Reverse shoulder replacement for severe superior humeral migration and medial glenoid erosion

The following case is a 55 y/o female with long history of shoulder pain and instability. She was diagnosed with cuff tear arthropathy and has no history of trauma. She has pseudoparalysis of the L shoulder with active FE of the shoulder to 45 degrees and intact deltoid muscle function. Due to pain and inability to maintain her active lifestyle she was treated with a reverse total shoulder replacement and was informed that the chances of glenoid loosening at 10 years postoperatively can be up to 25%.

The picture below demonstrates her active forward elevation

Radiographs below demonstrate a high riding humeral head, superior erosion of the glenoid and loss of glenohumeral joint space.

There are several classification systems for the cuff tear arthropathy however their value for clinical use is limited. A few of those are reported below



Cuff Tear Arthropathy: Seebauer Classification
Visotsky, Seebauer et al, JBJS-A, 86-A: 35-40, 2004 

Type 1A - Centered stable, Minimal superior migration,
               C-A arch acetabularization

Type 1B - Centered medialized, Minimal superior migration, 
              medial glenoid erosion, C-A arch acetabularization

Type 2 A - Decentered limited stable, superior translation, 
               superior-medial erosion
               significant C-A arch acetabularization

Type 2 B - Decentered unstable, anterior superior escape, 
                C-A arch and anterior structures deficient 

Glenoid erosion in cuff tear arthropathy: Sirveaux Classification
Sirveaux et al, JBJS (B), 86: 388-3985, 2004

E0: Humeral head migration without glenoid erosion
E1: Concentric glenoid erosion
E2: superior glenoid erosion
E3: inferior glenoid erosion



Intra-operative pictures are shown below. We found no rotator cuff tendons attached to the humerus with the exception of the subscapularis tendon that was repaired at the end of surgery.

No rotator cuff seen at the time of surgery

45 degree minimal humeral cut at 30 degrees of retroversion

Glenoid exposure. Suction tip placed at the 3 o'clock position

Placement of Guide Tap tilted 15 degrees inferior

After Reaming to the subchondral plate the baseplate was inserted and a 32mm -4 glenosphere was implanted

The humeral component was implanted and sutures were placed on the humerus for repair of the subscapularis tendon.

We prefer to implant the glenosphere first and do a conservative cut on the humeral side. During the trialing process with trail only on the humeral side and sequential reaming of the humeral side and bone resection aims at balancing of the shoulder. This method allows for bone preservation on the humeral side and the chances of intraoperative glenoid fracture are minimized because of no trailing on the glenoid side.

Final Xray is seen below with inferior placement of the glenoid to avoid notching. Minimal humeral bone resection was performed

6 Months after surgery her ROM and active forward elevation has significantly improved as shown below.