Clinical Review

The Effect of Humeral Inclination on Range of Motion in Reverse Total Shoulder Arthroplasty: A Systematic Review

Am J Orthop. 2016 May;45(4):E174-E179

Reverse total shoulder arthroplasty (RTSA) is a treatment option for patients with rotator cuff tear arthropathy, pseudoparalysis, and a functional deltoid.

Our hypothesis was that no significant difference in postoperative active range of motion (ROM) will be observed in patients with 135° and 155° humeral cup inclination.

A systematic review was registered with PROSPERO and performed with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating RTSA that reported the type of prosthesis as well as active postoperative ROM were eligible for inclusion. Minimum follow-up was 12 months. Pre- and postoperative ROM (and difference, Δ) was compared between RTSA humeral components with cup inclination 135° and 155°. Descriptive statistics were calculated, and the 2 groups were compared using 2-proportion z-test.

Sixty-five studies with 3302 patients (3434 shoulders; 1211 in the 135° group and 2223 in the 155° group) were included. Mean patient age was 71.1 ± 7.6 years, 71% were female, and mean follow-up was 37.2 ± 16.5 months. No significant difference existed between patient age at the time of surgery; the average age of patients in the 135° lateralized glenosphere group was 71.67 ± 3.8 years, while the average age of patients in the 155° group was 70.97 ± 8.8 years. Forward elevation, abduction, and external rotation all significantly improved following surgery in the 135° and 155° groups (P < .05). Patients in the 135° group had significantly greater improvement in external rotation (P < .001) and significantly more overall external rotation compared to the 155° group (P < .001). No significant difference existed between 135° and 155° groups in ROM improvements (Δ) in forward elevation (P = .142) or abduction (P = .217).

Patients with a 135° humeral cup inclination in RTSA gain significantly more external rotation from pre- to postsurgery and have an overall greater amount of external rotation than patients who receive a 155° prosthesis.

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References

1. Flatow EL, Harrison AK. A history of reverse total shoulder arthroplasty. Clin Orthop Relat Res. 2011;469(9):2432-2439.

2. Hyun YS, Huri G, Garbis NG, McFarland EG. Uncommon indications for reverse total shoulder arthroplasty. Clin Orthop Surg. 2013;5(4):243-255.

3. Erickson BJ, Frank RM, Harris JD, Mall N, Romeo AA. The influence of humeral head inclination in reverse total shoulder arthroplasty: a systematic review. J Shoulder Elbow Surg. 2015;24(6):988-993.

4. Gupta AK, Harris JD, Erickson BJ, et al. Surgical management of complex proximal humerus fractures--asystematic review of 92 studies including 4500 patients. J Orthop Trauma. 2015;29(1):54-59.

5. Feeley BT, Zhang AL, Barry JJ, et al. Decreased scapular notching with lateralization and inferior baseplate placement in reverse shoulder arthroplasty with high humeral inclination. Int J Shoulder Surg. 2014;8(3):65-71.

6. Kiet TK, Feeley BT, Naimark M, et al. Outcomes after shoulder replacement: comparison between reverse and anatomic total shoulder arthroplasty. J Shoulder Elbow Surg. 2015;24(2):179-185.

7. Alentorn-Geli E, Guirro P, Santana F, Torrens C. Treatment of fracture sequelae of the proximal humerus: comparison of hemiarthroplasty and reverse total shoulder arthroplasty. Arch Orthop Trauma Surg. 2014;134(11):1545-1550.

8. Baulot E, Sirveaux F, Boileau P. Grammont’s idea: The story of Paul Grammont’s functional surgery concept and the development of the reverse principle. Clin Orthop Relat Res. 2011;469(9):2425-2431.

9. Cazeneuve JF, Cristofari DJ. Grammont reversed prosthesis for acute complex fracture of the proximal humerus in an elderly population with 5 to 12 years follow-up. Orthop Traumatol Surg Res. 2014;100(1):93-97.

10. Naveed MA, Kitson J, Bunker TD. The Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures. J Bone Joint Surg Br. 2011;93(1):57-61.

11. Levy J, Frankle M, Mighell M, Pupello D. The use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty for proximal humeral fracture. J Bone Joint Surg Am. 2007;89(2):292-300.

12. Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010;92(15):2544-2556.

13. Atalar AC, Salduz A, Cil H, Sungur M, Celik D, Demirhan M. Reverse shoulder arthroplasty: radiological and clinical short-term results. Acta Orthop Traumatol Turc. 2014;48(1):25-31.

14. Raiss P, Edwards TB, da Silva MR, Bruckner T, Loew M, Walch G. Reverse shoulder arthroplasty for the treatment of nonunions of the surgical neck of the proximal part of the humerus (type-3 fracture sequelae). J Bone Joint Surg Am. 2014;96(24):2070-2076.

15. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1-e34.

16. The University of York Centre for Reviews and Dissemination. PROSPERO International prospective register of systematic reviews. Available at: http://www.crd.york.ac.uk/PROSPERO/. Accessed April 11, 2016.

17. The University of Oxford. Oxford Centre for Evidence Based Medicine. Available at: http://www.cebm.net/. Accessed April 11, 2016

18. Cowan J, Lozano-Calderon S, Ring D. Quality of prospective controlled randomized trials. Analysis of trials of treatment for lateral epicondylitis as an example. J Bone Joint Surg Am. 2007;89(8):1693-1699.

19. Clark JC, Ritchie J, Song FS, et al. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elbow Surg. 2012;21(1):36-41.

