Delta III reverse-ball-and-socket total shoulder prosthesis for acute complex fractures of the proximal humerus in elderly population

Background

The Delta III semi-constrained reverse-ball-and-socket total shoulder prosthesis works only with an intact deltoid muscle. Our purpose is to evaluate the results in a consecutive series of acute complex fractures of the proximal humerus in elderly population with a poor bone quality when the main problem is to obtain a reliable and efficient re-fixation of the tubercles with classical orthopaedic devices.

Methods

From 1993 to 2005, 36 Delta III were implanted, 27 three-part, and four-part displacements and nine fracture-dislocations, in 3 males for 33 females, for 16 dominant sides, with an average age of 75 years. The surgery was realized under general anaesthesia, in semi-sitting position, by an antero-lateral approach with retroversion of the humeral-cemented stem of 20° to 0°. Post-operative physiotherapy was not always realizable.

Results

The results were estimated with the clinical Constant scoring system, AP and lateral view X-rays. Twenty-five cases were reviewed because nine were deceased and two moved out. At a mean follow-up of 71 months, the Constant score was 59 points for a contra-lateral shoulder evaluated at 81. The results were good in respect of pain (14.1), activity (14.3), strength (14.1), anterior elevation (7.5), abduction (6.5), but very poor for external (1.1), and internal (1.4) rotations. The radiographs showed: one aseptic glenoid loosening at 12-year follow-up with surgical revision, 14 inferior scapular notching (seven stages 1, five stages 2, one stage 3, one stage 4), 14 inferior spurs stable after emergence without clinical repercussion, four medial and two lateral proximal humeral bone loose, and two medial humeral lucent lines.

Conclusions

For acute complex fractures of the proximal humerus, in elderly population with poor bone quality, when an efficient and reliable re-fixation of the tubercles is difficult or impossible, the Delta III prosthesis is a possible alternative with good functional outcome except rotations but with a lot of worrying inferior scapular notching.     

Biomechanical relevance of glenoid component positioning in the reverse Delta III total shoulder prosthesis

The presence of a notch at the inferior part of the scapular neck is a common radiographic finding in patients treated with a reverse Delta III shoulder prosthesis. It is thought that this notch is a result of mechanical contact between the polyethylene cup of the humeral implant and the inferior glenoid pole during adduction of the arm. This in vitro study assessed the effect of glenoid component positioning on glenohumeral range of motion in 8 shoulder specimens. Four different positions of the glenosphere were tested: glenosphere centered on the glenoid, leaving the inferior glenoid rim uncovered (configuration A); glenosphere flush with the inferior glenoid rim (configuration B); glenosphere extending beyond the inferior glenoid rim (configuration C); and glenosphere tilted downward 15 degrees (configuration D). The respective mean adduction and abduction angles in the scapular plane were -25 degrees and 67 degrees for configuration A, -14 degrees and 68 degrees for configuration B, -1 degrees and 81 degrees for configuration C, and -9 degrees and 75 degrees for configuration D. Placing the glenosphere distally (test configuration C) significantly improved adduction and abduction angles compared with all other test configurations (P < .001).     

Revision of shoulder replacement with a reversed shoulder prosthesis (Delta III): report of five cases.

The authors report on their experience in revision total shoulder arthroplasty using the Delta III shoulder prosthesis, a reversed constrained prosthesis which is known to give good functional results in the rotator cuff-deficient shoulder. It was implanted in patients with a failed total or hemishoulder prosthesis. The Constant-Murley score was used to assess the functional outcome. The preliminary results achieved in four patients (one bilaterally) are discussed and compared with the results of other treatments. After two years follow-up, the Constant-Murley score has improved from 14/100 preoperatively to 62/100 postoperatively. Although these initially good functional results may be temporary and loosening may occur over the longer term, the authors recommend the Delta III shoulder prosthesis as an alternative solution for revision shoulder arthroplasty.     

