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

Reverse total shoulder arthroplasty in 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.

                                               

===

Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

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.

Rotator cuff surgery in the weight-bearing shoulder - a challenging situation

Arthroscopic rotator cuff repair in the weight-bearing shoulder.

These authors reviewed 46 'weight bearing' shoulders in wheelchair-bound patients having arthroscopic cuff repair with a mean follow-up of 46 months.

Of the shoulders, 87% had supraspinatus involvement, 70% had subscapularis involvement, and 57% had an anterosuperior lesion involving both the supraspinatus and subscapularis. 

The authors describe the use of an abduction splint for 6 weeks after surgery in cases of supraspinatus and infraspinatus involvement with increased tension on the repair. Patients were hospitalized for about 10 weeks in a center for paraplegic patients. The postoperative rehabilitation

protocol included use of an electronic wheelchair and strictly passive exercises under the supervision of a physical therapist during the first 6 weeks. After 6 weeks, limited indoor manual wheelchair use was allowed. Transfer training was started after 8 weeks invariably with the use of a transfer board until 4 months postoperatively.

33% of the repair attempts failed by ultrasound, 5 of these 17 patients had a clear traumatic event.

The patients showed improvements in the Constant-Murley score from 50 points  preoperatively to 80 points postoperatively and in the American Shoulder and Elbow Surgeons score from 56 points preoperatively to 92 points postoperatively, with a mean postoperative Subjective Shoulder Value of 84%.

Comment: Patients using wheelchairs are special. They are usually intensely dedicated to their personal independence.  They place extraordinary loads on their rotator cuffs: in ambulation, in transferring in and out of automobiles, chairs, bed and toilet, in work, in sports, in loading their chair in and out of a car and in the occasional fall.  The paraplegia often is accompanied by a high body mass index because of the difficulty in getting aerobic exercises. As shown in this study, the tear pattern in these patients has a high rate of subscapularis involvement (70%), suggesting that wheelchair users may place more load on this tendon than other patients. 

Paraplegic patients having cuff surgery require extraordinary care in their rehabilitation. The authors do not describe how the repair is protected from loading when the patient rises from the bed or chair or performs transfers during the first two months after surgery. In our experience the difficulty of caring for a repair under these circumstances is huge.  

Readers should take a look at a prior post regarding cuff surgery in wheelchair-bound patients.

In our practice, acute tears in wheelchair-bound patients receive consideration for acute repair after a thorough discussion of the complexities of the prolonged rehabilitation period. Chronic tears are generally managed with activity modification and device assists (lifts for getting the chair in a car, transfer boards, elevated toilet seats, overhead bars), help with body weight reduction if necessary, and fall prevention strategies. Surgery is not encouraged for most degenerative tears. 

===

Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

Click here to see the new Rotator Cuff Book

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.

Rotator cuff tears in paraplegic patients - is the rehabilitation worth it?

Reconstruction of rotator cuff tears in wheelchair-bound paraplegic patients

These authors reported on 13 paraplegic patients (8 men and 5 women; 16 shoulders) who underwent rotator cuff repair.. The average age at the time of surgery was 48.7 years. The causes of paraplegia were poliomyelitis in 9 patients, spinal fracture in 4, and cerebral infarction in 2. Open rotator cuff repair was performed in 11 patients and arthroscopic repair in 2 patients.

There were 2 (12.5%) medium tears, 3 (18.8%) large tears, and 11 (68.7%) massive tears.

After surgery, no wheelchair propulsion was allowed for 6 months postoperatively. The shoulders were assessed with the American Shoulder and Elbow Surgeons (ASES) score and Constant score as well as magnetic resonance imaging or ultrasonography  at an average of 31.2 months (min 12 months) postoperatively.

After repair an abduction brace was used for two months. Patients were advised not to use the affected arm for leaning, wheelchair pushing or propulsion, for 6 months. 

The retear rate was 12%. The functional scores were improved in the two patients with retears visual analog pain scales improved form 7 to 2 and from 8 to 2. ASES scores were 100 and 60 points and Constant scores were 99 and 60 points, respectively.  These scores were essentially the same as those of patients with intact repairs.

 Comment: Shoulder symptoms are very common in individuals with paraplegia. Often these are due either to cuff tendon failure or to degenerative arthritis related in large part to the need to use the arms for transfer, propulsion, and lifting their wheelchairs in and out of vehicles. Cuff tears have been reported in up to three-quarters of individuals with paraplegia.

This paper points out the tremendous morbidity inherent in protecting a cuff repair in an individual with paraplegia: one half year of loss of independence. While the authors stated that wheelchair ambulation was not allowed for 6 months, they did not explain how the repairs were protected when the patient rose from bed or chair or toilet. These activities apply major loads to the cuff - perhaps even greater than those involved in pushing a wheelchair.

This was a very small series, but the suggestion is that the results of the failed repairs were not obviously worse than those of repairs that remained intact. This brings up the question of the value of the heavily protective program.

Finally, the retear rate of 12% reported here is less than half that reported for ambulatory patients (27% retear rate  in a recent review of the literature), making one wonder if this figure is truly representative of the failure rate of repairs in individuals with paraplegia - especially considering the fact that most of the tears in this series were 'massive'.

===

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

To see the topics covered in this Blog, click here

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'