SummaryIntroductionReverse shoulder arthroplasties (RSA) can be performed using a Deltopectoral (DP) or alternatively a Transdeltoid (TD) approach.HypothesisAlthough the humeral cut is lower by TD approach, this should not affect postoperative functional results.Material and methodsThis retrospective multicentric study evaluated the complete medical records of RSA implanted between October 2003 and December 2008. Inclusion criteria were: follow-up of at least 1year, a complete file including a comparative radiological work-up making it possible to analyze eventual arm and humeral lengthening. Evaluation of postoperative function was based on Active Anterior Elevation (AAE).ResultsWe studied 144 RSA in 142 patients. One hundred and nine RSA were implanted by the DP approach and 35 by the TD approach. Mean lengthening of the humerus compared to the controlateral side by DP approach was 0.5±1.3cm while there was a mean shortening of −0.5±1.0cm by TD approach (P<0.001). The difference in cut was partially compensated by using thicker polyethylene inserts with the TD approach. Mean arm lengthening compared to the controlateral side was 1.7±1.7cm by DP approach and 1.2±1.4cm by TD approach (mean difference 0.5cm; (95% CI −0.1; 1.2). AAE for RSA by DP approach was 145±22° and 135±29° by TD approach (mean difference 10°, 95% CI −1; 21).DiscussionRSA results in improved AAE because of restored deltoid tension and an increase in the deltoid lever arm. The humeral cut by TD is lower, but this was partially corrected in this study by the use of thicker polyethylene inserts. Nevertheless there is no significant clinical difference in postoperative function between the two approaches.Level of EvidenceLevel IV. Retrospective therapeutic study

Collin, P.

Edwards, T.B.

Lubbeke, A.

Lädermann, A.

Sirveaux, F.

Walch, G.

Elsevier - Publisher Connector 

Influence of surgical approach on functional outcome in reverse shoulder arthroplasty 

