Predictors of Internal Rotation after Reverse Shoulder Arthroplasty

Document Type : RESEARCH PAPER


Washington University School of Medicine Department of Orthopaedic Surgery, MO, USA


Objectives: Internal rotation (IR) remains unpredictable following reverse total shoulder arthroplasty (rTSA). This study aimed to determine if increasing IR limits range of motion in other planes, and to determine pre- and intra-operative factors associated with post-operative IR.
Methods: A retrospective analysis of a single surgeon’s primary rTSA with a single implant was undertaken, excluding patients with acute fracture or infection. A lesser tuberosity osteotomy (LTO) or subscapularis peel tenotomy was performed and repaired at the surgeon’s discretion. One hundred sixty rTSA were included; 142 (88.8%) had documented IR both pre-operatively and at one-year follow-up. Variables were collected to determine their effect on IR at the 1-year follow-up point. A multivariate logistic regression was used to determine independent predictors of sufficient IR.
Results: Average age was 69.8 (range: 55-86) years and 55% (88/160) were female. Preoperatively, 20.4% of patients (29/142) had sufficient IR. This improved to 32.4% (46/142) one year following surgery, p<0.001). Factors associated with sufficient post-operative IR were female sex (p=0.05), decreasing body mass index (p=0.04), pre-operative IR (p=0.01), preoperative external rotation (ER) in adduction (p<0.001), radiographic evidence of LTO healing (p=0.02), increased one-year postoperative forward elevation (p<0.001), and increased one-year postoperative ER (p<0.001). Increased postoperative IR did not adversely affect forward elevation or ER. On multivariate analysis, higher preoperative IR and one-year postoperative forward elevation were independently associated with sufficient one-year postoperative IR.
Conclusion: IR following rTSA continues to be modest and unpredictable. Independent predictors of sufficient post-operative internal rotation were higher preoperative IR and one-year postoperative forward elevation. In a Grammont-style rTSA system, humeral version, glenosphere lateralization, and glenosphere size do not appear to impact IR. Importantly, achieving sufficient IR does not come at the expense of other planes of motion.
Level of evidence: III


