REVERSE GEOMETRY TOTAL SHOULDER ARTHROPLASTY……BEYOND EXPECTATIONS?

Rachael Daw February 2014

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AIM! To discuss current thinking on the

potential functional outcome of Reverse Geometry Total Shoulder Arthroplasty !

! To consider the implications of improved clinical outcomes for rehabilitationNW

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HISTORICAL PERSPECTIVE! The first TSR, a salvage procedure for TB,

was essentially a reverse geometry design!

Jules Emile Pean ,1893.

Neer’s Mark I reverse prosthesis

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THE MODERN REVERSE TSR

Paul Grammont, 1985

“ The patient who has lost function doesn’t care about the design of the prosthesis that will be implanted but only about it’s effectiveness in the recovery of the lost function”NW

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SALVAGE PROCEDURE?! The Grammont design successfully achieves I. Improved stability II. Compensation for the absent cuff III. Reduced risk of mechanical failure ! Despite this still carries significant risks ! Boileau et al (2006), recommended that the

reverse prosthesis must be considered a salvage procedure, limited to patients over 70.

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EXPECTED OUTCOMES! From a recent literature review the

average outcomes following primary RTSR are:

Forward Flexion -122.5◦ Abduction - 117.6◦ Ext. Rotation - 32.1◦ Constant Score - 62

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OUR EXPERIENCEFLEXION ACHIEVED

% of patients

> 90◦ > 120◦ >150◦ELECTIVE 86 59 23TRAUMA 90 55 15

TOTAL 88 57 19

17% of the total patient cohort < 70

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REHAB CONSIDERATIONS! Increasing number of younger patients! Increasingly active older patient population! Increasing number of patients achieving

greater ROM! Is this going to increase physicaldemand on the prosthesis beyondIts capability?!

SHOULD WE BE WORRIED?

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BIOMECHANICS! Mahfour et al (2005) found;! RTSR experiences kinematic patterns and

torque forces most similar to the normal shoulder (compared to anatomical TSR and cuff deficient shoulders).

! Scapula rotation contributed more greatly to overall elevation

! Subjects having had either type of TSR had smaller bearing surface forces than normal or cuff deficient shoulders.

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BIOMECHANICS! Mahnic deToledo et al (2012) found; ! No significant differences between the

scapulothoracic kinematics of anatomic or RTSR subjects.

! In general there was greater upward rotation of the scapula with loading in those with arthroplasty (opposite pattern to the normal shoulder)

! ROM analysed only up to 90◦ elevation.

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QUESTIONS…..! Biomechanical research is insufficient and

inconclusive.! Can the modern prosthesis withstand

conditions similar to the native shoulder in the long term?

! Does rehab make a difference to outcome?! What should be the focus of rehab for the high performing patient?! Limitations?

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RECOMMENDED REHAB! Blacknall and Neumann (2011) ! Evaluation based rehab protocols should

consider; ! Healing times, pathophysiology, anatomy

and biomechanics ! Pre-morbid conditions ! Response to treatment ! PATIENTS ABILITIES

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EXERCISE PRESCRIPTION! ‘Raison d’être’ for the procedure? ! FUNCTION, FUNCTION, FUNCTION! ! ↑ scapular rotation with elevation can ↑function, but failure to correct on lowering can cause ↑ prosthesis wear and notching

! Focus on quality and technique with maintenance of CONTROL throughout.

! Will control in greater ranges be sufficient to prevent excess wear?

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REHAB RELATED RISKS! NOTCHING, ↑ with poor scapulothoracic

control, (particularly on lowering) ! DISLOCATION, ↑ HBB, combined

extension, IR and add. ! GLENOID COMPONENT LOOSENING, ↑

with lifting and weight-bearing through the upper limb

! ? Any risks associated with ↑ ROM

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CASE STUDY! 65 year old �, left RTSR for revision of failed

hemiarthroplasty post # ! Early onset notching (grade II) noted at 2/12 ! Significant scapulothoracic hitching and reduced

glenohumeral movement also noted at consultation ! Following specialist shoulder physiotherapy to

address deltoid function and scapulothoracic control, ROM and QOM improved significantly

! No further progression of notching seen.

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JAN 2013 FEB 2013

AUGUST 2013

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LIMITATIONS?! Golant et al (2012) ! Little literature on sports participation

post TSR in general and no literature on sporting activity for RTSR in particular

! Survey of ASES: 36.1% allow high-load non-contact sports 72.2% allow low-load sports 17.9% allow contact sports 51.3% allow non-upper extremity sports

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WHAT DO YOU THINK?

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CONCLUSION! More questions than answers! ! RESEARCH IS NEEDED; ! to investigate the biomechanical

capabilities of the RTSR and ! to establish outcomes of younger pts and

those who have performed better (eg ? earlier failure)

! But……..

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CONCLUSION! The potential number of patients in this

group remains small ! Those wanting to achieve high level

function is smaller still, so….. ! How much do we really need to worry?NW

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REFERENCES! Grammont's Idea: The Story of Paul Grammont's Functional Surgery Concept and the Development of the Reverse

Principle. Baulot E, Sirveaux F, Boileau P. Clinical Orthopaedics and related Research. 2011; 469: 2425-2431. ! Evolution of the reverse total shoulder prosthesis. Jazayeri R. Bulletin of the NYU Hospital for Joint Diseases. 2011; 69

(1): 50-55. ! Neer Award 2005: The Grammont reverse shoulder prosthesis: Results in cuff tear arthritis, fracture sequelae, and

revision arthroplasty. Boileau P, Watkinson D, Hatzidakis A M, Hovorka I. Journal of Shoulder & Elbow Surgery. 2006; 15(5):527-540.

! Grammont reverse prosthesis: Design, rationale, and biomechanics. Boileau P, Watkinson DJ, Hatzidakis AM, and Balg F. Journal of Shoulder and Elbow Surgery. 2005; 14: 147-161s.

! Kinematic and clinical evaluation of shoulder function after primary and revision reverse shoulder prostheses. D. Alta T, Bergmann JH, Jan Veeger DJ. Journal of Shoulder and Elbow Surgery. 2011; 20: 564-570.

! Kinematic evaluation of patients with total and reverse shoulder arthroplasty during rehabilitation exercises with different loads. Toledo JM,Loss JF, Janssen TW, van der Scheer JW, Alta TD, Willems WJ, Veeger DH. Clinical Biomechanics . 2012; 27 (8):793-800.

! Invivo determination of the dynamics of normal, rotator cuff-deficient, total, and reverse replacement shoulders. Mahfouz M, Nicholson G, Komistek R, Hovis D, Kubo M. Journal of Bone and Joint Surgery-american volume. 2005; 87A:107-113. Supplement: 2

! Rehabilitation following reverse total shoulder replacement. Blacknall J, Neumann L. Shoulder & Elbow. 2011; 3(4):232-240.

! Return to sports after shoulder arthroplasty: A survey of surgeons' preferences.Golant A. Christoforou D, Zuckerman J.D, Kwon YW. Journal of Shoulder and Elbow Surgery. 2012; 21(4):554-560.

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