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Better exposure among benefits of RSA vs hemiarthroplasty for four-part fractures
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KOHALA COAST, Hawaii — Although reverse total shoulder arthroplasty is easier to perform and results in better early outcomes than hemiarthroplasty for patients with four-part fractures, a presenter at Orthopedics Today Hawaii noted complications and uncertainty regarding long-term results with the reverse procedure.
“[Reverse total shoulder arthroplasty] is easier to perform than you think, because of the exposure that you can get,” Christopher S. Ahmad, MD, of Columbia University, said during in his presentation. “The tuberosity healing is not required, and the results are going to continue to show [that patients] are performing well. We have to be careful of the complications.”
Advantages and indications
Tuberosity displacement is not as much of a concern with reverse shoulder arthroplasty (RSA) as it is for hemiarthroplasty, according to Ahmad. For RSA, the prostheses are constrained and tension the deltoid “which medializes the center of rotation,” allowing for better deltoid function, he said.
“It makes your deltoid replace the need for a rotator cuff,” he added. “The first indication [for the procedure] was for rotator cuff arthropathy.”
Christopher S.
Ahmad
Other indications for RSA include failed hemiarthroplasty and proximal implant migration.
“There may be options in the future with new designs where, instead of having to get this well-fixed stem out, you can just convert the stem to a reverse shoulder replacement,” Ahmad, an Orthopedics Today Editorial Board member, said.
He noted that stem position is critical in hemiarthroplasty. “The architecture is disorienting,” Ahmad said. The biology of the tuberosity is not supportive of the hemiarthroplasty prosthesis, he added, and results may vary. In comparison, RSAs are easier to perform because surgeons can get good exposure and the procedure lacks the need for tuberosity healing.
Complications and outcomes
Complications of RSA include instability, dislocation, acromial stress injury, loss of fixation, scapular notching and neurologic complications as the injured extremity tensions, Ahmad said. It is important that the base plate is well-positioned, otherwise the medial aspect of the polyethylene and base plate may hit the scapula and cause notching and fixation issues. To avoid instability, Ahmad suggested tensioning the deltoid.
“Do not over tension [the deltoid] so that you put too much stress on the overall system, fatiguing the deltoid, and maybe even getting a stress injury to the acromium,” he said.
Published studies show that RSA outperformed hemiarthroplasty in terms of gained motion and forward elevation, Ahmad said. In registries, patients with RSAs have similar outcomes to hemiarthroplasties at 6 months, but at 5 years, the results indicate that RSAs are superior. “We do not know what the long-term results are,” Ahmad said. – by Renee Blisard Buddle
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Disclosure: Ahmad is a consultant for Arthrex and Acumed and performs contracted research for Arthrex, MLB, Stryker and Zimmer.
Perspective
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John W. Sperling, MD, MBA
The indications for the use of the reverse arthroplasty continue to grow significantly. Improved understanding of the biomechanics of the procedure, longer clinical follow-up and decreased complications are all driving this trend.
One area that has seen a dramatic increase in the use of the reverse arthroplasty is the treatment of four-part fractures in elderly patients. As noted by Dr. Ahmad, the primary reason for this trend is more predictable outcomes with the reverse arthroplasty compared to hemiarthroplasty. The reverse arthroplasty provides the opportunity for restoration of function, even in the setting of tuberosity resorption. Data is also emerging that tuberosity healing may be higher with reverse arthroplasty compared to hemiarthroplasty. This provides an additional reason to consider the use of the reverse for these fractures.
As noted by Dr. Ahmad, the evolution of convertible stems that can be used for hemiarthroplasty or reverse arthroplasty has provided additional flexibility for the surgeon at the time of the primary procedure. In addition, a convertible stem can simplify the revision of a hemiarthroplasty to a reverse arthroplasty, if this is needed in the future.
Early results of reverse arthroplasty for fracture are encouraging. Additional long-term studies will be necessary to further refine the indications for this procedure.
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