This week’s Orthopaedic Crossfire® debate was part of the 18th Annual Current Concepts in Joint Replacement® (CCJR®), Spring meeting, which took place in Las Vegas. This week’s topic is “Four-Part FX in an Active 70-Year-Old: Reverse Is Overkill” For is William N. Levine, M.D., Columbia University, New York, New York. Opposing is Jon J.P. Warner, M.D., Harvard Medical School, Boston, Massachusetts. Moderating is Thomas S. Thornhill, M.D., Brigham and Women’s Hospital, Boston, Massachusetts.
Intro: Moderator Thornhill: Ringling Brothers Barnum and Bailey circus closed their tent after 146 consecutive years so now the greatest show on earth is CCJR.
Seth is the CCJR ringmaster and has put this meeting on for 36 years in Orlando and 18 years here in Las Vegas for a total of 54 times. He has trained over 2,500 orthopedic surgeons from around the world. Seth you are a true innovator in orthopedic education. You can see this sort of electronic use and everything else that we have and we all owe you a great deal of gratitude.
We are going to start out with a very interesting and very pertinent shoulder debate; “Four-Part FX in an Active 70-Year-Old: Reverse is Overkill” and the affirmative is my friend Bill Levine, Chairman at Columbia University.
Dr. Levine: We are talking about reverse shoulder and I am against a guy who is brilliant, erudite and Past President of the American Shoulder and Elbow Society (ASES).
He runs an institute for crying out loud, so it’s really hard to go against that.
AND he is friends with legendary Harvard Professor Michael Porter which he’ll tell you about, I’m sure, throughout his talk.
I’m just a simple guy from Fargo, North Dakota. I was born in 1964—which was the same year Supreme Court Justice Potter Stewart said about pornography; “I know it when I see it”. I feel the same way about value.
Point number 1: we are operating on way too many proximal humeral fractures and I think all of us need to recognize that.
Vani Sabesan from Michigan did a registry review looking at 550,000 patients from 2004-2014 (Aging Clin Exp Res, 2017). The ORIF prevalence in that 10-year period is going through the roof and the reverse shoulder is starting to come close to hemiarthroplasty for four-part fractures. They extrapolated their data out to 2032 and pretty much everybody in the room is going to get a plate and lots of us are going to have reverses on the current trend.
So why would you use a reverse total shoulder arthroplasty? It’s more expensive. It leads to more functional restrictions for this active 70-year-old patient. And there are more long-term durability concerns than other options.
Why not use a hemiarthroplasty? It’s less expensive, there are no restrictions in function and it leads reliably to pain relief.
Here is a real problem JP is going to have to defend. His good friend Rich Hawkins from South Carolina recently published a paper with JT Tokish showing that reverse isn’t even better than doing nothing in their small cohort (JSES, 2016). I am wondering what JP is going to say to us in a few minutes.
Point number 2: comparing hemiarthroplasty to reverse. We have poor studies of a retrospective nature, very small numbers.
If we look at what is available there is a study back in 2009 (Gallinet, Orthop Trauma) that showed better forward elevation and better abduction with reverse but, not surprisingly, better rotation because of tuberosity healing with hemiarthroplasty. Their DASH scores or patient reported outcomes were identical.
Here is the real concern reported in this paper: 3 patients had tuberosity failure which we know leads to catastrophic failure for hemiarthroplasty (n=21). But 15 of this very small cohort of reverse patients (n=19) had scapular notching, which initially we thought wasn’t a big deal, but now following the French 30-year history with reverse, we know is a big deal and does lead to clinical failures.
A systematic review by my former fellow, John Bell (JSES, 2013), showed improved forward flexion and functional outcomes with reverse as well as equal complications. And our Canadian colleagues showed in a cost utility model using Canadian data, very clear to point out, not American data, found a reverse was more cost effective than a hemiarthroplasty (Osterhoff, Value in Health, 2017).
