2.7. Reverse shoulder arthroplasty

Although hemiarthroplasty and TSA had shown superiorities to each other in the absence of rotator cuff, instability, superior migration, weakness of the arm and limited range of motion created concerns [113–116]. Van de Salde et al. correlated the joint space obliteration with rotator cuff fatty infiltration [117]. Grammont et al. in 1993 designed an anatomically inverse implant. Humeral cup became concave and glenoid became convex. Thus, the rotator cuff's altering muscle vectors against the deltoid could be neglected and the implant would become deltoid dependent. Also for its design joint movement center was medialized and located inferiorly, thus increased the moment arm of the deltoid and eliminated the forces applying to glenoidal component [118]. Because of the deltoid dependency, perioperative assessment of deltoid tension after insertion of the implant carries great importance (Figure 4) [116].

Rittmeister et al. published their experience with RSA in 2001. Seven patients (eight shoulders) were included and inclusion criteria was determined as joint pain, restricted joint movements which deteriorates daily living, evaluation of irreparable rotator cuff and advanced destructive pattern in radiological examination. Their mean follow-up duration was 54.3 months. Their main concerns were the glenoidal component and cuff pathology. Because of the inclusion criteria, advanced staged patients' glenoidal bone stock was not ideal for the insertion of the screws, thus loosening of the glenoidal component and perioperative glenoid fractures were encountered. Additional concern in rheumatoid shoulder, teres minor, infraspinatus were damaged in addition to supraspinatus, which created stability issues for the implant [116]. Another study by John et al. included 20 patients with 22 advanced staged rheumatoid shoulders. The evaluation of the patients was made by patient orientated and a clinical assessment with a mean follow-up of 24.3 months. They concluded that in patients with torn rotator cuff and advanced radiological changes, RSA improved the quality of life. Only complication mentioned was scapular notching which did not progress after 1 year of follow-up and also did not significantly change the functional outcome of the patients [119].

In contrast, Tiusanen et al. included 76 RSA patients who needed to be revised after hemiarthroplasty failure. In their retrospective natured study, evaluations were made preoperatively and 1, 3, 6, 12, 36 months after surgery. They stated that even though the results were from a revised patient group, their range of motions increased gradually till their postoperative first year, after that a steady state was encountered. Patient satisfaction was achieved for 90% of the patients and no major complications were seen [120].

Holcomb et al. presented a larger case series (21 patients) with a mean 36 months follow-up. Included patients demonstrated heterogeneity for Larsen classification. For the Larsen Grade IV and V patients, glenoid structural autografts were used which were acquired from humeral head. The results revealed good functional outcomes and pain relief. Eight patient stated good or excellent outcome. Against the statement of Rittmeister, they found fewer complications

Publication

Kelly et al.

41 57 (range

36 months

Daily living

Daily living

20

29

%88

 1 due to rotator cuff tear)

(postoperative

 pain

Non-constraint

arthroplasty is a valuable

surgical option with excellent

pain relief and moderate

functional outcome which is due to impaired rotator cuff

With the restoration of mechanical integrity; pain

relief, motion

can be achievable with total

shoulder arthroplasty.

improvements

 total shoulder

> activities: 30 (score

value: min.9,

max.36)

activities: 16 (score

value: min.9,

max.36)

(1987) [105]

Friedman

24 59 (range

54 months

Pain score: 1.1 (score

Pain score: 4.3 (score

38

11

%92

 None

> value: min:1, max:5)

Daily living activity:

3 (score value: min:

0, max:5)

value: min:1, max:5) Daily living activity:

1 (score value: min:

0, max:5)

Sneppen

62 57 (range:

92 months

ASES: 15.02

 ASES: 28

44

6

%89

 1 (glenoid loosening)

 The presence of proximal migration does not effect the

functional outcomes, but even

pain relief and motion

improvement

with total shoulder arthroplasty, glenoidal loosening is a major concern

Even the radiolucency

are high in operated rheumatoid shoulders, not all

patients had shown loosening

and required revision.