Main Subjects

1. Valenti P, Sauzières P, Katz D, Kalouche I, Kilinc AS. Do less medialized reverse shoulder prostheses increase motion and reduce notching? Clin Orthop Relat Res. 2011; 469(9):2550-2557. doi: 10.1007/s11999-011-1844-8.
2. Drake GN, O’Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease. Clin Orthop Relat Res. 2010; 468(6):1526-1533. doi: 10.1007/s11999-009-1188-9.
3. Ek ETH, Neukom L, Catanzaro S, Gerber C. Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than 65 years old: results after five to fifteen years. J Shoulder Elbow Surg. 2013; 22(9):1199-1208. doi:10.1016/j.jse.2012.11.016.
4. Ernstbrunner L, Suter A, Catanzaro S, Rahm S, Gerber C. Reverse Total Shoulder Arthroplasty for Massive, Irreparable Rotator Cuff Tears before the Age of 60 Years: Long-Term Results. J Bone Joint Surg Am. 2017; 99(20):1721-1729. doi:10.2106/JBJS.17.00095.
5. Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. J Bone Joint Surg Am. 2010; 92(15):2544-2556. doi:10.2106/JBJS.I.00912.
6. Nolan BM, Ankerson E, Wiater JM. Reverse total shoulder arthroplasty improves function in cuff tear arthropathy. Clin Orthop Relat Res. 2011; 469(9):2476-2482. doi: 10.1007/s11999-010-1683-z.
7. Petrillo S, Longo UG, Papalia R, Denaro V. Reverse shoulder arthroplasty for massive irreparable rotator cuff tears and cuff tear arthropathy: a systematic review. Musculoskelet Surg. 2017;101(2):105-112. doi:10.1007/s12306-017-0474-z.
8. Sellers TR, Abdelfattah A, Frankle MA. Massive Rotator Cuff Tear: When to Consider Reverse Shoulder Arthroplasty. Curr Rev Musculoskelet Med. 2018; 11(1):131-140. doi: 10.1007/s12178-018-9467-2.
9. Wall B, Nové-Josserand L, O’Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am. 2007; 89(7):1476-1485. doi:10.2106/JBJS.F.00666.
10. Young SW, Zhu M, Walker CG, Poon PC. Comparison of functional outcomes of reverse shoulder arthroplasty with those of hemiarthroplasty in the treatment of cuff-tear arthropathy: a matched-pair analysis. J Bone Joint Surg Am. 2013; 95(10):910-915. doi:10.2106/JBJS.L.00302.
11. Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg. 14(1 Suppl S):147S-161S. doi:10.1016/j.jse.2004.10.006.
12. Clark JC, Ritchie J, Song FS, et al. Complication rates, dislocation, pain, and postoperative range of motion after reverse shoulder arthroplasty in patients with and without repair of the subscapularis. J Shoulder Elbow Surg. 2012; 21(1):36-41. doi:10.1016/j.jse.2011.04.009.
13. Rol M, Favard L, Berhouet J, la Société d’orthopédie de l’Ouest (SOO). Factors associated with internal rotation outcomes after reverse shoulder arthroplasty. Orthop Traumatol Surg Res. 2019; 105(8):1515-1519. doi:10.1016/j.otsr.2019.07.024.
14. Triplet JJ, Everding NG, Levy JC, Moor MA. Functional internal rotation after shoulder arthroplasty: a comparison of anatomic and reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2015; 24(6):867-874. doi:10.1016/j.jse.2014.10.002.
15. Aleem AW, Chamberlain AM, Keener JD. The functional internal rotation scale: a novel shoulder arthroplasty outcome measure. JSES Int. 2020; 4(1):202-206. doi:10.1016/j.jses.2019.10.002.
16. Kim MS, Jeong HY, Kim JD, Ro KH, Rhee SM, Rhee YG. Difficulty in performing activities of daily living associated with internal rotation after reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2020; 29(1):86-94. doi:10.1016/j.jse.2019.05.031.
17. Rojas J, Joseph J, Liu B, Srikumaran U, McFarland EG. Can patients manage toileting after reverse total shoulder arthroplasty? A systematic review. Int Orthop. 2018; 42(10):2423-2428. doi: 10.1007/s00264-018-3900-4.
18. Rojas J, Joseph J, Srikumaran U, McFarland EG. How internal rotation is measured in reverse total shoulder arthroplasty:a systematic review of the literature. JSES Int. 2020; 4(1):182-188. doi:10.1016/j.jses.2019.10.109.                  19. Southard EJ, Ode G, Simon P, et al. Comparing patient-reported outcome measures and physical examination for internal rotation in patients undergoing reverse shoulder arthroplasty: does surgery alter patients’ perception of function? J Shoulder Elbow Surg. 2021; 30(7S):S100-S108. doi:10.1016/j.jse.2021.01.020.
20. Berhouet J, Garaud P, Favard L. Influence of glenoid component design and humeral component retroversion on internal and external rotation in reverse shoulder arthroplasty: a cadaver study. Orthop Traumatol Surg Res. 2013; 99(8):887-894. doi:10.1016/j.otsr.2013.08.008.
