Ashley Webb

December 8, 2008

The reverse shoulder prosthesis was developed by Proffessor Paul Grammont in the 1980’s in France.1

Due to some unsatisfactory results, Grammont revised the prosthesis in 1991 to the Delta-III version of the prosthesis.

FDA approved it for use, and the first surgery was performed in the United States in March of 2004.

Diagnoses include: rheumatoid arthritis, osteoarthritis, massive rotator cuff tear, and traumatic injuries

ages 65 years or older

the presence of decreased function due to massive rotator cuff dysfunction

an activity level with LOW functional demands.

The deltoid muscle becomes the prime mover of the shoulder joint.1

The prosthesis changes the concave surface of the joint to the humeral head, and the convex surface to the glenoid surface.

The deltoid muscle insertion is moved distal to increase the lever arm.

Performed in France over a 10 year period consisted of 457 patients with rTSA 2

Approximately 85% of the patients were available for a two year postoperative follow-up.

Active elevation improved significantly, however active internal and external rotation did not.

Another study performed by Wall, et al., researchers examined 240 reverse total shoulder arthroplasties performed in France 3

Follow up on 191 of the reverse total shoulder arthroplasty prostheses 39.9 months postoperatively

Results were as follows: active Elevation improved from 86° to 137°, Internal Rotation improved from the level of L5 to the

level of L4; no significant improvement was seen in External

Rotation.

Seebaur4 reported on another clinical study which included 400 reverse total shoulder arthroplasties

Postoperative results ranged from 110° to 140° of active forward flexion

Also a gain of 20° of external rotation when the arm was held in abduction. No improvement of external rotation was seen with the arm at the side.

This study also found that pain relief was substantial.

Gerber, et al.5 performed a study based on 12 reverse total shoulder arthroplasties that used the Delta-III prosthesis along with a latissimus dorsi transfer.

Results were as follows: average forward flexion improved from 94° preoperatively to 139° postoperatively, abduction improved from 87° to 145°, and strength also improved from .25 kg to 4.12 kg.

However, Gerber, et al. reported a significant increase in functional external rotation, citing the fact that “deficient external rotation with the arm at the side does not correlate with shoulder disability, as deficient external rotation with the arm in space does.”5(pg.945)

Possibly due to this increase in functional

ability, the subjective shoulder values from the patients improved almost threefold from 23% to 64%. Also activities of daily living scores tripled from 2.3 to 7.9 points based on a ten point scale.

Complication rates have been reported as high as 60%.4

Infection is a possible complication.2,3

The design of the prosthesis favors infection: due to the empty space around the prosthesis,usually a second or third surgery for most

patients.4 Age group for this operation is older

individuals who may have other co-morbidities making them more susceptible to infections.2

Loosening of the glenoid component of the prosthesis.2

This complication is usually caused by glenoid bone deficiency suboptimal positioningsecondarily to trauma to the arm

Matsen, et al.2 also suggested to make sure the prosthesis is positioned low on the glenoid bone and the inferior fixation screw is securely anchored in the best scapular bone available so the prosthesis can withstand both superiorly and inferiorly directed loads.

Dislocation is also a common complication.4

Certain surgical approaches have higher dislocation rates. The deltopectoral approach has the highest dislocation rate. However, this is the most common approach due to the straightforwardness of the approach.

AVOID Extension ROM and exercises to help prevent dislocation for first 4-6 weeks

Guery, et al.6 assessed sixty replacements after ten years.

Overall, they found that the prosthesis was good 8 years after the procedure.

Two main breaks in the survival curve:3 years the first break occurred due to early

loosening of the prosthesis6 years when functional deterioration began

Guery, et al.6 also discovered that certain patient groups had more favorable outcomes then others.

Patients with rheumatoid arthritis had poor outcomes. This group had the highest percentage of surgical revisions. Also posttraumatic arthritis had worse results.

“Patients with primary rotator cuff tear arthropathy, primary osteoarthritis with a rotator cuff tear, and a massive rotator cuff tear without arthritis had the best final outcomes” for the reverse total shoulder arthroplasty.3(pg.1483)

52 y.o. white female

Presented into outpatient PT c/o pain s/p Right reverse total shoulder arthroplasty

Initial shoulder injury happened 2 years priorInitially ORIF surgery for proximal humerus fx3 following surgeries that resulted in removal

of hardware

Right hand dominent

Rated pain on 10+ on a VAS

Co-morbidities: hypertension, depression, and a previous right total hip arthroplasty, obese

Medications: Cardizem, Celebrex, Cymbalta, and Percocet

Pt. Goal: Return to work as an LPN

The operative note from her surgeon revealed she had some avascular necrosis of the humeral head, which was fixed during surgery.