Total shoulder arthroplasty

relieves pain, improves strength and range of motion,

and also use of cemented humeral stem and pegged glenoidal component result in

The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452

> good fixation

 rates

 can be achieved

et al. [107]

Stewart

37 55 (range

114 months

N/A

N/A

22

33

%89

 6 (3 glenoidal

component loosening, 2

humeral component

loosening, 1 deep

infection)

et al. [106] Trail et al.

40 59.1 12.7 61 months

[108]

Betts et al.

14 47.7 (range

231.6 months

N/A

N/A

15

20

N/A

 5 (1

rotator cuff tear, 1

infection, 1 aseptic

loosening of both

components,

unclear

 2 reasons

post-operative

Even though total shoulder

arthroplasty enables the daily life activity, due to rotator cuff

deficiency in rheumatoid

shoulder, loosening rates are

increased.

189

[104]

21–67)

(range 198–

285.6)

(range 25–

Constant: 12.3

Constant: 33.7

17

20

N/A

 N/A

> ASES: 56.9

> ASES: 22.3

> > 105.6)

22–71)

(range 84–

156)

31–75)

(range: 52–

139)

et al. [97]

32–79)

(range 24–

120)

21–59)

(range 12–66)

 N Age

Follow-up

 PRE-op score

 Post-op score

 Improvement

Improvement

Satisfaction

 Complication

Conclusion

in FF

in ER

(mean)


surgical technique for overwhelming the most common complication of the TSA. In the longterm follow-up, the radiolucencies around components had created concerns about loosening, but the progression of radiolucencies is more trustworthy for this diagnosis [50]. Summary of

.

Although hemiarthroplasty and TSA had shown superiorities to each other in the absence of rotator cuff, instability, superior migration, weakness of the arm and limited range of motion

rotator cuff fatty infiltration [117]. Grammont et al. in 1993 designed an anatomically inverse implant. Humeral cup became concave and glenoid became convex. Thus, the rotator cuff

altering muscle vectors against the deltoid could be neglected and the implant would become deltoid dependent. Also for its design joint movement center was medialized and located inferiorly, thus increased the moment arm of the deltoid and eliminated the forces applying to glenoidal component [118]. Because of the deltoid dependency, perioperative assessment of

Rittmeister et al. published their experience with RSA in 2001. Seven patients (eight shoulders) were included and inclusion criteria was determined as joint pain, restricted joint movements which deteriorates daily living, evaluation of irreparable rotator cuff and advanced destructive pattern in radiological examination. Their mean follow-up duration was 54.3 months. Their main concerns were the glenoidal component and cuff pathology. Because of the inclusion

screws, thus loosening of the glenoidal component and perioperative glenoid fractures were encountered. Additional concern in rheumatoid shoulder, teres minor, infraspinatus were damaged in addition to supraspinatus, which created stability issues for the implant [116]. Another study by John et al. included 20 patients with 22 advanced staged rheumatoid shoulders. The evaluation of the patients was made by patient orientated and a clinical assessment with a mean follow-up of 24.3 months. They concluded that in patients with torn rotator cuff and advanced radiological changes, RSA improved the quality of life. Only complication mentioned was scapular notching which did not progress after 1 year of follow-up

In contrast, Tiusanen et al. included 76 RSA patients who needed to be revised after hemiarthroplasty failure. In their retrospective natured study, evaluations were made preoperatively and 1, 3, 6, 12, 36 months after surgery. They stated that even though the results were from a revised patient group, their range of motions increased gradually till their postoperative first year, after that a steady state was encountered. Patient satisfaction was achieved for 90% of the patients and

Holcomb et al. presented a larger case series (21 patients) with a mean 36 months follow-up. Included patients demonstrated heterogeneity for Larsen classification. For the Larsen Grade IV and V patients, glenoid structural autografts were used which were acquired from humeral head. The results revealed good functional outcomes and pain relief. Eight patient stated good or excellent outcome. Against the statement of Rittmeister, they found fewer complications

and also did not significantly change the functional outcome of the patients [119].

deltoid tension after insertion of the implant carries great importance (Figure 4) [116].

