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Bilateral reverse total shoulder arthroplasty—functional outcome and activities of daily living
ARTICLE IN PRESS J Shoulder Elbow Surg (2016) ■■, ■■–■■
www.elsevier.com/locate/ymse
Bilateral reverse total shoulder arthroplasty—functional outcome and activities of daily living Ofer Levy, MD, MCh(Orth), FRCS*, Joanna Walecka, MD, George Arealis, MD, Oren Tsvieli, MD, Giuseppe Della Rotonda, MD, Ruben Abraham, FRCA, Ioannis Polyzois, MD, Zac Jurkowski, BSc, Ehud Atoun, MD Reading Shoulder Unit, Royal Berkshire Hospital and Berkshire Independent Hospital, Reading, UK Background: Reverse total shoulder arthroplasty (rTSA) has gained popularity in recent years, providing good shoulder elevation, yet less predictable rotations. Good rotations are crucial for performance of activities of daily living (ADLs), including personal hygiene. Concerns remain regarding bilateral rTSA over lack of rotations bilaterally and resultant difficulties with ADLs. This study examined the outcome of patients with bilateral rTSA in restoration of function and ADLs. Methods: Data were prospectively collected for 19 patients (15 women, 4 men; 38 shoulders), with a mean age of 74.5 years, who underwent staged bilateral rTSA between 2007 and 2013. Mean follow-up was 48.4 months (range, 24-75 months). Patients were evaluated clinically using the Constant score, patient’s satisfaction, Subjective Shoulder Value, and the Activities of Daily Living External and Internal Rotations (ADLEIR) score. Video clips were also recorded for documentation at all visits. Results: Mean duration between staged operations was 18.2 months (range, 3-46 months). The Constant score improved from 18.7 to 65.1 points (age- and sex-adjusted, 100.2). Elevation improved from 57.5° to 143°, internal rotation (IR) from 9° to 81° (30 shoulders could reach above the sacroiliac joint), and external rotation (ER) from 20° to 32° (35 shoulders had >20° ER in adduction, 31 shoulders had full ER in elevation). The Subjective Shoulder Value improved from 2.1 of 10 to 9.2 of 10. Mean ADLEIR score was 33 of 36 (P < .001 for all). Most patients resumed their leisure and sport activities (gardening, golf, swimming, bowling). Conclusion: Bilateral rTSA results in marked and predictable improvement in all movements, pain relief, and functional outcomes, with high patient satisfaction and high ADLEIR score. All patients were able to perform perineal hygiene after their rTSA. Most patients had no limitation in ADLs and their leisure activities. Level of evidence: Level IV; Case Series; Treatment Study © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Shoulder; arthroplasty; stemless; replacement; activities; ADL; rotation; function
The Royal Berkshire Hospital Audit and Review Board approved the study (Study No. N3114). *Reprint requests: Ofer Levy, MD, MCh(Orth), FRCS, Reading Shoulder Unit, Royal Berkshire Hospital and Berkshire Independent Hospital, Reading, Berkshire, RG1 6UZ, UK. E-mail address: [email protected] (O. Levy).
Reverse total shoulder arthroplasty (rTSA) has gained in popularity in recent years and has excellent outcomes for a variety of indications9,11-13,15,20,30,32,42-45 such as severe rotator cuff tear arthropathy (CTA), rheumatoid arthritis,18,49 failed arthroplasty,24,34 acute fractures,8,23 and fracture sequela.19,28,48
1058-2746/$ - see front matter © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. http://dx.doi.org/10.1016/j.jse.2016.09.010
ARTICLE IN PRESS 2 rTSA provides good range of shoulder elevation; however, restoration of active rotational movements is less predictable and has been unreliable in past series.1,44 Good rotational movements are obligatory for performance of activities of daily living (ADLs), internal rotation (IR) for activities regarding perineal and self-hygiene,21,31,35 and external rotation (ER) for reaching with the hand to the mouth and head (for eating, drinking, and combing the hair).21 The capability of performing these ADLs provides independence for many of these usually elderly patients.45 Werner et al45 found that active ER (AER) did not improve but actually decreased by a mean of 5°, particularly in elevation and abduction. The loss of AER was also observed by Baulot et al.4 Therefore, concerns remain regarding performing bilateral rTSA because of the lack of rotational movements bilaterally and the resultant difficulties with ADLs. Several authors have recommended caution with bilateral rTSA.7,32,45,46 Some even suggested performing rTSA on one side to achieve good elevation and an anatomic prosthesis on the other side to compensate and have good rotational movements but without good elevation. Bilateral rTSA is indicated in the case of bilateral CTA. Osteoarthritis and inflammatory arthritis often occur bilaterally, requiring arthroplasty treatment of both shoulders.14 Conversely, bilateral rTSA as a surgical treatment for bilateral, symptomatic CTA has been reported to produce unfavorable outcomes with respect to patient quality of life. Difficulties with IR and ER and the associated infringement on ADLs, specifically the inability to perform perineal care associated with toileting and bathing, have made surgeons reluctant to perform the procedure.35,37 The use of bilateral arthroplasty has proven successful in several other orthopedic procedures. Procedure outcomes in bilateral total hip arthroplasty5,26,33 and bilateral total knee arthroplasty3,36 have both been extensively reviewed. Although a few studies have examined bilateral shoulder arthroplasty, most reports have focused on bilateral anatomic TSA14,17 or a combination of TSA and rTSA.22 The number of reports examining bilateral rTSA is even more limited.29,40,41,46 This study examined the clinical and radiographic outcomes of patients with bilateral rTSA in restoration of function and their ability to resume ADLs and more. Our null hypothesis was that bilateral rTSA would cause lack of rotational movements bilaterally and resultant difficulties with ADLs.
Materials and methods Review of the prospectively collected data revealed 19 patients (38 shoulders) who underwent staged bilateral rTSA at our institution between 2007 and 2013, with a minimum of 2 years of followup after the second operation. There were 15 women and 4 men, the mean age at surgery was 74.5 years (range, 63-90 years), and the mean follow-up was 48.4 months (range, 24-75 months). The indications for surgery were CTA in 13 patients (one side was fracture sequela in 2 patients), after failed rotator cuff repairs of massive
O. Levy et al. cuff tears in 1, osteoarthritis in 1, and rheumatoid arthritis in 4. In 6 patients the rTSA was performed as revision arthroplasty. In 5 patients, one side was operated on as revision arthroplasty, and 1 patient with rheumatoid arthritis underwent bilateral revision arthroplasties (Table I). All cases were performed at a high-volume shoulder arthroplasty center by a single surgeon (O.L.). All of the primary procedures and all but 1 of the revisions were performed through the Neviaser-MacKenzie anterosuperior approach. 27 Only 1 revision of a well-fixed stemmed TSA (Biomodular; Biomet, Warsaw, IN, USA) to a stemmed Verso rTSA (Innovative Design Orthopaedics, London, UK; formerly Biomet, Swindon, UK) was performed through the deltopectoral approach to allow performing humeral window osteotomy for removal of the stem. The same Verso implant was used in all procedures. In all the primary cases and in 3 of the revisions, the stemless metaphyseal prosthesis was used. In 4 revision cases of failed stemmed arthroplasty the Stemmed Verso implant was used. A humeral cut of 155° in 30° retroversion was performed in all shoulders, and the humeral component was inserted in 30° of retroversion. However, this implant has a 10° angled dialable polyethylene liner that changes the angle of the humeral component to 145° and allows for final fine adjustment of the optimal version in each patient to achieve the optimal arc of rotations.2,25 The implant has a +3-mm lateralized center of rotation (LCOR) from the glenoid face incorporated in the glenosphere.2,25 The posteroinferior rotator cuff was absent in 36 shoulders; however, the surgeon always attempted to approximate any existing remnant of the teres minor. The teres minor was present in 2 shoulders operated on for osteoarthritis. A standardized postoperative rehabilitation protocol was followed in all patients. Patients were evaluated clinically and radiographically preoperatively and postoperatively at 3 weeks, 3 months, 6 months, 1 year, and yearly thereafter. Three patients died of unrelated causes more than 2 years after the last operation, so their last follow-up data were considered. Shoulder function was assessed using the Constant score (CS),10 patient’s satisfaction score, Subjective Shoulder Value (SSV),16 or Single Assessment Numeric Evaluation (SANE),47 and the Activities of Daily Living External and Internal Rotations score (ADLIER) score, which was modified from the ADLER (Activities of Daily Living Requiring External Rotation) score.6 The ADLEIR score questionnaire assesses 12 different activities that represent ADLs such as to comb the hair, to shave (men) or apply make-up (women), to brush teeth, to dress without help, to fill a glass from a full bottle, to drink with a full glass, to use their hand to eat with a utensil or eat soup with full spoon, to shake hands or open a door, to use a telephone at the ear level, to write/ type or play the piano, to use and remove object from their back pocket, to manage toileting, and to wash the armpit and the back of the opposite shoulder. All these activities should be performed without the help of flexing the neck or bending the trunk and without the help of first abducting the elbow (ie, without doing a Hornblower sign). Each activity is scored as 0 = unable to do, 1 = very difficult to do, 2 = somewhat difficult to do, 3 = not difficult at all. The total score is 36 points (Table II). Patient satisfaction and pain relief were assessed on a 0 to 10 and a 0 to 15 visual analog scale, accordingly. The patients’ function and range of motion were clinically assessed by independent observers. A goniometer was used to measure range of motion in forward elevation, abduction, ER, and IR in a
Patient demographics and operative data Diagnosis
Primary/Revision TSA Implant revised
1
F
2
M
3
F
4†
F
5
M
6
F
7†
M
8
F
9
F
10
F
11
F
12†
F
13
F
14
F
15
F
16
F
17
F
18
F
19
M
Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Rheumatoid arthritis Rheumatoid arthritis Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Rheumatoid arthritis Rheumatoid arthritis Cuff arthropathy Fracture sequela Fracture sequela Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Rheumatoid arthritis Rheumatoid arthritis Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Failed RCR Failed RCR Rheumatoid arthritis Rheumatoid arthritis Osteoarthritis Osteoarthritis Cuff arthropathy Cuff arthropathy
Primary Revision Primary Primary Revision Primary Primary Primary Primary Primary Primary Primary Primary Primary Primary Primary Revision Primary Primary Revision Primary Revision Primary Primary Primary Primary Primary Primary Primary Primary Primary Primary Revision Revision Primary Primary Primary Primary
74 76 77 77 78 80 78 80 67 68 86 89 64 67 75 76 66 68 78 78 80 81 80 81 68 72 74 75 83 85 64 65 65 66 81 81 63 65
Right Left Right Left Left Right Right Left Right Left Right Left Right Left Right Left Right Left Right Left Left Right Left Right Right Left Right Left Right Left Left Right Left Right Right Left Left Right
Implant
Verso* Stemmed hemiarthroplasty (Nottingham)** Stemmed Verso Verso Verso Resurfacing (Copeland)** Verso Verso Verso Verso Verso Verso Verso Verso Verso Verso Verso Verso Stemmed hemiarthroplasty (Nottingham)** Stemmed Verso Verso Verso Stemmed rTSA (Delta)*** Stemmed Verso Verso Resurfacing (Copeland)** Verso Verso Verso Verso Verso Verso Verso Verso Verso Verso Verso Stemmed TSA (Biomodular)** Stemmed Verso Resurfacing (Copeland)** Verso Verso Verso Verso Verso
FU Time between ops sides (mo) (mo) 60 44 60 53 67 42 49 27 66 59 69 30 44 27 70 57 71 43 68 59 54 41 44 40 75 30 61 57 56 30 52 33 44 32 28 24 48 24
16 6 24 26 7 39 30 13 28 8 12 3 46 4 25 19 12 3 24
F, female; FU, follow-up M, male, RCR, rotator cuff repair; rTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty. * Innovative Design Orthopaedics, London, UK; ** Biomet, Warsaw, IN, USA; *** Depuy, Warsaw, IN, USA. † Deceased.
