APEX Shoulder Mastering Surgical Techniques for Clinical Success-Reverse Shoulder Arthroplasty

Reverse Shoulder Arthroplasty
Video Transcription
Tiger Lee, Mike O'Brien, Andrew Rizzano. This is our distinguished panel and we're gonna launch back into arthroplasty. We're gonna go right into it, okay. We've got  three cases. We've got a bonus one if we have time, but Mike this is case one, okay. No curveballs on this one. 68 year old female, chronic right shoulder pain,  falls, so post-traumatic, no pertinent past medical or surgical history. What jumps out to you on this physical exam? Do you trust it? Are you doing anything  to work this up further? Notice how stiff she is, active elevation 20, passive 90, and she declined supraspinatus testing. So I always, I think people that withdraw  from palpation in the office is a poor prognostic indicator. So when you just try and touch them or ask them to do something and their pain is out of  proportion to what you would expect, I always tell them that they're gonna have a rough time with surgery. Do you escort them down to Wendell Hurd's office or  what's your next step? I send them to Tiger. Tell them they're soft and then...  And so I give them a one-way ticket. Maybe that's the one to try the suprascapular nerve injection in and say when do I come back? Never. All right, Tiger, are you doing any  lidocaine injections or anything like that to work up whether this is real or psychosomatic or what? What do you say? I think, I mean I know not really, you know,  if she had never had any treatment for somebody who comes in the first time seeing me, I think doing a chorozomal injection, just to see how she does 10 minutes  after and if it improves her function and her motion, it gives you a little idea what's going on. But typically I don't do just a diagnostic. I just see  if they can improve the motion, improve the motion. But if they never had any treatment, I think doing an injection with lidocaine and chorozomal is  helpful to see what the real exam is. So Mike's verbally costing her. Tiger's going to inject her. Andrew, what would you do for this lady? Yeah, so she's super  stiff and kind of hypersensitive. She seems like emotionally a little, what I see a lot in my office. So a lot of times with them, I'll give them like a five-day  steroid pack, give them a little PT because they're not going to tolerate injection. They won't let you touch them. So give them a steroid pack, give them a PT,  give them a little TLC and give them a couple weeks before I see them back. So at what point in time, Andrew, would you call this pseudoparalysis? Is it  mandated that we inject this individual before we assign that diagnosis? Is that more of a subjective thing? I think it's a little more subjective. So I usually  tell the fellows if they have good passive range of motion, they cannot actively forward flex past 90 degrees. I call it a pseudoparalysis. Okay. You know,  Tiger likes to go to his go-to source. Even OrthoBullets says pseudoparalysis is the inability to elevate the arm over 90 degrees. So there  we have defining our terms, right? Pseudoparesis, pseudoparalysis. Pseudoparesis is probably more where she lives. Tiger, anything that scares you about these  x-rays? Does it match up with her exam? I mean, go back to the slide. I think this is really important, this last slide you have, because in my experience, people  who have pseudoparalysis, truly they cannot lift the shoulder. They have active foreflexion, 25 like this, and then possibly full pass range motion, but they  cannot lift it. They cannot hold it up. If they have true pseudoparalysis, doing a transfer does not work. Doing a cuff tear, partial repair, lat, dorsi, whatever you  want to do, they're not going to work in these patients. Those patients need to reverse. It doesn't matter how old they are. It doesn't matter what they do. If  they have true pseudoparalysis, it's very difficult to reverse. Pseudoparesis, they can lift up 30, 45, 50. They can hold it up. Those are patients who do pretty well with  the transfer and partial repair, and you know, those are patients I'm thinking in my head, probably doing something other than reverse. Unless they have arthritis, it'll  work. Yeah, that's a good point, right? So that's just stratifying. You're talking about chronic, a chronic case though, right? Chronic, yeah. Yeah, somebody that comes in  that just had some traumatic massive rotator cuff tear. Yeah, no, it's chronic. I'm talking about chronic, yeah.  