Current Concepts in Shoulder Replacement

1

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