Prosthetic component relationship of the reverse Delta III total shoulder prosthesis in the transverse plane of the body

The Delta III (DePuy International Ltd, Leeds, UK) reverse total shoulder prosthesis has provided a successful functional outcome in cuff tear arthropathy (CTA); however, internal and external rotation remain compromised. Positioning of the prosthetic components in the transverse plane has theoretically been suggested to affect rotation. Twenty-seven patients who received a Delta III reversed total shoulder prosthesis for CTA were analyzed (mean follow-up, 43 months) using standard radiographs and computed tomography. The position of the prosthetic components and the possible influence of scapular rotation was analyzed using a uniform spatial reference system using axes in reference to the sagittal or coronal plane. We assessed impingement of the humeral component on the glenoid neck in neutral and internal rotation. An increase in the anterior divergence of the glenoid and humeral prosthetic components correlates with an increase in radiologically measured internal rotation (r = 0.932, P < .001). The uniformity of the reference system used seems to allow accurate positioning of the components intraoperatively and can be useful for analysis of the prosthetic component relationship postoperatively.     

The reverse shoulder prosthesis for primary and secondary treatment of proximal humeral fractures: a case report

Humeral head fractures are very common among elderly people, often requiring shoulder arthroplasty. One requirement for good function after shoulder arthroplasty is an intact or at least reparable rotator cuff. In patients with multifractured and or osteoporotic tuberosities, refixation leads to the potential risk of redislocation and resorption of the tuberosities or coexisting irreparable rotator cuff tears lead to a high failure rate after implantation of traditional fracture prosthesis, whereas the reverse shoulder arthroplasty may provide better outcome. Here we report of a 79-year-old woman, who fractured both humeral heads at different times. Her right side was treated with a fracture prosthesis, which had to be converted after 2 years to a reverse shoulder prosthesis. Because of coexisting irreversible rotator cuff tear accompanying the second humeral head fracture on her left side, this patient was primarily treated with a reverse shoulder prosthesis. During the most recent follow up, 33 months after reverse shoulder arthroplasty on the left side and 39 months on the right side, the age- and gender-adapted constant score was 88 compared to 59 on the right side. The primary or secondary implantation of the reverse shoulder prosthesis in proximal humeral fractures has to be planned carefully, since long-term results are still lacking and treatment options after failed reverse shoulder arthroplasty are few. Generally, primary implantation of traditional fracture prosthesis is indicated in most cases of humeral head fractures; but in carefully selected cases primary reverse shoulder arthroplasty may be superior and lead to better outcome. Therefore, future research should be conducted to find criteria where the reverse shoulder arthroplasty is indicated as first line treatment of proximal humeral head fractures in elderly patients.     

Predictors of scapular notching in patients managed with the Delta III reverse total shoulder replacement

BACKGROUND: The reverse Delta III shoulder prosthesis can relieve pain and restore function in patients with cuff tear arthropathy. The most frequently reported radiographic complication is inferior scapular notching. The purpose of the present study was to evaluate the clinical relevance of notching and to determine the anatomic and radiographic parameters that predispose to its occurrence. METHODS: Seventy-seven consecutive shoulders in seventy-six patients with an irreparable rotator cuff deficiency were managed with a reverse Delta III shoulder arthroplasty and were followed clinically and radiographically for a minimum of twenty-four months. The effects of cranial-caudal glenoid component positioning and the prosthesis-scapular neck angle on the development of inferior scapular notching and clinical outcome were assessed. RESULTS: All shoulders that had development of notching did so in the first fourteen months. Of the seventy-seven shoulders that were studied, thirty-four (44%) had inferior scapular notching, twenty-three (30%) had posterior notching, and six (8%) had anterior notching. Osteophytes along the inferior part of the scapula occurred in twenty-one (27%) of the seventy-seven shoulders. The angle between the glenosphere and the scapular neck (r = 0.667) as well as the craniocaudal position of the glenosphere (r = 0.654) were highly correlated with inferior notching (p < 0.001). A notching index was calculated with use of the height of implantation of the glenosphere and the postoperative prosthesis-scapular neck angle. This allowed prediction of the occurrence of notching with a sensitivity of 91% and specificity of 88%. The height of implantation of the glenosphere had approximately an eight times greater influence on inferior notching than the prosthesis-scapular neck angle did. Inferior scapular notching was associated with a significantly poorer clinical outcome. CONCLUSIONS: Inferior scapular notching after reverse total shoulder arthroplasty adversely affects the intermediate-term clinical outcome. It can be prevented by optimal positioning of the glenoid component.     

Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis

BACKGROUND: The Delta III reverse-ball-and-socket total shoulder implant is designed to restore overhead shoulder function in the presence of irreparable rotator cuff deficiency by using the intact deltoid muscle and the stability provided by the prosthetic design. Our purpose was to evaluate the clinical and radiographic results of this arthroplasty in a consecutive series of shoulders with painful pseudoparesis due to irreversible loss of rotator cuff function. METHODS: Fifty-eight consecutive patients with moderate-to-severe shoulder pain and active anterior elevation of <90 degrees due to an irreparable rotator cuff tear were treated with a Delta III total shoulder replacement at an average age of sixty-eight years. Seventeen of the procedures were the primary treatment for the shoulder, and forty-one were revisions. The patients were examined clinically and radiographically after an average duration of follow-up of thirty-eight months. RESULTS: On the average, the subjective shoulder value increased from 18% preoperatively to 56% postoperatively (p < 0.0001); the relative Constant score, from 29% to 64% (p < 0.0001); the Constant score for pain, from 5.2 to 10.5 points (p < 0.0001); active anterior elevation, from 42 degrees to 100 degrees (p < 0.0001); and active abduction, from 43 degrees to 90 degrees (p < 0.0001). The patients for whom the implantation of the Delta III prosthesis was the primary procedure and those who had had previous surgery showed similar amounts of improvement. The total complication rate, including all minor complications, was 50%, and the reoperation rate was 33%. Of the seventeen primary operations, 47% (eight) were associated with a complication and 18% (three) were followed by a reoperation. Of the forty-one revisions, 51% (twenty-one) were associated with a complication and 39% (sixteen) were followed by a reoperation. Subjective results and satisfaction rates were not influenced by complications or reoperations when the prosthesis had been retained. CONCLUSIONS: Total shoulder arthroplasty with the Delta III prosthesis is a salvage procedure for severe shoulder dysfunction caused by an irreparable rotator cuff tear associated with other glenohumeral lesions. Complications were frequent following both primary and revision procedures, but they rarely affected the final outcome. The procedure has a substantial potential to improve the condition of patients with severe shoulder dysfunction, at least in the short term.     

The Delta III reverse shoulder replacement for cuff tear arthropathy: a single-centre study of 50 consecutive procedures

The combination of an irreparable tear of the rotator cuff and destructive arthritis of the shoulder joint may cause severe pain, disability and loss of independence in the aged. Standard anatomical shoulder replacements depend on a functioning rotator cuff, and hence may fail in the presence of tears in the cuff. Many designs of non-anatomical constrained or semi-constrained prostheses have been developed for cuff tear arthropathy, but have proved unsatisfactory and were abandoned. The DePuy Delta III reverse prosthesis, designed by Grammont, medialises and stabilises the centre of rotation of the shoulder joint and has shown early promise. This study evaluated the mid-term clinical and radiological results of this arthroplasty in a consecutive series of 50 shoulders in 43 patients with a painful pseudoparalysis due to an irreparable cuff tear and destructive arthritis, performed over a period of seven years by a single surgeon. A follow-up of 98% was achieved, with a mean duration of 39 months (8 to 81). The mean age of the patients at the time of surgery was 81 years (59 to 95). The female to male ratio was 5:1. During the seven years, six patients died of natural causes. The clinical outcome was assessed using the American Shoulder and Elbow score, the Oxford Shoulder Score and the Short-form 36 score. A radiological review was performed using the Sirveaux score for scapular notching. The mean American Shoulder and Elbow score was 19 (95% confidence interval (CI) 14 to 23) pre-operatively, and 65 (95% CI 48 to 82) (paired t-test, p < 0.001) at final follow-up. The mean Oxford score was 44 (95% CI 40 to 51) pre-operatively and 23 (95% CI 18 to 28) (paired t-test, p < 0.001) at final follow-up. The mean maximum elevation improved from 55° pre-operatively to 105° at final follow-up. There were seven complications during the whole series, although only four patients required further surgery.     

Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients

Proximal humerus fractures are the third most common fracture in elderly patients. Hemiarthroplasty has been the treatment of choice in patients with bone quality and fracture patterns not amenable to open reduction and internal fixation. Reverse total shoulder arthroplasty is a newer option that appears to be less dependent on tuberosity healing than hemiarthroplasty. The authors hypothesized that reverse total shoulder arthroplasty provides improved functional outcomes compared with hemiarthroplasty for fractures in elderly patients.A retrospective review was performed of all patients treated with arthroplasty for acute proximal humerus fractures in an orthopedic practice using a Current Procedural Terminology code search, patient charts, and radiographs. Validated outcome scores were used to assess satisfaction, function, and general well-being. Twenty-three patients were treated for acute proximal humerus fractures (11 reverse total shoulder arthroplasties and 12 hemiarthroplasties). Three patients were lost to follow-up, and 6 patients were deceased. Mean follow-up was 3.6 years (range, 1.3-8 years). Reverse total shoulder arthroplasty outperformed hemiarthroplasty with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score.Reverse total shoulder arthroplasty is a reliable option for acute, proximal humerus fractures that are not amenable to closed treatment or reconstruction in elderly patients. Improved functional outcomes when compared with hemiarthroplasty must be balanced against the increased cost and limited life expectancy of patients with this injury.     

The reversed Delta shoulder prosthesis in reconstruction of the proximal humerus after tumour resection

The authors present two series of six and seven patients respectively, with a tumour of the proximal humerus, who were treated at two different institutions with a Delta type inverted shoulder prosthesis (DePuy International Ltd) after a Malawer type Ia or Ib resection. The rationale of using an inverted shoulder prosthesis is the aim to improve the functional outcome in rotator cuff deficient shoulders. This type of prosthesis medializes and lowers the centre of rotation, lengthens the lever arm of the deltoid muscle and improves its function. At one institution the resected part of the humerus was re-implanted after extracorporeal irradiation. It was fixed intramedullarly by cementation of the humeral prosthetic component to facilitate restoration of humeral height. This graft allowed reinsertion of muscles (deltoid, pectoralis, biceps) thus improving power generation postoperatively. The largest glenosphere, size 42, was routinely used to reconstruct the glenoid; this theoretically improves the functional outcome (increased external rotation) and stability. At the other institution no graft augmentation was used except in one patient. The height of the humeral prosthetic component was assessed after resection of the tumour by measurement of the resected part. The prosthetic stem was fitted in the remaining part of the humeral diaphysis, in three cases by cementation and in three cases by press-fit (hydroxyapatite coating). Muscle balance was appreciated intra-operatively. Stability of the prosthesis was directly related to the level of resection. Both techniques resulted in a minimum active abduction of 60 degrees, reaching 90 degrees or more in most patients. When compared to other results in the literature, this is a major functional improvement. The mean adjusted postoperative Constant score was 72.5% (range: 30-90%), and the mean MSTS score was 75.8% (range 36.7-96.7%).     

Treatment of distal radius fractures with external fixation: technical considerations for rehabilitation

Wrist external fixation with or without K-wire stabilization has been shown to be a reliable treatment method for unstable fractures of the distal radius. The technique of external fixation of the wrist has been historically based on the premise that fracture reduction can be achieved and maintained using the principles of ligamentotaxis. It is now well recognized that sustained longitudinal traction applied with a wrist external fixator can lead to complications. This review outlines the authors' preferred technique of using the external fixator as a neutralization device rather than as a traction device. The absence of sustained radiocarpal traction during distal radius fracture healing may facilitate postoperative rehabilitation.