ARTICLE IN PRESS
Patient Sex Age at surgery Side (y)
Bilateral reverse total shoulder arthroplasty outcome
Table I
3
4
Table II
Activities of daily living external and internal rotations (ADLEIR) scores* Shave/ apply make up
Brush teeth
Dress without help
Fill glass from full bottle
Drink with full glass
Eat soup with full spoon
Shake hand/open door
Use phone
Write/ play piano
Remove object from back pocket
Wash back opposite shoulder
Total ADLEIR score
1
3 2 3 3 2 2 3 3 3 3 2 2 3 3 3 3 3 3 3 0 3 3 3 3 1 3 3 3 1 1 3 3 3 3 3 3 3 3 3 3
3 1 3 3 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 1 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 3 3 3 2 2 3 3 3 3 2 2 3 3 3 3 3 3 3 1 3 3 3 3 3 3 3 3 2 2 3 3 3 3 3 3 3 3 3 3
2 1 3 3 1 1 3 3 3 3 2 2 3 3 3 3 3 3 2 1 3 3 3 3 2 3 3 3 3 1 3 3 3 3 3 3 3 3 3 3
3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3
2 1 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 3 3 3 3 2 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3
3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3 3 3 1 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 0 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 0 3 3 1 1 3 3 3 3 2 2 1 2 3 3 3 3 3 3 3 3 3 3 1 3 3 3 1 1 3 3 3 3 3 3 3 2 3 3
3 0 3 3 0 0 2 2 3 3 2 2 1 2 3 3 3 3 3 0 3 3 3 3 1 3 3 3 2 2 3 3 3 3 3 3 3 3 2 3
34 18 36 36 26 26 35 35 36 36 31 30 32 34 36 36 36 36 35 15 36 36 36 36 27 36 36 36 30 26 36 36 36 36 36 36 36 35 33 36
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Mean Median
ADLEIR, Activities of Daily Living External and Internal Rotations. * All these activities should be performed without the help of flexing the neck or bending the trunk and without the help of first abducting the elbow (ie, without doing a Hornblower sign). The points allocated for each activity are 0 = unable to do, 1 = very difficult to do, 2 = somewhat difficult to do, 3 = not difficult at all. The total score is 36 points.
ARTICLE IN PRESS
Comb hair
O. Levy et al.
Patient
ARTICLE IN PRESS Bilateral reverse total shoulder arthroplasty outcome standardized fashion. Video clips of the patients’ function and range of motion were recorded preoperatively and at each follow-up visit for further documentation. Strength of abduction was measured with a hand-held digital dynamometer (IDO Isometer; Innovative Design Orthopaedics).
Radiographic assessment All radiographs were assessed by 2 independent experienced shoulder surgeons. Postoperative radiographic analysis was performed using a true anteroposterior view of the shoulder and axillary view radiographs. A standardized template was used to assess postoperative radiographs for displacement, migration, or subsidence of the implant, appearance of radiolucent lines, osteolysis, or signs of stress shielding. The Nerot-Sirveaux glenoid notching classification38 was assessed as well.
Figure 1 Mean range of motion at last follow-up. ABD, abduction; ER, external rotation; FE, forward elevation; IR, internal rotation.
5
Statistical methods Data were collected prospectively and recorded using a dedicated Access database (Microsoft Corp, Redmond, WA, USA). Improvement, or gain, in functionality (CS), patient satisfaction, Subjective Shoulder Value (SSV16 or Single Assessment Numeric Evaluation47), and the ADLEIR scores was calculated for each patient by comparing the latest observed postoperative value to the corresponding preoperative value, and the significance of the difference was tested using the paired t test. Improvement over time in the CS was assessed preoperatively, immediate postoperatively, at 3 weeks, at 3, 6, 9, and 12 months, and annually thereafter using all clinical data. Statistical analysis was performed with SAS 8.2 software (SAS Institute Inc., Cary, NC, USA).
Results The mean duration between the staged operations was 18.2 months (range, 3-46 months). The average CS improved from 18.7 points (range 2-38 points) to 65.1 points (range 3484.3 points). The age- and sex-adjusted CS improved to 100.2 at the last follow-up (Table III). Active elevation improved from 58° to 143° (median, 150°; range, 40°-180°), and 37 shoulders had elevation >90°. Active abduction improved from 60° to 130° (median, 120°; range, 40°-180°), and 35 shoulders had abduction >90°. Active IR (AIR) improved from 9° to 81° (median, 80°; range, 45°90°), and 30 shoulders could reach above the sacroiliac joint. AER improved from 20° to 32° (median, 30°; range, 0°70°), 35 shoulders had >20° ER in adduction, and 31 shoulders had full ER in elevation. Each gain was statistically significant (P < .001; Figs. 1, 2, and 3 and Table IV). The SSV improved from 2.1 of 10 to 9.2 of 10 (P < .001). The mean ADLEIR score at the last follow-up was 33 of 36
Figure 2 The range of motion for all the patients and all the shoulders. ABD, abduction; ER, external rotation; FE, forward elevation; IR, internal rotation.
ARTICLE IN PRESS 6
O. Levy et al. Table III
Follow-up Constant scores and Subjective Shoulder Value scores
Patient
Pain
ADL
ROM
Strength (lb)
Total CS
Age at FU (y)
Age-/sex-adjusted CS
SSV
1
15 15 15 15 15 15 15 12 15 15 15 15 15 15 15 15 9 9 9 5 15 15 15 15 12 15 15 15 15 15 15 13 15 15 15 15 15 15 14 15
20 16 20 20 18 18 18 15 20 20 12 12 16 16 20 20 12 12 17 9 20 20 20 20 11 20 20 20 18 18 20 19 18 20 20 20 20 14 18 20
24 14 40 40 14 14 24 24 40 40 8 8 22 24 28 28 32 32 26 10 40 40 18 18 14 36 40 40 22 20 40 40 20 26 36 36 36 38 28 27
6.92 3.60 9.30 9.28 9.96 8.60 8.12 6.84 6.34 6.42 3.60 2.42 3.94 2.92 6.28 4.56 4.56 2.72 1.72 0 6.90 7.18 3.84 2.80 3.64 10.90 7.00 7.70 3.36 5.54 6.02 7.58 0.44 7.46 8.02 6.18 7.98 6.69 6 6
65.9 48.6 84.3 84.3 57.0 55.6 65.1 57.8 81.3 81.4 38.6 37.4 56.9 57.9 69.3 67.6 57.6 55.7 53.7 24.0 81.9 82.2 56.8 55.8 40.6 81.9 82.0 82.7 58.4 58.5 81.0 79.6 53.4 68.5 79.0 77.2 79.0 73.7 65 66
78 78 80 80 82 82 80 80 71 71 90 90 67 67 79 79 70 70 82 82 83 83 82 82 72 72 79 79 86 86 69 69 69 69 83 83 67 67 77 79
101.5 79.7 118.9 118.8 93.4 91.2 100.3 89.1 114.7 114.8 82.6 80.1 72.3 73.6 106.7 104.0 87.5 84.7 88.1 39.4 134.3 134.8 93.2 91.5 62.6 126.1 126.3 127.4 95.7 96.0 123.2 121.0 81.2 104.1 129.6 126.6 100.3 93.6 100.2 98
10 10 10 10 10 10 10 9 10 10 6 6 10 10 9 9 8 8 8 8 10 10 10 10 5 10 10 10 8 8 10 10 10 10 10 10 10 8 9.2 10
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Mean Median
ADL, activities of daily living; CS, Constant score; FU, follow-up; ROM, range of motion; SSV, Subjective Shoulder Value.
