Management of arthritis of the shoulder Omar Haddo Consultant Orthopaedic Surgeon
Diagnosis Pain - with activity initially. As disease progresses night pain is common and sleep difficult Stiffness trouble with daily activity Mechanical symptoms - grinding, catching, locking Sternoclavicular joint Acromioclavicular joint Glenohumeral joint History / Examination / Investigations
Shoulder Arthritis Osteoarthritis Inflammatory Arthritis Cuff Tear Arthropathy Osteonecrosis Post traumatic Septic Arthritis
Sternoclavicular arthritis Pain medially Associated with bony lump Xrays CT Exclude Sepsis Tumour
Sternoclavicular arthritis Conservative treatment Nonsteroidals Activity Modification Steroid injection Operative treatment Joint resection Not as successful as ACJ
Acromioclavicular Arthritis Bad Xrays are not always symptomatic Osteolysis of distal clavicle Repetitive overhead activity can lead to microtrauma. Most often occurs in weightlifters/body builders and football players. Also occurs in hockey players and has been reported in lacrosse players. More often occurs in men, but has been reported in female bodybuilders. Beware MRI report
Acromioclavicular Arthritis Conservative treatment Nonsteroidals Activity Modification Steroid injection Operative treatment ACJ resection
Glenohumeral Arthritis Osteoarthritis Posterior glenoid erosion Flattening of the humeral head Rotator cuff tears are uncommon in OA
Glenohumeral Arthritis Inflammatory Arthritis Peri-articular erosions and osteopenia Adjacent joint involvement (elbow, C-spine) Cuff function Cuff Tear Arthropathy Superior migration of humeral head Articulates with acromion as well
Glenohumeral Arthritis Osteonecrosis Consider causes Corticosteroids Alcoholism Sickle cell diesese Lupus Idiopathic Usually younger patients with adequate bone stock.
Glenohumeral Arthritis Post Traumatic May have mal-union of tuberosities, distorting normal anatomic landmarks May have axillary nerve palsy. Many have soft-tissue contractures and muscle weakness Age of patient
Glenohumeral Arthritis Conservative Activity modification Physiotherapy Maintains range of motion Strengthens surrounding musculature Decreases inflammation Oral medication Injection Steroids vs Hyaluronic acid
Glenohumeral Arthritis Operative Arthroscopic debridement Arthroplasty Hemi Total Resurfacing Reverse
Arthroscopic Debridement Arthroscopic debridement of synovium, labrum and loose articular cartilage Biceps tenotomy Subacromial decompression Rotator interval and capsular release ACJ excision Burkhead, et al. Shoulder arthritis in the young adult: arthroscopy to arthroplasty. Instr Course Lect. 2006. Flatow, et al. Management of glenohumeral arthritis: a role for arthroscopy? Orthop Clin North Am. 2003. Weinstein, et al. Arthroscopic debridement of the shoulder for osteoarthritis. Arthroscopy. 2000.
Arthroscopic Debridement Young and active patients Elderly with significant comorbidities Early disease Short term benefit
Which implant?
Total Shoulder vs Hemi vs Resurfacing Better functional scores with TSR than Stemmed Hemi Glenoid component remains an issue Better results with Copeland resurfacing hemiarthroplasty than Stemmed Hemi Kirkley et al, 2000 better pain relief with TSR Gartsman, 2000 - better pain relief with TSR Levy, O. and S.A. Copeland, Cementless surface replacement arthroplasty of the shoulder. 5- to 10- year results with the Copeland mark-2 prosthesis. J Bone Joint Surg Br, 2001. Bryant D, Litchfield R; J Bone Joint Surg Am. 2005 Sep;87(9):1947-56. 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. Bunker T. Shoulder & Elbow. 2011 April; Vol 3 (2): 64 73.Stemless shoulder replacement, the best of both worlds: a personal view
Which Glenoid Poly vs metal backed Flat back or curved Pegs vs keel Cemented vs uncemented Boileau P, Avidor C. J Shoulder Elbow Surg. 2002 Jul-Aug;11(4):351-9. Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study.
Surface replacement Pros: Bone conserving Restores anatomy Easy to perform Good results Cons: Overstuffing joint Glenoid erosion Difficult to expose glenoid
Anatomical shoulder Pros: Standard Good if not enough bone stock Cons: Wrong alignment Overstuffing Bone loss Fractures
Reverse shoulder Pros: Restores movement with CTA Cons Scapula notching No way back
Contraindications 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 replacement.
Complications Dislocation Rotator cuff tear / dysfunction Glenoid wear / loosening Infection Stiffness Heterotropic ossification Fracture Nerve injury
Ultimate bail-out Excision arthroplasty Shoulder arthrodesis Also considered for Septic arthritis
My philosophy Bone conserving Right implant for right diagnosis Plan B intraop and in failure Backed by evidence Small learning curve (for surgeon and theatre staff) Company support???cost
The Future Stemless systems Universal systems Biological resurfacing and interposition arthroplasty Meniscal allograft / Graft Jacket Microfracture / ACI Navigation Robotics
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