Arthroplasty of Shoulder

Capt; Myo Kyaw Kyaw

PG-4
23.5.2022
Outline

1) Pre operative planning

2) Hemiarthroplasty

3) Total shoulder arthroplasty

4) Reverse total shoulder arthroplasty

5) Complications

6) Surgical techniques
PREOPERATIVE PLANNING

• Careful evaluation of the radiographs and the CT scans

• Three-dimensional CT scans to optimize implant position, size, and

range of motion

• Previous shoulder surgery – infection (Cutibacterium acnes)

HEMIARTHROPLASTY
INDICATIONS

• End-stage joint degeneration in a patient with a contraindication to

glenoid resurfacing
• Young laborers, patients with glenoid bone stock insufficiency,
patients with high activity levels, and those with preserved glenoid
cartilage may benefit from hemiarthroplasty
• Rotator cuff tears remain a contraindication to prosthetic glenoid
resurfacing
 Matsen et al. listed five situations
(1) The humeral joint surface is rough, but the cartilaginous surface of the glenoid
is intact, and there is sufficient glenoid arc to stabilize the humeral head;

(2) There is insufficient bone to support a glenoid component;

(3) There is fixed upward displacement of the humeral head relative to the glenoid
(as in cuff tear arthropathy or severe rheumatoid arthritis);

(4) There is a history of remote joint infection;

(5) Heavy demands would be placed on the joint (anticipated heavy loading from
occupation, sport, or lower extremity paresis)
Contraindications

1) Recent sepsis,

2) Neuropathic joint, a paralytic disorder of the joint,

3) Deficiencies in shoulder cuff and deltoid muscle function,

4) Lack of patient cooperation

SURGICAL TECHNIQUE
• Goal of hemiarthroplasty is restoration of the humeral articular surface
to its normal location and configuration

• Glenoid is not replaced, the size, radius, and orientation of the

prosthetic joint surface must duplicate that of the original biologic
humeral head
• A “big head” humeral prosthesis
that can “overstuff” the joint

• limit range of motion and lead to

rotator cuff failure
MODIFIED HEMIARTHROPLASTY: INTERPOSITION ARTHROPLASTY AND
GLENOIDPLASTY (REAM AND RUN)

• Various types of glenoid resurfacing procedures, particularly for

younger, higher-demand patients
• Allow the metal humeral head to articulate with a cushioning surface
rather than with the native glenoid in an effort to minimize arthritic
progression and subsequent pain

• Concentric reaming of the glenoid combined with shoulder

hemiarthroplasty, the “ream and run” procedure
• Fascial

• Free fascia lata graft

• Commercially available patch devices

• Lateral meniscal allografts

RESURFACING HEMIARTHROPLASTY
• To preserve proximal humeral bone stock

• Do not use a stem for intramedullary fixation but instead form a cap
over the humeral articular surface and are typically stabilized with a
smaller post in the metaphysis

• Reduce eccentric glenoid loading compared with stemmed

hemiarthroplasty
TOTAL SHOULDER ARTHROPLASTY
• Well-established procedure with an excellent long-term track record of
pain relief and functional improvements
INDICATIONS
• Primary - end stage glenohumeral joint degeneration with an intact
rotator cuff

• Osteoarthritis, rheumatoid arthritis, osteonecrosis, posttraumatic

arthritis, and capsulorrhaphy arthropathy
Contraindication

• Active or recent infection

• Irrepairable rotator cuff tears

• Paralysis with complete loss of function of the deltoid

• Uncorrectable glenohumeral instability

REVERSE TOTAL SHOULDER
ARTHROPLASTY
• In 1983, Neer, Craig, and Fukuda described “cuff-tear arthropathy” as
a distinct form of osteoarthritis associated with a massive chronic tear
of the rotator cuff.
• Rotator cuff arthropathy is characterized by pain, poor active motion,
near-normal passive motion, crepitus, weakness, and occasionally
significant fluid buildup under the deltoid

• Elevation of the humeral head, formation of an acromiohumeral

pseudoarticulation, and loss of joint space at the glenohumeral joint
• Glenohumeral instability - proximal migration of the humerus relative
to the glenoid, resulting in erosion of the superior glenoid and the
caudal surface of the acromion.

