https://hartfordsportsorthopedics.com/ In this presentation, Dr. Mazzara discusses the pathology, surgical techniques, and potential complications during a total shoulder replacement and a reverse total shoulder replacement. To learn more about shoulder replacements, please visit: https://hartfordsportsorthopedics.com/total-shoulder-replacement-arthroplasty-south-windsor-rocky-hill-glastonbury-ct/

1. Total Shoulder Arthroplasty
JAMES T MAZZARA, MD
ORTHOPEDIC ASSOCIATES OF HARTFORD
CONNECTICUT JOINT REPLACEMENT SURGEONS, LLC
CONNECTICUT JOINT REPLACEMENT INSTITUTE
BONE AND JOINT INSTITUTE
EASTERN CONNECTICUT HEALTH NETWORK

2. Contact Information
James T Mazzara, MD
Orthopedic Associates of Hartford, PC
29 Haynes Street
Manchester, CT 06040
_________________
150 Enterprise Drive
Rocky Hill, CT 06067
860-649-2267
www.HartfordSportsOrthopedics.com

3. The Shoulder Complex
Deltoid Muscle
Pectoralis
Clavicle (Collar Bone)

4. The Shoulder Complex
Deltoid muscle
removed

5. The Shoulder Complex

6. Glenohumeral Joint

7. Coracoacromial Arch
 Acromion & CA
ligament
 Protective arch
over the GH joint
 Secondary
restraint for the
humeral head

8. Scapula to Humerus, Radius, Ulna
 Move & stabilize the shoulder
complex
 Deltoid
 Supraspinatus
 Infraspinatus
 Teres Minor
 Subscapularis
 Teres major
 Coracobrachialis
 Biceps
 Triceps

9. Scapulothoracic Muscles
 Serratus anterior
 Trapezius
 Rhomboids
 Pectoralis minor
 Levator scapulae

10. Humerus to Trunk Muscles
 Latissimus dorsi
 Pectoralis major (sternal
head)

11. Rotator Cuff
 Supraspinatus
 Active in any elevation
 Stabilizes the GH joint
 Suprascapular nerve (C5,
someC6)

12. Rotator Cuff
 Infraspinatus
 Depressor of the humeral
head
 Stabilizer against posterior
subluxation
 60% or external rotation
force
 Suprascapular nerve (C5, some
C6)

13. Rotator Cuff
 Teres Minor
 45% of external rotation
force
 Posterior branch of the axillary
nerve (C5-C6)

14. Rotator Cuff
 Subscapularis
 Anterior stability
 Internal rotation
 Depression of humeral head
 Compression of the
glenohumeral joint
 Upper and lower subscapular
nerves (C5-C6)

15. Bursa
 Subacromial and subdeltoid
bursa
 Coalesce to form one bursa
 Lubricate motion between
rotator cuff and overlying CA
arch

16. Rotator Cuff Balance
 Proper function depends
upon balance between
all muscle and ligament
forces around the
shoulder

17. Tendon Degeneration
 Age-related changes
 Decreased
vascularity at the
cuff insertion
 Fragmentation of
tendon with loss of
cellularity
 Disruption of tendon
bone attachment

18. Consequences of rupture
 Retracted cuff fibers place additional tension on
remaining microcirculation compromising cuff
viability
 Increasing amounts of tendon are exposed to
joint fluid which prevents tendon healing

19. Full Thickness Tears
 Loads are concentrated at the margins of the
tear
 Further tearing occurs with smaller loads
 Partial tears become complete
 Anterior supraspinatus tears extend posteriorly

20. Incidence of Rotator Cuff Tears
 MRI
 Partial and complete RC tear
 4%, < 40 yo
 54%, > 60 yo
 Ultrasound
 Partial and complete RC tear
 13%, >40 yo
 20%, >50 yo
 31%, >60 yo
 51%, > 80 yo
 Over 50% asymptomatic RC tears become symptomatic and progress over 3 years
Sports Med Arthrosc Rehabil Ther Technol. 2012; 4: 48.