I just wanted to make that clear for everybody. Yeah, that's a good point. Several of the alternatives to reverse suggest that they can reverse, you know,  pseudoparesis, but pseudoparalysis is probably a little bit of a different story. But isn't she,  her passive elevation is 90. Yeah. So she's got a frozen shoulder. Because pseudoparalysis, pseudoparesis is full passive motion with the inability to hold the arm at 90 or actively  elevate. So what do you do for that? I would say, I'm scared of those x-rays because they look  normal, you know? That I'm telling her, you have a frozen shoulder, and I'm gonna try and inject her,  put her on a dose pack, get her into PT, show her that her other arm moves normal and this one is  stiff. And so I think she needs rehab, she needs to work harder. I would not go straight to surgery  on this lady because she kind of freaks me out. She's got cataracts, she can't do injections.  Then I would do a dose pack and physical therapy. Okay, I think it's the same problem whether you  take it PO or injectable. All right, so we're getting an MRI. That's usually the way we deal  with histrionic patients in my office. We send them away, we see what happens, we treat them,  we try to do something to see if we can get a second look at her exam. Andrew, how do you look  at these MRIs? Is there anything you're looking for specifically? We talked about looking at the  teres as a potential predictive factor. What else do you see on this imaging? Yeah, so, you know,  she has supraspinous atrophy there. She has a little wear on the top of the humeral head. So  this didn't happen yesterday. So she's had a cuff tear for a while. She had acute fall, traumatic.  She's got a little bit of a frozen shoulder again. Like, these are the ones that an injection,  I think, could help them maybe get back to their baseline. It didn't happen yesterday. All right,  any other imaging you're going to get? I'd start there. I mean, obviously, I'm not going to jump  on an orthoplasty just yet. So that's what I would have gotten. No, I mean, does she have had a fall?  She had a fall? Yeah, nine months ago, maybe. I mean, if you look at the imaging, she doesn't  have arthritis. She's stiff. You can go back one slide. You know, there's no, there's not,  there's a little atrophy, but it's not much fat filtration. There's a big difference. And the  reason because it's atrophy, we look at the right side, is that if you have a sagittal cut and the  muscle is retracted, it's actually, the belly is retracted. If you fix them, it can reverse that  atrophy. So, and the second thing I look at is actually tendon length. If you look at the, here,  the tendon length is actually quite big. It's probably 1.2 centimeters. So, tendon length is  long. In my mind, that could be fixable because if you, you know, if you look at Gerber's paper,  he said that 1.7 or less tendon length, those are ones that fail. But she has pretty decent length and she's stiff. I would inject and see how she does and go from there, you know?  You realize we're on the reverse shoulder arthroplasty panel. I know. I know. That's why I'm so confused why you're showing us a frozen shoulder. So, we get a CAT scan.  Reverse. That's what we do, buddy. Reverse. We get a CAT scan. No significant deformity. Still frozen.  These are our options, which Tiger has alluded to. Massive irreparable cuff tear. In all fairness,  she comes back at her second visit. She's not as bad with passive range of motion. So, I think that was maybe a little bit of a documentation error the first go around. But  still has significant pain constellation. So, I'm less concerned about frozen shoulder or say  we've just treated the frozen shoulder. In this case, we're going forward with the reverse. But  this is the broader vehicle to just have a quick discussion, rapid-fire fashion. What's your preferred design for your implant, Mike? Are you 135, 155? Are you hybrid?  More of a 135 lateral on the humerus guy. So, I'm on the right image. Medial glenoid, lateralized humerus, try and increase deltoid rep. All right. Tiger?  I do 135 for the stem. And it will be a little bit of lateralization off the base plate. And  then I do an onlay stem, which is a little bit of lateralization off the humerus as well. Okay. Andrew?  I try to, I go back and forth depending on the patient. So, usually my kind of go-to is a plus  three base plate. I put it inferior. I pick the glenosphere that covers the glenoid. I don't go  to a 39 for males, 36 for females. I try to cover because I think if you get too big, you know,  they lack internal rotation. I usually use an onlay and I start at 140 and I feel the tension and I'll either go to 135 or 145. I like the first point you talked about.  