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Expanded indications to lead next phase in reverse shoulder arthroplasty concept
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Reverse shoulder arthroplasty is gaining popularity for an expanding array of indications as more surgeons use what some consider the most innovative shoulder procedure concept to emerge in the last decade for restoring motion and relieving pain in patients with shoulder injuries that were once thought untreatable.
“Reverse prosthesis is really ‘a miracle’ because 10 or 15 years ago we were unable to restore active elevation in patients with a cuff-deficient shoulder. With a regular anatomical prosthesis, we could only improve rotation,” Pascal Boileau, MD, professor and head of the department of orthopaedic surgery and sports traumatology at Archet 2 Hospital, in Nice, France, told Orthopaedics Today Europe.
A milestone in reconstructive shoulder surgery, Charles Neer developed the concept of reverse shoulder arthroplasty (RSA) in the 1970s. However, flaws in the design of early prostheses resulted in high glenoid loosening rates and poor functional outcomes. It was not until 1985, when Paul Grammont replaced the traditional glenoid socket with a fixed glenosphere on the scapular neck, medializing and lateralizing the center of glenohumeral rotation, that the foundations were laid for RSA systems available today.
Since Grammont’s DELTA prosthesis (DePuy, Warsaw, U.S.A.) first came to market in 1991, numerous modifications, innovations and improvements have made RSA a key tool in the armamentarium of shoulder surgeons.
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Image: Franck Fernandes |
“It’s a great implant. It takes away pain and it restores motion, but it’s an implant that is difficult to use and has specific indications,” Orthopaedics Today Europe Editorial Board member Pierre Hoffmeyer, MD, professor of orthopaedics and chairman of the department of surgery at the University Hospital of Geneva, said. “If something goes wrong with the procedure the complications can be drastic, which is less the case with the standard prosthesis.”
Areas of concern
Primarily indicated as an implant for older patients with severe shoulder dysfunction caused by irreparable rotator cuff failure, data from multiple case series involving these patients indicate substantial improvements in Constant scores, average active horizontal elevation greater than 110º and favorable long-term stability vs. traditional anatomic arthroplasty and hemiarthroplasty. But there are few long-term data to support expanding RSA indications, and many agree that concerns are valid regarding placing this technology in the hands of more, and often less experienced, surgeons.
At the same time, debate is ongoing about the best surgical approach to use, which complications affect outcomes most and those prosthesis design innovations best suited to overcome these challenges.
“We know many of the complications today and how to avoid them,” said Boileau, who has trained 38 international fellows to perform this procedure and won a 2007 Neer Award for best RSA research. “It is important that new surgeons not make the same mistakes that we did initially.”
Orthopaedics Today Europe recently spoke with Boileau and other shoulder surgeons experienced with RSA about these issues.
Expanding indications
The ideal patient for RSA is aged older than 70 years, has an intact deltoid and decreased functional demand with preoperative active elevation less than 90º, data from clinical trials indicate.
“Results with the reverse implant are in many cases better than what we would obtain from a hemiarthroplasty or from a conventional total shoulder arthroplasty,” Bo Sanderhoff Olsen, MD, PhD, an orthopaedic surgeon at Herlev University Hospital in Copenhagen, said. “In many ways, an RSA gives you more secure and better results.”
This is why surgeons have gotten more comfortable performing RSAs; many have started to use the prosthesis in other difficult-to-treat patient groups, according to Olsen.
“Revision of traditional shoulder replacement is a very largely evolving indication, especially after failed fracture prosthesis,” Christian Gerber, MD, chairman in the department of orthopaedics at the University of Zurich, in Switzerland, said, noting the majority of RSAs he performs are revisions.
Olsen agreed. Of the 44 RSAs his group performed last year, 24 were revisions.
“RSA is very well-suited to this indication,” he said.
Other clinical scenarios in which RSA is becoming more common include patients with tumors, very elderly patients with acute proximal humerus fractures and those with chronic pseudoparalysis related to massive rotator cuff tears without arthritis.
