Reverse TSA: Extending the indications Edwin E Spencer Jr. MD Knoxville Orthopaedic Clinic Knoxville, TN

Disclosures I am a consultant for Tornier and receive royalties for products and have received research funding I am a consultant for DJO and Conventus

Reverse TSA Is the reverse TSA the answer for everything that ails the shoulder, or is it the new century snake oil? First commercially introduced in 2004, the incidence is rising at a rate 3x faster than primary shoulder replacement We will also discuss some common indications and extended indications with some precautions

Indications Primary CTA Massive RCT without OA or failed RCR Proximal humeral malunions Proximal humeral nonunions Acute proximal humeral fractures Glenoid bone loss Instability with combined soft tissue and osseous defects

Mastering the primary CTA: Some assembly required Not all CTA is the same… Some have retained function (FE) while others are pseudoparalytic Some have retained ER while others have a lag Some are stiff and arthritic Some have a thin acromion Some are osteoporotic Some have retained subscap function

Reverse for CTA…not all the same Elderly female with standard CTA with a very stiff arthritic joint, superior migration, but a thin acromion Male with retained FE to 1400 with pain and normal acromion with no break in Maloney’s line

Customize the reverse The reverse is a non-anatomic prosthesis so a gain in one area is usually at the expense of another Be cognizant of the bone quality The point is that 3 areas must be balanced or considered in a reverse Preop function Stability / Stiffness Impingement free ROM

Customize the Reverse Especially if the acromion is thin, place a little more loose with the AHD/humeral arm ratio at 10 or less If the joint is very stiff and bone quality is poor, try not to distalize as much and favor lateralization to decrease load on acromion Lateralize to maximize ER strength Repair subscap for stability and IR Can use eccentric sphere with eccentricity posterior to gain IR ROM Possible tuberoplasty to obtain impingement free ROM

Customize the Reverse If the function ( FE and ER ) are good preop, then try not to alter the deltoid length/tension relationship (ie do not get the deltoid off of Blix curve). Minimize the amount of lengthening If there is an ER lag, then consider a lat transfer To gain active IR, place humeral component in less retroversion, minimize lengthening, increase subcoracoid space (room for LT to pass under conjoined tendon)

Massive RCT without OA Several factors are associated with recurrent RCT’s and poor outcomes Age greater than 70 Massive tear (greater than 2 tendons) Goutallier II or greater fatty infiltration In these cases a reverse might be a better option especially if it is a revision If the preop function is OK, then a partial repair with limited decompression could be considered or SCR

Proximal Humeral Malunion Some humeral malunions associated with bone loss and cuff dysfunction require the use of a reverse

Proximal Humeral Malunion In this case a lat transfer was performed as well and some of the humeral bone loss was addressed with modular prosthesis

Surgical Neck Nonunions One of the first expanded indications Martinez et al evaluated 18 nonunions treated with reverse (6 with humeral allograft) Significant improvement in Constant scores with FE improving from 350 to 900 and ER from 150 to 300 2 dislocations

Surgical Neck Nonunions It is important to address the posterior cuff to prevent an ER lag This case was performed before we had fracture specific stems Now I use fx specific stems and treat like reverse for fx If the bone is too bad, consider using humeral allograft with cuff attached and sew allograft to native cuff

Reverse for glenoid retroversion Walch reported a 20% rate of glenoid loosening in B2 glenoids and this correlated with : >70% subluxation of humeral head >270 of glenoid retroversion

Reverse for glenoid retroversion This was a female patient who was very stiff with 00 ER Wanted to lateralize and did so with bone graft Know your system and what it can do

Reverse for glenoid retroversion Large male patient with B3 glenoid with 270 retroversion Stiff with preop FE 700 and 00 ER Glenoid vault 19mm

Reverse for glenoid retroversion -The patient was large enough (humerus) to accept this prosthesis which allows more lateralization through the prosthesis obviating bone graft. -70% of the baseplate was supported by native glenoid

How much support do you need? Formaini and Levy et al evaluated the amount of support required by the baseplate in a foam bone model Found that 25% was the point at which there was enough micromotion (150microns) that might impede bone integration Formaini et al JSES 2015

Glenoid Bone Loss in Revision Cemented hemiarthroplasty with 10mm glenoid vault depth

Glenoid Bone Loss in Revision Scapular allograft can be used. Perform the reverse on the scapula Cut out the portion that is needed

Glenoid Bone Loss in Revision Impact the baseplate into position and secure with screws Graft integrated after one year

Contained Glenoid Bone Loss Loose keeled glenoid with RC deficiency Intraop picture of contained defect

Contained Glenoid Bone Loss Preparing iliac crest with baseplate reamers Iliac crest graft in place in defect

Combined Deficiencies and Instability Problems: -Chronic anterior instability -RCT -Chronic soft tissue contracture -Glenoid bone loss

Combined Deficiencies and Instability Anterior bone loss The native head is used as graft

Combined Deficiencies and Instability Solutions: -Head is used as graft -Soft tissue contractures are released -Reverse TSA performed for RC deficiency and to provide stable fulcrum for rotation

Failed Hemi’s for Fracture Standard reverse without need for grafting the glenoid Cemented into existing mantle and secured tuberosities to shaft

Failed Revision Reverse TSA Problems: -Tuberosities failed to heal -Proximal humeral bone loss -Increased stress on implant caused it to fracture

Revision Reverse Arthroplasty Boileau et al evaluated 37 revision reverses Found 48% were for instability, 21% for humeral loosening or fracture, and 19% for infection Instability was associated with humeral shortening and medialization Loosening and fractures associated with proximal humeral bone loss There is some overlap in causes but lets see how address these

Failed Revision Reverse TSA Humeral allograft (APC) performed after all the cement was removed APC cabled in place. Allograft comes with RC still attached and is sutured to the anterior and posterior cuff (soft tissue) for stability

Failed Revision Reverse TSA 1 year out from revision with allograft incorporating

Reverse TSA Indications The most predictable outcome is in the primary CTA patient or the patient with a failed RCR The most difficult are the combined deficiencies such as with glenoid and humeral bone loss, RC insufficiency, and instability. It is even more challenging in the patient with with a cemented stem that needs to be removed

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