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Rockwood: The Shoulder, 4th ed.

TREATMENT

Nonsurgical

Strengthening of the deltoid muscle and remaining rotator cuff muscle can result in improved function. Injection

of corticosteroids into the joint can be tried to relieve pain in combination with oral analgesics. This can besufficient in patients with mild or moderate pain and loss of function. The use of repeated steroid injections is

discouraged.

Ar throscopic Surgery

Arthroscopic dbridement and biceps tenotomy has been reported to improve function in patients with cuff tear

arthopathy. [50,51] This can be tried, particularly in elderly patients with low demands and in patients not willing

to undergo major surgery. It might relieve pain but does not restore function in pseudoparalytic shoulders.

Ar throdesis

Good pain relief can be achieved by performing an arthrodesis in patients with cuff tear arthropathy (Fig. 23-

13). In patients with pseudoparalysis, an arthrodesis can also improve functional range of motion. However,

increased load on the thoracoscapular articulation and the acromioclavicular joint can cause pain from these

locations. In 1991, Arntz and colleagues reported 10 patients who underwent arthrodesis for irreparable cuff

tears. [52] The arthrodesis improved active forward elevation by a mean of 15 degrees. They concluded that

arthrodesis could be indicated in patients with massive irreparable cuff tears and significant deltoid deficiency

or in young patients with significant strength demands at low angles of flexion.

Pgina 1 de 38TREATMENT from Rockwood: The Shoulder on MD Consult

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Resection arthroplasty is a poor solution that yields an unstable, nonfunctional, often painful shoulder and thus

should not be carried out as a primary surgical treatment in these patients.

Anatomic Unconstrained Arthrop las ty

Total Shoulder Arthroplasty

The superior migration of the humeral head in patients with cuff tear arthropathy creates eccentric load on the

glenoid component. This has been called the rocking horse effect;it results in increased rates of loosening. [53]

In 1991, Lohr and Cofield reported better pain relief in total shoulder arthroplasty compared to hemiarthroplasty

in 22 patients with cuff deficiency, but an increased incidence of radiographic and clinical loosening. [54] Similar

findings were reported by Franklin and colleagues in a study where three of nine patients with cuff deficiency

needed early revision after total shoulder arthroplasty. [53] Due to this increased risk of glenoid loosening,

anatomic total shoulder replacement is not recommended in patients with significant cuff deficiency.

Hemiarthroplasty

Hemiarthroplasty has been the treatment of choice for the arthritic shoulder with cuff deficiency. Due to the

clinical success of the Grammont reverse ball-and-socket arthroplasty, the indication for using a

hemiarthroplasty is more limited. The results after hemiarthroplasty are unpredictable, and Neer proposed the

term limited-goal rehabilitationfor these patients. [1] Persistent pain has been reported in 6% to 53% of the

FIGURE 23-13 Arthrodesis in a 54-year-old man for massive rotator cuff tear and osteoarthritis.




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patients after hemiarthroplasty; active elevation is reported at 60 to 70 degrees preoperatively improving to 90

to 120 degrees postoperatively (Table 23-2). [3,5562]

TABLE 23-2 -- Results of Hemiarthroplasty in Arthritic Rotator CuffDeficient Shoulders

An oversized humeral head has been suggested to create a better articulation with the acromion and the

coracoacromial arch. However, Sanchez and colleagues could not find a correlation between head size andfunction, and there are several disadvantages. An oversized humeral head can increase the joint reaction

forces and possibly more-rapid bone resorption. [60] A large head makes it more difficult to partially repair the

rotator cuff. A larger head puts the center of rotation more lateral than inferior, which contributes a

biomechanical disadvantage to the deltoid by shortening the lever arm. Any attempt to even partially repair the

deficient rotator cuff becomes much more difficult with a larger humeral head.

Several techniques have been proposed and used for this purpose. Pollock, [59] Cantrell and Burkhead, [63] and

DiGiovanni [3] advocated the use of subscapularis tendon transfer to a more superior position as a method for

superior stabilization of the humeral head. The subscapularis tendon can then be reinserted into the top of the

greater tuberosity. The use of anatomic, or slightly smaller, humeral head size facilitates this transfer. This

option is limited to patients who have a functional unshortened subscapularis tendon.

In an attempt to improve results of hemiarthroplasty in patients with cuff tear arthropathy, a specific head hasbeen designed: the CTA head (Fig. 23-14). It has a lateral extension over the greater tuberosity, producing a

greater arc for articulation against the glenoid fossa and the undersurface of the acromion and coracoacromial

arch. The head size is anatomic, thus there is no overstuffing of the joint.

Reference No.