“The common denominator is that the rotator cuff is first severely dysfunctional, causing symptoms that the patient cannot tolerate, and dysfunction which by other means cannot be surgically reconstructed,” Gerber said.
But Boileau warned about “the dangers of over indicating,” explaining not all patients are good surgical candidates.
Surgeons should avoid performing RSA in patients with scapula-deficiencies or a non-functioning deltoid, and in those with infections.
“Some surgeons use this prosthesis for massive cuff tears in patients that can still elevate the arm and this is a mistake. This is not a prosthesis designed to relieve pain only. It is designed to restore active elevation,” Boileau said.
Hoffmeyer echoed Boileau’s point about the importance of proper patient selection, expressing concerns about using RSA in younger patients.
“Patients tend to do well for the first 10 years after the procedure, but then there is a drop in survival and patients begin to develop pain and loss of function,” he said.
Among the few long-term follow-up studies of RSA patients, data from a 2006 study by Favard et al indicate that 58% of 77 patients who underwent 80 reverse prostheses implantations had absolute Constant scores <30 at 10-year follow-up.
Data from another 10-year follow-up study by Favard et al published in 2011, which involved 464 patients, indicated survivor-free revision rates were 89%.
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“If you put this prosthesis in younger patients, there is a good chance that it will need to be revised after 10 years,” Hoffmeyer said.
More complications than with total shoulders
Complication rates with RSA are typically higher than those in patients who receive traditional unconstrained shoulder implants and can range from 5% to 28% depending on such factors as indication, integrity of the patient’s subscapularis tendon and surgeon experience.
“The most frequent complication overall is instability,” Gerber said. Infection rates are two-to-three times higher with RSA than with standard shoulder arthroplasty “because of the geometry of the implant, which leaves a space beneath the shoulder on the acromion.”
Among 284 patients in a 2010 trial by Trappery et al, instability most frequently occurred among primary RSA patients with fracture sequelae (7 of 25; 28%). Infection rates were also higher among patients who had RSA to revise a previous shoulder arthroplasty (5 of 72) compared with those undergoing primary RSA (3 of 212; 7% vs. 1%).
Furthermore, patients with instability and infection had poorer outcomes than those who did not based on ASES, Western Ontario Osteoarthritis of the Shoulder Index, and Constant scores.
“If there is any doubt about localized, low-grade infections in patients undergoing revisions, I prefer to do a two-step procedure,” Boileau said, noting he performs a biopsy to determine the bacteria responsible after explanting the prosthesis and prescribes an appropriate antibiotic for 6 to 8 weeks before re-implantion. “This is a very difficult and risky procedure that only very specialized surgeons should perform,” Boileau said.
Whenever problems with RSA can be mastered without removing the prosthesis, outcomes “remain surprisingly good,” Gerber said.
Design innovations, solutions
Other problems with RSA, including scapular notching and mechanical failures, such as loosening of the screws affixing the glenoid to the baseplate, are common, but technological innovations in prosthesis design and surgical technique do offer solutions.
Scapular notching, a problem occurring in 50% to 90% of RSA patients, occurs when the medial aspect of the humeral component contacts the inferior aspect of the glenoid.
“The most frightening problem initially was inferior impingement, in which the polyethylene component of the humeral cap wears against the pillar of the scapula, leading to bone lysis and loosening of the prosthesis,” Boileau said.
Surgeons have since learned that positioning the glenoid component at the inferior edge of the native glenoid surface helps reduce such notching, he said, and increasing lateralization and height of the prostheses minimizes instability.
One method, bony-increased offset or BIO RSA, which Boileau developed, enables accomplishing both these tasks.
“One day I thought, instead of throwing away the humeral head, I could perform a graft on the glenoid side to create a scapula with a long neck,” he explained.
In fact, by combining his BIO RSA technique with a special base plate that uses longer pegs and screws, Boileau said he has overcome many of the original problems associated with reverse implants by minimizing scapular impingement and maximizing glenoid fixation.
