Shoulder Arthroplasty Review. Gregory P. Nicholson, M.D.

Transcription

1 Shoulder Arthroplasty Review Gregory P. Nicholson, M.D. Midwest Orthopaedics at Rush Rush University Medical Center Chicago, Illinois Etiologies of degenerative joint disease of shoulder: Osteoarthritis Rheumatoid Arthritis/Inflammatory Arthritis Cuff Teat Arthopathy Post traumatic Post surgical/post-capsulorrhapy DJD AVN Others Pre-operative Evaluation: 1. History Pain Location, duration, night pain, character Injections: location, response Therapy NSAIDs Function Active motion, Passive motion, loss of ADL ability Recreation Occupation Surgical History Rotator cuff surgery Instability/Dislocations Trauma History 2. Physical Examination Inspection Atrophy around shoulder girdle Scapular dyskinesis Swelling (under deltoid in CTA)

2 Incisions/scars Other shoulder Ipsilateral arm- elbow and hand Palpation Crepitus Range of motion parameters and motion loss (Passive range of motion with evaluation of scapular vs. GH motion) Pain location AC joint, biceps, radicular patterns Range of Motion Passive vs Active vs Active Assisted Compare to contra-lateral shoulder Cervical Spine status Lower extremity issues- walker, cane dependent, etc Obesity- BMI Medical Co-morbidities DM, HTN, CAD, pulmonary, other musculoskeletal conditions 3. Radiographs True AP (Grashey view), Axillary, outlet views These are the minimum that are required! Plain radiographs can tell the tale: Joint space narrowing Glenoid morphology: A1,A3,B1,B2,C Acromiohumeral distance Bone erosion Bone Quality Osteophytes AVN Vascular clips: previous mastectomy Need to further imaging 4. Advanced Imaging Studies a. Limited CT scan Shoulder in center of gantry 3-5 mm cuts from AC thru the glenoid

3 -Will give excellent information on glenoid osteology and retroversion - Give information on RC muscle belly status -Less time, money, radiation than standard CT -Do not need 3D recon for most DJD conditions of shoulder b. MRI Most patients walk in with MRI from primary care MD Excellent for soft tissue, not as good for osseous aspects c. Artho/CT Patients with complex deformity, previous surgery, metallic retained implants d. CT scan with 3D reconstruction Complex post-traumatic or post surgical deformity 5. Laboratory Studies Typically not needed However: If any previous surgery: CBC, Sed Rate, CR-P Aspiration Cell count, cultures, gram stain Office vs OR setting Pre-operative evaluation will help determine: - Pattern of joint disease -Magnitude of motion loss and shoulder dysfunction -Potential rotator cuff involvement and rehabilitation -Will help determine implant choices and realistic functional outcomes for the patient Osteoarthritis Cuff Pathology 1. Rare 3-10% 2. Repairable 3. Usually does not affect outcome

4 Rheumatoid Arthritis A. Cuff Pathology 1. Common (Only 16 25% normal) 2. Attenuation (35%) 3. Tears (40%) 4. Contractures B. Osseous Pathology 1. Glenoid Wear 2. Humeral Wear C. Medical Pathology 1. Multiple Joints 2. Poisons Cuff Tear Arthropathy The degenerative condition itself is a consequence of the primary rotator cuff insufficiency Pain Poor Active ROM; Pseudo-paralysis Almost Normal Passive ROM Dysfunction IV. Complications of Shoulder Arthroplasty 1. Early Prosthesis Problems a. Instability b. Aseptic loosening c. Septic loosening 2. Late Prosthesis Problems a. Glenoid loosening b. Radiolucent lines? c. Poly wear? 3 Stiffness 4. Subscapularis weakness, deficiency? 5. Infection 6. Intra-op/ Peri-prosthetic fx 7. Neurologic injury 8. Late glenoid erosion from hemi-

5 Recent Studies and What can we say about Results Comparison Problems A. Follow-up time frames B. Pre-op diagnosis mixture C. Rotator Cuff status D. Outcome measures E. Radiographic evaluation F. Differences in technique, implant design, materials, cement vs. noncement, and time Single Diagnosis- Osteoarthritis Godeneche JSES Shoulders Avg. F/U= 30 months (1-6.5 yrs) Excellent 59% Patient Satisfaction 94% Good 18% Fair 15% Poor 8% Re-op 4.9% Correlation of RCT or fatty infiltration of cuff muscle with a decrease in Constant Score and Active Forward Elevation Glenoid radiolucencies in 58%, progressive in 23% Radiolucencies associated with decrease in Constant Score Mixed Diagnosis Torchia JSES Shoulders, 89 available for F/U at avg. 12 yrs. (5-17) Active ROM Avg. AFE= Normal RC Small RCT Large RCT

