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Total Shoulder Arthroplasty | Reverse Shoulder Replacement | South Windsor, Rocky Hill, Glastonbury CT
- 1. Total Shoulder Arthroplasty JAMES T MAZZARA, MD ORTHOPEDIC ASSOCIATES OF HARTFORD CONNECTICUT JOINT REPLACEMENT SURGEONS, LLC CONNECTICUT JOINT REPLACEMENT INSTITUTE BONE AND JOINT INSTITUTE EASTERN CONNECTICUT HEALTH NETWORK
- 2. Contact Information James T Mazzara, MD Orthopedic Associates of Hartford, PC 29 Haynes Street Manchester, CT 06040 _________________ 150 Enterprise Drive Rocky Hill, CT 06067 860-649-2267 www.HartfordSportsOrthopedics.com
- 3. The Shoulder Complex Deltoid Muscle Pectoralis Clavicle (Collar Bone)
- 4. The Shoulder Complex Deltoid muscle removed
- 7. Coracoacromial Arch Acromion & CA ligament Protective arch over the GH joint Secondary restraint for the humeral head
- 8. Scapula to Humerus, Radius, Ulna Move & stabilize the shoulder complex Deltoid Supraspinatus Infraspinatus Teres Minor Subscapularis Teres major Coracobrachialis Biceps Triceps
- 9. Scapulothoracic Muscles Serratus anterior Trapezius Rhomboids Pectoralis minor Levator scapulae
- 10. Humerus to Trunk Muscles Latissimus dorsi Pectoralis major (sternal head)
- 11. Rotator Cuff Supraspinatus Active in any elevation Stabilizes the GH joint Suprascapular nerve (C5, someC6)
- 12. Rotator Cuff Infraspinatus Depressor of the humeral head Stabilizer against posterior subluxation 60% or external rotation force Suprascapular nerve (C5, some C6)
- 13. Rotator Cuff Teres Minor 45% of external rotation force Posterior branch of the axillary nerve (C5-C6)
- 14. Rotator Cuff Subscapularis Anterior stability Internal rotation Depression of humeral head Compression of the glenohumeral joint Upper and lower subscapular nerves (C5-C6)
- 15. Bursa Subacromial and subdeltoid bursa Coalesce to form one bursa Lubricate motion between rotator cuff and overlying CA arch
- 16. Rotator Cuff Balance Proper function depends upon balance between all muscle and ligament forces around the shoulder
- 17. Tendon Degeneration Age-related changes Decreased vascularity at the cuff insertion Fragmentation of tendon with loss of cellularity Disruption of tendon bone attachment
- 18. Consequences of rupture Retracted cuff fibers place additional tension on remaining microcirculation compromising cuff viability Increasing amounts of tendon are exposed to joint fluid which prevents tendon healing
- 19. Full Thickness Tears Loads are concentrated at the margins of the tear Further tearing occurs with smaller loads Partial tears become complete Anterior supraspinatus tears extend posteriorly
- 20. Incidence of Rotator Cuff Tears MRI Partial and complete RC tear 4%, < 40 yo 54%, > 60 yo Ultrasound Partial and complete RC tear 13%, >40 yo 20%, >50 yo 31%, >60 yo 51%, > 80 yo Over 50% asymptomatic RC tears become symptomatic and progress over 3 years Sports Med Arthrosc Rehabil Ther Technol. 2012; 4: 48.
- 21. Progressive Tearing Spacer effect of the cuff is lost Humeral head displaces superiorly Biceps tendon hypertrophies then ruptures Biceps may dislocate medially if the transverse humeral ligament tears
- 22. Early Cuff Failure Compression of the humeral head is less effective Deltoid pulls head upward Upward pull of the deltoid results in cuff abrasion & further cuff damage
- 23. Chronic Cuff Failure Humeral head articulates with the CA arch Secondary joint disease occurs called cuff tear arthropathy
- 24. Rotator Cuff Tear Arthropathy Massive cuff tears lead to joint degeneration
- 25. Chronic Rotator Cuff Tears Muscle atrophy Fatty infiltration of muscle belly Tendon retraction Bone osteoporosis Loss of muscle and tendon excursion Irreversible Progressively worse
- 26. Radiographs Acromial shape Position of humeral head AC arthritis Calcific tendinitis Glenohumeral arthritis Destructive lesions
- 27. 1 & 2: AP in Scapular Plane 2 Views: IR, ER Calcium deposits Greater tuberosities: excrescences, cysts
- 28. 3: Axillary View Evaluate GH joint & tuberosities Glenoid version Joint space narrowing Os acromiale
- 29. 4: Outlet View Evaluate subacromial space Acromial shape and thickness
- 30. 5: 30O Caudal Tilt View AP view with a 30O caudal tilt Demonstrates anterior acromial projection Bone spurs
- 31. Rotator Cuff Imaging MRI 90% accurate in diagnosing complete RC tears 70% accurate in diagnosing partial RC tears
- 32. CT Scan Horizontal or transverse plane 3D imaging of the shoulder Glenoid bone loss Glenoid version
- 33. MRI Evaluate status of rotator cuff Intact or torn Size of tear if present Repairable or not Presence of atrophy in the muscle Percentage of fatty infiltration
