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The Use of the Reverse Shoulder Prosthesis for the Treatment of Failed Hemiarthroplasty for Proximal Humeral Fracture
Jonathan Levy, MD1; Mark Frankle, MD2; Mark Mighell, MD2; Derek Pupello, BS2
1 Orthopaedic Institute at Holy Cross Hospital, 4725 North Federal Highway, Fort Lauderdale, FL 33308
2 Florida Orthopaedic Institute, 13020 Telecom Parkway North, Temple Terrace, FL 33637. E-mail address for M. Frankle: frankle@pol.net
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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 Encore Medical Corporation (ENMC). In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (ENMC). Also, a commercial entity (ENMC) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a 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.
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Investigation performed at the Florida Orthopaedic Institute, Temple Terrace, Florida

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Feb 01;89(2):292-300. doi: 10.2106/JBJS.E.01310
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Abstract

Background: Humeral hemiarthroplasty is an established treatment for patients with selected fractures of the proximal part of the humerus. However, a subset of patients have development of glenoid arthritis and rotator cuff deficiency due to tuberosity failure. To date, there has been no reliable salvage procedure for this problem.

Methods: Over a period of five years, twenty-nine patients (twenty-five women and four men) with a mean age of sixty-nine years (range, forty-two to eighty years) were managed with removal of a hemiarthroplasty prosthesis and revision with a Reverse Shoulder Prosthesis alone or in combination with a proximal humeral allograft. Patients were followed clinically and radiographically for an average of thirty-five months. All patients were evaluated with use of the American Shoulder and Elbow Surgeons score; the Simple Shoulder Test; range-of-motion measurements, including abduction, forward flexion, and external rotation; and a rating scale for overall satisfaction with the outcome of the surgery. Patients were assessed preoperatively and at all follow-up points beginning at three months postoperatively.

Results: The average total American Shoulder and Elbow Surgeons score improved from 22.3 preoperatively to 52.1 at the time of the last follow-up (p < 0.001). The average American Shoulder and Elbow Surgeons pain score improved from 12.2 to 34.4 (p < 0.001), and the average American Shoulder and Elbow Surgeons function score improved from 10.1 to 17.7 (p = 0.058). The average Simple Shoulder Test score improved from 0.9 to 2.6 (p = 0.004). Forward flexion improved from 38.1° to 72.7° (p < 0.001), and abduction improved from 34.1° to 70.4° (p < 0.001). The overall complication rate was 28% (eight of twenty-nine). At the time of the latest follow-up, sixteen patients rated the outcome as good or excellent, seven rated it as satisfactory, and six were dissatisfied. Four of the six patients who were dissatisfied had been managed with a Reverse Shoulder Prosthesis alone.

Conclusions: The Reverse Shoulder Prosthesis offers a salvage-type solution to the problem of failed hemiarthroplasty due to glenoid arthritis and rotator cuff deficiency following tuberosity failure. The early results reported here are promising. In cases of severe proximal humeral bone deficiency, augmentation of the Reverse Shoulder Prosthesis with a proximal humeral allograft may improve patient satisfaction.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

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    References

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    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 26, 2007
    Dr. Frankle et al. respond to Dr. Alam et al.
    Florida Orthopaedic Institute 13020 Telecom Parkway Tampa, Florida 33637

    We thank Dr Alam and colleagues for their comments on our recent article[1]. We have responded to each of their questions below:

    1. We agree that the wording may have been confusing so we will clarify. We revised 57 patients with a failed hemiarthroplasty done originally for fracture to a reverse shoulder arthroplasty over our entire experience from 1999-2005 (this manuscript was written at the end of 2005). There were 32 patients that underwent reverse shoulder arthroplasty for this indication from 1999-2003 (i.e. at least 24 months post surgery at the time this manuscript was written) and all were included in this study. Three of the patients died before obtaining 2 years of follow-up leaving 29 for analysis. We did not exclude 49% of the patients.

    2. Apropos of Dr. Alam’s inquiry, we too were pleasantly surprised at the low incidence of complications. In retrospect many factors were responsible for our low rate of complication including: 1) The anatomical center of rotation of the glenosphere used in this group of patients provides for a smaller dead space accounting for a lower likelihood of postoperative hematoma and prevents mechanical abrasion of the humerus against the scapular neck thus preventing scapular notching found with other reverse shoulder arthroplasties with medial centers of rotation [2-6]. 2) The humeral component used in this group of patients was small in diameter so the majority of humeral implants were cemented into the previous cement mantle thus avoiding humeral complications associated with cement removal of the humerus. 3) Finally, our clinical practice has allowed us to have a large experience in shoulder arthroplasty. The familiarity we have in performing complex arthroplasties has provided an ideal environment to become technically comfortable in treating this difficult group of patients. The authors state that our short follow-up may explain the low complication rate but the average length of follow-up on the study they cite with a 45% complication rate was 40 months while our follow up was 35 months.

