Solution to Rotator Cuff Deficient Shoulder

1. Principles of reverse shoulder
replacement

4. Rotator Cuff - Components
 Supraspinatus
 Infraspinatus
 Teres Minor
 Subscapularis

5. Rotator Cuff - Components
 Supraspinatus
 Infraspinatus
 Teres Minor
 Subscapularis
Which is the 5th component?

6. Rotator Cuff: Prime Functions
 Prime INITIATOR of Abduction
 ROTATION of the Humerus (90% of external rotation
strength)
 STABILISER of the joint (Muscular balance)
 COMPRESSOR of the Humeral head into the glenoid
fossa
DELTOID ---- FORCE of Abduction (55%)

7. Biomechanics:
ARM ELEVATION
STABILITY: Rotator Cuff & Long head of Biceps
Shoulder Girdle Complex muscles
FORCE & ENDURANCE: Deltoid
Rotator Cuff
BALANCE BETWEEN DELTOID FORCE & ARM WEIGHT

8. DELTOID/ ROTATOR CUFF MOMENT > ARM
WEIGHT MOMENT = ELEVATION

9. Rotator Cuff Tear - Minor
 Elevation normal – ENDURANCE
shorter
 Elevation by external rotation of the
shoulder – biceps becomes the head
depressor for the deltoid to act

10. Rotator Cuff Tears - Massive
 Force Imbalance –
Instability
 Superior subluxation of
the humeral head
 Deltoid Retraction
 Non-functional joint

11. ROTATOR CUFF TEAR
WHY ?

12. Vascular Anatomy
 Critical Zone – Supraspinatus
Codman, Lindblom, Uhthoff and co-workers
 Adequate Vascularity
Moseley & Goldie. JBJS45B:780;1963
Swiontkowski et al. Laser Doppler Studies. St
Louis:Mosley Year book,1990:208
Rathman & Mcnab JBJS:52B:540;1970 – Poor filling
in adducted position

13. ROTATOR CUFF TEAR – WHY?
 Aging is the single most important
contributing factor
Uhthoff HK, Sarkar K In Matsen FA et al (eds). The
Shoulder:AAOS:1993,269-278

14. ROTATOR CUFF TEAR – WHY?
LOADING ENVIRONMENT
 Compressive Load between the
humeral head and the coracoacromial
arch
Ziegler et alJBJS:1996
 Shearing Load to the deep surface
of the tendon by the glenoid rim
Matsen FA et al Practical Evaluation and
Management of the shoulder;WB Saunders:1994

15. ROTATOR CUFF TEAR
WHO?

16. ROTATOR CUFF TEAR – WHO?
 Age 45 yrs
 40% “never done strenuous physical
work”
 Cuff defects frequently bilateral
 Many heavy manual labourers never
develop cuff defects
 50% no recollection of shoulder trauma
Neer CS II Impingement Lesions,Clin Orth173:70-
77;1983

17. Rotator Cuff Arthropathy

18. What can be done to bring back force
equilibrium?
 Cuff Repair
 Deltoid Power
 Lower humeral
head
 Stabilise centre of
rotation

19. How can the deltoid power be
increased?
• Medialising the
centre of rotation
 By increasing its
lever arm – LD
 Humerus brought
down

20. TRADITIONAL SOLUTIONS
 Hemiarthroplasty
 Total Shoulder
Replacement
INSTABILITY FAILURE

21. Prof Grammont’s Concept
 CR – medialised
 10mm more lateralisation of humerus L2>L1
 Deltoid force / Length increased (164%) F2>F1

22. Prof Grammont’s Concept:
DELTA SHOULDER REPLACEMENT

23. Delta Shoulder System

24. Clinical Presentation
 Pain
 Loss of Function

25. ASSESSMENT OF SUPRAPINATUS &
INFRASPINATUS MUSCLES

26. Investigation

27. MAGNETIC RESONANCE IMAGING
SCAN

28. MRI – Coronal Views

29. SURGICAL DETAILS

30. Deltoid Splitting Approach
Transverse Incision

31. Exposure of the Lesion
Longitudinal Incision

32. EXPOSURE OF THE HUMERAL
HEAD

33. PREPARATION OF HUMERAL HEAD

34. GLENOID PREPARATION

35. GLENOID PREPARATION

36. DEFINITIVE PROSTHESIS
METAGLENE

37. IMPLANT ASSEMBLY

38. HUMERAL IMPLANT ASSEMBLY

39. FINAL REDUCTION

40. REHABILITATION
 Rest: 3 days (Pain relief)
 Assessed by Upper Limb Therapist
 Passive assisted exercises
 Active assisted exercises after 2-3 weeks
 Use arm for daily activities
 Home Exercise Programme

41. RADIOGRAPHIC EVALUATION

42. LD 88 O

44. LD 88 O

45. MA 78 O

46. MA 78 O

47. 6 months
16 months

48. SA 77 O

49. RESULTS
 Valenti PH, D. Boutens, C. Nerot et al
 Long Term Results >5 years
 Jan 91 – Dec 94
 10 centres in Europe
 Results of 39 presented & then Published in
“Shoulder Arthroplasty”

50. CONSTANT SCORE
Pre-op Post-op
PAIN (15) 3 13
MOBILITY (20) 9 28
DAILY ACTIVITIES
(40)
6 14
STRENGTH (25) 3 8

51. MOVEMENTS
PRE - OP POST - OP
FORWARD FLEXION 60
(30-100)
120
(90-150)
EXTERNAL ROTATION 10 40
INTERNAL ROTATION LIMITED

52. COMPLICATIONS
 Sepsis 2
 Glenoid Component Loosening 1
 Glenoid Impingement – Notching of
the Infra-glenoid tubercle

53. Thank You