Increase in reverse arthroplasty leads to utilization concerns

Reverse shoulder arthroplasty has limitations despite high survivorship.

In the past decade, published research has identified an increase in shoulder arthroplasty procedures performed in the United States. Some orthopedic surgeons associate this increase with the approval of reverse total shoulder arthroplasty by the FDA in 2004.

“Shoulder arthroplasty is growing at an incredible rate; much faster than hip or knee replacement and much of that growth in the last 10 years has been due to reverse shoulder replacement,” Patrick J. Denard, MD, of Southern Oregon Orthopedics, told Orthopedics Today.

Although the original indication for reverse shoulder arthroplasty was rotator cuff tear arthropathy in patients older than 65 years, sources noted the indications have expanded to include proximal humerus fractures, certain massive irreparable rotator cuff tears with or without glenohumeral arthritis, failed rotator cuff repairs, anatomic total shoulder arthroplasty (TSA) and primary arthritis with certain deformities.

“We will use [reverse shoulder arthroplasty] for primary arthritis with significant glenoid bone deficiency. We will use it for people with irreparable or massive cuff tears where the rotator cuff is unlikely to heal. We will use it for trauma, [and] tumor reconstructions,” Joshua S. Dines, MD, of Hospital for Special Surgery, said. “The indications have expanded and it has become a boon to the orthopedic practice and shoulder surgeons, in general. It has also become a great bail out for failed anatomic shoulder arthroplasty,” he said.

Expanded indications

According to Jonathan C. Levy, MD, chief of orthopedics at Holy Cross Orthopedic Institute, one reason for these expanded indications is surgeons have gained confidence in the procedure after seeing its outcomes.

When reverse TSA was first used, there was a complication rate of 30% to 50%. Now, however, survivorship at 10 years has improved to 90%, Denard said.

“[In] the Australian joint registry data at 7 years after implant, if you compare a reverse to an anatomic [total shoulder arthroplasty] the survival rate is the same ... or better with reverse,” Denard, an Orthopedics Today Editorial Board Member, said.

Source: Lauren Levy

These data on good long-term survivorship with reverse TSA have not only led to application to additional disease processes, but also to the procedure being performed in younger patients, according to Levy.

“Now that we are starting to see reverse shoulder replacements that have 10-year results with no drop in function, we are gaining confidence in the technology,” Levy told Orthopedics Today. “We are applying it to patients who are younger and who have different disease processes that we thought might benefit from the reverse shoulder replacement but were apprehensive to use it on them because we did not know the 10-year results and we did not know how we might be able to manage failures.”

Positive outcomes

Compared with anatomic shoulder replacement or superior capsular reconstruction (SCR), sources who spoke with Orthopedics Today said reverse TSA may be an easier and more straightforward procedure, depending on the case.

“You can do [a reverse shoulder arthroplasty] through different surgical approaches,” Joseph D. Zuckerman, MD, professor in and chair of the department of orthopedic surgery at NYU Langone Health, told Orthopedics Today, noting most surgeons would use a deltopectoral approach, the same type of approach used for anatomic TSA. “I think that it is a more straightforward operation than an anatomic because it is a more constrained joint,” he said.

Also, because reverse TSA tends to be more constrained, Denard said stability is easier to achieve surgically vs. anatomic TSA.

“That constraint is what leads to the fact that you can have less range of motion with a reverse compared to an anatomic, so it is a tradeoff,” Denard said.

Zuckerman said published results show a significant decrease in infection and dislocation rates for reverse TSA.

Changes in component design have led to improved outcomes, Denard said. “When the reverse was first designed, the weak link was fixation on the glenoid side and there were compromises made to accommodate that. Now the prostheses are more anatomically designed and the anatomy is respected more and that is leading to improvement in range of motion and decreased complications,” he said.

With improvements in fixation on the glenoid side of contemporary reverse TSA components, Levy noted surgeons have turned their attention to humeral fixation through osseointegration and non-cementing techniques.

Patient-specific planning software and instrumentation can help surgeons plan the surgery and select the best implants before going into the OR, Dines said.