Mean Follow-up

(mo)

Preoperative Elevation

(degrees)

Postoperative Elevation

(degrees)

Pollock et al, [59] 1992 30 41 64 108

Arntz et al, [55] 1993 18 25-122 66 109

Williams and Rockwood,[61] 1996

21 48 70 120

Field et al, [57] 1997 16 33 60 100

Zuckerman et al, [62] 2000 15 28 69 86

Sanchez-Sotelo et al, [60]

2001

33 60 72 91




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A size-adapted head, which does not decease the lever arm significantly and which articulates under the

acetabularized coracoacromial arch as a fulcrum, was introduced as a specific implant in hemiarthroplasty a

few years ago. The prosthesis design, with its greater lateral coverage of the head, prevents the painful

impingement of the eroded and uncovered greater tuberosity against the acromion in abduction and flexion andin external rotation (Fig. 23-15). Early clinical results [64,65] show encouraging outcomes in patients whose joint

still is biomechanically balanced and stable and whose humeral head (i.e., center of rotation) has not migrated

extremely anterosuperiorly. These patients have only a minor amount of static and dynamic superior

displacement of the center of rotation. The studies clearly demonstrate that a nearly intact and well-functioning

subscapularis and an intact coracoacromial arch are important prerequisites for a good clinical outcome of this

type of shoulder arthroplasty for cuff tear arthropathy.

FIGURE 23-14 Hemiarthroplasty with a laterally extended cuff tear arthropathy (CTA) head.A,CTA prosthesis. B,Diagram of

installed prosthesis.




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Bipolar Arthroplasty

A bipolar arthroplasty has a humeral component with a stem and a fixed head upon which a mobile outer shell

is placed, usually through a snap-fit mechanism (Fig. 23-16). [6670] The idea was to have a hemiarthroplasty

acting like a total shoulder replacement by having motion between the fixed head and the outer shell.

FIGURE 23-15 Rationale for a laterally extended cuff tear arthropathy (CTA) head. Left, Abduction and external rotation are

limited due to painful impingement against uncovered greater tuberosity. Dashed red linesradiating up and to the left indicate

impingement. Right,The laterally extended CTA head allows a greater arc of motion in abduction and greater external rotation

by coverage of the greater tuberosity.




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In 1988, Swanson and colleagues reported on 35 shoulders (rheumatoid arthritis in 20, degenerative arthritis in

10, post-traumatic lesions in 5) with a mean follow-up of 63 months. [67] Complete pain relief was seen in 15

patients, and there was a modest increase in range of motion.

The bipolar implant was recommended in patients with severe arthritic changes with vertical subluxation of the

humeral head, namely, cuff tear arthropathy. Worland and coworkers reported on 33 patients with cuff tear

arthropathy treated with a bipolar arthroplasty; 22 of these patients had a follow-up between 24 and 48

months. [69,70] In these 22 patients, active forward elevation increased from 38 to 67 degrees, and external

rotation increased from 12 to 51 degrees. UCLA score increased from a mean of 9.2 to 26. One patient

underwent revision 4 years after surgery. Lee and Nieman reported on 13 patients with rotator cuffdeficient

arthritic shoulders that underwent bipolar arthroplasty. [66] Seven patients had rheumatoid arthritis and the rest

had revisions of failed previous reconstructions, including 5 total shoulder replacements. The rheumatoid group

had good pain relief but only a modest improvement in range of motion.

Today, the bipolar arthroplasty is not widely used. The outcome is unpredictable and there has been concern

with overstuffing the joint.

Reverse Arthroplasty

Reverse arthroplasty prostheses have the convex head on the glenoid side and the concave component on the

humeral side. Most of the early designs failed on the glenoid side due to a small glenoid ball with lateralized

center of rotation. The present design is based on the concept of the Delta prosthesis designed by Paul

FIGURE 23-16 Radiograph showing a bipolar arthroplasty with varus tilting of the outer shell of the bipolar prosthesis, superior

migration, and secondary erosion of the lateral clavicle and the acromioclavicular joint.




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Grammont in Dijon, France. The biomechanical principles of the reverse design have already been discussed.

The Delta prosthesis relies on the deltoid muscle for function and stability. In 1993, Grammont and Baulot

reported on the first 14 cases with the Delta reverse ball-and-socket arthroplasty with good pain relief and

improved function. [13] It can give excellent pain relief and restoration of active range of motion in patients with

painful pseudoparalytic shoulders. [13,14,45,7174]

Due to lack of long-term follow-up studies, the Delta prosthesis is primarily recommended in older patients with

cuff tear arthropathy. Many patients who would have received a hemiarthroplasty in the past are now treated

with the reverse arthroplasty. However, patients with good active range of motion despite arthritis and a

massive rotator cuff tear (biomechanically balanced shoulder) can still have a good outcome with a

hemiarthroplasty.