(34 of 36 on right shoulder and 32 of 36 on the left shoulder; Table II). All patients retained independence with personal hygiene and were able to perform perineal hygiene after their rTSAs. Most patients had no limitation in any of the ADLs, including to comb their hair, to shave (men) or apply make-up (women), to brush teeth, to dress without help, to fill a glass from a full bottle, to drink with a full glass, to use their hand to eat with a utensil or to eat soup with full spoon, to shake hands or open a door, to use a telephone at the ear level, to write/type or play piano, to use and remove an object from their back pocket, to wash the armpit and the back of the opposite shoulder, and to
manage toileting (Table II). Most patients resumed their other activities without limitations, including their leisure activities such as gardening, golf, swimming, and bowling.
Complications There were no intraoperative complications. Late traumatic fracture of the scapular spine occurred in patients 13 and 10 after a fall on the tip of the shoulder on one side. The fracture occurred 2 months postoperatively in patient 13, and she was operated on with plating of the spine of the scapula and the acromion. She made a moderate recovery, with almost
ARTICLE IN PRESS Bilateral reverse total shoulder arthroplasty outcome Table IV
7
Range of motion
Patient
FE (°)
ABD (°)
ER in elevation
ER in ADD (°)
IR in ABD (°)
IR HBB
ER points (/10)
IR HBB points (/10)
1
160 90 180 180 120 120 150 150 180 180 90 90 120 120 150 140 180 180 130 40 180 180 120 120 90 180 180 180 100 100 180 180 90 150 160 160 170 170 143 150
130 90 180 180 90 90 90 90 180 180 90 90 120 120 90 90 180 180 90 40 180 180 90 90 80 180 180 180 100 100 180 180 80 120 160 160 160 160 130 120
Full elevation Behind head, elbow FWD Above head, elbow back Full elevation Above head, elbow FWD Above head, elbow FWD Above head, elbow back Above head, elbow back Full elevation Full elevation Nil Nil Above head, elbow back Above head, elbow back Behind head, elbow back Behind head, elbow back Full elevation Full elevation Above head, elbow back Nil Full elevation Full elevation Behind head, elbow back Behind head, elbow back Above head, elbow FWD Full elevation Full elevation Full elevation Above head, elbow back Above head, elbow back Full elevation Full elevation Above head, elbow back Above head, elbow back Full elevation Full elevation Full elevation Full elevation
60 20 40 30 30 30 10 0 50 50 20 20 30 30 30 30 50 50 30 0 30 30 20 30 30 30 30 30 70 70 30 45 30 40 20 20 20 20 32 30
80 70 90 90 80 80 80 70 90 90 45 45 90 90 90 80 90 80 90 90 90 90 90 80 50 80 90 90 80 80 90 90 80 80 80 80 80 80 81 80
SI joint SI joint T10 T10 Buttock Buttock SI joint SI joint T10 T10 Buttock Buttock Buttock SI joint Waist Waist Buttock Buttock Waist Waist T6 T6 SI joint SI joint SI joint T6 T6 T6 SI joint Buttock T6 T7 SI joint SI joint Waist Waist T10 T10
10 8 10 10 2 2 8 8 10 10 0 0 8 8 6 6 10 10 8 0 10 10 4 4 2 10 10 10 4 4 10 10 8 8 10 10 10 10 7.3 8
4 4 10 10 2 2 4 4 10 10 2 2 2 4 6 6 2 2 6 6 10 10 4 4 4 10 10 10 4 2 10 10 4 4 6 6 8 8 6 5
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Mean Median
ABD, abduction; ADD, adduction; ER, external rotation; FE, forward elevation; FWD, forward; HBB, hand behind the back; IR, internal rotation; SI, sacroiliac; T, thoracic vertebrae.
no pain but limited function (final raw CS, 40.6). The scapular spine fracture in patient 10 occurred 8 years after rTSA. She declined any further surgery because of comorbidities (final raw CS, 24.0).
Radiographic analysis The postoperative radiographic analysis showed no radiolucencies around the humeral or glenoid components at the latest follow-up. There were no cases of prosthetic humeral or glenoid migration, change in position over time, or loosen-
ing of the short metaphyseal reverse humeral and the glenoid components. There was no subsidence of the prostheses and no evidence of proximal resorption of bone around the short humeral implant to suggest stress shielding. In 2 patients who underwent revision of stemmed prostheses to stemmed Verso implant with massive allograft, some resorption of the allograft was observed but without loosening or subsidence of the prosthesis. No glenoid notching was observed in 35 shoulders. Patient 5 showed Nerot-Sirveaux grade 2 glenoid notching on both shoulders, without affecting the excellent clinical results.
ARTICLE IN PRESS 8 Patient 13, with the scapular spine fracture, showed grade 3 glenoid notching.
Discussion Concerns have been raised regarding performing bilateral rTSA over introducing rotational deficit bilaterally and resultant difficulties with ADLs.7,32,45,46 Our null hypothesis was that bilateral rTSA would cause lack of rotational movements bilaterally and resultant difficulties with ADLs. Our study indicates improvements in all the movements. Flexion improved from 58° to 143°, with 37 shoulders having elevation above 90° that allowed use the arm above shoulder level; abduction improved from 60° to 130°, with 35 shoulders having abduction above 90°. AER improved to 32°. In 35 shoulders, ER in adduction was >20°, and 31 shoulders had full ER in elevation, and the patients could reach easily behind their head and neck. AIR improved from 9° to 81°, and 30 shoulders could reach above the sacroiliac joint. Each gain was statistically significant (P < .001; Fig. 3). The minimal functional range of movement necessary for performing ADLs remains undetermined. Namdari et al31 attempted to define the average shoulder range of motion necessary to perform functional tasks of daily living in healthy volunteers.31 They determined that less than full range of motion is adequate to perform many functional tasks. The average range of motion measurements reported to perform these tasks were 121° of elevation, 46° of extension, 128° of abduction, 116° of cross-body adduction, 59° of ER with the
O. Levy et al. arm abducted to 90°, and 102° of IR with the arm at the side. However, they did not examine ER with the arm beside the body or IR with hand behind the back. Looking at the data presented in the tables in their article, the mean functional range of motion in normal shoulders in healthy volunteers are ER of 36.5° and IR of 93.6°.31 The ranges of movements in our study correspond favorably with the measurements of Namdari et al. Furthermore, the various shoulder functional scores significantly improved. We have used several validated functional score: the Constant Score,10 the SSV,16 and the ADLEIR score (modified ADLER score6). The changes in the Constant score (from 18.7 to 65.1 points; age- and sex-adjusted CS improved to 100.2), the SSV (from 2.1 to 9.2 of 10), and ADLEIR score (to 33 of 36; 34 on the right and 32 on the left) were all statistically significant (P < .001). By definition, improvements in these scores indicate patients’ increased ability to return to their previous lifestyles and perform ADLs. This result was further supported by patients’ reported activities and their ability to return to leisure activities, including gardening, bowling, swimming, and golf. Boileau et al6 described the ADLER score to assess functional AER, by asking the patients how easily they could perform ADL tasks that involve ER for their performance. We modified this score to include IR aspects as well. We added 2 questions regarding AIR and reaching with the hand behind the back: can the patient take an object from the opposite back pocket (to assess ability to reach for perineal hygiene and able to tuck shirt in), and how well can the patient wash the back of the opposite shoulder.
Figure 3 Radiographic outcomes and range of motion are shown for an 84-year-old woman at 4 years after left primary Verso (Innovative Design Orthopaedics, London, UK; formerly Biomet, Swindon, UK) reverse total shoulder arthroplasty and 3 years after right revision from resurfacing to Verso reverse total shoulder arthroplasty.
ARTICLE IN PRESS Bilateral reverse total shoulder arthroplasty outcome Questions concerning the validity of bilateral rTSA procedures have been examined in a small selection of articles.29,40,41,46 One of the first case reports was by Ueblacker et al,41 which recounted the results of 1 patient with severe syringomyelia who underwent bilateral rTSA. Satisfactory results were obtained: the patient’s IR substantially improved in addition to regaining the ability to perform perineal care. Recent studies have examined the outcomes of bilateral rTSA in case series.29,40,46 Wiater et al46 reported in a case series of 16 patients that although significant improvements occurred in several patient-reported outcome scores and pain, there were no significant improvements in AER or AIR. Stevens et al40 reported results of a series of staged bilateral rTSAs in 15 patients with the diagnosis of CTA. They reported 121° of elevation and 29° of ER but did not report a value for IR. They found no improvement of AER for the first shoulder and even 15° decreased AER for the second shoulder. Although 80% of the patients could perform perineal care with at least 1 shoulder, 26% (1 in 4) found it very difficult or were unable to remove an object from their back pocket. Recently, Morris et al29 reported the results of bilateral rTSAs in a series of 11 patients presenting with CTA. They reported a significant improvement in shoulder function scores and mobility (except IR) with an elevation of 130° and ER of 28°. In their study, 82% after the first rTSA and 63.6% after the second rTSA achieved more than 121° of flexion, but no patients achieved more than 59° of ER. After comparing outcomes between shoulders, Wiater et al46 concluded that the first shoulder offered more benefit to the patient than the second shoulder.
