Abstract
Introduction
Reverse shoulder arthroplasty (rTSA) increases the deltoid abductor moment arm length to facilitate the restoration of arm elevation; however, rTSA is less effective at restoring external rotation. This analysis compares the muscle moment arms associated with two designs of rTSA humeral trays during two motions: abduction and internal/external rotation to evaluate the null hypothesis that offsetting the humerus in the posterior/superior direction will not impact muscle moment arms.
Methods
A 3-D computer model simulated abduction and internal/external rotation for the normal shoulder, the non-offset reverse shoulder, and the posterior/superior offset reverse shoulder. Four muscles were modeled as 3 lines from origin to insertion. Both offset and non-offset reverse shoulders were implanted at the same location along the inferior glenoid rim of the scapula in 20° of humeral retroversion. Abductor moment arms were calculated for each muscle from 0° to 140° humeral abduction in the scapular plan using a 1.8: 1 scapular rhythm. Rotation moment arms were calculated for each muscle from 30° internal to 60° external rotation with the arm in 30° abduction.
Results
During abduction with the normal shoulder, the subscapularis and infraspinatus act as abductors throughout the range of motion and the teres minor converts from an adductor to abductor at 60°. In the non-offset reverse shoulder, the subscapularis converts from an adductor to abductor at 82°, the infraspinatus converts at 68°, and the teres minor converts at 135°. Because the offset humeral tray shifts the humerus superiorly relative to the non-offset tray, each muscle converts from an adductor to abductor earlier in abduction, where the subscapularis converts at 62°, the infraspinatus converts at 43°, and the teres minor converts at 110°. During rotation (Figures 1–3), both the offset and non-offset reverse shoulders decrease the internal rotation capability of the subscapularis and teres major but increase the external rotation capability of the infraspinatus and teres minor relative to the normal shoulder. Because the offset tray shifts the humerus posteriorly, the internal rotation capability of the subscapularis and teres major is decreased by 7.1 and 9.5 mm while the external rotation capability of the infraspinatus and teres minor is increased by 8.6 and 7.8 mm, respectively.
Discussion and Conclusions
Changing humeral position using an offset humeral tray modified the function of each muscle. In abduction, the offset tray caused each muscle to convert from adductors to abductors earlier. Improved abduction capability limits each muscle's antagonistic behavior with the deltoid, potentially reducing the deltoid force required to elevate the arm. In rotation, the offset tray caused the posterior shoulder muscles to be more effective external rotators. Improved external rotation capability is important for patients with external rotation deficiency; as external rotation is required for many activities of daily living, increasing the rotator moment arm lengths of the only two external rotators is advantageous to restore function. Therefore, we reject the null hypothesis and conclude the offset humeral tray does impact muscle moment arms with rTSA. Future work should evaluate the clinical significance of these observed changes in muscle moment arms.