Olsen agreed that since incorporating these two techniques – lower glenoid placement and the BIO RSA approach – scapular notching is rarely a problem for him anymore.
“I still see it occasionally, but I rarely see a loose implant due to scapular notching.”
However, the evidence is split on whether notching actually leads to poorer patient outcomes, Gerber said. “We have not yet figured out if patients do poorly and then notch, or if they notch and then as a result, do poorly,” he said.
But, Gerber reports he has still not seen a patient experience glenoid loosening attributable to notching.
“I think the problem is overstated.”
Deltopectoral vs. superior approach
Currently two main surgical approaches to RSA exist – the deltopectoral approach and the superior approach.
“In primary cases the two approaches are about comparable. Selection depends mostly on the preference of the surgeon,” said Gerber, who uses both approaches, deciding which is best based on the patient. “We use the superior approach when we are afraid of instability and … the deltopectoral approach for all revision surgeries, which make up the majority of our cases.”
Olsen, who also performs mostly revision surgeries — 27 out of 62 RSAs last year — reports using only the deltopectoral approach.
“Most of my patients already have an incision in the deltopectoral groove, and therefore, it is easier for me to use the incision that was used before,” he said.
Boileau also prefers the deltopectoral approach, but acknowledged there are advantages and disadvantages to both options.
“The main advantage with the superior approach is there is a direct track for the drilling and placement of the glenoid implant, and you do not have to detach the remaining subscapularis,” he said.
Disadvantages of the superior approach are it is difficult to place the glenoid low, which can increase scapular notching, and difficult to ream the glenoid surface vertically, he said.
“If you rim with superior tilt or if the glenoid surface is worn superiorly and you are unable to correct it, then there is an increased risk for glenoid loosening,” he said.
The disadvantage with the deltopectoral approach is detaching the subscapularis tendon makes instability more likely.
“On the other hand, you can go very low on the glenoid, you can rim with anterior tilt, and you can better avoid scapular notching,” Boileau said.
“I don’t think that there is any substantial evidence to support that one approach or one prosthesis is distinctly better than another,” Gerber said, adding these debates are mostly industry driven.
Future of RSA
More studies are necessary to determine long-term patient outcomes with ever-expanding RSA indications, but many believe improved prosthesis design and the increased availability of training opportunities for young surgeons will result in better patient treatments.
“When it works well RSA is really great and the patients are very happy. RSA prostheses are getting better. There are new incremental changes being made which make the implant easier, more mobile and more forgiving,” Hoffmeyer said. “As the designs evolve, the complication rates will probably drop, but they will never reach zero, because it is still a difficult implant to put in.”
In the meantime, surgeons just starting out should avoid performing more complicated revisions to RSAs, pay close attention to patient selection and seek training from qualified mentors experienced in RSA to avoid the many potential complications it can pose. – by Nicole Blazek
References:
- Boileau P, Moineau G, Roussanne Y, et al. Bony increased-offset reversed shoulder arthroplasty: Minimizing scapular impingement while maximizing glenoid fixation. Clin Orthop Relat Res. 2011;doi:10.1007/s11999-011-1775-4.
- Boileau P, Pennington SD, Alami G. Proximal humeral fractures in younger patients: Fixation techniques and arthroplasty. J Shoulder Elbow Surg. 2011;20:S47-S60.
- Guery J, Favard L, Sirveaux F et al. Reverse total shoulder arthroplasty. Survivorship analysis of eighty replacements followed for five to ten years. J Bone Joint Surg Am. 2006;88:1742-1747.
- Hatzidakis AM, Norris TR, Boileau P. Reverse shoulder arthroplasty: indications, technique, and results. Tech Shoulder Elbow Surg. 2005;6:135-149.
- Jazayeri R, Kwon YW. Evolution of the reverse total shoulder prosthesis. Bull NYU Hosp Jt Dis. 2011;69:50-55.
- Trappery GJ, O’Connor DP, Edwards TB. Clin Orthop Relat Res. 2010 Nov 23. Online First.
