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In the name of God

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Title: In the name of God


1
In the name of God
2
Shoulder Arthroplasty in Geriatrics
  • Mohsen Mardani-Kivi M.D.
  • Assistant Prof. Orthopaedic Dept.
  • Guilan University of Medical Sciences

3
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

4
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

5
Background
  • Fractures in the elderly osteoporotic patient
    represent a challenge to the orthopaedic surgeon
  • The goal of treatment is to restore the
    pre-injury level of function

6
  • 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.

7
Indications for Shoulder Arthroplasty
  • Osteoarthritis
  • Rheumatoid arthritis
  • Rotator cuff tear arthropathy
  • Avascular necrosis
  • Post-traumatic arthritis
  • Severe proximal humeral fractures

8
Arthroplasty Options
Hemiarthroplasty
Reverse Total Shoulder
Total Shoulder
Resurfacing
9
Surgical Approach
Deltopectoral
Coracoid
10
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.

11
  • 1974- Neer II Prosthesis. Modified Neer I to
    conform to a glenoid component.

12
  • 1970s - constrained components were popular, but
    follow-up reports demonstrated high rates of
    loosening, particularly of the glenoid component.

13
  • 1980s Modular humeral components were
    developed, along with cementless glenoid fixation
    using polyethylene on a metal backing.

14
Humeral Components
PROX POROUS COATED
FULLY POROUS COATED
CEMENTED
Good for osteopenic bone Lower risk of
intra-operative fracture More stress-shielding Ha
rd to revise
Need good bone stock
Need good bone stock Higher risk intra-operative
fracture More stress shielding Hard to revise
Higher risk of intra-operative fracture Less
stress-shielding Easier to revise
15
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.

16
The Need for Modularity
  • F-H Offset
  • B-C Head thickness
  • D-E 8mm
  • Top of humeral head is higher than greater
    tuberosity

17
The Need for Modularity
  • Reestablishing normal glenohumeral anatomic
    relationships is important to ensure optimal
    results. Iannotti JP JBJS 74A 1992

18
Other Anatomic Variables to Consider
  • Glenoid 2 anteversion to
  • 7 retroversion
  • Humeral Head 20 - 40 retroversion
  • Axial CT of the glenohumeral joint is a valuable
    pre-op planning tool.

19
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.

20
Resurfacing
  • Young patients
  • Preserve bone
  • Glenoid?

21
Hemiarthroplasty
  • INDICATIONS
  • Uninvolved Glenoid
  • Osteonecrosis
  • Proximal Humerus Fx
  • Osteoarthritis
  • Rheumatoid Arthritis?
  • Unstable forces on Glenoid
  • Significant Rotator Cuff Tear

22
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

23
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

24
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

25
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

26
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

27
Hemi vs Total 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
  • 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

28
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

29
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.

30
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

31
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 Sep87(9)1947-56.
  • Included 4 RCTs
  • 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

32
Recommendations based on Evidence
  • The results of arthroplasty in osteoarthritis of
    the shoulder. Haines JF et al. J Bone Joint Surg
    Br. 2006 Apr88(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

33
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

34
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

35
Rheumatoid Arthritis
  • Peri-articular erosions
  • Peri-articular osteopenia
  • Thin cortices
  • Adjacent joint involvement

36
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.

37
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38
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

39
Hemiarthroplasty
  • Complications are infrequent
  • - infection
  • - nerve injury
  • - iatrogenic fracture
  • - ectopic bone formation
  • - component failure and loosening

40
TOTAL SHOULDER ARTHROPLASTY
41
Complications TSA
  • Glenoid loosening
  • Humeral loosening
  • Glenoid wear (hemi)
  • Instability
  • Rotator cuff tears
  • Periprosthetic Fx
  • Infection
  • Nerve Injuries

42
Complications
  • Instability 1.2
  • Excessive Retro/Anteversion
  • Head too small
  • Head too low (post fracture)
  • Subscap rupture

43
Complications
  • Rotator Cuff Tear 2
  • Results in superior migration of humerus and
    glenoid loosening
  • Glenoid loosening

44
Complications
  • Infection 0.5
  • Staph Aureus
  • More common after revision surgery

45
Complications
  • Heterotopic Ossification 10 -45
  • Males
  • Dx osteoarthitis
  • Low grade
  • Non-progressive
  • Does not affect outcome
  • Sperling, Cofield et al

