Evolving Role of Reverse Shoulder Replacement

Derek Cuff, M.D.Suncoast Orthopaedic Surgery and Sports Medicine

Gulfcoast Orthopaedic Rehab Conference

Evolving Role of RTSR

• Goals

– 1. Discuss initial use of RTSR

– 2. Discuss how the implant works

– 3. Discuss newer indications

– 4. Discuss how we rehab these patients

Evolving Role of RTSR

• Indications

– Primary: Glenohumeral arthritis and massive rotator cuff tear

Evolving Role of RTSR

– RTC centers humeral head

– Provides stable fulcrum

– Deltoid assists with elevation

Evolving Role of RTSR

Evolving Role of RTSR

• Massive RTC tear destabilizes the shoulder

• Alters the mechanics of the shoulder

• With time degenerative changes may occur

Evolving Role of RTSR

• Arthropathy develops

– Inability to overhead elevate

– Pain

– Poor function

Evolving Role of RTSR

Evolving Role of RTSR

• How does it work?

– Takes torn rotator cuff muscles out of equation

– Recruits healthy deltoid muscle to take over and do the work

– Gives stability and smooth painless surfaces to allow motion

Evolving Role of RTST

• Reversing Joint gives a stable fulcrum

• Deltoid can fully elevate arm

• Humerus rotates around fixed sphere

Operation

• Remove arthritis from humeral head– Replace with metal stem

and plastic socket

• Remove arthritis from glenoid– Replace with metal

glenosphere

• FDA approval in 2003

• Cuff et al., 2008- 93% success rate

• Cuff et al. 2012- 94% survivorship at 5 years

• 10 year data coming in the next year

Evolving Role of RTSR

• Early success has led to new sets of indications

• Multiple other complex problems can be addressed by RTSR

• Utilized as a salvage treatment for difficult clinical scenarios

Evolving Role of RTSR

• Massive RTC tear with no OA

– Failed previous repairs

– Ignored chronic tears

– Using an artificial implant for a soft tissue problem

• Mulieri et al, 2010

– 69 patients in study

– Good results

– 92% patients were satisfied

– Option as last resort for these patients

Evolving Role of RTSR

• Failed total shoulder

– Unstable

– Rotator cuff non-functional

– Deltoid can still power this

– Black et al. JSES 2014• 36 patients with good results

Evolving Role of RTSR

• Severe proximal humerus fracture in elderly

– Partial replacement with repair of the tuberosities was standard

– If they don’t heal then poor function

– Reverse relies on the deltoid to power

Evolving Role of RTSA

• Cuff et al JBJS 2013– RTSA– 27 patients– 91% success rate

– Hemiarthroplasty– 24 patients– 61% success rate

Evolving Role of RTSR

• Failed ORIF of fracture

– Remove hardware and place a reverse

Evolving Role of RTSR

• Chronic dislocation in elderly

– Often has glenoid bone lose

– Often have RTC tear

– Restores stability and function

Evolving Role RTSR

• Post-op PT controversial

– All over the board

– Sometimes repair subscap at end of the case

– Often no rotator cuff left to protect

– Still concerns about instability post-op

Evolving Role of RTSR

• Biggest early concern

• First 12 weeks

• Beware of over aggressive motion

• Avoid WB/pushing up from chair

Evolving Role of RTSR

• My approach

– Immobilizer for 6 weeks

– Pendulums and active elbow wrist and hand

– Outpatient PT weeks 6-12 for ROM

– Gentle strengthening at 12 weeks

Evolving Role of RTSR

• Watch out for acromial stress fracture

• Typically 3-4 months post op

• Notify surgeon ASAP

• Otto et al., JSES 2013; 2-3% incidence

Summary

• You will see more and more RTSR patients in the coming years

• Salvage option for many conditions

• Important to familiarize yourself with procedure

• PT may be highly variable between surgeons

Thank You