Seebauer's Preferred Approach: CTA-Head Hemiarthroplasty

Indications

The ideal patient for a CTA-head hemiarthroplasty is one with a biomechanically balanced shoulder without an

anterior escape of the humeral head. That means patients who have a painful arthritic shoulder but without a

complete functional impairment (pseudoparalysis). In the clinical situation that means that patients have a

forward flexion of more than 100 degrees, which they can hold for a few minutes and without anterior escape of

the humeral head (no dynamic superior escape).

X-rays should be analyzed to determine whether the joint is still centered and meeting the criteria for type Ia or

Ib according to our classification (see Fig. 23-10). In very painful shoulders it is important to determine whether

the functional impairment is pain related or really a structurally caused pseudoparesis. In these cases we

recommend an injection test with a minimum of 20 mL of local anesthesia and to retest the patient's function 30

minutes after the injection. Patients whose shoulder function improves and who attain the criteria after the

injection are good candidates for a hemiarthroplasty with the CTA-head prosthesis. In doubtful cases it is

sometimes helpful to do a dynamic fluoroscopic examination with resisted flexion and abduction to check the

stability of the joint against superior translation. Sometimes this is the only way to identify patients with a

dynamic type of superior instability. Patients with a static type of superior dislocation are not candidates for joint

replacement with hemiarthroplasty with a CTA-head prosthesis.

Patients who have a mild superior translation and good residual function (some superior migration of the center

of rotation but residual resistance against complete superior escape because of an intact coracoacromial arch)are more difficult to assess. In this specific patient group we recommend the CTA-head prosthesis in younger

patients (


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posterior-superior cuff tears, sometimes detachment of only the superior third of the subscapularis tendon is

enough to get a sufficient approach to easily produce an anterior-superior dislocation of the humeral head. (Fig.

23-17) If the capsule is tight, it is possible to release the capsule from the tendon without detaching the inferior

half of the tendon. We do this by coming from the inside, carrying out the dissection of the anterior and inferior

capsule from the inside, and holding away the attached subscapularis tendon with a Langenbeck retractor

anteriorly.

The biceps tendon, if still present, is always tenotomized and fixed extra-articularly by simple transosseous

sutures in the bicipital groove or beneath the pectoralis major tendon insertion. The intra-articular part of the

tendon is cut off. The osteophytes are removed stepwise along the anatomic neck, starting at the anterior-

superior corner of the bicipital groove and working inferiorly and posteriorly. This gives additional clearance for

head dislocation and resection without the necessity of completely detaching the subscapularis. Subscapularis

integrity and good subscapularis function are the key factors for a good final clinical outcome in treatment of

balanced (compensated) cuff tear arthropathy with a hemiarthroplasty and the CTA-head prosthesis.

Head Resection

The head can be resected using the intramedullary or the extramedullary resection guide of the Global

Advantage system. (Fig. 23-18) The radius of curvature of the resected head is measured by a template. If the

head is severely deformed, the radius of the glenohumeral joint orin cases with some deformation of the

glenoidthe radius of curvature of the new articulation underneath the coracoacromial arch and the superior

part of the glenoid is measured using the opaque testing components of the glenoid trials (Fig. 23-19). After thehead resection, the humeral shaft is prepared the same as for the Global Advantage stem: reaming the canal,

opening the epiphysis with a box osteotome, and broaching the canal with the appropriate broach, which is

simultaneously the trial prosthesis.




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FIGURE 23-18 Head resection.A,Extramedullary. B,Intramedullary guided.




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At this point, the decision must be made whether to use a regular modular head or the laterally enlarged CTA-

head prosthesis. If only the superior part of the greater tuberosity is uncovered and the infraspinatus tendon

insertion is still intact to a great extent, a hemiarthroplasty with a regular modular head (centric or eccentric) of

appropriate size (radius and head) is recommended. The CTA-head prosthesis is recommended if major partsof the greater tuberosity are uncovered. Attempts at partial reconstruction of the posterior-superior cuff are only

undertaken if the tendon quality is appropriate, if tendon retraction is no greater than grade 2 according to

Patte, and if fatty infiltration of the corresponding muscle belly of the infraspinatus is no greater than grade 2.

That means only if there is a predictable healing of the repair should it be attempted. Partial repairs at the

expense of tightening the soft tissue envelope and therefore reducing the achievable range of motion are not

reasonable.