9 Our study confirms consistent significant improvements in function and range of motions in active elevation, abduction, AER, and AIR. Our study confirms as well no difference between the first and second sides, similar to both Morris et al29 and Stevens et al.40 The right dominant side was slightly better in our series, but without statistical significance (Fig. 4). The reason for the differential between studies is unclear, although differences in implant design, surgical approach and technique, integrity of the posterior rotator cuff, repair of the subscapularis, postoperative rehabilitation, and patient demand may all play a role. The implant design may have an effect on the range of motion and function achieved. The type of prosthesis used, whether LCOR or medialized (MCOR) from the glenoid, the amount of lateralization, and the humeral component inclination (neck-shaft) angle differ among the different prostheses and may affect the scapular impingement, range of movement, and function. Furthermore, as the rTSA hinges around the center of rotation in the glenosphere (unlike the anatomic TSA that spins around its center of rotation), the degree of retroversion used to insert the humeral component determines the range of free ER and IR before abutment of the humeral bearing on the inferior neck of the glenoid, anterior and posterior respectively, occurs. Stephenson et al39 showed that as retroversion was increased, the relative amount of ER increased and IR decreased. Maximum ER at 0° abduction was −1° ± 4° at 20° anteversion, 15° ± 3° at neutral, 28° ± 4° at 20° retroversion, and 44° ± 5° at 40° retroversion (P < .05). Maximum IR at 0° abduction was 128° ± 9° at 20° anteversion, 112° ± 9° at neutral, 99° ± 8° at 20° retroversion, and 83° ± 8° at 40°
Figure 4 Comparison of range of motion (ROM), Constant score (CS), and Subjective Shoulder Value (SSV) between the right and the left shoulders. ABD, abduction; ADD, adduction; ADL, activities of daily living; ADLEIR, Activities of Daily Living External and Internal Rotations; ER, external rotation; FE, forward elevation; HBB, hand behind the back; IR, internal rotation; ROM, range of motion.
ARTICLE IN PRESS 10 retroversion (P < .05). They concluded that the optimal retroversion for the reverse shoulder humeral component is between 20° and 40° of retroversion, which more closely restores a functional arc of motion without impingement.39 In the Stevens et al40 series, 4 different types of rTSA prostheses were used, with a mix of LCOR and MCOR, cemented and press-fit humeral stems. The Wiater et al46 series included 3 different types of rTSA prostheses with a mix of LCOR and MCOR implants. Morris et al29 used 1 type of MCOR implant with inclination (neck-shaft) angle of 155°. We used the same Verso implant in all of the procedures. This implant has +3-mm LCOR from the glenoid face incorporated in the glenosphere. The humeral inclination (neckshaft) angle cut is of 155°. This was performed in 30° retroversion in all the shoulders. The humeral shell component was inserted in 30° of retroversion in all the shoulders. However, this implant has a 10° angled dialable polyethylene liner that changes the final humeral component inclination angle to 145° and allows for final fine adjustment of the optimal version in each patient to achieve the optimal arc of rotations. That these design features are partly responsible for the improved function and range of movements in our series is possible. This may be the reason, as well, for very low degree of glenoid notching observed in our series. All procedures but one were performed using the anterosuperior approach, preserving the good function of the anterior and posterior fibers of the deltoid muscle. Although the posteriorinferior rotator cuff and the subscapularis were absent in almost all shoulders, the surgeon always attempted to approximate and repair any existing remnant of the teres minor and the subscapularis attempting to balance the remnant tissues. The postoperative rehabilitation and patient compliance, may also have contributed to the good outcome. The timing of each respective procedure has also come into question when examining bilateral rTSA. Gerber et al14 and Gruson et al17 both analyzed the results of bilateral anatomic TSAs (only 1 bilateral rTSA in the Gerber et al series) performed in a single-stage vs. staged fashion. Gerber et al14 indicated better results when both procedures were performed simultaneously, whereas Gruson et al17 advocated for staged procedures to allow for appropriate tissue healing and rehabilitation between the 2 sides. In reviewing other case series in the literature for bilateral rTSA, all of the authors recommend a staged approach. The mean interval reported between procedures was 13.7 months in the Wiater et al46 study, 21.6 months in the Stevens et al40 study, and 8.0 months in the Morris et al29 study. Our study indicates similar results with a mean duration of 18.2 months between shoulders (range, 3-46 months). The minimal interval in our study is 3 months, but in our view, this can be shortened to 6 weeks if the patient shows quick recovery. Our study has several limitations. The sample size was relatively small, and there is some heterogeneity in the preoperative patient diagnoses. However, this heterogeneity
O. Levy et al. does not overshadow the functional achievement in the ability to perform ADLs. In addition, the variation of diagnoses allowed for a larger series and more significant data. The strengths of this study are that all cases were performed at a single, high-volume shoulder arthroplasty center by a single surgeon. The same implant was used in all patients with the same surgical technique, the same retroversion, and also the same rehabilitation protocol. The follow-up used validated shoulder outcome scores and no patient was lost to follow-up at mean of 48.4 months (100% follow-up). Questions about whether these results are dependent on implant design or surgical technique remain open.
Conclusion Bilateral rTSA results in marked and predictable improvement in all movements, pain relief, and functional outcomes, with high patient satisfaction and a high ADLEIR score. All patients were able to perform perineal hygiene after their rTSA. Most patients had no limitation in ADLs or in their leisure activities.
Disclaimer Ofer Levy receives equity and royalties from Innovative Design Orthopaedics (IDO) as designing surgeon. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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ARTICLE IN PRESS Bilateral reverse total shoulder arthroplasty outcome 7. Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. Neer Award 2005: the Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg 2006;15:527-40. http://dx.doi.org/10.1016/j.jse.2006.01.003 8. Boyle MJ, Youn SM, Frampton CM, Ball CM. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. J Shoulder Elbow Surg 2013;22:32-7. http://dx.doi.org/10.1016/j.jse.2012.03.006 9. Bufquin T, Hersan A, Hubert L, Massin P. Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up. J Bone Joint Surg Br 2007;89:516-20. http://dx.doi.org/ 10.1302/0301-620X.89B4.18435 10. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;214:160-4. 11. Cuff D, Pupello D, Virani N, Levy J, Frankle M. Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency. J Bone Joint Surg Am 2008;90:1244-51. http://dx.doi.org/10.2106/JBJS.G.00775 12. Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M. The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am 2005;87:1697-705. http://dx.doi.org/10.2106/JBJS.D.02813 13. Gallo RA, Gamradt SC, Mattern CJ, Cordasco FA, Craig EV, Dines DM, et al. Instability after reverse total shoulder replacement. J Shoulder Elbow Surg 2011;20:584-90. http://dx.doi.org/10.1016/j.jse.2010.08.028 14. Gerber C, Lingenfelter EJ, Reischl N, Sukthankar A. Single-stage bilateral total shoulder arthroplasty: a preliminary study. J Bone Joint Surg Br 2006;88:751-5. http://dx.doi.org/10.1302/0301-620x.88b6.17601 15. Gerber C, Pennington SD, Nyffeler RW. Reverse total shoulder arthroplasty. J Am Acad Orthop Surg 2009;17:284-95. 16. Gilbart MK, Gerber C. Comparison of the subjective shoulder value and the Constant score. J Shoulder Elbow Surg 2007;16:717-21. http://dx.doi.org/10.1016/j.jse.2007.02.123 17. Gruson KI, Pillai G, Vanadurongwan B, Parsons BO, Flatow EL. Early clinical results following staged bilateral primary total shoulder arthroplasty. J Shoulder Elbow Surg 2010;19:137-42. http://dx.doi.org/ 10.1016/j.jse.2009.04.005 18. Holcomb JO, Hebert DJ, Mighell MA, Dunning PE, Pupello DR, Pliner MD, et al. Reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Shoulder Elbow Surg 2010;19:1076-84. http://dx.doi.org/ 10.1016/j.jse.2009.11.049 19. Kilic M, Berth A, Blatter G, Fuhrmann U, Gebhardt K, Rott O, et al. Anatomic and reverse shoulder prostheses in fracture sequelae of the humeral head. Acta Orthop Traumatol Turc 2010;44:417-25. http://dx.doi.org/10.3944/aott.2010.2272 20. Klein SM, Dunning P, Mulieri P, Pupello D, Downes K, Frankle MA. Effects of acquired glenoid bone defects on surgical technique and clinical outcomes in reverse shoulder arthroplasty. J Bone Joint Surg Am 2010;92:1144-54. http://dx.doi.org/10.2106/JBJS.I.00778 21. Langer JS, Sueoka SS, Wang AA. The importance of shoulder external rotation in activities of daily living: improving outcomes in traumatic brachial plexus palsy. J Hand Surg Am 2012;37:1430-6. http://dx.doi.org/ 10.1016/j.jhsa.2012.04.011 22. Latif V, Denard PJ, Young AA, Liotard JP, Walch G. Bilateral anatomic total shoulder arthroplasty versus reverse shoulder arthroplasty. Orthopedics 2012;35:e479-85. http://dx.doi.org/10.3928/01477447 -20120327-25 23. Lenarz C, Shishani Y, McCrum C, Nowinski RJ, Edwards TB, Gobezie R. Is reverse shoulder arthroplasty appropriate for the treatment of fractures in the older patient? Early observations. Clin Orthop Relat Res 2011;469:3324-31. http://dx.doi.org/10.1007/s11999-011 -2055-z 24. Levy J, Frankle M, Mighell M, Pupello D. The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture. J Bone Joint Surg Am 2007;89:292-300. http://dx.doi.org/10.2106/jbjs.e.01310
