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Evolution of tsa1


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Evolution of tsa1

  1. 1. The Evolution of Materials & Techniques in Total Shoulder Arthroplasty Manos Antonogiannakis Director 3rd Orthopaedic Department Ygeia Hospital - Center for Shoulder Arthroscopy
  2. 2. 1893 Jules E. Pean 1st successful shoulder replacement -26 years before the first hip replacement -tuberculosis infected shoulder of a 32-year-old Parisian -2 years later implant removed because of sepsis 2 platinum loops connecting the scapula to a paraffin-hardened rubber ball
  3. 3. Themistocles Gluck had already designed an ivory shoulder hemiarthroplasty
  4. 4. 1951 Baron and Senn acrylic prosthesis to replace the proximal humerus 1953 de Anquin performed 11 acrylic shoulder replacements for fracture allows tendinous reattachment around the prosthesis BUT poor wear characteristics anchorage difficulty component breakage
  5. 5. Semiconstrained devices English McNab prosthesis Mazas nonretentive prosthesis Hooked DANA prosthesis by Amstutz DANA total shoulder system was the first system with multiple head and glenoid sizes
  6. 6. Constrained Bickel prosthesis (1970) By Mayo Clinic Cement stem & small metallic ball Polyethylene socket within the glenoid vault Bone removal from the scapula High complication rates & revision
  7. 7. Constrained Stanmore prosthesis by Lettin and Scales Standard ball-and-socket Increased constraint Glenoid 3 long pegs cemented Range of motion inconsistent and disappointing High revision rates
  8. 8. Bipolar designs Smooth, concentric contact Decreased contact stress & friction Increased moment arm Bateman developed 2 bipolar designs
  9. 9. 1953 Charles S. Neer II - The original Neer I Vitallium (cobalt-chrome alloy) One stem size & 44mm radius head Hole in the lateral neck Top of the head slightly flattened
  10. 10. 1953, the Neer I prosthesis available in three stem sizes 1955, that number increased to five, four fins, multiple fenestrations for bone ingrowth 1955 Neer’s clinical series was first published in the Journal of Bone and Joint Surgery and consisted of using his shoulder prosthesis in 12 cases with excellent and satisfactory results.
  11. 11. Development of the Neer II in 1970 & 1st generation prosthesis Monoblock humeral stem and cemented, all-polyethlene keeled component flute for cement egress 2 holes for suture fixation standard stem lengths with 3 diameters & 2 head lengths
  12. 12. Modular or 2nd generation prosthesis in 1980 Biomet, Cofield, Global Did not achieve Neer’s aim of mimicking the normal anatomy restoring the center of rotation Two major problems were encountered: 1.the prosthetic head was often malpositioned 2.the head was frequently oversized.
  13. 13. Modular & Adaptable 3rd generation prosthesis in 1990 Modularity = different sizes Adaptability = restoration of the COR anatomical unconstrained recreate normal anatomy variable inclination and offset The Aequalis prosthesis adopted these criteria and became the first third-generation shoulder replacement Gilles Walch , Pascal Boilleau , Christian Gerber
  14. 14. Glenoid resurfacing prosthesis The first glenoid component introduced by Neer in 1972 all-polyethylene oval-shaped curved back triangular keel designed for cementation Major concern radiolucencies at cement-bone interface and loosening
  15. 15. What surface geometry? Anatomic versus oval Flat or Convex back keeled or pegged designs What material? All-polyethylene Metalbacked (1984 Neer ) Hydroxyapatite-coated Plasma-sprayed Tantalum (Zimmer) Trabecular Titanium (Lima)
  16. 16. Convex or flat back? The convex-back glenoid component outperformed the flat-back What is the optimal mismatch between components? radial mismatch appears to be optimised at greater than 5.5 mm Cemented or uncemented glenoid? cementless metal-backed components inferior to cemented all-polyethylene implants
  17. 17. The Reverse TSA • Although very good results were obtained with the Anatomic TSA it required a functioning rotator cuff • Reverse shoulder arthroplasty became the solution for that problem
  18. 18. 1970-1973 The Neer Mark Ι,ΙΙ,III by Neer & Averill 1st fixed fulcrum prosthesis reverse ball-and-socket glenoid keeled & cemented Mark I : larger ball allow more motion Mark II : small ball & cuff reattach but limited ROM Mark III: axial rotation in the humeral stem Due to failures Neer abandoned constrained designs
  19. 19. 1972 Reeves spiked glenoid component cemented 1972 Gerard component screwed into the glenoid without cement vs Mark & Reeves implants
  20. 20. But.. none of these reverse devices caught on as a viable option
  21. 21. The resurgence of RSA 1985 Trompette prosthesis 1. 2/3 of a sphere 2. PE humeral stem 3. Cemented glenosphere The prototype dates from 1985 The first implantation was in 1986 LATERALIZED COR
  22. 22. 1991 Delta III ( the first reverse that survived the test of time) 2 innovations glenoid large ball humerus inclination of 155˚( non anatomic) 1. Half of sphere 2. Polyethylene cup 3. Modular 4. Baseplate fixed with two diverging polar screws & two equatorial screws In 1995 glenoid fixed with a porus coating central peg COR AT THE LEVEL OF THE GLENOID MEDIALIZATION & DISTALIZATION OF THE
