This week’s Orthopaedic Crossfire® debate was part of the 19th Annual Current Concepts in Joint Replacement® (CCJR®), Spring meeting, which took place in Las Vegas. This week’s topic is “Severe Glenoid Bone Loss in a 70-Year-Old: Reverse is the Way to Go.” For is John W. Sperling, M.D., Mayo Clinic, Rochester, Minnesota. Opposing is Charles M. Jobin, M.D., Columbia University, New York, New York. Moderating is Thomas S. Thornhill, M.D., Harvard Medical School, Boston, Massachusetts.
Patients over 70 years old are a large and growing patient population and many live alone at home.
For this patient population, what are the potential benefits of an anatomic total shoulder arthroplasty? One benefit comes to the top and that is improved internal rotation compared to reverse shoulder arthroplasty.
What are the challenges of anatomic total shoulder arthroplasty?
Longer operating room time. Longer recovery with the need for assistance to allow the subscapularis to heal.
With the anatomic, it’s critical to get the subscapularis to be able to heal for good function of the implant. There is also a more difficult glenoid exposure compared to reverse shoulder arthroplasty. Additionally, implant position of the glenoid is much less forgiving with an anatomic compared to reverse shoulder arthroplasty. And there is also a concern over a higher rate of glenoid loosening.
Now, what are the benefits of reverse shoulder arthroplasty?
Shorter operating room time. Faster recovery without the need for the subscapularis to heal.
Many U.S. surgeons have abandoned closing the subscapularis at the end of a reverse shoulder arthroplasty. There’s no doubt there’s easier glenoid exposure with a reverse compared to an anatomic. And, the sphere of the glenosphere does provide a more forgiving implant position compared to an anatomic glenoid.
The reverse arthroplasty does give you the ability to better manage joint subluxation. It eliminates the concern over rotator cuff insufficiency as patients age.
We know, of course, that rotator cuff deficiency and insufficiency increases with age and the reverse arthroplasty provides you some assurance that cuff failure will not doom your implant to failure. There is also a lower rate of glenoid loosening when compared to anatomic.
The Australian Joint Registry follows patients very methodically. Reviewing the overall cumulative percent of revision of primary total shoulder arthroplasty and comparing anatomic to reverse, there is a higher rate of revision with reverse in the first six months, but over time the risk of revision is much higher with an anatomic than reverse arthroplasty.
You also have a better ability to manage glenoid bone loss. There is a wide variety of different systems out there that allow you to be able to do that and preserve glenoid bone.
For a recent 72-year-old female patient of mine who lives alone at home and had a longstanding history of shoulder arthritis and significant bone loss, we made up for the missing bone with an augment. We put the pin in and were able to ream the glenoid down to get approximately 50% contact. We prepared the glenoid, reamed the deficient side and were able to place an implant that made up for the missing bone.
So, in conclusion, the increased technical difficulty of an anatomic total shoulder together with concerns of subscapularis insufficiency, glenoid component loosening, and a lack of strong evidence of superiority do not warrant changing from reverse arthroplasty in patients over 70 years old.
