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• W4229333669 abstract "Where Are We Now? Paul Grammont and his research team in the 1970s helped develop and usher in the modern era of the reverse total shoulder prosthesis. One of Grammont’s principles was having a medialized center of rotation in a nonanatomic location because glenoid baseplate fixation in the early designs was much more tenuous, and prototypes that attempted to lateralize the center of rotation often failed through the mechanism of pull out. Because of this, first-generation reverse shoulder arthroplasties placed the center of rotation at the glenoid to try to minimize baseplate pull out. The unintended consequences were medial scapular notching and decreased external rotation. Today, proponents of the medial center of rotation generally obtain good results [9], but concerns about scapular notching and decreased ROM have guided others to explore the merits of lateralization [2, 5] and even use a more varus neck-shaft angle. Recent baseplate design improvements have allowed for lateralization seemingly without increased rates of glenoid failure; this has resulted in the current “medial versus lateral center of rotation” debate. Reverse total shoulder arthroplasty (RTSA) has progressed from a limited salvage procedure for rotator cuff arthropathy and anterosuperior escape in the septuagenarian to a mainstream option for shoulder arthritis or even irreparable, chronic rotator cuff tears in the absence of arthritis. Today, implant companies provide more than 30 different implant systems for the surgeon to choose from. In the current study, Nunes et al. [8] conducted a systematic review to determine whether lateralized (RTSAs perform as advertised, in terms of acceptable complication, revision, and scapular notching rates. They included data on 1813 patients in the nine studies that met their inclusion criteria. The authors found that lateralized reverse shoulder designs provide similar levels of pain reduction and improvements in PROMs with some increased external rotation than medialized center of rotation RTSA, which is important. Based on these findings, surgeons should consider using a reverse shoulder system that provides for a more lateral center of rotation to decrease scapular notching and the resultant osteolysis and provide for more ROM in external rotation without the addition of latissimus and teres major transfers. Where Do We Need To Go? Regarding medial versus lateral offset options, we still need to determine which one is the best. In a randomized controlled study, Greiner et al. [5] found that lateralized RTSA had better external rotation than the nonlateralized RTSA group. Hasan et al. [6] noted this finding in their prospective multicenter study as well, in which the external rotation improvement exceeded the MCID, with a low risk of notching and stress fractures. Cuff et al. [3], in their clinical series, found only 9% of shoulders demonstrated notching, and they observed 90% survivorship at 10-year follow-up with one lateralized design. In the current study, Nunes et al. [8] help us understand that baseplate loosening, or pull-out, is not a concern, and at mid-term follow-up, lateral offset RTSA is a viable option. But we have yet to determine whether lateralized implants perform better than those with a medial center of rotation. Therefore, longer follow-up studies are needed to determine whether the risk of notching stays low and ROM improvements persist. It is, of course, much more complicated than simply choosing a medial or lateral center of rotation. Werthel and colleagues [10] have classified RTSA implants into five categories of 5-mm increments for global offset (medialized RTSA, minimally lateralized RTSA, lateralized rTSA, highly lateralized RTSA, and very highly lateralized RTSA). And to further confuse the matter, implants also can vary in terms of baseplate position, baseplate inclination, glenosphere size, humeral version, humeral tray offset, humeral stem shape, and length. Indeed, within only one implant system (of the 30+ that are commercially available), dozens of permutations are possible. At this point, it is unlikely that there will be a hands-down winner in any systematic review, as the indications for RTSA are broadening and as the implant options and variations continue to increase. How Do We Get There? Longer-term follow-up studies and systematic reviews of implants within a given global offset group, as well as experience gleamed from implant registries, may give us some clarity about whether lateralized implants perform better than those with a medial center of rotation or vice versa. It took 5 to 7 years for us to recognize that notching is associated with decreased functional outcome scores, including ASES, Constant, UCLA, and SST scores [7]. Perhaps with longer follow-up studies, an unintended consequence of lateralization will be recognized. There is potential for well-designed computer simulation methodologies like multiobjective design optimization techniques, which include normal and abnormal anatomical models to help us narrow down the parameters and positions of various implants as Elwell et al. [4] did in their paper looking at the trade-off between ROM and stability in reverse shoulder prostheses. In the meantime, since the surgeon is the method, each surgeon must utilize a system that yields good results, with minimal notching, few acromial and scapular spine stress fractures, and a low risk of instability. Stay in touch with your patients and their outcomes and stay in tune with the research as it comes out because it’s a jungle out there. The implant companies are changing designs faster than they can be studied. One recent example of the utility of registries was noted in the Australian Orthopaedic Association National Joint Replacement Registry, where the 2021 review [1] documented a 1-year revision rate of a new reverse shoulder prosthesis of 5%. Industry may not be as forthcoming as we might want, so, as noted above, it behooves us to monitor the relevant sources." @default.
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• W4229333669 date "2022-01-26" @default.
• W4229333669 modified "2023-09-27" @default.
• W4229333669 title "CORR Insights®: Improved Clinical Outcomes After Lateralized Reverse Shoulder Arthroplasty: A Systematic Review" @default.
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• W4229333669 doi "https://doi.org/10.1097/corr.0000000000002129" @default.
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