RESULTS AND COMPLICATIONS OF SHOULDER ARTHROPLASTY

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RESULTS AND COMPLICATIONS OF SHOULDER ARTHROPLASTY

• James M. Steinberg, D.O.

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Types of Shoulder Arthroplasty

• Hemiarthroplasty humeral head replacement
• Constrained Total Shoulder Arthroplasty
  ball-in-socket
• Unconstrained Total Shoulder Arthroplasty
  anatomic or resurfacing
• Tissue Ingrowth Total Shoulder Arthroplasty
  bony and fibrous growth into the prosthetic
  elements

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Indications for Shoulder Arthroplasty

• Trauma typically in three and four part
  proximal humerus fractures
• Avascular Necrosis of the Humeral Head
• Osteoarthritis
• Rheumatoid Arthritis
• Goal pain relief and restoration of movement

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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

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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

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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

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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

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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

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Hemiarthroplasty

• Complications are infrequent
• - infection
• - nerve injury
• - iatrogenic fracture
• - ectopic bone formation
• - component failure and loosening

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Hemiarthroplasty

• Postoperative instability
• - lack of healing of the capsule, rotator
  cuff, or tuberosities
• - excessively strong healing with abundant
  fibrosis
• Careful reconstruction of the capsule and rotator
  cuff are crucial
• Attention to physical therapy postoperatively
• If above are followed, complications are uncommon

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Constrained Total Shoulder Arthroplasty

• Ball-in-socket prosthesis
• Most studies have found that pain relief is
  satisfactory but return of motion, abduction is
  limited
• Complication rate high
• Semiconstrained/hooded glenoid components have
  been designed
• - results and complications similar to
  ball-in-socket device

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Constrained Total Shoulder Arthroplasty Results

• Coughlin et al.(1979) 16 shoulders, 100 pain
  relief, avg. 104 degrees of active abduction, 1
  infection and 1 instability
• Lettin et al.(1982) 40 shoulders, 90 pain
  relief, avg. 70 degrees of active abduction, 3
  instability and 10 glenoid loosening
• Gristina Webb(1982) 20 shoulders, 100 pain
  relief, avg. 58 degrees of active abduction, 2
  instability

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Constrained Total Shoulder Arthroplasty Results

• Brostrom et al.(1992) 23 shoulders, 65 pain
  relief, avg. 35 degrees of active abduction, 1
  infection, 1 fracture, 1 instability, 3 glenoid
  loosening
• Laurence(1991) 71 shoulders, 80 pain relief,
  avg. 76 degrees of active abduction, 1
  instability, 1 glenoid loosening, 4 humeral
  loosening

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Semiconstrained Total Shoulder Arthroplasty
Results

• Mazas de la Caffiniere(1982) 32 shoulders,
  91 pain relief, 3 infections, 1 nerve injury, 9
  instability, 2 glenoid loosening
• Amstutz et al.(1988) 10 shoulders, 100 pain
  relief, avg. 85 degrees of active abduction, 1
  fracture, 1 glenoid loosening

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Constrained Total Shoulder Arthroplasty

• Complications
• - infection
• - fracture
• - nerve injury
• - ectopic bone formation
• - dislocations
• - component loosening or material failure

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Constrained Total Shoulder Arthroplasty

• Majority of complications are instability and
  glenoid component loosening
• Most dislocations and component failure require
  revision
• Based on the high complication rate and lack of
  return of abduction, its use is rarely indicated

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Unconstrained Total Shoulder Arthroplasty

• Neer type of unconstrained TSA is the standard
  implant which others must be compared
• Indicated in patients with OA, RA, and arthritis
  secondary to a previous trauma
• No or slight pain is present in 90 of patients
  treated

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Unconstrained Total Shoulder Arthroplasty

• Patients with diagnosis of RA typically only have
  a return of active abduction about one half
  normal
• Patients with diagnosis of OA typically only have
  a return of active abduction about three-fourths
  normal

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Unconstrained Total Shoulder Arthroplasty Results

• Neer et al.(1982) 194 shoulders, clinical
  ratings 101 excellent, 28 satisfactory, 21
  unsatisfactory, 43 limited rehabilitation, 1
  infection, 1 fracture, 6 instability, 7
  impingement/cuff/tuberosity problem
• Cofield(1984) 73 shoulders, 92 pain relief,
  avg. 120 degrees of elevation, avg. 48 degrees of
  external rotation, 1 nerve injury, 6
  impingement/cuff/tuberosity problem, 3 glenoid
  loosening
• Barrett et al.(1989) 140 shoulders, 93 pain
  relief, avg. 90 degrees of elevation, avg. 40
  degrees of external rotation, 2 nerve injury, 4
  instability, 3 impingement/ cuff/tuberosity
  problem

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Unconstrained Total Shoulder Arthroplasty Results

• Hawkins et al.(1989) 70 shoulders, 90 pain
  relief, avg. 131 degrees of elevation, avg. 36
  degrees of external rotation, 4 fracture, 1
  instability, 2 impingement/cuff/tuberosity
  problem, 2 glenoid loosening
• Boyd et al.(1991) 131 shoulders, 95 pain
  relief, avg. 100 degrees of elevation, avg. 33
  degrees of external rotation, 2 fracture, 1
  nerve injury, 2 instability, 1 glenoid loosening

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Unconstrained Total Shoulder Arthroplasty

• Complications
• -rotator cuff or tuberosity difficulties
• -instability
• -glenoid loosening
• -infection
• -intraoperative or postoperative fracture
• -nerve injury
• -ectopic bone formation

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Unconstrained Total Shoulder Arthroplasty

• Review of 1046 Neer total shoulder replacement
  the complication rate was 12, majority being an
  impingement/ cuff/ tuberosity problem
• Results are substantially better than the results
  of constrained or semiconstrained
• Rate of revision is low, most commonly for
  glenoid loosening

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Tissue Ingrowth Total Shoulder Arthroplasty

• Developed by English Macnab
• Components are porous and allow for tissue
  ingrowth
• Glenoid component has superior extension and
  therefore acts as a semiconstrained device
• Pain relief was satisfactory in 85-90 of
  patients
• Return of movement limited
• Important to have adequate bone and joint
  stability

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Tissue Ingrowth Total Shoulder Arthroplasty
Results

• Faludi Weiland(1983) 13 shoulders, avg. 75
  degrees of active abduction, 1 infection, 2
  fractures, 1 instability
• McElwin English(1987) 13 shoulders, 85 pain
  relief, avg. 56 degrees of active abduction, 1
  fracture, 1 instabilty, 3 component failures, 2
  glenoid loosening
• Mayo Clinic(83-86) 32 shoulders, 96 pain
  relief, avg. 145 degrees of active abduction, 1
  infection, 2 glenoid loosening, 1 humeral
  loosening

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Tissue Ingrowth Total Shoulder Arthroplasty

• Complications slightly more common than in
  unconstrained implants
• -fracture
• -instability
• -component failure
• -component loosening

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Summary

• Hemiarthroplasty is effective in acute fractures,
  (3 and 4 part), and in AVN of the humeral head
• If there is moderate glenoid involvement an
  unconstrained total shoulder arthroplasty is the
  better choice
• Little indication for constrained or
  semiconstrained devices
• With adequate bone, tissue ingrowth systems may
  be a viable alternative to cemented unconstrained
  systems