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1 Nolan R. May, MD Kearney, NE Heartland Surgery Center, Kearney NE Not relevant to this presentation. 1

What are the indications for total shoulder arthroplasty? What are the differences between total shoulder arthroplasty and reverse shoulder arthroplasty? What are the 4 S of the shoulder?

2 What are the indications for total shoulder arthroplasty? What are the differences between total shoulder arthroplasty and reverse shoulder arthroplasty? What are the 4 S of the shoulder? Use patient age as an aid to diagnosis Become consistent with a shoulder physical exam. What are the indications for total shoulder arthroplasty? What are the differences between total shoulder arthroplasty and reverse shoulder arthroplasty? What does the future of shoulder arthroplasty look like? 2

3 Strength Stability Flexibility Strength Stability Flexibility 3

4 Minimally constrained ball-and-socket joint Mobility Stability Static Stabilizers Bone/Cartilage Dynamic Stabilizers Rotator cuff Scapula muscles Shoulder ~33% constraint Hip >50% constraint 4

4 S s Stiffness Strength Stability Smoothness Stiffness: Limited active and passive ROM Patient complaints of inability to reach Often normal x-rays Strength Weak on exam Normal x-rays Unable to lift

5 4 S s Stiffness Strength Stability Smoothness Stiffness: Limited active and passive ROM Patient complaints of inability to reach Often normal x-rays Strength Weak on exam Normal x-rays Unable to lift overhead or with elbow away from body Get MRI to evaluate rotator cuff Stability Shoulder moves, dislocation, ER reduction, Laxity vs Instability Smoothness Crepitus/grinding Check ROM, painful Abnormal x-rays 5

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Do you have any numbness or tingling down into your hand?

7 Was there any trauma? Does this shoulder pain keep you up at night? Does it hurt to move your neck? Do you have any numbness or tingling down into your hand? Order of importance: Nerves Motion Strength/Stability Neck Hand/wrist/elbow Sensation Strength Active ROM Look for atrophy Passive ROM Standing Supine Tenderness Strength 7

8 AP True AP Axillary Lateral Outlet Progressive Cartilage wear Loss of the Cue Ball Degenerative Condition Impaired Function Inflammation Pain Stiffness Motion Loss 8

Joint Space Narrowing Bone Spurs Contracture

9 Joint Space Narrowing Bone Spurs Contracture of soft tissues: ligaments, capsule Bone Erosion NSAIDS ICE Activity Modifications Injections: Cortisone Viscosupplementation PRP Stem Cells 9

10 Arthroscopic Debridement Shoulder Arthroplasty Kent W, Johnson L. Shoulder Arthroplasty: Pioneers, Choices and Controversy. WebmedCentral ORTHOPAEDICS 2011;2(6):WMC doi: /journal.wmc

11 Osteoarthritis Rheumatoid Arthritis Rotator Cuff Tear Arthropathy Avascular Necrosis Post-Traumatic Arthritis Severe proximal humerus fractures 11

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US Volume 2000 18,000 total or partial shoulders in US 2013 45,000 2017 >53,000 5% of joint replacements Jules Emile Pean 1893 Debrided

13 US Volume ,000 total or partial shoulders in US , >53,000 5% of joint replacements Jules Emile Pean 1893 Debrided tuberculosis from 37y.o. male Implanted a platinum and rubber replacement Increased ROM and strength Infection recurred Prosthesis removal at 2 years 13

Sir John Charnley 1922-1982 British Hip Replacement

$Fit 11/12 fracture patients pain free Neer II 1973$ Monoblock 2 head sizes Cement Fixation 1974 OA patients 20

14 Sir John Charnley British Hip Replacement Pioneer Charles Neer Pioneer for Total shoulder replacement Neer I 1951 Monoblock fixed 1 head size Press Fit 11/12 fracture patients pain free Neer II 1973 Monoblock 2 head sizes Cement Fixation 1974 OA patients 20 excellent 20 satisfactory 4 unsatisfactory Glenoid component Late 1970 s 14

