Arthritis basics and managment copy
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This document discusses shoulder arthritis and its management. It begins by outlining the two broad types of arthritis - those with an intact rotator cuff and those with a torn rotator cuff. It then discusses the two broad types of shoulder replacements - anatomical and reverse geometry. Making the right diagnosis and assessment of bone stock, predicting rotator cuff failure, and performing a good surgery are key to avoiding complications. Trends in shoulder replacements over time and future projections are also presented.
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Arthritis basics and managment copy
- 1. Shoulder Arthritis and Management Puneet Monga Consultant Orthopaedic Shoulder Surgeon
- 2. Broadly 2 types of Arthritis RC Intact RC Torn
- 3. Shoulder replacements Broadly 2 types Anatomical Reverse geometry
- 6. Management • Early stages • Analgesia • Activity modification • Physiotherapy • Advanced • Joint Replacement
- 7. NJR 2015 = 1 replacement/ surgeon / month NJR 2016 = Median 13 replacements / surgeon /year
- 8. Trends; combined data from international shoulder registries- E Griffiths, P Monga 2016 Proportion of Shoulder Replacements by Type % anatomic %Reverse %Hemis FDA Approval for Reverse- 2003
- 9. Future projections- by 2030 Demand projected to increase by 755.4% Prediction of increased complication and revision load Clin Orthop Relat Res. 2015 Jun;473(6):1860-7. doi: 10.1007/s11999-015-4231-z. Epub 2015 Mar 11. Future patient demand for shoulder arthroplasty by younger patients: national projections. Padegimas EM1, Maltenfort M, Lazarus MD, Ramsey ML, Williams GR, Namdari S.
- 11. Increased use of TSR- Influence of training Surgeons with fellowship training in shoulder surgery are more likely to perform TSA over Hemi arthroplasty for OA
- 12. Guidelines - AAOS AAOS recommends TSR over HSA for GH OA 2011
- 13. Increased use of Reverse- Influence of training • Reverse for trauma • 2005 - 2% • 2007- 4% • 2012 - 38%
- 14. Increased use of Reverse- Influence of training • Shoulder Surgeons (fellowship trained) • 5 times more likely to use arthroplasty for fractures • 20 times more likely to use reverse
- 15. Future projections- by 2030 • Demand projected to increase by 333.3% in <55 year old pts • Demand projected to increase by 755.4% in >55 year old pts • Rate of hemiarthroplasty declining by 16% in < 55 year • Hence prediction of increased revision loadClin Orthop Relat Res. 2015 Jun;473(6):1860-7. doi: 10.1007/s11999-015-4231-z. Epub 2015 Mar 11. Future patient demand for shoulder arthroplasty by younger patients: national projections. Padegimas EM1, Maltenfort M, Lazarus MD, Ramsey ML, Williams GR, Namdari S.
