The article entitled "The Use of the Reverse Shoulder Prosthesis for
the Treatment of Failed Hemiarthroplasty for Proximal Humeral Fracture"
by Levy et al. in this issue describes how the reverse shoulder prosthesis
offers a reasonable, and perhaps the only, salvage solution for the
complications that occur following the use of a prosthesis for the treatment
of some fractures of the proximal part of the humerus. The authors point out
that the reverse shoulder prosthesis should only be implanted by shoulder
surgeons who have experience in reconstructive shoulder surgery.
As one of the senior shoulder surgeons in this country and a founding
member of the American Shoulder and Elbow Surgeons, I wrote this editorial to
let the reader know that, yes indeed, there is a new and different prosthesis
that is available for the treatment of selected severe uncommon shoulder
problems. While I have a financial relationship with the DePuy Orthopaedics
company in that I receive royalties from several of their shoulder products, I
do not implant their Delta Reverse Shoulder Prosthesis, nor do I receive
royalties for its use. The reverse shoulder prosthesis is indeed a new concept
in the United States for the management of patients who have irreparable loss
of the rotator cuff and severe arthritis of the shoulder combined with severe
loss of shoulder function. This prosthesis was first developed by Professor
Paul Grammont in the mid-1980s in Dijon, France, and has been extensively used
in Europe up to the current time. The original prosthesis consisted of an
all-polyethylene trumpet-shaped humeral component that articulated with a
metal or ceramic ball that was secured in the
glenoid1. Both
components were cemented in place. The preliminary findings were published in
1987 and, because of unsatisfactory results, modifications were made by
Professor Grammont until the Delta III version became available in
19912,3.
The name of this prosthesis is significant in that, as there is extensive loss
of the rotator cuff, the deltoid muscle alone is used to power shoulder
function. The Grammont Delta prosthesis was produced by Medinov in Roanne,
France, and was later purchased by Landanger in France and then by DePuy
Orthopaedics of Warsaw, Indiana, which is a subsidiary of Johnson and Johnson.
Because the prosthesis had been used so extensively in Europe, it was
submitted to the Food and Drug Administration for approval for use in the
United States. Approval was granted in late November 2003, and the first
surgery was performed in March 2004. The other companies in the United States
that market a reverse shoulder prosthesis are Encore, Tornier, and Zimmer. In
Europe, Lima (Italy), Aston (France), and Implants Industrie (France) produce
a reverse prosthesis.
Because the reverse prosthesis is different from the standard
hemiarthroplasty or total shoulder arthroplasty prosthesis, DePuy recommended
that orthopaedic surgeons in the United States attend a one-day course to
learn about the surgical procedure, its indications and contraindications, and
its complications. During the course, either live surgical procedures were
performed or videotapes of the procedures were reviewed and then lectures were
presented by experienced surgeons. An opportunity to work with these surgeons,
during which the attendees used the actual instrument sets and inserted the
prosthesis into synthetic shoulder bones, was then available. Between 2004 and
2006, 840 orthopaedic surgeons attended these courses.
The ideal candidate for the reverse shoulder prosthesis is an elderly
patient (seventy years of age and older) who has rotator cuff arthropathy,
i.e., a patient who has irreparable loss of the rotator cuff, arthritis of the
shoulder, pain, and minimal if any shoulder function. The reverse shoulder
prosthesis is also used to provide function in some patients who have had a
failed shoulder arthroplasty and in selected patients in whom the treatment of
a shoulder fracture with a prosthesis has failed because of disruption of the
tuberosities of the humerus and the coracohumeral arch, allowing for the
development of anterior/superior escape of the shoulder. With the prosthesis
properly in place, the pain is eliminated or decreased and the deltoid muscle
can once again achieve function. Sometimes the shoulder function can be
dramatic in that the patient can easily move the arm to the overhead
position4-24.
