty demonstrated that - for appropriately selected patients - each of these procedures can be effective in the management of cuff tear arthropathy. They retrospectively reviewed 103 patients with CTA treated with shoulder arthroplasty, the type of which was determined by the patient's preoperative ability to actively elevate the arm. Outcome measures included the change in the Simple Shoulder Test (SST), the percent maximum improvement in SST (%MPI), and the percentage of patients exceeding the minimal clinically important difference (MCID) for the change in SST and %MPI. 

Both arthroplasties resulted in clinically significant improvement. 

56% of the 103 patients were managed with RSA. Patients having RSA improved from a mean preoperative SST score of 1.7 to a postoperative score of 6.3 (p<0.01). Instability accounted for most of the RSA complications. The improvements in the 12 individual functions of the Simple Shoulder Test are shown below.

44% of the 103 patients were managed with CTAH. Patients having CTAH improved from a preoperative SST score of 3.1 to a postoperative score of 7.6 (p<0.001). Instability did not occur in any of the CTAH patients. The improvements in the 12 individual functions of the Simple Shoulder Test are shown below.

Comment: It is apparent that the cuff tear arthropathy hemiarthroplasty provides a robust surgical alternative to RSA for active patients with cuff tear arthropathy having preoperative active elevation above the horizontal.

The authors of Drivers of inpatient hospitalization costs, joint-specific patient-reported outcomes, and health-related quality of life in shoulder arthroplasty for cuff tear arthropathy. recently sought to assess the hospitalization costs and improvements in comfort, function and health related quality of life (HRQoL) for these two types of shoulder arthroplasty in the management of CTA. They found that CTAH had a lower revision rate and significantly lower hospitalization cost due to the relatively greater expense of the RSA implants. 

In the treatment of cuff tear arthropathy, the CTA hemiarthroplasty can provide a safe and cost-effective alternative to RSA for patients with retained active elevation.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Instability and dislocation after reverse total shoulder arthroplasty - are we any smarter about preventing them?

Instability is one of the most common complications after a reverse total shoulder.

The 56 authors of Predictors of Dislocations after Reverse Shoulder Arthroplasty: A study by the ASES Complications of RSA Multicenter Research Group identified 6,621 patients from a multicenter database with minimum 3 month (mean 19.4, range 3-84) followup after a primary or revision reverse total shoulder (RSA) performed by one of 24 experienced surgeons. The study population was 40% male with an average age of 71.0 years. The rate of dislocation was 2.1% (n=138) for the whole cohort, 1.6% (n=99) for primary RSAs, and 6.5% for revision RSAs.

Dislocations occurred at a median of 7.0 weeks after surgery; 23.0% followed a trauma.

The risk factors for dislocation identified in this study were non-modifiable:
(1) diagnosis other than glenohumeral osteoarthritis with an intact rotator cuff (e.g. fracture non-union, rotator cuff disease, failed prior arthroplasty).
(2) history of postoperative subluxations prior to radiographically confirmed dislocation,
(3) male sex,
(4) trauma
and
(5) no subscapularis repair.


Comment:
These authors did not identify modifiable risk factors for dislocation, such as implant type, implant size, implant position, distalization, lateralization, unwanted contact between the humeral component and scapula, or rehabilitation.

By contrast, the authors of Dislocation following reverse total shoulder arthroplasty found two modifiable risk factors - inadequate soft-tissue tensioning and bony impingement (especially in adduction) -  among 14 early (less than three months after surgery) and 5 late (more than 3 months after surgery) dislocations. Non-modifiable risk factors included male sex and prior surgery on the shoulder. Other findings associated with dislocation included asymmetric liner wear and mechanical liner failure; these factors may be modified by prosthesis design and surgical technique.

The authors of Classification of instability after reverse shoulder arthroplasty guides surgical management and outcomes and Revision for instability following reverse total shoulder arthroplasty: outcomes and risk factors for failure identified four categories of factors that contributed to instability in 36 patients having revision of a reverse total shoulder for glenohumeral instability. Many of these are related to implant design and surgical technique and are, therefore, modifiable. The most common mechanism leading to persistent instability was loss of compression.

 (D/R ratio is the ratio of the depth of the polyethylene cup divided by the radius of the cup's concavity).