We're going to revisit that here in a minute because I, you know, we've always kind of  fallen under these normative, I do this for this person, right? Big male, 39. Real big male, 42.  But when you look at it, that front-to-back diameter can sometimes set you up for subcoracoid  impingement, idiopathic pain constellations. And so, that's a lesson I've learned the hard way.  And so, then there's the broader inlay-onlay discussion, which I think will continue to come up. It sounds like majority are onlay?  Majority are onlay. I use the, so if you look at the concept, an inlay can't be an onlay. You put a tray on it. Sure.  So, if you're going to use an inlay, we talk to our fellows is what is your objective? We're trying to get increased impingement for range of motion. So,  if you're going to use an inlay, you have to build up a lot on the glenoid side. So,  I'll put a plus six base plate in the eccentric glenosphere when we use an inlay because I want to build up as much to make up that distance.  Which comes with experience, you know, because obviously then you can overstuff it and you can  be left chasing your tail with the humeral side, which I've definitely done too. So, we do. We  plan for a reverse shoulder arthroplasty. Again, as I alluded to earlier, we do all routine preoperative planning. Everybody does the same from what I gather? Yes.  Okay. And so, this is a pretty straightforward one. You know, this is the one where I will  traditionally do a plus three on the glenoid side and then I usually go neutral on the glenosphere  and then at this point in time was doing more onlay. And so, looking at it in a dynamic fashion,  trying to maximize your placement, I was trying to look at, you can see from front to back,  it's kind of a little bit faint, but you could suggest that I'm a little bit oversized, right? And so, this may be one that you could consider going to a smaller glenosphere.  And so, these are the post-operative images. Tiger, any critiques?  It looks good. I think you did a plus, what are you, plus three? Yeah. The base plate. Yeah, it looks good. Is the end position okay?  Yeah, it looks great. You know, I mean, I put a little bit till on it, but, you know, like an inferior till, 10 degrees or so, but it looks good.  I like too that, you know, when you look at the floor of the infraspinatus fossa and your central screw, that you have a little inferior tilt.  So, I think we've learned that's very important to not be superiorly tilted. Yeah. So, the position of your base plate and your glenosphere looks great.  And I use a 10 degree drill guide for that central screw, but yeah, it's pretty neutral.  Anybody go more inferior routinely with a little bit more overhang or do you just kind of stay flush?  I try and stay flush because I have done that and I've, I think, lengthened them too much, distalized too much. Yeah. And then that can be a problem. Yeah, I'll just shut up.  Yeah. So, she comes back 13 weeks doing five pound kettlebell swings with her PT out in St. Elsewhere Hospital and she notes a pop, presents with this.  So, Andrew, what are you doing with these? You encounter it. It's an acute acromial fracture. So, early on, eight years ago when I started, I left a lot of them. Yeah.  They healed and their pain went away, but their function was poor. Yeah. Then I think we've gotten better at fixing them.  We have a great traumatologist in our group that loves these.  And so, we double scrub them and he's fixed a lot for me. Does he do locums?  He'll take a bus trip. Yeah. So, depending on the patient, what they're willing to tolerate,  we've tended towards fixing a little bit more of these. Yeah. This is a broken diving board. You can see it. It's tilted down a little bit further,  but we watch it. We place it under a sling for three to four weeks. We repeat and we image her and she comes back at 26 months.  And just so you know, there are complications that can occur after reverse acromial fracture. As one of them, you need to counsel your patients on that.  This is the Levy classification. We talked a little bit about some of the risk factors. For me, the biggest one is unoptimized osteoporosis. So, just make sure you're doing that.  The technical factors are how much tension you're putting on. And certainly, the onlay design here definitely contributes. We talked about prevention being the biggest issue.  You also, when you treat them, I prefer a 90-90 plating. These have to be acute. If you're getting to them late, I think, unfortunately, it's too difficult to address.  