Are too many reverse TSAs being done? Problems it is causing

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1 Are too many reverse TSAs being done? Problems it is causing Hithem Rahmi, DO John Itamura, MD The Kerlan Jobe Orthopaedic Clinic Professor of Orthopaedic Surgery Keck School of Medicine University of Southern California Dr Pean 1893 Platinum and rubber prosthesis Used for TB Explanted at two years secondary to infection Modern RTSA History Paul Grammont 1986 FDA approval 2004 Initially requirement for courses to use Very restricted use initially Now any surgeon can put one in 1

2 Editorial in JBJS(A), 2007 CA Rockwood, Jr Reverse TSA can have spectacular results in the hands of experienced surgeons Recommended inexperienced surgeons to : Watch videotapes Know the prosthesis and shoulder aatomy Practice on cadavers Operate with an experienced surgeon JBJS 2013 Evaluated the use of hemiarthroplasty and total shoulder arthroplasty from Total shoulder arthroplasties saw an increase 2.5 fold from , likely due to the FDA approval of RSA in 2003 Common indication for shoulder arthroplasty was osteoarthritis Fishing study using the 2011 national database 14,041 patients with TSA 5,466 patients with RTSA P<.001 female gender and fracture P=004 perioperative mortality P<.001: pneumonia, VTE Increased hospital cost by $11,530 2

3 National inpatient sample ,485 shoulder arthroplasty procedures identified 33% RTSA, 44% TSA, 23% HHR RTSA: 90% RCTA, Fracture10% HHR: OA 45%, Fracture 38% TSA 93% for OA Mortality.08% atraumatic,.53% traumatic etiology (p<.001) National Database from , 052 shoulder arthroplasties 58% TSA 43% RTSA Patients undergoing RTSA are at higher risk for In hospital death Multiple complications Prolonged stay Increased cost Non routine discharge Demographics Classic indication is Rotator Cuff Tear Arthropathy Elderly population 70 or greater Take into account physiologic age Sedentary/Low demand Compliant with lifting restrictions Low/no impact activity Must have a functioning deltoid 3

4 Bad Protoplasm Diabetes Table 1: Metabolic endocrine workup Morbid obesity 25 hydroxyvitamin D Calcium Gupta, JSES 2013 Phosphorus alkaline phosphatase Magnesium Beck,, J Hand S, 2013 Intact parathyroid hormone Growth hormone Insulin like Poor nutrition growth factor 1 Thyroid function tests Cortisol (serum) Alcohol (Ponce, 2015) or 24 hour urine (calcium, crosslinked n telopeptide of Type 1 substance abuse collagen [ntx], cortisol) Workman s compensation Testosterone Free testosterone Crazy or dementia Follicle stimulating hormone Luteinizing hormone I prefer to use the metabolic and Prolactin endocrine workup described by Serum and urine protein electrophoresis Comprehensive Brinker, et al, JOT 2007 metabolic profile (CMP) Complete blood count (CBC) adrenocorticotropic hormone Immunofixation electrophoresis BMI and RTSA Gupta,A., et al, JSES, 2013 BMI >35kg/m2 Higher overall complication rate (P<.05) Intraoperative EBL(P=.05) Beck, JD.,et al., J Hand S(A), patients: 17 obese, 36 overweight, 23 normal weight Complication rate significantly higher in obese group (35%) compared to normal weight group (4%) Surgeon Selection Are all surgical skillsets equal? Is your surgeon subspecialty trained? Does white hair mean that your surgeon is better? Is your surgeon OCD? Can you surgeon have a bad surgical day? Are new shiny parts better than the old proven parts? Does your surgeon read or keep up to date? Is your surgeon certified and/or recertified with the ABOS? Is there a learning curve for newer procedures? 4

5 Surgeon Experience Walch, G., et al., JSES, 2012 Comparing results of 2 consecutive series of 240 rtsa Main surgical indication was cuff tear arthropathy Constant score increased (P<.001) Complications decreased from 19 to 10.8 percent Dislocations reduced from 7 to 3.2 percent Infections decreased from 4 to.9 percent Revision rate decreased from 7.5 to 5 percent Notching remained the same, but less severity Twenty consecutive patients Second consecutive 10 patients with lower intraoperative complication rate 33 complications in 15 patients 11 patients with 22 intraoperative complications 8 patients with 11 postoperative complications CORR RSA performed by 1 fellowship trained surgeon from Mean 19.4 month f/u 19 complications (9.9%) Complications rate was higher in the first 40 shoulders (23.1%) than the last 160 shoulders (6.5%) More complications seen in revision cases than primary Concluded that the early complication based learning curve for reverse total shoulder arthroplasty is approximately 40 cases. 5