21. Boulahia A, Edwards TB, Walch G, Baratta R V. Early results of a reverse design prosthesis in the treatment of arthritis of the shoulder in elderly patients with a large rotator cuff tear. Orthopedics. 2002; 25(2):129-133. doi: 10.3928/0147-7447-20020201-16.
22. Collin P, Matsukawa T, Denard PJ, Gain S, Lädermann A. Pre-operative factors influence the recovery of range of motion following reverse shoulder arthroplasty. Int Orthop. 2017; 41(10):2135-2142. doi: 10.1007/s00264-017-3573-4.
23. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987 ;( 214):160-164.
24. Eichinger JK, Rao M V, Lin JJ, et al. The effect of body mass index on internal rotation and function following anatomic and reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2021; 30(2):265-272. doi:10.1016/j.jse.2020.06.008.
25. Erickson BJ, Harris JD, Romeo AA. The Effect of Humeral Inclination on Range of Motion in Reverse Total Shoulder Arthroplasty: A Systematic Review. Am J Orthop (Belle Mead NJ). 45(4):E174-9.
26. Frankle M, Siegal S, Pupello D, Saleem A, Mighell M, Vasey M. The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients. J Bone Joint Surg Am. 2005; 87(8):1697-1705. doi:10.2106/JBJS.D.02813.
27. Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994 ;( 304):78-83.
28. Jeon BK, Panchal KA, Ji JH, et al. Combined effect of change in humeral neck-shaft angle and retroversion on shoulder range of motion in reverse total shoulder arthroplasty - A simulation study. Clin Biomech (Bristol, Avon). 2016; 31:12-19. doi:10.1016/j.clinbiomech.2015.06.022.
29. Kalouche I, Sevivas N, Wahegaonker A, Sauzieres P, Katz D, Valenti P. Reverse shoulder arthroplasty: does reduced medialisation improve radiological and clinical results? Acta Orthop Belg. 2009; 75(2):158-166.
30. Krämer M, Bäunker A, Wellmann M, Hurschler C, Smith T. Implant impingement during internal rotation after reverse shoulder arthroplasty. The effect of implant configuration and scapula anatomy: A biomechanical study. Clin Biomech (Bristol, Avon). 2016; 33:111-116. doi:10.1016/j.clinbiomech.2016.02.015.
31. Maurer A, Fucentese SF, Pfirrmann CWA, et al. Assessment of glenoid inclination on routine clinical radiographs and computed tomography examinations of the shoulder. J Shoulder Elbow Surg. 2012; 21(8):1096-1103. doi:10.1016/j.jse.2011.07.010.
32. Sirveaux F, Favard L, Oudet D, Huquet D, Walch G, Molé D. Grammont 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(3):388-395. doi:10.1302/0301-620x.86b3.14024.
33. Streit JJ, Shishani Y, Gobezie R. Medialized Versus Lateralized Center of Rotation in Reverse Shoulder Arthroplasty. Orthopedics. 2015; 38(12):e1098-103. doi: 10.3928/01477447-20151120-06.
34. Wirth B, Kolling C, Schwyzer HK, Flury M, Audigé L. Risk of insufficient internal rotation after bilateral reverse shoulder arthroplasty: clinical and patient-reported outcome in 57 patients. J Shoulder Elbow Surg. 2016; 25(7):1146-1154. doi:10.1016/j.jse.2015.11.010.
35. Friedman RJ, Flurin PH, Wright TW, Zuckerman JD, Roche CP. Comparison of reverse total shoulder arthroplasty outcomes with and without subscapularis repair. J Shoulder Elbow Surg. 2017; 26(4):662-668. doi:10.1016/j.jse.2016.09.027.
36. Stephenson DR, Oh JH, McGarry MH, Rick Hatch GF, Lee TQ. Effect of humeral component version on impingement in reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2011; 20(4):652-658. doi:10.1016/j.jse.2010.08.020.
37. Huish EG, Athwal GS, Neyton L, Walch G. Adjusting Implant Size and Position Can Improve Internal Rotation After Reverse Total Shoulder Arthroplasty in a Three-dimensional Computational Model. Clin Orthop Relat Res. 2021; 479(1):198-204. doi:10.1097/CORR.0000000000001526.
38. Karelse ATJA, Bhatia DN, De Wilde LF. Prosthetic component relationship of the reverse Delta III total shoulder prosthesis in the transverse plane of the body. J Shoulder Elbow Surg. 17(4):602-607. doi:10.1016/j.jse.2008.02.005.
39. Langohr GDG, Giles JW, Athwal GS, Johnson JA. The effect of glenosphere diameter in reverse shoulder arthroplasty on muscle force, joint load, and range of motion. J Shoulder Elbow Surg. 2015; 24(6):972-979. doi:10.1016/j.jse.2014.10.018.