And I've tried those, and unfortunately, that's been fraught with a little bit of failure. But I just saw her back this week, and you can see this is her motion.  So that frozen shoulder, we cured it, Mike. There's no heal like cold steel. And Nicole shot the photo. She was a little too unsteady with the camera,  so I had to make the world's largest circle, and I still could barely cover her face. Thanks, Nicole. Case two. All right, this is the next one. This gets a little juicy.  This is right up your alley, Tiger. This is a classic BU patient. You can see we've got a whole host of past medical history diagnoses.  If it's not prisoner homeless, it's not a classic BU patient, buddy. She's not in an orange jumpsuit, but there are some red flags based on that history.  And she presents a similarly bad range of motion. Mike, you might call this frozen shoulder, but I might say that it's post-fracture related, right?  So here's the initial radiographs. Who would manage this operatively at this juncture in time? No takers? How about now? She presents from two months later, coming from the home.  This is actually how I first met her. Looks like the artist formerly known as the humoral head is lying outside lateral to the shaft there.  I'm trying to make heads or tails on how this got awry, but what would you do at this point? Andrew? I mean, this is tough. The ward of the state. She's got pain. The dominant arm.  Does it matter? Not really. I mean, her function's got to be terrible. So I mean, if this is something that obviously she's not going to live with, the operative indication,  I mean, for this, you're going to have to try to osteotomize the tuberosities, which is a 50-50 chance you can heal. And when they don't heal, you lose your deltoid drape  and they dislocate. And their function's poor anyway. So I mean, this is a tough one. If you could not operate on it, I would. But I'm guessing we fix it.  You see the timeline, two months to five months. We did give it a good college try, right? We tried to tell her, this is not a painful entity. Let's see if therapy can do more.  Yeah, they're her humoral heads located. So I think it's fine. All right. Tiger, what are you doing? Well, I mean, I think- Reverse panel. Yeah, it's reverse.  You can't fix this arthroscopically. But I would try to osteotomize wherever the fracture is, get a plate, and then see if you can reduce it back. And try to plate it.  You want to basically keep the tuberosity if you can, because that gives you stability. You're plating first and then reverse? No, I would osteotomize that and then  try to see if I can osteo, as I bring it back, try to put it in an anatomic location with a plate and then put the reverse in. But if you're going to do that, what you got to do  is you got to put the plate on. You got to do unicorcal screws that provisionally hold it. Put the stem in, and then you put the trowel in. You put the brooch in.  You don't put the real thing in. And then you check that out. And then if it works, great. If it doesn't, then you could do it the way it is. But I worry about the tensioning.  If you can't do it that way, then I try to get the tuberosity in the back and try to fix the tuberosity to the reverse stem. And then the final plate, if I put a plate  and try to fix this with a reverse, I put the final component, the stem in, and I drill the screws centrally around the stem after. So a provisional fix of plate was unicorcal  and then put the final stem in. And then you drill the final screws, offsetting the final stem, and then reduce it. Mike, anything different?  No, that sounds hard, but it sounds really cool. I would do a fresh stem. I love you, Tiger. I love you, but I just went long stem, and we used just suture fixation.  I used some cerclage cabling system, radiolucent. Probably the bigger question I have on this, and I felt like we were able to get lucky on this.  It was difficult to get it all disimpacted, and there was a little bit of a fibrous union. But there was all this callus, this HO that formed there, which is really, really  difficult to work through. And these are our post-operated grafts. Again, she's done quite well. Her pain is improved. My questions are- Can I ask you a quick question?  Did you do a retentive liner or a semi-constrained liner? Because these have a higher rate of dislocation. Truthfully, I can't remember if I did on this one.  