As emphasized in The normal shoulder, aTSA, and RSA are stabilized by concavity compression and in the articles referenced above, stability of the reverse requires a compressive force aligned with a competent concavity = concavity compression.

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Reverse total shoulder: does physical therapy improve patient satisfaction and reduce instability?

The authors of Active Physical Therapy Does Not Improve Outcomes After Reverse Total Shoulder Arthroplasty: A Multi-Center, Randomized Clinical Trial sought to compare range of motion (ROM), patient-reported outcomes (PROs), postoperative stability, complications and patient satisfaction after reverse total shoulder arthroplasty between patients receiving a structured home exercise program (HEP) (n=46) and those placed on active, supervised physiotherapy (PT) (n=43) in a multi-center randomized clinical trial.

Complications occurred in 13% of HEP and 17% of PT patients. 

There were no significant differences between groups in PROs or ROM at final follow-up.

12% (72/82) of patients described some symptoms of instability within one year postoperatively. 

While 90% (74/82) were satisfied with the outcomes,

 only 76% (62/82) stated that they would have the surgery again, given the opportunity.

Comment: Interestingly a larger clinical trial comparing PT to home exercises has been posted (see Physical Therapy After Reverse Total Shoulder Arthroplasty), but the results are not yet available.

Home exercises have some tangible advantages: less cost, less travel, and greater ability to tailor the program to the specific needs and tolerance of each patient. Offering ready access to the surgical team via email or phone can enable patients to ask questions and to be assured they're on the right track.
 

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth
Follow on facebook: click on this link
Follow on facebook: https://www.facebook.com/frederick.matsen
Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

Recurrent dislocations of reverse total shoulder arthroplasty

Acromiohumeral Cerclage in Reverse Total Shoulder Arthroplasty for Recurrent

Instability

Recurrent shoulder instability is one of the most frequent complications following reverse total shoulder arthroplasty (rTSA); by contrast, instability is rare after anatomic total shoulder arthroplasty.

In many cases recurrent instability of an rTSA can be managed by correcting component malposition,  upsizing the diameter of the glenosphere, adjusting soft tissue tension, avoiding unwanted contact between the humeral component and use of a retentive liner for the humeral component.

However, some case are refractory to these approaches. 

These authors describe the 1 year outcomes for 10 patients (4 female/6 male average age 64 years) in which an acromiohumeral cerclage technique was used in which the humeral component was stabilized with nonabsorbable, high-tensile suture tape looped through transosseous acromial drill tunnels as an augment to other approaches to enhance stability.

The acromial holes:

The humeral fixation (left - through holes in prosthesis fin, right - around prosthesis neck): 

These patients had an average of 2.1 revisions prior to revision with suture cerclage

augmentation. Many had procedures prior to their index reverse total shoulder.

At followup, the VAS score decreased from an average of 5.9 to 1.6, the ASES score increased from an average of 28 to 80, and active forward elevation increased from 41 to 130. 

All patients remained stable with well-positioned prostheses since their final operations with no recurrent dislocations or acromial complications. Radiographs are seen below.

Comment: Instability after a reverse total shoulder can be a devastating complication. The results reported here are surprisingly good without recognized complications. Longer term followup with a larger series of patients will be important for assessing the risk of acromial fracture and failure of fixation. Interestingly, the authors state, "although we had no acromial complications with this technique in any patient at an average of 2 years postoperatively, we think there is merit to at least considering removing the cerclage after reasonable period of stability to avoid any catastrophic acromial complications."

You can support cutting edge shoulder research that is leading to better care for patients with shoulder problems, click on this link.

Follow on twitter: https://twitter.com/shoulderarth

Follow on facebook: click on this link

Follow on facebook: https://www.facebook.com/frederick.matsen

Follow on LinkedIn: https://www.linkedin.com/in/rick-matsen-88b1a8133/

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Obesity is a risk factor for dislocation, fracture, and revision after shoulder arthroplasty

Risk of poor outcomes in patients who are obese following total shoulder arthroplasty and reverse total shoulder arthroplasty: a systematic review and meta-analysis

These authors conducted a systematic review to investigate the impact of obesity ( (body mass index > 30 kg/m2) on outcomes following total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

They found that patients who were obese were at increased odds of a dislocation (OR, 2.49; 95% confidence interval [CI], 2.32-2.66), fracture (OR, 1.92; 95% CI, 1.77-2.08), and revision (OR, 1.49; 95% CI, 1.40-1.58) following TSA or RTSA. 

