Shoulder Arthroplasty: Pioneers, Choices and Controversy

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1 Article ID: Shoulder Arthroplasty: Pioneers, Choices and Controversy Corresponding Author: Dr. William Kent, Foundation doctor, Eastbourne District General Hospital - United Kingdom Submitting Author: Dr. William Kent, Foundation doctor and Sports Scientist, Eastbourne District General Hospital - United Kingdom Article ID: Article Type: Review articles Submitted on:14-jun-2011, 07:23:25 PM GMT Article URL: Subject Categories:ORTHOPAEDICS Keywords:Orthopaedics, Arthroplasty, Education Published on: 15-Jun-2011, 04:00:46 PM GMT How to cite the article:kent W, Johnson L. Shoulder Arthroplasty: Pioneers, Choices and Controversy. WebmedCentral ORTHOPAEDICS 2011;2(6): Source(s) of Funding: No external sources of funding were recieved for this paper. Competing Interests: All authors declare no competing interests WebmedCentral > Review articles Page 1 of 8

2 Shoulder Arthroplasty: Pioneers, Choices and Controversy Author(s): Kent W, Johnson L Abstract Shoulder arthroplasty is an important orthopaedic topic. This paper provides an introduction to the key issues, which will allow readers to approach the topic with confidence. A brief discussion of the history and development of shoulder replacements is included along with an outline of the indications and types of prosthesis available. The controversies and limitations of the evidence regarding the appropriate choice of prosthesis are also discussed to highlight the need for further research in this area. An outline of the rehabilitation procedure is presented because this vital part of the procedure is poorly covered in medical textbooks and curriculum. Introduction A shoulder arthroplasty is the replacement of one or both of the articular surfaces that comprise the glenohumeral joint. In the UK approximately 2400 shoulder replacement surgeries are performed each year. 1 In comparison, an estimated hip and knee replacements are performed each year. 1 As the population ages and technological advances continue, these numbers are likely to increase. This article provides an introduction to glenohumeral (shoulder) arthroplasty, its indications, contraindications and evidence for its use. Origin, development and classification The first shoulder replacements were ivory shoulder prostheses described by Themistocles Gluck in a report published in 1891, but the results of these operations were not published.2 Following the work of Gluck, Jules-Emile Péan performed the first metal shoulder artroplasty in 1893 to replace a glenohumeral joint destroyed by tuberculosis.2 Unfortunately, despite initial success the platinum and rubber prosthesis had to removed approximately 2 years after implantation because of uncontrollable infection. Despite this early promise the shoulder arthroplasty did not become widely accepted until Neer developed and introduced a humeral prosthesis in 1951 for the treatment of severe proximal humeral fractures.3 The improved pain relief and function noted after this operation compared with resection arthrodesis (the standard treatment of that time) stimulated interest and an expansion in the indications for shoulder arthroplasty. In the 1970s a shoulder arthroplasty incorporating a glenoid component as well as a humeral component was introduced in an attempt to improve the long-term outcomes for patients with degenerative arthritis off the glenoid fossa.4 The last few decades have seen a considerable growth in the field with improvements in hip and knee replacements leading the way. More than 70 types of shoulder prosthesis have now been developed and they can be classified using a variety of methods.5,4 A useful classification for the non-specialist is to classify the prostheses into 3 types which are readily identifiable on an x-ray: 1) hemiarthroplasty (HA), 2) total shoulder arthroplasty (TSA), and 3) reverse total shoulder arthroplasty (RTSA).5 A HA (or partial shoulder arthroplasty) is the replacement of only the humeral head and the patient s own glenoid fossa is left intact (fig 1a). TSA is the replacement of both the humeral head and the glenoid with artificial articular surfaces (fig 1b). As with the TSA the newer RTSA procedure involves the replacement of both articular surfaces, but the ball and socket are switched so that the ball is on the glenoid and the socket is on the humerous (fig 1c). The RTSA procedure is designed specifically for use in shoulders with irreparably damaged rotator cuff muscles6, when the use of a HA or TSA is not advised.5,7 It is becoming widely accepted and is a valuable alternative in patients with failed arthroplasty or previously unreconcstrucable shoulders.5,6 Indications and contraindications Shoulder arthroplasty is considered a viable option for patients with proximal humeral fractures, and patients with inflammatory or destructive arthritis unresponsive to non-surgical management. 8 A shoulder arthroplasty is contraindicated in patients with active infection, Charcot s arthropathy and severe neurological WebmedCentral > Review articles Page 2 of 8

