8A little history1893- French surgeon Pean inserted platinum and rubber components to replace a shoulder joint destroyed by tuberculosis.1951- Neer I, Vitallium Hemiarthroplasty prosthesis which resulted in pain relief and good function compared to previous options.
91974- Neer II Prosthesis. Modified Neer I to conform to a glenoid component. Courtesy of Smith & Nephew
101970’s - constrained components were popular, but follow-up reports demonstrated high rates of loosening, particularly of the glenoid component.
111980’s – Modular humeral components were developed, along with cementless glenoid fixation using polyethylene on a metal backing.
1240 Shoulders with 3 year follow up. Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study.Boileau P, Avidor C, J Shoulder Elbow Surg Jul-Aug;11(4):351-9.40 Shoulders with 3 year follow up.Metal-backed – 2% radiolucent lines, 100% progressive, 25% loose in 3 years. Associated with shift and osteolysis.Cemented – 80% radiolucent lines, 25% progressive. None loose in 3 years.
13Other Problems with Metal-Backed Glenoid Components Metal-backing increased the thickness of the component and often lead to over-stuffing of the joint.To avoid over-stuffing the joint, the polyethylene thickness had to be reduced, resulting in accelerated poly wear & failurePoly-metal disassociation occurred with unacceptable frequency.
14Humeral Components CEMENTED PROX POROUS COATED FULLY POROUS COATED Good for osteopenic boneLower risk of intra-operative fractureMore stress-shieldingHard to reviseNeed good bone stockNeed good bone stockHigher risk intra-operative fractureMore stressshieldingHard to reviseHigher risk of intra-operative fractureLess stress-shieldingEasier to revise
15Cemented vs Press-fit Humeral Components Harris, Jobe and Dai reported less micro-motion with proximally-cemented stems.Fully cemented stems provide no additional benefit or stability over proximally- cemented stems.Sanchez-Sotelo reported a low rate of stem loosening regardless of fixation, but press-fit prostheses developed more radiolucent lines in the first 4 years.
16The Need for Modularity F-H OffsetB-C Head thicknessD-E = 8mmTop of humeral head is higher than greater tuberosity
17The Need for Modularity Reestablishing normal glenohumeral anatomic relationships is important to ensure optimal results Iannotti JP; JBJS 74A 1992
18Other Anatomic Variables to Consider Glenoid : 2° anteversion to7° retroversionHumeral Head: 20° - 40° retroversionAxial CT of the glenohumeral joint is a valuable pre-op planning tool.
19Contraindications to Shoulder Arthroplasty Active or recent shoulder joint infectionParalysis with complete loss of rotator cuff and deltoid functionA neuropathic arthropathyIrreparable rotator cuff tear is a contraindication to glenoid resurfacing.
20OsteoarthritisIn addition to the universal features of osteoarthritic joints (joint space narrowing, cyts, osteophytes…), the shoulder can also demonstratePosterior glenoid erosionFlattening of the humeral headEnlargement of the humeral headRotator cuff tears are uncommon in OA
21Hemi vs Total Shoulder Easy procedure Short Operating time Less risk of instabilityCan be revised to TSALess reliable pain reliefProgressive Glenoid erosion may cause results to deteriorate over timeNeed concentric glenoidMore consistent pain reliefBetter fulcrum for active motionDifficult procedureLonger OR timePoly wear can cause loosening of both componentsMore Glenoid bone loss
22Recommendation based on Experience Neer, 1998“When the articular surface of the glenoid is good, the results of hemiarthroplasty are similar to those of TSA. Wear on the glenoid has not been a problem if the articular surface was good at the time of surgery and glenohumeral motion was re-established”
23Recommendations based on Evidence Kirkley et al, 200042 pts, 3 surgeons (stratified)One year follow-upNo significant difference in WOSI, ASES, DASH Constant Score or ROM.Trend towards better pain relief with TSA.2 Hemi patients crossed over to TSA after 1 year follow-up.
24Recommendations based on Evidence Gartsman, 200051 shouldersAverage f/u of 35 monthsNo difference in ASES or UCLA scores.Significantly better pain relief with TSA3 pts crossed over to TSA by 35 months
25A 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.Bryant D, Litchfield R; J Bone Joint Surg Am Sep;87(9):Included 4 RCT’sAverage 2 year follow-up.TSA resulted in significantly improved UCLA scores, pain relief and increased forward elevation (by 13°).This meta-analysis concluded that at 2 years of follow-p, TSA provided a better functional outcome, however the problems of glenoid component loosening in the TSA group and progressive glenoid erosion in the hemi group may affect the eventual long-term outcome.Longer follow-up is necessary
26Recommendations based on Evidence The results of arthroplasty in osteoarthritis of the shoulder. Haines JF et al. J Bone Joint Surg Br Apr;88(4):Prospective study of 124 shoulder arthroplasties for OA (Hemi and TSA)Similar improvement in pain and function in both groups if rotator cuff was intact . Better results with Hemi if + rotator cuff tearHemi Revision at mean of 1.5 years for glenoid painTSA Revision at mean of 4.5 years for glenoid loosening
27Technical Issues to Consider OA tends to result in posterior glenoid wear/erosion, which, if accepted, will lead to a retroverted glenoid component.Compensate by anterior reaming or placing the humeral component in LESS retroversion.Failure to do so will result in Posterior Instability
29Rheumatoid Arthritis Cemented short-stemmed prosthesis Gill, Cofield et al recommend at least 60mm between the cement mantles of ipsilateral shoulder and elbow arthroplasties.If this cannot be achieved, join both cement mantles together.
