5-10 YEAR EXPERIENCE WITH STEMLESS ARTHROPLASTY PETER HABERMEYER DEUTSCHES SCHULTERZENTRUM MUNICH Germany Disclosures Consultant for Arthrex Inc. Royalties Arthrex Inc. INDICATIONS FOR STEMMLES TSA 1. POSTTRAUMATIC OSTEOARTHRITIS 2. IDIOPATHIC OSTEOARTHRITIS 3. DISLOCATION ARTHROPATHY 4. AVASCULAR OSTEONECROSIS 5. RHEUMATOID ARTHRITIS ( CENTERED FORM ) 1
CONTRA - INDICATIONS FOR STEMMLES TSA 1. OSTEOPOROSIS ( T SCORE < - 2.5 SD ) CONTRA - INDICATIONS FOR STEMMLES TSA 1. OSTEOPOROSIS ( T SCORE < - 2.5 SD ) 2. BONE CYST FORMATION ( RA ) 3. EPILEPSY HUMERAL HEAD GEOMETRY & BIOMECHANICS OF STEMLESS HEAD REPLACEMENT Design principle: Primary stability by shifting & fixation of the trunion to the center of rotation 2
DESIGN RATIONAL OF STEMLESS IMPLANTS metaphyseal epiphyseal metaphyseal metaphyseal 04: TESS (Biomet) 05: Eclipse (Arthrex) 10: Simpliciti (Tornier) EPIPHYSEAL & METAPHYSEAL FIXATION TO PREVENT MIGRATION FINITE ELEMENT ANALYSIS ECLIPSE CRANIAL LOADING: Reduction of migration to 0.2mm with cortical support of the trunion MIDTERM RESULTS OF STEMLESS SHOULDER ARTHROPLASTY Evaluation of clinical and radiological results with 5-8 years after stemless humeral head replacement 3
AIM OF THE STUDY Evaluation of clinical and radiological results with 9 & 10 years after stemless humeral head replacement OWN RESULTS WITH A FUP OF 9 & 10 YEAR N = 49 (27f / 22m) Ø FU: 9 years (90-127 Mo) Ø Age 56 years (21-81y) 32 HSA (65%) / 17 TSA (35%) Lost of FUP n=6, FUP rate: 88% Follow-up: 6 Wo, 3 Mo, 6 Mo, 12 Mo, annually Constant Score X-ray in 3 planes INDICATIONS No of patients 25 15 10 5 0 24 7 primary OA Posttraumatic Instability 7 2 1 2 CTA Postinfectious Arthritis Revision arthroplasty 4
CONSTANT-SCORE pre-op / post-op TOTAL FU 9 years, age 56y, n=43 P P<0.0001 80 79 Pre-OP 70 P<0.0001 Post-OP 60 62 50 52 40 42 P=0.001 30 P<0.0001 P=0.008 P=0.67 24 17 10 8 12 9 13 7 8 0 rel. CS (%) CS Pain ADL ROM Strength Significant improvement of overall Constant Score, pain, ADL & ROM P 80 70 60 50 40 30 10 0 79 79 62 63 rel. CS (%) CONSTANT-SCORE POST-OP HSA vs TSA P > 0,05 12 13 12 15 HSA TSA 24 23 10 6 CS Pain ADL ROM Strength No difference in Constant score and its subcategories ROM POST-OP HSA vs TSA P 1 100 80 60 40 0 P > 0.05 118 119 106 103 HSA TSA 43 42 active flexion active abduction active external rotation No difference in active ROM 5
RESULTS POSTTRAUMATIC AVN N=24 (14f/10m) Ø age 57 years (37-81y) Ø Follow-up 108 Mo (90-127 Mo) chron. fracture Boileau I 15 HSA 5 TSA P 80 70 60 50 CONSTANT-SCORE POSTTRAUMATIC pre- / post-op P=0.001 77 FU 109 Mo, age 57y, n=24 P=0.001 60 Pre-OP Post-OP 40 48 38 P=0.014 30 P=0.002 P=0.05 21 P=0.9 10 8 12 8 12 16 7 8 0 rel. CS (%) CS Pain ADL ROM Strength Significant improvement of overall Constant Score, pain, ADL & ROM ROM POSTTRAUMATIC pre- / post-op P 1 100 80 60 40 0 89 FU 109 Mo, age 57y, n=24 P=0.031 106 P=0.013 66 8 active flexion active abduction active external rotation 92 Pre-OP Post-OP P<0,0001 Significant improvement of flexion, abduction, ext. rotation 35 6
