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