6 Pain Relief 83% pain relief Increase pain correlated with glenoid loosening Radiographic Analysis Humerus Press-fit Cemented 49% shift in position 0% shift in position Glenoid 75 of 89 (84%) with radiolucencies 39 (44%) loose 34 (38%) shift in position Lucencies more common in males Pre-op dx did not correlate with presence of lucencies Time Pain relief 93% decrease to 83% due to glenoid loosening Glenoid revision rate for loosening 5.6% (5 cases) Kaplan-Meier Survival for TSA: 10 Years 93% 15 Years 87% Anatomic TSA I. Soft tissue balancing operation Humeral anatomy: Variable Neck-shaft angle Posterior offset Medial offset Head Height to Size is relatively fixed ratio:.74 Glenoid Anatomy Walch Morphology Re-establish relative normal version Secure Fixation Exposure is the key Advanced imaging to determine glenoid osteology pre-op Summary - TSA is predictable and durable treatment option for DJD - Pre-op diagnosis will effect treatment choices

7 - Rotator Cuff status will have major effect on AFE and outcome scores - Cemented humeri do not move nor cause pain - Cemented glenoids will have and/or develop radiolucent lines - Cemented glenoids will have progressive lucencies 10-50% - Glenoid loosening increases with time - Clinical results will decrease with time, due primarily to pain, which is due to glenoid loosening - Poly wear debris has not been identified as a major factor Survival Rates: 5 year 98% 8 year 93% 10 year 85% yr % Reverse Shoulder Arthroplasty Indications for Reverse Shoulder Arthroplasty A. Symptomatic cuff deficiency with joint injury B. Pain C. Poor active elevation D. Shoulder dysfunction E. No other satisfactory option is available Terminology/Definition of Cuff Deficiency and Joint Injury: Cuff Tear Arthropathy or Arthritis with Massive Cuff Tear A. Large Rotator Cuff Tear (Irreparable) B. Upward Humeral Migration C. Subacromial Narrowing D. Glenohumeral Cartilage Wear

8 Are There Classifications With Relevance? Radiographic classifications : Sirveaux/Oudet Hamada Seebauer However there are no classification schemes commonly in use that allow communication for: severity of involvement, pre-op motion, magnitude of cuff deficiency, or factors associated with success or failure of treatment. Hemiarthroplasty versus Reverse Arthroplasty Age-matched, Diagnosis-matched, No previous surgery-matched population. Comparative Study of Hemi- vs. Reverse for CTA Favard, et al Nice HHR 80 Reverse Prosthesis AFE: HHR = 96 degrees RBS = 138 degrees Constant: HHR = 46.1 RBS = of 62 HHR had progressive acromial wear on radiologic follow-up Problem Conditions Previous RCR, CA arch violation, poor AROM, Irreparable RC tissue, Atrophy of RC muscle belly, pain, dysfunction CTA with pseudoparalysis (AFE < 45 degrees) Previous CA arch surgery Multiple Failed RCR Syndrome -CA arch deficiency -RC deficiency -Loss of containment -Severe dysfunction

9 Anterosuperior Instability (ASI) Failed Hemi/Bipolar for Fracture (usually GT non-union, malunion, or gone) Failed Hemi/Bipolar for CTA VIII. Consider Using the Reverse as the Primary Arthroplasty CTA with pseudoparalysis (AFE < 60 degrees) CTA with insufficiency fx of acromion Previous CA arch violation Anterosuperior Instability (ASI) Multiple Failed RC Repair Syndrome IX. Biomechanical Considerations in Reverse Arthroplasty Design I. Constrained and Semi-Constrained Designs A. Prevent Upward Migration B. Fixed Fulcrum for action C. Based off Hip designs 1. Poor motion (rarely > 90 degrees) 2. Early Failure Scapular fixation failure due to excessive torque at interface II. Grammont Design Reverse Arthroplasty A B present Delta concept III. Advantages from Earlier Designs A. Large Hemispheric ball on glenoid 1. Back of glenosphere in direct contact with prepared bone surface 2. More stability than a smaller ball More surface contact area 3. Greater potential arc of motion B. Smaller lateral offset to glenoid component 1. Absence of neck 2. Center of rotation of glenoid component in contact with glenoid bone 3. Reduced forces at implant-bone interface

