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Shoulder arthroplasty

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Shoulder arthroplasty

  1. 1. Shoulder Arthroplasty Daniel Penello Upper Extremity Rounds April 26, 2006
  2. 2.  Lesions of the shoulder requiring arthroplasty are much less common than lesions involving the weight- bearing joints of the body, such as the hip and knee.
  3. 3. The Shoulder  Greatest ROM  No inherent bony stability  Relies on soft tissues for stability  Many injuries involve the soft tissues (rotator cuff, labrum)  Little glenoid bone stock
  4. 4. Indications for Shoulder Arthroplasty  Osteoarthritis  Rheumatoid arthritis  Rotator cuff tear arthropathy  Avascular necrosis  Post-traumatic arthritis  Severe proximal humeral fractures
  5. 5. Hemiarthroplasty Total Shoulder Reverse Total Shoulder Arthroplasty Options
  6. 6. Surgical Approach Deltopectoral Coracoid
  7. 7. A little history  1893- French surgeon Pean inserted platinum and rubber components to replace a shoulder joint destroyed by tuberculosis.  1951- Neer I, Vitallium Hemiarthroplasty prosthesis which resulted in pain relief and good function compared to previous options.
  8. 8.  1974- Neer II Prosthesis. Modified Neer I to conform to a glenoid component.  Courtesy of Smith & Nephew
  9. 9.  1970’s - constrained components were popular, but follow-up reports demonstrated high rates of loosening, particularly of the glenoid component.
  10. 10.  1980’s – Modular humeral components were developed, along with cementless glenoid fixation using polyethylene on a metal backing.
  11. 11. Cemented polyethylene versus uncemented metal- backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study. Boileau P, Avidor C, J Shoulder Elbow Surg. 2002 Jul- Aug;11(4):351-9. 40 Shoulders with 3 year follow up.  Metal-backed – 2% radiolucent lines, 100% progressive, 25% loose in 3 years. Associated with shift and osteolysis.  Cemented – 80% radiolucent lines, 25% progressive. None loose in 3 years.
  12. 12. Other Problems with Metal-Backed Glenoid Components  Metal-backing increased the thickness of the component and often lead to over- stuffing of the joint.  To avoid over-stuffing the joint, the polyethylene thickness had to be reduced, resulting in accelerated poly wear & failure  Poly-metal disassociation occurred with unacceptable frequency.
  13. 13. Humeral Components CEMENTED PROX POROUS COATED FULLY POROUS COATED Good for osteopenic bone Lower risk of intra-operative fracture More stress- shielding Hard to revise Higher risk of intra-operative fracture Less stress- shielding Easier to revise Need good bone stock Need good bone stock Higher risk intra-operative fracture More stress shielding Hard to revise
  14. 14. Cemented vs Press-fit Humeral Components  Harris, Jobe and Dai reported less micro- motion with proximally-cemented stems.  Fully cemented stems provide no additional benefit or stability over proximally- cemented stems.  Sanchez-Sotelo reported a low rate of stem loosening regardless of fixation, but press- fit prostheses developed more radiolucent lines in the first 4 years.
  15. 15. The Need for Modularity  F-H Offset  B-C Head thickness  D-E = 8mm Top of humeral head is higher than greater tuberosity
  16. 16. The Need for Modularity  Reestablishing normal glenohumeral anatomic relationships is important to ensure optimal results. Iannotti JP; JBJS 74A 1992
  17. 17. Other Anatomic Variables to Consider  Glenoid : 2° anteversion to 7° retroversion  Humeral Head: 20° - 40° retroversion  Axial CT of the glenohumeral joint is a valuable pre-op planning tool.
  18. 18. Contraindications to Shoulder Arthroplasty  Active or recent shoulder joint infection  Paralysis with complete loss of rotator cuff and deltoid function  A neuropathic arthropathy  Irreparable rotator cuff tear is a contraindication to glenoid resurfacing.
