How about another one? Different implant, 2-year follow-up, great outcomes. Similar radiolucent scores compared to a non-wedge poly (Bull, HJD, 2015). These are encouraging.
Well, let’s talk about reverse. And John didn’t really touch on reverse for these bad retroversions. He showed us a slide from the Australian Joint Registry that was all comers of reverse. Reverse with posterior glenoid bone loss is a problem. And here’s the expert—Gilles Walch (J Bone Joint Surg Am, 2013)—27 reverses, 32 degrees retroverted; 4.5-year follow-up; 15% complications. Baseplate loosening; neurologic injury, notching.
This has been repeated by another study by another group—McFarland (J Bone Joint Surg Am, 2016)—42 patients. Again, highly retroverted; 32 degrees. He also found baseplates failing, requiring revision.
A case of mine—59-year-old woman; B2 glenoid, 25 degrees retroverted. She is 2-years post-operative and has amazing motion. She wouldn’t have that with a reverse, John.
So, what’s the best study out there comparing things? Well, this is a study from our expert, John Sperling, comparing total shoulders to reverses in exactly the patient cohort we want (J Orthop Surg (Hong Kong), 2018). Those with B2 glenoids. Those with posterior wear. This is hot off the presses, just this year. Here’s what he found. He found that there were zero revisions in his total shoulder patients, and that total shoulder patients had better ASES [American Shoulder and Elbow Surgeons] scores and higher satisfaction than his reverse patients.
In conclusion, total shoulder for B2 with balancing provides better pain relief, motion and strength. Reverse provides worse functional outcomes measured by ASES and satisfaction. So, total shoulder should be considered. It does risk developing radiolucent lines, but it doesn’t burn the bridges like a failed reverse.
There’s a great quote by a Nobel Prize winner, Christian Lange, “Technology is a useful servant, but dangerous master.”
Moderator Thornhill: Charlie used some of your published material in order to make his points. I feel honor-bound to give you a minute to respond.
Dr. Sperling: We’ve learned over time that recovery for the reverse is different than the anatomic. It allows you to accelerate the rehab program. Many patients with bone deficiency are elderly and live alone. The reverse allows you to address that.
Moderator Thornhill: Okay, so Charlie, how much retroversion in the glenoid, based on CT, would you think that you could still grind down the anterior part of the glenoid?
Dr. Jobin: I think that there are a few concepts. One is high side reaming. One is an augmented poly. And a third would be reverse. My sort of cut-off for these high side reaming is the 20-degree mark—15 to 20 degrees—I’m worried about not being able to correct that to neutral or to within 10 degrees. When I’m passed that 20-degree mark, I’m considering augmented polyethylene. And if I’m way outside C glenoid B3 type range, I definitely have reverse as a back-up.
But I can tell you, my reverse patients—while the recovery is faster, they do not have the same satisfaction, the same range of motion. They have trouble going behind their back to use the toilet. They have trouble cutting their steak. They don’t have that internal rotation strength. So, it’s a different type of success and it’s not as good as a total shoulder.
