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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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)

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

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

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

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

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

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

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

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

27. 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

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

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

30. 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

31. 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

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

33. 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

34. Thank You