• Rotator cuff tears have been implicated in early glenoid component

loosening in total shoulder replacements, and irreparable tears are a
contraindication to traditional glenoid resurfacing
Contraindication
• Loss or inactivity of the deltoid and excessive glenoid bone loss that
would not allow secure implantation of the glenoid component
• Biomechanically, the reverse prosthesis works
by reestablishing a fulcrum around which the
deltoid muscle can power shoulder motion

• Reverse prosthesis corrects this by moving

the center of rotation of the shoulder medially
and distally and reestablishing a
semiconstrained fulcrum around that fixed
point
• The reverse prosthesis places high shear stresses across the glenoid,
several investigators have sought to define the factors most important
in maximizing glenoid fixation
COMPLICATIONS OF SHOULDER
ARTHROPLASTY
• Occur late in the postoperative course (5 to 10 years after surgery)

• Component loosening has been reported to occur approximately 8

years after surgery, infection at 12 years

• Periprosthetic fractures at 6 years

Reverse total shoulder arthroplasty

• Scapular notching

• Hematoma formation

• Glenoid dissociation
INTRAOPERATIVE COMPLICATIONS
• fracture, usually of the humeral shaft in the mid to distal diaphysis
• Nerve injury

• Malpositioning of components

• Fracture - errors in surgical technique, such as inadvertent reaming,

overzealous impaction, or manipulation of the upper extremity during
exposure of the glenoid
• Humeral shaft fracture is most likely at two points in the surgical procedure

• Reaming process - excessive torque can be generated that generates a spiral

fracture.

• The second critical period is during the reduction and dislocation maneuver
to test implant stability

• Fractures of the glenoid are extremely rare and usually occur in osteopenic
bone
• Malposition of the humerus is noted with an uncemented component,
it can typically be disimpacted and repositioned
POSTOPERATIVE COMPLICATIONS
• Glenoid loosening,
• Glenohumeral instability,
• Rotator cuff tears,
• Reriprosthetic fracture,
• Infection,
• Deltoid rupture,
• Tuberosity nonunion or malunion,
• Humeral loosening, impingement,
• Heterotopic bone formation,
• Mechanical failure of components, and loss of motion
GLENOID LOOSENING
• One third of all complications.

• Loosening of the glenoid component is significantly more common than

loosening of the humeral component

• A shift in the position of the glenoid component or circumferential radiolucent

lines at least 1.5 mm wide are evidence of a loose glenoid component

• Polyethylene debris from glenoid wear has been reported in approximately

20% of revision shoulder arthroplasty cases
HUMERAL LOOSENING
• Humeral radiolucent lines are not nearly as common as radiolucent
lines around the glenoid component

• Diagnosed by a change in implant position or progression to

circumferential radiolucent lines
Instability
• Second leading cause (30% of all complications)
• 80% of instability - anterior or superior
instability

• Anterior instability most commonly is associated

with subscapularis failure, glenoid anteversion,
malrotation of the humeral component, or
anterior deltoid dysfunction
• Posterior instability - malpositioning of the components but may be multifactorial

• Inferior instability is related to the loss of normal humeral height and is most
common after hemiarthroplasty for proximal humeral fractures

• Removal of too much of the proximal humerus, with resultant inferior placement
of the humeral head, can lead to inferior instability

• Revision surgery usually is necessary to restore humeral length and regain deltoid
strength
PERIPROSTHETIC FRACTURE
• 0.5% to 2%

• Humeral shaft fractures are most frequent in women and in patients

with rheumatoid arthritis
Wright and Cofield Classification
• Type A - extend proximally from the tip of the prosthesis,
• Type B - are centered at the tip of the prosthesis,
• Type C - involve the humeral shaft distal to the prosthesis
Treatment
• Type A – revision arthroplasty and fracture stabilization

• Type B - a fracture brace if acceptable alignment can be obtained

• If union is delayed, open reduction and internal fixation with a plate
and screws and cerclage wiring, without prosthesis removal

• Type C - immobilization and can be managed as other fractures of the

humeral shaft
ROTATOR CUFF FAILURE
• 1% to 2%

• Rupture of the subscapularis tendon is involved in most rotator cuff

tears

• Multiple operations, overstuffing of the joint, overly aggressive

therapy involving external rotation during the early postoperative
period, and tendon compromise by lengthening techniques
INFECTION
• 1% to 2%

• Risk of infection in patients with diabetes mellitus, rheumatoid

arthritis, systemic lupus erythematosus, remote sites of infection, and
those undergoing shoulder injection within 3 months of surgery

