The Reverse Total Shoulder Prosthesis

The article entitled “The Use of the Reverse Shoulder Prosthesis for the Treatment of Failed Hemiarthroplasty for Proximal Humeral Fracture” by Levy et al. in this issue describes how the reverse shoulder prosthesis offers a reasonable, and perhaps the only, salvage solution for the complications that occur following the use of a prosthesis for the treatment of some fractures of the proximal part of the humerus. The authors point out that the reverse shoulder prosthesis should only be implanted by shoulder surgeons who have experience in reconstructive shoulder surgery.

As one of the senior shoulder surgeons in this country and a founding member of the American Shoulder and Elbow Surgeons, I wrote this editorial to let the reader know that, yes indeed, there is a new and different prosthesis that is available for the treatment of selected severe uncommon shoulder problems. While I have a financial relationship with the DePuy Orthopaedics company in that I receive royalties from several of their shoulder products, I do not implant their Delta Reverse Shoulder Prosthesis, nor do I receive royalties for its use. The reverse shoulder prosthesis is indeed a new concept in the United States for the management of patients who have irreparable loss of the rotator cuff and severe arthritis of the shoulder combined with severe loss of shoulder function. This prosthesis was first developed by Professor Paul Grammont in the mid-1980s in Dijon, France, and has been extensively used in Europe up to the current time. The original prosthesis consisted of an all-polyethylene trumpet-shaped humeral component that articulated with a metal or ceramic ball that was secured in the glenoid1. Both components were cemented in place. The preliminary findings were published in 1987 and, because of unsatisfactory results, modifications were made by Professor Grammont until the Delta III version became available in 19912,3. The name of this prosthesis is significant in that, as there is extensive loss of the rotator cuff, the deltoid muscle alone is used to power shoulder function. The Grammont Delta prosthesis was produced by Medinov in Roanne, France, and was later purchased by Landanger in France and then by DePuy Orthopaedics of Warsaw, Indiana, which is a subsidiary of Johnson and Johnson. Because the prosthesis had been used so extensively in Europe, it was submitted to the Food and Drug Administration for approval for use in the United States. Approval was granted in late November 2003, and the first surgery was performed in March 2004. The other companies in the United States that market a reverse shoulder prosthesis are Encore, Tornier, and Zimmer. In Europe, Lima (Italy), Aston (France), and Implants Industrie (France) produce a reverse prosthesis.

Because the reverse prosthesis is different from the standard hemiarthroplasty or total shoulder arthroplasty prosthesis, DePuy recommended that orthopaedic surgeons in the United States attend a one-day course to learn about the surgical procedure, its indications and contraindications, and its complications. During the course, either live surgical procedures were performed or videotapes of the procedures were reviewed and then lectures were presented by experienced surgeons. An opportunity to work with these surgeons, during which the attendees used the actual instrument sets and inserted the prosthesis into synthetic shoulder bones, was then available. Between 2004 and 2006, 840 orthopaedic surgeons attended these courses.

The ideal candidate for the reverse shoulder prosthesis is an elderly patient (seventy years of age and older) who has rotator cuff arthropathy, i.e., a patient who has irreparable loss of the rotator cuff, arthritis of the shoulder, pain, and minimal if any shoulder function. The reverse shoulder prosthesis is also used to provide function in some patients who have had a failed shoulder arthroplasty and in selected patients in whom the treatment of a shoulder fracture with a prosthesis has failed because of disruption of the tuberosities of the humerus and the coracohumeral arch, allowing for the development of anterior/superior escape of the shoulder. With the prosthesis properly in place, the pain is eliminated or decreased and the deltoid muscle can once again achieve function. Sometimes the shoulder function can be dramatic in that the patient can easily move the arm to the overhead position4–24.