11 25. Levy O, Narvani A, Hous N, Abraham R, Relwani J, Pradhan R, et al. Reverse shoulder arthroplasty with a cementless short metaphyseal humeral implant without a stem: clinical and radiologic outcomes in prospective 2- to 7-year follow-up study. J Shoulder Elbow Surg 2016;25:1362-70. http://dx.doi.org/10.1016/j.jse.2015.12.017 26. Macaulay W, Salvati EA, Sculco TP, Pellicci PM. Single-stage bilateral total hip arthroplasty. J Am Acad Orthop Surg 2002;10:217-21. 27. Mackenzie DB. The antero-superior exposure for total shoulder replacement. Orthop Traumatol 1993;2:71-7. 28. Martinez AA, Calvo A, Bejarano C, Carbonel I, Herrera A. The use of the Lima reverse shoulder arthroplasty for the treatment of fracture sequelae of the proximal humerus. J Orthop Sci 2012;17:141-7. http://dx.doi.org/10.1007/s00776-011-0185-5 29. Morris BJ, Haigler RE, O’Connor DP, Elkousy HA, Gartsman GM, Edwards TB. Outcomes of staged bilateral reverse shoulder arthroplasties for rotator cuff tear arthropathy. J Shoulder Elbow Surg 2015;24:474-81. http://dx.doi.org/10.1016/j.jse.2014.08.008 30. Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am 2010;92:2544-56. http://dx.doi.org/10.2106/JBJS.I.00912 31. Namdari S, Yagnik G, Ebaugh DD, Nagda S, Ramsey ML, Williams GR Jr, et al. Defining functional shoulder range of motion for activities of daily living. J Shoulder Elbow Surg 2012;21:1177-83. http://dx.doi.org/10.1016/j.jse.2011.07.032 32. Nolan BM, Ankerson E, Wiater JM. Reverse total shoulder arthroplasty improves function in cuff tear arthropathy. Clin Orthop Relat Res 2011;469:2476-82. http://dx.doi.org/10.1007/s11999-010-1683-z 33. Parvizi J, Tarity TD, Herz A, Klein GR, Sharkey PF, Hozack WJ, et al. Ninety-day mortality after bilateral hip arthroplasty. J Arthroplasty 2006;21:931-4. http://dx.doi.org/10.1016/j.arth.2006.02.080 34. Patel DN, Young B, Onyekwelu I, Zuckerman JD, Kwon YW. Reverse total shoulder arthroplasty for failed shoulder arthroplasty. J Shoulder Elbow Surg 2012;21:1478-83. http://dx.doi.org/10.1016/j.jse.2011.11.004 35. Raiss P, Rettig O, Wolf S, Loew M, Kasten P. [Range of motion of shoulder and elbow in activities of daily life in 3D motion analysis]. Z Orthop Unfall 2007;145:493-8. http://dx.doi.org/10.1055/s-2007-965468 36. Restrepo C, Parvizi J, Dietrich T, Einhorn TA. Safety of simultaneous bilateral total knee arthroplasty. A meta-analysis. J Bone Joint Surg Am 2007;89:1220-6. http://dx.doi.org/10.2106/jbjs.f.01353 37. Sirveaux F, Molé D. Failures of the reverse prosthesis: identifying the problems. In: Cofield RH, Sperling JW, editor. Revision and complex shoulder arthroplasty. Philadelphia, PA: Lippincott, Williams & Wilkins; 2010. p. 18-28. 38. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. Results of a multicentre study of 80 shoulders. J Bone Joint Surg Br 2004;86:388-95. http://dx.doi.org/10.1302/0301-620X.86B3.14024 39. Stephenson DR, Oh JH, McGarry MH, Rick Hatch GF 3rd, Lee TQ. Effect of humeral component version on impingement in reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2011;20:652-8. http://dx.doi.org/10.1016/j.jse.2010.08.020 40. Stevens CG, Struk AM, Wright TW. The functional impact of bilateral reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2014;23:13418. http://dx.doi.org/10.1016/j.jse.2013.12.012 41. Ueblacker P, Ansah P, Vogt S, Imhoff AB. Bilateral reverse shoulder prosthesis in a patient with severe syringomyelia. J Shoulder Elbow Surg 2007;16:e48-51. http://dx.doi.org/10.1016/j.jse.2006.12.003 42. Walch G, Bacle G, Lädermann A, Nové-Josserand L, Smithers CJ. Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeon’s experience? J Shoulder Elbow Surg 2012;21:1470-7. http://dx.doi.org/10.1016/j.jse.2011.11.010 43. Walker M, Willis MP, Brooks JP, Pupello D, Mulieri PJ, Frankle MA. The use of the reverse shoulder arthroplasty for treatment of failed total shoulder arthroplasty. J Shoulder Elbow Surg 2012;21:514-22. http://dx.doi.org/10.1016/j.jse.2011.03.006
ARTICLE IN PRESS 12 44. Wall B, Nové-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am 2007;89:1476-85. http://dx.doi.org/ 10.2106/JBJS.F.00666 45. Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am 2005;87:1476-86. http://dx.doi.org/10.2106/JBJS.D.02342 46. Wiater BP, Boone CR, Koueiter DM, Wiater JM. Early outcomes of staged bilateral reverse total shoulder arthroplasty: a case-control study. Bone Joint J 2013;95-b:1232-8. http://dx.doi.org/10.1302/0301-620x .95b9.31445
O. Levy et al. 47. Williams GN, Gangel TJ, Arciero RA, Uhorchak JM, Taylor DC. Comparison of the Single Assessment Numeric Evaluation method and two shoulder rating scales. Outcomes measures after shoulder surgery. Am J Sports Med 1999;27:214-21. 48. Willis M, Min W, Brooks JP, Mulieri P, Walker M, Pupello D, et al. Proximal humeral malunion treated with reverse shoulder arthroplasty. J Shoulder Elbow Surg 2012;21:507-13. http://dx.doi.org/10.1016/ j.jse.2011.01.042 49. Young AA, Smith MM, Bacle G, Moraga C, Walch G. Early results of reverse shoulder arthroplasty in patients with rheumatoid arthritis. J Bone Joint Surg Am 2011;93:1915-23. http://dx.doi.org/10.2106/ jbjs.j.00300
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Bilateral reverse total shoulder arthroplasty—functional outcome and activities of daily living Ofer Levy, MD, MCh(Orth), FRCS*, Joanna Walecka, MD, George Arealis, MD, Oren Tsvieli, MD, Giuseppe Della Rotonda, MD, Ruben Abraham, FRCA, Ioannis Polyzois, MD, Zac Jurkowski, BSc, Ehud Atoun, MD Reading Shoulder Unit, Royal Berkshire Hospital and Berkshire Independent Hospital, Reading, UK Background: Reverse total shoulder arthroplasty (rTSA) has gained popularity in recent years, providing good shoulder elevation, yet less predictable rotations. Good rotations are crucial for performance of activities of daily living (ADLs), including personal hygiene. Concerns remain regarding bilateral rTSA over lack of rotations bilaterally and resultant difficulties with ADLs. This study examined the outcome of patients with bilateral rTSA in restoration of function and ADLs. Methods: Data were prospectively collected for 19 patients (15 women, 4 men; 38 shoulders), with a mean age of 74.5 years, who underwent staged bilateral rTSA between 2007 and 2013. Mean follow-up was 48.4 months (range, 24-75 months). Patients were evaluated clinically using the Constant score, patient’s satisfaction, Subjective Shoulder Value, and the Activities of Daily Living External and Internal Rotations (ADLEIR) score. Video clips were also recorded for documentation at all visits. Results: Mean duration between staged operations was 18.2 months (range, 3-46 months). The Constant score improved from 18.7 to 65.1 points (age- and sex-adjusted, 100.2). Elevation improved from 57.5° to 143°, internal rotation (IR) from 9° to 81° (30 shoulders could reach above the sacroiliac joint), and external rotation (ER) from 20° to 32° (35 shoulders had >20° ER in adduction, 31 shoulders had full ER in elevation). The Subjective Shoulder Value improved from 2.1 of 10 to 9.2 of 10. Mean ADLEIR score was 33 of 36 (P < .001 for all). Most patients resumed their leisure and sport activities (gardening, golf, swimming, bowling). Conclusion: Bilateral rTSA results in marked and predictable improvement in all movements, pain relief, and functional outcomes, with high patient satisfaction and high ADLEIR score. All patients were able to perform perineal hygiene after their rTSA. Most patients had no limitation in ADLs and their leisure activities. Level of evidence: Level IV; Case Series; Treatment Study © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Shoulder; arthroplasty; stemless; replacement; activities; ADL; rotation; function
The Royal Berkshire Hospital Audit and Review Board approved the study (Study No. N3114). *Reprint requests: Ofer Levy, MD, MCh(Orth), FRCS, Reading Shoulder Unit, Royal Berkshire Hospital and Berkshire Independent Hospital, Reading, Berkshire, RG1 6UZ, UK. E-mail address: [email protected] (O. Levy).
Reverse total shoulder arthroplasty (rTSA) has gained in popularity in recent years and has excellent outcomes for a variety of indications9,11-13,15,20,30,32,42-45 such as severe rotator cuff tear arthropathy (CTA), rheumatoid arthritis,18,49 failed arthroplasty,24,34 acute fractures,8,23 and fracture sequela.19,28,48
1058-2746/$ - see front matter © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. http://dx.doi.org/10.1016/j.jse.2016.09.010
ARTICLE IN PRESS 2 rTSA provides good range of shoulder elevation; however, restoration of active rotational movements is less predictable and has been unreliable in past series.1,44 Good rotational movements are obligatory for performance of activities of daily living (ADLs), internal rotation (IR) for activities regarding perineal and self-hygiene,21,31,35 and external rotation (ER) for reaching with the hand to the mouth and head (for eating, drinking, and combing the hair).21 The capability of performing these ADLs provides independence for many of these usually elderly patients.45 Werner et al45 found that active ER (AER) did not improve but actually decreased by a mean of 5°, particularly in elevation and abduction. The loss of AER was also observed by Baulot et al.4 Therefore, concerns remain regarding performing bilateral rTSA because of the lack of rotational movements bilaterally and the resultant difficulties with ADLs. Several authors have recommended caution with bilateral rTSA.7,32,45,46 Some even suggested performing rTSA on one side to achieve good elevation and an anatomic prosthesis on the other side to compensate and have good rotational movements but without good elevation. Bilateral rTSA is indicated in the case of bilateral CTA. Osteoarthritis and inflammatory arthritis often occur bilaterally, requiring arthroplasty treatment of both shoulders.14 Conversely, bilateral rTSA as a surgical treatment for bilateral, symptomatic CTA has been reported to produce unfavorable outcomes with respect to patient quality of life. Difficulties with IR and ER and the associated infringement on ADLs, specifically the inability to perform perineal care associated with toileting and bathing, have made surgeons reluctant to perform the procedure.35,37 The use of bilateral arthroplasty has proven successful in several other orthopedic procedures. Procedure outcomes in bilateral total hip arthroplasty5,26,33 and bilateral total knee arthroplasty3,36 have both been extensively reviewed. Although a few studies have examined bilateral shoulder arthroplasty, most reports have focused on bilateral anatomic TSA14,17 or a combination of TSA and rTSA.22 The number of reports examining bilateral rTSA is even more limited.29,40,41,46 This study examined the clinical and radiographic outcomes of patients with bilateral rTSA in restoration of function and their ability to resume ADLs and more. Our null hypothesis was that bilateral rTSA would cause lack of rotational movements bilaterally and resultant difficulties with ADLs.