“In the future, what I think is going to be great will be combining research that is currently underway into the biomechanics of reverse TSA, including the size and lateralization of the glenosphere and options for humeral component neck-shaft angles, with specific software to tailor a prosthesis to what that patient is expecting,” he said.

Stephen S. Burkhart, MD, of San Antonio Orthopaedic Group, said positive outcomes of reverse TSA in the literature have given surgeons “permission to go ahead and do what is the easier option for the surgeon, even though it may not be the best option for the patient,” which may contribute to possible overuse of the procedure.

“I think the biggest category of potential overuse of reverse TSA is in active patients with large or massive rotator cuff tears who do not have glenohumeral arthritis. These are patients who might be better served by arthroscopic rotator cuff repair or by arthroscopic SCR. However, some surgeons feel compelled to be able to take care of as many of their own patients as possible and not refer them away and the reverse TSA has offered them what they perceive as an easier way to do that,” Burkhart told Orthopedics Today. “But, I am trying to bring to the forefront the fact that, yes, it may be easier, but it may not be the best thing for the patient.”

Burkhart said, reverse TSA may be a reasonable option for patients with massive, irreparable rotator cuff tears who are elderly, relatively inactive and unlikely to overstress the shoulder or for individuals be unable to complete prolonged rehabilitation.

“[A] patient who has a lot of medical comorbidities where ... you do not want to do a long operation on them, they are going to be better off if they have a shorter operation,” he said. “However, in my opinion, younger and more active patients should be offered arthroscopic rotator cuff repair or SCR.”

Zuckerman said reverse TSA may be overused for indications that have not fully evolved. There is uncertainty at what age patients should undergo reverse TSA instead of anatomic TSA.

Denard said it is difficult to prove reverse TSA is overutilized.

Although Dines has noticed an increase in the use of reverse TSA in his practice, this is largely due to the expanded indications sources mentioned.

“There is certainly a danger that it can be overutilized. To me overutilized means there is something else that could have been done that would have been a better option,” Levy, an Orthopedics Today Editorial Board Member, said. “Where we see that the most is in the setting of massive rotator cuff tears without arthritis.”

Sources said infection and patients with inadequate bone stock are contraindications for reverse TSA.

“The biomechanics of the reverse ... depend on the deltoid muscle working well,” Dines said. “If somebody did not have a deltoid that worked, that would potentially be a contraindication, especially if they were undergoing the surgery for functional gain.”

The indications for surgery and the activity level the patient seeks postoperatively also play a role in whether a reverse TSA should be performed.

“I might see a patient who I think is a candidate for reverse shoulder arthroplasty, but they love doing bench press and CrossFit workouts and pull-ups that are going to beat it up,” Dines said.

Reverse TSA limitations

Despite its high survival rates, reverse TSA imparts some functional limitations, such as limited internal rotation, according to Levy.

After reverse TSA, patients may be at risk for a revision, depending on the primary surgical indication, Dines said.

“If you are [doing a reverse shoulder arthroplasty] for cuff tear arthropathy, those results are great. There is a long survivorship and the results are excellent,” he said. “If you are doing it for a traumatic malunion, there is a higher risk of instability, infection, [and] things of that nature.”

Difficulty revising failed primary reverse TSA depends on the cause of failure. Polyethylene component change may be easy whereas glenoid baseplate loosening can be a more difficult problem, according to Dines.

Some surgeons may be hard pressed for a solution in patients who have a more severe cause of failure of the primary arthroplasty, he said.

“When you have already taken a shoulder ... with a rotator cuff [tear] and now you put in a reverse, you completely changed the mechanics of the shoulder [and] you start running out of bone and soft tissue to work around, if it fails,” Dines said.

Burkhart said not only is reverse TSA associated with a higher overall complication rate than arthroscopic approaches for treatment of massive rotator cuff repairs, the infection rate is also higher for reverse TSA compared with arthroscopic repair or arthroscopic SCR.

“It is tempting for surgeons to do the convenient thing for themselves and to choose a faster operation and tell people they will get well quicker. But, they do that at the expense of not being able to preserve the joint, of exposing the patient to a higher complication rate by far and by taking away options in the future, which some of these younger, active people are most likely going to need,” Burkhart, who an Orthopedics Today Editorial Board Member, said.

