Name: Anatomic and Reverse TSA: Traditional, Short Stem, or Stemless
Uploaded: 2019-09-27T00:00:00Z
Channel: Arthrex
Description: Justin W. Griffin, MD, (Virginia Beach, VA) discusses the various stem lengths used in anatomic and reverse shoulder arthroplasty. He highlights the options for addressing patients’ unique circumstances.

<p>Justin W. Griffin, MD, (Virginia Beach, VA) discusses the various stem lengths used in anatomic and reverse shoulder arthroplasty. He highlights the options for addressing patients’ unique circumstances.</p>

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VID1-000248-en-US | B | Anatomic and Reverse TSA: Traditional, Short Stem, or Stemless

Justin W. Griffin

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Anatomic and Reverse TSA: Traditional, Short Stem, or Stemless

I'm Justin Griffin from Virginia, and I'm going to talk to you today about AnaToemic and reverse total shoulder arthroplasty. Really about stem length between the stemless, the short stem and traditional stems. So the conversation in shoulder arthroplasty has classically been really focused on the glenoid side. Most of our difficulties have focused on that side. So some of the questions that I'm going to seek to answer for us today is, is there an optimal stem length? What problems can we really solve with shorter stems, and what do we really know about these stems. So we looked a little bit at this in terms of how to patients do. And we know that patients with prior surgery may not do as well as others. But what factors can we control. We know that we can control soft tissue management. In shoulder arthroplasty. We know that we can get the components in a proper position and we can optimize our fixation, which is really the focus of this talk. This patient, as you can see up here, was very happy six months after her shoulder arthroplasty to catch the largest fish that she had ever had. This is what we're really looking for is our end position. We we know that the head is a variable size and in relationship to the canal, it's in a variable position. So we have to choose a head size that is fixed because that really doesn't change. And this starts with really an excellent humeral cut. We also want to use a prosthetic system that really adapts to the anatomy, because we know that regardless of stem length, if we get the head in a great position, the patients will do very well. So what happens if we get this wrong? This is a patient that was referred to me who had a very large, overstuffed Stem, and we had to revise this to reverse arthroplasty only four months after his index operation. He ended up getting a very nice result, but we'd like to avoid this type of an outcome. So some of the progression in shoulder arthroplasty is really towards shorter. But the question is is shorter really better? And so when we look at short stem implants we have to ask the question are they all the all the same? When we look at the world's literature on stress shielding, some good finite element analysis studies have been done that show that as the implants get shorter, the bone stresses medially become more like the intact humerus. So there's a good study recently that was published showing that the short stem implant, the apex implant, has excellent two year outcomes. This is coming up on five year data which is looking encouraging as well. And in a comparative study looking at the stress shielding between two implants and a competitive short stem, the medial calcar osteolysis was almost three times as high. And so we have to ask ourselves a question. Well, it doesn't seem to matter now, but will it matter later? And ultimately, will this osteolysis turn into a problem for the patient? So the advantage of a short stem seems reasonable, that we can assume that there's less blood loss, that the stress shielding is less, that we can adapt a subscapularis repair in a reliable way around a short stem implant. Some of the questions that remain is is it Is it safe with an LTO? Are all stems going to do as well if you choose to do an LTO for your patients? And then there's the FiberTape compression bridge with Kevin touched on a little bit, which serves as a nice adjunct for how you can repair the subscapularis. So from the time of Doctor Near in the first generation implants, we're now into the fourth generation, and we have to wonder, how long do these implants really last? We know that certain factors lend towards patients not doing as well as you can see here. So we have to ask how do we revise these? As a young surgeon I'm always asking what's the next operation? And for me that implants on the left makes me concerned that I'm going to have a hard time revising that long stem, lateral fin, large head. This is going to be a challenge. I think we have to look for something more bone preserving, something that's going to respect the anatomy a little bit more and make it easier down the road if and when the implants fail, because we'd like to avoid this situation. What about stemless shoulder arthroplasty? If we look at the stemless implants on the market, what are they seeking to achieve? So the reasons that we need to consider a stemless arthroplasty are that it preserves bone, avoids the diaphyseal stress riser. It's independent of the humeral shaft. And so potentially we can get our implants in a more anatomic position with decreased over time and potentially a greater reliability. So there certainly are some differences in fixation as was alluded to earlier. If we look at the bone modeling studies, the peripheral bone for the 1 to 2cm around the cortex seems to be the best bone in stemless shoulder arthroplasty. So we want an implant that has both peripheral and central fixation to achieve this. So the stemless device that is the Eclipse has a good study by Obermeyer showing that there was certainly less