Title: In the name of God
1In the name of God
2Shoulder Arthroplasty in Geriatrics
- Mohsen Mardani-Kivi M.D.
- Assistant Prof. Orthopaedic Dept.
- Guilan University of Medical Sciences
3Background
- 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
4Proximal 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
5Background
- 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.
7Indications for Shoulder Arthroplasty
- Osteoarthritis
- Rheumatoid arthritis
- Rotator cuff tear arthropathy
- Avascular necrosis
- Post-traumatic arthritis
- Severe proximal humeral fractures
8Arthroplasty Options
Hemiarthroplasty
Reverse Total Shoulder
Total Shoulder
Resurfacing
9Surgical Approach
Deltopectoral
Coracoid
10A 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.
14Humeral 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
15Cemented 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.
16The Need for Modularity
- F-H Offset
- B-C Head thickness
- D-E 8mm
- Top of humeral head is higher than greater
tuberosity
17The Need for Modularity
- Reestablishing normal glenohumeral anatomic
relationships is important to ensure optimal
results. Iannotti JP JBJS 74A 1992
18Other 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.
19Contraindications 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.
20Resurfacing
- Young patients
- Preserve bone
- Glenoid?
21Hemiarthroplasty
- INDICATIONS
- Uninvolved Glenoid
- Osteonecrosis
- Proximal Humerus Fx
- Osteoarthritis
- Rheumatoid Arthritis?
- Unstable forces on Glenoid
- Significant Rotator Cuff Tear
22Hemiarthroplasty
- 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
23Hemiarthroplasty
- 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
24Hemiarthroplasty
- 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
25Hemiarthroplasty
- 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
26Osteoarthritis
- 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
27Hemi 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
28Recommendation 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
29Recommendations 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.
30Recommendations 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
31A 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
-
32Recommendations 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
33Technical 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
34Hemiarthroplasty
- 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
35Rheumatoid Arthritis
- Peri-articular erosions
- Peri-articular osteopenia
- Thin cortices
- Adjacent joint involvement
36Rheumatoid 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(No Transcript)
38Rheumatoid 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
39Hemiarthroplasty
- Complications are infrequent
- - infection
- - nerve injury
- - iatrogenic fracture
- - ectopic bone formation
- - component failure and loosening
40TOTAL SHOULDER ARTHROPLASTY
41Complications TSA
- Glenoid loosening
- Humeral loosening
- Glenoid wear (hemi)
- Instability
- Rotator cuff tears
- Periprosthetic Fx
- Infection
- Nerve Injuries
42Complications
- Instability 1.2
- Excessive Retro/Anteversion
- Head too small
- Head too low (post fracture)
- Subscap rupture
43Complications
- Rotator Cuff Tear 2
- Results in superior migration of humerus and
glenoid loosening - Glenoid loosening
44Complications
- Infection 0.5
- Staph Aureus
- More common after revision surgery
45Complications
- Heterotopic Ossification 10 -45
- Males
- Dx osteoarthitis
- Low grade
- Non-progressive
- Does not affect outcome
- Sperling, Cofield et al
46Complications
- Stiffness
- Depends on indication for arthroplasty
- Subscap shortening
- Oversized components
- Inappropriate rehab
47Complications
- Periprosthetic Fracture
- Intra-op 1
- Post-op 0.5 - 2
- Most common in RA
- 85 women
- Glenoid fractures are rare
48Complications
- Axillary nerve injury
- Rare
- Higher risk during revision surgery
- Usually a neuropraxia
49REVERSE TSA
50Reverse Shoulder Replacement
- Great solution to difficult problems
- Expanding list of uses
- Beware high complication rate
51Grammont 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)
52Biomechanical Theory
53Grammont 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.
54Grammont reverse TSA
Grammont Reverse Shoulder Arthroplasty -
Biomechanics
- Large glenoid ball component offers a greater arc
of motion
55Reverse 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.
56Drake GN, OConnor DP, Edwards TB. Indications
for reverse total shoulder arthroplasty in
rotator cuff disease. Clin Orthop Relat Res.
20104681526-1533.
57Indications 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)
58Rotator 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
59Rotator 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.
60Surgical Options
- Hemiarthroplasty with a large head
- Repair of rotator cuff and TSA
- Reverse TSA
61Outcomes 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.
62Outcomes 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.
63Outcomes 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
64Outcomes 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--
- Medical management of the pain / physical therapy
- Arthroscopic lavage / arthroscopic débridement
- Hemiarthroplasty
- Arthrodesis
- Total shoulder arthroplasty
69Conventional Total Shoulder Arthroplasty
- Because of superior humeral head migration,
eccentric loading on the glenoid component
resulted in rocking-horse glenoid loosening
70Unconstrained TSA abandoned b/c of glenoid
loosening
- Limited pain relief
- Modest improvement in active elevation or
abduction
7160 y/o Female With Rheumatoid Arthritis and Pain
72Metastatic renal cell
Metastatic Renal Cell Cancer to Right Humerus
73Contraindications of rTSA
- Marked deltoid deficiency
- History of previous infection
- Use sparingly in patients less than 65 years old
- Advanced glenoid destruction
74Complication rates
Complication Rates for Reverse TSA Higher
intraoperative and postoperative complication
rates for reverse TSA (mean 24) vs. conventional
TSA (mean 15)
75Surgical 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
79Reverse Total Shoulder Arthroplasty is Hard to
Revise
- Little Glenoid bone stock once component is
removed.
80Review
- -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
81Post 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
82Activities after TSA
83Activities after TSA
84Decision Algorithm in Rotator Cuff Tears with OA
85Decision Algorithm in Rotator Cuff Tears with OA
86The 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?
87Thank You