1. Evolving Role of Reverse Shoulder Replacement Derek Cuff, M.D. Suncoast Orthopaedic Surgery and Sports Medicine Gulfcoast Orthopaedic Rehab Conference

2. Evolving Role of RTSR Goals – 1. Discuss initial use of RTSR – 2. Discuss how the implant works – 3. Discuss newer indications – 4. Discuss how we rehab these patients

3. Evolving Role of RTSR Indications – Primary: Glenohumeral arthritis and massive rotator cuff tear

4. Evolving Role of RTSR – RTC centers humeral head – Provides stable fulcrum – Deltoid assists with elevation

5. Evolving Role of RTSR

6. Massive RTC tear destabilizes the shoulder Alters the mechanics of the shoulder With time degenerative changes may occur

7. Evolving Role of RTSR Arthropathy develops – Inability to overhead elevate – Pain – Poor function

8. Evolving Role of RTSR

9. How does it work? – Takes torn rotator cuff muscles out of equation – Recruits healthy deltoid muscle to take over and do the work – Gives stability and smooth painless surfaces to allow motion

10. Evolving Role of RTST Reversing Joint gives a stable fulcrum Deltoid can fully elevate arm Humerus rotates around fixed sphere

11. Operation Remove arthritis from humeral head – Replace with metal stem and plastic socket Remove arthritis from glenoid – Replace with metal glenosphere

12. FDA approval in 2003 Cuff et al., 2008- 93% success rate Cuff et al. 2012- 94% survivorship at 5 years 10 year data coming in the next year

13. Evolving Role of RTSR Early success has led to new sets of indications Multiple other complex problems can be addressed by RTSR Utilized as a salvage treatment for difficult clinical scenarios

14. Evolving Role of RTSR Massive RTC tear with no OA – Failed previous repairs – Ignored chronic tears – Using an artificial implant for a soft tissue problem

15. Mulieri et al, 2010 – 69 patients in study – Good results – 92% patients were satisfied – Option as last resort for these patients

16. Evolving Role of RTSR Failed total shoulder – Unstable – Rotator cuff non-functional – Deltoid can still power this – Black et al. JSES 2014 36 patients with good results

18. Evolving Role of RTSR Severe proximal humerus fracture in elderly – Partial replacement with repair of the tuberosities was standard – If they don’t heal then poor function – Reverse relies on the deltoid to power

19. Evolving Role of RTSA Cuff et al JBJS 2013 – RTSA – 27 patients – 91% success rate – Hemiarthroplasty – 24 patients – 61% success rate

20. Evolving Role of RTSR Failed ORIF of fracture – Remove hardware and place a reverse

21. Evolving Role of RTSR Chronic dislocation in elderly – Often has glenoid bone lose – Often have RTC tear – Restores stability and function

22. Evolving Role RTSR Post-op PT controversial – All over the board – Sometimes repair subscap at end of the case – Often no rotator cuff left to protect – Still concerns about instability post-op

23. Evolving Role of RTSR Biggest early concern First 12 weeks Beware of over aggressive motion Avoid WB/pushing up from chair

24. Evolving Role of RTSR My approach – Immobilizer for 6 weeks – Pendulums and active elbow wrist and hand – Outpatient PT weeks 6-12 for ROM – Gentle strengthening at 12 weeks

25. Evolving Role of RTSR Watch out for acromial stress fracture Typically 3-4 months post op Notify surgeon ASAP Otto et al., JSES 2013; 2-3% incidence

26. Summary You will see more and more RTSR patients in the coming years Salvage option for many conditions Important to familiarize yourself with procedure PT may be highly variable between surgeons

27. Thank You