10 C. Medialization and Inferiorization of Center or Rotation 1. Recruits more deltoid muscle fibers for action (elevation) 2. Increases deltoid tension 3. Better deltoid function in absence of rotator cuff 4. Increased deltoid torque due to increased lever arm and force IV. Technical Issues with Impact from this design A. Inferior glenosphere placement 1. Largest area of glenoid surface area and vault volume 30 mm. circle with a superior tubercle 2. Allows humerus to not impinge on scapula in adduction (? Prevents scapular notching) 3. Deltoid and myofascial sleeve tension 4. Will create deadspace under deltoid (potential hematoma formation) 5. Will lengthen the arm and avg. of 15 mm. 6. Potential for over-tensioning with acromial stress fracture B. Inferior Tilt to Component 1. Prevents scapular impingement in adduction 2. Compression forces under the baseplate thru position and ROM 3. Superior tilt: tension forces under component; early failure 4. Allows a closer to normal scapulo-humeral rhythm during elevation V. Problems A. Instability It is a semi-constrained device Only so much motion available prior to the end arc Under-tensioning of deltoid with global decoaptation of humerus to glenoid B. Limit to ER 1. Posterior abutment of humerus upon scapula 2.? Contributes to early instability with open-book anteriorly with ER and extension 3. Slackening of any remaining posterior RC muscles C. Scapular Notching D. Glenoid Loosening

11 E. Polyethylene wear X. Technical Considerations with Reverse Shoulder Arthroplasty Glenoid Component is the Key! Placement Issues Inferior Position Glenoid is 30mm circle with a tubercle on top Place the baseplate on the 30mm circle. Rim of baseplate is on inferior rim of glenoid bone Remove labrum and hyaline cartilage to see the inferior rim Drill guide to position center drill hole correctly Must do an inferior capsular release off glenoid Best done thru deltopectoral approach Inferior Tilt (10 degrees) Inferior tilt: compressive forces upon baseplate thru ROM Less scapular impingement (notch) in adduction Hand Ream, Inferior pressure Create Subchondral Smile thru the bone Crescent shaped area of early cancellous bone showing Stop- Accept depth- May need to bone graft superior defect Superior-central defect in 25-30% Do not try to change retroversion dramatically Screw Placement Find the best bone for the screws It is not necessarily at the 12 and 6 o clock positions Divergent screws Lateral pillar and Coracoid base Humerus Component Placement Issues Version Between 0 and 20 degrees of retroversion Adjust with trial reduction to allow at least 20 degrees ER at side Increase retroversion of humerus = More ER prior to abutment Height 1 mm push-pull Snap fit reduction Strap muscle tendons will be tight Lengthen the arm approx. 1.5 cm. Drain for 24 Hrs Deadspace created, potential for hematoma formation

12 Stability If stability is a question (ie- revision): Use abduction pillow for 3-5 weeks Absolute Necessities for Reverse Prosthesis Intact Deltoid Adequate Glenoid Bone Stock Proper design Informed surgeon and patient XIII. Complications (Reported Rates 15-25%) Even significantly higher rate in revision surgeries 1. Infection 2. Hematoma 3. Dislocation 4. Glenoid Loosening 5. Glenoid/Scapular Notching Potential Problems Poor rotational ability ( ER and IR can be limited due to design) But also due to poor posterior RC status Teres Minor status is important Longevity Poor decisions, Poor technique This is not an easy operation! XIV. Clinical/Demographic Characteristics of Reverse Population 1. Older than TSA ( Avg. 10 yrs. Older) 2. Co-morbidity (Avg. 2+ more) 3. Length of Stay issues (Longer due to infirmity of age, family, comorbidity, medical, mobility issues) XV. Summary Cuff-deficient shoulders with painful degenerative disease is an unsolved surgical problem at this time Population is getting progressively older and more active at the same time New options are presenting themselves be careful what you chose Reverse Prosthesis: Provide stability, relieve pain, and improve potential active elevation