Orthopaedics & Traumatology: Surgery & Research (2011) 97, 579—582
ORIGINAL ARTICLE
Inﬂuence of surgical approach on functional outcome
in reverse shoulder arthroplasty
A. Lädermanna,∗, A. Lubbekea, P. Collinb, T.B. Edwardsc, F. Sirveauxd,
G. Walche
a Department of Orthopaedic Surgery and Traumatology, Geneva University Hospitals, 4, rue Gabrielle-Perret-Gentil,
1211 Genève, Switzerland
b Saint-Grégoire Private Hospital Center, 6, boulevard Boutière, 35768 Saint-Grégoire cedex, France
c Fondren Orthopedic Group, Houston, Texas, USA
d Centre chirurgical Émile-Gallé Surgical Center, 49, rue Hermite, 54000 Nancy, France
e Orthopaedic Center and Jean-Mermoz Private Hospital, 24, avenue Paul-Santy, 69008 Lyon, France
Accepted: 11 April 2011
KEYWORDS
Reverse shoulder
arthroplasty;
Function;
Surgical approaches
Summary
Introduction: Reverse shoulder arthroplasties (RSA) can be performed using a Deltopectoral
(DP) or alternatively a Transdeltoid (TD) approach.
Hypothesis: Although the humeral cut is lower by TD approach, this should not affect postop-
erative functional results.
Material and methods: This retrospective multicentric study evaluated the complete medical
records of RSA implanted between October 2003 and December 2008. Inclusion criteria were:
follow-up of at least 1 year, a complete ﬁle including a comparative radiological work-up mak-
ing it possible to analyze eventual arm and humeral lengthening. Evaluation of postoperative
function was based on Active Anterior Elevation (AAE).
Results: We studied 144 RSA in 142 patients. One hundred and nine RSA were implanted by
the DP approach and 35 by the TD approach. Mean lengthening of the humerus compared to
the controlateral side by DP approach was 0.5± 1.3 cm while there was a mean shortening of
−0.5± 1.0 cm by TD approach (P < 0.001). The difference in cut was partially compensated by
using thicker polyethylene inserts with the TD approach. Mean arm lengthening compared to
the controlateral side was 1.7± 1.7 cm by DP approach and 1.2± 1.4 cm by TD approach (mean
0.1; 1.2). AAE for RSA by DP approach was 145± 22◦ and 135± 29◦difference 0.5 cm; (95% CI −
by TD approach (mean difference 10◦, 95% CI −1; 21).
∗ Corresponding author. Tel.: +41 22 372 79 08; fax: +41 22 372 79 03.
E-mail address: alexandre.laedermann@hcuge.ch (A. Lädermann).
1877-0568/$ – see front matter © 2011 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.otsr.2011.04.008
580 A. Lädermann et al.
Discussion: RSA results in improved AAE because of restored deltoid tension and an increase in
the deltoid lever arm. The humeral cut by TD is lower, but this was partially corrected in this
study by the use of thicker polyethylene inserts. Nevertheless there is no signiﬁcant clinical
difference in postoperative function between the two approaches.
Level of Evidence: Level IV. Retrospective therapeutic study.
© 2011 Elsevier Masson SAS. All rights reserved.
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The choice of the surgical approach was essentially based
upon the surgeon’s preferences. A Reversed Aequalis
implant (Tornier Inc, Montbonnot, France) was used in all
cases. The surgical technique was standardized and has been
described in detail [4,5]. The postoperative protocol and
Figure 1 The epicondylar line (EL) was deﬁned between the
most lateral part of the epitrochlea and the epicondyle on X-
rays using a postoperative ipsilateral ruler. The diaphyseal axis
(DA) was deﬁned as a line going through the center of the proxi-
mal humeral medullary canal. The intersection between EL and
DA represents the point C and the intersection between DA and
the top of the humeral head is point H. Point A is the intersec-
tion of a perpendicular line going intersecting the most lateral,
inferior point of the acromion. Point P is the intersection of antroduction
everse shoulder arthroplasty (RSA), which was ﬁrst devel-
ped by Paul Grammont [1], is a real advancement in
houlder surgery. The geometric inversion of the implanted
oint components has two essential biomechanical conse-
uences. Medialization of the center of rotation optimizes
he deltoid lever arm, so that more anterior and posterior
uscle ﬁbers are solicited and centrifugal forces are trans-
ormed into centripetal forces. Increasing the subacromial
pace by lowering the humerus results in an increase in
eltoid strength by restoring deltoid tension which corrects
otator cuff deﬁciencies. The indications for this technique
ave progressively been extended and more and more of
hese arthroplasties are now performed. Different surgical
pproaches are possible for this type of arthroplasty.
The transacromial approach, used by Grammont, is
ow less popular. The Deltopectoral (DP) and Transdeltoid
TD) approaches are now the most common approaches,
nd they both have their advantages and disadvantages.
he DP approach allows better positioning of the glenoid
omponent, reducing loosening and inferior impingement.
oreover active external rotation is better preserved with
his approach [2]. Also, this approach does not compromise