Comment: Shoulder arthroplasty is most often an elective procedure. Obesity appears to be a risk factor for surgical complications, but is also likely to be associated with risks of medical complications, such as obstructive sleep apnea, deep venous thrombosis, and pulmonary emboli. 

To see a YouTube of our technique for a total shoulder arthroplasty, click on this link.

To see a YouTube of our technique for a reverse total shoulder arthroplasty, click on this link.

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To see our new series of youtube videos on important shoulder surgeries and how they are done, click here.

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Reverse total shoulder - complicated by dislocation

Instability after reverse total shoulder arthroplasty

These authors reviewed 119 patients having reverse total shoulder finding that eleven patients (9.2%) demonstrated instability in the early postoperative period (average of 8 weeks postoperatively (range, 3 days-5 months)).

Instability was associated with male sex, history of prior open shoulder surgery, and preoperative diagnoses of fracture sequelae, proximal humeral or tuberosity nonunion and absence of subscapularis repair.  

The authors found that a more horizontal (155°) humeral neckshaft angle and a medialized center of rotation glenoid design were associated with a higher likelihood of stability.

Five of the 11 patients sustained a second dislocation requiring another operation. Treatment for the initial dislocation event by placement of a thicker polyethylene insert alone was often inadequate.

The authors suggested increasing the size of the humeral insert or using a larger glenosphere to obtain optimal soft tissue tension and mitigate the risk of redislocation.

Comment: Dislocation has been and remains the most frequent complication of reverse total shoulder arthroplasty (see this link).

In our experience, the management of instability after a reverse total shoulder requires a careful assessment of many factors, including patient compliance, deltoid tone, unwanted contact between the humeral polyethylene and the scapula (inferiorly or posteriorly), polyethylene wear, component malposition, component loosening, posterior soft tissue tightness and infection.

Revision surgery needs to address each of these potential factors. Revision to a glenoshere with a large diameter of curvature has been useful in increasing stability.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art"  regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Can notching be a problem after reverse total shoulder? Yes!

Eight years ago, a patient had this type of reverse total shoulder implanted in the right shoulder. Note the close proximity between the humeral polyethylene and the inferior screw (arrow).

Seven years later the patient was complaining of shoulder pain and had the x-ray shown below. The arrow points to scapular notching from contact of the bone of the scapular with the polyethylene of the humeral cup. This notching has exposed the inferior screw.

Eight months later, the shoulder dislocated and could not be stably reduced. The x-ray below shows the dislocated reverse with the notched scapula.

At revision surgery, the polyethylene was seen to be eroded so that it no longer functioned as a complete cup - this allowed the shoulder to dislocate. The appearance of the polyethylene is show below.

We revised this shoulder by removing the prominent screw, replacing the glenosphere with one of a larger diameter of curvature, and using humeral spacers to improve stability by increasing the compressive force at the joint.

This case demonstrates that notching can be a problem and that the resulting loss of the polyethylene concavity can allow the reverse total shoulder to dislocate.

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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages   arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Reverse total shoulder - risk of dislocation

Instability after reverse total shoulder arthroplasty

Many designs of reverse total shoulder are now available.

The outcome of the arthroplasty depends not only on the prosthesis, but also on patient characteristics, shoulder characteristics, and surgical technique

These authors evaluated 119 patients with and without a prosthetic dislocation after reverse total shoulder arthroplasty (RTSA) to identify risk factors for instability.

Eleven patients (9.2%) demonstrated instability in the early postoperative period, occurring at an average of 8 weeks postoperatively (range, 3 days-5 months). All dislocations were anterior (see below right).

All failed attempts at closed reduction. The most common preoperative diagnosis for performing a RTSA was rotator cuff tear arthropathy (55%).  

A more horizontal (155°) humeral neckshaft angle and a medialized center of rotation glenoid design were associated with a higher likelihood of stability.

Postoperative instability was associated with male gender, history of prior open shoulder surgery (82%), and preoperative diagnoses of fracture sequelae, particularly proximal humeral or tuberosity nonunion. Absence of subscapularis repair was an independent predictor of instability.

Revision surgery failed in 5 of the 11 patients (45%); these patients sustained a second dislocation requiring another operation.