- 34. Native Glenoid Highly variable anatomy Size, inclination, version Version 2 degrees retroversion 12 degrees anteversion to 14 degrees retroversion
- 35. Prevalence of Shoulder Arthritis Affects 20% of population over 65 yo Incidence of joint replacement Hip > Knee > Shoulder Of 1.07 million joint replacements in 2004 4% (43,000) were total and reverse total shoulders Shoulder OA is third most common large joint Usually diagnosed in later stages Non weight bearing joint Earliest stages are found arthroscopically 4-17% in routine shoulder arthroscopy
- 36. Causes of Shoulder Arthritis Aging related delay in repair Biochemical changes, change in water content collagen degradation Abnormal joint loading Compression, Overloading, Wear and tear Joint stabilization surgery Created excessing anterior tightness Thermal capsular shrinkage, Bupivacaine or Lidocaine infusion pump
- 37. Causes of Shoulder Arthritis Inflammatory arthritis Trauma and articular injury Instability and dislocation Single shoulder dislocation: 19 times higher risk Osteonecrosis Idiopathic Chronic steroids, Radiation (breast cancer), excessive alcohol, sickle cell, medication
- 38. Causation of Arthritis and RC Tears Age (degeneration) and acromial morphology (Impingement) contribute to cuff tears Incidence of tears is low before 40 yo. Incidence increases in 50-60 yo & increases with age RCT must to a certain extent be considered as normal degeneration Not all tears cause pain and impairment Many cuff tears occur in 50-60 yo, with sedentary life style and no history of injury or heavy labor 40% of those w/ cuff tears have never done strenuous work Cuff defects are frequently bilateral Many heavy laborers never get cuff tears
- 39. Osteonecrosis Osteonecrosis / Avascular Necrosis Idiopathic Post-traumatic Anatomic neck fractures Steroid or Alcohol Use
- 40. Contraindications to TSR Active infection Neuroarthropathy Insensate joint Paralysis of musculature Neurologic
- 41. Anatomic Shoulder Replacement Indications Arthritis Osteonecrosis Neurologically intact Intact rotator cuff Anatomic Shoulder Reverse Total Shoulder
- 42. Contraindications to Glenoid Implantation Relative Contraindications Age <50 yo High functional demand Significant bone loss Rotator cuff dysfunction
- 43. Contraindication to Anatomic TSR Humeral head escapes though defect in Coraco-acromial through deltoid Acromioplasty with ligament release Anatomic shoulder arthroplasty will fail Deficient rotator cuff Unable to elevate arm Glenoid loosening Only option is a reverse TSR Must have functional deltoid Sufficient bone
- 44. Total Shoulder Arthroplasty First done in 1974 First Total shoulder with glenoid resurfacing Overall 93% survivorship at 10 years 87% survivorship at 15 years
- 45. Anatomic Glenoid Component Most common longer term complication Loosening 24% of all long term complications Implant design Technique Patient characteristics Rotator cuff integrity Indolent infection
- 46. Hemiarthroplasty Outcomes without Glenoid Resurfacing 60% dissatisfied at 15 years Risk of revision 4 times greater than TSR with glenoid Ream and Run Develop fibrocartilage layer on glenoid 20 months to achieve acceptable pain relief Best in men >60 yo Allograft resurfacing
- 47. Glenoid Failure Higher in patients with higher functional requirements Higher with rotator cuff tears
- 48. Glenoid Failure Progressing lucent lines Rocking horse phenomenon Glenoid is edge loaded Retroverted glenoid Superior inclination Joint instability Rotator cuff tear Due to inflammatory reaction related to wear particles of metal or polyethylene
- 49. Humeral Component Shorter stems preserve more bone Press fit, no cement May lead to early loosening Lucent lines seen around implant in 22% at 3 years
- 50. Stemless Humeral Component 83% humeral component survival at 20 years Failure due to periprosthetic fracture Loosening of stems
- 51. Problems with Stemless Design
- 56. Complications of Anatomic TSR Periprosthetic fractures 1.6 – 2.3% Infection 0 – 4% Instability 0.9 – 1.8% Rotator cuff tear 1.3 – 7.8% Glenoid loosening 8% Most do not require revision Neuropraxia 0.6 – 1.6% Mostly axillary nerve or brachial plexus
- 57. Outcomes of TSR, <65 yo Systematic Review (Meta analysis) Patients younger than 65 yo 9.4 years 17.4% underwent revision (52% of these for glenoid loosening) 54% glenoid loosening 60 – 80% implant survivorship 10 – 20 years Results in younger patients are not as good as overall TSA population BUT better than pre op JSES July 2017Volume 26, Issue 7, 1298–1306