stress yielding 0% in a small study versus a lot more in the long stem comparison. So the literature support is very large for this implant. If you look at this, it's very good, if not better than the third and fourth generation implants and potentially equal to them. And so with post-traumatic Traumatic arthritis as you saw an x ray earlier. This might answer a very important question for some of our patients with complex deformities. This is a video demonstrating the technique for the Eclipse implant with the trunion insertion. Certainly this is bone preserving. And you could allow yourself to have a very anatomic replacement and put the head exactly where you want it, which ultimately is what matters for this surgery. So the challenges of replacement, there are some. So these are a couple of referral patients. You can see there were some problems with the greater tuberosity and overstuffed implant there. And so we have to be careful that we don't cut these patients in varus. I think it's very difficult because you don't have the training wheels of a short stem. And so I think that we have to also think about our subscapularis fixation in terms of how we achieve that. With a stemless implant. You can revise these very reliably, but sometimes they're not as easy to remove. I will say that the suture cup does fit nicely from an inlay perspective directly into that if you choose to use this. Us. So from a reverse standpoint, we do know from certain small studies, and these are really the only studies out there that we do have better outcomes in certain cases when converted from a stemless implant. So what's next in stemless? I think we have to think about how to improve our substrate fixation. I think it would be helpful to have some specific humorous instrumentation and collect our outcomes in this regard. From a reverse standpoint, how do we look at the stem length in reverse shoulder arthroplasty? That's part of our conversation. But we have to think about inlays and onlays. Can we offset the device in terms of how we address the humeral bone in the metaphysis in the small patients, we want a system that will really adapt to their anatomy and be able to handle some complex deformity in the revision situation. There's very little data. If you look at the world's literature on short stem reverse arthroplasty. This recent study, published in the Journal of Shoulder and Elbow, demonstrated that there may be increased osteolysis with cortical contact and increased fill in reverse short stems. So some of this matters in the in the way that you put it in and the implant geometry. We also know that an inlay has less of an increased stress riser from a fracture standpoint. If you look at this recent series demonstrating a 4.8% fracture risk from an acromial stress fracture with an inlay design. I think the shape ultimately matters a lot. If you look at this left image, you can see that the Calcar is not particularly supported here. This implant is likely loose, and if you look at the image on the other side, we certainly have a more anatomic appearing medial support. So the humeral deformity that I see sometimes in my practice is a challenge. And so we want to have a very small stem. This is actually on your right a five stem with a 33. It actually looks slightly big for that patient. So we want to know our implant geometry so that we can achieve this. This was a fish mouth deformity with a complex deformity. It was able to be handled in this situation. So for me I really like this. This is some emerging implants that are available in a limited user release. This is a short stem apex that's going in. And we know based on the first 50 or so cases that there's excellent stability here and that the early follow up is excellent even in revision situations. So this is an 82 year old female that I put this in. And her bone quality was very good. And I felt that this was incredibly stable at the end of the case. So what about this patient? This is a challenging case. A patient over the age of 70 years old, an incredible amount of pain, a very traumatic post traumatic problem that was tried to be removed. And she came to me to see can we achieve anything together? And I think the question here is this is very idealized. Certainly the rotator cuff is a problem. And this may be a case where we have to think about a stemless reverse, potentially in the future. If we think about a stemless reverse, we know that the early European experience seemed to be good. But then there was a recall that happened that wasn't so good. And so I think that we have to proceed with caution here. There's currently an IDE underway in the United States, but there's not currently an available stemless reverse arthroplasty on the market. So the future is this. I think this is a 54 year old patient of mine who had a broken, dissociated, gleniffer very bad problem. And so this is really what we have to watch out for, which is why I like a 135 Lateralized design to avoid these type of problems. So the ultimate determining factor is time. And so we have to wait for our outcomes and follow them with the shoulder arthroplasty registry. And look at Soas and look at our data and determine how are we doing. So in summary, I think we have to always choose the correct head size and position. And that ultimately matters more than anything else. Stem length is really only one modifiable risk factor of stress. We have to get the scalp repair right, and we may have room to grow. From a Stem standpoint, future work will include humeral specificity in terms of our cut and accommodating deformity. I do think the short stem reverse results are very encouraging. Early and above all else, it matters how our patients do. Thank you very much.

Anatomic and Reverse TSA: Traditional, Short Stem, or Stemless

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