Better Constant Scores and Active Forward Elevation Using Deltopectoral Versus Anterosuperior Approach for Reverse Shoulder Arthroplasty: Matched Cohort Study.

Purpose: To determine, from a sizable cohort of reverse shoulder arthroplasty (RSA), whether the deltopectoral (DP) or anterosuperior (AS) approach grant better outcomes at a minimum follow-up of 24 months. Methods: The authors reviewed 743 RSAs in patients with primary osteoarthritis (OA) with or without rotator cuff lesions and secondary OA due to rotator cuff tears. The DP approach was used in 540 and the AS approach in 203. Pre- and post-operative constant scores (CSs) and shoulder range of motion were recorded. Results: Of the initial cohort of 743 shoulders, 193 (25.7%) were lost to follow-up, 16 (2.1%) died, and 33 (4.4%) were revised; 540 shoulders were operated using DP approach (73%), of which 22 were revised (4.1%), while 203 were operated using the AS approach (27%), of which 11 were revised (5.4%). Propensity score matching resulted in two groups: 172 shoulders operated by DP approach, and 88 shoulders operated by AS approach. Comparing outcomes of the matched groups at 2 or more years also revealed that, compared to the AS approach, the DP approach resulted in significantly better post-operative CSs (67.3 ± 14.0° vs 60.8 ± 18.3, P = 0.017), active forward elevation (137° ± 27.4° vs 129° ± 29.8; P = 0.031). Conclusion: At 2 or more years following RSA, the DP approach granted significantly better CS (by 6.5 points) and active forward elevation (by 8°) compared to the AS approach. The differences observed are clinically relevant and must be considered to manage patient expectations following RSA and for selecting surgical approach depending on their functional needs. Level of evidence: III, comparative study.

Intraoperative repair of functional subscapularis during RSA by deltopectoral approach could improve internal rotation but does not prevent anterior dislocation.

INTRODUCTION: The role of the subscapularis following reverse shoulder arthroplasty (RSA) remains controversial as repair could restore adequate internal rotation and shoulder stability, but might compromise external rotation. The purpose of this multi-centre study, on a large cohort of RSAs performed using the deltopectoral approach, was to determine the effect of subscapularis preoperative status and intraoperative repair on range of motion, clinical scores and rates of complications at a minimum follow-up of 2 years. HYPOTHESIS: Repair of a functional subscapularis grants better internal rotation and stability without compromising external rotation. MATERIALS AND METHODS: We retrospectively reviewed records of all RSAs (n=916) performed by 14 surgeons that participated in a large national society symposium, and excluded 234 operated by the anterosuperior approach, 42 operated for rheumatoid arthritis, fractures, instability or post traumatic sequalae, and eight that had adjuvant latissimus dorsi tendon transfer (LDTT). This left 632 RSAs, in which the subscapularis was detached in 594, and repaired after detachment in 495. Patients completed pre- and postoperative Constant Score and postoperative Subjective Shoulder Value (SSV). Active forward elevation, active external rotation (ER), and active internal rotation (IR) were recorded pre- and postoperatively. Complications following RSA that required conservative treatment, reoperation without implant removal, as well as reoperation with implant removal were recorded. RESULTS: Of the initial cohort of 632 shoulders, 120 (19%) were lost to follow-up, 12 (2%) died due to causes unrelated to RSA, and 26 (4%) were revised with implant removal. Of the remaining 474 shoulders, 259 (55%) had a functional repaired subscapularis (Group FR), 59 (12%) had a non-functional repaired subscapularis (Group nFR), whereas 68 (14%) had a not repaired subscapularis (Group nR). Comparison of patient demographics revealed no significant differences among the three groups. Postoperative Constant Score (p=0.031) and SSV (p=0.016) were significantly different among the three groups, but effect sizes were small and not clinically relevant. Differences in postoperative ER as well as postoperative IR were not significant among the three groups: 91 (35%) gained functional IR in Group FR, 11 (19%) in Group nFR, and 13 (19%) in Group nR. Three shoulders (1.2%) reported subjective instability and 1 (0.4%) dislocated in Group FR, but none in either Groups nFR or nR. DISCUSSION: Despite statistically significant differences in Constant Score and SSV among the three groups, the clinical relevance of these differences is negligible, so repair of functional subscapularis has little or no influence on functional outcomes. During RSA by deltopectoral approach, repair of a functional subscapularis could slightly improve internal rotation in some patients but does not compromise external rotation, forward elevation or clinical scores, while repair of a non-functional subscapularis, compared to non-repair, did not improve range of motion or clinical scores. LEVEL OF EVIDENCE: III; retrospective comparative.