6 Is it better to go to the local hospital or go the House of God? JSES patients with Grammont prosthesis 40 month f/u Complication rate higher in revision group (47% vs 5%) Post op Constant score and ASES were higher in CTA versus revision group Results less predictable in revision cases Infection should be suspected in revision cases 232 patients Average age 72.7 years All etiology subgroups had substantial increases of function Patients with diagnosis of RCTA, OA, RCT did better than those with revision arthroplasty and post traumatic OA Revision arthroplasty group had a higher complication rate than primary r TSAs 6

7 Relative Young/high demand Laborer Charcot/ neuropathic Glenoid bone erosion/ defect No/little conservative treatment Poor ER strength Absolute Non functioning deltoid Active infection Contraindications JSES, 2013 rtsa (46 to 64 years) 5 to 15 year follow up Constant, strength, pain, and FF all improved 37.5 % complications 15 % failures ( 3 infection, 3 glenoid loosening) RTSA provides significant improvement, but it is imperative that high complication rate explained to patient JBJS(A), 2013 Multicenter review, 66 patients Average age of 52.2 years 46% multiple prior procedures 36.5 month follow up 81% patient satisfaction rate 15% complication rate 43 % scapular notching 7

8 JSES, shoulders 54 year average age 2.7 year f/u 83% had previous surgery with 2.5 case avg Success rate 75% 25% failure rate Limited goal procedure, longer term follow up needed JSES patients Mean age 60 years Indications RCTA OA Osteonecrosis f/u of 3 years Significant functional and pain improvement Complicatoins Notching (18%) Dislocation (3%) No loosening Deltoid Dysfunction Ladermann,A, et al, JBJS(B), patients with impairment of deltoid underwent RTSA 38 month follow up 18% complications, 2 dislocations FF: 50 to 121 degrees Constant: 24 to percent satisfaction rate Pre operative deltoid impairment is not absolute contraindication 8

9 Expanding Indications for RSA The large increase in the use of RSA in the US is due to the multitude of glenohumeral disorders that it has been adopted for, including: Proximal humerus fractures Rheumatoid Arthritis Fracture malunion and nonunion Revision arthroplasty Tumor Severe glenoid bone wear JBJS 2013 Evaluated hemiarthoplasty vs RSA for 3 and 4 part proximal humerus fractures 53 patients Avg. age 74.7 years 26 = hemiarthroplasty, 27= RSA f/u minimum 2 years Conclusion = RSA had better clinical outcomes and similar complication rate compared to hemiarthoplasty JSES 2016 Evaluated RSA for PHF (proximal humerus fracture) 49 patients underwent RSA 13 for acute PHF 13 for malunion/nonunion 12 for failed PHF HA 11 for failed ORIF Found that equivalent outcomes are achieved for acute fracture RTSA and malunion/nonunion RTSA. Also primary RTSA outperformed RTSA done as a revision procedure. The similar outcomes for acute primary RTSA and delayed primary RTSA provide the surgeon flexibility with surgical timing and planning for patients with significant PHF. 9

10 JSES patients with RSA had revision surgery Minimum 2 year f/u Most common cause for revision was instability (48%) Underestimation of humeral shortening and excessive medialization were common causes of recurrent prosthetic instability. The 32 patients that retained a reverse shoulder prosthesis had their Constant score increase from 19 points to 47 points 31 patients Average f/u of 40.7 months Average age = 68.7 years 17 failed HA (12 for proximal humerus fracture and 5 for arthritis), 8 failed TSA, and 6 failed RSA (4 due to infection and 2 due to instability) Significant improvement in ASES, UCLA, and VAS scores Patients with failed TSA had greater improvement but was not statistically significant JSES

11 Notching causing baseplate failure RSA for Glenoid Bone Loss JBJS(A) 2010 Klein et. al. demonstrated that severe glenoid bone loss should not be a contraindication to RSA Altering the direction of the baseplate guidepin for the central screw to gain adequate purchase into the spine of the scapula and bone grafting can achieve stable fixation for the glenoid component Patients with glenoid bone loss had clinical outcomes comparable to those with normal glenoid anatomy 11

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15 80 year old stuntman Non dominant hand Hemiarthroplasty type c genoid Arthrex implant Pain Pain Pain Removed implant PMMA Spacer P bacter on 7 of 14 cultures 15

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19 RSA for Tumor Total Scapulectomy and constrained RSA for Ewing s Sarcoma of the scapula J. Surg. Oncol

20 Summary The utilization of RSA has significantly increased in the past decade. RSA use continues to rise due to expanding indications outside of rotator cuff tear arthropathy. 20

21 Thank you! 21