Materials and methods Review of the prospectively collected data revealed 19 patients (38 shoulders) who underwent staged bilateral rTSA at our institution between 2007 and 2013, with a minimum of 2 years of followup after the second operation. There were 15 women and 4 men, the mean age at surgery was 74.5 years (range, 63-90 years), and the mean follow-up was 48.4 months (range, 24-75 months). The indications for surgery were CTA in 13 patients (one side was fracture sequela in 2 patients), after failed rotator cuff repairs of massive
O. Levy et al. cuff tears in 1, osteoarthritis in 1, and rheumatoid arthritis in 4. In 6 patients the rTSA was performed as revision arthroplasty. In 5 patients, one side was operated on as revision arthroplasty, and 1 patient with rheumatoid arthritis underwent bilateral revision arthroplasties (Table I). All cases were performed at a high-volume shoulder arthroplasty center by a single surgeon (O.L.). All of the primary procedures and all but 1 of the revisions were performed through the Neviaser-MacKenzie anterosuperior approach. 27 Only 1 revision of a well-fixed stemmed TSA (Biomodular; Biomet, Warsaw, IN, USA) to a stemmed Verso rTSA (Innovative Design Orthopaedics, London, UK; formerly Biomet, Swindon, UK) was performed through the deltopectoral approach to allow performing humeral window osteotomy for removal of the stem. The same Verso implant was used in all procedures. In all the primary cases and in 3 of the revisions, the stemless metaphyseal prosthesis was used. In 4 revision cases of failed stemmed arthroplasty the Stemmed Verso implant was used. A humeral cut of 155° in 30° retroversion was performed in all shoulders, and the humeral component was inserted in 30° of retroversion. However, this implant has a 10° angled dialable polyethylene liner that changes the angle of the humeral component to 145° and allows for final fine adjustment of the optimal version in each patient to achieve the optimal arc of rotations.2,25 The implant has a +3-mm lateralized center of rotation (LCOR) from the glenoid face incorporated in the glenosphere.2,25 The posteroinferior rotator cuff was absent in 36 shoulders; however, the surgeon always attempted to approximate any existing remnant of the teres minor. The teres minor was present in 2 shoulders operated on for osteoarthritis. A standardized postoperative rehabilitation protocol was followed in all patients. Patients were evaluated clinically and radiographically preoperatively and postoperatively at 3 weeks, 3 months, 6 months, 1 year, and yearly thereafter. Three patients died of unrelated causes more than 2 years after the last operation, so their last follow-up data were considered. Shoulder function was assessed using the Constant score (CS),10 patient’s satisfaction score, Subjective Shoulder Value (SSV),16 or Single Assessment Numeric Evaluation (SANE),47 and the Activities of Daily Living External and Internal Rotations score (ADLIER) score, which was modified from the ADLER (Activities of Daily Living Requiring External Rotation) score.6 The ADLEIR score questionnaire assesses 12 different activities that represent ADLs such as to comb the hair, to shave (men) or apply make-up (women), to brush teeth, to dress without help, to fill a glass from a full bottle, to drink with a full glass, to use their hand to eat with a utensil or eat soup with full spoon, to shake hands or open a door, to use a telephone at the ear level, to write/ type or play the piano, to use and remove object from their back pocket, to manage toileting, and to wash the armpit and the back of the opposite shoulder. All these activities should be performed without the help of flexing the neck or bending the trunk and without the help of first abducting the elbow (ie, without doing a Hornblower sign). Each activity is scored as 0 = unable to do, 1 = very difficult to do, 2 = somewhat difficult to do, 3 = not difficult at all. The total score is 36 points (Table II). Patient satisfaction and pain relief were assessed on a 0 to 10 and a 0 to 15 visual analog scale, accordingly. The patients’ function and range of motion were clinically assessed by independent observers. A goniometer was used to measure range of motion in forward elevation, abduction, ER, and IR in a
Patient demographics and operative data Diagnosis
Primary/Revision TSA Implant revised
1
F
2
M
3
F
4†
F
5
M
6
F
7†
M
8
F
9
F
10
F
11
F
12†
F
13
F
14
F
15
F
16
F
17
F
18
F
19
M
Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Rheumatoid arthritis Rheumatoid arthritis Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Rheumatoid arthritis Rheumatoid arthritis Cuff arthropathy Fracture sequela Fracture sequela Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Rheumatoid arthritis Rheumatoid arthritis Cuff arthropathy Cuff arthropathy Cuff arthropathy Cuff arthropathy Failed RCR Failed RCR Rheumatoid arthritis Rheumatoid arthritis Osteoarthritis Osteoarthritis Cuff arthropathy Cuff arthropathy
Primary Revision Primary Primary Revision Primary Primary Primary Primary Primary Primary Primary Primary Primary Primary Primary Revision Primary Primary Revision Primary Revision Primary Primary Primary Primary Primary Primary Primary Primary Primary Primary Revision Revision Primary Primary Primary Primary
74 76 77 77 78 80 78 80 67 68 86 89 64 67 75 76 66 68 78 78 80 81 80 81 68 72 74 75 83 85 64 65 65 66 81 81 63 65
Right Left Right Left Left Right Right Left Right Left Right Left Right Left Right Left Right Left Right Left Left Right Left Right Right Left Right Left Right Left Left Right Left Right Right Left Left Right
Implant
Verso* Stemmed hemiarthroplasty (Nottingham)** Stemmed Verso Verso Verso Resurfacing (Copeland)** Verso Verso Verso Verso Verso Verso Verso Verso Verso Verso Verso Verso Stemmed hemiarthroplasty (Nottingham)** Stemmed Verso Verso Verso Stemmed rTSA (Delta)*** Stemmed Verso Verso Resurfacing (Copeland)** Verso Verso Verso Verso Verso Verso Verso Verso Verso Verso Verso Stemmed TSA (Biomodular)** Stemmed Verso Resurfacing (Copeland)** Verso Verso Verso Verso Verso
FU Time between ops sides (mo) (mo) 60 44 60 53 67 42 49 27 66 59 69 30 44 27 70 57 71 43 68 59 54 41 44 40 75 30 61 57 56 30 52 33 44 32 28 24 48 24
16 6 24 26 7 39 30 13 28 8 12 3 46 4 25 19 12 3 24
F, female; FU, follow-up M, male, RCR, rotator cuff repair; rTSA, reverse total shoulder arthroplasty; TSA, total shoulder arthroplasty. * Innovative Design Orthopaedics, London, UK; ** Biomet, Warsaw, IN, USA; *** Depuy, Warsaw, IN, USA. † Deceased.
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Patient Sex Age at surgery Side (y)
Bilateral reverse total shoulder arthroplasty outcome
Table I
3
4
Table II
Activities of daily living external and internal rotations (ADLEIR) scores* Shave/ apply make up
Brush teeth
Dress without help
Fill glass from full bottle
Drink with full glass
Eat soup with full spoon
Shake hand/open door
Use phone
Write/ play piano
Remove object from back pocket
Wash back opposite shoulder
Total ADLEIR score
1
3 2 3 3 2 2 3 3 3 3 2 2 3 3 3 3 3 3 3 0 3 3 3 3 1 3 3 3 1 1 3 3 3 3 3 3 3 3 3 3
3 1 3 3 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 1 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 3 3 3 2 2 3 3 3 3 2 2 3 3 3 3 3 3 3 1 3 3 3 3 3 3 3 3 2 2 3 3 3 3 3 3 3 3 3 3
2 1 3 3 1 1 3 3 3 3 2 2 3 3 3 3 3 3 2 1 3 3 3 3 2 3 3 3 3 1 3 3 3 3 3 3 3 3 3 3
3 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3
2 1 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 3 3 3 3 2 3 3 3 3 2 3 3 3 3 3 3 3 3 3 3
3 3 3 3 3 3 3 3 3 3 3 2 3 3 3 3 3 3 3 1 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 1 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 0 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
3 0 3 3 1 1 3 3 3 3 2 2 1 2 3 3 3 3 3 3 3 3 3 3 1 3 3 3 1 1 3 3 3 3 3 3 3 2 3 3
3 0 3 3 0 0 2 2 3 3 2 2 1 2 3 3 3 3 3 0 3 3 3 3 1 3 3 3 2 2 3 3 3 3 3 3 3 3 2 3
34 18 36 36 26 26 35 35 36 36 31 30 32 34 36 36 36 36 35 15 36 36 36 36 27 36 36 36 30 26 36 36 36 36 36 36 36 35 33 36
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Mean Median
ADLEIR, Activities of Daily Living External and Internal Rotations. * All these activities should be performed without the help of flexing the neck or bending the trunk and without the help of first abducting the elbow (ie, without doing a Hornblower sign). The points allocated for each activity are 0 = unable to do, 1 = very difficult to do, 2 = somewhat difficult to do, 3 = not difficult at all. The total score is 36 points.
ARTICLE IN PRESS
Comb hair
O. Levy et al.
Patient
ARTICLE IN PRESS Bilateral reverse total shoulder arthroplasty outcome standardized fashion. Video clips of the patients’ function and range of motion were recorded preoperatively and at each follow-up visit for further documentation. Strength of abduction was measured with a hand-held digital dynamometer (IDO Isometer; Innovative Design Orthopaedics).