- 17. • First recorded shoulder arthroplasty • 1893, Paén, Paris. • Tubercular arthritis • Rubber humeral head, Platinum shaft, attached with a wire. Further wire attached to Glenoid • Removed at 2 years Lugli T: Artificial shoulder joint by Péan (1893). The facts of an exceptional intervention and the prosthetic method. Clin Orthop 1978; 133: 215-218
- 18. • Themistocles Gluck • Romanian Surgeon in Germany • Second half of 19th Century • For tuberculosis • Ivory • Thought leader Gluck T: Referat über die Durch das moderne chirugishe Experiment gewonnenen positiven Resultate betreffend die Nacht und den Ersatz von defecten hoherer Gewebe sowie über die Verwertung resorbirbarer und lebendiger Tamons in der Chirurgie. Arch Klin Chir 1891; 41: 187- 239
- 19. First Generation • Monoblock implants • 1951 Kruger; Aseptic necrosis • 1953 Charles Neer Proximal humeral fractures (1953) • 1974 Total shoulder replacement for glenohumeral arthrtis (1974) Kruger FJ: A vitallium replica arthroplasty on the shoulder: a case report of aseptic necrosis of the proximal of the humerus. Surgery. 1951; 30: 1005-1011 Neer CS: Articular surface replacement for the humeral head. J bone Joint Surg Am 1955; 37: 215-228
- 20. Second generation • Modular Humeral head size • Did not cater to the variation in anatomy of the proximal humeral adequately
- 21. Third Generation • Anatomic study; Modeled proximal humerus on a sphere and a cylinder • Variability in • Humeral head diameter • Articular Surface diameter • Articular surface thickness • Inclination • Retroversion • Posterior offset • Medial offsetBoileau P, Walch G: Anatomical study of the proximal humerus: Surgical technique consideration and prosthetietic design rationale. Walch G, Boileau P(ed): Shoulder Arthroplasty. Berlin, Springer, 1999 Robertson DD, Yuan J, Bigliani LU, Flatow E, Yamaguchi K. Three-Dimensional Analysis of the Proximal Part of the
- 22. Third Generation • The Anatomic (adaptable) prosthesis. • Adapt the prosthesis to the patient • Neck Cut along the patient’s retroversion • Humeral head Diameter choices • Neck Shaft Angle choices • Offset variable and can be dialled in
- 23. Glenoid resurfacing • 1974 Neer CS. First report for GH arthritis • Keeled Rectangular • Cemented • Congruous articular surface Image courtesy: AAOS
- 24. Glenoid design • Convex back vs Flat back • Convex back • Bone preserving • Better resistance to shear forces • Lesser Radioluscent lines Anglin C, Wyss UP, Pichora DR: Mechanical testing of shoulder prosthesis and recommendation for glenoid design, J Shoulder Elbow Surg 2000; 9: 323-3331 Image Courtesy: IJSS
- 25. Glenoid design • Conforming vs non conforming • Conforming: minimise wear, stable • Non conforming: Lack of translation • 6 to10mm diameter mismatch optimum Image courtesy: Matsen et al J Bone Joint Surg Am. 2002 Dec;84-A(12):2186-91. The influence of glenohumeral prosthetic mismatch on glenoid radiolucent lines: results of a multicenter study. Walch G1, Edwards TB, Boulahia A, Boileau P, Mole D, Adeleine P.
- 26. Glenoid design • Keeled vs Pegged vs Fluted • Debate still open • Gartsmann et al-Pegged fewer radioluscencies • Gazielly D et al; Keeled better • Nuttall et al Fluted peg: high early looseningGartsman GM1, Elkousy HA, Warnock KM, Edwards TB, O'Connor DP.Radiographic comparison of pegged and keeled glenoid components. J Shoulder Elbow Surg. 2005 May-Jun;14(3):252-7. Nuttall D1, Haines JF, Trail IA The early migration of a partially cemented fluted pegged glenoid component using radiostereometric analysis. J Shoulder Elbow Surg. 2012 Sep;21(9):1191-6.
- 27. Glenoid design • Cemented vs Uncemented • Metal backed designs Issue: Glenoid Poly thickness • High failure rates with traditional prosthesis • ?Role in revision and Bone deficiency • ? Hybrid models Image Courtesy: Prof IA Trail 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. Boileau P, Avidor C, Krishnan SG, Walch G, Kempf JF, Molé D.
