Current Concepts in Shoulder Replacement
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J.R. Rudzki gave a presentation on current concepts in shoulder replacement. He discussed the anatomy of the shoulder joint and causes of shoulder arthritis. Treatment options were reviewed, including arthroplasty when conservative measures fail. Surgical techniques for hemiarthroplasty and total shoulder arthroplasty were outlined. Clinical studies showed that both procedures improve function, though total arthroplasty may provide better outcomes. Complications were noted to occur in about 5% of cases. Emerging concepts around reverse total shoulder arthroplasty for rotator cuff arthropathy were presented.
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Current Concepts in Shoulder Replacement
- 1. 1 J.R. Rudzki, MD, MSc Washington Orthopaedics & Sports Medicine Clinical Assistant Professor Dept. of Orthopaedic Surgery George Washington University School of Medicine Washington, DC Current Concepts In Shoulder Replacement
- 2. Disclosure Previous direct & indirect funding & support for research & education from: • Philips Medical Imaging • Bristol-Myers-Squib • Smith & Nephew • NIH (CT Chen) • HSS Institute for Sports Medicine Research • Major League Baseball Arthrex – Consultant AJSM, JBJS – Reviewer AAOS – Evaluation Committee
- 3. Shoulder Joint • Minimally constrained ball-and-socket joint • Mobility Stability Anatomy • Static Stabilizers • Joint surfaces • Capsulolabral complex • Dynamic Stabilizers • Rotator cuff • Scapular stabilizer muscles
- 4. Glenohumeral Ligaments (static stabilizers) Structural thickenings of capsule •Superior: supraglenoid tubercle •Middle: glenoid or labrum LT •Inferior: neck/labrum LT Anatomy
- 5. • Supraglenoid / superior labral origin • Function = Controversial • Commonly degenerated in patients with shoulder arthritis Long Head Biceps Tendon Anatomy
- 6. What is shoulder arthritis? Degenerative condition of progressive cartilage wear: • Inflammation • Pain • Stiffness • Motion Loss Impaired Function
- 7. What does shoulder arthritis look like? Narrowing of Joint Space: - From cartilage wear Bone Spurs: - From cartilage wear & articulation of bone-on bone Ligament Contracture: - From inflammation & motion loss Progressive Deformity: - Erosion of socket
- 9. What are the treatment options for shoulder arthritis? Anti-Inflammatory Medications Ice & Activity Modification Cortisone Injections Synthetic Lubricant Injection ??? Reduce Pain & Inflammation
- 11. Background Goals: • Pain Relief • Optimal Shoulder Function Technical Points: • Restore Proximal Humeral & Glenoid Anatomy • Balance Soft Tissues > 7000 Shoulder Arthroplasties performed annually in U.S.
- 12. 128 shoulders studied at 3-5 year follow-up Avg # shoulder fxns that performable improved from 4/12 preop to 9/12 Function improved in ninety-six shoulders (94%). The better the preoperative function, the better the follow-up function. On average, pts regained ~ 2/3rds of the functions absent preop. 73% chance of regaining a fxn that was absent before surgery chance of losing a function present before surgery was 6%. Matsen et al., JBJS, 2002 How well does it work?
- 13. Both total shoulder arthroplasty & hemiarthroplasty improve disease- specific & general quality-of life measurements two years after surgery.
