Arch Orthop Trauma Surg (2014) 134:317–323 DOI 10.1007/s00402-013-1908-1
ORTHOPAEDIC SURGERY
Reverse total shoulder arthroplasty after failed deltoid flap reconstruction Alberto Giuseppe Schneeberger · Timo Marco Müller · Wolfram Steens · Christoph Thür
Received: 16 July 2013 / Published online: 23 January 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Hypothesis Reverse shoulder arthroplasty (RSA) yields unsatisfactory results after deltoid flap reconstruction due to defect of the deltoid muscle. Methods We retrospectively reviewed the outcome of 19 patients after failed deltoid flap reconstruction treated with RSA. Follow-up was after a mean of 4.5 years. Results Seven patients (37 %) had nine postoperative complications requiring totally 16 revision surgeries. Nonetheless, at latest follow-up, 17 patients had no or mild, two had moderate, and none had severe pain. Before RSA; 13 patients had a pseudoparesis. At latest follow-up, none of the patients had a pseudoparesis. Mean flexion was 121° (90°–160°). Abduction strength averaged 2.3 kg (range 0–5.4 kg). The mean constant score was 70 % (range 28– 98 %). Of the 19 patients, 15 were very satisfied with the outcome, four were satisfied, and none was dissatisfied. The mean overall subjective shoulder value was 73 % (30– 95 %) of the value of a normal shoulder. Conclusions Despite of a localized defect of the deltoid muscle after deltoid flap repair, RSA can reliably be associated with a satisfactory outcome. A. G. Schneeberger (*) Endoclinic Zurich, Klinik Hirslanden, Witellikerstr. 40, 8032 Zurich, Switzerland e-mail: ags@schulter‑ellbogen.ch T. M. Müller University of Zurich, Zurich, Switzerland W. Steens Orthopädisch-Neurochirurgisches Zentrum, Recklinghausen, Germany C. Thür Pyramide in Schwerzenbach, Zurich, Switzerland
Keywords Reverse total shoulder prosthesis · Arthroplasty · Deltoid flap · Muscle flap · Shoulder · Revision
Introduction The deltoid flap has been used for the treatment of irreparable rotator cuff tears [1, 15, 17, 28]; and it can still be considered an alternative when treating younger patients with irreparable rotator cuff tears [25]. In elderly patients, however, the first choice for treatment of irreparable rotator cuff tears may be reverse shoulder arthroplasty (RSA) [33]. RSA reliably restores shoulder function for the treatment of irreparable rotator cuff deficiency [3, 4, 6–9, 12, 16, 18–23, 30–33]. The success of RSA depends on the integrity of the deltoid muscle. Various conditions such as injury to the deltoid muscle from fractures, surgical approaches or sacrifice of part of the muscle for deltoid flap reconstructions cause damage to the deltoid muscle; and this might jeopardize the functional outcome after RSA. The size of the deltoid flap may vary based on the preference of the surgeon [1, 10, 15, 25, 28]. The size of the deltoid flap used in this study measured 4 cm at the base of the flap, 4 cm at each side and 1 cm at the apex of the flap indicating that an important part of the antero-lateral deltoid muscle was sacrificed (Fig. 1). Considering this defect of the deltoid muscle, rather unfavorable outcomes of RSA after deltoid flaps would be expected. Surprisingly, two case reports have shown satisfactory outcomes of RSA after deltoid flap repairs [14, 25]. In addition, one case of successful RSA was reported after a spontaneous irreparable rupture of the middle portion of the deltoid muscle [29]. It was therefore the aim of this
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Arch Orthop Trauma Surg (2014) 134:317–323
study to retrospectively review the outcome of RSA after failed deltoid flap repairs.