Preparation of the Greater Tuberosity

Once the final decision for reconstruction with a CTA-head prosthesis is established, a specific resection guide

for the greater tuberosity is mounted to the trial prosthesis (broach) (Fig. 23-20) and the greater tuberosity is

resected (Fig. 23-21). The resection jig is removed, and the corners are trimmed with a rongeur or a bur (Fig.

23-22). The trial head of the appropriate diameter that best fits the radius of curvature of the glenoid and theresected head is chosen (Fig. 23-23).

FIGURE 23-19 Measuring head diameter by template (top) or indirectly by glenoid trial. The cuff tear arthropathy (CTA) heads

are available in diameters of 44 to 56 mm (bottom),with two head heights (18 and 23 mm) for each diameter.




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FIGURE 23-20 Resection tool for greater tuberosity mounted to a Global Advantage trial broach.A,Attachment of the fixation

device for the greater tuberosity cutting guide on the trial stem. B,Fixing the cutting guide for the greater tuberosity to the trial

stem (view from above).

FIGURE 23-21 Resection of the tip of the greater tuberosity.A, Dotted lineillustrates bone to be removed. B,Saw blade

gliding on the cutting guide.




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FIGURE 23-22 Final trimming of greater tuberosity by rongeur or bur.Arrowspoint to bone to be removed.




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Head Size

There are four diameters (44, 48, 52, and 56 mm) and two heights (18 and 23 mm) for each diameter available.

The prosthesis must be tested to determine which height gives the best stability and lowering of the center of

rotation without deteriorating the capacity of the soft tissue envelope and consequently the range of motion.

The smoothness and stability of articulation beneath the coracoacromial arch has to be considered. Therefore

the translation capacity in the anteroposterior plane has to be tested and should be about 50% of the glenoid

extent. The internal and external rotation with the arm abducted should achieve a minimum of 75 degrees. The

opposite shoulder should be easily reached in a cross-body motion.

Care must be taken not to choose a head that is too large and hangs over the anterior or posterior resection

level of the head. An anterior overhang threatens the subscapularis and leads to hardware impingement

against the tendon from inside the joint, with consequent failure of the tendon insertion. Therefore, in severely

femoralized heads with extended superolateral osteophytes, the posterolateral aspects of the humeral head

must be contoured inferior to the outlines of the most suitable prosthetic head (Fig. 23-24; see Fig. 23-23) to

get a perfect articulation with no impingement of the proximal humerus beneath the acetabularized

coracoacromial arch.

FIGURE 23-23 Attaching the trial head and adjusting the bony contours for perfect articulation beneath the coracoacromial

arch.




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After testing is finished, the broach is removed and the definitive implant is assembled. The implantation could

be done with or without cement. We prefer a cementless implant in case of a possible later revision to a

reverse shoulder arthroplasty. For a cementless implantation in cases with poor proximal cancellous bone, we

like to do some impaction bone grafting specifically on the medial calcarepimetaphyseal junction to produce agood press-fit and to avoid medialization and varus malalignment of the prosthesis.

Implantation and Subscapularis Reattachment

Before implantation, heavy (minimum No. 2) transosseous nonabsorbable sutures are placed at the resection

level of the subscapularis detachment, passing through the bone tunnels, which are far enough away from the

resection line to prevent a pullout of the suture (Fig. 23-25). We prefer to do the bone-tunneling with the

sutures in a U-type mattress style to provide a good bony bridge against pullout. After the prosthesis is

implanted, the proximal humerus is trimmed laterally and posteriorly to create a perfect femoralized shape of

the proximal humerusarthroplasty complex. The detached subscapularis tendon is fixed with MasonAllen

stitches with the prepositioned transosseous sutures (minimum of three). After thorough irrigation we bring in a

suction drain and then close the deltopectoral interval and subcutaneous tissue layer and the skin.

FIGURE 23-24 Definitive implant in place.

(Courtesy C. Basamania, MD, Duke University).




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Postoperative Care

Patients are positioned in a sling and kept in a sling for a minimum of 2 weeks during the day and for 6 weeks

at night. After 2 weeks, the sling is primarily used to prevent accidental external rotation, which places the

subscapularis repair at risk. Patients are started with active assisted flexion and abduction exercises on the firstpostoperative day. We limit the external rotation for the first 2 weeks to 0 degrees, then for 2 weeks to 15

degrees and for another 2 weeks to 30 degrees. Patients are allowed to use the arm for self-care from day 1

on. Resistance exercises are started at 6 weeks for the residual cuff, with the exception of the subscapularis.

Resistance exercises are added for the subscapularis after 12 weeks.

