Download - Current Concepts in Shoulder Replacement
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J.R. Rudzki, MD, MScWashington Orthopaedics & Sports Medicine
Clinical Assistant Professor
Dept. of Orthopaedic Surgery
George Washington University School of Medicine
Washington, DC
Current Concepts
In Shoulder
Replacement
Disclosure
Previous direct & indirect funding & support for
research & education from:• Philips Medical Imaging
• Bristol-Myers-Squib
• Smith & Nephew
• NIH (CT Chen)
• HSS Institute for Sports Medicine Research
• Major League Baseball
Arthrex – Consultant
AJSM, JBJS – Reviewer
AAOS – Evaluation Committee
Shoulder Joint
• Minimally constrained
ball-and-socket joint
• Mobility Stability
Anatomy
• Static Stabilizers• Joint surfaces
• Capsulolabral complex
• Dynamic Stabilizers• Rotator cuff
• Scapular stabilizer muscles
Glenohumeral Ligaments(static stabilizers)
Structural thickenings of capsule
•Superior: supraglenoid tubercle
•Middle: glenoid or labrum LT
•Inferior: neck/labrum LT
Anatomy
• Supraglenoid / superior labral
origin
• Function = Controversial
• Commonly degenerated in
patients with shoulder arthritis
Long Head Biceps Tendon Anatomy
What is
shoulder arthritis?Degenerative condition of
progressive cartilage wear:
• Inflammation
• Pain
• Stiffness
• Motion Loss
Impaired
Function
What does shoulder
arthritis look like?Narrowing of Joint Space:- From cartilage wear
Bone Spurs:- From cartilage wear & articulation of bone-on bone
Ligament Contracture:- From inflammation & motion loss
Progressive Deformity:
- Erosion of socket
What are the
treatment options for
shoulder arthritis?Anti-Inflammatory Medications
Ice & Activity Modification
Cortisone Injections
Synthetic Lubricant Injection ???
Reduce Pain
&
Inflammation
When conservative
management fails,
Background
Goals:• Pain Relief
• Optimal Shoulder Function
Technical Points:• Restore Proximal Humeral & Glenoid Anatomy
• Balance Soft Tissues
> 7000 Shoulder Arthroplasties
performed annually in U.S.
128 shoulders studied at 3-5 year follow-up
Avg # shoulder fxns that performable improved from 4/12 preop to 9/12
Function improved in ninety-six shoulders (94%).
The better the preoperative function, the better the follow-up function.
On average, pts regained ~ 2/3rds of the functions absent preop.
73% chance of regaining a fxn that was absent before surgery
chance of losing a function present before surgery was 6%.
Matsen et al., JBJS, 2002
How well does it work?
Both total shoulder arthroplasty & hemiarthroplasty improve disease-
specific & general quality-of life measurements two years after surgery.
Operating Room• Regional Anesthesia
• Beach Chair Position
• Space Suits
• IV Antibiotics
Incision & Approach
•Between Deltoid &
Pectoralis Muscles
Subscapularis Tenotomy
Removal of osteophytes
Exposure of Humeral Head
Cutting the Humerus
• Version
• Neck Shaft
Angle
• External
guide
• Anatomic
landmarks
Anterior and inferior capsular release
on the glenoid side (glenoid exposure)
Exposing the Glenoid Socket
Glenoid Insertion
• Hemostasis, pressurization
Humeral Stem
Insertion
Hemiarthroplasty vs.
Total Shoulder Arthroplasty
Gartsman, et al. - Prospective Randomized
Study in 51pts w/ OA &
Intact Rotator Cuff
Mean Follow-Up = 35 months (r: 24-72 mos)
Signficant Improvements in: Pain Relief
Internal RotationTSA Group
P < 0.05
Patient Satisfaction, Fxn, StrengthNot statistically significant
No revisions from TSA cohort at mean 35 month follow-up
Three hemiarthroplasties required revision for glenoid
resurfacing (12%)
Bryant et al, JBJS 2005
JBJS 2000
Data further substantiated by recent JBJS Meta-analysis
Hemiarthroplasty vs.
Total Shoulder ArthroplastyTotal Shoulder = Excellent Operation for
appropiately indicated patients
Why not for everyone with glenohumeral OA?
Primary concern affecting longevityGlenoid
Loosening
Current Kapplan-Meier Survivorship Data is comparable to
Hip & Knee arthroplasty and appears to represents an effective,
durable procedure.
Significant
Potential
Problem
Metal-Backed Glenoid Components
Cemented Poly Components
Deshmukh et al., JSES 2005
Associated with:• Prosthetic component mismatch
• Mechanical wear of polyethylene
components
• Osteolysis (stress shielding) with
metal components
• Component malpositionin
• Poor bone stock
• Rotator cuff deficiency
Glenoid Loosening Glenoid Fixation
Nyffeler & Gerber et al, JSES 2006
Anatomic Considerations Glenoid Version
Glenoid erosion & excesive
retroversion can induce:• distorted anatomy
• posterior luxation
• may contribute to
posterior capsular laxity
• require restoration of
near normal version for
appropriate glenoid
component seating & stability
Why is glenoid erosion a challenge
& what do we do about it?
3-Dimensional CaT Scan Reconstruction
Glenoid Retroversion &
Excessive Posterior Wear Glenoid Version
• Preop Axillary Plain Film
How do we identify it?
• Preop MRI
• Preop CT Scan (Pacemaker)
Clinical Assessment at
Time of SurgeryConsider role of glenoid version
in cases of difficult exposure
despite appropriate releases
Complications
• Anterosuperior Escape
• Infection
• Tuberosity Migration / Nonunion
• Glenoid Erosion / Loosening
• Nerve Injury
• Subscap Repair Failure
Estimated mean complication rate = ~5%
• Pseudoparalysis
Emerging Concepts
191 reverse TSA followed for avg 40 months
• Avg Constant score improved from 23 to 60 points
• 173 of the 186 patients were satisfied or very satisfied
• Patients with:
• Primary rotator cuff tear arthropathy
• Primary osteoarthritis with a rotator cuff tear
• Massive rotator cuff tear had better outcomes
• Complications = ~12%
• Dislocation (15 cases) & infection (8 cases) were
the most common complications JBJS 2007
Emerging Concepts
80 reverse TSA followed for minimum 5 yrs
Survival rate with replacement or glenoid loosening were
91% & 84%, respectively, at 120 months.
Shoulders that had arthropathy with a massive rotator cuff
tear demonstrating a significantly better result than those that
had a disorder with another etiology (p < 0.05).
JBJS 2007
Emerging Concepts
80 reverse TSA followed for minimum 5 yrs
A second break started at ~ 6 years & reflected
progressive deterioration of the functional result.
Conclusions: Reverse total prosthesis should be reserved
for treatment of very disabling shoulder
arthropathy with massive rotator cuff rupture,
& it should be used exclusively in patients
over 70 years-old with low functional
demands.
JBJS 2007
78 year-old female
with Rotator Cuff
Arthropathy
Case Example: 85 y/o Female Malunion
Current Concepts in
Shoulder Arthroplasty
J.R. Rudzki, MD, MScWashington Orthopaedics & Sports Medicine
Clinical Assistant Professor
Dept. of Orthopaedic Surgery
George Washington University School of Medicine
Washington, DC
Thank You
February 19, 2014
37
J.R. Rudzki, MD, MScWashington Orthopaedics & Sports Medicine
Clinical Assistant Professor
Dept. of Orthopaedic Surgery
George Washington University School of Medicine
Washington, DC
Current Concepts
In Shoulder
Replacement
Thank You