20. Sayana MK, Kakarala G, Bandi S, Wynn-Jones C. Medium term results of reverse total shoulder replacement in patients with rotator cuff arthropathy. Ir J Med Sci. 2009;178(2):147-150.

21. Valenti P, Kilinc AS, Sauzieres P, Katz D. Results of 30 reverse shoulder prostheses for revision of failed hemi- or total shoulder arthroplasty. Eur J Orthop Surg Traumatol. 2014;24(8):1375-1382.

22. Ladermann A, Denard PJ, Boileau P, et al. Effect of humeral stem design on humeral position and range of motion in reverse shoulder arthroplasty. Int Orthop. 2015;39(11):2205-2213.

23. Vasen AP, Lacey SH, Keith MW, Shaffer JW. Functional range of motion of the elbow. J Hand Surg Am. 1995;20(2):288-292.

24. Namdari S, Yagnik G, Ebaugh DD, et al. Defining functional shoulder range of motion for activities of daily living. J Shoulder Elbow Surg. 2012;21(9):1177-1183.

Reverse total shoulder arthroplasty (RTSA) has become a reliable treatment option for many pathologic conditions of the shoulder, including rotator cuff arthropathy, proximal humerus fractures, and others.^1-4While the treatment outcomes have generally been reported as good, some concern exists over the postoperative range of motion (ROM) in patients following RTSA, including external rotation.^5-7 The original RTSA design was introduced by Neer in the 1970s and has undergone many modifications since that time.^1,2 The original Grammont-style prosthesis involved medialization of the glenoid, inferiorizing the center of rotation (with increased deltoid tensioning), and a neck-shaft angle of 155°.^1,8 While clinical results of the 155° design were encouraging, concerns arose over the significance of the common finding of scapular notching, or contact between the scapular neck and inferior portion of the humeral polyethylene when the arm is adducted.^9,10

To address this concern, a prosthesis design with a 135° neck-shaft angle was introduced.¹¹ This new design did significantly decrease the rate of scapular notching, and although some reported a concern over implant stability with the 135° prosthesis, recent data has shown no difference in dislocation rates between the 135° and 155° prostheses.³ A different variable that has not been evaluated between these prostheses is the active ROM that is achieved postoperatively, and the change in ROM from pre- to post-RTSA.^12,13 As active ROM plays a significant role in shoulder function and patient satisfaction, the question of whether a significant difference exists in postoperative ROM between the 135° and 155° prostheses must be addressed.

The purpose of this study was to perform a systematic review investigating active ROM following RTSA to determine if active postoperative ROM following RTSA differs between the 135° and 155° humeral inclination prostheses, and to determine if there is a significant difference between the change in preoperative and postoperative ROM between the 135° and 155° prostheses. The authors hypothesize that there will be no significant difference in active postoperative ROM between the 135° and 155° prostheses, and that the difference between preoperative and postoperative ROM (that is, the amount of motion gained by the surgery) will not significantly differ between the 135° and 155° prostheses.

Methods

A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using a PRISMA checklist.¹⁵ Systematic review registration was performed using the PROSPERO international prospective register of systematic reviews (registration date 3/9/15, registration number CRD42015017367).¹⁶ Two reviewers independently conducted the search on March 7, 2015 using the following databases: Medline, Cochrane Central Register of Controlled Trials, SportDiscus, and CINAHL. The electronic search citation algorithm utilized was: (((((reverse[Title/Abstract]) AND shoulder[Title/Abstract]) AND arthroplasty[Title/Abstract]) NOT arthroscopic[Title/Abstract]) NOT cadaver[Title/Abstract]) NOT biomechanical[Title/Abstract]. English language Level I-IV evidence (2011 update by the Oxford Centre for Evidence-Based Medicine¹⁷) clinical studies that reported the type of RTSA prosthesis that was used as well as postoperative ROM with at least 12 months follow-up were eligible. All references within included studies were cross-referenced for inclusion if missed by the initial search. If duplicate subject publications were discovered, the study with the longer duration of follow-up or larger number of patients was included. Level V evidence reviews, letters to the editor, basic science, biomechanical studies, arthroscopic shoulder surgery, imaging, surgical technique, and classification studies were excluded. Studies were excluded if both a 135° and 155° prosthesis were utilized and the outcomes were not stratified by the humeral inclination. Studies that did not report ROM were excluded.

A total of 456 studies were located, and, after implementation of the exclusion criteria, 65 studies from 2005-2015 were included in the final analysis (Figure). Subjects of interest in this systematic review underwent a RTSA. Studies were not excluded based on the surgical indications (rotator cuff tear arthropathy, proximal humerus fractures, osteoarthritis) and there was no minimum follow-up or rehabilitation requirement. Study and subject demographic parameters analyzed included year of publication, journal of publication, country and continent of publication, years of subject enrollment, presence of study financial conflict of interest, number of subjects and shoulders, gender, age, the manufacturer and type of prosthesis used, and the degree of the humeral inclination (135° vs 155° humeral cup). Preoperative ROM, including forward elevation, abduction, external rotation with the arm adducted, and external rotation with the arm at 90° of abduction, were recorded. The same ROM measurements were recorded for the final follow-up visit that was reported. Internal rotation was recorded, but because of the variability with how this measurement was reported, it was not analyzed. Clinical outcome scores and complications were not assessed. Study methodological quality was evaluated using the Modified Coleman Methodology Score (MCMS).¹⁸