- Zumstein MA, Pinedo M, Old J, Boileau P. Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2011;20:146-157.
- Pascal Boileau, MD, can be reached at +33 492 03 64 97; email: boileau.pascal@wanadoo.fr.
- Christian Gerber, MD, can be reached at +41 44 386 30 04; email: christian.gerber@balgrist.ch.
- Pierre Hoffmeyer, MD, can be reached at +41-79-680-46-71; email: pierre.hoffmeyer@efort.org.
- Bo Sanderhoff Olsen, MD, PhD, can be reached at +45 31 25 54 54; bosolsen@jubii.dk.
- Disclosures: Gerber, Hoffmeyer and Olsen have no relevant financial disclosures. Boileau is co-inventor of the Aequalis (Tornier Inc.) reverse shoulder prosthesis.
What is your best indication for reverse arthroplasty and why?
Two optimal indications
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Basically all shoulder pathology with severe involvement of the rotator cuff is eligible for a reverse arthroplasty.
The present indications for the reverse prosthesis in the shoulder are cuff tear arthropathy (CTA), massive cuff tears without arthritis, sequela of fracture treatment with a non-functioning cuff, failed primary total shoulder arthroplasty (TSA) with a standard hemi or total shoulder prosthesis, tumor surgery, rheumatoid arthritis with cuff involvement, acute fractures, as well as chronic dislocation in the elderly. But, the two most important indications in my clinic are CTA/massive cuff lesions and revisions.
The basic prerequisite is a well-functioning deltoid muscle and reasonable glenoid bone quality to enable fixation of the base plate.
The best results related to the improvement of the Constant score in my series were achieved in patients with CTA or massive cuff tears, ie, Constant scores from 60-65, that have an intact subscapularis and teres minor muscle. Although the reverse prosthesis can function well without one or both of these muscles, the external and/or internal rotation strength decreases considerably when they are absent.
The most important drawback of this prosthesis is the limited internal rotation, as well as hardly any improvement of external rotation. These factors should be communicated to patients prior to surgery. Some other issues of concern are the higher rate of postoperative complications compared to standard TSA and notching of the glenoid, although the clinical consequences of this problem are minimal.
Although using this prosthesis is still regarded as a salvage procedure for older patients, its current long-term results show a high survival rate.
W. Jaap Willems, MD, PhD, is an
orthopaedic surgeon at Onze Lieve Vrouwe Gasthuis in Amsterdam.
Disclosure: He has no relevant financial disclosures.
One best indication: Cuff tear arthropathy
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My main indication for reverse shoulder arthroplasty (RSA) is cuff tear arthropathy. The reason for this indication is related to the soft tissue quality and to the bone-related changes: absence of the cuff, rounded humeral head in contact with the undersurface of the acromion. The problem to address is having a sufficient enough deltoid to implant a functional RSA.
In cases when the deltoid is poor, the RSA will not function and the patient is left with a pseudo-paralytic shoulder. A different situation occurs relative to the absence of external rotation for a lesion impacting the whole posterior-superior cuff (supraspinatus, infraspinatus and teres minor), even in a functional shoulder. In these cases, the transfer of latissimus dorsi can help recreate the posterior bridle of the cuff leading to a recovery of external rotation.
In the case of fractures in elderly patients, aged more than 70 years old, the use of RSA is increasing with wonderful results due to the possibility of letting the patient move the shoulder starting the day after the operation, permitting their early return to previous daily living activities.
The RSA prosthesis is an important device even in revision cases for failed hemi or total shoulder arthroplasty because in these cases the use of RSA can give patients the possibility to increase what was once typically poor range of movement. But, in these cases the surgery is more also demanding due to the poor quality of the tissues and their lack of elasticity which can increase the risk of instability of the implant. For these reasons, in revision cases, I prefer to implant a bigger glenosphere.
Giuseppe Porcellini, MD, is Chief of
Unit of Shoulder Surgery at D. Cervesi – Hospital Cattolica – Italy.
Disclosure: He has no relevant financial disclosures.