Anatomic Total Shoulder Arthroplasty: Optimizing Outcomes and Avoiding Complications
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1 Anatomic Total Shoulder Arthroplasty: Optimizing Outcomes and Avoiding Complications Dr. Ryan T. Bicknell, MD, MSc, FRCSC Associate Professor Division of Orthopaedic Surgery, Departments of Surgery, Mechanical and Materials Engineering, Queen s University, Kingston, ON, Canada rtbickne@yahoo.ca
2 Disclosures Consulting DePuy Orthopaedics Zimmer-Biomet Inc. Institutional/Research DePuy Orthopaedics Zimmer-Biomet Inc. Conmed Linvatec
3 Outline Pre-op Evaluation Clinical Radiographic Surgical Technique Patient Positioning Exposure/Subscapularis Glenoid Reconstruction Humeral Reconstruction Rehabilitation
4 Outline Pre-op Evaluation Clinical Radiographic Surgical Technique Patient Positioning Exposure/Subscapularis Glenoid Reconstruction Humeral Reconstruction Rehabilitation
5 Introduction
6 Maximizing Outcomes Disease related factors Patient related factors Surgeon related factors The surgeon is the method Dr. Rick Matsen
7 Maximizing Outcomes Avoiding This Achieving This
8 Pre-op Evaluation
9 Clinical Evaluation Range of Motion IR contracture/loss of ER Cuff status C-spine Recognize 2 causes of arthritis Co-morbidities and risk stratification
10 Radiographic Evaluation Axillary view CT Scan ± 3D
11 Walch J Arth 1999 Radiographic Evaluation Glenoid Wear/Version (Walch Classification) A Central wear Beyond coracoid base B/C biconcave/retroverted > 20, post HH subluxation
12 Radiographic Evaluation Cuff Status CT fatty atrophy MRI if still in question Intra-op final assessment
13 Surgical Technique
14 Patient Positioning Shoulder over edge of bed Free movement of arm Medial scapula stabilized on edge of bed Rolled towel to antevert Arm positioners are helpful
15 Exposure/Subscapularis Release of adhesions 360 SSC release Keep capsule with SSC Particularly if thin Robust SSC repair Tendon medialization? Not a junior resident job!
16 Glenoid Reconstruction Exposure is key! Not a junior resident job... Remove self-retractor Brachial plexus compression Glenoid bone stock = Gold Ream enough not too much! Bone support > version correction Retractor removal can facilitate reaming
17 Humeral Reconstruction
18 Important Anatomic Relationships Humeral Head Size Humeral Head Position Highly variable Patient-to-patient Side-to-side
19 Important Anatomic Relationships Humeral Head Size ROC mm Smaller in women Coronal sagittal? Height affects offset
20 Important Anatomic Relationships Head-shaft Angle Mean degrees Range degrees Pearl JSES 1996
21 Important Anatomic Relationships Retroversion Mean - 30 degrees Range degrees Pearl JSES 2005
22 Important Anatomic Relationships Offset Coronal (medial) 4-14 mm Transverse (posterior) mm Robertson ASES 1999, Ballmer JSES 1993
23 Anatomic Humeral Reconstruction Why Important? Head Size Too large - ROM, glenoid forces Too small - tuberosity impingement, glenoid pointloading Head Position Altered cuff tension (from over-coverage) GT/LT abutment on glenoid (from under-coverage) Williams JSES 2001
24 Anatomic Humeral Reconstruction Two Philosophies 1. Fixed neck cut adapt patient to implant Early designs/techniques Soft tissue balancing 2. Anatomic neck cut adapt implant to patient Newer designs/techniques Advantage of stemless?
25 Humeral Reconstruction 1. Humeral releases Inferior release past 6 o clock
26 Humeral Reconstruction 2. Osteophyte removal Define true anatomic neck Particularly inferior varus deformity
27 Humeral Reconstruction 3. Head resection along anatomic neck Retroversion (~ ) Neck-shaft angle (~135 )
28 Humeral Reconstruction 3. Head resection along anatomic neck Superior resection should abut cuff insertion Protect cuff!
29 Humeral Reconstruction 4. Size humeral head and rotate eccentricity Cover cut surface Prefer undersize > oversize
30 Humeral Reconstruction 5. Trial reduction Assess tension 50% posterior translation Loosest shoulder will ever be is in surgery Prefer loose > tight
31 Humeral Reconstruction 6. Final implant Impaction bone graft (from humeral head) Place stitches for SSC repair
32 Post-Op Rehabilitation Early (<6 week) Protect subscapularis repair P & AAROM only, limit ER to 30 or as assessed intraop Late (>6 weeks) AROM Progressive strengthening Limit heavy labor/impact
33 Conclusions Set yourself up for success Pre-op evaluation prevents surprises Recognize deformity Positioning Exposure is key! Anatomic reconstruction Careful rehabilitation
34 Thank You Queen s University Upper Extremity Fellowship Dr. David Pichora and Dr. Ryan Bicknell Queen's University Kingston, ON, Canada rtbickne@yahoo.ca
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