Transcript No Slide Title

Shoulder Arthroplasty
in Geriatrics
Mohsen Mardani-Kivi M.D.
Assistant Prof. Orthopaedic Dept.
Guilan University of Medical Sciences
Background
 The most common fractures in the
elderly osteoporotic patient include:
 Hip Fractures
 Femoral neck fractures
 Intertrochanteric fractures
 Subtrochanteric fractures




Ankle fractures
Proximal humerus fracture
Distal radius fractures
Vertebral compression fractures
Proximal Humerus
 Background
 Very common fracture seen in geriatric
populations
 112/100,000 in men
 439/100,000 in women
 Result of low energy trauma
 Goal is to restore pain free range of shoulder
motion
Background
 Fractures in the elderly
osteoporotic patient
represent a challenge
to the orthopaedic
surgeon
 The goal of treatment
is to restore the preinjury level of function
 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.
Indications for Shoulder
Arthroplasty






Osteoarthritis
Rheumatoid arthritis
Rotator cuff tear arthropathy
Avascular necrosis
Post-traumatic arthritis
Severe proximal humeral fractures
Arthroplasty Options
Hemiarthroplasty
Reverse Total
Shoulder
Total Shoulder
Resurfacing
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.
 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.
Humeral Components
CEMENTED
PROX POROUS
COATED
FULLY POROUS
COATED
Good for
osteopenic bone
Need good
bone stock
Need good bone
stock
Lower risk of
intra-operative
fracture
Higher risk of
intra-operative
fracture
Higher risk
intra-operative
fracture
More stress
More stressshielding
Less stressshielding
Hard to revise
Easier to revise
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
7° retroversion
to
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.
Resurfacing
 Young patients
 Preserve bone
 Glenoid?
Hemiarthroplasty
 INDICATIONS
 Uninvolved Glenoid




Osteonecrosis
Proximal Humerus Fx
Osteoarthritis
Rheumatoid Arthritis?
 Unstable forces on
Glenoid
 Significant Rotator
Cuff Tear
Hemiarthroplasty
 Neer type of prosthesis has been
available for over 40 years
 Utilization in old trauma:
- typically provides pain relief but
incomplete motion
- surgical procedure often difficult
due
to fibrosis of tissue and
bone deformity
Hemiarthroplasty
 Utilization in old trauma:
 Tanner & Cofield(1983): 28 shoulders, 89%
pain relief, avg. 112 degrees of active
abduction, 1 nerve injury, 3 tuberosity/cuff
problems, 2 instability, 1 ectopic bone
 Hawkins et al.(1987): 9 shoulders, 67%
pain relief, avg. 140 degrees of active
abduction, no complications
Hemiarthroplasty
 Utilization in AVN:
- typically provides pain relief and near
normal return of movement
- rotator cuff and glenoid surface are
usually intact
Rutherford & Cofield(1987): 11 shoulders,
100% pain relief, 161 degrees of active
abduction, no complications
Hemiarthroplasty
 Utilization in osteoarthritis:
 results similar to those found with
AVN because the rotator cuff remains
intact and a relatively painless
articulation is created
 Zuckerman & Cofield(1986): 36
shoulders, 83% pain relief, avg. 132
degrees of active abduction, no
complications
Osteoarthritis
 In addition to the universal
features of osteoarthritic joints (joint
space narrowing, cysts, 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
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
Total
 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
Hemiarthroplasty
 Utilization in rheumatoid arthritis:
- pain relief often provided
- return of motion depends on the
extent of disease involvement of the
rotator cuff and capsular tissues
 Zuckerman & Cofield(1986): 36
shoulders, 89% pain relief, avg. 106
degrees of active abduction, 1
infection, 1 nerve injury, 1 fracture
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
Hemiarthroplasty
 Complications are infrequent:
- infection
- nerve injury
- iatrogenic fracture
- ectopic bone formation
- component failure and
loosening
TOTAL SHOULDER
ARTHROPLASTY
Complications TSA








Glenoid loosening
Humeral loosening
Glenoid wear (hemi)
Instability
Rotator cuff tears
Periprosthetic Fx
Infection
Nerve Injuries
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 outcome
Sperling, 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
REVERSE TSA
Reverse Shoulder
Replacement
Great solution to difficult problems
Expanding list of uses
Beware high complication rate
Grammont reverse TSA
Grammont Reverse Shoulder Arthroplasty

Designed in 1985 by Paul
Grammont

Used in Europe for past 20 years,
approved by FDA in March, 2004 in
U.S.