  19. 19. Osteoarthritis  In addition to the universal features of osteoarthritic joints (joint space narrowing, cyts, osteophytes…), the shoulder can also demonstrate  Posterior glenoid erosion  Flattening of the humeral head  Enlargement of the humeral head  Rotator cuff tears are uncommon in OA
  20. 20. Hemi vs Total Shoulder  Easy procedure  Short Operating time  Less risk of instability  Can be revised to TSA  Less reliable pain relief  Progressive Glenoid erosion may cause results to deteriorate over time  Need concentric glenoid  More consistent pain relief  Better fulcrum for active motion  Difficult procedure  Longer OR time  Poly wear can cause loosening of both components  More Glenoid bone loss
  21. 21. Recommendation based on Experience  Neer, 1998 “When the articular surface of the glenoid is good, the results of hemiarthroplasty are similar to those of TSA. Wear on the glenoid has not been a problem if the articular surface was good at the time of surgery and glenohumeral motion was re-established”
  22. 22. Recommendations based on Evidence Kirkley et al, 2000  42 pts, 3 surgeons (stratified)  One year follow-up  No significant difference in WOSI, ASES, DASH Constant Score or ROM.  Trend towards better pain relief with TSA.  2 Hemi patients crossed over to TSA after 1 year follow-up.
  23. 23. Recommendations based on Evidence Gartsman, 2000  51 shoulders  Average f/u of 35 months  No difference in ASES or UCLA scores.  Significantly better pain relief with TSA  3 pts crossed over to TSA by 35 months
  24. 24. A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. Bryant D, Litchfield R; J Bone Joint Surg Am. 2005 Sep;87(9):1947-56. Included 4 RCT’s Average 2 year follow-up. TSA resulted in significantly improved UCLA scores, pain relief and increased forward elevation (by 13°). This meta-analysis concluded that at 2 years of follow-p, TSA provided a better functional outcome, however the problems of glenoid component loosening in the TSA group and progressive glenoid erosion in the hemi group may affect the eventual long-term outcome. Longer follow-up is necessary
  25. 25. Recommendations based on Evidence  The results of arthroplasty in osteoarthritis of the shoulder. Haines JF et al. J Bone Joint Surg Br. 2006 Apr;88(4):496-501  Prospective study of 124 shoulder arthroplasties for OA (Hemi and TSA)  Similar improvement in pain and function in both groups if rotator cuff was intact . Better results with Hemi if + rotator cuff tear  Hemi  Revision at mean of 1.5 years for glenoid pain  TSA  Revision at mean of 4.5 years for glenoid loosening
  26. 26. Technical Issues to Consider  OA tends to result in posterior glenoid wear/erosion, which, if accepted, will lead to a retroverted glenoid component.  Compensate by anterior reaming or placing the humeral component in LESS retroversion.  Failure to do so will result in Posterior Instability
  27. 27. Rheumatoid Arthritis  Peri-articular erosions  Peri-articular osteopenia  Thin cortices  Adjacent joint involvement
  28. 28. Rheumatoid Arthritis  Cemented short-stemmed prosthesis  Gill, Cofield et al recommend at least 60mm between the cement mantles of ipsilateral shoulder and elbow arthroplasties.  If this cannot be achieved, join both cement mantles together.
  29. 29. Rheumatoid Arthritis  Generally, TSA performed due to destruction of the glenoid articular surface by the disease.  Glenoid erosion may require bone grafting, however, if glenoid is eroded to the level of the coracoid process, glenoid resurfacing is contraindicated
  30. 30. Rotator Cuff Arthropathy  Described by Neer, Craig and Fukada in 1983.  A distinct form of osteoarthritis associated with a massive chronic rotator cuff tear.  Generally, rotator cuff tears occur in less than 10% of shoulders with OA
  31. 31. Rotator Cuff Arthropathy  A function of the rotator cuff is to depress the humeral head and keep it centered on the glenoid fossa.  Massive rotator cuff tears result in proximal migration of the humeral head.  This is a contraindication to glenoid resurfacing as it results in eccentric (superior) glenoid loading and early component loosening.
