shoulder arthroplasty daniel penello upper extremity rounds april 26, 2006
TRANSCRIPT
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Shoulder Arthroplasty
Daniel PenelloUpper Extremity RoundsApril 26, 2006
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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.
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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
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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
Arthroplasty Options
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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- Neer II 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 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.
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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.
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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
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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.
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The Need for Modularity
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 for Modularity
Reestablishing normal glenohumeral anatomic relationships is important to ensure optimal results. Iannotti JP; JBJS 74A 1992
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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.
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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 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
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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
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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
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.
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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 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
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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 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
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Rheumatoid Arthritis Peri-articular erosions Peri-articular
osteopenia Thin cortices Adjacent joint
involvement
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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.
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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
Hemiarthroplasty with 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 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
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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
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Reverse Total Shoulder Arthroplasty is 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 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).
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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
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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 Cuff Tear 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 Ossification 10 -45%
Males Dx = osteoarthitis Low grade Non-progressive Does not affect outcomeSperling, Cofield et al
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Complications
Stiffness
Depends on 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 nerve injury
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