–116]. Van de Salde et al. correlated the joint space obliteration with

' glenoidal bone stock was not ideal for the insertion of the

' s

the literature for TSA can be found in Table 5

2.7. Reverse shoulder arthroplasty

criteria, advanced staged patients

no major complications were seen [120].

created concerns [113

188 Advances in Shoulder Surgery

The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452 189


Table5.SummaryofpreviouspublicationsabouttotalshoulderarthroplastyinRApatients.

and only three required revision surgery. Two of these three were evaluated as periprosthetic infection which occurred after 7 weeks and 6 years after surgery. They explained their low infection rates to routinely used tobramycin added methylmethacrylate. They supported that even though all rotator cuff muscles are affected by fatty infiltration, the choice of RSA is reasonable with improved functional outcomes, pain relief and low complication rates [121]. Guery et al. in 2006 published a survival analysis for RSA. They advocated that because of high infection rate and low quality of glenoid bone stock in RA, the use of RSA was contraindicated [122]. But after 5 years, Young et al. in the same institute published their experience of RSA in RA with an intermediate follow-up (3.8 years). No complications were seen that needs to be intervened by surgery. The structural bone graft acquired from resected humeral head is enough for restoring glenoidal bone stock and healing of the graft was satisfactory. As for the

Figure 4. Reverse shoulder arthroplasty surgery. (A) Preoperative AP plain radiography. (B) Preoperative coronal CT

The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452 191

scan. (C) Early postoperative plain radiography. (D) Postoperative 6th month plain radiography.

Figure 4. Reverse shoulder arthroplasty surgery. (A) Preoperative AP plain radiography. (B) Preoperative coronal CT scan. (C) Early postoperative plain radiography. (D) Postoperative 6th month plain radiography.

and only three required revision surgery. Two of these three were evaluated as periprosthetic infection which occurred after 7 weeks and 6 years after surgery. They explained their low infection rates to routinely used tobramycin added methylmethacrylate. They supported that even though all rotator cuff muscles are affected by fatty infiltration, the choice of RSA is reasonable with improved functional outcomes, pain relief and low complication rates [121].

Guery et al. in 2006 published a survival analysis for RSA. They advocated that because of high infection rate and low quality of glenoid bone stock in RA, the use of RSA was contraindicated [122]. But after 5 years, Young et al. in the same institute published their experience of RSA in RA with an intermediate follow-up (3.8 years). No complications were seen that needs to be intervened by surgery. The structural bone graft acquired from resected humeral head is enough for restoring glenoidal bone stock and healing of the graft was satisfactory. As for the

Publication

Clement

29 55 (range

132 months

Constant: 20.6

 Constant: 33.5

> et al. [103]

Abbreviations:

Table 5.

Summary of previous

publications

 about total shoulder

arthroplasty

 in RA patients.

 ER, external rotation; FF, forward flexion; ASES, American Shoulder and Elbow Surgeons Score.

35–86)

(range 96–

168)

 N Age

Follow-up

 PRE-op score

 Post-op score

 Improvement

Improvement

Satisfaction

 Complication

Conclusion

in FF

4

10

N/A

 5 (3 superior luxation of

Hydroxyapatite

backed glenoid components key features for survival are

the low profile metal back,

hydroxyapatite

fixation of glenoid component

with screws

 cover and

 covered metal

190 Advances in Shoulder Surgery

humeral head, 1 for infection, 1 for aseptic

loosening)

in ER

(mean)


functional outcome, the forward flexion was increased to 138.6

rotation was improved significantly when the arm was abducted 90

prognostic factor for periprosthetic infection after RSA application [124].

In 2016, Liu et al. evaluated the osteoarthritic patients

younger than 70 of age and had a rotator cuff deficiency [125].

summarized in Table 6

surgical treatment are patients

prosthesis. If the patients

3. Conclusion

.

outcome according to the total shoulder and hemiarthroplasty patients with the same radiographic properties. Eleven patients were stated as good or excellent result. But for the external rotation, the increase was not statistically significant. With an intact teres minor, external

