Shoulder Arthroplasty

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					 Shoulder Arthroplasty



Daniel Penello
Upper Extremity Rounds
April 26, 2006
 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.
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
Indications for Shoulder
Arthroplasty
   Osteoarthritis
   Rheumatoid arthritis
   Rotator cuff tear arthropathy
   Avascular necrosis
   Post-traumatic arthritis
   Severe proximal humeral fractures
Arthroplasty Options




Hemiarthroplasty
                                    Reverse Total
                                    Shoulder


                   Total Shoulder
Surgical Approach

                Deltopectoral




     Coracoid
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.
 1974- Neer II Prosthesis. Modified
  Neer I to conform to a glenoid
  component.




   Courtesy of Smith & Nephew
 1970’s - constrained
  components were
  popular, but follow-up
  reports demonstrated
  high rates of
  loosening, particularly
  of the glenoid
  component.
 1980’s – Modular humeral
  components were developed, along
  with cementless glenoid fixation using
  polyethylene on a metal backing.
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.
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.
Humeral Components
                  PROX POROUS        FULLY POROUS
CEMENTED
                  COATED             COATED

Good for          Need good          Need good bone
osteopenic bone   bone stock         stock
Lower risk of     Higher risk of     Higher risk
intra-operative   intra-operative    intra-operative
fracture          fracture           fracture
                                     More stress
More stress-      Less stress-       shielding
shielding         shielding          Hard to revise
Hard to revise    Easier to revise
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.
The Need for Modularity
 F-H Offset
 B-C Head
  thickness
 D-E = 8mm
  Top of humeral
  head is higher
  than greater
  tuberosity
The Need for Modularity
 Reestablishing normal glenohumeral
  anatomic relationships is important to
  ensure optimal results.
  Iannotti JP; JBJS 74A 1992
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.
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.
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
Hemi               vs           Total Shoulder
   Easy procedure               More consistent pain
   Short Operating time          relief
   Less risk of instability     Better fulcrum for
   Can be revised to TSA         active motion


   Less reliable pain relief      Difficult procedure
   Progressive Glenoid            Longer OR time
    erosion may cause              Poly wear can cause
    results to deteriorate          loosening of both
    over time                       components
   Need concentric                More Glenoid bone loss
    glenoid
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”
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.
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
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
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
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
Rheumatoid Arthritis
 Peri-articular erosions
 Peri-articular
  osteopenia
 Thin cortices
 Adjacent joint
  involvement
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.
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
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
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.
Surgical Options

 Hemiarthroplasty with a large head

 Repair of rotator cuff and TSA

 Reverse TSA

   “Clayton Spacer”
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.
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.
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.
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
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
Reverse Total Shoulder
Arthroplasty is Hard to Revise


                   Little Glenoid bone
                    stock once
                    component is
                    removed.
Osteonecrosis
Causes:

   Corticosteroids
   Alcoholism
   Sickle cell diesese
   Lupus
   Idiopathic
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).
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
Choice of Prosthesis
Consider

 Patient age
 Condition of glenoid surface and bone
  stock
 Axillary nerve palsy is a relative
  contraindication to arthroplasty
Complications
 Instability 1.2%

   Excessive Retro/Anteversion
   Head too small
   Head too low (post fracture)
   Subscap rupture
Complications
 Rotator Cuff Tear 2%

 Results in superior migration of
  humerus and glenoid loosening

 Glenoid loosening
Complications
 Infection   0.5%

 Staph Aureus
 More common after revision surgery
Complications
 Heterotopic Ossification    10 -45%

        Males
        Dx = osteoarthitis
        Low grade
        Non-progressive
        Does not affect outcome
Sperling, Cofield et al
Complications
 Stiffness

 Depends on indication for
  arthroplasty
 Subscap shortening
 Oversized components
 Inappropriate rehab
Complications
 Periprosthetic Fracture
 Intra-op 1%
 Post-op 0.5 - 2%

 Most common in RA
 85% women
 Glenoid fractures are rare
Complications
 Axillary nerve injury

 Rare
 Higher risk during revision surgery
 Usually a neuropraxia
Ultimate Bail -Outs

 Excision Arthroplasty

 Shoulder Arthrodesis
Thank You