Shoulder Arthroplasty Daniel Penello Upper Extremity Rounds April 26, 2006.

Shoulder Arthroplasty

Daniel PenelloUpper Extremity RoundsApril 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

Hemiarthroplasty

Total Shoulder

Reverse Total Shoulder

Arthroplasty Options

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

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

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 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

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 outcomeSperling, 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