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Predictors of Scapular Notching in Patients Managed with the Delta III Reverse Total Shoulder Replacement
Ryan W. Simovitch, MD1; Matthias A. Zumstein, MD1; Eveline Lohri, MD1; Naeder Helmy, MD1; Christian Gerber, MD, FRCSEd1
1 Department of Orthopaedics, University of Zürich, Uniklinik Balgrist, Forchstrasse 340, 8008 Zürich, Switzerland. E-mail address for C. Gerber: christian.gerber@balgrist.ch
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the ResOrtho Foundation Zürich. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedics, University of Zürich, Uniklinik Balgrist, Zürich, Switzerland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Mar 01;89(3):588-600. doi: 10.2106/JBJS.F.00226
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Abstract

Background: The reverse Delta III shoulder prosthesis can relieve pain and restore function in patients with cuff tear arthropathy. The most frequently reported radiographic complication is inferior scapular notching. The purpose of the present study was to evaluate the clinical relevance of notching and to determine the anatomic and radiographic parameters that predispose to its occurrence.

Methods: Seventy-seven consecutive shoulders in seventy-six patients with an irreparable rotator cuff deficiency were managed with a reverse Delta III shoulder arthroplasty and were followed clinically and radiographically for a minimum of twenty-four months. The effects of cranial-caudal glenoid component positioning and the prosthesis-scapular neck angle on the development of inferior scapular notching and clinical outcome were assessed.

Results: All shoulders that had development of notching did so in the first fourteen months. Of the seventy-seven shoulders that were studied, thirty-four (44%) had inferior scapular notching, twenty-three (30%) had posterior notching, and six (8%) had anterior notching. Osteophytes along the inferior part of the scapula occurred in twenty-one (27%) of the seventy-seven shoulders. The angle between the glenosphere and the scapular neck (r = 0.667) as well as the craniocaudal position of the glenosphere (r = 0.654) were highly correlated with inferior notching (p < 0.001). A notching index was calculated with use of the height of implantation of the glenosphere and the postoperative prosthesis-scapular neck angle. This allowed prediction of the occurrence of notching with a sensitivity of 91% and specificity of 88%. The height of implantation of the glenosphere had approximately an eight times greater influence on inferior notching than the prosthesis-scapular neck angle did. Inferior scapular notching was associated with a significantly poorer clinical outcome.

Conclusions: Inferior scapular notching after reverse total shoulder arthroplasty adversely affects the intermediate-term clinical outcome. It can be prevented by optimal positioning of the glenoid component.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Mark A. Frankle, M.D.
    Posted on March 08, 2007
    Reverse Total Shoulder Replacement
    Florida Orthopaedic Institute, 13020 Telecom Parkway, Tampa, FL 33637

    EDITOR'S NOTE: The corresponding author of this article was invited to respond to this letter, but to date, has not done so.

    To The Editor:

    After reading the article, “Predictors of Scapular Notching in Patients Managed with the Delta III Reverse Total Shoulder Replacement"(1), I have some questions I hope the authors will address. The authors describe in detail that the glenosphere should be placed in a slightly inferior position on the glenoid. However, in my experience there are several situations in which, due to bone loss, the glenosphere may not be able to be placed in the location the authors describe and achieve adequate fixation. In those situations one wonders where the author would place the glenosphere, and if they are unable to place it in this desired position, would that increase their incidence of scapular notching?

    Unfortunately, those excluded from the study were patients with revision of a previous arthroplasty, treatment of acute fracture, posttraumatic deformity, or posttraumatic arthritis. It is just this subset of patients in which bone loss may occur and the glenopshere may not be able to be placed in the optimal location, and it would have been interesting to see their results of notching in this population.

    Also, moving the glenosphere inferior distally translates the humerus, and may put tension on the soft tissue envelope around the shoulder. Have the authors had problems with difficult intraoperative reductions or post-operative dislocations, and have they had any patients with traction type nerve injuries after surgery? Were there any acromial fractures in this group? Displacing the humerus distally would also seem to increase the dead space around the shoulder joint and implant. Have the authors had many post-operative hematomas as a result of this?

    Lastly, the authors state that with their inclusion criteria there were 107 shoulders for the study but 30 were removed before the final evaluation. Possible removal from the study included resection arthroplasty or revision to a second prosthesis prior to the twenty-four months. How many of this 30 were removed for this reason, and what was the mode of early failure in these patients?

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    Reference:

    1. Simovitch RW, Zumstein MA, Lohri E, Helmy N, Gerber C. Predictors of scapular notching in patients managed with the Delta III reverse total shoulder replacement. J Bone Joint Surg Am. 2007;89:588-600.

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