- 58. Outcomes of TSA on Younger Patients Ages 37 – 60 yo, mean age 55 yo 13 year follow up 21 patients 2 shoulder revised 2 recommended revisions Without revision 95% good or very good results Increased glenoid radiolucent line over time Bone Joint J. 2017 Jul;99-B(7):939-943
- 59. Reverse Total Shoulder Arthroplasty Indications Pain with cuff tear arthropathy Failed hemiarthroplasty with irreparable cuff tear Pseudoparalysis (Loss of motion) Impaired function 3 and 4 part shoulder fractures in older patients, >70 yo Non union of shoulder fracture Severe rheumatoid arthritis
- 60. Reverse Shoulder Arthroplasty Intact deltoid Sufficient bone
- 62. Complications of Reverse TSR Scapular notching Infection Dislocation Component instability / loosening Acromial fracture Hardware failure Nerve damage Intraoperative fracture Heterotopic ossification
- 63. Reverse Shoulder Replacements Left hemiarthroplasty for fracture, Tuberosity nonunion, nonfunctional rotator cuff Revised w/ proximal humeral replacement, Reverse TSR, bone grafted humerus
- 64. Reverse Shoulder Replacements Nonunion, malunion anatomic neck fracture Revised to Reverse TSR
- 65. Reverse Shoulder Replacements Osteonecrosis humeral head. Old fracture repair Revised to Reverse TSR. Post op fall and fracture required ORIF humeral shaft
- 66. Long term Outcomes: RTSR, in <60 yo, RCT 23 shoulders, mean age 57 yo Improved pain and function Improved motion and strength Sustained beyond 10 years Results we equal in those who had previous surgery and those who did not Notching increased over time 39% complication rate 2 failed RTSA J Bone Joint Surg Am. 2017 Oct 18;99(20):1721-1729
- 67. RTSA and RTW Outcomes Non Workers Comp 40 patients, 56-82 yo Average RTW: 2.3 months, 0.5 – 11 months Average 1.4 months sedentary work Average 4.0 months light work 96.2% good to excellent outcomes 5% retired related to shoulder limitations No patients involved in moderate to heavy work No patients had workers compensation claims Orthopedics. 2016;39(2):e230-e235
- 68. RTSA & RTW in Workers Comp Patients 14 patients, average age 61 yo 14% RTW rate for WC claim group 45.5% RTW rate in non WC group J Shoulder Elbow Surg. 2015; 24(3):453–459.
- 69. Reverse TSA Complications Complication # of shoulders Definitive Treatment Persistent stiffness 1 Nonoperative Persistent pain 1 Arthroscopic debridement Mechanical block 1 Arthroscopic removal of avulsed tuberosity Early dislocation (<6w) 1 Open reduction. Liner exchange Late dislocation 3 Closed reduction. Open reduction and liner exchange Glenoid component dissociation 1 Conversion to hemiarthroplasty Infection 2 Debridement & liner exchange. Removal of prosthesis, cement spacer
- 70. Post op TSR Out patient or Overnight Certain payers permit TSR at Ambulatory Surgery Center Medicare will not Pain medications 1-3 weeks May need meds before therapy 3 weeks May use arm out of sling for light ADL 6 weeks Out of sling full time Use arm as tolerated Still have stiffness and weakness
- 71. Post Op Rehabilitation Arm immobilizer, up to 6 weeks Passive motion 1-4 weeks Active assisted motion 4-6 weeks Active motion, stretching 6-10 weeks Strengthening 10-12 weeks Therapy 3-4 months (3x/w to 1x/w) 1 year home exercises Motion improves up to 2 years Maximal Medical Improvement I year More like 2 years
- 72. Ability to work Risk of injury Gradual transitional return to work Capacity improves over time Work capacity is not work tolerance Accommodations by employer RTW, no use of shoulder: 2-6 weeks Use shoulder for reaching, ADL, gradual lifting: 6-12 weeks More reaching and lifting: 12-26 weeks Long term restrictions 50 pounds max lift. 25 pounds overhead lift
- 73. Return to sports: Surgeon Survey No restrictions on nonimpact sports Sports with light upper extremity impact Golf, aerobics, swimming Allowed after TSR and with experience for RTSR Sports with fall potential Tennis, skiing, basketball, soccer Allowed after TSR, undecided not allowed after RTSR High impact sports Weightlifting, waterskiing, volleyball Undecided after TSR. Not allowed after RTSR J Shoulder Elbow Surg. 2011 Mar;20(2):281-9. doi: 10.1016/j.jse.2010.07.021. Epub 2010 Nov 4. Long-term activity restrictions after shoulder arthroplasty: an international survey of experienced shoulder surgeons. Magnussen RA1, Mallon WJ, Willems WJ, Moorman CT 3rd.
- 74. Impairment Ratings , AMA guides, 6th ed Implant with normal motion 20 – 25% UE Resection with normal motion 26 – 34% UE Complicated, Unstable, Infected 34 – 46% UE
- 77. Thank You 90 years old