Ekelund's Preferred Approach: Reverse Arthroplasty

The reverse arthroplasty can be inserted through a standard deltopectoral approach. However, Grammont

favored a superior deltoid-splitting approach for primary cases and the deltopectoral approach for revisions.

The superior splitting approach gives excellent exposure of the glenoid, and there is no need to cut the

remaining rotator cuff tendons. If a deltopectoral approach is used, the subscapularis tendon needs to be

divided, and there may be difficulties reattaching this tendon. A deltopectoral approach has been associated

with higher dislocation rates, and the superior deltoid-splitting approach has been reported to have a higherincidence of notching. [75] We prefer the deltoid-splitting approach for primary Delta cases and the deltopectoral

approach for revisions.

FIGURE 23-25 Subscapularis reattachment.A,Sutures placed for subscapularis reattachment. B,Subscapularis reattached.




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Patient Positioning

The patient is placed in the beach chair position. The sterile field should include the upper arm down to the

elbow.

Surgical Exposure

The superior deltoid-splitting approach (McKenzie-type approach) is described here.

A 6- to 7-cm skin incision is made along the lateral edge of the acromion along Langer's lines. After

subcutaneous dissection, the deltoid muscle is split. Starting from the acromioclavicular joint, about 5 to 6 mm

behind the tip of the acromion, the deltoid is split in a straight lateral direction, extending 4 to 5 cm from the

acromion edge. The deltoid can be released from the tip of the acromion by removing soft tissue only or by

releasing the deltoid insertion with a small piece of bone. The coracoacromial ligament is removed and a small

acromioplasty is performed to create more room. The subacromial bursa is removed and adhesions are

released. A self-holding Gilpi retractor is used.

In most cases, the humeral head can now be dislocated superiorly into the wound by extension and external

rotation of the arm and by pushing the humerus superiorly by applying a superior force on the elbow (Fig. 23-

26). The remnants of the rotator cuff are inspected. If the infraspinatus or teres minor (or both) is present, care

is taken to protect these during surgery to maintain external rotation postoperatively. The subscapularis should

be preserved, although sometimes, particularly in stiff shoulders, the superior edge of the subscapularis needsto be removed. If the biceps tendon is present, a tenotomy or a tenodesis is performed.




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The humeral canal is opened by removing the hard sclerotic bone on the top of the humeral head to introduce

the reamers (Figs. 23-27 and 23-28). After reaming to the appropriate size, a cutting jig is applied to perform

the head cut (Fig. 23-29). We perform the head cut in neutral, that is, with no retroversion (see Fig. 23-29).

FIGURE 23-26 Superior-lateral approach to the shoulder in a patient with a massive rotator cuff tear. The head is displaced

anterosuperiorly for humeral head resection.

FIGURE 23-27 The forearm is used as a reference point to determine the version of the head cut. Red linesindicate degree of

retro- or anteversion of the humeral component relative to the forearm.




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FIGURE 23-28 The humeral canal is opened and reamed. The red dotshows the point for reaming. Red dotshows entry point.




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Glenoid Component

A special retractor is put underneath the glenoid to push away the humerus to expose the glenoid (Fig. 23-30).

A complete circumferential release is made around the glenoid to define the bony anatomy.

FIGURE 23-29 The cutting jig is applied.




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One of the most important steps of the procedure is correct placement of the glenoid component. It should be

placed as low as possible to reduce the risk of notching (Fig. 23-31). A superior tilt must also be avoided (Fig.

23-32). A positioning guide is used to place the metaglene base plate at the inferior border of the glenoid fossa.

A guide pin is introduced. A small, cannulated, curved back reamer is used to prepare the surface (Fig. 23-33).Excessive reaming should be avoided and, when possible, the subchondral bone should be preserved. A hand-

held reamer is then used to remove bone superiorly and, if necessary, anteriorly, posteriorly, or inferiorly to

create a flat surface for the glenosphere (the ball) (Fig. 23-34).

FIGURE 23-30 A special glenoid retractor (fork retractor) is placed under the glenoid to give the surgeon an appropriate view

of the glenoid surface.




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FIGURE 23-31 The metaglene component should be placed as low as possible in the lower part of the circle. The red dot

indicates the center of the circle. Red dotshows entry point for the guide pin.




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FIGURE 23-32 A guide pin is placed using the aiming guide. Avoid superior tilt.




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FIGURE 23-33 A cannulated reamer is used to prepare the glenoid surface for the metaglene base plate.