he deltoid, which is the future motor of the shoulder. Logi-
ally, it is generally used in case of revision surgery. The TD
pproach has the advantage of obtaining better postopera-
ive stability, in particular, because the subscapularis tendon
nd the anterior ligament complex are preserved. [2]. Thus
t is less necessary to lengthen the arm, potentially reduc-
ng the incidence of neurological damage, or fracture of the
cromion or scapular spine [3]. The TD approach can be indi-
ated in case of RSA for fractures of the superior humerus
r if there is a history of surgery with this same approach.
here are no studies in the literature to date which show
hat one approach is better than another. To our knowledge
here are no studies comparing the functional results after
SA with the two types of surgical approach. We hypothe-
ized that the humeral cut was lower with the TD approach,
ut that this would not affect postoperative function. The
im of this study was to evaluate the functional results after
SA using the DP or TD approaches as well as lengthening of
he arm and the humerus.
aterials and methodshis retrospective study analyzed RSA performed between
ctober 2003 and December 2008 in four centers. Four of
he authors of this study performed the arthroplasties (GW,
C, TBE, FS). Inclusion criteria were: (1) primary surgery,
p
I
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l2) a follow-up of at least one year, (3) evaluation of func-
ional results at the ﬁnal follow-up based on Active Anterior
levation (AAE) graded by goniometry and (4) a complete
adiological work-up allowing evaluation and comparison
f arm (acromion-elbow distance) and humeral (top of the
ead-elbow) lengths on the operated and controlateral sides
sing a previously validated protocol (Fig. 1) [3].
urgical techniqueerpendicular line on DA going through the top of the implant.
f enlargement by the X-ray is taken into account, the length
f humerus is represented by the distance C—H or C—P and the
ength of the arm by C—A.
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1RSA: inﬂuence of surgical approach
rehabilitation also followed a previously validated protocol
[6].
Statistical analysis
Demographic data were compared between the two groups
using a non-parametric Mann-Whitney U test for continuous
variables and the Chi2 test and Pearson coefﬁcient (or the
Fisher exact test in small groups) for categorical variables.
The mean differences and the corresponding 95% conﬁdence
intervals were also calculated for the principle results (arm
length, humeral length, AAE) (95% CI). Statistical analy-
ses were performed using version 15.0 SPSS software for
Windows® (SPSS Inc., Chicago, Illinois, USA).
Results
This study included 144 RSA in 143 patients. Preoperative
data for the study population are shown in Table 1. Both
groups were similar for mean age, operated side, domi-
nant side and follow-up. There were more women in the
TD group. The clinical and radiological results are shown in
Table 2. The mean postoperative AAE was 140± 27◦ (range,
30—180◦). The AAE was 145◦ in the DP approach group and
135◦ in the TD approach group with a mean difference of 10◦
(95% CI −1; 21).
There was a mean lengthening of the humerus compared
to the controlateral side by the DP approach, while there
was a mean shortening by TD approach and the difference
was statistically signiﬁcant (mean difference 1 cm, 95% CI
0.5; 1.5). This difference in the cut was partially com-
pensated for by the implantation of thicker polyethylene
inserts when the TD approach was used (Table 2). The differ-
ence in arm lengthening compared to the controlateral side
between the two approaches was 0.5 cm (95% CI −0.1; 1.2).
Augmentation devices were used in the DP group to restore
humeral length in case of revision surgery and traumatic
sequellae in seven cases and for perioperative instability
h
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Table 1 Preoperative demographic data.
Delto
Women (%) 75 (68
Men (%) 34 (31
Mean age±DS 72.8±
Side (%)
Right 79 (72
Left 30 (27
Dominant shoulder (%) 70.6
Diagnosis (%)
Glenohumeral arthritis 94 (86
Rheumatoid polyarthritis 4 (3.7
Trauma or sequellae 8 (7.3
Avascular necrosis 1 (0.9
Recurrent glenohumeral instability 2 (1.8
Mean follow-up±DS 18.3±
SD: standard deviation.581
n one case. The three patients in whom bilateral RSA was
equired had complete initial radiological work-ups so radi-
logical data were available for both implants.
iscussion
SA can be an alternative therapeutic option for a cer-
ain number of glenohumeral pathologies that may result
n functional deﬁciencies that are often signiﬁcant as well
s severe pain. Function is improved with these implants
ecause deltoid tension is restored and the deltoid lever arm
s increased. In this study, mean postoperative AAE was 140◦.
hese functional results are comparable to those described
y Sirveaux et al. [7]. The mean AAE by the TD approach
as slightly lower (by 10◦) than by the DP approach. This
ifference between the two approaches is not clinically sig-