  32. 32. Surgical Options  Hemiarthroplasty with a large head  Repair of rotator cuff and TSA  Reverse TSA  “Clayton Spacer”
  33. 33. Outcomes of Hemiarthroplasty  Rockwood: 86% satisfactory results after 4 years  Zuckerman: 93% adequate pain relief and 90% had improved function for ADL’s.  Sanches-Sotelo: 75% modest improvements in ROM and strength for ADL’s. Good pain relief.
  34. 34. Outcomes of Hemiarthroplasty  Field et al, and Sanchez-Sotelo reported that impaired deltoid function and previous subacromial decompression (loss of coracoacromial ligament) were significantly associated with clinical shoulder instability post hemiarthroplasty.
  35. 35. Reverse Total Shoulder Arthroplasty  Lateralizes the centre of rotation and places the deltoid at a mechanical advantage.  More inherent stability and prevents proximal migration of humeral head.
  36. 36. Outcomes of the Reverse Total Shoulder  The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two- year follow-up study of sixty patients. Frankle M, Siegel S, J Bone Joint Surg Am. 2005 Aug;87(8):1697-705  Average age = 70  Improved ASES scores  Improved ROM Flex: 55  105° Abd: 41  102°  17% Complication rate  7 failures  5 revised to new Reverse TSA  2 revised to Hemiarthroplasties
  37. 37. Outcomes of the Reverse TSA (Delta III prosthesis)  Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball- and-socket total shoulder prosthesis. Werner CM, Glbart M, J Bone Joint Surg Am. 2005 Jul;87(7):1476-86.  58 consecutive patients, average age = 68  41 cases were revisions  Follow up = 38 months  Improved Constant Score, Pain reduction and improved ROM. ROM: Flex: 42  100° Abd: 43  90°  50% complication rate (including minor)  If a 1° surgery = 18% re-operation rate  If a Revision surgery= 39% re-operation rate
  38. 38. Reverse Total Shoulder Arthroplasty is Hard to Revise  Little Glenoid bone stock once component is removed.
  39. 39. Osteonecrosis Causes:  Corticosteroids  Alcoholism  Sickle cell diesese  Lupus  Idiopathic
  40. 40. Osteonecrosis  Usually young patients with adequate bone stock.  Prefer proximally porous-coated, press-fit humeral prosthesis.  less stress-shielding  easier to revise if necessary  Only resurface glenoid in stage V osteonecrosis (glenoid erosion).
  41. 41. Post-Traumatic Arthritis  Due to fractures treated conservatively  May have mal-union of tuberosities, distorting normal anatomic landmarks  12% of patients have axillary nerve palsies (Neer).  Many have soft-tissue contractures and muscle weakness
  42. 42. Choice of Prosthesis Consider  Patient age  Condition of glenoid surface and bone stock  Axillary nerve palsy is a relative contraindication to arthroplasty
  43. 43. Complications  Instability 1.2%  Excessive Retro/Anteversion  Head too small  Head too low (post fracture)  Subscap rupture
  44. 44. Complications  Rotator Cuff Tear 2%  Results in superior migration of humerus and glenoid loosening  Glenoid loosening
  45. 45. Complications  Infection 0.5%  Staph Aureus  More common after revision surgery
  46. 46. Complications  Heterotopic Ossification 10 -45%  Males  Dx = osteoarthitis  Low grade  Non-progressive  Does not affect outcome Sperling, Cofield et al
  47. 47. Complications  Stiffness  Depends on indication for arthroplasty  Subscap shortening  Oversized components  Inappropriate rehab
  48. 48. Complications  Periprosthetic Fracture  Intra-op 1%  Post-op 0.5 - 2%  Most common in RA  85% women  Glenoid fractures are rare
  49. 49. Complications  Axillary nerve injury  Rare  Higher risk during revision surgery  Usually a neuropraxia
  50. 50. Ultimate Bail -Outs  Excision Arthroplasty  Shoulder Arthrodesis
  51. 51. Thank You

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