13 For Cuff Deficiency and Joint Injury where no other satisfactory option exists References 1. Boileau P, Watkinson DJ, Hatzidakis AM, Balg F. Grammont reverse prosthesis: design, rationale, and biomechanics. J Shoulder Elbow Surg Jan;14(1 Suppl S):147S 161S. doi: /j.jse Chalmers PN, Rahman Z, Romeo AA, Nicholson GP. Early dislocation after reverse total shoulder arthroplasty. J Shoulder Elbow Surg Nov 1;doi: /j.jse Cuff D, Pupello D, Virani N, Levy J, Frankle M. Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency. The Journal of Bone and Joint Surgery Jun;90(6): doi: /jbjs.g Edwards TB, Kadakia NR, Boulahia A, Kempf J-F, 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 p doi: /mse.2003.S Favard L, Katz D, Colmar M, Benkalfate T, Thomazeau H, Emily S. Total shoulder arthroplasty - arthroplasty for glenohumeral arthropathies: results and complications after a minimum follow-up of 8 years according to the type of arthroplasty and etiology. Orthop Traumatol Surg Res Jun;98(4 Suppl):S41 7. doi: /j.otsr Gupta AK, Chalmers PN, Rahman Z, Bruce B, Harris JD, McCormick F, et al. Reverse total shoulder arthroplasty in patients of varying body mass index. J Shoulder Elbow Surg Sep 30;doi: /j.jse Kappe T, Cakir B, Reichel H, Elsharkawi M. Reliability of radiologic classification for cuff tear arthropathy. J Shoulder Elbow Surg Jun;20(4): doi: /j.jse Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am Dec 21;93(24): doi: /jbjs.j Levine WN, Fischer CR, Nguyen D, Flatow EL, Ahmad CS, Bigliani LU. Longterm follow-up of shoulder hemiarthroplasty for glenohumeral osteoarthritis. J Bone Joint Surg Am Nov 21;94(22):e164. doi: /jbjs.k.00603

14 25. Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis Nov 3;92(15): Available from: 73&retmode=ref&cmd=prlinksdoi: /JBJS.I Nolan BM, Ankerson E, Wiater JM. Reverse total shoulder arthroplasty improves function in cuff tear arthropathy. Clin. Orthop. Relat. Res Sep;469(9): doi: /s z 27. Patel DN, Young B, Onyekwelu I, Zuckerman JD, Kwon YW. Reverse total shoulder arthroplasty for failed shoulder arthroplasty. J Shoulder Elbow Surg Nov;21(11): doi: /j.jse Raiss P, Schmitt M, Bruckner T, Kasten P, Pape G, Loew M, et al. Results of cemented total shoulder replacement with a minimum follow-up of ten years. J Bone Joint Surg Am Dec 5;94(23):e doi: /jbjs.k Rasmussen JV, Jakobsen J, Brorson S, Olsen BS. The Danish Shoulder Arthroplasty Registry: clinical outcome and short-term survival of 2,137 primary shoulder replacements. Acta Orthop Apr;83(2): doi: / Sershon RA, Van Thiel GS, Lin EC, McGill KC, Cole BJ, Verma NN, et al. Clinical outcomes of reverse total shoulder arthroplasty in patients aged younger than 60 years. J Shoulder Elbow Surg Oct 12;doi: /j.jse Smith T, Gettmann A, Wellmann M, Pastor F, Struck M. Humeral surface replacement for osteoarthritis. Acta Orthop Oct;84(5): doi: / Walch G, Badet R, Boulahia A, Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. Journal of Arthroplasty Sep;14(6): Walch G, Young AA, Boileau P, Loew M, Gazielly D, Molé D. Patterns of loosening of polyethylene keeled glenoid components after shoulder arthroplasty for primary osteoarthritis: results of a multicenter study with more than five years of follow-up. J Bone Joint Surg Am Jan 18;94(2): doi: /jbjs.j Wall B, Nové-Josserand L, O'Connor DP, Edwards TB, Walch G. Reverse total shoulder arthroplasty: a review of results according to etiology. J Bone Joint Surg Am Jul;89(7): doi: /jbjs.f Werner CML, Steinmann PA, Gilbart M, Gerber C. Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverseball-and-socket total shoulder prosthesis. J Bone Joint Surg Am. 2005

15 Jul;87(7): doi: /jbjs.d Young AA, Smith MM, Bacle G, Moraga C, Walch G. Early results of reverse shoulder arthroplasty in patients with rheumatoid arthritis. The Journal of Bone and Joint Surgery Oct 19;93(20): doi: /jbjs.j Young AA, Walch G, Pape G, Gohlke F, Favard L. Secondary rotator cuff dysfunction following total shoulder arthroplasty for primary glenohumeral osteoarthritis: results of a multicenter study with more than five years of followup. J Bone Joint Surg Am Apr 18;94(8): doi: /jbjs.j.00727