    3. Indeed statistically we did not prove that the allograft is better. We do feel that based on our experience that restoration of the bone loss seen on the proximal humerus is advantageous for the patient. Based on the improvement in function, reduction of pain, relatively low complication rate and overall patient satisfaction we continue to utilize the Reverse Shoulder Prosthesis to treat the previously untreatable triad of a hemiarthoplasty used to treat a proximal humeral fracture in which the rotator cuff has structurally failed leading to glenohumeral instability and the progression of erosion of the glenoid articular cartilage.

    References:

    1. Levy J, Frankle M, Mighell M, Pupello D. The use of Reverse Shoulder Prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture. J Bone Joint Surg Am. 2007;89:292-300

    2. Valenti P, Boutens D, Nerot C. Delta III prosthesis for osteoarthritis with massive rotator cuff tear: Long term results. Shoulder Prosthesis 2000 2000:253-8.

    3. Boulahia A, Edwards TB, Walch G, Baratta RV. Early results of a reverse design prosthesis in the treatment of arthritis of the shoulder in elderly patients with a large rotator cuff tear. Orthopedics 2002;25-2:129-33.

    4. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Mole D. Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff. J Bone Joint Surg Br. 2004;86:388-95

    5. Werner CM, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005;87(7):1476-86.

    6. Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae and revision arthroplasty. J Shoulder Elbow Surg. 2006;15:527-40.

    Mahbub Alam
    Posted on March 06, 2007
    Caution with Recommendations for Use of Reverse Shoulder Prosthesis
    Princess Royal Hospital, Haywards Heath, West Sussex, RH16 4EX, UK

    To The Editor:

    We read with interest the article by Levy et al.(1)and the editorial by Rockwood CA Jr (2). We would like to make the following additional points:

    1. During the study period, fifty-seven patients underwent revision to the Reverse Shoulder Prosthesis after developing problems following primary hemiarthroplasty for proximal humeral fractures but only twenty-nine of the fifty seven patients (a drop out rate of 49%) were included in the study. We feel the inclusion and exclusion criteria need more explanation.

    2. Of great interest, only eight of the twenty-nine study patients(28%) had a complication. This is a surprisingly low result for such a difficult group of patients. Complication rates for revision surgery using a reverse shoulder prosthesis in experienced hands have been reported as high as 45%(3) and 33%(4). However, it is possible that this low complication rate may be explained by the short follow-up, (minimum 24 months with an average of 35 months). Complications reported in the literature following reverse shoulder prosthesis but not listed in this report include scapular spine fracture, glenoid loosening, haematoma, postoperative stiffness and venous thrombosis(3,4). Late complications, such as glenoid notching and acromial fatigue fractures(5), may not appear until follow-up times beyond those reported in this study.

    3. The authors recommend the use of proximal humeral allograft augmentation for patients with associated extensive proximal humeral bone loss. However, only eight patients underwent augmentation surgery and only four showed radigraphic evidence of bone integration. This is not strong evidence on which to base a recommendation for proximal humeral allograft augmentation.

    In light of our concerns regarding this study, we do not believe the authors have shown that the the Reverse Shoulder Prosthesis is efficacious in this group of patients.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. 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.

    References:

    1.Jonathan Levy, Mark Frankle, Mark Mighell, and Derek Pupello, The use of the Reverse Shoulder Prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture, J Bone Joint Surg Am 2007 Feb;89(2):292-300.

    2. Rockwood CA Jr. The Reverse Total Shoulder Prosthesis: The new kid on the block. J Bone Joint Surg Am 2007 Feb;89(2):233-5.

    3. Boileau P, Watkinson D, Hatzidakis AM, Hovorka I. The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae and revision arthroplasty. J Shoulder Elbow Surg. 2006;15:527-40.

    4. Walch G, Wall B, Mottier F. Complications and revision of the reverse prosthesis, a multicentre study of 457 cases. In: Walch G, Boileau P, Mole D, Favard L, Levigne C, Sirveaux F, editors. Reverse shoulder arthroplasty: clinical results, complications, revision. Montpellier, France: Sauramps Medical; 2006. Page 335-52.

    5. McFarland EG, Sanguanjit P, Tasaki A, Keyurapan E, Fishman EK, Fayad LM. The Reverse Shoulder Prosthesis: A review of imaging features and complications, Skeletal Radiol 2006;35(7):488-96.

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