3 diseases (e.g. brachial plexus palsy which increase the risk of unstable joints). 9 To avoid inappropriate expectations, if a patient is to have surgery they must be aware that the aim of the surgery is to reduce pain and improve function but regaining full range of motion is unlikely and abduction of the shoulder is commonly limited to 130 o. 10 Choice of arthroplasty The selection of shoulder prosthesis is a much-debated topic amongst shoulder surgeons. There are a variety of conditions that the shoulder artroplasty is used to treat and there is a lack of high quality clinical trials to support one type of prosthesis over another.7,11 Compounding the situation further is the complexity of the shoulder joint and many patient specific factors which have to be taken into consideration including; individual anatomy, bone stock and the integrity of the supporting soft tissues.8 Surgeon specific factors such as training, technical ability, and experience with the different prostheses are also important. Suggestions for when the different types of prostheses should be used have been made5,7 (table 1) but the evidence supporting these suggestions is weak to moderate in quality at best.7 For example, glenohumeral osteoarthritis (OA) is the most common indication for shoulder arthroplasty and in patients with adequate bone stock and intact rotator cuff both HA and TSA provide good pain relief and improved function in the majority of patients.8 HA is a simple procedure but continued glenoid erosion can occur producing further loss of function, increased pain and possibly the need for revision surgery. The TSA was developed in an attempt to prevent these complications but it is more complex, more expensive and associated with greater blood loss.12 Concerns have also been raised regarding the rate of loosening of the glenoid component.8 Studies comparing HA to TSA suggest that TSA for primary OA generally provides better functional outcomes8,12, pain relief8, and lower rates of revision.5 But the debate as to which prosthesis is best continues because of inconsistent conclusions and the low quality of the studies on which this suggestion is based.7,8,12 Until better quality research is produced this debate is likely to continue and the lack of robust evidence based guidelines for the different patient populations means that the surgeon s experience and preference for a particular prosthesis is likely to continue to be the deciding factor in the choice of arthroplasty. Postoperative Rehabilitation Inpatient stay is generally between 2-5 days. During this time a rehabilitation programme is introduced as soon as possible after the operation15 and input from the occupational therapists can help the patient to adapt to performing activities of daily living (e.g. dressing, personal care and removing and replacing the sling) with only limited use of the operated arm. Many surgeons prefer a sling to be worn for the first month (especially at night) to prevent external rotation and keep the arm close to the body.10,15 Before the patient is discharged they should be given a follow up orthopaedic appointment and fully informed with written instructions about the risk and signs of complications, which if suspected should be reported immediately.10 The multidisciplinary team (MDT) in particular physiotherapists are essential to the successful rehabilitation of patient following shoulder arthroplasty.10 However, there is a lack of evidence evaluating the benefit of physiotherapy for patients7 and current rehabilitation strategies are based on basic science principles of tissue healing and experience, tailored to individual clinical presentation.6,13,14 Each surgeon has their own preferred protocol, but the general principles of a rehabilitation programme are usually the same. The patient progresses over 3-6 months through four stages: passive, active, resistance and functional exercises with the aim of achieving pain free shoulder function. Physiotherapy begins with passive mobilisation and progresses to active assisted movements14 to prevent adhesion and capsular contracture.16 The safe range of motion is dictated by the type of surgical approach and the amount of movement achieved intra-operatively.14 The patient must also be reminded to move the other joints of the arm (elbow, wrist and fingers) regularly to prevent stiffness whilst the arm is in a sling. The operated arm is not to be used for transferring from bed to chair or sitting to standing and nothing heavier than a cup of tea is to be lifted for the first 6 weeks.15 A graded strengthening programme is then instigated during outpatient physiotherapy appointments and the patients are educated on how to complete this by themselves at home. The aim is to strengthen the muscles surrounding the prosthesis to stabilise the joint and facilitate improvements in the active range of motion at the joint. Improvements in function occur most rapidly early in the rehabilitation process but can continue for up to 18 months post-operation.15 WebmedCentral > Review articles Page 3 of 8