Components: Humeral component,
polyethylene insert, glenosphere,
metaglene (baseplate)
Biomechanical Theory
Grammont reverse TSA
Grammont Reverse Shoulder Arthroplasty - Biomechanics

The lever arm
distance (L) is
increased and
deltoid force (F) is
increased by
lowering and
medializing the
center of rotation
which is now also
fixed

Torque (F x L) in abducting
the arm is increased.
Grammont reverse TSA
Grammont Reverse Shoulder Arthroplasty - Biomechanics

Large glenoid ball
component offers a
greater arc of motion
Reverse TSA recruits more deltoid fibers
Grammont Reverse Shoulder Arthroplasty - Biomechanics
Ant.
Pos.
Medializing the center of
rotation recruits more of
the deltoid fibers for
elevation or abduction
Drake GN, O’Connor DP, Edwards TB. Indications for reverse total shoulder arthroplasty in rotator cuff disease.
Clin Orthop Relat Res. 2010;468:1526-1533.
Indications of rTSA
• Rotator cuff tear arthropathy
•
Failed hemiarthroplasty with irreparable rotator
cuff tears
•
Pseudoparalysis (i.e., inability to lift the arm above the
horizontal) because of massive, irreparable rotator
cuff tears
• Some reconstructions after tumor resection
•
Some fractures of the shoulder (Neer three-part
or four-part fx)
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
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.
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
Cuff Tear Arthropathy – Clinical Presentation
--
Physical Exam:

•
Swelling about the glenohumeral joint
•
Atrophy of the supraspinatus and
infraspinatus muscles
•
Pseudoparalysis
Imaging
--

Superior migration of
humeral head

Severe destructive GJH
osteoarthritis
Imaging
--

Massive tears of the
supraspinatus and
infraspinatus tendons
with muscle atrophy

Glenohumeral joint
destruction
Treatment
--
•
•
Medical management of the pain / physical
therapy
Arthroscopic lavage / arthroscopic débridement
•
Hemiarthroplasty
•
•
Arthrodesis
Total shoulder arthroplasty
Conventional Total Shoulder Arthroplasty
Because of superior
humeral head
migration, eccentric
loading on the
glenoid component
resulted in “rockinghorse” glenoid
loosening
Unconstrained TSA abandoned b/c of glenoid loosening

Limited pain relief

Modest improvement in
active elevation or
abduction
60 y/o Female With Rheumatoid Arthritis and Pain
Metastatic Renal Cell Cancer to Right Humerus
Metastatic renal cell
Contraindications of rTSA
• Marked deltoid deficiency
• History of previous infection
• Use sparingly in patients less than 65
years old
• Advanced glenoid destruction
Complication rates
Complication Rates for Reverse TSA
Higher intraoperative and
postoperative complication
rates for reverse TSA (mean
24%) vs. conventional TSA
(mean 15%)
Surgical Outcomes
-Post-op complications
-Hardware instability or dislocation (abd with ER)
-Nerve damage
-Infection
-Hematoma
-Intra-operative fracture
-Complication rates are 2-68%1
Dislocation
Scapular Notching




Nerot Classification of
Scapular notching
Grade 1: Confined to
the scapular pillar
Grade 2: Notch outline
contacts lower
Grade 3: Notch over
the lower screw
Grade 4: Notch
extends to baseplate.
Acromial Stress Fracture
 Increased load
on the
acromion may
also explain
rare
complication of
scapular spine
fracture
Reverse Total Shoulder
Arthroplasty is Hard to Revise
 Little Glenoid bone
stock once component
is removed.
Review
-What are some indications for a rTSA?
-GH joint arthritis with irreparable RC
-Revision of failed TSA or hemiarthroplasty
-Over the age of 70 years
-Who is not appropriate for a rTSA procedure?
-Glenoid destruction
-Deltoid that is not intact
-Patient wanting high functional return
-What is the most common surgical complication?
-hardware instability or dislocation
Post Operative Rehab
 TSA
 Check range in OR
 Start AAROM POD 1
 Active ROM as
tolerated
 Protect Subscap 4-6
weeks
 Strengthening at 4-6
weeks
Activities after TSA
Activities after TSA
Decision Algorithm in
Rotator Cuff Tears with OA
Reverse
Debridement
Hemiarthroplasty
Decision Algorithm in
Rotator Cuff Tears with OA
Patient with Rotator Cuff Tear
Limited Arthropathy
Manage the RCT
Severe Arthritis
No Superior Migration
Hemiarthroplasty
(conventional or CTA type)
Superior Migration
Reverse TSA
The future?
 New or coming trends in treatment of
proximal humeral fracturs:




Locking plates?
Increasing
Arthroplasty?
Increasing
Early arthroplasty surgery? Better than late!
Reversed shoulder arthroplasty?Even better?
Thank You