I have concerns with the reverse shoulder prosthesis. I believe that it should only be employed by shoulder surgeons who have extensive experience in shoulder arthroplasty (i.e., those who perform a minimum of fifteen to twenty shoulder arthroplasty procedures per year). Only an experienced shoulder surgeon can successfully perform this procedure because he or she is extremely familiar with the anatomy and function of the shoulder and respects the indications and contraindications for this prosthesis. The inexperienced surgeon may be tempted to use a reverse shoulder prosthesis for patients who only have severe arthritis or those who only have massive loss of the rotator cuff, thus extending the indications beyond those that are currently acceptable. Furthermore, the experienced shoulder surgeon is aware of alternative procedures such as the use of hemiarthroplasty. For example, some patients with severe cuff tear arthropathy who have retained 70° or 80° of active elevation can be very effectively managed with a hemiarthroplasty procedure. The experienced shoulder surgeon is acutely aware that even when the reverse shoulder prosthesis is used for the proper indications and is perfectly implanted, the complication rates have ranged from 13% to 50%5–9,12,19,21–23. Many of these complications are serious, and the surgeon must recognize that this prosthesis is an implant of last resort and must be certain that he or she can treat the complications that will occur. I believe that mastering the complications associated with this implant is beyond the potential of the inexperienced shoulder surgeon.

The most recent report on complications associated with the reverse shoulder prosthesis was presented at the Closed Meeting of the American Shoulder and Elbow Surgeons in September 2006 by G. Walch of Lyon, France and his associates. They conducted a multicenter review of 457 patients who were managed with the reverse shoulder prosthesis between 1992 and 200225. Two hundred and ninety-seven operations were performed in patients who had not had prior surgery, ninety were performed in patients who had had a failed hemiarthroplasty or total shoulder arthroplasty, and seventy were performed in patients who had had failed shoulder operations other than shoulder arthroplasty. The authors reported that, overall, 25.6% of the patients had either an intraoperative or a postoperative complication. They noted higher complication rates among patients undergoing revision surgery. Specifically, the rate of intraoperative complications was 31% among patients managed with revision surgery as compared with 2.7% among those managed with primary surgery, and the rate of postoperative complications was 33% among patients managed with revision surgery as compared with 12.6% among those managed with primary surgery. Instability was the most common postoperative complication, followed by infection, humeral fracture, glenoid loosening, humeral loosening, humeral disassembly, glenoid disassembly, hematoma, neurapraxia, scapular spine fracture, postoperative stiffness, and venous thrombosis.

The most recent study is from Pascal Boileau et al.6, who reported on forty-five patients who received the Grammont Delta III prosthesis between 1997 and 2002. The authors reported a complication rate of 24%, and, as was the case in the Walch study, there was a much higher complication rate (45%) among patients managed with revision surgery. In their extensive review, which represented one of the largest Delta prosthesis series to date, they stated, “On the basis of the current design and results, the reverse prosthesis should be considered a salvage procedure: its use should be limited to elderly patients, arguably those aged over 70 years, with poor function and severe pain related to cuff deficiency. A Reverse Prosthesis should not be offered to a young individual who desires to have a normal shoulder and will demand more of the prosthesis than it is designed to do.”6

In 2005, Gerber and associates23 concluded that the Delta III prosthesis is a valuable choice for the treatment of severe dysfunction of the shoulder and went on to state, “because of the high complication rate and the fact that there may be long-term complications that are not yet known, arthroplasty with this implant should be reserved as a salvage procedure for situations in which an acceptable clinical outcome cannot be expected with another treatment modality.”

If some of the best and most experienced shoulder surgeons in the world have reported complications and failures in association with this procedure, I am concerned that the inexperienced surgeon may have an even higher rate of complications. To better prepare oneself for the successful use of the reverse shoulder prosthesis, an inexperienced shoulder surgeon should (1) be familiar with and study shoulder anatomy, (2) review videotapes on the surgical technique of the reverse shoulder prosthesis, (3) practice the surgical technique on cadavers, (4) take a course offered by one of the companies that offers the reverse shoulder prosthesis, and (5) operate with a shoulder surgeon who is experienced in the use of the reverse shoulder prosthesis that one plans to use.

In summary, the reverse shoulder prosthesis can yield satisfactory and even spectacular results when used by an experienced shoulder surgeon. Even then, the rates of intraoperative and postoperative complications are high compared with those associated with standard hemiarthroplasty or total shoulder arthroplasty procedures. In light of this information, the general orthopaedic surgeon must be very cautious when deciding to use the reverse shoulder prosthesis.