ASSESSMENT OF RLL & STRESS SHIELDING b a c a b c ASSESSMENT OF HUMERAL HEAD MIGRATION Fleischer Gerhard 2 mo post-op 1 year post-op 3 years post-op 9 years post-op RC-DEFICIENCY = Migration & loss of shoulder function RADIOLOGICAL RESULTS HUMERUS Incomplete RLL < 1mm 2.9% Loosening 0% Resorption of greater tub. 1 case Stress shielding zone A 29.4% ap Humeral head migration 14.7% 7
RADIOLOGICAL RESULTS GLENOID SIDE HSA: glenoid wear after HSA: 1 (2,3%) Revision to TSA TSA: incomplete RLL < 1mm 27.3% No loosening 06 16 1 (2.3%) Late infection Explantation 7 mo post-op 6 (14%) RC deficiency COMPLICATIONS HUMERERAL SIDE 1x Pect. major transfer 6 weeks post-op 1x Reverse shoulder arthroplasty 74 mo post-op 1 (2.3%) greater tuberosity resorption without revision 1 (2.3%) proximal humeral fracture at the surgical neck by a fall 7 weeks post-op conservative treatment 9.3% revisions on humeral side POSTTRAUMATIC AVN 79 years, female Abduction 70 Flexion 50 ER -10 Severe pain 8 years after injury 8
POSTTRAUMATIC AVN Abduction 90 Flexion 100 IR L1 ER 30 Pain 14/15 1 year post-op CHRONICH LOCKED POSTERIOR FRACTURE DISLOCATION & AVN M.M., 81y CHRONICH LOCKED POSTERIOR FRACTURE DISLOCATION & AVN 6 Mo post-op ROM: Flexion 110 ERO 30 Constant Score 42 points (65,6%) M.M., 81y 9
DISCUSSION: CONVERTIBLE VS REVERSIBLE PERIPROSTHETIC FRACTURE CONCLUSION 12/05 04/06 Good functional results after 9-10 years Excellent results in posttraumatic cases No revision due to loosening Stress Shielding - within the area of physiologic lower bone substance Good reversibility Easy revision in periprosthetic fracture 10
Llength of time of surgery 08.02.16 THANK YOU FOR YOUR KIND ATTENTION! WHAT IS BETTER? HABERMEYER ET AL.16 TYPE STEMLESS TSA Uncemented Stem Prosthesis TSA Indication N Follow-up Rate Ø FU (min 60) [months] Primary OA (10f/10m) 70% Primary OA (13f/7m) 85% 68 70 Ø Age 65 69 PROSPECTIVE RANDOMIZED STUDY : SHAFT VS STEMMLESS ADVANTAGES STEMMLESS HHR Length of time of Surgery Min P=0,032 Matched pair analysis 117 97 Significant reduction of length of surgery ( Min) using the stemless implant > 17% Type of prosthesis Habermeyer P et al. DVSE 09 11
STEMMED vs STEMLESS TSA FUNCTIONAL RESULTS 80 70 60 50 40 30 10 0 P>0.05 70 73 Constant Score (P) P>0.05 12 13 P>0.05 16 16 P>0.05 Stemmed Stemless 29 33 11 8 P>0.05 Pain ADL ROM Strength STEMMED vs STEMLESS TSA Assessment of RLL b a a b c C b a c C a b Habermeyer P 10 STEMMED vs STEMLESS TSA Radiological Results Stemless TSA Stemmed TSA Stress shielding 26,7% 47,1% RLL humeral Component 0 0 No implant related Complications 12
DISCUSSION: COMPLICATIONS STANDARD STEM vs ECLIPSE COMPLICATIONS Stemmed Implants (Denard PJ JSES 13, Young AA JBJS Am 12, Raiss P JBJS Am 14) Eclipse RC-defects up to 16.8% 14% Loosening of the humeral component Complication rate (without glenoid & without RCT) 0% - 2% 0% 8% 7% CASE PRESENTATIONS POSTTRAUMTIC AVN 3 years after ORIF F. A., 50 y 1 year post-op 5 years post-op 7 years post-op 13
POSTTRAUMATIC ARTHRITIS / AVN & RC at Risk G.S., 46 y POSTTRAUMATIC ARTHRITIS / AVN & RC at Risk Eclipse & convertible glenoid G.S., 46 y Revision to RSA REVISION TO RSA Failed Hemiarthroplasty by RC Defect 14
IDIOPATHIC AVN ST. III F. H., 56 J 1 year post-op 2 years post-op 5 years post-op POSTINFECTIOUS ARTHRITIS J. M., 58 y 2 years post-op 3 years post-op 8 years post-op 15