The inferior/medial shift in the center of rotation (CoR) associated with reverse shoulder arthroplasty (rTSA) shortens the anterior and posterior shoulder muscles; shortening of these muscles is one explanation for why rTSA often fails to restore active internal/external rotation. This study quantifies changes in muscle length from offsetting the humerus in the posterior/superior directions using an offset humeral tray/liner with rTSA during two motions: abduction and internal/external rotation. The offset and non-offset humeral tray/liner designs are compared to evaluate the null hypothesis that offsetting the humerus in the posterior/superior direction will not impact muscle length with rTSA.
A 3-D computer model was developed to simulate abduction and internal/external rotation for the normal shoulder, the non-offset reverse shoulder, and the posterior/superior offset reverse shoulder. Seven 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. Muscle lengths were measured as the average of the 3 lines simulating each muscle and are presented as an average length over each arc of motion (0 to 65° abduction with a fixed scapula and 0 to 40° of internal/external rotation with the humerus in 0° abduction) relative to the normal shoulder.
Both the offset and non-offset reverse shoulders shifted the CoR medially by 27.1 mm and inferiorly by 4.5 mm relative to the normal shoulder. The offset humeral tray/liner shifted the humerus posteriorly and superiorly relative to the non-offset reverse shoulder. As depicted in Figures 1–3, the inferior shift in the CoR elongated the anterior, middle, and posterior heads of the deltoid for both the offset and non-offset reverse shoulders during both types of motions. The more superior position of the humerus with the offset tray elongating the deltoid less than did the non-offset tray. As depicted in Figures 2 and 3, the medial shift in the CoR shortened the subscapularis, infraspinatus, teres major, and teres minor for both the offset and non-offset reverse shoulders during both types of motions. However, the more posterior position of the humerus with the offset tray better restored the anatomic muscle length of all 7 muscles during both types of motion.
Discussion and Conclusions
Offsetting the humerus in the posterior/superior direction using the offset humeral tray/liner altered muscle lengths and resulted in more anatomic muscle tensioning (e.g. each muscle length approached 0%) relative to the non-offset reverse shoulder. These observations related to muscle shortening may describe the mechanism for instability and poor internal/external rotation with rTSA; and if so, more anatomic muscle tensioning with the offset humeral tray offers the potential for improved internal/external rotation capability. Based upon these results, we reject the null hypothesis and conclude that offsetting the position of the humerus in the posterior/superior direction does impact muscle length with rTSA. Future work should evaluate the clinical significance of these observed changes in muscle length.