Some of the teres minor insertion was saved

However, he was unable to perform a latissmus dorsi transfer as planned due to some unexpected bleeding.

The surgeon was able to achieve 60° of external rotation and 170° of forward flexion passively with the prosthesis in place under anesthesia

20 days postoperatively

wearing a gunslinger brace for her right upper extremity, which was to be worn for 6 weeks

PROM measurements: external rotation was 35°, forward flexion was 90°, and internal rotation was 25 degrees taken to patient point of pain

Strength measurements included elbow flexion and extension which were 4/5, with wrist flexion and extension and hand strength measuring grossly 5/5.

Pt seen 3 x week with coordinating HEP

Due to this being a Worker’s Compensation case the pt. was initially only approved 12 visits

Codman pendulum exercises She also performed passive forward flexion in the

supine position with a stick, and passive external rotation in the supine position with a pillow under her humerus with a stick times two minutes each.

Passive forward flexion by sliding a towel across the table

She would perform bilateral upper extremity weight shifting for joint approximation

Therapist performed PROM of the right upper extremity in the forward flexion plane, abduction plane, external rotation and internal rotation planes with the arm abducted at approximately 40°.

Pulleys Electrical stimulation with a TENS unit to the

glenohumeral joint area, in combination with simultaneous cryotherapy and vasoneumatic compression times 15 minutes

Use her last 2 visits for strengthening and HEP before DC

Released from wearing her sling

Patient was instructed in and performed supine passive forward flexion stretches of her right arm using the left arm.

She performed AROM forward flexion in the supine position starting from 90° and going as far as she could, into further flexion, then back to 90°.

Exercise using theraband tubing in the following directions: abduction with the elbow extended, adduction, flexion, and extension.

Received E.stim. Cryotherapy with vasoneumatic compression

Strengthening program resulted in Increased pain with decrease strength

6 more visits approvedSeen 2 x weekMaintain strength program

Therapist performing PROM except extensionFinger ladder, Nesar slide at 45 degrees, and

swiss ball exercises were addedOn 16th visit internal rotation behind the back

was added

AROM measurements: Flexion 110° in standingExternal Rotation 20° in supine with arm

abductedInternal Rotation at L5

Pain 2/10 normally, 5/10 at worst

Pt. had several of the contraindications to the procedure including: age, multiple surgeries, high functional demand

Patient was able to regain good flexion and abduction range of motion for the glenohumeral joint postoperatively. However, she gained very little rotational movement in external and internal rotation.

Reverse total shoulder arthroplasty is a relatively new procedure in America- first performed in 2004

It is a salvage procedure that is a last effort to preserve shoulder function in patients who have irreparable damage to their rotator cuff.

With this case study patient the reverse total shoulder arthroplasty gave this younger patient a chance to still have functional use of her shoulder

1. Rockwood, C. The reverse total shoulder prosthesis: the new kid on the block. The Journal of Bone and Joint Surgery. 2007;89:233-4.

2. Matsen, F.A., Boileau, P., Walch, G., Gerber, C., Bicknell, R. The reverse total shoulder arthroplasty. The Journal of Bone and Joint Surgery. 2006;88:660-6.

3. Wall, B., Nove-Josserand, L., O’Conner, D., Edwards, B., Walch, G. Reverse total shoulder arthroplasty: a review of results according to etiology. The Journal of Bone and Joint Surgery. 2007;89:1476-85.

4. Seebauer, L. Total reverse shoulder arthroplasty: European lessons and future trends. The American Journal of Orthopedics. 2007;36(12 Supplement):22-28.

5. Gerber, C., Pennington,S., Lingenfelter, E., Sukthankar, A. Reverse delta-III total shoulder replacement combined with latissimus dorsi transfer. The Journal of Bone and Joint Surgery. 2007;89:940-7.

6. Guery,J. et al. Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years. The Journal of Bone and Joint Surgery. 2006;88:1742-7.

7. Ramsey, M., Getz, C., Parsons, B. What’s new in shoulder and elbow surgery. The Journal of Bone and Joint Surgery. 2008;90:677-87.

8. Abrahamsen, C. Rehabilitation protocol for reverse total shoulder replacement. Available from http:// cabrahamsenmd.com/forms/reverseshoulder_protocol.pdf. Accessed on April 15, 2008.

9. Brigham and Women’s Hospital. Reverse total shoulder protocol. 2007. Available from http:// www.brighamandwomens.org. Accessed on April 8, 2008.

Questions???