Study
Etiology
Age
F/U(mo)
# RSA
Forward flexion
External rotation
Constant
ASES
Satisfaction (%)
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Sirveaux et al. [27]
CTA
73
44
80
73
138
–
–
23
66
–
–
93
Frankle et al. [24]
CTA
71
33
60
55
105
12
41
–
–
34
68
95
Naveed et al. [25]
CTA
81
39
50
55
105
–
–
–
–
19
65
–
Nolan et al. [26]
CTA
74
24
71
61
121
14
15
28
62
26
76
–
Boileau et al. [16]a
CTA, revision, fracture sequelae
72
40
45
55
121
7
11
17
58
–
–
91
CTA
–
–
21
53
123
9
14
18
66
–
–
95
Cuff et al. [17]
CTA, MCT, prior RCR, revision, nonunion
70
62
74
64
144
15
51
–
–
32
75
–
Cuff et al. [18]
CTA, MCT, prior RCR, revision, nonunion
72
28
96
64
118
13
28
–
–
30
78
94
Ek et al. [19]
CTA, MCT
60
93
40
72
119
27
26
34
74
–
–
–
Favard et al. [20]
CTA, MCT, primary OAb
73
90
148
69
129
2
11
33
85
–
–
–
Wall et al. [22]a
Mixedc
73
40
191
86
137
8
6
23
60
–
–
93
CTA
–
–
74
76
142
5
7
22
65
–
–
96
Werner et al. [23]a
CTA, revision, prior surgery
68
38
58
42
100
17
12
29
64
–
–
–
CTA
–
–
17
43
103
–
–
35
72
–
–
–
In an early RSA multicenter study, Sirveaux et al. [27] evaluated 80 Grammont-style RSA in patients with massive irreparable rotator cuff tears and glenohumeral arthritis from 1991 to 1999. A variety of surgical approaches were used including superolateral (72 %), deltopectoral (20 %), transacromial (4 %), and mixed (4 %). Additionally, the implant underwent multiple design changes during this time period, most notably on the glenoid side, which transitioned from a threaded implant to a Morse taper. Despite this variability, the results of the study demonstrated dramatic improvements in Constant score (22.6–65.6 points), forward elevation (73o–138o), and external rotation in abduction (17o–40o) with 96 % of patients demonstrating no or minimal pain and 93 % patient satisfaction at an average of 44-month follow-up. The authors did note a significant difference in the improvement of the Constant score with an intact teres minor muscle (67 vs. 58 points, p = 0.01). The complication rate was not clearly defined in this study; however, 6.3 % of patients experienced glenoid loosening and implant migration with a 25 % rate of stable radiolucency. Prior to the Morse taper design change, unscrewing of the glenosphere occurred in 7 of 19 cases (37 %). Inferior scapular notching occurred in 64 % of shoulders and although not considered a complication, the authors noted a significant (p < 0.05) decrease in Constant score with grades 3 and 4 notching [27].
In the first study which utilized a glenosphere with a more lateralized center of rotation, Frankle et al. [24] evaluated 60 RSA performed by a single surgeon on patients with CTA and glenohumeral arthritis at a mean of 33-month follow-up between 1998 and 2002. Patients demonstrated significant improvements (p < 0.0001) in the range of motion (ROM) and outcomes measures with 95 % patient satisfaction. American Shoulder and Elbow Surgeons (ASES) Total scores improved from 34.3 to 68.2 points. Visual analog scale (VAS) function improved from 2.7 to 6.0, and VAS pain improved from 6.3 to 2.2. Forward elevation improved from 55o to 105o, and abduction improved from 41o to 102o. For the first time, improvements in external rotation were described for RSA, with improvements observed from 12o to 41o. While there were no cases of scapular notching, a complication rate of 17 % was observed. Revision was required for 7 patients (12 %) due to glenoid baseplate failure [24].
Naveed et al. [25] evaluated 50 Grammont-style RSA performed by a single surgeon with an average 39-month follow-up. All prostheses were Delta III reverse replacements performed after 1999 reflecting the modern baseplate design changes. The authors transitioned from the use of a deltoid splitting approach to a deltopectoral approach for improved access to the inferior glenoid for baseplate placement. The authors demonstrated significant (p < 0.001) improvements in ASES, Oxford Shoulder Score (OSS), and forward elevation. Mild to no pain was reported by 84 % of patients while 16 % reported moderate pain. Scapular notching was noted in 70 % of patients. Complications were reported in 7 patients (14 %) with 4 (8 %) requiring further surgery [25].
Nolan et al. [26] examined a single surgeon cohort of 71 RSA performed for Hamada grades IV and V CTA at an average of 24-month follow-up. The authors demonstrated significant improvements in ASES, Constant score, subjective shoulder value (SSV), VAS pain, and forward elevation. Forward elevation improved from 61o to 121o, and external rotation was not significantly improved. The reported complication rate was 23 %; however, authors, unlike others, included many systemic complications most of which were minor. Considering only implant-related complications, the rate was 17 %; there were no revisions or reoperations. Notching occurred in 49 % of patients and 13 % demonstrated baseplate radiolucency [26].