Even Holcomb et al. [121] stated their infection rate for 9.5% in 21 patients, Young et al. [123] stated 0% infection rate after RSA in rheumatoid shoulder. But a larger case series was published by Morris et al. with 42 rheumatoid shoulders contributing in 301 RSA. Only 5% of patients with RA were infected and required revision. They concluded that RA was not a bad

roplasty surgeries. Even though minor population represents the RA patients, it may give some clue for the functionality of RSA. Inclusion criteria were the patients who had a contraindication for TSA and RSA or hemiarthroplasty was decided. A total of 102 RSA and 71 hemiarthroplasty patients were evaluated for 31.7 and 62.9 months, respectively. They concluded that RSA had a better return to sports activities than hemiarthroplasty, especially when the patient was female,

In conclusion, the choice for RSA is reserved for old aged, irreparable rotator cuff deficient patients. According to larger case series, the patients with morning stiffness, advanced radiological destruction of glenohumeral joint is considered to be the indication for RSA. The challenges for low glenoidal bone stock can be overwhelmed with the use of autografts acquired from humeral head to reinforce the glenoidal bone stock [50]. In the light of recent literature, we can assume that RSA will play role in young-aged patients due to return to sports rate and improved functional status. The functional status and complications of previous literature about RSA are

We tried to simplify the indications, advantages and disadvantages above-mentioned treatment options in Table 7 and Figure 5. Main critical factors for decision making for optimal

glenoid bone stock. Treatment for young-aged patients will require a long-term survival rated surgical treatments or a short-term treatment with preservation of bone stock to revise to

bursectomy may be preferred, but if it is moderately or severely deformed, rotator cuff status becomes the main identifier. If rotator cuff is intact, surgeon can prefer hemiarthroplasty or resurfacing arthroplasty which preserves glenoidal bone stock and with good survival rate. With torn rotator cuff, the situation becomes more dire, even though good functional outcomes can be achieved with anatomic TSA and rotator cuff repair, in long-term follow-up rotator cuff degeneration is inevitable which results in pain because of superior migration of prosthesis and loss of glenoidal bone stock, also tragically glenoidal component loosening due to rocking

' age, functional demand, rotator cuff status and remaining

' radiological evaluation is below Larsen class II, synovectomy or

which was a good functional

193

[123].

The Rheumatoid Shoulder: Current Surgical Treatments http://dx.doi.org/10.5772/intechopen.71452

' return to sports after RSA or hemiarth-

functional outcome, the forward flexion was increased to 138.6 which was a good functional outcome according to the total shoulder and hemiarthroplasty patients with the same radiographic properties. Eleven patients were stated as good or excellent result. But for the external rotation, the increase was not statistically significant. With an intact teres minor, external rotation was improved significantly when the arm was abducted 90 [123].

Even Holcomb et al. [121] stated their infection rate for 9.5% in 21 patients, Young et al. [123] stated 0% infection rate after RSA in rheumatoid shoulder. But a larger case series was published by Morris et al. with 42 rheumatoid shoulders contributing in 301 RSA. Only 5% of patients with RA were infected and required revision. They concluded that RA was not a bad prognostic factor for periprosthetic infection after RSA application [124].

In 2016, Liu et al. evaluated the osteoarthritic patients' return to sports after RSA or hemiarthroplasty surgeries. Even though minor population represents the RA patients, it may give some clue for the functionality of RSA. Inclusion criteria were the patients who had a contraindication for TSA and RSA or hemiarthroplasty was decided. A total of 102 RSA and 71 hemiarthroplasty patients were evaluated for 31.7 and 62.9 months, respectively. They concluded that RSA had a better return to sports activities than hemiarthroplasty, especially when the patient was female, younger than 70 of age and had a rotator cuff deficiency [125].

In conclusion, the choice for RSA is reserved for old aged, irreparable rotator cuff deficient patients. According to larger case series, the patients with morning stiffness, advanced radiological destruction of glenohumeral joint is considered to be the indication for RSA. The challenges for low glenoidal bone stock can be overwhelmed with the use of autografts acquired from humeral head to reinforce the glenoidal bone stock [50]. In the light of recent literature, we can assume that RSA will play role in young-aged patients due to return to sports rate and improved functional status. The functional status and complications of previous literature about RSA are summarized in Table 6.
