In Defense of Primary Reverse Total Shoulder Arthroplasty for Rotator Cuff Tear Arthropathy

Darren S. Drosdowech, M.D., FRCSC
Hand and Upper Limb Centre
St Joseph's Health Centre
University of Western Ontario
London, ON,

The Problem
Patients with rotator cuff tear arthropathy (RCTA) most often present with painful arthritis combined with loss of active forward elevation (AFE) secondary to a massive rotator cuff tear. The principles defining surgical treatment of end-stage RCTA are:

  1. Pain reduction.
  2. Restoring as close to a functional range of motion as possible.

Hemiarthroplasty alone may initially address arthritic pain but has been shown to have limited gains in elevation and a reduction in efficacy over time with longer-term follow-up1,2,3. Improved active motion may be possible by using tendon transfers (ex. latissimus dorsi for external rotation) to provide a vector in place of absent/dysfunctional rotator cuff musculature but are rarely sufficient to centre the humeral head within the glenoid and alone have limited potential to create significant gains in AFE4.

The Solution
Reverse total shoulder arthroplasty (RSA) was developed to provide a solution that addresses both pain reduction and improved AFE5. By creating a fixed, medialized centre-of-rotation through a semi-constrained bearing surface, patients are able to achieve major improvements in AFE, pain control and function6,7. To date, there has not been any other surgical procedure that can reliably address these deficiencies with a singular prosthesis.

Still, many surgeons remain skeptical regarding routine use of this implant as long-term functional outcome and implant survivorship remain largely unknown. Guery et al8 have recently reported an implant survival rate of 91% at 120 months in patients with RCTA but have noticed a reduction in pain control and functional scores at six years postoperatively. Although the authors were unable to identify the exact cause of these changes, they warn that surgeons should continue to exercise extreme caution when considering the use of an RSA especially in younger patients. Mechanical consequences of implant failure have been and are being addressed by improved surgical techniques9,10 and modified implant designs.

The Problem with Hemiarthroplasty
Hemiarthroplasty has gained appeal due to its technical ease and promising early clinical results. However, given the anterosuperior shift of the shoulder's centre-of-rotation, the risk for progressive painful eccentric glenoid wear remains concerning and constitutes one of the major risk factors for clinical failure1 (Figure 1). This creates a complex situation where structural glenoid bone grafting combined with the usual challenges of revision surgery (ex. removal of well-fixed humeral stem) in a single or staged procedure may be required in order to convert the failed hemiarthroplasty to a stable RSA (Figure 2). Further loss of rotator cuff integrity/function after hemiarthroplasty is not uncommon and also may prompt consideration for a revision procedure. Primary use of the RSA would minimize these risks.

Figure 1. (Click thumbnail for larger image)

A. Preoperative AP radiograph demonstrating eccentric anterosuperior glenoid erosion after hemiarthroplasty. 

B. Postoperative AP radiograph of same patient using RSA as revision implant. Selective inferior reaming of native glenoid required to accomplish correct alignment of glenoid component.

Figure 1A drosdowechfigure1a.jpgFigure 1Bdrosdowechfigure1b.jpg

Developing Concepts
Surgeons are becoming increasingly aware of the contributions of active external rotation (AER) to overhead function. In many cases of advanced RCTA, patients may demonstrate significant deficits of AER which are often not addressed by using a reverse prosthesis alone. Gerber11 and Boileau12 have reported on the combined use of a latissimus transfer and RSA which has shown promise in restoring both AFE and AER in order to permit more phyisiologic shoulder function. This concept of combined arthroplasty and tendon transfer requires a fixed centre-of-rotation which is not possible with the use of a hemiarthroplasty.

Figure 2.
A. Intraoperative view of glenoid during revision arthroplasty. Structural bone graft has been provisionally fixed with K-wires to deficient glenoid.
B. Reverse glenoid baseplate in position with screws used to transfix structural graft.
C. Postoperative AP radiograph of completed revision. Note structural graft under superior portion of glenoid component to provide neutral orientation of glenosphere.

 

Figure 2Adrosdowechfigure2a.jpg Figure 2Bdrosdowechfigure2b.jpg

Figure 2Cdrosdowechfigure2c.jpg

The Verdict
RSA for RCTA combines the benefits of a glenoid and humeral arthroplasty to address pain control with the restoration of fixed centre-of-rotation mechanics thus allowing for improved AFE. Intermediate follow-up results demonstrate reliable implant survivorship and the lowest complication rate amongst all indications for an RSA - yet should alert surgeons to the potential for limited durability of pain control and function. Additional advanced deficits of AER can be addressed by simultaneously using a latissimus dorsi transfer as this has shown promise in early clinical follow-up.

References

  1. Sanchez-Sotelo J., Cofield R.H., Rowland C.M. Shoulder hemiarthroplasty for glenohumeral arthritis associated with severe rotator cuff deficiency. JBJSA Dec 2001; 83-A(12): 1814-22
  2. Field L.D., Dines D.M., Zabinski S.J., Warren R.F. Hemiarthroplasty of the shoulder for rotator cuff arthropathy. JSES Jan/Feb 1997;Vol 6(1): 18-23
  3. Zuckerman J.D., Scott A.J., Gallagher M.A. Hemiarthroplasty for cuff tear arthropathy. JSES May/June 2000;Vol 9(3): 169-72
  4. Ianotti J.P., Hennigan S., Herzog R., Kella S., Kelley M., Leggin B., Williams G.R. Latissimus dorsi tendon transfer for irrepairable posterosuperior rotator cuff tears. Factors affecting outcome. JBJSA Feb 2006; 88(2): 342-8
  5. Grammont P.M., Baulot E. Delta shoulder prosthesis for rotator cuff rupture. Orthopedics Jan 1993; Vol 16(1): 33-36
  6. Werner C.M.L., Steinmann P.A., Gilbart M., Gerber C. Treatment of painful pseudoparalysis due to irrepairable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. JBJSA Jul 2005; Vol 87-A(7): 1476-86
  7. Boileau P., Watkinson D., Hatzidakis A.M., Hovorka I. Neer Award 2005: The Grammont reverse shoulder prosthesis: Results in cuff tear arthritis, fracture sequelae and revision arthroplasty. JSES Sept/Oct 2006; Vol 15(5):527-40.
  8. Guery J., Favard L., Sirveaux F., Oudet D., Walch G. Reverse Total Shoulder Arthroplasty. Survivorship analysis of eighty replacements followed for five to ten years. JBJSA 2006; 88:1742-1747
  9. Nyffeler R.W., Werner C.M.L. Simmen B.R., Gerber C. Analysis of a retrieved Delta III total shoulder prosthesis. JBJSB Nov 2004; Vol 86-B (8): 1187-91
  10. Nyffeler R.W., Werner C.M.L., Gerber C. Biomechanical relevance of glenoid component positioning in the reverse Delta III total shoulder prosthesis. JSES Sept/Oct 2005; Vol 14(5): 524-28
  11. Gerber C., Pennington S.D., Lingenfelter E.J., Sukthankar A. Reverse Delta-III total shoulder replacement combined with latissimus dorsi transfer. A preliminary report. JBJSA 2007. May: 89(5): 940-7
  12. Boileau P., Chuinard C., Rousanne Y., Neyton L., Trojani C. Modified latissimus dorsi and teres major transfer through a single deltopectoral approach for external rotation deficit of the shoulder: as an isolated procedure or with a reverse arthroplasty. JSES Nov/Dec; Vol 16(6): 671-82.

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