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J Biomech ; 37 11 : Chirurgie ; 99 9 : Using structural bone grafts with a cemented TSA implant on the glenoid side will result in high complications with little bone incorporation, he said. Using glenoid bone grafts with reverse arthroplasty has been a major value for us, allowing better alignment of the glenoid to its more natural state in conjunction with the placement of the metaglenoid or glenoid base plate.
While the graft is often successful, there is currently no consensus on the best graft type. Autograft is used by most surgeons for primary RSA, but insufficient results using allograft, autograft and bone graft substitutes has lead many surgeons to choose a method that works best for them, Iannotti said.
Even after learning the basic tenets of RSA, there is a steep learning curve associated with the procedure. I believe that has been the learning curve, and there is no question that time, for me anyway, has made me comfortable with all those issues. Once the surgeon understands the biomechanics and design features of the reverse arthroplasty and they have had the opportunity to witness the various steps performed by an expert, they can extrapolate their skills with total shoulder arthroplasty in terms of the exposure and management of the soft tissues and apply this to the reverse arthroplasty.
Some initial published reports noted high complication rates with RSA. The investigators found noticeable radiographic changes in the implant at 5 years. The rate of short-term complications has decreased in recent years due to increased surgical experience with the procedure, Wirth said.
In his first year of performing RSA, he had five cases of instability. However, he noted that during the past 4 years, he has not had a case of dislocation. Milder complications, such as hematomas, often do no warrant another surgical intervention, he added. I would say [complications are] considerably lower if you look at the mainstream patient group who meets the primary indication.
Revising a reverse can be difficult based on the lack of glenoid bone, as opposed to the humeral-side bone loss, which can be solved with a long RSA stem or intercalary allograft. In these cases, Iannotti said he uses a two-stage salvage procedure that manages components based on bone incorporation. Conservative pain management, resection arthroplasty and fusion are options for failed RSA procedures in elderly patients or in patients with severe bone loss or comorbidities.
The key to determining the next step in managing a failed RSA is to find out the cause of implant failure, Iannotti said. In some cases, the answer for a failed RSA is a revision with bone grafting on the glenoid side, Romeo said. Although the prices of reverse shoulder implants are often twice that of traditional shoulder implants, hospitals receive the same reimbursement regardless of which procedure is performed. Although Wirth said there is no discussion about reimbursement for RSA at his university hospital, he noted that several colleagues working in for-profit hospitals have been asked to limit the number of RSAs performed per year because the hospitals lose money with each procedure.
It will be less of a controversial issue of [whether] I use a Grammont style prosthesis or do I use a lateral offset prosthesis. Hopefully, there will be fewer stems that have to be removed just to put in a reverse. Initially, my indication for reverse shoulder arthroplasty was limited to rotator cuff arthropathy in patients 70 years old and older. As I have become more comfortable with the outcome and longevity of the procedure, I have lowered the age that I consider performing a reverse arthroplasty.
In addition, I have expanded the indications to include massive irreparable rotator cuff tears with pseudoparalysis, inflammatory arthritis with rotator cuff insufficiency and acute four-part proximal humeral fractures in elderly patients. It has also become clear to a number of surgeons that the amount of glenoid bone stock necessary for a reverse arthroplasty is less than that for an anatomic glenoid component.
Therefore, reverse arthroplasty may be considered in patients with an intact rotator cuff and severe glenoid bone loss in both the primary and revision setting. Biomechanical and clinical research has significantly improved our understanding of key technical aspects of the procedure to improve survival and minimize complications. The availability of uncemented humeral designs has also significantly advanced the use of reverse arthroplasty.
This has decreased the overall operative time and facilitated the ease of future revision surgery if necessary. Convertible stems that can be used for hemiarthroplasty, total shoulder arthroplasty or reverse arthroplasty have also significantly improved flexibility at the time of surgery.
In the younger patient, advanced bearing surfaces have been introduced in an effort to decrease polyethelene wear. Therefore, encouraging clinical experience coupled with supportive peer-reviewed published data has resulted in the expansion of indications for the reverse arthroplasty. Paul Grammont. This French surgeon is credited with the creation of reverse shoulder replacement. Focused on finding a way to help those with rotator cuff tears too severe for standard shoulder replacements, this innovative design literally reversed the orientation of the ball and socket.
Since reverse total shoulder replacement has been successfully used across the world. Europe has led the way with this procedure and the knowledge of these past procedures has been used to continually improve shoulder surgery for people across the globe. If you are considering shoulder replacement surgery, but you do not fit the normal candidacy, this alternative to a standard shoulder replacement might be correct for you.
One of the biggest factors taken into account when deciding upon the best surgery options for a patient is to determine the condition of the rotator cuff.
Reverse shoulder replacement is best for candidates who have a severely torn rotator cuff. Remember, rotator cuffs are not always torn through one traumatic incident, they often tear over time. The first step towards discovering if this surgery is right for you is to consult with an experienced surgeon. Any surgical procedure comes with its own set of risks and benefits. It truly is important that you feel comfortable asking your surgeon any questions you have and that you are provided with a thorough evaluation.
If you are interested in scheduling a consultation with Dr. Kovack, click here to get in touch. Kovack is an experienced reverse total shoulder replacement surgeon in Ohio. Have you been told that you need a total shoulder replacement but you are too young or too active but cannot live with the pain and want a solution?
There is an alternative to conventional shoulder replacement for you - Total Shoulder Resurfacing. Have you been told you need a shoulder replacement? Make sure you do your homework because there are different options depending on the circumstances. Make sure you chose the right surgeon and the right option for you.
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