I have concerns with the reverse shoulder prosthesis. I believe that it
should only be employed by shoulder surgeons who have extensive experience in
shoulder arthroplasty (i.e., those who perform a minimum of fifteen to twenty
shoulder arthroplasty procedures per year). Only an experienced shoulder
surgeon can successfully perform this procedure because he or she is extremely
familiar with the anatomy and function of the shoulder and respects the
indications and contraindications for this prosthesis. The inexperienced
surgeon may be tempted to use a reverse shoulder prosthesis for patients who
only have severe arthritis or those who only have massive loss of the rotator
cuff, thus extending the indications beyond those that are currently
acceptable. Furthermore, the experienced shoulder surgeon is aware of
alternative procedures such as the use of hemiarthroplasty. For example, some
patients with severe cuff tear arthropathy who have retained 70° or
80° of active elevation can be very effectively managed with a
hemiarthroplasty procedure. The experienced shoulder surgeon is acutely aware
that even when the reverse shoulder prosthesis is used for the proper
indications and is perfectly implanted, the complication rates have ranged
from 13% to
50%5-9,12,19,21-23.
Many of these complications are serious, and the surgeon must recognize that
this prosthesis is an implant of last resort and must be certain that he or
she can treat the complications that will occur. I believe that mastering the
complications associated with this implant is beyond the potential of the
inexperienced shoulder surgeon.
The most recent report on complications associated with the reverse
shoulder prosthesis was presented at the Closed Meeting of the American
Shoulder and Elbow Surgeons in September 2006 by G. Walch of Lyon, France and
his associates. They conducted a multicenter review of 457 patients who were
managed with the reverse shoulder prosthesis between 1992 and
200225. Two hundred
and ninety-seven operations were performed in patients who had not had prior
surgery, ninety were performed in patients who had had a failed
hemiarthroplasty or total shoulder arthroplasty, and seventy were performed in
patients who had had failed shoulder operations other than shoulder
arthroplasty. The authors reported that, overall, 25.6% of the patients had
either an intraoperative or a postoperative complication. They noted higher
complication rates among patients undergoing revision surgery. Specifically,
the rate of intraoperative complications was 31% among patients managed with
revision surgery as compared with 2.7% among those managed with primary
surgery, and the rate of postoperative complications was 33% among patients
managed with revision surgery as compared with 12.6% among those managed with
primary surgery. Instability was the most common postoperative complication,
followed by infection, humeral fracture, glenoid loosening, humeral loosening,
humeral disassembly, glenoid disassembly, hematoma, neurapraxia, scapular
spine fracture, postoperative stiffness, and venous thrombosis.
The most recent study is from Pascal Boileau et
al.6, who reported
on forty-five patients who received the Grammont Delta III prosthesis between
1997 and 2002. The authors reported a complication rate of 24%, and, as was
the case in the Walch study, there was a much higher complication rate (45%)
among patients managed with revision surgery. In their extensive review, which
represented one of the largest Delta prosthesis series to date, they stated,
"On the basis of the current design and results, the reverse prosthesis
should be considered a salvage procedure: its use should be limited to elderly
patients, arguably those aged over 70 years, with poor function and severe
pain related to cuff deficiency. A Reverse Prosthesis should not be offered to
a young individual who desires to have a normal shoulder and will demand more
of the prosthesis than it is designed to
do."6
In 2005, Gerber and
associates23
concluded that the Delta III prosthesis is a valuable choice for the treatment
of severe dysfunction of the shoulder and went on to state, "because of
the high complication rate and the fact that there may be long-term
complications that are not yet known, arthroplasty with this implant should be
reserved as a salvage procedure for situations in which an acceptable clinical
outcome cannot be expected with another treatment modality."
If some of the best and most experienced shoulder surgeons in the world
have reported complications and failures in association with this procedure, I
am concerned that the inexperienced surgeon may have an even higher rate of
complications. To better prepare oneself for the successful use of the reverse
shoulder prosthesis, an inexperienced shoulder surgeon should (1) be familiar
with and study shoulder anatomy, (2) review videotapes on the surgical
technique of the reverse shoulder prosthesis, (3) practice the surgical
technique on cadavers, (4) take a course offered by one of the companies that
offers the reverse shoulder prosthesis, and (5) operate with a shoulder
surgeon who is experienced in the use of the reverse shoulder prosthesis that
one plans to use.
In summary, the reverse shoulder prosthesis can yield satisfactory and even
spectacular results when used by an experienced shoulder surgeon. Even then,
the rates of intraoperative and postoperative complications are high compared
with those associated with standard hemiarthroplasty or total shoulder
arthroplasty procedures. In light of this information, the general orthopaedic
surgeon must be very cautious when deciding to use the reverse shoulder
prosthesis.