Shoulder arthroplasty

Shoulder arthroplasty

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  Shoulder Arthroplasty Daniel Penello UpperExtremity Rounds April 26, 2006
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   Lesions ofthe shoulder requiring arthroplasty are much less common than lesions involving the weight- bearing joints of the body, such as the hip and knee.
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  The Shoulder  GreatestROM  No inherent bony stability  Relies on soft tissues for stability  Many injuries involve the soft tissues (rotator cuff, labrum)  Little glenoid bone stock
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  Indications for Shoulder Arthroplasty Osteoarthritis  Rheumatoid arthritis  Rotator cuff tear arthropathy  Avascular necrosis  Post-traumatic arthritis  Severe proximal humeral fractures
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  Hemiarthroplasty Total Shoulder Reverse Total Shoulder ArthroplastyOptions
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  Surgical Approach Deltopectoral Coracoid
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  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.
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   1974- NeerII Prosthesis. Modified Neer I to conform to a glenoid component.  Courtesy of Smith & Nephew
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   1970’s -constrained components were popular, but follow-up reports demonstrated high rates of loosening, particularly of the glenoid component.
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   1980’s –Modular humeral components were developed, along with cementless glenoid fixation using polyethylene on a metal backing.
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  Cemented polyethylene versusuncemented 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.
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  Other Problems withMetal-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.
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  Humeral Components CEMENTED PROXPOROUS 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
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  Cemented vs Press-fitHumeral 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.
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  The Need forModularity  F-H Offset  B-C Head thickness  D-E = 8mm Top of humeral head is higher than greater tuberosity
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  The Need forModularity  Reestablishing normal glenohumeral anatomic relationships is important to ensure optimal results. Iannotti JP; JBJS 74A 1992
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  Other Anatomic Variablesto 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.
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  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.
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  Osteoarthritis  In additionto 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
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  Hemi vs TotalShoulder  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
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  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”
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  Recommendations based on Evidence Kirkleyet 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.
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  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
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  A comparison ofpain, 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
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  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
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  Technical Issues toConsider  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
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  Rheumatoid Arthritis  Peri-articularerosions  Peri-articular osteopenia  Thin cortices  Adjacent joint involvement
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  Rheumatoid Arthritis  Cementedshort-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.
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  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
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  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
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  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.
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  Surgical Options  Hemiarthroplastywith a large head  Repair of rotator cuff and TSA  Reverse TSA  “Clayton Spacer”
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  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.
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  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.
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  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.
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  Outcomes of theReverse 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
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  Outcomes of theReverse 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
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  Reverse Total Shoulder Arthroplastyis Hard to Revise  Little Glenoid bone stock once component is removed.
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  Osteonecrosis Causes:  Corticosteroids  Alcoholism Sickle cell diesese  Lupus  Idiopathic
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  Osteonecrosis  Usually youngpatients 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).
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  Post-Traumatic Arthritis  Dueto 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
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  Choice of Prosthesis Consider Patient age  Condition of glenoid surface and bone stock  Axillary nerve palsy is a relative contraindication to arthroplasty
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  Complications  Instability 1.2% Excessive Retro/Anteversion  Head too small  Head too low (post fracture)  Subscap rupture
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  Complications  Rotator CuffTear 2%  Results in superior migration of humerus and glenoid loosening  Glenoid loosening
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  Complications  Infection 0.5% Staph Aureus  More common after revision surgery
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  Complications  Heterotopic Ossification10 -45%  Males  Dx = osteoarthitis  Low grade  Non-progressive  Does not affect outcome Sperling, Cofield et al
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  Complications  Stiffness  Dependson indication for arthroplasty  Subscap shortening  Oversized components  Inappropriate rehab
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  Complications  Periprosthetic Fracture Intra-op 1%  Post-op 0.5 - 2%  Most common in RA  85% women  Glenoid fractures are rare
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  Complications  Axillary nerveinjury  Rare  Higher risk during revision surgery  Usually a neuropraxia
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  Ultimate Bail -Outs Excision Arthroplasty  Shoulder Arthrodesis
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  Thank You