Shoulder Prosthesis SSSR Postoperative Imaging · Shoulder Prosthesis Postoperative Imaging Florian...

Shoulder Prosthesis

Postoperative Imaging

Florian M. Buck, MD

1. Nov. 2014

Shoulder Prosthesis

Surgical Approach Findings

Postoperative Problems

Imaging ModalitiesSSSR

1. Nov. 2014

Shoulder Prosthesis

Anatomical Prostheses

- Conventional prosthesis

- Fracture prosthesis

Inversed prosthesis

Glenoid components

What are we talking about

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Shoulder Prosthesis

Anatomical Total Shoulder Prosthesis

+ Glenoid Allograft

Different Types

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Shoulder Prosthesis

Inversed Total Shoulder Prosthesis

Different Types

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Deltopectoral approach

• Between deltoid and pectoralismajor muscle

• Same approach as for instability surgery

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• Between deltoid and pectoralismajor muscle

• Same approach as for instability surgery

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• Detachment of subscapularistendon more often than lesser tubercle osteotomy

• Fixation with transosseousseam

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Complications of deltopectoral approach

• Subscapularis muscleinsufficiency due to tendondetachment

Ref.: Scheibel et al. AJSM, 2007

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Axillar nerve branch injury• Deltoideus fatty change

Intraoperative Nerve Injury

Brachial plexus unjury• Plexus traction due to

lengthening of the arm & preoperatively shortenedarm (high Hamda grade)

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Symptoms• Deltoid muscle dysfunction

• Inferior instability

• if deltoid muscle function isinsufficient not even inverse prosthesis can be used

Intraoperative Nerve Injury

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Imaging Modalities

Plain Films

MR Imaging

Computed TomographySSSR

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Plain Films

Shoulder Status

H0 view G0 view

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Plain Films

Shoulder Status

H0 view G0 view Neer view axial / crosstable view

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Computed Tomography

Anatomical Prosthesis

Conventional CT CT Recon with tripleslice thickness

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Computed Tomography

Inversed Prosthesis

Conventional CT D60s Kernel & IMAR 3D

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MR Tomography

Inversed Prosthesis

PD WARP

• Location of glenoshpere screws• Soft tissues around joint

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MR Tomography

Inversed Prosthesis

PD WARP

• Osseous structures

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MR Tomography

Inversed Prosthesis

• AC joint arthrosis (DD acromial fx)• Muscle atrophy• Humeral shaft loosening

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MR Tomography

Teres Major Transfer Teres major Transfer (L‘Episcopo transfer)

Internal rotation External rotation

Ref.: Boileau P. Modified latissimus dorsi and teres major transfer. JSES 2007;16:671-682. Boileau P. Reversed shoulder arthroplasty withmodified l‘Episcopo. JSES 2010;19:20-30.

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Complications of Shoulder Arthroplasty

Multitude of complications reported:

• Prosthetic loosening• Glenohumeral instability• Periprosthetic fracture• Rotator cuff tears• Infection• Neural injury• Deltoid muscle dysfunction

Ref.: Bohsali KI, Wirth MA, Rockwood CA. Complications of total shoulder arthroplasty. J Bone Joint Surg Am. 2006 Oct;88(10):2279-92.

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Complications

Complications in 33 series including 2540 shoulders:

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Prosthetic Loosening

Humeral Component

Migration InfectionLoosening

Ref.: Buck FM, et al. Shoulder arthroplasty. Eur Radiol. 2008 Dec.;18(12):2937-2948

• rare• often in combination with infection

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Humeral Capping

Resurfacing – Cap Granuloma in humeral head

• 1% loosening (instead of 0.5% - double risk)• Granuloma formation

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Glenoid Component• frequent• unresolved problem

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Glenoid Component• frequent• unresolved problem

Glenosphere Loosening - superior tilting/dislocation

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Scapular Notching

Inversed Prosthesis• frequent (ca. 60% after 4 years)• not associated with inferior functional

outcome

Grading:

Ref.: Boileau P et al. Neer Award 2005: The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. JSES 2006 Sep;15(5):527–40. Levigne C et al. Scapular notching in reverse shoulder arthroplasty. JSES 2008;17(6):925-35.

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Scapular Notching

Grade III

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Scapular Notching

Inversed Prosthesis• associated with:

- too high position of glenosphere- superior tilting

• mostly posteroinferior location• probably caused by

abduction/elevation and external rotation

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Glenohumeral Instability

Second leading cause of prosthesis dysfunction

Anterior:• most common instability (80%)• subluxation of > 5 mm seen on cross-

table view• Causes:

- Subscapularis insufficiency- Anteversion of glenoid component- Oversized humeral head- Decreased humeral retroversion (< 20°)

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Anterior Subluxation of Humeral Head?

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Anterior Deltoid Muscle Detachment

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Superior:• Acromiohumeral distance < 5mm on

G0 a.p. view• Associated:

- Anterior instability and rotator cuff tears (supraspinatus tendon)

- Cranial placement of the humeral component with relative lengthening of the humerus

- Superior tilting of glenoid component

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Posterior:• Causes:

- Wide dorsal capsule- Anterior soft tissue contracture- Infraspinatus tendon deficiency- Malrotation of humeral component

(retroversion > 45°)- Dorsal glenoid defect- Retroversion of glenoid component (> 20°)

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Inferior:• Causes:

- Shortened humerus (e.g. after proximal humeral fractures or after humeral defects in tumor surgery)

- Deltoid muscle weakness in axillary nerve palsy or deltoid muscle detachment

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Humeral Torsion

Measurement according to Hernigou et al.• Proximal:

Line perpendicular to the articuar surface

• Distal Reference: Transepicondylar line

Ref.: Hernigou et al. Determining humeral retroversion with CT. JBJS Am. 2002;84-A(10):1753-62.

