If we look at Level II evidence (it’s very hard to get to Level I) we find a study that compared hemiarthroplasty versus reverse total (Cuff and Pupello, JBJS-Am 2013). They found a statistically significant difference in the ASES score and active flexion in terms of hemiarthroplasty versus reverse total (62 vs. 77 and 100 vs. 139, respectively). Another study (Chalmers, et al., JSES 2014), same thing, very significant difference in reverse total versus hemiarthroplasty. In a Level II comparative analysis (Sebastia-Forcada, et al., JSES 2014), the authors report that reverse total shoulder procedures, if done properly, and I think the learning curve is dropping significantly for people, are very successful.
Why is this a problem?
If you have a malunion and the anatomy is distorted, Gerber and others (Raiss, et al, JBJS 2016) have shown us that the outcome of reverse as a salvage is poor. Your best shot is your first shot.
If you look at the Constant score and flexion in those settings, not so good: 9.5% complication rate, improvement is not as good as with a primary reverse for proximal humerus fracture. Your best success is acute reverse and if you look at primary versus revision you can see the difference (Dezfuli, et al., JSES 2016).
Now, one word about value.
Reverse is more cost effective than hemiarthroplasty whether it’s Canadian dollars or U.S. dollars. It doesn’t matter because the complications in post-acute care are critically affected by the speed with which an individual mobilizes and the lack of complications.
Final point. I would tell you that I can show you show case after case after case of individuals over 70 who would agree with me about the quality of life that this gives them.
Moderator Thornhill: You know it’s very interesting that Dr. Neer who taught all of us a whole lot had a very good way of taking the patients who weren’t going to do well and put them into the category of limited goals, so I think it would be a nice thing to be able to take a Mulligan when you can.
I have a question and maybe to both of you. Bill, tell me do you think that the status of the rotator cuff at the time of the fracture would alter or have you chosen reverse versus hemi?
Dr. Levine: Oh, no question. If you are considering a standard hemiarthroplasty we always have to talk to the patient about making an intraoperative switch to a reverse if there is any question about the cuff integrity or the tuberosities.
If the tuberosities are quite poor, horribly osteoporotic, where you know you are going to have tuberosity concerns, I don’t think you are doing that patient any favors by doing a hemiarthroplasty. The only thing I would say about this debate, since we are supposed to choose the sides and go with it in a biased fashion, is that J.P. gave a phenomenal talk, but he didn’t really talk about the main issue. This being, what do you do with the 71-year-old active patient? Not most 70-year olds. The 71-year-old who wants to play tennis and wants to do higher level activities. Are you going to let that patient do all of those things with the reverse and then potentially diminish their durability? That’s the challenge I think we face with the reverse because of course we get the great results that you showed for routine daily life activities.
Moderator Thornhill: So, J.P., rotator cuff, is it important? And my second question to you is: Would you let a patient on the dominant side play tennis after a reverse?
Dr. Warner: The answer is yes and not just yes but yes with evidence, at least individual evidence. At 71-years old they are playing recreational tennis and golf for that matter. The other point about the rotator cuff I think is less the issue than bone quality to be fair. And as long as we are talking about data, the Australian registry has clearly shown that reverse has greater durability than total shoulder arthroplasty.
Moderator Thornhill: Who should do these reverse shoulders?
Dr. Warner: Well, I think anyone can do them although there is a significant learning curve. Outcomes drive things, period, end of story.
Moderator Thornhill: Okay gentlemen, thank you very much, it’s a wonderful debate. It’s interesting this sort of is the old adage that orthopedists use data like drunks use lamp posts much more for support than illumination so they did a great job. Thank you.
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