These authors review their experience with reverse total shoulder arthroplasty (RTSA) in the treatment of glenohumeral osteoarthritis (GHOA). Their goal was to determine if preoperative glenoid morphology was associated with the clinical outcome.
The procedure was performed through a standard deltopectoral approach with biceps tenodesis to the pectoralis major tendon. The subscapularis was peeled from the lesser tuberosity and repaired at the end of the procedure when possible. The DJO Altivate system was used in 196/197 patients. Whenever possible, DJO glenospheres were lateralized to + 6mm utilizing 36 N and 32-4 for males and females, respectively. Glenoid bone loss was addressed with eccentric reaming of the anterior high side to maximize back-end coverage (> 75%) and suitable fixation of the glenoid baseplate. In extreme cases of posterior retroversion where glenoid surface area coverage by the baseplate could not be corrected beyond 75% (n= 5), humeral head autograft was utilized to restore bony anatomy. The humeral side was addressed with a non-cemented inlay design and a standard-length humeral stem and a standard or +4mm polyethylene insert.
Of 247 consecutive patients, 197 were available 22 at a minimum 2-year follow-up (80%). Significant improvements were seen in American Shoulder and Elbow Surgeons (ASES), visual analog scale (VAS) pain scores, Single Assessment Numeric Evaluation (SANE), and range of motion (ROM) from baseline to final postoperative follow-up in the combined patient cohort (all P < .001). Most (98.0%) patients reached the minimal clinically important difference (MCID) and 90.9% of patients reached the substantial clinical benefit (SCB) for the ASES. No significant differences were found amongst Walch sub-types in terms of pre- to postoperative improvement in ASES (P= .39), SANE (P= .4), VAS-pain (P= .49), forward elevation (P = .77), external rotation (P = .45) or internal rotation (P= 0.1).
The only significant difference in postoperative outcomes between Walch glenoid-subtypes was higher postop ASES scores among type-B3 glenoids compared to type-A1 glenoids (P= .03) on univariate analysis. However, no individual Walch glenoid subtype was associated with lower postop ASES scores on multivariable analysis (P>0.05).
Of the 197 patients 1 patient (B3 glenoid) underwent revision for baseplate failure resulting in a revision rate of 0.50%. Eight patients sustained an orthopedic related complication (4.06%). Transient radial nerve injury occurred in 1 C glenoid patient (0.51%). Brachial plexopathy persisted in 1 A1 patient (0.51%). Additional complications included 2 (1.02%) acromial stress fractures (A1, B2), 2 (1.02%) baseplate failures (B2, B3), and 1 (0.51%) intraoperative fracture greater tuberosity fracture (A1).
The authors concluded that primary RTSA provides excellent short-term outcomes in patients with glenohumeral arthritis with intact rotator cuff, regardless of the degree of preoperative glenoid deformity.
Comment: There is a substantial trend to apply the reverse total shoulder to cases of osteoarthritis with an intact rotator cuff. This series demonstrates that in experienced hands, a standard approach to the RTSA can effectively manage a wide variety of arthritic pathologies. The authors point out that the use of RTSA attempts to address the three most common complications of anatomic total shoulder: glenoid component loosening, rotator cuff failure and subscapularis failure. Of course, the RTSA comes with its own series of complications: instability, acromial and spine fractures, scapular notching, baseplate failure, fracture, neurologic injuries, and deltoid failure. With the large amount of data coming available, clinical research can be expected to clarify the long-term advantages and risks of these two procedures for patients with osteoarthritis and an intact cuff, recognizing that these patients vary not only with respect to their glenohumeral pathoanatomy, but also with respect to their age, sex, and activity expectations.
A recent post (see this link) pointed out that in a series of 2000 arthroplasties, RTSA was associated with lower final ASES scores than an anatomic TSA.
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