Delta and Bone deficiencies - ShoulderDoc.co.uk

Werner et al. JBJS 2005 Delta reverse 50 patients (50/58)• 17 cuff tear arthropathy• 41 revision of failedarthroplasties 15 men 43 women Mean age 68 (44-84) Mean follow up 38months (minimum 24)

Results Werner et alprimarypreop postop Constant score 35 72(relative) Active forw flex 43 103 Pain (VAS) 5,9 1,8Only patients with active FF < 90degrees

Complications Werner etal. Infection3/17 Hematoma 3/17 Dislocation 1/17 Disloc PE insert 1/17 Fx acr/spine 1/17 No loosening Total 9/17

Radiographs 48 pts avaiable for radiographic followup 46 % of patients had notching grade 3-4(Nerot) Notching did not affect clinical outcome

Walsh series, JBJS 2007240 reverse arthroplasty, 31% wasCTA patients

Walsh series- Notching 152/186 with 2 years follow up hadadequate X-rays 51% had notching Constant score 61 in pts w notching Constant score 59 in pts withoutnotching

St Göran´s Hospital Follow up Female 43Male 1962 (17 primary) Mean age 74 (range 42-94) Minimum follow up Independent observer2 years Only pseudopartalytic shoulders

Ekelund CTA primary Constant 16 53 p

Complications Ekelund 2 infections No asepticloosening

Revision arthroplasty Flexion 23 86 p

Sirveaux et al. JBJS 2004 Delta reverse 80 shoulders (77pts) (80/92) 14 men, 63 women Mean age 73 (60-86) Follow up mean44,5 months (24-97

Results Sirveaux et al. Constant scorePreopPostop23 (4-50) 66 (34-85) P

Complications Sirveaux etal. 4 revisions (1 infection, 3loosening/unscrewing) Glenoid loosening 6%(5/80) Humeral loosening 1%(1/80) Scapula notch 50%(grade 3-4 in 16%)• Grade 3-4 affectedConstant score(p

Survivorship Sirveaux et al. If failure = revisionsurgery, theprobability of nothaving a revision at 8years was 95% If failure = revision,unscrewing,loosening orsignificant pain; thesurvivorship was 29%at 8 years

Specific problems Restoration of external rotation• combine with latissimus dorsi/ teresmajor transfer Scapula notching• Excessive polyethylene wear• Osteolysis• Clinical significance unclear• Surgical technique and implant design

Anatomy If IS and Teres minor are missing oratrophic worse clinical results(Constant score)French multicenter studyTeres minor IntactCS68Teres minor affected CS 61Boileau et al. 2005Teres minor ok CS 66Teres minor torn CS 46Gerber et al 2007Teres minor OK CS 83%Teres minor atrophic CS 61%

My technique lat dorsitransfer Through the Deltopectoralincision• Release only sup 1,5-2cm of pec major• Release if possible onlylat dorsi, sometimesalso teres major• Pull it around humerus• Reattach more suptowards the area forteres minor insertion,(osteosutures)• Orthosis 4 weeks

Indications Lack of strength in external rotationin 0 abduction and 90 degrees ofabduction• Pos ”hornblower´s sign” ”Younger” patient population amongthe reverse group og patients

Reported complicationsInfectionDislocationScapula notchingLooseningGlenoid unscrewing (olddesign)Humerus unscrewing(humerus defect)Fx tip of the implantHematomaDislocation insertFracture of the spine ofscapula

Delta 1995-2002 118 Deltas, 79 women, 34 male 45 were revisions of failed anatomicalimplants 26 pts have undergone reoperations ( 22%)• Revisions cases (27%), primary Delta (19%) Infections 7,6% (9/118) Dislocations 7,6% (9/118), 8 in revision cases 12 pts (10%) had 2 or more reoperationsafter Delta implantation

Delta Xtend 2006- Over 100 cases No infections 2 dislocations both in revisions 1 humeral loosening in a crutchdependent obese patient with proxboneloss

ComplicationsTry save the Deltaarthroplasty if• dislocation• infection• looseningResection arthroplastyrareConvert it to ahemiarthroplasty byreplacing insert withhead, bone graftglenoid.

”I love the Delta…” Preop:• 85 years old lady• Severe pain 5 years• Pseudoparalysis• Cuffteararthropathy• Depression Postop Delta• No pain• No limitation offunction

Summary reversed arthroplastyCan restore function inpseudoparalytic shouldersExcellent pain reliefCannot restore external rotation• Lat dorsi/TM transferScapula notching a concern• Need more longterm follow upto evaluate clinical significance• Low metaglene positioningRate of complications significantlyreduced with new design andimproved technique

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