- 28. Getting It Right First Time
- 30. • Step 1 Using the Correct implant • Step 2 Assessment of Bone Stock • Step 3 Predicting Cuff failure • Step 4 Performing a good operation
- 31. Step 1 = Choosing the right Implant Evolution =
- 32. Broadly 2 types of Arthritis RC Intact RC Torn
- 33. Shoulder replacements Broadly 2 types Anatomical Reverse geometry
- 35. Modern humeral stem Kruger FJ: A vitallium replica arthroplasty on the shoulder: a case report of aseptic necrosis of the proximal of the humerus. Surgery. 1951; 30: 1005-1011 Neer CS: Articular surface replacement for the humeral head. J bone Joint Surg Am 1955; 37: 215-228 Boileau P, Walch G: Anatomical study of the proximal humerus: Surgical technique consideration and prosthetietic design rationale. Walch G, Boileau P(ed): Shoulder Arthroplasty. Berlin, Springer, 1999
- 36. Glenoid design • Convex back vs Flat back • Conforming vs non conforming Anglin C, Wyss UP, Pichora DR: Mechanical testing of shoulder prosthesis and recommendation for glenoid design, J Shoulder Elbow Surg 2000; 9: 323-3331J Bone Joint Surg Am. 2002 Dec;84-A(12):2186-91. The influence of glenohumeral prosthetic mismatch on glenoid radiolucent lines: results of a multicenter study. Walch G1, Edwards TB, Boulahia A, Boileau P, Mole D, Adeleine PGartsman GM1, Elkousy HA, Warnock KM, Edwards TB, O'Connor DP.Radiographic comparison of pegged and keeled glenoid components. J Shoulder Elbow Surg. 2005 May-Jun;14(3):252-7.Nuttall D1, Haines JF, Trail IA The early migration of a partially cemented fluted pegged glenoid component using radiostereometric analysis. J Shoulder Elbow Surg. 2012 Sep;21(9):1191-6. Gazielly D, El-abaid R: comparitive results of three types of polythelene cemented glenoid componenets. Recul de 2 à 10 Ans. Paris, Sauramps Medical, 2001, 483-488 Image Courtesy: IJSS Image courtesy: Matsen et al • Keeled vs Pegged vs Fluted • Cemented vs Uncemented “Convex Back, Non conforming, cemented All-poly pegged”
- 37. Reverse geometry • Many unsuccessful attempts at reverse geometry • Paul Grammont 1985 pioneered new generation reverse Grammont’s Idea The Story of Paul Grammont’s Functional Surgery Concept and the Development of the Reverse Principle Emmanuel Baulot MD, Franc¸ois Sirveaux MD, Pascal Boileau MD Clin Orthop Relat Res (2011) 469:2425–2431
- 38. Glenoid Notching
- 40. Notching solution- Offset Increasing offset - bone / metal
- 42. Step 2- Assessment of Bone Stock
- 44. Assessing the Glenoid • CT • 3D printing • PSI
- 45. Current Imaging
- 46. “3D Printing represents a quantum jump in defining and assessing Orthopaedic osteology” - Al Najjer, Monga; June2014
- 48. Custom Jig
- 49. 3D Printed Custom Implant Puneet Monga Wrightington Hospital
- 50. Implantation
- 51. Step 3- Predicting Cuff Failure
- 52. RA- Cuff failure/ loose Glenoid
- 54. Predicting cuff failure • Anatomical TSR in young pt with debatable cuff quality? • Anatomical TSR in cuff intact Patients > 80 years ? Gazielly DF, Scarlat MM, Verborgt O. Long-term survival of the glenoid components in total shoulder replacement for arthritis. Int Orthop. 2015 Feb;39(2):285-9. doi: 10.1007/s00264-014-2637-y. Epub 2014 Dec 24.
- 55. Step 4- Performing a good operation
- 56. Better outcomes in high volume centres / surgeons Jain N, Pietrobon R, Hocker S, et al; The relationship between surgeon and hospital volume and outcomes for shoulder arthroplasty. J Bone Joint Surg Am. 2004 Mar;86-A(3):496-505. Hammond JW, Queale WS, Kim TK, et al; Surgeon experience and clinical and economic outcomes for shoulder arthroplasty. J Bone Joint Surg Am. 2003 Dec;85-A(12):2318-24.
- 59. Bone Loss / Revision
- 61. “No Object is so beautiful that, under certain conditions, it will not look ugly” - Oscar Wilde