4 Complications Conclusions Despite requiring more operative time, the complication rate following shoulder arthroplasty is less than with knee or hip arthroplasty. 17,18 Specific complications to be aware of include: instability, rotator cuff damage, ectopic ossification, glenoid component loosening, intraoperative fracture, nerve injury, infection, and humeral component loosening. 4 Prosthesis failure is also a possibility and the significance of peri-prosthetic lucency commonly seen on follow-up x-ray 19 is still to be determined. The incidence of thromboembolic disease (TED) is reported to be lower after shoulder arthroplasty (0.5-13%) compared with hip ( %) or knee ( %) arthroplsty. 20,21 However, one study noted that although the absolute frequency of thromboembolic disease was lower after shoulder arthroplasty compared with hip or knee arthroplasty, a comparatively larger percentage of these events were pulmonary embolisms. 20 The precision of this finding is unknown due to the limitations of the study, including: small sample size, retrospective design and the fact that only symptomatic TED were investigated in the study, which increase the possibility of error. Despite the limitations of this and other studies investigating complication rates, awareness of all of these possible complications is essential to direct post-operative assessment of the patient and further research. Long-term outcomes A study investigating 78 hemiarthroplasty and 36 TSA with a minimum of 15 years follow-up found that both operations provided long-term pain relief and improved shoulder function. 19 The estimated survival rates of hemiarthroplasty were 82% (95% CI, 74%-92%) at 10 years and 75% (95% CI, 64%-86%) at 20 years. The comparative figures for TSA were 97% (95% CI, 91%-100%) at 10 years and 84% (95% CI, 68%-98%) at 20 years. The generalisability of these results are limited because the study sample was young (19 In the absence of high quality clinical trials, the formation of a national database (like the national hip and knee database) may be the solution to answer these questions and the other controversies outlined above. A database would allow continuous feedback of data to surgeons, which could be used to improve surgical practice 22 but this would require a considerable investment of resources which unfortunately may not be available. The number of shoulder arthroplasty operations is likely to increase due to the aging population, technological and surgical advances improving the outcome of operations. This article provides the reader with an introduction to the 3 main types of shoulder arthroplasty and discusses their relative indications, contraindications, controversies and rehabilitation. It is our hope that after reading this article you will be more confident to discuss these considerations with all of the members of the MDT involved in patient care both before and after a shoulder arthroplasty. References 1.Ravenscroft M, Calvert P. Utilisation of shoulder arthroplasty in the UK. Ann R Coll Surg Engl Jan;86(1): Bankes MJ, Emery RJ. Pioneers of shoulder replacement: Themistocles Gluck and Jules Emile Péan. J Shoulder Elbow Surg Aug;4(4): NEER CS, BROWN TH, MCLAUGHLIN HL. Fracture of the neck of the humerus with dislocation of the head fragment. Am. J. Surg Mar;85(3): Wirth MA, Rockwood CA. Complications of shoulder arthroplasty. Clin. Orthop. Relat. Res Oct;(307): Wiater JM, Fabing MH. Shoulder arthroplasty: prosthetic options and indications. J Am Acad Orthop Surg Jul;17(7): Boudreau S, Boudreau ED, Higgins LD, Wilcox RB. Rehabilitation following reverse total shoulder arthroplasty. J Orthop Sports Phys Ther Dec;37(12): Guideline on Treatment of Glenohumeral Joint Osteoarthritis - AAOS [Internet]. [cited 2010 Jun 6];Available from: asp 8.Edwards TB, Kadakia NR, Boulahia A, Kempf J, Boileau P, Némoz C, et al. A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study. J Shoulder Elbow Surg Jun;12(3): Caniggia M, Fornara P, Franci M, Maniscalco P, Picinotti A. Shoulder arthroplasty. Indications, contraindications and complications. Panminerva Med Dec;41(4): Brown FM. Nursing care after a shoulder arthroplasty. Orthop Nurs Feb;27(1):3-9; quiz WebmedCentral > Review articles Page 4 of 8

5 Chronic Shoulder Pain: Part II. Treatment - February 15, American Family Physician [Internet]. [cited 2010 Jun 7];Available from: 12.Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A. 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. J Bone Joint Surg Am Sep;87(9): Wilcox RB, Arslanian LE, Millett P. Rehabilitation following total shoulder arthroplasty. J Orthop Sports Phys Ther Dec;35(12): Brems JJ. Rehabilitation following total shoulder arthroplasty. Clin. Orthop. Relat. Res Oct;(307): Preston M. Shoulder Joint Replacements Doctor Patient UK [Internet] Sep 9 [cited 2010 May 28];Available from: ements-what-a-gp-needs-to-know.htm 16.Deuschle JA, Romeo AA. Understanding shoulder arthroplasty. Orthop Nurs Oct;17(5):7-15; quiz Fehringer EV, Mikuls TR, Michaud KD, Henderson WG, O'Dell JR. Shoulder arthroplasties have fewer complications than hip or knee arthroplasties in US veterans. Clin. Orthop. Relat. Res Mar;468(3): Farmer KW, Hammond JW, Queale WS, Keyurapan E, McFarland EG. Shoulder arthroplasty versus hip and knee arthroplasties: a comparison of outcomes. Clin. Orthop. Relat. Res Feb;455: Sperling JW, Cofield RH, Rowland CM. Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elbow Surg Dec;13(6): Lyman S, Sherman S, Carter TI, Bach PB, Mandl LA, Marx RG. Prevalence and risk factors for symptomatic thromboembolic events after shoulder arthroplasty. Clin. Orthop. Relat. Res Jul;448: Willis AA, Warren RF, Craig EV, Adler RS, Cordasco FA, Lyman S, et al. Deep vein thrombosis after reconstructive shoulder arthroplasty: a prospective observational study. J Shoulder Elbow Surg Feb;18(1): Sharma S, Dreghorn CR. Registry of shoulder arthroplasty - the Scottish experience. Ann R Coll Surg Engl Mar;88(2): WebmedCentral > Review articles Page 5 of 8

6 Illustrations Illustration 1 Figure 1a) Shoulder hemiarthroplasty (HA) Illustration 2 Figure 1b) Total shoulder arthroplasty (TSA) WebmedCentral > Review articles Page 6 of 8

7 Illustration 3 Figure 1c) Reverse total shoulder arthroplasty (RTSA) Illustration 4 Table 1. Indications and contraindications for shoulder arthroplasty. WebmedCentral > Review articles Page 7 of 8

8 Disclaimer This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party. Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website. WebmedCentral > Review articles Page 8 of 8

Shoulder Replacement Commonly Asked Questions

Shoulder Replacement Commonly Asked Questions Patrick J Denard, MD Shoulder Specialist 2780 E. Barnett Rd Medford, OR 97530 541-779-6250 Background Information What is the anatomy of the shoulder? The