But it plays into our broader discussion about, how are you kicking this off? It's a traumatic event, and you don't want to over-lateralize  because you don't want to put too much pressure on the tuberosity. So Andrew, what's your go-to? Are you going neutral on the glenoid side?  So yeah, for all my fractures, I go neutral now because I did go lateral at first, and it was hard to reduce tuberosities at times. So I go neutral, neutral glenoid sphere.  And then if I need to build up, I do on the humeral side. But again, these, you usually put in looser because once you get your tuberosities around it,  it gets tighter, and they're a little stiffer. So once you surclose everything around, I mean, you're putting everything back on it.  So I go neutral at first, and then if I have to build up, I do on the humeral side. Tiger, anything different? I just wonder, you didn't put the screw in distally in the shaft.  Why not? There was two screw holes you can put in. You didn't do it as a press fit stem, but. It's an option. I didn't think we needed it for rotational stability.  When I trialed, it was actually a pretty good press fit. So in general, I think it is an option for that system. I have not availed myself of that opportunity yet.  My mentor used to say, hole is opportunity, not obligation. So I just probably observed that. And I didn't want to go try to create any stress risers distally.  I do a lot of these for my BU, because our trauma guys hates fractures, or they don't do any of the shoulder fractures, or even non-unions.  And I go big on the gonadsphere, because I think stability is the most important thing. If they're larger than me, I always go 42. I try a lot of those.  I just get the more tension and more stability. There's small females, maybe 36, 39, something like that. But I try to get a bigger gonadsphere if I can, just to maximize stability.  And then always, I try to get the tuberosity in the back tighter on the stem if I can. I think that's the key. Really, go out of your way to preserve that tuberosity.  Don't take it out. Try and keep it. I have a very low threshold to cement, if I don't think I have a good press fit. Cement the stem, just because they can rotate on you,  and then they can dislocate. Black and tan, like a little partial up top, or fully? The black and tan is great. That's a John Levy technique you guys can look up.  And so he cements distally, and then bone grafts proximally, and puts the tuberosities around it. And you really want to pack a lot of bone graft under the tuberosity, because you  want the tuberosity to heal to the shaft of the humerus, because it's not going to stick to the metal. Yeah, don't spike the humeral head on the floor. Take that.  Remove all that nice cancellous bone. Put it under the tuberosities. I want to get through this one additional one. All right, Rob. Andy took five minutes from me.  I'm taking it right back.  Sir, permission to get five more minutes? So this is a good one, Tiger. We're getting more and more BU as we get further along. 75, all right, he's got chronic right shoulder pain.  He's a non-vet. You can see he's had a mishap with his contralateral extremity. He's got pretty significant scoliosis. He's had a cumulative four failed rotator cuff surgeries.  And his daughter is the charge nurse at our OR. So in the words of our great philosopher Eminem, we have one shot, one opportunity. Tiger, what are you going to do with this?  Reverse. Reverse. That's correct. All right, let's see some images, though, first, OK? Mike, do these scare you at all? Yeah, he's very high. Proximal migration.  He's got a lot of thinning in his acromion. He looks osteopenic. He's been up there a long time, so I worry about creating a scapular spine fracture or acromion fracture in him.  Yeah, yeah, what do you think about that coracoid? Also looks bad. So does his sternoclavicular joint. Every joint looks bad, OK? Look how thin that is. Is it already broken?  It's already broken. Yeah, I think that's actually HO because I think he had some open approach. But you'll see it better here with some of the 3D recons.  But it doesn't make you feel any better. Also, he's got one arm. We talked about his internal rotation. If he can't wipe himself on one side,  you're not going to be wiping him the rest of your life, Brian. So it's going to be hard. Thank you for that segue, right? There's unpredictable functional outcomes.  We know the stakes of it. This is just lending some credibility of what Tiger is saying, right? To be able to manage toileting, only about 2 thirds  of patients being able to get to your opposite shoulder to wash, those are the stakes. So what's your approach? I can tell you this is mine.  