21. Progressive Tearing
 Spacer effect of the cuff is lost
 Humeral head displaces
superiorly
 Biceps tendon hypertrophies
then ruptures
 Biceps may dislocate medially
if the transverse humeral
ligament tears

22. Early Cuff Failure
 Compression of the humeral
head is less effective
 Deltoid pulls head upward
 Upward pull of the deltoid
results in cuff abrasion &
further cuff damage

23. Chronic Cuff Failure
 Humeral head articulates
with the CA arch
 Secondary joint disease
occurs called cuff tear
arthropathy

24. Rotator Cuff Tear Arthropathy
 Massive cuff tears lead to joint
degeneration

25. Chronic Rotator Cuff Tears
 Muscle atrophy
 Fatty infiltration of muscle
belly
 Tendon retraction
 Bone osteoporosis
 Loss of muscle and tendon
excursion
 Irreversible
 Progressively worse

26. Radiographs
 Acromial shape
 Position of humeral head
 AC arthritis
 Calcific tendinitis
 Glenohumeral arthritis
 Destructive lesions

27. 1 & 2: AP in Scapular Plane
 2 Views: IR, ER
 Calcium deposits
 Greater tuberosities:
excrescences, cysts

28. 3: Axillary View
 Evaluate GH joint &
tuberosities
 Glenoid version
 Joint space narrowing
 Os acromiale

29. 4: Outlet View
 Evaluate
subacromial space
 Acromial shape and
thickness

30. 5: 30O Caudal Tilt View
 AP view with
a 30O caudal tilt
 Demonstrates anterior
acromial projection
 Bone spurs

31. Rotator Cuff Imaging
 MRI
 90% accurate in
diagnosing
complete RC
tears
 70% accurate in
diagnosing
partial RC tears

32. CT Scan
 Horizontal or transverse
plane
 3D imaging of the shoulder
 Glenoid bone loss
 Glenoid version

33. MRI
 Evaluate status of rotator cuff
 Intact or torn
 Size of tear if present
 Repairable or not
 Presence of atrophy in the muscle
 Percentage of fatty infiltration

34. Native Glenoid
 Highly variable anatomy
 Size, inclination, version
 Version 2 degrees retroversion
 12 degrees anteversion to 14
degrees retroversion

35. Prevalence of Shoulder Arthritis
 Affects 20% of population over 65 yo
 Incidence of joint replacement
 Hip > Knee > Shoulder
 Of 1.07 million joint replacements in 2004
 4% (43,000) were total and reverse total shoulders
 Shoulder OA is third most common large joint
 Usually diagnosed in later stages
 Non weight bearing joint
 Earliest stages are found arthroscopically
 4-17% in routine shoulder arthroscopy

36. Causes of Shoulder Arthritis
 Aging related delay in repair
 Biochemical changes, change in water content
 collagen degradation
 Abnormal joint loading
 Compression, Overloading, Wear and tear
 Joint stabilization surgery
 Created excessing anterior tightness
 Thermal capsular shrinkage,
 Bupivacaine or Lidocaine infusion pump

37. Causes of Shoulder Arthritis
 Inflammatory arthritis
 Trauma and articular injury
 Instability and dislocation
 Single shoulder dislocation: 19 times
higher risk
 Osteonecrosis
 Idiopathic
 Chronic steroids, Radiation (breast
cancer), excessive alcohol, sickle cell,
medication

38. Causation of
Arthritis and RC Tears
 Age (degeneration) and acromial morphology (Impingement)
contribute to cuff tears
 Incidence of tears is low before 40 yo.
 Incidence increases in 50-60 yo & increases with age
 RCT must to a certain extent be considered as normal
degeneration
 Not all tears cause pain and impairment
 Many cuff tears occur in 50-60 yo, with sedentary life style and no
history of injury or heavy labor
 40% of those w/ cuff tears have never done strenuous work
 Cuff defects are frequently bilateral
 Many heavy laborers never get cuff tears

39. Osteonecrosis
 Osteonecrosis / Avascular
Necrosis
 Idiopathic
 Post-traumatic
 Anatomic neck fractures
 Steroid or Alcohol Use

40. Contraindications to TSR
 Active infection
 Neuroarthropathy
 Insensate joint
 Paralysis of musculature
 Neurologic

41. Anatomic Shoulder Replacement
Indications
 Arthritis
 Osteonecrosis
 Neurologically
intact
 Intact rotator cuff
Anatomic Shoulder Reverse Total Shoulder