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A central drill hole is made for the central peg. The guide pin is removed and the metaglene component is

introduced. The screw fixation starts with the inferior screw, which is aimed at the inferior bony collar of the

scapula (Fig. 23-35). This usually means that the inferior hole is rotated slightly posterior and the superior hole

is in a slightly anterior position. Ideally a 36- to 42-mm screw is used. The superior screw is placed. The drill

hole is aimed at the base of the coracoid. Usually a 30- to 36-mm screw is used. The new reverse design givesthe surgeon freedom to place the screw in different angles to find the best bone. After the inferior and superior

screws are placed, they are locked to create a locked-angle configuration. The anterior and posterior standard

or locking screws are introduced, completing the metaglene fixation (Fig. 23-36).

FIGURE 23-34 The hand-held cannulated reamer is used to complete the preparation.




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FIGURE 23-35 With a drill guide, the holes for the screws are drilled, starting with the inferior screw. The locking screws are

polyaxial.




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Preparation of the Humerus

The method for final preparation of the humerus depends on if a cemented or noncemented implant is used. A

monobloc cemented component is available with two different epiphyseal sizes and different stem sizes. The

noncemented humeral component is modular, allowing the surgeon to adapt the stem to the anatomy of thepatient by changing version and incorporating the offset of the post into the final component. A guide is

introduced into the humeral canal, and the proximal reaming is performed with the appropriate cannulated

reamer (Fig. 23-37).

FIGURE 23-36 All four screws in place, completing the metaglene fixation.




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Trial Reduction

A trial glenosphere is introduced. There are two sizes, 38 mm and 42 mm, and both are available as standard

and eccentric designs (Fig. 23-38). The advantage to the 42 mm is that it creates a greater overhang inferiorly,

which reduces notching. However, in small patients or tight shoulders, it may be necessary to use the 38-mm

glenosphere.

FIGURE 23-37 With a guide in place (left),the proximal humeral reaming is performed (right).




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The chosen humeral component is introduced (Fig. 23-39) and a polyethylene trial insert is chosen (Fig. 23-

40). There are three different heights: 3, 6, and 9 mm. They are available as standard design based on the

previous Delta arthroplasty or as hypermobile design with a reduced cup depth of 2 mm, giving a greater range

of motion but with less stability.

FIGURE 23-38 Trial humeral component.




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FIGURE 23-39 Trial glenosphere in place.




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After reduction, the stability is tested. The self-retaining retractors are removed and the arm is placed in various

degrees of rotation, flexion, and abduction. The arm is adducted to see that the two components do not

separate or subluxate. Separation or subluxation usually is caused by impingement of the humeral component

or humeral bone on the scapula neck, which needs to be corrected. In extension and external rotation, a small

opening between the two components can be seen, but the shoulder should remain stable. When the arm is

pulled downward, there should be no separation of the two components. If necessary, the inserts are changed

until satisfactory stability is achieved. In a few cases, particularly in revisions, it may be necessary to lengthen

the humeral component with a 9-mm lengthener and then try the inserts to achieve stability.

When stability is satisfactory, the definite glenosphere is placed on the metaglene (Fig. 23-41) and the chosen

humeral componentcemented or noncementedis placed in the humerus (Fig. 23-42). We recommend

performing a new trial reduction to see that the chosen insert is still giving good stability because the finalposition of the implants may be different compared to when the trial reduction was performed.

FIGURE 23-40 Both trial components with insert in position. Stability testing is performed.




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FIGURE 23-41 The definitive glenosphere is attached to the metaglene base plate.




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Wound Closure

After irrigation, the deltoid muscle is reattached to the acromion through nonabsorbable osteosutures. A drain

is used until the day after surgery. The deltoid split is closed with absorbable sutures. The arm is placed in a

sling. A postoperative radiograph is taken (Fig. 23-43).

FIGURE 23-42 The humeral component and the chosen polyethylene insert are inserted.




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Postoperative Rehabilitation

If a deltopectoral approach is used, the patient may start active range of motion the day after surgery and use

the arm as much as the pain allows. If the subscapularis has been repaired, the external rotation is restricted to

neutral the first 6 weeks.

If a deltoid-splitting approach has been used, passive range of motion is started the day after surgery. The

patient has the arm in a sling for 2 to 3 weeks. The patient may use the arm for easy activities of daily living

after 2 to 3 weeks and may start assisted active range of motion at the same time. The patient gradually

increases to free active range of motion 4 to 5 weeks after surgery. The patient should not use the operated

arm to push up from sitting to standing the first 6 weeks postoperatively.