iﬁcant. Whatever the choice, splitting the deltoid does
ot seem to modify functional results after physical reha-
ilitation. The type of approach should be decided upon
n relation to the surgeon’s experience and the patient’s
ndividual characteristics. Nevertheless, it seems logical to
se the DP approach for revision surgery. The TD approach
eems preferable in the presence of potential postoperative
nstability or in case of RSA for a fracture of the proximal
umerus. We did not ﬁnd any variation in the AAE in rela-
ion to the initial etiology. This does not support the results
btained by Wall et al. [8]. Until now, evaluation of deltoid
engthening has only been based on subjective perioperative
lements. By using objective pre- and postoperative mea-
ures for arm lengthening, we were able to show a difference
etween the DP and TD approaches. The humeral cut is
ower with the TD approach. This was partially compensated
or in this study by the use of a 9 and 12mm polyethy-
ene insert in 34.3% of cases and 42mm glenospheres in
1.4% of cases. Other studies have shown that restoring
umeral and arm length is crucial to obtain good functional
esults and implant stability [3,9]. It is therefore important
o correct the low humeral cut with a thicker polyethylene
nsert or even an augmentation device, whatever the surgi-
pectoral (n = 109) Transdeltoid (n = 35)
.8) 30 (85.7)
.2) 5 (14.3)
8.9 75.1± 6.4
.5) 27 (77.1)
.5) 8 (22.9)
65.7
.2) 34 (97.1)
) —
) 1 (2.9)
) —
) —
14.0 19.7± 12.9
582 A. Lädermann et al.
Table 2 Clinical and radiological results.
Deltopectoral (n = 109) Transdeltoid (n = 35) Mean difference (95% CI) p-value
Polyethylene thickness (%) 0.001
6 mm 99 (90.8) 23 (65.7)
9 mm 8 (7.3) 11 (31.4)
12 mm 2 (1.8) 1 (2.9)
Use of augmentation device 4 0 0.252
Size of the glenosphere
36 100 (91.7) 31 (88.6)
42 9 (8.3) 4 (11.4) 0.518
Mean AAE± SD (ranges) 145± 22◦ (80—180◦) 135± 29◦ (60—170◦) 10◦ (−1; 21) 0.113
Mean lengthening compared to controlateral side ± SD (ranges)
Humerus 0.5± 1.3 cm (−3.0 − 5.2 cm) −0.5± 1 cm (−4.7 − 1.6 cm) 1.0 cm (0.5; 1.5) < 0.001
Arm 1.7± 1.7 cm (−3.0 − 5.2 cm) 1.2± 1.4 cm (−3.5 − 3.1 cm) 0.5 cm (−0.1; 1.2) 0.062
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[SD: standard deviation, AAE: active anterior elevation.
al approach. Preoperative planning that makes it possible
o restore humeral and arm length during revision surgery,
r for implant replacement, fracture sequellae or substance
oss can be useful.
imiting factors
his study was limited by its retrospective and multi-
entric format making it difﬁcult to gather data and
mpossible to evaluate postoperative external rotation.
oreover preoperative functional data were not avail-
ble in all patients. Finally, there were relatively few
ases by TD approach (n = 35), resulting in a relatively
arge conﬁdence interval for the mean AAE differ-
nce.
onclusion
he humeral cut by the TD approach is lower, but this is par-
ially corrected by the use of a thicker polyethelene insert.
ostoperative anterior active elevation is fairly similar with
he two approaches.
isclosure of interestL, AL, PC: no conﬂict of interest.
BE, FS, GW: ﬁnancial interest in the company Tornier
.A.
[eferences
1] Grammont PM, Baulot E. Delta shoulder prosthesis for rotator
cuff rupture. Orthopedics 1993;16:65—8.
2] Molé D, Favard L. Excentered scapulohumeral osteoarthritis. Rev
Chir Orthop Reparatrice Appar Mot 2007;93(Suppl. 6):37—94.
3] Lädermann A, Williams MD, Melis B, Hoffmeyer P, Walch G.
Objective evaluation of lengthening in reverse shoulder arthro-
plasty. J Shoulder Elbow Surg 2009;18:588—95.
4] Boileau P, Walch G. The surgical anatomy and osteotomy tech-
nique for the humeral head. In: Walch G, Boileau P, editors.
Shoulder arthroplasty. Berlin: Verlag; 1999. p. 107—55.
5] Walch G, Wall B. Synthesis: indication and techniques of revision
arthroplasty with a reverse prosthesis. In: Walch G, Boileau P,
Molé D, Favard L, Lévigne C, Sirveau F, editors. Reverse shoulder
arthroplasty. Montpellier: Sauramps Médical; 2006. p. 243—6.
6] Liotard JP, Padey A. Prothèses d’épaule. État actuel. In: Boileau
P, Walch G, editors. Cahiers d’enseignement de la SOFCOT. Issy-
les-Moulineaux: Masson; 2008. p. 73—83.
7] Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Molé D. Gram-
mont inverted total shoulder arthroplasty in the treatment of
glenohumeral osteoarthritis with massive rupture of the cuff.
Results of a multicentre study of 80 shoulders. J Bone Joint Surg
Br 2004;86:388—95.
8] Wall B, Nove-Josserand L, O’Connor DP, Edwards TB, Walch G.
Reverse total shoulder arthroplasty: a review of results accord-
ing to etiology. J Bone Joint Surg Am 2007;89:1476—85.9] Lädermann A, Collin P, Sirveaux F, Mélis B, Bacle G, Walch G.
Inﬂuence of arm lengthening in reverse shoulder arthroplasty.
In: International Congress Shoulder Elbow Surgery; 2010, Sep
5—8; Edinburgh, Scotland. p. 47.


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Influence of surgical approach on functional outcome in reverse shoulder arthroplasty

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