42. Contraindications to Glenoid
Implantation
 Relative Contraindications
 Age <50 yo
 High functional demand
 Significant bone loss
 Rotator cuff dysfunction

43. Contraindication to Anatomic TSR
 Humeral head escapes though defect
in Coraco-acromial through deltoid
 Acromioplasty with ligament release
 Anatomic shoulder arthroplasty will fail
 Deficient rotator cuff
 Unable to elevate arm
 Glenoid loosening
 Only option is a reverse TSR
 Must have functional deltoid
 Sufficient bone

44. Total Shoulder Arthroplasty
 First done in 1974
 First Total shoulder with glenoid
resurfacing
 Overall 93% survivorship at 10 years
 87% survivorship at 15 years

45. Anatomic Glenoid Component
 Most common longer term complication
 Loosening
 24% of all long term complications
 Implant design
 Technique
 Patient characteristics
 Rotator cuff integrity
 Indolent infection

46. Hemiarthroplasty Outcomes without
Glenoid Resurfacing
 60% dissatisfied at 15 years
 Risk of revision 4 times greater than TSR with
glenoid
 Ream and Run
 Develop fibrocartilage layer on glenoid
 20 months to achieve acceptable pain relief
 Best in men >60 yo
 Allograft resurfacing

47. Glenoid Failure
 Higher in patients with higher
functional requirements
 Higher with rotator cuff tears

48. Glenoid Failure
 Progressing lucent lines
 Rocking horse phenomenon
 Glenoid is edge loaded
 Retroverted glenoid
 Superior inclination
 Joint instability
 Rotator cuff tear
 Due to inflammatory reaction related to
wear particles of metal or polyethylene

49. Humeral Component
 Shorter stems preserve
more bone
 Press fit, no cement
 May lead to early
loosening
 Lucent lines seen
around implant in 22%
at 3 years

50. Stemless Humeral Component
 83% humeral component survival at
20 years
 Failure due to periprosthetic fracture
 Loosening of stems

51. Problems with Stemless Design

52. Shoulder Replacement

53. Shoulder Replacement

54. Shoulder Replacement

55. Shoulder Replacement

56. Complications of Anatomic
TSR
 Periprosthetic fractures 1.6 – 2.3%
 Infection 0 – 4%
 Instability 0.9 – 1.8%
 Rotator cuff tear 1.3 – 7.8%
 Glenoid loosening 8%
 Most do not require revision
 Neuropraxia 0.6 – 1.6%
 Mostly axillary nerve or brachial plexus

57. Outcomes of TSR, <65 yo
 Systematic Review (Meta analysis)
 Patients younger than 65 yo
 9.4 years
 17.4% underwent revision (52% of these for glenoid
loosening)
 54% glenoid loosening
 60 – 80% implant survivorship 10 – 20 years
 Results in younger patients are not as good as overall
TSA population
 BUT better than pre op
 JSES July 2017Volume 26, Issue 7, 1298–1306

58. Outcomes of TSA on Younger Patients
 Ages 37 – 60 yo, mean age 55 yo
 13 year follow up
 21 patients
 2 shoulder revised
 2 recommended revisions
 Without revision
 95% good or very good results
 Increased glenoid radiolucent line over time
 Bone Joint J. 2017 Jul;99-B(7):939-943

59. Reverse Total Shoulder Arthroplasty
Indications
 Pain with cuff tear arthropathy
 Failed hemiarthroplasty with irreparable
cuff tear
 Pseudoparalysis (Loss of motion)
 Impaired function
 3 and 4 part shoulder fractures in older
patients, >70 yo
 Non union of shoulder fracture
 Severe rheumatoid arthritis

60. Reverse Shoulder Arthroplasty
 Intact deltoid
 Sufficient bone

61. Reverse Shoulder Arthroplasty

62. Complications of Reverse TSR
 Scapular notching
 Infection
 Dislocation
 Component instability / loosening
 Acromial fracture
 Hardware failure
 Nerve damage
 Intraoperative fracture
 Heterotopic ossification

63. Reverse Shoulder Replacements
Left hemiarthroplasty for fracture,
Tuberosity nonunion, nonfunctional
rotator cuff
Revised w/ proximal humeral
replacement, Reverse TSR, bone
grafted humerus