  23. 23. A paradigm shift Instead of trying to restore the anatomy To change the natural anatomy in order to have better functional results Instead of mimicking Nature Improve Nature
  24. 24. DELTA III - GOLD STANDARD - MEDIALIZATION Lever arm of deltoid & tension of deltoid fibers AA Elevation 130˚ but… slackening of the remaining cuff (IS, Tm, SSC ) scapular impigment : notching & bone loos & PE wear proper deltoid tension: instability 3-6% (no deltoid wrapping) acromion stress fracture
  25. 25. Solutions • Increasing the diameter of the glenosphere (36-44mm) • Eccentric glenosphere • Inferior and with a downward inclination, implantation of the glenosphere • Polyethylene glenospere • Lateralization of the glenosphere
  26. 26. LATERALIZATION OF THE GLENOSPHERE 1.Metallic offset lateralization 2/3 of a sphere (DJO) & glenosphere over the baseplate 2.Bony increased offset BIO RSA (P.Boileau)
  27. 27. LATERALIZATION IN HUMERUS Humeral cut 155˚ vs 135˚ PE inlay distalization PE onlay lateralization & distalization
  28. 28. The Swedish Registry from 1999
  29. 29. Resurfacing (Paralel line of development) In 1970s Bateman developed resurfacing device replaces only the humeral head & Jonsson similarly developed cup arthroplasty used in placed of fusion in rheumatoid arthritis
  30. 30. Resurfacing Evolution Advantage no stem Drawback glenoid erosion PyroCarbon’s Low surface friction Nonadhesive properties Contribute to preserving cartilage
  31. 31. Short stem & Stemless Humeral Bone preserving Avoidance of stress risers Recreated the anatomy Hydroxyapatite (HA) coating A need of good metaphyseal bone stock
  32. 32. CONVERTIBILITY Revise hemi & total-shoulder arthroplasties to a reverse shoulder Anatomical Shoulder Inverse/Reverse System, Zimmer The Aequalis Ascend Flex convertible shoulder system
  33. 33. Affinis Inverse -Mathysmedical Vitamys & Ceramys (an effort to improve on wear characteristics) oxidation resistance excellent wear and aging behaviour 5,4 times lower wear rate compared to CoCr - UHMWPE Vitamys Glenospheres highly cross-linked polyethylene addition of 0,1% atocopherol (vit E) Ceramys inlay nano-crystalline dispersion of 80% zirconium oxide& 20% aluminum oxide free of Co Cr & Nickel high resilience and durability
  34. 34. Zimmer Trabecular Tantalum • Exceptional initial fixation • High coefficient of friction between Trabecular Metal Material & cancellous bone • Enables vascularization • Maximizes bone and soft-tissue ingrowth • More normal bone remodeling
  35. 35. Lima Trabecular Titanium an effort to increase fixation strength to the sceleton a biomaterial that imitates trabecular bone morphology light weight corrosion resistance excellent biocompatibility high mechanical performance High open porosity & adequate pore size enhance cell migration vascularization transport of oxygen & nutrients ions & bone inducing factors osteoconduction & osteoinduction
  36. 36. Electron Beam Melting technology creation of any three-dimensional design either dense or porous parts produce exclusive implants reconstruct 3D patient anatomy through 3D printing ( CT scans and MRI data) PROMADE focused on implants designed specifically for the sole use of particular patient. SMR AXIOMA TT METAL BACK
  37. 37. It was a long road traveled • Today we can succed results of a magnitude unimaginable 20 gears ago Reverse TSA 3 months post-op Anatomic TSA 4 months post-op
  38. 38. And the evolution continues as ingenious surgeons strive to lessen human suffering and improve the quality of life of our patients The main issue being the longevity of the results
  40. 40. The shoulder arthroplasty “family tree” by R.Micael Gross
  41. 41. 1950 Frederick Krueger Vitallium mold prosthesis Egg-shaped head, rounded corners Cementless implantation Fenestrated stem for bone ingrowth
  42. 42. 1973 Interposition Arthroplasty by Swanson using Silastic In 1970s all polyethylene glenoid components used in the Neer & St.George prostheses, like Kenmore design
  43. 43. 1972 R. Kölbel prosthesis 1973 Kessel RSA cementless glenoid component with a single large self-tapping lag screw
  44. 44. 1975 Fenlin designed a 2-pieces glenoid component with 2 extensions 1978 Gristina Trispherical Prosthesis metal glenoid, two metal & two polyethylene hemispheres
  45. 45. Grammont’s first idea varus position of the humeral head The Ovoide prosthesis Introduced in 1980 Break the link with anatomy This prosthesis has theoretically two CORs. Abandoned because of problems of instability
  46. 46. LATERALIZATION GLENOSPHERE + HUMERUS Increase deltoid lever arm Increase tension ISS/Tm/SSc Increase compressive forces Increase stability Decrese medial impigment LATERALIZATION BOTH + INFERIOR TILT DISTALIZATION OF THE HUMERUS Increase deltoid tension but the same deltoid lever arm
  47. 47. Keeled versus pegged? The peg-shaped provides greater theoretic stability against shear forces Offset keel versus centered keel? Anterior offset demonstrates better resistance to bending compared with the centered keel