46
Complications
  • Stiffness
  • Depends on indication for arthroplasty
  • Subscap shortening
  • Oversized components
  • Inappropriate rehab

47
Complications
  • Periprosthetic Fracture
  • Intra-op 1
  • Post-op 0.5 - 2
  • Most common in RA
  • 85 women
  • Glenoid fractures are rare

48
Complications
  • Axillary nerve injury
  • Rare
  • Higher risk during revision surgery
  • Usually a neuropraxia

49
REVERSE TSA
50
Reverse Shoulder Replacement
  • Great solution to difficult problems
  • Expanding list of uses
  • Beware high complication rate

51
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)

52
Biomechanical Theory
53
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.

54
Grammont reverse TSA
Grammont Reverse Shoulder Arthroplasty -
Biomechanics
  • Large glenoid ball component offers a greater arc
    of motion

55
Reverse TSA recruits more deltoid fibers
Grammont Reverse Shoulder Arthroplasty -
Biomechanics
  • Medializing the center of rotation recruits more
    of the deltoid fibers for elevation or abduction

Pos.
Ant.
56
Drake GN, OConnor DP, Edwards TB. Indications
for reverse total shoulder arthroplasty in
rotator cuff disease. Clin Orthop Relat Res.
20104681526-1533.
57
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)

58
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

59
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.

60
Surgical Options
  • Hemiarthroplasty with a large head
  • Repair of rotator cuff and TSA
  • Reverse TSA

61
Outcomes of Hemiarthroplasty
  • Rockwood 86 satisfactory results after 4 years
  • Zuckerman 93 adequate pain relief and 90 had
    improved function for ADLs.
  • Sanches-Sotelo 75 modest improvements in ROM
    and strength for ADLs. Good pain relief.

62
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.

63
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 Aug87(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

64
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 Jul87(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

65
--
  • Cuff Tear Arthropathy Clinical Presentation
  • Physical Exam
  • Swelling about the glenohumeral joint
  • Atrophy of the supraspinatus and infraspinatus
    muscles
  • Pseudoparalysis

66
--
  • Imaging
  • Superior migration of humeral head
  • Severe destructive GJH osteoarthritis
  • Anterior or posterior humeral head subluxation

67
--
  • Imaging
  • Massive tears of the supraspinatus and
    infraspinatus tendons with muscle atrophy
  • Glenohumeral joint destruction
  • Fatty infilitration cuff of muscle

68
--
  • Treatment
  • Medical management of the pain / physical therapy
  • Arthroscopic lavage / arthroscopic débridement
  • Hemiarthroplasty
  • Arthrodesis
  • Total shoulder arthroplasty

69
Conventional Total Shoulder Arthroplasty
  • Because of superior humeral head migration,
    eccentric loading on the glenoid component
    resulted in rocking-horse glenoid loosening

70
Unconstrained TSA abandoned b/c of glenoid
loosening
  • Limited pain relief
  • Modest improvement in active elevation or
    abduction

71
60 y/o Female With Rheumatoid Arthritis and Pain
72
Metastatic renal cell
Metastatic Renal Cell Cancer to Right Humerus
73
Contraindications of rTSA
  • Marked deltoid deficiency
  • History of previous infection
  • Use sparingly in patients less than 65 years old
  • Advanced glenoid destruction

74
Complication rates
Complication Rates for Reverse TSA Higher
intraoperative and postoperative complication
rates for reverse TSA (mean 24) vs. conventional
TSA (mean 15)
75
Surgical Outcomes
  • -Post-op complications
  • -Hardware instability or dislocation (abd with
    ER)
  • -Nerve damage
  • -Infection
  • -Hematoma
  • -Intra-operative fracture
  • -Complication rates are 2-681

76
Dislocation
77
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.

78
Acromial Stress Fracture
  • Increased load on the acromion may also explain
    rare complication of scapular spine fracture

79
Reverse Total Shoulder Arthroplasty is Hard to
Revise
  • Little Glenoid bone stock once component is
    removed.

80
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

81
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

82
Activities after TSA
83
Activities after TSA
84
Decision Algorithm in Rotator Cuff Tears with OA
85
Decision Algorithm in Rotator Cuff Tears with OA
86
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?

87
Thank You
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