64. Reverse Shoulder Replacements
Nonunion, malunion
anatomic neck fracture
Revised to Reverse TSR

65. Reverse Shoulder Replacements
Osteonecrosis humeral head. Old
fracture repair
Revised to Reverse TSR. Post op
fall and fracture required ORIF
humeral shaft

66. Long term Outcomes: RTSR, in
<60 yo, RCT
 23 shoulders, mean age 57 yo
 Improved pain and function
 Improved motion and strength
 Sustained beyond 10 years
 Results we equal in those who had previous surgery and those who did not
 Notching increased over time
 39% complication rate
 2 failed RTSA
 J Bone Joint Surg Am. 2017 Oct 18;99(20):1721-1729

67. RTSA and RTW Outcomes
Non Workers Comp
 40 patients, 56-82 yo
 Average RTW: 2.3 months, 0.5 – 11 months
 Average 1.4 months sedentary work
 Average 4.0 months light work
 96.2% good to excellent outcomes
 5% retired related to shoulder limitations
 No patients involved in moderate to heavy work
 No patients had workers compensation claims
 Orthopedics. 2016;39(2):e230-e235

68. RTSA & RTW in Workers Comp
Patients
 14 patients, average age 61 yo
 14% RTW rate for WC claim group
 45.5% RTW rate in non WC group
 J Shoulder Elbow Surg. 2015; 24(3):453–459.

69. Reverse TSA Complications
Complication # of
shoulders
Definitive Treatment
Persistent stiffness 1 Nonoperative
Persistent pain 1 Arthroscopic debridement
Mechanical block 1 Arthroscopic removal of avulsed tuberosity
Early dislocation
(<6w)
1 Open reduction. Liner exchange
Late dislocation 3 Closed reduction. Open reduction and liner
exchange
Glenoid component
dissociation
1 Conversion to hemiarthroplasty
Infection 2 Debridement & liner exchange. Removal of
prosthesis, cement spacer

70. Post op TSR
 Out patient or Overnight
 Certain payers permit TSR at Ambulatory Surgery Center
 Medicare will not
 Pain medications 1-3 weeks
 May need meds before therapy
 3 weeks
 May use arm out of sling for light ADL
 6 weeks
 Out of sling full time
 Use arm as tolerated
 Still have stiffness and weakness

71. Post Op Rehabilitation
 Arm immobilizer, up to 6 weeks
 Passive motion 1-4 weeks
 Active assisted motion 4-6 weeks
 Active motion, stretching 6-10 weeks
 Strengthening 10-12 weeks
 Therapy 3-4 months (3x/w to 1x/w)
 1 year home exercises
 Motion improves up to 2 years
 Maximal Medical Improvement
 I year
 More like 2 years

72. Ability to work
 Risk of injury
 Gradual transitional return to work
 Capacity improves over time
 Work capacity is not work tolerance
 Accommodations by employer
 RTW, no use of shoulder: 2-6 weeks
 Use shoulder for reaching, ADL, gradual lifting: 6-12 weeks
 More reaching and lifting: 12-26 weeks
 Long term restrictions
 50 pounds max lift. 25 pounds overhead lift

73. Return to sports: Surgeon Survey
 No restrictions on nonimpact sports
 Sports with light upper extremity impact
 Golf, aerobics, swimming
 Allowed after TSR and with experience for RTSR
 Sports with fall potential
 Tennis, skiing, basketball, soccer
 Allowed after TSR, undecided not allowed after RTSR
 High impact sports
 Weightlifting, waterskiing, volleyball
 Undecided after TSR. Not allowed after RTSR
J Shoulder Elbow Surg. 2011 Mar;20(2):281-9. doi: 10.1016/j.jse.2010.07.021. Epub 2010 Nov 4.
Long-term activity restrictions after shoulder arthroplasty: an international survey of experienced shoulder surgeons.
Magnussen RA1, Mallon WJ, Willems WJ, Moorman CT 3rd.

74. Impairment Ratings , AMA guides, 6th ed
 Implant with normal motion
 20 – 25% UE
 Resection with normal motion
 26 – 34% UE
 Complicated, Unstable, Infected
 34 – 46% UE

75. Anatomic TSR Animation
www.Arthrex.com

76. Reverse TSR Animation
www.Arthrex.com

77. Thank You
90 years old