Overall Results

CTA-Head Hemiarthroplasty

Because this specific hemiarthroplasty for cuff-deficient arthritic shoulders has only been available for a short

time, as of late 2008, only oral presentations had been made and one paper submitted to a peer-reviewed

journal. Basamania [65] has performed more than 200 implantations, Trail [64] has experience with more than 80

hemiarthroplasties, and in our institution we have followed 21 patients with a follow-up more than 24 months.[46] These 21 patients had a cuff tear arthropathy type Ia, Ib, or IIa. None of them had completely unbalanced

FIGURE 23-43 Postoperative radiograph showing a noncemented Delta Xtend prosthesis.




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and decompensated rotator cuff tears. That means that all of them had a preoperative active elevation of more

than 100 degrees and they had a functioning subscapularis, which means that the belly press test was

negative or maximum 1 degree positive and the preoperative MRI did not show higher grades of subscapularis

atrophy or fatty degeneration (Fig. 23-44). We did a prospective clinical study with clinical and radiologic follow-

up immediately after surgery and at 6, 12, 24, and 36 months. The age- and sex-corrected Constant score at

latest follow-up, with a minimum follow-up of 24 months, was 75. The mean active elevation was 112 degrees.

Patients with a type Ia or Ib cuff tear arthropathy demonstrated a constant clinical result with minimal superior

migration of the center of rotation over the complete follow-up period (Fig. 23-45).

FIGURE 23-44 Typical indication for cuff tear arthropathy (CTA): a 55-year-old man with balanced (compensated) rotator cuff

defect.A,Type Ia cuff tear arthropathy (minimal superior migration, no significant instability). B,Preoperative MRI shows some

atrophy and secondary fatty degeneration of the superior part of the subscapularis and infraspinatus and advanced atrophy of

the supraspinatus. C,Radiograph taken 6 months after surgery shows a centered joint without any signs of superior migration.




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In patients with a type IIa arthropathy, we sometimes could observe a slow decrease of the Constant score

values and increasing superior migration with the development of a type IIb instability. A revision to a reverse

shoulder arthroplasty was necessary in two patients due to a secondary subscapularis tendon failure. In both

cases there was a history of prior rotator cuff surgery with acromioplasty and coracoacromial ligament

detachment (Fig. 23-46).

FIGURE 23-45 An 81-year-old man with type IIa cuff tear arthropathy.A,Preoperative (left) and immediate postoperative (first

day) (right) radiographs. The postoperative radiograph shows good centering of the head. The patient experienced nearly no

superior migration due to weakness of the deltoid postoperatively because of a continuous postoperative indwelling

interscalene catheter delivering pain therapy. B,Same patient 6 months after surgery. Left,Radiograph shows some superior

migration of the head. Center and right,Photographs show a very good clinical result. C,Same patient 2 years after surgery.

The radiographs show increasing superior migration, but the photographs show a still very good clinical result. There is no

anterosuperior translation in the Y view (right radiograph), proof of a good functioning subscapularisinfraspinatus force couple.




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Reverse Shoulder Arthroplasty

The Grammont Delta reverse shoulder prosthesis has been used for almost 20 years. Several studies have

evaluate this prosthesis for rotator cuffdeficient arthritic joints. No instability was found in these studies.

Reports of Bouttens [76] on 39 patients with rotator cuff tear arthropathy with 5-year follow-up and Favard [77] on

15 patients with 25 months of follow-up showed excellent results with regard to pain reduction and

improvement of active range of motion, with only one case of aseptic glenoid loosening in the Bouttens study.

Jacobs and colleagues [78] published their results with the use of the Delta Grammont reverse shoulder

prosthesis in seven patients with rotator cuff arthropathy. They found an increase in the mean Constant score

from 17.9 preoperatively to 56.7 postoperatively, with a mean follow-up of 16 months.

Boulahia [79] reported significant reduction of pain and significant improvement in forward elevation and function

with the Delta reverse shoulder prosthesis in 16 patients with arthritic shoulder joints and irreparable rotator

cuff tears, with one case of glenoid loosening.

FIGURE 23-46 Failed cuff tear arthropathy (CTA) head arthroplasty.A,Radiograph 6 months after surgery shows a stable

joint; the patient had good clinical function. Double-headed arrowindicates distance between humeral head and coracoid

process. B,Radiographs 12 months after treatment show slight superior migration and significant anterior displacement.Arrow

indicates contact between humeral head and coracoid process. C,Fluoroscopy 12 months after surgery demonstrates dynamic

anterosuperior instability. Deterioration of function was indicated by a positive belly press sign. Revision surgery proved failure

of the subscapularis tendon.Arrowindicates degree of superior migration.