Results for CTA with Glenohumeral Osteoarthritis in Series with Heterogeneous Populations
Wall et al. [22] evaluated the results of 191 Grammont-style RSA according to etiology with an average 40-month follow-up. CTA with glenohumeral arthritis comprised 30 % of the cohort while revision arthroplasty accounted for 23 %. The entire cohort demonstrated significant improvements in Constant score (22.8–59.7 points) and forward elevation (86o–137o) with 93 % satisfaction. Patients with revision arthroplasty and posttraumatic arthritis did worse than those with primary rotator cuff disease and/or osteoarthritis for Constant score (p = 0.006) and forward elevation (p = 0.001) with 89 % satisfaction versus 96 % (p = 0.083). These differences were attributed to preoperative level of dysfunction as magnitude of improvement was not significantly different between groups. Patients with CTA and glenohumeral OA demonstrated improvement in Constant score from 21.7 to 65.1, forward elevation from 76o to 142o, and external rotation in abduction from 29o to 43o. The overall complication rate was 19.1 % with a significant difference between revision and primary surgery (36.7 % vs. 13.3 %, p < 0.001) [22].
Werner et al. [23] assessed 17 patients with primary CTA and 41 patients undergoing revision surgery, including 21 patients with previous arthroplasty. The entire cohort demonstrated significant improvements in SSV, Constant score, forward elevation, and abduction (p < 0.0001) with a similar magnitude of improvement between groups. The final Constant score was significantly better in the primary surgery patients (72 vs. 58, p = 0.03). The overall complication was 50 % and similar between groups (47 % primary vs. 51 % revision); however, the reoperation rate differed significantly (18 % primary vs. 39 % revision, p = 0.005). There were no failures or prosthesis removals in the primary surgery group, 6 occurred in the revision group. The elevated complication rate can be attributed to the inclusion of postoperative hematoma as a complication. It has been suggested that postoperative hematoma is more common after RSA due to increased dead space in the glenohumeral joint. Notching occurred in 96 % of cases [23].
Boileau et al. [16] demonstrated significant improvement in Constant scores and forward elevation in 45 patients after 40-month follow-up. RSA was performed for 21 patients with CTA (Hamada II-V), 19 patients for revision, and 5 patients for fracture malunion. The Constant score (p = 0.01), adjusted Constant score (p = 0.004), ASES score (p = 0.002), and pain score (p = 0.01) were better in the CTA group. The overall complication rate was 24 %; however, the revision group experienced a higher complication rate (47 % vs. 19 %) and reoperation rate (45 % vs. 5 %) than the CTA group [16].
In 2008, Cuff et al. [18] reported on 96 lateralized RSA utilizing a redesigned baseplate with 5.0-mm peripheral locking screws to improve fixation over a previous study and an improved mastery of surgical techniques [24]. In this heterogeneous population, they demonstrated significant improvements in ASES, simple shoulder test (SST), forward elevation, abduction, and external rotation (p < 0.0001) with 94 % patient satisfaction. The patients with rotator cuff deficiency had significantly higher ASES scores (p < 0.001), SST scores (p = 0.009), and ROM than the group undergoing revision for failed arthroplasty. The complication rate was 9.4 % with no cases of baseplate mechanical failure [18], improving this surgeon’s earlier experience with the RSA procedure [24].
Most recently, Ek et al. [19] published on the results of RSA performed in patients younger than 65 years of age for irreparable rotator cuff tears with or without glenohumeral arthritis. The cohort consisted of 40 Grammont-style RSA with an average 93-month follow-up. The complication rate was 37.5 % with a 25 % rate of revision or implant removal. Despite the high complication rate, significant improvements in Constant score, SSV, forward elevation, abduction, pain, and strength were noted (p < 0.001) in patients that retained a RSA. There were no differences between patients with and without glenohumeral arthritis. Results were also unaffected by previous rotator cuff surgery. Notching occurred in 56 % of patients with increasing prevalence and stage over time. Constant scores were significantly better for patients without notching (85.6 % vs. 65.6 %, p = 0.02) [19].
These studies demonstrate the power of RSA to improve pain and function in patients with rotator cuff tear arthropathy and glenohumeral arthritis. Reliable improvements in pain and function can be expected for a variety of etiologies; however, patients with CTA and glenohumeral arthritis demonstrate significantly better functional results and decreased complication rates [16, 18, 22, 23].
There are several important observations that can be extrapolated from review of the literature. The literature universally reports that patients treated for primary rotator cuff tear arthropathy demonstrate the best overall outcomes after RSA. Additionally, those surgeons who have reported results at different time points have observed improved results over time—relating to improvements in implant design, surgical technique, and surgeon experience. This has since been confirmed in several studies which have attempted to quantify a learning curve for performing RSA [28–31]. Despite these dramatic functional improvements, concerns over implant longevity and complication rates have led most authors to recommend limiting the use of RSA to elderly, low demand patients [32]. As further study of long-term outcomes evolves, our confidence in utilizing this technology for younger, more active patients may change.
Implant Survivability
Although RSA has been performed in Europe for over 20 years, the technology was approved by the FDA in 2003 for use in the USA. Therefore, the majority of early reports focused on short- and medium-term outcomes. The use of RSA has traditionally been recommended in elderly, lower demand patients, in part, due to this lack of long-term follow-up data. As demonstrated in Table 14.2, several recent studies have addressed the issue of longevity with survival analyses utilizing various endpoints including survival free from revision, loosening, pain, and decreasing Constant scores [17, 19–21, 27].
Table 14.2
Implant survival rates
Study | # RSA | F/U(mo) | Revision | Loosening | Pain | Constant <30 |
|---|---|---|---|---|---|---|
Sirveaux et al. [27] | 80 | 44 | 95 % 8 years | 91 % at 5 years 75 % at 7 years 30 % at 8 years | 88 % at 5 years 72 % at 7 years 29 % at 8 years | – |
Guery et al. [21]* | Entire cohort (80) | 70 | 91 % at 10 years | 84 % (10 years) | – | 88 % at 6 years 58 % at 10 years
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 2 Reverse Total Shoulder Arthroplasty: Biomechanics and Design Challenges
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