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Humeral Torsion

Measurement according to Hernigou et al.• Proximal:

Line perpendicular to the articuar surface

• Distal Reference: Transepicondylar line

• Normal values:- Retroversion of 10-50°

(wide range)- Side-to-Side Difference only 2°

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Rotational Misplacement

A rare problem• Shaft is placed to allow for

future conversion to inverse prosthesis

• Head can be positioned almost freely on the shaft

• Problem Fracture prosthesis: Tubercula do not fit tendon position

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Reference Line

Case: Inversed Prosthesis, 10° Antetorsion

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Case: Inversed Prosthesis, 10° Antetorsion

Reference Line

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Periarticular Ossification

Grading according to Kjaersgaard

Grade 0: No ossification

Grade 1: Ossification occupying < 50% of joint space

Grade 2: Ossification occupying > 50% of joint space

Grade 3: Bridging of joint

Ref.: Kjaesgaard P et al. Heterotopic bone formation following total shoulderarthroplasty. J Arthroplasty 4:99-104.

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Periarticular Ossification

Grading according to Kjaersgaard

• Develop early in the postoperative course

• Typically low grade and often clinically unimportant

Ref.: Kjaesgaard P et al. Heterotopic bone formation following total shoulderarthroplasty. J Arthroplasty 4:99-104.

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Prevalence

Ref.: Levy JC et al. Classification of postoperative acromial fracturesfollowing reverse shoulder arthroplasty. JBJS Am. 2013 Aug 7;95(15):e1041.

• Around 5%

Scapular Fractures & Inverse Prosthesis

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• Text

Periprosthetic Fractures

Prevalence

Classification

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Periprosthetic Fractures

Intraoperative Fracture

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Classification

• Type I: Acromion

Involvement of insertion of a portion of anterior and middle deltoid origin

• Type II: Scapular spineInvolvement of at least the entire middledeltoid origin

• Type III: Base of scapular spineInvolvement of the entire middle and posterior deltoid origin

Scapular Fractures

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Classification

• Type I

often chronic

Scapular Fractures

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Classification

• Type II

Scapular Fractures

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Classification

• Type III

Scapular Fractures

sagittal

axial coronal

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Acromion Fractures & Inversed Prosthesis

Ref.: Frankle M et al. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. JBJS Am. 2006 Sep;88 Suppl 1 Pt 2:178-90.

Lateral position of rotation center

• Deltoideus can act

• Less force needed

• More stress on acromion

• Lengthening of arm – Tension on deltoideus muscle

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Acromion Fractures & Inverse Prosthesis

Ref.: Otto RJ et al Scapular fractures after reverse shoulder arthroplasty: evaluation of risk factors and the reliability of a proposed classificaton. JSES. 2013 Nov;22(11):1514-21.

Detection of Fractures

• 80% visible on plain films

• Helpful signs:

- Decreasing acromion-tuberosity distance

normal

fracture

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Acromion Fractures & Inverse Prosthesis

Ref.: Otto RJ et al Scapular fractures after reverse shoulder arthroplasty: evaluation of risk factors and the reliability of a proposed classificaton. JSES. 2013 Nov;22(11):1514-21.

Detection of Fractures

• 80% visible on plain films

• Helpful signs:

- Decreasing acromion-tuberosity distance

- Increasing acromial tilt

normal

fracture

Don’t forget to inspect cross-table and Neer view for spine fractures!

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Conclusion

Take Home Messages

• Knowledge about the prosthesis types used

• Surgical approach and associated problems

• Imaging of the postoperative shoulder

• Most common postoperative complications

1. Nov. 2014

Thank you for your attention!SSSR

1. Nov. 2014

Articular Metallosis

Metal-on-Metal• Polyethylene wearing

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Articular Metallosis

Metal-on-Metal• Lymphocellular infiltration

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Fractures

Early, Late or Incidental

• Early:

Intraoperative Fractures

• Late:

Insufficiency fractures

• Incidental:

Traumatic (e.g. fall)

Inversed prosthesis, Hamada , Os aromiale

Risk factors:

Osteoporosis, Surgery Technique

Ref.: Hamada K et al. Roentgenographic findings in massive rotator cufftears. A long-term observation. CORR 1990;(254):92-6.Wall B et al. Reverse Total Shoulder Arthroplasty: A review of resultsaccording to etiology. JBJS Am. 2007;89:1476-85.

1. Nov. 2014

Fractures

Hamada Classification

Ref.: Hamada K et al. Roentgenographic findings in massive rotator cufftears. A long-term observation. CORR 1990;(254):92-6.

Pathologic Stage:

1. AHI > 6mm

2. AHI < 6mm

3. Acetabulatsation – 2 subtypes:

- concave underfurface of acromion

- spur along coraco-acromial lig.

4. Narrowing glenohumeral joint

5. Humeral head collapse

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Fractures

Early, Late or Incidental

• Early:

Intraoperative Fractures

• Late:

Insufficiency fractures

• Incidental:

Traumatic (e.g. fall)

Hamada , Os aromiale, Inversedprosthesis

Risk factors:

Age: Comorbidity, osteoporosis

Osteoporosis, Surgery Technique

Ref.: Hamada K et al. Roentgenographic findings in massive rotator cufftears. A long-term observation. CORR 1990;(254):92-6.Wall B et al. Reverse Total Shoulder Arthroplasty: A review of resultsaccording to etiology. JBJS Am. 2007;89:1476-85.

1. Nov. 2014

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