Reverse Total Shoulder Arthroplasty: A New Frontier (of Complications)
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1 Reverse Total Shoulder Arthroplasty: A New Frontier (of Complications) Emilie Cheung, MD Associate Professor Chief Shoulder Elbow Svc Stanford University Department of Orthopedic Surgery
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3 Procedure volumes and rates increased at annual rates of 6% to 13% from 1993 to Compared with 2007 levels, projected procedures were predicted to further increase by between 192% and 322% by The revision burden increased from approximately 4.5% to 7%. The growth rates of upper extremity arthroplasty >= THA, TKA. Of particular concern was the increased revision burden.
4 Indications for RTSA 1. Cuff Tear Arthropathy 2. Massive RCT 3. Pseudoparalysis 4. RA 5. Fx sequelae 6. Complications of ORIF 7. Complications of HHR 8. Complications of TSA
5 Indications No other satisfactory option available
6 Alternatives to Reverse Hemi Conventional Unconstrained TSA Arthrodesis Bipolar hemi
7 Advantages of Reverse Semi-constrained Resurfaces both pain generators in arthritis: glenoid and humerus Does not rely upon the supraspinatus for function Eliminates need for prolonged rehab associated with RCR Will allow pts to use hand away from body
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11 4 yrs. Left shoulder
12 Concerns Long-term mechanical failure rate unknown When complications happen, they may be catastrophic Revising a failed reverse is a technical challenge As with other new technologies, it may be subject to overuse
13 Complications: Outline Instability Hematoma Infection Pptx fracture Glenoid loosening Scapular notching
14 Results Study Favard, CORR 2011 Patient s Results % 10 yrs Comments Results & xrays deteriorate with time Wall, JBJS % satisfied CTA, RTC with OA, MRTC better outcomes Guery, JBJS % 7 yrs Frankle, JBJS 2005 Sirveaux, JBJS 2004 Results decline after 8 yrs 60 94% satisfied 17% complications, 13% revision 77 96% no-minimal pain Flurin, ORS Improvements in pain & function 88% 5 yrs 8.9% notching, no instability or glenoid failures
15 RSA: Systematic Review Zumstein et al, JSES level IV, 3 level II studies 782 RSAs >24 month f/u 71% Grammont, 29% Encore 42% subscap repaired 44% problem, 24% complication rate 2x in revisions, higher in RA & Fx, DP approach 3.5% reoperation, 10% revision rate
16 Complications Complication/Problem Percentage Scapular Notching 34.5% Instability 4.7% Infection 3.8% Aseptic Glenoid Loosening 3.5% Intraoperative Fractures 2.9% Hematomas 2.6% Acromion & Spine Fractures 1.5% Glenoid Disassembly 1.5% Humeral Disassembly 1.5% Zumstein et al, JSES 2012
17 Instability 0-30% Risk Factor Comments Study DP Approach 97% of 37 cases Zumstein JSES 2011 Revision 2x more likely, 87.5% requiring re-operation Subscapularis repair Articulation Version 5.1%, all occurred in irreparable subscap Compressive force>socket depth>glenosphere size Neutral humeral version, <10 0 glenosphere retroversion Zumstein JSES 2011 Edwards JSES 2009 Guittierrez CORR 2008 Favre JSES 2010
18 Anterior Subscap repair DP approach Dynamic stability Version Neutral-20 0 humeral retroversion Neutral glenosphere Scaled contralateral xrays Revision with humeral bone loss Appropriate height Adequate deltoid tension Instability
19 Instability
20 Infection 1-15% Risk Factor Comments Study Revision 2x more likely Zumstein JSES 2011 Hematomas 20 cases, 70% required intervention no subsequent infection P. Acnes 75% of shoulder revision arthroplasty Rheumatoid Arthritis Concerns regarding infection Zumstein JSES 2011 Kelly CORR 2009 Guery JBJS 2006