Reverse shoulder arthroplasty for primary glenohumeral osteoarthritis: significantly different characteristics and outcomes in shoulders with intact vs. torn rotator cuff.

PURPOSE: To compare outcomes of reverse shoulder arthroplasty (RSA) for primary osteoarthritis (OA) with and without rotator cuff (RC) tears to those with secondary OA due to RC tears. METHODS: We reviewed records of all patients who received RSA for primary OA or secondary OA. All patients had preoperative radiographs, computed tomographic arthrography (CTA), and/or magnetic resonance imaging (MRI) scans of their shoulders to assess their etiology, glenoid morphology, and fatty infiltration. Pre- and postoperative (at minimum follow-up of 2 years) Constant scores and range of motion were compared between patients who had RSA for primary OA with and without RC tears to those with secondary OA due to RC tears. RESULTS: Of the initial cohort of 605 shoulders (583 patients), 153 were lost to follow-up (25.3%), 25 required revision with implant removal (4.1%), and 13 died of causes unrelated to the surgery (2.1%), and left a final cohort of 414 patients. Of the final cohort, 97 had primary OA with intact RC, 62 had primary OA with RC tears, and 255 had secondary OA. Postoperative Constant scores were significantly higher for primary OA with intact RC (73.8 ± 14.3), compared with both primary OA with RC tears (66.1 ± 14.6, P < .001) and secondary OA (64.1 ± 14.8, P < .001). There were no differences in pre- or postoperative scores between primary OA with RC tears and secondary OA. CONCLUSION: At 2 or more years following RSA, Constant scores were significantly higher for primary OA with intact RC, compared to either primary OA with RC tears or secondary OA, whereas there were no differences in pre- or postoperative scores of shoulders that had primary OA with RC tears vs. secondary OA. The authors recommend distinguishing primary OA with intact RC from primary OA with RC tears, as the two have considerably different characteristics and prognosis following RSA.

Reverse total shoulder arthroplasty. Survivorship analysis of eighty replacements followed for five to ten years.

BACKGROUND: Reverse total shoulder arthroplasty is currently being used to treat selected patients with disabling shoulder arthropathy. The purposes of this study were to investigate the medium-term results of reverse total shoulder arthroplasty and to analyze the influence of etiology on the result. METHODS: We carried out a multicenter study with a minimum follow-up of five years and determined the survival rate of the prosthesis according to the initial etiology of the shoulder arthropathy. Eighty prostheses were implanted in seventy-seven patients between 1992 and 1998. Sixty-six shoulders had an arthropathy with a massive rotator cuff tear, and fourteen shoulders had a disorder with another etiology (rheumatoid arthritis, trauma, or revision arthropathy). At the time of review, eighteen patients had died and two were lost to follow-up. The remaining fifty-seven patients (sixty shoulders) were examined or interviewed by telephone at a mean follow-up of 69.6 months. Cumulative survival curves were generated with replacement of the prosthesis, glenoid loosening, and a functional Constant score of <30 as the end points. RESULTS: The survival rate with replacement of the prosthesis and glenoid loosening as the end points were 91% and 84%, respectively, at 120 months, with shoulders that had arthropathy with a massive rotator cuff tear demonstrating a significantly better result than those that had a disorder with another etiology (p < 0.05). On the other hand, the survival rate with an absolute Constant score of <30 as an end point was 58% at 120 months, with no significant difference with respect to etiology. Two breaks were observed in the survival curves. The first concerned survival until replacement of the prosthesis and occurred at around three years, reflecting early loosening of the prosthesis. The curve then became stable. A second break started at around six years and reflected progressive deterioration of the functional result. CONCLUSIONS: Our findings indicate that the reverse total prosthesis should be reserved for the treatment of very disabling shoulder arthropathy with a massive rotator cuff rupture, and it should be used exclusively in patients over seventy years old with low functional demands.