The deltoid flap repairs had been performed by two surgeons: in 17 cases by the senior author (C.T.) and twice by the first author (A.G.S.) using always the same surgical technique that has been previously described [25]. Some features of this technique are emphasized. The approach of the deltoid flap repair consisted of detachment of the anterior deltoid from the distal clavicle and from the anterior part of the acromion, of AC joint resection and acromion elevation osteotomy. The antero-lateral deltoid flap measured at the apex about 1 cm, and at the two sides and at the base about 4 cm each (Fig. 1). The time between deltoid flap and RSA averaged 3 years and 8 months (5 months–10 years). The indication for RSA was early failure of the deltoid flaps in eight cases. Eleven patients initially had a good outcome after deltoid flap repair, and showed deterioration of their clinical results after an average of 6 years (2–10) due to flap tears in nine cases, development of glenohumeral arthrosis in one case and pain in another case. Before RSA, 16 out of 19 patients had significant pain, whereas three patients had no pain. Thirteen of the patients had a pseudoparesis (defined as active shoulder elevation of
ORTHOPAEDIC SURGERY
Reverse total shoulder arthroplasty after failed deltoid flap reconstruction Alberto Giuseppe Schneeberger · Timo Marco Müller · Wolfram Steens · Christoph Thür
Received: 16 July 2013 / Published online: 23 January 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract Hypothesis Reverse shoulder arthroplasty (RSA) yields unsatisfactory results after deltoid flap reconstruction due to defect of the deltoid muscle. Methods We retrospectively reviewed the outcome of 19 patients after failed deltoid flap reconstruction treated with RSA. Follow-up was after a mean of 4.5 years. Results Seven patients (37 %) had nine postoperative complications requiring totally 16 revision surgeries. Nonetheless, at latest follow-up, 17 patients had no or mild, two had moderate, and none had severe pain. Before RSA; 13 patients had a pseudoparesis. At latest follow-up, none of the patients had a pseudoparesis. Mean flexion was 121° (90°–160°). Abduction strength averaged 2.3 kg (range 0–5.4 kg). The mean constant score was 70 % (range 28– 98 %). Of the 19 patients, 15 were very satisfied with the outcome, four were satisfied, and none was dissatisfied. The mean overall subjective shoulder value was 73 % (30– 95 %) of the value of a normal shoulder. Conclusions Despite of a localized defect of the deltoid muscle after deltoid flap repair, RSA can reliably be associated with a satisfactory outcome. A. G. Schneeberger (*) Endoclinic Zurich, Klinik Hirslanden, Witellikerstr. 40, 8032 Zurich, Switzerland e-mail: ags@schulter‑ellbogen.ch T. M. Müller University of Zurich, Zurich, Switzerland W. Steens Orthopädisch-Neurochirurgisches Zentrum, Recklinghausen, Germany C. Thür Pyramide in Schwerzenbach, Zurich, Switzerland
Keywords Reverse total shoulder prosthesis · Arthroplasty · Deltoid flap · Muscle flap · Shoulder · Revision
Introduction The deltoid flap has been used for the treatment of irreparable rotator cuff tears [1, 15, 17, 28]; and it can still be considered an alternative when treating younger patients with irreparable rotator cuff tears [25]. In elderly patients, however, the first choice for treatment of irreparable rotator cuff tears may be reverse shoulder arthroplasty (RSA) [33]. RSA reliably restores shoulder function for the treatment of irreparable rotator cuff deficiency [3, 4, 6–9, 12, 16, 18–23, 30–33]. The success of RSA depends on the integrity of the deltoid muscle. Various conditions such as injury to the deltoid muscle from fractures, surgical approaches or sacrifice of part of the muscle for deltoid flap reconstructions cause damage to the deltoid muscle; and this might jeopardize the functional outcome after RSA. The size of the deltoid flap may vary based on the preference of the surgeon [1, 10, 15, 25, 28]. The size of the deltoid flap used in this study measured 4 cm at the base of the flap, 4 cm at each side and 1 cm at the apex of the flap indicating that an important part of the antero-lateral deltoid muscle was sacrificed (Fig. 1). Considering this defect of the deltoid muscle, rather unfavorable outcomes of RSA after deltoid flaps would be expected. Surprisingly, two case reports have shown satisfactory outcomes of RSA after deltoid flap repairs [14, 25]. In addition, one case of successful RSA was reported after a spontaneous irreparable rupture of the middle portion of the deltoid muscle [29]. It was therefore the aim of this
13
318
Arch Orthop Trauma Surg (2014) 134:317–323
study to retrospectively review the outcome of RSA after failed deltoid flap repairs.
The deltoid flap repairs had been performed by two surgeons: in 17 cases by the senior author (C.T.) and twice by the first author (A.G.S.) using always the same surgical technique that has been previously described [25]. Some features of this technique are emphasized. The approach of the deltoid flap repair consisted of detachment of the anterior deltoid from the distal clavicle and from the anterior part of the acromion, of AC joint resection and acromion elevation osteotomy. The antero-lateral deltoid flap measured at the apex about 1 cm, and at the two sides and at the base about 4 cm each (Fig. 1). The time between deltoid flap and RSA averaged 3 years and 8 months (5 months–10 years). The indication for RSA was early failure of the deltoid flaps in eight cases. Eleven patients initially had a good outcome after deltoid flap repair, and showed deterioration of their clinical results after an average of 6 years (2–10) due to flap tears in nine cases, development of glenohumeral arthrosis in one case and pain in another case. Before RSA, 16 out of 19 patients had significant pain, whereas three patients had no pain. Thirteen of the patients had a pseudoparesis (defined as active shoulder elevation of