31Rheumatoid ArthritisGenerally, TSA performed due to destruction of the glenoid articular surface by the disease.Glenoid erosion may require bone grafting, however, if glenoid is eroded to the level of the coracoid process, glenoid resurfacing is contraindicated
32Rotator Cuff Arthropathy Described by Neer, Craig and Fukada in 1983.A distinct form of osteoarthritis associated with a massive chronic rotator cuff tear.Generally, rotator cuff tears occur in less than 10% of shoulders with OA
33Rotator Cuff Arthropathy A function of the rotator cuff is to depress the humeral head and keep it centered on the glenoid fossa.Massive rotator cuff tears result in proximal migration of the humeral head.This is a contraindication to glenoid resurfacing as it results in eccentric (superior) glenoid loading and early component loosening.
34Surgical Options Hemiarthroplasty with a large head Repair of rotator cuff and TSAReverse TSA“Clayton Spacer”
35Outcomes of Hemiarthroplasty Rockwood: 86% satisfactory results after 4 yearsZuckerman: 93% adequate pain relief and 90% had improved function for ADL’s.Sanches-Sotelo: 75% modest improvements in ROM and strength for ADL’s. Good pain relief.
36Outcomes of Hemiarthroplasty Field et al, and Sanchez-Sotelo reported that impaired deltoid function and previous subacromial decompression (loss of coracoacromial ligament) were significantly associated with clinical shoulder instability post hemiarthroplasty.
37Reverse Total Shoulder Arthroplasty Lateralizes the centre of rotation and places the deltoid at a mechanical advantage.More inherent stability and prevents proximal migration of humeral head.
38Outcomes of the Reverse Total Shoulder The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients. Frankle M, Siegel S, J Bone Joint Surg Am Aug;87(8):Average age = 70Improved ASES scoresImproved ROM Flex: 105°Abd: 102°17% Complication rate7 failures 5 revised to new Reverse TSA 2 revised to Hemiarthroplasties
39Outcomes of the Reverse TSA (Delta III prosthesis) Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis. Werner CM, Glbart M, J Bone Joint Surg Am Jul;87(7):58 consecutive patients, average age = 6841 cases were revisionsFollow up = 38 monthsImproved Constant Score, Pain reduction and improved ROM.ROM: Flex: 100°Abd: 90°50% complication rate (including minor)If a 1° surgery = 18% re-operation rateIf a Revision surgery= 39% re-operation rate
40Reverse Total Shoulder Arthroplasty is Hard to Revise Little Glenoid bone stock once component is removed.
42Osteonecrosis Usually young patients with adequate bone stock. Prefer proximally porous-coated, press-fit humeral prosthesis.less stress-shieldingeasier to revise if necessaryOnly resurface glenoid in stage V osteonecrosis (glenoid erosion).
43Post-Traumatic Arthritis Due to fractures treated conservativelyMay have mal-union of tuberosities, distorting normal anatomic landmarks12% of patients have axillary nerve palsies (Neer).Many have soft-tissue contractures and muscle weakness
44Choice of Prosthesis Consider Patient age Condition of glenoid surface and bone stockAxillary nerve palsy is a relative contraindication to arthroplasty
45Complications Instability 1.2% Excessive Retro/Anteversion Head too smallHead too low (post fracture)Subscap rupture
46Complications Rotator Cuff Tear 2% Results in superior migration of humerus and glenoid looseningGlenoid loosening
47Complications Infection 0.5% Staph Aureus More common after revision surgery
48Complications Heterotopic Ossification 10 -45% Males Dx = osteoarthitisLow gradeNon-progressiveDoes not affect outcomeSperling, Cofield et al
49Complications Stiffness Depends on indication for arthroplasty Subscap shorteningOversized componentsInappropriate rehab
50Complications Periprosthetic Fracture Intra-op 1% Post-op 0.5 - 2% Most common in RA85% womenGlenoid fractures are rare
51Complications Axillary nerve injury Rare Higher risk during revision surgeryUsually a neuropraxia