• Immunosuppressive chemotherapy, systemic corticosteroids, multiple

steroid injections, and previous shoulder surgery
• early (3 to 6 weeks after surgery)
• One-stage irrigation and debridement with replacement components,
along with appropriate parenteral antibiotic therapy

• late, removal of the implants and all cement

• Placement of an antibiotic-impregnated spacer helps to sterilize the
soft-tissue envelope, and a 6-week course of parenteral antibiotics can
be followed by implantation of revision components with the use of
antibiotics in the cement
DELTOID MUSCLE DYSFUNCTION
• Caused by axillary nerve injury or detachment of the deltoid muscle
can result in a catastrophic loss of shoulder function

HETEROTOPIC OSSIFICATION
• 10% to 45%
• low grade, is present early in the postoperative period, is non
progressive, and does not adversely affect clinical results
 STIFFNESS

• Postoperative stiffness, typically manifested by loss of forward elevation

or external rotation, usually results from oversizing of components,
shortening or overtightening of the subscapularis, or insufficient
rehabilitation

• Soft-tissue balancing procedures to completely mobilize the

subscapularis in anatomic arthroplasty
• Excision of the anterior capsule and release of the rotator interval and
coracohumeral ligament may be required

• If the subscapularis is still tight, a Z-plasty lengthening in the frontal

plane

• 1 cm of lengthening equals approximately 20 degrees of increased

external rotation.
COMPLICATIONS OF REVERSE TOTAL
SHOULDER ARTHROPLASTY
• Notching of the scapula - 10% to 96%

• Inferior placement of the baseplate with inferior tilt are the two most
important factors to decrease notching.
Nerot classified - four grades, ranging from none to
notching severe enough to cause glenoid loosening
Instability
• 5%
• Muscle forces across the joint appear to be the primary determinant of
implant stability, and an irreparable subscapularis tendon

• Risk factors - male gender, history of prior open shoulder surgery, and
operative indication of fracture sequelae
Acromial stress fractures
• 4%

• Overlengthening of the deltoid at the time of reverse total shoulder

arthroplasty
 Surgical Technique (Hemiarthroplasty)
• Beach chair position to allow
positioning of the patient at the top and
edge of the table
• The medial border of the scapula
should be free and off the table,
allowing full adduction to gain access
to the intramedullary canal
• Make an incision anteriorly,
approximately one third to halfway
between the coracoid and the lateral
aspect of the acromion
• Prepare the humeral canal, using the humeral axis to reference the
osteotomy.

• Initially, open the canal with a high-speed burr at the base of the
rotator cuff footprint and ream it to a size where appropriate fit is felt

• Use a cutting guide that employs extramedullary referencing, using the

axis of the forearm as the reference point, with the cutting guide
pinned into position at 30 degrees of retroversion
• Confirm glenoid cartilage to provide an adequate bearing surface for
the metal humeral head

• Place a trial humeral head and reduce the glenohumeral joint using
internal rotation and gentle traction

• Perform a tight closure of the rotator interval and the subscapularis

Surgical Technique ( Total Shoulder
Arthroplasty)
• Expose the glenoid by placing a retractor on the posterior aspect of the
glenoid to sublux the humerus posteriorly

• Glenoid is not adequately exposed until the anterior, posterior,

superior, and inferior aspects of the glenoid can be seen

• Glenoid vault is debrided, make a centering hole, typically with a

guide
• Anchoring pegs or keel to provide secure fixation and reduce the risk
of loosening

• After cementing, insert the glenoid component and maintain thumb

pressure until the cement has hardened
Surgical Technique ( Reverse Total Shoulder
Arthroplasty)

• Cemented or uncemented or short stem in humeral component

• Glenoid starting point inferiorly 1 to 2 mm to allow inferior placement

of the baseplate and place the guide pin in 10 to 15 degrees of inferior
tilt, again to prevent scapular notching
• Ream the glenoid until the “smiley face” is achieved, with
bleeding cancellous bone inferiorly and hard sclerotic bone
superiorly

• Impact the baseplate and secure

it with screws
• Reduction and dislocation more difficult than the total shoulder arthroplasty

• Longitudinal traction and forward elevation on the arm

• 2 to 3 mm of gapping in the glenohumeral articulation once the joint is

reduced without loss of stability

• Subscapularis repair after reverse total shoulder arthroplasty remains

controversial
THANK YOU