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The reverse ball and socket: When is it indicated?
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When considering constrained shoulder prostheses, surgeons must distinguish between ball and socket designs and reverse ball and socket designs. The Delta III Grammont is a semiconstrained reverse ball and socket prosthesis originally designed by Paul Grammont in Dijon, France, in 1987 and subsequently modified in 1991. This prosthesis has been used since its inception in France, shortly thereafter throughout Europe and, more recently, in the United States. I have used the Grammont prosthesis since September 1995. I will use this experience to define the indications for its use.
The prosthesis
Shoulder anatomy is reversed in the Grammont prosthesis. The humeral head is concave and the glenoid is spherical. The glenoid implant is made of two components. The base plate is a metallic disk with a central peg and four holes for screw fixation. The central peg and medial surface of the base plate are covered by hydroxyapatite.
To ensure primary stability, four 4.5-mm screws are used in fixation. The second component, the glenosphere, is available in two diameters (36-mm and 42-mm) and is secured to the base plate. From 1987 to 1995, the glenosphere was peripherally screwed onto the base plate. Because of patients with dissociation of the glenosphere and base plate, the locking mechanism was modified in 1996 to a spherical morse taper with a central safety screw.
Two types of humeral stems are available. A smooth finish stem is available for cemented implantation and a hydroxyapatite-coated stem is available for uncemented implantation. Three lengths (100-mm, 150-mm and 180-mm) and four diameters (6-mm, 9-mm, 12-mm and 15-mm) are available.
The epiphyseal component of the humeral implant is screwed on the stem and has a lateral fin to prevent rotation. The epiphyseal component is available in two sizes for cemented or uncemented use. The humeral cup is made of high-density polyethylene. The concave surface is one-third of a sphere and locks into the epiphyseal component. The humeral cup is available in two diameters and two thicknesses allowing selection of appropriate deltoid tension.
Two surgical approaches can be used to implant the prosthesis — the superior approach as originally described by Grammont with an acromial osteotomy or detachment of the deltoid from the anterior aspect of the acromion, and the anterior classic deltopectoral approach without release of the deltoid acromial attachment.
Indications for the reverse ball and socket prosthesis
From 1995 to 2003, 240 reverse prostheses were implanted at our institution. During this time, 759 nonconstrained anatomic prostheses were implanted. Among the 240 reverse prostheses implanted, 186 (76.5%) were implanted as a primary prosthesis and 54 (24.5%) as a revision arthroplasty.
Cuff tear arthropathy
Cuff tear arthropathy was initially described by Neer in 1983 as a pathology associating collapse and upward migration of the humeral head related to massive rotator cuff tears. Cuff tear arthropathy was limited to patients with an area of collapse of the proximal aspect of the articular surface. Neer emphasized that degeneration of the glenohumeral articular cartilage and osteopenia of the subchondral bone must be differentiated from the sclerotic humeral head enlarged by marginal osteophytes typical of primary glenohumeral osteoarthritis.
In his initial description of 26 patients with cuff tear arthropathy, Neer noted anterior or posterior dislocations or subluxations of the humeral head were frequent. The large osteophytes that are characteristic of osteoarthritis were not seen. In 11 patients, the glenoid had become deeply eroded and in most patients there was rounding off of the greater tuberosity. In some patients, erosion of the undersurface of the anterior third of the acromion and the acromioclavicular joint occurred.
The term cuff tear arthropathy should also include presence of glenohumeral osteoarthritis without collapse of the humeral head, a biconcave deformation of the glenoid in the frontal plane resulting from superior erosion of the glenoid and large osteophytes of the humeral head. It seems reasonable that this entity is secondary to a massive rotator cuff tear with subsequent upward migration of the humeral head. Cuff tear arthropathy was the cause for 29% of the prostheses implanted as a primary arthroplasty. Women represented 81.5%, and the average age was 74.3 years.
Primary glenohumeral osteoarthritis
Although primary glenohumeral osteoarthritis is described by Neer as a typical indication for nonconstrained shoulder arthroplasty, variations in the anatomic and radiographic presentation may be observed and negatively influence the results of a nonconstrained total shoulder arthroplasty. Relative indications for the reverse ball and socket prosthesis in primary osteoarthritis include associated full thickness tearing of the supraspinatus and infraspinatus, narrowing of the acromiohumeral distance with contact area between the humeral head and acromion with or without acetabulization of the acromion. I used the reverse prosthesis in 44 shoulders with primary glenohumeral osteoarthritis representing 24% of the indications for a primary reverse prosthesis. These patients tended to be slightly older than the patients with classic cuff tear arthropathy.
Posttraumatic arthritis
In patients older than 70 years of age, nonunion of the surgical neck of the humerus or severe malunions or nonunions of the tuberosities represent an imposing surgical challenge. It is difficult to obtain healing of the tuberosities after hemiarthroplasty, even with the use of concomitant bone grafting. We have implanted 31 reverse prostheses for posttraumatic arthritis (16.6% of primary prostheses), providing restoration of active pain-free elevation. Thirteen patients had one to five previous surgical procedures to treat the fracture.
Failure of rotator cuff surgery
Although failure of a rotator cuff repair is not always responsible for poor results, in cases in which repair or acromioplasty was ill advised, the patient is left with a loss of active elevation (pseudoparalytic shoulder), pain and dynamic anterior superior subluxation of the humeral head. This complication may be treated successfully with the reverse prosthesis, allowing restoration of active elevation. We have implanted 25 reverse prostheses for failure of a rotator cuff repair.