I did some very careful planning on this one. I went inlay, was really concerned about the potential risk for acromial stress fracture. I was also really concerned about him  being able to accomplish his ADLs. Triple, I was very concerned about putting him in varus because he had very, very, actually, incredibly tight canal.  He had some odd bony morphology. And so I've over-corrected him into a little bit of algus. So I've probably created him a little bit more 155-ish.  But he's got a good inlay tray around him. And we hugged it just at the inferior most margin of the glenoid and went very conservative with his rehab.  You did a wedge superiorly to correct the superior tilt, right? Yeah. You can't appreciate that really fully here. Because it's really tilted superiorly. I think that's great.  I think that's one where you don't want to distalize it, just like you're showing. And play it a little high if you need to. Because scapular notching is going  to be a better complication than an acromion fracture. 14 weeks post-op, he should be coming back for a six-month. Anything you guys would do differently?  I think this guy is at, I tell everybody, they have four major risk factors, right? Nerve injury, infection, fracture, dislocation. He's on all of them, right?  He's at a high risk for infection because he's had prior arthroscopic surgeries or open surgeries with anchors and sutures. So extensive debridement, multiple washes,  an inlay because he's so high and you have to build up on the glenoid side. So that looks great. How long did you keep him in a sling since he only has one arm?  I did a full six weeks on him. And I delayed rehab until four weeks. Can he wipe himself? He can, believe it or not. What version do you put your hemo side?  Did you dial it neutral just to increase the area? I just matched what he had. I think it was about 30 degrees, if I'm being honest, somewhere between 20 and 30.  But it was a little hard. It's great. Somehow I got back to the beginning. Mike, one quick pearl for the audience on reverse, and we'll just run down the list. One quick pearl.  Take home message. Taking too long. Tiger. One? Yeah. Well, I mean, I think one thing is just for reduction. And when you, at least the stem I use,  if you do the glonsphere, you put the trowel in. You put the cover on the trowel. And then you put your finger in there with the arm in neutral. If it's a tight finger, every time,  you know that's a tensioning. At least for me, it's about a standard tray. So I barely trowel anymore in the primary version. Almost never trowel, unless I have a question.  If it's a little loose, you go up and you trowel a little bit. But if it's a tight single, that's one thing I learned is you can use your finger  to feel the tensioning between the glonsphere and the cut, and then with the protector to know what that tension is, what you need to do. If you can't get your finger in there,  you've got to cut low on the humeral shaft more. Otherwise, it's not going to reduce for most. Another thing is that sling. I don't use sling anymore.  I just give them for a week and tell them. You just for this guy? This guy would do a sling. But for most primary reverse, I don't think you need it.  A week, and I just tell them, get out a sling, start using your arm. Primary reverse. And I repair a subscap every time. My favorite stability test is at the end  with the arm in neutral. I put hook my finger under the medial calcar, and I try and pull it out lateral. And if I can dislocate it that way, I trial every time still.  I go up in the poly. If I can hook that medial calcar and pull, and I can't pull it out, then I leave it. So I think for cuff tear arthropathy, I put him in a little tighter.  Cuff intact OA, I put in a little looser. Yeah, that kind of matches. I think there's so many options with all the systems that you can get decision fatigue.  So you have to figure out your algorithm. So we tell the fellows, stable implants, to have a stable joint that adequately tensions the muscle tendons that you have.  So you have to figure out what you're tensioning. Do you have a cuff? Do you have your whole deltoid? And how are you measuring that tension?  You know, we feel the deltoid, we feel the conjoined, we feel the axillary nerve every time. So you have to think about that algorithm and how you're going to try to achieve it.  That's a great panel. Thanks for covering a lot of ground. Those are great cases. I appreciate it, guys. I think-
Asset Caption
Moderator: Brian Waterman, M.D.
Panel: Xinning Li, M.D., Michael O’Brien, M.D., Andrew Razzano, D.O.