Radiographic assessment All radiographs were assessed by 2 independent experienced shoulder surgeons. Postoperative radiographic analysis was performed using a true anteroposterior view of the shoulder and axillary view radiographs. A standardized template was used to assess postoperative radiographs for displacement, migration, or subsidence of the implant, appearance of radiolucent lines, osteolysis, or signs of stress shielding. The Nerot-Sirveaux glenoid notching classification38 was assessed as well.
Figure 1 Mean range of motion at last follow-up. ABD, abduction; ER, external rotation; FE, forward elevation; IR, internal rotation.
5
Statistical methods Data were collected prospectively and recorded using a dedicated Access database (Microsoft Corp, Redmond, WA, USA). Improvement, or gain, in functionality (CS), patient satisfaction, Subjective Shoulder Value (SSV16 or Single Assessment Numeric Evaluation47), and the ADLEIR scores was calculated for each patient by comparing the latest observed postoperative value to the corresponding preoperative value, and the significance of the difference was tested using the paired t test. Improvement over time in the CS was assessed preoperatively, immediate postoperatively, at 3 weeks, at 3, 6, 9, and 12 months, and annually thereafter using all clinical data. Statistical analysis was performed with SAS 8.2 software (SAS Institute Inc., Cary, NC, USA).
Results The mean duration between the staged operations was 18.2 months (range, 3-46 months). The average CS improved from 18.7 points (range 2-38 points) to 65.1 points (range 3484.3 points). The age- and sex-adjusted CS improved to 100.2 at the last follow-up (Table III). Active elevation improved from 58° to 143° (median, 150°; range, 40°-180°), and 37 shoulders had elevation >90°. Active abduction improved from 60° to 130° (median, 120°; range, 40°-180°), and 35 shoulders had abduction >90°. Active IR (AIR) improved from 9° to 81° (median, 80°; range, 45°90°), and 30 shoulders could reach above the sacroiliac joint. AER improved from 20° to 32° (median, 30°; range, 0°70°), 35 shoulders had >20° ER in adduction, and 31 shoulders had full ER in elevation. Each gain was statistically significant (P < .001; Figs. 1, 2, and 3 and Table IV). The SSV improved from 2.1 of 10 to 9.2 of 10 (P < .001). The mean ADLEIR score at the last follow-up was 33 of 36
Figure 2 The range of motion for all the patients and all the shoulders. ABD, abduction; ER, external rotation; FE, forward elevation; IR, internal rotation.
ARTICLE IN PRESS 6
O. Levy et al. Table III
Follow-up Constant scores and Subjective Shoulder Value scores
Patient
Pain
ADL
ROM
Strength (lb)
Total CS
Age at FU (y)
Age-/sex-adjusted CS
SSV
1
15 15 15 15 15 15 15 12 15 15 15 15 15 15 15 15 9 9 9 5 15 15 15 15 12 15 15 15 15 15 15 13 15 15 15 15 15 15 14 15
20 16 20 20 18 18 18 15 20 20 12 12 16 16 20 20 12 12 17 9 20 20 20 20 11 20 20 20 18 18 20 19 18 20 20 20 20 14 18 20
24 14 40 40 14 14 24 24 40 40 8 8 22 24 28 28 32 32 26 10 40 40 18 18 14 36 40 40 22 20 40 40 20 26 36 36 36 38 28 27
6.92 3.60 9.30 9.28 9.96 8.60 8.12 6.84 6.34 6.42 3.60 2.42 3.94 2.92 6.28 4.56 4.56 2.72 1.72 0 6.90 7.18 3.84 2.80 3.64 10.90 7.00 7.70 3.36 5.54 6.02 7.58 0.44 7.46 8.02 6.18 7.98 6.69 6 6
65.9 48.6 84.3 84.3 57.0 55.6 65.1 57.8 81.3 81.4 38.6 37.4 56.9 57.9 69.3 67.6 57.6 55.7 53.7 24.0 81.9 82.2 56.8 55.8 40.6 81.9 82.0 82.7 58.4 58.5 81.0 79.6 53.4 68.5 79.0 77.2 79.0 73.7 65 66
78 78 80 80 82 82 80 80 71 71 90 90 67 67 79 79 70 70 82 82 83 83 82 82 72 72 79 79 86 86 69 69 69 69 83 83 67 67 77 79
101.5 79.7 118.9 118.8 93.4 91.2 100.3 89.1 114.7 114.8 82.6 80.1 72.3 73.6 106.7 104.0 87.5 84.7 88.1 39.4 134.3 134.8 93.2 91.5 62.6 126.1 126.3 127.4 95.7 96.0 123.2 121.0 81.2 104.1 129.6 126.6 100.3 93.6 100.2 98
10 10 10 10 10 10 10 9 10 10 6 6 10 10 9 9 8 8 8 8 10 10 10 10 5 10 10 10 8 8 10 10 10 10 10 10 10 8 9.2 10
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Mean Median
ADL, activities of daily living; CS, Constant score; FU, follow-up; ROM, range of motion; SSV, Subjective Shoulder Value.
(34 of 36 on right shoulder and 32 of 36 on the left shoulder; Table II). All patients retained independence with personal hygiene and were able to perform perineal hygiene after their rTSAs. Most patients had no limitation in any of the ADLs, including to comb their hair, to shave (men) or apply make-up (women), to brush teeth, to dress without help, to fill a glass from a full bottle, to drink with a full glass, to use their hand to eat with a utensil or to eat soup with full spoon, to shake hands or open a door, to use a telephone at the ear level, to write/type or play piano, to use and remove an object from their back pocket, to wash the armpit and the back of the opposite shoulder, and to
manage toileting (Table II). Most patients resumed their other activities without limitations, including their leisure activities such as gardening, golf, swimming, and bowling.
Complications There were no intraoperative complications. Late traumatic fracture of the scapular spine occurred in patients 13 and 10 after a fall on the tip of the shoulder on one side. The fracture occurred 2 months postoperatively in patient 13, and she was operated on with plating of the spine of the scapula and the acromion. She made a moderate recovery, with almost
ARTICLE IN PRESS Bilateral reverse total shoulder arthroplasty outcome Table IV
7
Range of motion
Patient
FE (°)
ABD (°)
ER in elevation
ER in ADD (°)
IR in ABD (°)
IR HBB
ER points (/10)
IR HBB points (/10)
1
160 90 180 180 120 120 150 150 180 180 90 90 120 120 150 140 180 180 130 40 180 180 120 120 90 180 180 180 100 100 180 180 90 150 160 160 170 170 143 150
130 90 180 180 90 90 90 90 180 180 90 90 120 120 90 90 180 180 90 40 180 180 90 90 80 180 180 180 100 100 180 180 80 120 160 160 160 160 130 120
Full elevation Behind head, elbow FWD Above head, elbow back Full elevation Above head, elbow FWD Above head, elbow FWD Above head, elbow back Above head, elbow back Full elevation Full elevation Nil Nil Above head, elbow back Above head, elbow back Behind head, elbow back Behind head, elbow back Full elevation Full elevation Above head, elbow back Nil Full elevation Full elevation Behind head, elbow back Behind head, elbow back Above head, elbow FWD Full elevation Full elevation Full elevation Above head, elbow back Above head, elbow back Full elevation Full elevation Above head, elbow back Above head, elbow back Full elevation Full elevation Full elevation Full elevation
60 20 40 30 30 30 10 0 50 50 20 20 30 30 30 30 50 50 30 0 30 30 20 30 30 30 30 30 70 70 30 45 30 40 20 20 20 20 32 30
80 70 90 90 80 80 80 70 90 90 45 45 90 90 90 80 90 80 90 90 90 90 90 80 50 80 90 90 80 80 90 90 80 80 80 80 80 80 81 80
SI joint SI joint T10 T10 Buttock Buttock SI joint SI joint T10 T10 Buttock Buttock Buttock SI joint Waist Waist Buttock Buttock Waist Waist T6 T6 SI joint SI joint SI joint T6 T6 T6 SI joint Buttock T6 T7 SI joint SI joint Waist Waist T10 T10
10 8 10 10 2 2 8 8 10 10 0 0 8 8 6 6 10 10 8 0 10 10 4 4 2 10 10 10 4 4 10 10 8 8 10 10 10 10 7.3 8
4 4 10 10 2 2 4 4 10 10 2 2 2 4 6 6 2 2 6 6 10 10 4 4 4 10 10 10 4 2 10 10 4 4 6 6 8 8 6 5
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 Mean Median
ABD, abduction; ADD, adduction; ER, external rotation; FE, forward elevation; FWD, forward; HBB, hand behind the back; IR, internal rotation; SI, sacroiliac; T, thoracic vertebrae.
no pain but limited function (final raw CS, 40.6). The scapular spine fracture in patient 10 occurred 8 years after rTSA. She declined any further surgery because of comorbidities (final raw CS, 24.0).
Radiographic analysis The postoperative radiographic analysis showed no radiolucencies around the humeral or glenoid components at the latest follow-up. There were no cases of prosthetic humeral or glenoid migration, change in position over time, or loosen-
ing of the short metaphyseal reverse humeral and the glenoid components. There was no subsidence of the prostheses and no evidence of proximal resorption of bone around the short humeral implant to suggest stress shielding. In 2 patients who underwent revision of stemmed prostheses to stemmed Verso implant with massive allograft, some resorption of the allograft was observed but without loosening or subsidence of the prosthesis. No glenoid notching was observed in 35 shoulders. Patient 5 showed Nerot-Sirveaux grade 2 glenoid notching on both shoulders, without affecting the excellent clinical results.
ARTICLE IN PRESS 8 Patient 13, with the scapular spine fracture, showed grade 3 glenoid notching.