Massive rotator cuff tear with chronic pseudoparalytic shoulder
When pseudoparalysis with or without anterior superior dynamic instability of the humeral head has been present for more than six months, surgeons have not been able to successfully relocate the humeral head and restore active anterior elevation with rotator cuff repair or tendon transfers. These patients are often pain free and complain only of loss of active mobility. Imaging studies demonstrate severe tendon ruptures with fatty infiltration of the subscapularis, supraspinatus and infraspinatus muscles. We have implanted 19 reverse prostheses for this etiology and have found stability of the prosthesis and restoration of active elevation.
Rheumatoid arthritis
Rheumatoid arthritis is often coupled with complete insufficiency of the rotator cuff, superior migration of the humeral head, superior glenoid wear and osteopenic bone. Results published by Rittmeister and colleagues suggest that the reverse prosthesis should be used selectively and cautiously in these patients because the poor bone quality can lead to failure of glenoid component fixation. Nevertheless, we have used the reverse prosthesis in five patients with rheumatoid arthritis (2.6% of the primary prostheses).
Fracture in elderly patients
In patients older than 78 years of age, obtaining tuberosity healing after hemiarthroplasty is difficult. The reverse prosthesis offers an acceptable alternative to hemiarthroplasty in this difficult situation. We have used the reverse prosthesis in three patients with acute fracture and have been successful in restoring painless active anterior elevation.
Tumor
DeWilde and colleagues reported the use of the reverse prosthesis in reconstruction after tumor resection when the margin of resection includes the rotator cuff insertion. DeWilde published four cases and we have performed two cases. In contrast, syringomyelia (neuropathic arthropathy) is a contraindication for the reverse prosthesis because the patient is pain free and the risk of instability of the reverse prosthesis is evident.
Revision arthroplasty
Patients undergoing revision arthroplasty are the most challenging and the reverse prosthesis has provided acceptable results in the majority of these patients. Failed hemiarthroplasty for fracture with a deficient rotator cuff is an appropriate indication for a reverse prosthesis, as no other satisfactory option exists. Surgeons have been unable to obtain healing of the greater tuberosity using bone grafting in such patients. We performed 18 reverse prostheses for this complication. The mean age was 66.7 years. In eight patients, the tuberosities disappeared; eight patients showed migration or nonunion of the tuberosities; and in two patients, the greater tuberosity was severely malunited.
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Loosening of glenoid in total shoulder arthroplasty with a deficient rotator cuff is probably the most challenging patient subset. Goals of surgery include restoration of glenoid bone stock and reduction of the superiorly migrated humeral head. We treated 14 patients with a one- or two-stage revision. Six patients underwent revision using the reverse prosthesis in one stage without bone grafting of the glenoid; five patients underwent reconstruction of the glenoid with a corticocancellous iliac crest bone graft and implantation of a reverse prosthesis performed at a single surgical setting; and three patients underwent reconstruction of the glenoid with a corticocancellous iliac crest bone graft and second-stage implantation of a reverse prosthesis after graft incorporation. Static subluxation of nonconstrained prosthesis either anteriorly or posteriorly is difficult to treat. After many attempts and failures to stabilize nonconstrained prostheses through other means, we have used the reverse prosthesis in eight of these cases (four with anterior subluxation and four with posterior subluxation). Failed hemiarthroplasty implanted for posttraumatic arthritis is characterized by pain, stiffness, erosion of the glenoid and, most frequently, malunion of the tuberosities.
In our experience, it is difficult to obtain painless range of motion after revision with nonconstrained prosthesis. Seven cases were revised with a reverse prosthesis. Although humeral head replacement was reported as a satisfactory option to treat patients with cuff tear arthropathy, in the mid- or long- term, it is not uncommon to observe painful secondary erosion of the acromion, the superior part of the glenoid, or both. Five cases were revised with a reverse prosthesis.
Complications
Dissociation of the glenosphere from the base plate has been reported. Complications related to the transacromial approach with nonunion of the acromial osteotomy have been reported by Rittmeister and colleagues. During the eight-year period of our prospective study, we observed a complication rate of 10.8% leading to a 4.6% reoperation rate. The rate of complications was twice as high in patients undergoing revision arthroplasty compared with primary arthroplasty. Dislocation of the humeral component was the most frequent complication observed and was related to inadequate deltoid muscle tension.
Although we observed some transient neurologic complications, there were no permanent neurologic problems despite placing the maximum tension possible on the deltoid by using minimal humeral head resection. Of the patients with a prosthetic dislocation, 10 patients were stable after closed reduction of the implant and five underwent reoperation to increase the length of the humerus using an augmentation spacer. We observed two patients with glenoid loosening, both of which were related to incorrect surgical technique. Fracture of the humeral diaphysis at the distal tip of the prosthesis was observed in four patients, and one patient required surgical treatment. Finally, we observed a scapular notch in approximately 50% of the patients during the first two postoperative years. None of the scapular notches in our series evolved to glenoid loosening.
Conclusion
The Grammont reverse prosthesis, initially designed for glenohumeral arthritis with rotator cuff deficiency, is assuming a greater role in shoulder reconstruction in situations in which no other satisfactory options exist. As surgeons’ experience with the reverse prosthesis has grown, so has confidence in its use.
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