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Can anatomic shoulder arthroplasty be as effective as reverse arthroplasty for glenohumeral arthritis?

Issue: August 2019

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Click here to read the Cover Story, "Increase in reverse arthroplasty leads to utilization concerns."

Anatomic total shoulder arthroplasty remains the gold standard

Anatomic TSA has been used to improve function and decrease pain in patients with shoulder arthritis since about 1970. Modern reverse shoulder arthroplasty was developed and introduced in Europe in the late 1980s due to disappointing results of anatomic shoulder arthroplasty in patients with shoulder arthritis and massive rotator cuff tears. The success of reverse shoulder arthroplasty in this patient population has led to the expansion of the indications for reverse replacement to include shoulder arthritis with an intact cuff, especially with substantial glenoid bone deformity. Despite this expansion, anatomic arthroplasty remains the procedure of choice for patients with shoulder arthritis, an intact rotator cuff and mild to moderate glenoid deformity. The return of motion, especially internal rotation, is better with anatomic replacement. In addition, the infection rates of 1% vs.1.5% to 2% and dislocation rates of 1% vs. 1.5% to 2% are lower with anatomic replacement, multiple sources reported. Finally, stress fractures of the scapular spine and acromion are unique to reverse TSA (3% to 11%) and usually result in permanent decrease in function and an increase in pain. Reverse TSA, therefore, is currently reserved for patients with substantial rotator cuff dysfunction and/or severe glenoid deformity. Advances in surgical technique and technology will improve the results of both anatomic and reverse TSA, but anatomic arthroplasty will likely remain the procedure of choice for many patients with shoulder arthritis.

• References:
• Florschütz AV, et al. J Shoulder Elbow Surg. 2015;doi:10.1016/j.jse.2014.12.036.
• Floyd SB, et al. JSES Open Access. 2018;doi:10.1016/j.jses.2017.10.002.
• Kiet TK, et al. J Shoulder Elbow Surg. 2015;doi:10.1016/j.jse.2014.06.039.
• Ponce BA, et al. J Shoulder Elbow Surg. 2015;doi:10.1016/j.jse.2014.08.016.
• Simovitch RW, et al. J Bone Joint Surg Am. 2017;doi:10.2106/JBJS.16.01387.
• Somerson JS, et al. J Shoulder Elbow Surg. 2018;doi:10.1016/j.jse.2018.03.025.

• For more information:
• Gerald R. Williams Jr., MD, is the John M. Fenlin Jr., MD professor of shoulder and elbow surgery at Rothman Orthopaedic Institute in Philadelphia.

Disclosure: Williams reports he receives royalties from DePuy Synthes and DJO.

Reverse total shoulder arthroplasty is an ideal procedure

Not only can reverse TSA be as effective as anatomic shoulder arthroplasty, there are many scenarios in which it may be more effective.

Anatomic shoulder arthroplasty is the gold standard and is effective in younger patients with little bony deformity and a rotator cuff that will heal perfectly after replacement and repair. Although this surgery has been the accepted standard for years, there is a documented history of poor clinical outcome, and even failure, due to rotator cuff failure and glenoid loosening.

Clinical results with reverse TSA are more consistently outstanding and patients can be active in sports that include golf, tennis, light weightlifting and swimming. Two recent studies documented more than 90% survivability at 10-year follow-up. Additionally, reverse TSA is effective for many conditions other than massive rotator cuff tears to include bone loss and fractures. As arthritis advances, loss of native glenoid bone stock and glenoid deformity may occur, leading to shoulder imbalance, instability and glenoid loosening. As patients age, concomitant rotator cuff insufficiency and rotator cuff tears are often present. The ability for the subscapularis to heal postoperatively diminishes and subscapularis failure may lead to instability, loosening and failure.

Because reverse TSA solves the problem of bone loss and deformity, as well as rotator cuff insufficiency, it is an ideal procedure for glenohumeral arthritis, especially in patients with bone loss or deformity, as well as in patients older than 70 years with poor rotator cuff function or tears.

• References:
• Bacle G, et al. J Bone Joint Surg Am. 2017;doi:10.2106/JBJS.16.00223.
• Boileau P, et al. J Shoulder Elbow Surg. 2006;doi:10.1016/j.jse.2006.01.003.
• Cuff DJ, et al. J Bone Joint Surg Am. 2017;doi:10.2106/JBJS.17.00175.
• Franklin JL, et al. J Arthroplasty. 1988;3:39-46.
• Mizuno N, et al. J Bone Joint Surg Am. 2013;doi:10.2106/JBJS.L.00820.
• Utz CJ, et al. J Shoulder Elbow Surg. 2011;doi:10.1016/j.jse.2011.03.024.

• For more information:
• Patrick St. Pierre, MD, is director of the Shoulder and Elbow Service and Orthopedic Research at Desert Orthopedic Center and Eisenhower Health in Rancho Mirage, California.

Disclosure: St. Pierre reports he is a consultant and speaker for and receives royalties from DJO, Zimmer Biomet and Stryker.