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Rittmeister and colleagues [80] reported the use of Grammont reverse shoulder prosthesis in eight rheumatoid

arthritic shoulders with nonreconstructive rotator cuff lesions. They found significant pain reduction and active

range of motion improvement at a mean follow-up of 54 months (range, 41-79 months). The Constant score

improved from a mean of 17 points preoperatively to a mean of 63 points. However, two patients developed

clinically significant aseptic loosening of the glenoid component. In three patients, operated through a

transacromion approach, a refixation of the acromion was needed shortly after the primary surgery. The

refixation problem was solved when a deltopectoral approach was used.

The reverse shoulder design does have potential benefits with good results shown for the early and midrange

follow-up periods, [45,81,82] especially when rotator cuff arthropathy patients are separated from those of

rheumatoid arthritis.

Some recent studies have had larger series of cuff tear arthropathy patients and longer follow-ups are reported.

In these studies, the good clinical outcome in a midterm perspective could be confirmed. [14,30,45,7274,83]

In 2006 the results of 457 patients who had surgery between 1992 and 2002 were published in a French

multicenter study. [86] The results of a continuous prospective clinical and radiologic follow-up study of more

than 400 reverse shoulder arthroplasties performed between 1997 and 2006 at our institution were also

presented. [45,46] A few more peer-reviewed clinical outcome papers have been published since 2004. [30,72,74]

The outcome and the results of all these studies have a very uniform message: Despite the difficultpreoperative condition of the joint and rotator cuff, the clinical outcome is unexpectedly good; there is a

significant difference in clinical outcome dependent on the underlying indications; and the results for cuff tear

arthropathy are superior to revisions of failed hemiarthroplasties or total arthroplasties and superior to reverse

shoulder arthroplasty for fracture sequelae. For cuff tear arthropathy indications, the reported overall Constant

scores are 55 to 65 points, which means an age- and sex-related value of 80% to 95% in this specific elderly

population.

Concerning range of motion and function, the reverse shoulder arthroplasty restores active elevation but not

active rotation in completely cuff-deficient shoulders. The gain in active flexion is surprisingly high in the cuff

tear arthropathy group; postoperative values range from 110 to 140 degrees for this patient group. If some

parts of the posterior cuff (inferior third of the infraspinatus and teres minor) are still functioning, the external

rotation function is also acceptable, and the patient has gained a good external rotation in the space

(abduction) and an external rotation of 15 to 20 degrees with the arm at the side, but no improvement ofexternal rotation in comparison to preoperatively could be expected.

A common problem is the limited amount of achievable internal rotation (active and passive), which is directly

related to the reverse prosthesis design and implantation technique. [14] Theoretically, the amount of accessible

internal rotation is getting better with a more anteverted orientation of the humeral component. [84] An extremely

anteverted deviation from the physiologic retroversion is limited by the bony geometry of the head anteriorly

and would also increase the existing headshaft offset of the humerus in the posterior direction.

Long-Term Results

The good clinical results seem to deteriorate after 6 to 7 years. [72,85] The survivorship is significantly worse in

the revision group or in the fracture-sequelae group. Whether this is in a direct connection with the concurrent

progression of inferior glenoid bone erosion (inferior notching) is still under discussion. [16,75]

Simovitch [16] has proved that the clinical results are significantly worse in patients with higher grades of glenoid

notching. The French multicenter study group, on the contrary, found no correlation between notching and

clinical outcome. It is not clear whether inferior notching is a precursor or warning sign of threatening glenoid

component loosening. Indirect proof of the risk potential of high-grade inferior notching is the parallel increase

of higher degrees of notching and revisions for component loosening after 6 years. Although notching is not yet

a proven precursor of loosening, it should not be considered a harmless and unavoidable phenomenon of

reverse shoulder arthroplasty. Notching should be considered a result of the extra-anatomic design of

Grammont's reverse prosthesis, where the hemisphere is directly positioned on the glenoid surface.

Numerous studies report notching rates from 40% to 100% (Table 23-3). The degree of notching is graded in

five types, where grade 3 is erosion beyond the inferior screw, indicating evolution, and grade 4 is erosion

under the base plate as a first sign of loosening (see Fig. 23-6). Interestingly, Simovitch[16]

has shown that inaddition to inferior notching in 44% of the cases, 8% had anterior notching and 30% had posterior notching.

Whether the inferior glenoid notching should be considered a complication or an inevitable sequela of

Grammont's type of reverse shoulder arthroplasty is still under discussion.




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TABLE 23-3 -- Inferior Glenoid Notching in Reverse Shoulder Arthroplasty

Indisputably, higher grades of inferior notching are increasing with time, and in the follow-up period of 6 to 10

years, a significant increase can be observed. However, there is no proven statistical connection between the

increase in the notching phenomenon and the concurrent significant increase in frequency of unsatisfactory

clinical results (Constant score