15 3 rd Generation 1992 Separate head and stem Modularity Version Offset Inclination 4 th Generation 2013 Bone preservation Neer # studies: Poorer outcomes with rotator cuff not functional Developed constrained system that he later abandoned 15

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17 Goals: Pain relief Function restoration General Anesthesia +/- regional nerve blocks Beach Chair Positioning Space Suits Pre-op IV antibiotics Deltopectoral Approach 17

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19 Anatomic Total Shoulder Reverse Total Shoulder Anatomic Total Shoulder Reverse Total Shoulder 19

20 PACU x-rays Sling x 6 weeks NV Assessment PO and IV pain control Post-op Antibiotics Physical Therapy 20

No active shoulder motion for 4 weeks, all planes No active internal rotation for 6 weeks Keep wound dry Icing 3 times/day for 20 minutes Pendulums 3x/day x 30 seconds

Advance to full AROM (ER 60 ); Add stretching in forward elevation (if lacking). Never stretch in abduction/er. Mean complication rate: 2-5% Infection (0.

21 No active shoulder motion for 4 weeks, all planes No active internal rotation for 6 weeks Keep wound dry Icing 3 times/day for 20 minutes Pendulums 3x/day x 30 seconds 2-6 weeks AAROM All planes limit ER to 30 With cane progress to finger ladder/wall climbs/pulley system Pulleys for home exercise program 8 weeks Full PROM, ER to 60, Advance to full AROM (ER 60 ); Add stretching in forward elevation (if lacking). Never stretch in abduction/er. Mean complication rate: 2-5% Infection (0.7%) Glenoid Loosening (6%) Does not always correlate with symptoms Radiolucent lines (84%) Subscap failure Fracture ( %) Nerve Injury (1-4.3%) Rotator Cuff Tear (1.3%) Instability 21

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International Journal of Shoulder Surgery. 2008;2(1):1-3. doi:10.4103/0973-6042.39579.

23 Sperling JW, Kaufman KR, Schleck CD, Cofield RH. A biomechanical analysis of strength and motion following total shoulder arthroplasty. International Journal of Shoulder Surgery. 2008;2(1):1-3. doi: / Sperling JW, Kaufman KR, Schleck CD, Cofield RH. A biomechanical analysis of strength and motion following total shoulder arthroplasty. International Journal of Shoulder Surgery. 2008;2(1):1-3. doi: /

24 Levy et. al (2016) 230 patients Minimum 12 months follow-up TSA for OA Intact cuff Pre-operative motion in all directions was predictive of post-op motion Co-morbidities was not BMI associated with decrease in post-op ROM J Shoulder Elbow Surg Jan;25(1): doi: /j.jse

25 85% rate of return to one or more sporting activity 5.3 months: mean return timeframe 25

26 AOSSM 2017 Annual Meeting 93.2% satisfaction rate 82.4% returned to similar or higher level of sport Average return: 6.7 months No revisions within 5 years Fitness sports: 97.2% Golf: 93.3% Singles tennis: 87.5 % Swimming: 87.5% Basketball: 75% 26

$Anatomic Reverse Reverse for fracture 94% of shoulder motion occurred below 80 degrees of elevation for total, reverse, and contralateral$

27 Anatomic Reverse Reverse for fracture 94% of shoulder motion occurred below 80 degrees of elevation for total, reverse, and contralateral shoulders. Goal: pain relief trumps motion. J Shoulder Elbow Surg Feb;27(2): doi: /j.jse Epub 2017 Nov

28 Glenoid bone loss associated with osteoarthritis according to Walch, et al Challenges in Reverse Shoulder Arthroplasty: Addressing Glenoid Bone LossAdam J. Seidl, MD; Gerald R. Williams, MD; Pascal Boileau, MDOrthopedics. 2016;39(1):

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Shoulder Arthroplasty

Shoulder Arthroplasty Nathan G. Everding, MD Specializing in Hand, Wrist, Elbow & Shoulder Surgery Syracuse Orthopedic Specialists SJH Family Practice Refresher course 3/8/19 Shoulder Arthroplasty Rate