Advantages to medialize less

Transcription

1 Advantages to medialize less less RSP? Clinical and radiological results Ph Valenti, D Katz, Ph Sauzieres J Kany, K Elkolti, P Gleyze Paris, Lorient, Toulouse, Lyon, Colmar

2 Delta RSP CTA pseudoparalytic shoulder Gold standard? YES AAElevation 130

3 BUT Delta RSP CTA pseudoparalytic shoulder Gold standard? - No improvement External rotation - Internal rotation is limited - Shoulder aspect

4 Glenoid notch 40 à 74% 25% type IV!!! Medial impingement Glenoid wear osteolysis Type IV influence clinical results Glenoid loosening Bone defect Revision more difficult Favard 2001, Sauzieres 2001, Valenti 2001, Boileau 2004, Chillemi 2004, Sirveaux 2004, Mole Favard French group 2007

5 How to improve External and Internal Rotation? How to prevent Glenoid notch? - Lowering glenoid component - Improvement design RSP -New design which allow Less medialization of the humerus

6 How to prevent glenoid notching If you use DELTA design Low implantation of the glenosphere Glenosphere 42 Lateralized PE Cup Bone graft between MB and glenoid P Boileau RSA BIO ICSS Bahia 2007 Healing of bone graft???

7 How to prevent glenoid notching Change prosthesis design ( Delta Extend, Duocentric) Glenosphere over flow inferior part of the glenoid

8 How to prevent glenoid notching INCREASE LATERAL OFFSET (Encore, Arrow) Center of rotation more lateralized Humeral stem lateralized delta ARROW Encore

9 Lateralisation of center of rotation DELTA ARROW 8.7 mm + lateral

10 Shape of humeral component more lateralized DELTA ARROW A B>A B

11 Validation of new hypothesis - Comparative and retrospective study - 51 Delta 51 Arrow - Clinical evaluation: Constant score score - Radiological evaluation : AP neutral view Limits!!!: reproductibility,, position of the arm, aspect of the acromion and tuberosities

12 Epidemiology n=51 DELTA ARROW Cases Average age (Y) CTA (Hamada 4,5) RMC (Hamada 1,2,3) Follow up (months) Pre op Constant score homogeneous groups

13 HA HA AGT AGT C.GT C.GT Arrow Delta

14 Radiological results n=51 DELTA ARROW p Center of rotation/ GT (C.GT) <0,05 Acromion / humerus (AH) < 0,05 Acromion / GT (AGT) ns Glenoid notch 30 c 0 c 0,001 ARROW is more lateralized than DELTA With a Same lowering NO GLENOID NOTCH

15 Clinical results n=51 DELTA ARROW p Constant ns Pain /15 pts ns Daily activity/20 pts 14,5 14,5 ns Strength /25pts ns Superior Strength for DELTA

16 Clinical results n=51 DELTA ARROW p AAE ns ER < 0.05 ER <0.05 IR pts <0.05 Range of ROTATION > for ARROW

17 Hamada 3

18 Litterature review - External rotation? RSP RSP and Episcopo when? - Instability?

19 hypothesis Recruiting medial fibers of the deltoid and tensionning remaining external and medial rotators seems improving range of rotation. Anatomic DELTA ARROW P Boileau JSES jan/ Feb 2005

20 RSP alone Gain in external rotation? RSP center rotation Medialized (L offset <) (Delta D, Aequalis Tornier ) Limited 2 to 10 - SOFCOT 2006 Delta 484 c RCO to12 24 to42 to42 - Wall B et Al Delta/Tornier 199 c 5 to7 29 to43 to43 JBJS Am Werner et Al Delta 58c JBJS Am 2005 Less 5 - Boileau P et Al Delta 45c 7 to 11 JSES Sirveaux et Al Delta 80c 23 to32 to32 17 to40 to40

21 RSP alone Gain in external rotation? Gain in ER is higher 15 to 30 RSP center rotation less medialized (L offset >) (Encore M, Arrow FH) Frankle M et Al 2005 JBJS ER1 ER2 60 RSP FU>2y 12 to 41 Valenti Ph et Al 2008 in press 15 to to RSP FU>2y

22 Lateralisation center of rotation MB Risk of glenoid loosening increase shearing forces to MB Prevention - Convex Metal back - Press fit (HA) No radiolucent line NO glenoid loosening N= 51 Arrow 1998 Frankle and col JSES 7 glenoid loosening / 60 cases FU 2 years

23 Reverse shoulder prosthesis doesn t t improve external rotation? WHEN. Lesion of SS nerve by posterior screw(is). Teres minor minor absent,atrophic atrophic,fatty infiltration +++ Coracoid notch Tm

24 RSP + Tendon transfer Indications - Pseudoparalytic shoulder (after > 6 months of physiotherapy) - No active External rotation with the arm at the side with the arm at 60 abduction - Hornblower sign : Lack of Active ER Transfer LD and TM around the humerus

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26 Post operative

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28 % instability RSP reported in the litterature - SOFCOT c / 527 3,6% RCO Wall B et Al 15c / 199 7,5% JBJS Am Werner et Al 5c / 58 8,5% JBJS Am Boileau P et Al 3c / 45 6,6% JSES Arrow serie 3c / 180 1,6% Mainly in case of revision

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30 Advantages less medialized RSP Better external +++ internal + Rotation No glenoid Notch More stability (revision ) Better shoulder contour Active anterior elevation Still acceptable

31 Merci pour votre attention