21 Infection Hematomas 1-21% Aggressively treat HV drain 24 hours Restrict early motion Revisions P. Acnes Hold cultures x 2 weeks Rheumatoid arthritis
22 Glenoid Loosening % Risk Factor Comments Study Bony Ingrowth Screw Angle Lateral Offset Locking Screws Lack of baseplate ingrowth associated with failure Increasing screw angle minimizes micromotion 11.7% glenoid sided failure correlated with poor fixation and superior tilt 5mm Locking screws kept micromotion below 150 microns despite 70% moment arm increase Cheung JAAOS 2011 Hopkins JSES 2008 Frankle JBJS 2005 Harman JSES 2005 Cuff JBJS 2008
23 Glenoid Loosening Fixation Bony ingrowth Peripheral screws Large diameter Locking Variable angle Decrease moment arm Minimize lateral offset
24 Glenoid Loosening Equinoxe baseplate Large surface area Bone ingrowth Anatomic Curved backside Shear Compressive Cortical bone preserving 20x stronger than cancellous Screws 4.5mm variable angle lag-locking Baseplate compression Six options Central bone cage Glenoid vault fixation
25 Fractures % Trauma Risk Factor Comments Study Acromial Insufficiency Acromial & Scapular spine Fractures Rheumatoid Arthritis All 11 cases of Postop humeral fx associated with traumatic event 9%, good results despite preop acquired or congential pathology 1.5%, conservative tx of acromial fx no (-) influence, sx of scapular spine (-) outcome 22%, increased risk of intra & postop fracture Zumstein JSES 2011 Walch JSES 2009 Zumstein JSES 2011 Young JBJS 2011
26 Acromial fractures Thin acromion is best neglected Os acromial Spine fractures Conservative treatment Abduction pillow x 6-8 weeks Cortisone injection?orif Humeral fractures Small cemented stem in RA Fall precautions Sling, Cane, Endocrine, PCP Fractures
27 Scapular notching
28 Scapular Notching 50-96% Vanhove Acta OB 2004, Boileau JSES 2006, Levigne JSES 2008, Kalouche Acta OB 2009 Incidence & extent of notching increases with f/u (7 yrs) Simovitch JBJS shoulders, 2 yrs f/u 44% notching Lower Constant scores Less ROM Cristofari JBJS shoulders 6.6 yrs f/u 53% notching 64% baseplate loosening 2.7% revision Sirveaux JBJSBr shoulders, 3.7 yrs f/u 63.6% notching 6.2% baseplate loosenig Lower Constant scores
29 Scapular Notching 50-96% Risk Factor Comments Study Humeral Neck Shaft Angle Glenosphere Diameter was most avoiding impingement 42mm glenosphere avoiding impingement Gutierrez CORR 2008 Gutierrez CORR 2008 Lateral Offset Lateralized COR resulted in 0% notching Valenti CORR 2011 Frankle JBJS 2005 Cuff JBJS 2008
30 Scapular Notching 50-96% Inferior Tilt Inferior Tilt Risk Factor Comments Study avoiding impingement Does not reduce incidence or severity of notching, 75% tilt group, 86% control group (PRCT) Cuff JBJS 2008 Gutierrez CORR 2008 Edwards JSES 2011
31 Risk Factor Comments Study Glenoid Position Scapular Notching 50-96% Glenoid Position & Scapular Neck Angle Inferior placement of glenosphere reduces notching Neck angle & glenoid position are coupled, higher angle more overhang Gutierrez CORR 2008 Levigne JSES 2008 Nyffeler JSES 2005 Boileau JSES 2006 de Wilde Acta Orth 2010 Simovitch JBJS 2007
32 Inferior glenosphere placement Avoid superior tilt Increase offset Decrease neck shaft angle of humerus Increase glenosphere diameter Avoid excessive medial reaming Scapular Notching
33 Summary Instability Hematoma Infection Pptx fracture Glenoid loosening Scapular notching
34 Thank You
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