Treatment for the initial dislocation event by placement of a thicker polyethylene insert was inadequate in 45% of the patients and required another revision with a larger glenosphere and thicker humeral inserts.

Comment: This paper again points to the problem of dislocation after reverse total shoulder arthroplasty. The 9% rate of dislocations requiring revision surgery is a concern.

The majority of these patients received a reverse total shoulder because of cuff tear arthropathy. It is not stated how many of these actually had pseudoparalysis.

Our practice is to offer a CTA prosthesis to patients with cuff tear arthropathy and retained active elevation to avoid the instability risks of a reverse total shoulder. See this link. We have had no instances of dislocation with the CTA prosthesis.

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Use the "Search" box to the right to find other topics of interest to you. 

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Shoulder arthroplasty failure - one complication gives rise to another - l’abîme appelle l’abîme

Cutaneous metallosis following reverse total shoulder arthroplasty

A woman with a medical history of obesity, gout, non–insulin-dependent type 2 diabetes mellitus, hypertension, and hypercholesterolemia had 

(1) an anatomic total shoulder arthroplasty (TSA) for end-stage glenohumeral arthritis. This was complicated by glenoid loosening. 

(2) a revision was performed at which time an intraoperative gram stain revealed gram-positive cocci in clusters and gram-negative bacilli; both the glenoid and humeral components were explanted and replaced with a hemiarthroplasty with an antibiotic-impregnated cement spacer.
(3) Approximately a year later, a revision TSA was performed.  

(4) A year later a resection arthroplasty was performed for a loose glenoid component and persistent pain.
(5) Several years later she underwent a revision to an RTSA to improve function and pain.
(6) Three months postoperatively the shoulder was found to be unstable as shown below

She had dark pigmentation surrounding the incision on the anterior shoulder and chest wall .

(7) Approximately eight years after her index procedure she underwent explantation and resection arthroplasty. At nearly 2 years after the second resection arthroplasty, the patient remained dissatisfied with her shoulder.

Comment: The French have a saying, "l’abîme appelle l’abîme", meaning one problem brings on another. Here we see a patient with comorbidities that experienced septic glenoid loosening after a total shoulder and several operations later was left with a flail shoulder.  It is not uncommon to see such situations where revisions of revisions fail, creating a costly outcome for the patient.

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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Locked dislocation of a total shoulder

A lady in her 50s had a total shoulder for arthritis at another clinic

 Seven years after her surgery she presented to us with a painful stiff shoulder and these x-rays showing a locked posterior dislocation and a loose glenoid component.

We wanted to avoid the risks associated with a reverse total shoulder in this setting.

Instead we converted the shoulder to a hemiarthroplasty, which was surprisingly stable and which will enable us to start immediate rehabilitation.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Dislocation after reverse total shoulder

Classification of instability after reverse shoulder arthroplasty guides surgical management and outcomes

Recognizing that dislocation is the leading mechanical complication of reverse total shoulder, these authors sought to develop a classification for instability after RSA, to describe the clinical outcomes of patients stabilized operatively, and to identify those patients at higher risk of recurrence.

Their classification system is shown below.

They reviewed 43 revision cases in 34 patients. In the revisions the authors usually upsized the glenosphere to 40 or 44 neutral, often with +6 or +8 mm humeral offset and semiconstrained liners.

Persistent instability most commonly occurred in persistent deltoid dysfunction and postoperative acromial fractures but also in 1 case of soft tissue impingement. Twenty-one patients remained stable at minimum 2 years of follow-up and had significant improvement of clinical outcome scores and range of motion.

Comment: Instability after a reverse total shoulder remains a substantial problem. Additional insight into the factors affecting stability can be gained from this article:

Hierarchy of Stability Factors in Reverse Shoulder Arthroplasty

These authors asked: (1) what is the hierarchy of importance of joint compressive force, prosthetic socket depth, and glenosphere size in relation to stability, and (2) is this hierarchy defined by underlying and theoretically predictable joint contact characteristics? They examined the intrinsic stability in terms of the force required to dislocate the humerosocket from the glenosphere of eight commercially available reverse shoulder arthroplasty devices. The hierarchy of factors was led by compressive force followed by socket depth; glenosphere size played a much lesser role in stability of the reverse shoulder arthroplasty device. Similar results were predicted by a mathematical model, suggesting the stability was determined primarily by compressive forces generated by muscles.
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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.