RADIOGRAPHIC AND ANATOMIC PREDICTORS TO PREVENT SCAPULAR NOTCHING IN THE DELTA III REVERSE TOTAL SHOULDER REPLACEMENT

Abstract

INTRODUCTION: The reverse DELTA III shoulder prosthesis can successfully relieve pain and restore function in cuff tear arthropathy. The most frequently reported complication is inferior scapular notching. The purpose of this study was to evaluate the clinical relevance of notching and to determine the anatomic and radiographic parameters that predispose to its occurrence.

STUDY PROTOCOL: Seventy-seven consecutive shoulders of 76 patients of an average age of 71 years with an irreparable rotator cuff deficiency were treated with a reverse DELTA III shoulder arthroplasty and followed clinically and radiographically under fluoroscopic control for a minimum of 24 months (mean: 44, range: 24 to 96). The effect of glenoid cranial caudal component positioning and of the prosthesis–scapular neck angle on the development of inferior scapular notching and clinical outcome was assessed.

RESULTS: All shoulders which developed notching did so in the first fourteen months. Forty-four percent of the shoulders had inferior scapular notching, 30% had posterior notching and anterior notching (8%) was rare. Osteophytes along the inferior scapula occurred in 27% of the shoulders. The angle between the glénosphère and the scapular neck (r=+0.677)) as well as the craniocaudal position of the glénosphère (r=+0.654) were highly correlated with inferior notching (p< 0.001). A notching index (notching index = height of prosthesis + (prosthesis scapular neck angle x 0.13) was calculated using the height of implantation of the glénosphère and the postoperative prosthesis scapular neck angle: This allowed a prediction of the occurrence of notching with a sensitivity of 91% and specificity of 88%. The height of implantation of the glenosphere had a greater influence on inferior notching than the prosthesis scapular neck angle by a factor of approximately 1:8. Inferior scapular notching was associated with a significantly poorer clinical outcome than absence of inferior notching: At final follow-up, the respective average subjective shoulder values were 62% and 71% (p=0.032), relative Constant scores were 72% and 83% (p=0.028), abduction strength was 4.3 versus 8.7 kilograms (p< 0.001), active abduction was 102° versus 118° (p=0.033) and flexion averaged 110° versus 127° (p=0.004).

DISCUSSION: Inferior scapular notching after reverse total shoulder arthroplasty adversely affects midterm clinical outcome. It can be prevented by optimal positioning of the glenoid component.