Rehabilitation approaches

With few evidence-based guidelines for reverse TSA, more research is needed into the best rehabilitation methods, Denard said.

“If you survey American Shoulder and Elbow Surgeons, you will see a wide variance from people using a sling for 2 weeks to using a sling for 6 weeks and there is a paucity of literature with rehab right now after shoulder replacement,” he said.

Zuckerman said patients progress faster after reverse TSA than after anatomic TSA. He allows his patients with reverse TSA to begin active range of motion sooner than his patients who undergo anatomic TSA, for example.

Patients on whom Zuckerman performs reverse TSA use a sling for about 2 weeks compared with 5 weeks for patients who undergo an anatomic TSA.

Levy said his patients undergo a “self-directed rehabilitation program, protecting the arm in a sling for a 6-week period.” Rehabilitation will understandably be longer in patients who undergo concomitant subscapularis repair with reverse TSA, he said.

Often, surgeons perform reverse TSA because a patient does not have a rotator cuff or a subscapularis, Dines said. “We will often start physical therapy the day afterwards in the hospital, start moving it to get their motion back because you do not have to protect their rotator cuff repair,” he said. “That differs from an anatomic shoulder arthroplasty, for instance, where you have to repair the subscapularis.”

Know the indications, available systems

Regardless of whether reverse TSA is being overused and despite its limitation, Denard said the procedure provides a reliable solution for conditions that otherwise did not have a solution.

“Use of the reverse has been a game changer,” Zuckerman said. “It is still an operation that requires exacting technique and meticulous handling of the soft tissues ... with careful insertion of the components and careful monitoring postoperatively.”

Dines said orthopedic surgeons interested in adding reverse TSA to their armamentarium should learn the intricacies of the procedure and understand its appropriate indications. He said surgeons should be familiar with the various reverse TSA implant systems and maximize their features to “provide patients with the most benefits.”

It is also important for surgeons to recognize the difference between joint-preserving and joint-destructive operations and to learn how to preserve some of the patient’s shoulder for possible future operations, Burkhart said.

“While [reverse shoulder arthroplasty] works in the majority of cases, it is a patient’s last procedure in many cases and it does have a high complication rate in certain cases, especially with [surgeons] who have not [had a lot of experience with it],” Dines said.

Denard suggested surgeons attend cadaver training and discuss the indication and nuances of the various techniques with experts on the procedure.

“Take advantage of all the opportunities that are available from an education standpoint before you dive in to doing reverse shoulder replacement,” Levy said. “There is a wealth of knowledge that can be learned from those who have done this several hundred or thousand times.” – by Casey Tingle

• References:
• Dillon MT, et al. Arthritis Care Red (Hoboken). 2017;doi:10.1002/acr.23167.
• Familiari F, et al. EFFORT Open Rev. 2018;doi:10.1302/2058-5241.3.170044.
• Jain NB, et al. J Shoulder Elbow Surg. 2014;doi:10.1016/j.jse.2014.06.055.

• For more information:
• Stephen S. Burkhart, MD, can be reached at 400 Concord Plaza Dr., San Antonio, TX 78216; email: ssburkhart@msn.com.
• Patrick J. Denard, MD, can be reached at 2780 E. Barnett Road, Medford, OR 97504; email: pjdenard@gmail.com.
• Joshua S. Dines, MD, can be reached at 523 East 72nd St., 3rd Floor, New York, NY 10021; email: ironsm@hss.edu.
• Jonathan C. Levy, MD, can be reached at 5597 North Dixie Highway, Fort Lauderdale, FL 33334; email: jonlevy123@yahoo.com.
• Joseph D. Zuckerman, MD, can be reached at 301 E. 17th St., New York, NY 10003; email: annie.harris@nyulangone.org.

Disclosures: Burkhart reports he is a consultant for and receives inventor royalties from Arthrex. Denard and Dines report they are consultants for Arthrex. Levy reports he is a consultant for and receives royalties from DJO. Zuckerman reports he is a design surgeon of a shoulder arthroplasty system for Exactech.

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