- 14. Operating Room • Regional Anesthesia • Beach Chair Position • Space Suits • IV Antibiotics
- 15. Incision & Approach •Between Deltoid & Pectoralis Muscles
- 17. Removal of osteophytes Exposure of Humeral Head
- 18. Cutting the Humerus • Version • Neck Shaft Angle • External guide • Anatomic landmarks
- 19. Anterior and inferior capsular release on the glenoid side (glenoid exposure) Exposing the Glenoid Socket
- 20. Glenoid Insertion • Hemostasis, pressurization
- 24. Hemiarthroplasty vs. Total Shoulder Arthroplasty Gartsman, et al. - Prospective Randomized Study in 51pts w/ OA & Intact Rotator Cuff Mean Follow-Up = 35 months (r: 24-72 mos) Signficant Improvements in: Pain Relief Internal Rotation TSA Group P < 0.05 Patient Satisfaction, Fxn, Strength Not statistically significant No revisions from TSA cohort at mean 35 month follow-up Three hemiarthroplasties required revision for glenoid resurfacing (12%) Bryant et al, JBJS 2005 JBJS 2000 Data further substantiated by recent JBJS Meta-analysis
- 25. Hemiarthroplasty vs. Total Shoulder Arthroplasty Total Shoulder = Excellent Operation for appropiately indicated patients Why not for everyone with glenohumeral OA? Primary concern affecting longevity Glenoid Loosening Current Kapplan-Meier Survivorship Data is comparable to Hip & Knee arthroplasty and appears to represents an effective, durable procedure. Significant Potential Problem Metal-Backed Glenoid Components Cemented Poly Components Deshmukh et al., JSES 2005
- 26. Associated with: • Prosthetic component mismatch • Mechanical wear of polyethylene components • Osteolysis (stress shielding) with metal components • Component malpositionin • Poor bone stock • Rotator cuff deficiency Glenoid Loosening Glenoid Fixation Nyffeler & Gerber et al, JSES 2006
- 27. Anatomic Considerations Glenoid Version Glenoid erosion & excesive retroversion can induce: • distorted anatomy • posterior luxation • may contribute to posterior capsular laxity • require restoration of near normal version for appropriate glenoid component seating & stability Why is glenoid erosion a challenge & what do we do about it?
- 28. 3-Dimensional CaT Scan Reconstruction
- 29. Glenoid Retroversion & Excessive Posterior Wear Glenoid Version • Preop Axillary Plain Film How do we identify it? • Preop MRI • Preop CT Scan (Pacemaker) Clinical Assessment at Time of Surgery Consider role of glenoid version in cases of difficult exposure despite appropriate releases
- 30. Complications • Anterosuperior Escape • Infection • Tuberosity Migration / Nonunion • Glenoid Erosion / Loosening • Nerve Injury • Subscap Repair Failure Estimated mean complication rate = ~5% • Pseudoparalysis
- 31. Emerging Concepts 191 reverse TSA followed for avg 40 months • Avg Constant score improved from 23 to 60 points • 173 of the 186 patients were satisfied or very satisfied • Patients with: • Primary rotator cuff tear arthropathy • Primary osteoarthritis with a rotator cuff tear • Massive rotator cuff tear had better outcomes • Complications = ~12% • Dislocation (15 cases) & infection (8 cases) were the most common complications JBJS 2007
- 32. Emerging Concepts 80 reverse TSA followed for minimum 5 yrs Survival rate with replacement or glenoid loosening were 91% & 84%, respectively, at 120 months. Shoulders that had arthropathy with a massive rotator cuff tear demonstrating a significantly better result than those that had a disorder with another etiology (p < 0.05). JBJS 2007
- 33. Emerging Concepts 80 reverse TSA followed for minimum 5 yrs A second break started at ~ 6 years & reflected progressive deterioration of the functional result. Conclusions: Reverse total prosthesis should be reserved for treatment of very disabling shoulder arthropathy with massive rotator cuff rupture, & it should be used exclusively in patients over 70 years-old with low functional demands. JBJS 2007
- 34. 78 year-old female with Rotator Cuff Arthropathy
- 35. Case Example: 85 y/o Female Malunion
- 36. Current Concepts in Shoulder Arthroplasty J.R. Rudzki, MD, MSc Washington Orthopaedics & Sports Medicine Clinical Assistant Professor Dept. of Orthopaedic Surgery George Washington University School of Medicine Washington, DC Thank You
- 37. February 19, 2014 37 J.R. Rudzki, MD, MSc Washington Orthopaedics & Sports Medicine Clinical Assistant Professor Dept. of Orthopaedic Surgery George Washington University School of Medicine Washington, DC Current Concepts In Shoulder Replacement Thank You