DePuy CTA Hemiarthroplasty versus Traditional Hemiarthroplasty

DePuy CTA Hemiarthroplasty
versus Traditional
Hemiarthroplasty
Carl J. Basamania, MD, FACS
The PolyClinic and Swedish
Orthopaedic Institute
Seattle, Washington

Cuff Tear Arthropathy Treatment
Options
• Rehabilitation
• Rotator cuff debredment
• Rotator cuff repair
• Arthrodesis
• Resectional arthroplasty
• Total shoulder arthroplasty
• Humeral head replacement
• Reverse total shoulder arthroplasty

Humeral head replacement for massive
rotator cuff tear

Study
Arntz et
al.(1993)
Williams and
Rockwood
(1996)
Field et al.
(1997)
Zuckerman et
al. (2000)
Cofield et al
(2001)
Number of
patients
Duration of
Follow-up
(years)
No or Mild
Postoperative
Pain
(no. of
shoulders)
Preop
Postop.
Active
Elevation (deg)
18 3 61% (11) 66 (44-90)
112 (70-160)
21 4 86% (18) 70 (0-155)
120 (15-160)
16 3 81% (13) 60 (40-80)
100 (80-130)
15 2 47% (7) 69 (20-140)
86 (45-140)
33 5 73% (24) 72 (30-150)
91 (40-165)
Successful
Results based
on limited
goals
(no. of
shoulders)
Not reported
86% (18)
63% (10)
Not reported
67% (22)
Total/Average 103 3.4 69.2% 67.4 to 101.8
(+34.4 degrees)
72%

Bipolar Results
Study Number of patients Duration of
Follow-up (years)
Preop./Postop.
Active Elevation
(deg)
Worland et al 1997 22 28 38 - 67
Sotereanos et al.
2003
14 27.8 30 - 88
Duranthon et al
2002
13 28 78 - 69
Total/Mean 49 27.9 48.7 – 74.7

Background
• The concept of the CTA head in massive cuff tear
patients with stable and possibly limited stability
kinematics was:
• accept the proximal migration
• decrease the coefficient of friction with a
smooth articular surface
• articulate with both the glenoid and acromion
• This should allow the deltoid and remaining
muscles of the cuff to function more efficiently
• More closely mimics their “new normal anatomy”

Surgical Technique

360 degree capsular release

Case Example
62 y.o. Rhd male,
pain x 10 yrs;
now functionally
fused left
shoulder, VAS
10/10

Subscapularis Takedown

Attaching the CTA cutting jig

Final trim

Before and After

Subscapularis Repair

Drill holes

Pass Sutures

Subscapularis Repair

Subscapularis Repair

Subscapularis Deficiency
• Consider transfer of the pectoralis muscle
Over conjoined tendon
Under conjoined tendon

Postop

1 Year Postop

3 years post-op

Postop Care
• Majority of surgeries done under regional
anesthesia as outpatient with 23 hour postop
observation
• No sling
• Cryotherapy first 2 weeks
• ADL’s as tolerated permitted day of surgery
• Stretching/resistance exercises at 6 weeks
• Ad lib activity at 12 weeks

“Sublime Supine”
• All postop rehab is
done with patient in
supine position
• Scapular kinematics
are improved
• Start with pass and
well arm assisted
ROM
• Progress to anterior
deltoid strengthening
• Increase resistance
and inclination as
tolerated

Results
• 132 primaries, w/ ≥ 24 months f/u
• Seebauer IA/B - IIA
• 89 had previous surgery, 12 had > 2 prior surgeries
• Average FF: Preop - 65 Postop – 128
• Range 70 – 160
• Average ER: Preop – 8 Postop - 30
• Pain VAS: Preop – 9.4 Postop – 1.4
• SST score: Preop – 1.1 Postop – 8.6
• ASES score: Preop – 28 Postop - 76
• Satisfaction: 88% rated result as good or excellent
• 84% of surgeries were performed under regional
anesthesia as an outpatient procedure

Results of CTA in Seebauer IIB
• 23 patients
• 16 failed TSA arthroplasty
• Average FF: Preop - 37 Postop - 70
• Pain VAS: Preop - 10 Postop – 4
• Satisfaction: 12 poor, 8 fair, 3 good
• Overall, poor subscapularis function correlated
with poor function

To Date:
• Complications:
• Five postop arthrofibrosis
• Tx’d with arthroscopic debredment
• One acromial fracture after fall
• Two subscap ruptures after falls
• No progressive glenoid/acromial wear
• Two revisions to Delta (subscap ruptures)
• 1.5% revision rate

Failed CTA after Fall – increased
superior migration due to subscap rupture
Before
After

Increased anterior translation on
axillary after rupture
Before
After

Later rupture of subscap – treated
with Delta reverse TSA

Two years postop
• 82 year old female
• Swims in lake 2 times/day

• 85 year old
• Declined a Delta
• Two years post-op
both shoulders
• Week prior to last
clinic visit:
• Dug a 20m
drainage ditch
• Cut an 6m
groove in
concrete with a
hammer and
chisel
• Rebuilt his boat
motor

Observations
• Keys to a good CTA:
• Intact or “functional” coracoacromial arch
• Intact subscapularis
• Proper anatomic sizing

Proper Anatomic Sizing is Key

Non-anatomic sizing

Delta or CTA Candidate?

Who Gets What???
• If the patient can forward flex at least
70 – 80 degrees and have an intact subscap:
• They have stable kinematics
• They would probably do well with a CTA
• If they cannot:
• They may have unstable kinematics
(Seebauer IIB)
• They would probably do better with a Delta

CTA or Delta?
• These are two almost
distinctly different
groups
• Reverse prosthesis is
probably “overkill” in
patients with an intact
coracoacromial arch
and NO superior
escape
• Yes, it may do well but
is it necessary?

Defect type and recommended type
of prosthesis
Defect-type Ia Ib IIa IIb
Prosthesis CTA CTA CTA
?Delta ® Delta ®

There’s a time and place for both

CTA versus Reverse Arthroplasty
• The Reverse shoulder should be reserved for:
• Salvage cases when no other viable
alternative for treatment exists
• Low demand patients
• Physiologically over 70 years of age
• What are the “Societal costs” of a reverse TSA
compared to a CTA?

Conclusion
• CTA hemiarthoplasty can provide excellent
results in patients with a functional
subscapularis and stable kinematics
• Reverse TSA should be reserved for low
demand, older patients with unstable
kinematics
• Education and training is the key in getting
better results

CTA or Delta?

Right CTA, Left Delta

Thank you!