Discussion Concerns have been raised regarding performing bilateral rTSA over introducing rotational deficit bilaterally and resultant difficulties with ADLs.7,32,45,46 Our null hypothesis was that bilateral rTSA would cause lack of rotational movements bilaterally and resultant difficulties with ADLs. Our study indicates improvements in all the movements. Flexion improved from 58° to 143°, with 37 shoulders having elevation above 90° that allowed use the arm above shoulder level; abduction improved from 60° to 130°, with 35 shoulders having abduction above 90°. AER improved to 32°. In 35 shoulders, ER in adduction was >20°, and 31 shoulders had full ER in elevation, and the patients could reach easily behind their head and neck. AIR improved from 9° to 81°, and 30 shoulders could reach above the sacroiliac joint. Each gain was statistically significant (P < .001; Fig. 3). The minimal functional range of movement necessary for performing ADLs remains undetermined. Namdari et al31 attempted to define the average shoulder range of motion necessary to perform functional tasks of daily living in healthy volunteers.31 They determined that less than full range of motion is adequate to perform many functional tasks. The average range of motion measurements reported to perform these tasks were 121° of elevation, 46° of extension, 128° of abduction, 116° of cross-body adduction, 59° of ER with the
O. Levy et al. arm abducted to 90°, and 102° of IR with the arm at the side. However, they did not examine ER with the arm beside the body or IR with hand behind the back. Looking at the data presented in the tables in their article, the mean functional range of motion in normal shoulders in healthy volunteers are ER of 36.5° and IR of 93.6°.31 The ranges of movements in our study correspond favorably with the measurements of Namdari et al. Furthermore, the various shoulder functional scores significantly improved. We have used several validated functional score: the Constant Score,10 the SSV,16 and the ADLEIR score (modified ADLER score6). The changes in the Constant score (from 18.7 to 65.1 points; age- and sex-adjusted CS improved to 100.2), the SSV (from 2.1 to 9.2 of 10), and ADLEIR score (to 33 of 36; 34 on the right and 32 on the left) were all statistically significant (P < .001). By definition, improvements in these scores indicate patients’ increased ability to return to their previous lifestyles and perform ADLs. This result was further supported by patients’ reported activities and their ability to return to leisure activities, including gardening, bowling, swimming, and golf. Boileau et al6 described the ADLER score to assess functional AER, by asking the patients how easily they could perform ADL tasks that involve ER for their performance. We modified this score to include IR aspects as well. We added 2 questions regarding AIR and reaching with the hand behind the back: can the patient take an object from the opposite back pocket (to assess ability to reach for perineal hygiene and able to tuck shirt in), and how well can the patient wash the back of the opposite shoulder.
Figure 3 Radiographic outcomes and range of motion are shown for an 84-year-old woman at 4 years after left primary Verso (Innovative Design Orthopaedics, London, UK; formerly Biomet, Swindon, UK) reverse total shoulder arthroplasty and 3 years after right revision from resurfacing to Verso reverse total shoulder arthroplasty.
ARTICLE IN PRESS Bilateral reverse total shoulder arthroplasty outcome Questions concerning the validity of bilateral rTSA procedures have been examined in a small selection of articles.29,40,41,46 One of the first case reports was by Ueblacker et al,41 which recounted the results of 1 patient with severe syringomyelia who underwent bilateral rTSA. Satisfactory results were obtained: the patient’s IR substantially improved in addition to regaining the ability to perform perineal care. Recent studies have examined the outcomes of bilateral rTSA in case series.29,40,46 Wiater et al46 reported in a case series of 16 patients that although significant improvements occurred in several patient-reported outcome scores and pain, there were no significant improvements in AER or AIR. Stevens et al40 reported results of a series of staged bilateral rTSAs in 15 patients with the diagnosis of CTA. They reported 121° of elevation and 29° of ER but did not report a value for IR. They found no improvement of AER for the first shoulder and even 15° decreased AER for the second shoulder. Although 80% of the patients could perform perineal care with at least 1 shoulder, 26% (1 in 4) found it very difficult or were unable to remove an object from their back pocket. Recently, Morris et al29 reported the results of bilateral rTSAs in a series of 11 patients presenting with CTA. They reported a significant improvement in shoulder function scores and mobility (except IR) with an elevation of 130° and ER of 28°. In their study, 82% after the first rTSA and 63.6% after the second rTSA achieved more than 121° of flexion, but no patients achieved more than 59° of ER. After comparing outcomes between shoulders, Wiater et al46 concluded that the first shoulder offered more benefit to the patient than the second shoulder.
9 Our study confirms consistent significant improvements in function and range of motions in active elevation, abduction, AER, and AIR. Our study confirms as well no difference between the first and second sides, similar to both Morris et al29 and Stevens et al.40 The right dominant side was slightly better in our series, but without statistical significance (Fig. 4). The reason for the differential between studies is unclear, although differences in implant design, surgical approach and technique, integrity of the posterior rotator cuff, repair of the subscapularis, postoperative rehabilitation, and patient demand may all play a role. The implant design may have an effect on the range of motion and function achieved. The type of prosthesis used, whether LCOR or medialized (MCOR) from the glenoid, the amount of lateralization, and the humeral component inclination (neck-shaft) angle differ among the different prostheses and may affect the scapular impingement, range of movement, and function. Furthermore, as the rTSA hinges around the center of rotation in the glenosphere (unlike the anatomic TSA that spins around its center of rotation), the degree of retroversion used to insert the humeral component determines the range of free ER and IR before abutment of the humeral bearing on the inferior neck of the glenoid, anterior and posterior respectively, occurs. Stephenson et al39 showed that as retroversion was increased, the relative amount of ER increased and IR decreased. Maximum ER at 0° abduction was −1° ± 4° at 20° anteversion, 15° ± 3° at neutral, 28° ± 4° at 20° retroversion, and 44° ± 5° at 40° retroversion (P < .05). Maximum IR at 0° abduction was 128° ± 9° at 20° anteversion, 112° ± 9° at neutral, 99° ± 8° at 20° retroversion, and 83° ± 8° at 40°
Figure 4 Comparison of range of motion (ROM), Constant score (CS), and Subjective Shoulder Value (SSV) between the right and the left shoulders. ABD, abduction; ADD, adduction; ADL, activities of daily living; ADLEIR, Activities of Daily Living External and Internal Rotations; ER, external rotation; FE, forward elevation; HBB, hand behind the back; IR, internal rotation; ROM, range of motion.
ARTICLE IN PRESS 10 retroversion (P < .05). They concluded that the optimal retroversion for the reverse shoulder humeral component is between 20° and 40° of retroversion, which more closely restores a functional arc of motion without impingement.39 In the Stevens et al40 series, 4 different types of rTSA prostheses were used, with a mix of LCOR and MCOR, cemented and press-fit humeral stems. The Wiater et al46 series included 3 different types of rTSA prostheses with a mix of LCOR and MCOR implants. Morris et al29 used 1 type of MCOR implant with inclination (neck-shaft) angle of 155°. We used the same Verso implant in all of the procedures. This implant has +3-mm LCOR from the glenoid face incorporated in the glenosphere. The humeral inclination (neckshaft) angle cut is of 155°. This was performed in 30° retroversion in all the shoulders. The humeral shell component was inserted in 30° of retroversion in all the shoulders. However, this implant has a 10° angled dialable polyethylene liner that changes the final humeral component inclination angle to 145° and allows for final fine adjustment of the optimal version in each patient to achieve the optimal arc of rotations. That these design features are partly responsible for the improved function and range of movements in our series is possible. This may be the reason, as well, for very low degree of glenoid notching observed in our series. All procedures but one were performed using the anterosuperior approach, preserving the good function of the anterior and posterior fibers of the deltoid muscle. Although the posteriorinferior rotator cuff and the subscapularis were absent in almost all shoulders, the surgeon always attempted to approximate and repair any existing remnant of the teres minor and the subscapularis attempting to balance the remnant tissues. The postoperative rehabilitation and patient compliance, may also have contributed to the good outcome. The timing of each respective procedure has also come into question when examining bilateral rTSA. Gerber et al14 and Gruson et al17 both analyzed the results of bilateral anatomic TSAs (only 1 bilateral rTSA in the Gerber et al series) performed in a single-stage vs. staged fashion. Gerber et al14 indicated better results when both procedures were performed simultaneously, whereas Gruson et al17 advocated for staged procedures to allow for appropriate tissue healing and rehabilitation between the 2 sides. In reviewing other case series in the literature for bilateral rTSA, all of the authors recommend a staged approach. The mean interval reported between procedures was 13.7 months in the Wiater et al46 study, 21.6 months in the Stevens et al40 study, and 8.0 months in the Morris et al29 study. Our study indicates similar results with a mean duration of 18.2 months between shoulders (range, 3-46 months). The minimal interval in our study is 3 months, but in our view, this can be shortened to 6 weeks if the patient shows quick recovery. Our study has several limitations. The sample size was relatively small, and there is some heterogeneity in the preoperative patient diagnoses. However, this heterogeneity
O. Levy et al. does not overshadow the functional achievement in the ability to perform ADLs. In addition, the variation of diagnoses allowed for a larger series and more significant data. The strengths of this study are that all cases were performed at a single, high-volume shoulder arthroplasty center by a single surgeon. The same implant was used in all patients with the same surgical technique, the same retroversion, and also the same rehabilitation protocol. The follow-up used validated shoulder outcome scores and no patient was lost to follow-up at mean of 48.4 months (100% follow-up). Questions about whether these results are dependent on implant design or surgical technique remain open.
Conclusion Bilateral rTSA results in marked and predictable improvement in all movements, pain relief, and functional outcomes, with high patient satisfaction and a high ADLEIR score. All patients were able to perform perineal hygiene after their rTSA. Most patients had no limitation in ADLs or in their leisure activities.
Disclaimer Ofer Levy receives equity and royalties from Innovative Design Orthopaedics (IDO) as designing surgeon. The other authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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