How to manage Loss of Rotation with a Reverse Shoulder Prosthesis

Nicola Ivaldo

Mario Rossoni

Giovanni Caione

Luca Pizzella

Private hospital - Villa Igea , Acqui Terme, Italy

Delta Reverse Prostheses : Result on active elevation

Patient - Pre - op

See Below Video 1

Delta Reverse Prostheses : Result on active elevation

Patient - Post - op

See Below Video 2

Rotation

1) Internal rotation

Reason for poor internal rotation with Reverse Shoulder Prosthesis

Limited ROM ( semi-constrained implant )

Perhaps also pect major, lat dorsi & teres mayor strenght.

reduced anterior deltoid strenght

Less efficient subscapularis

Reason for poor internal rotation with Reverse Shoulder Prosthesis

Internal rotation

Sirveaux & cw: ( JBJS B Apr 2004 )

S-scap

Capsule

Solutions

1) Respect the subscapularis

Solutions

2) Reconstruct the subscapularis

Solutions

3) Respect the Lesser Tuberosity

L TL T

Respecting the lesser tuberosity means retroversion of the humeral component

Delta in severe trauma sequelae

Delta in severe trauma sequelae

See Below Video 3

reverse in acute fractures

Tuberosity partial reconstruction

L T G T

reverse pt in acute fractures

BD 4 m.BD 4 m.

Rotation

2) External rotation

Delta reverse prosthesis : Result with external rotation

Sirveaux : RE 1 3.5° -11.2°( JBJS B Apr 2004 ) RE 2 17° - 40°

Boileau: RE 1 7° -11°( JSES Jan Feb 2005 )

Gerber: RE 1 17° -12°( JBJS A Jul 2005 )

Average Constant Score = 67 pts

CS in cases of torn Teres Minor = 58 pts

Sirveaux and cw

J.B.J.S. Br. Apr 2004

Constant Score results depend on Teres Minor status

teres minor

NORMAL

MIDDLE

DEGENERATION

TORN OR SEVERE DEGEN

22 ( 19.5 %)

49 ( 43.3% )

42 ( 37.2 %)

Teres minor status (113 Delta)

Teres minor

Intraoperative observation

The dropping sign in abduction

See Below Video 4

The dropping sign in adduction

Teres minor intact

or middle

degeneration

Teres minor torn

or severe

degeneration

AVG Active Ex Rot 1

+ 18.3° AVG Active Ex Rot 1

- 11.5°

See Below Video 5

Medialization of humeral center of rotation

Decrease in the strength of posterior deltoid

Reason for poor external rotation

Frankle M. and cw. JBJS A. August 2005

Pre op Post op gain p

external

rotation

12.0 41.1 29.1 < 0.0001

Delta offset increase offset

Pre op Post op gain p

external

rotation

11.2 17.6 6.4 0.28 ( ns)

Simovitch & cw J.B.J.S. Am. Mar 2007

baseplate failures

Frankle M. and cw. JBJS A. August 2005

How to increase active external rotation?

Latissimus dorsi transfer

Advantages of latissimus dorsi transfer througth a deltopectoral approach

Commonly used approach for TSA

Entire procedure in beach chair position

Single incision

Operative time 20 – 30 m more than standard DeltaReverse Shoulder Prosthesis

Surgical technique

Pect major

Pect major

Surgical technique

Latissimus dorsi

Latissimus dorsi

Surgical technique

teres major

Surgical technique

Surgical technique

See Below Video 6

Miniaci A. and cw JSES Sept Oct 2004

….Axillary nerve crosses from anterior to posterior over the superior border of teres major approximately 27.1 ± 8.9 mm from this muscle's humeral attachment…..

Axillary nerve

Latissimus dorsi

Axillary nerve

Surgical technique

Humeral implant

Surgical technique

Pect major

Delta and latissimus dorsi: pre-op

InitialsInitials ageage GG painpain useuse AFEAFE AER2AER2 AIRAIR StrenghtStrenght

ptsptsCSCS

SOSO 7878 mm 00 sternumsternum 7070 00 sacrumsacrum 00 1616

AEAE 7575 mm 77 neckneck 7070 +10+10 D8D8 00 3636

PLPL 7272 ff 33 beltbelt 2020 -10-10 trocanttrocant 00 99

RARA 7777 ff 77 neckneck 6060 00 D12D12 00 2929

BMBM 7979 ff 33 neckneck 100100 +20+20 D12D12 66 4444

AverageAverage 76.276.2 4.44.4 neckneck 6464 +4+4 L3L3 1,21,2 26.826.8

Delta and latissimus dorsi: post-op

casecase painpain useuse AFEAFE AER2AER2 AIRAIR StrenghtStrenght

ptsptsCSCS

SOSO 1515 headhead 140140 +60+60 L3L3 88 6666

AEAE 1515 normalnormal 160160 +50+50 D12D12 66 6969

PLPL 1313 headhead 110110 +30+30 D12D12 44 5656

RARA 1010 headhead 140140 +40+40 D12D12 55 5656

BMBM 1515 headhead 170170 +70+70 gluteusgluteus 1010 6969

AverageAverage

GAINGAIN

13.613.6

9.29.2

headhead 144144

+80+80

+50+50

+46+46

L3L3 6.66.6

4.44.4

63.263.2

36.436.4

Recover of external rotation in abduction after Delta + GD

at 6 months = 50 °

at 2 y = 38 °

Delta + latissimus + teres mayor

TMLD

We should replace Teres Minor !

Teres minor

LD and TM

Delta compared to delta + LD transfer

Delta compared to delta + LD transfer

Delta

Delta+ LD Transfer

See Below Video 7

per la cortese per la cortese attenzioneattenzione

For your kind attention.For your kind attention.

GrazieGrazieThank YouThank You