Tuesday, 8th September 2020
SHOULDER ARTHROPLASTY
TYPES - INDICATION - REHABILITATION
Case Report
A 63-year-old male, retired electrician, presented to accident and emergency
following electric shock.
He had bilateral burns to the hands, full thickness in places and painful, stiff
shoulders.
There was no other injury noted at that time and no neurovascular deficit was
documented.
He was referred to the plastic surgeons regarding the burns
X-rays (Fig. 1) of the shoulders showed bilateral, comminuted, displaced proximal
humeral fractures.
He had a CT scan of both shoulders (Fig. 2) which confirmed bilateral posterior four-
part fracture— dislocations.
Cooke, Stephen & Hackney, Roger. (2005). Bilateral posterior four-part fracture–dislocations of the shoulders following electric shock: A case report and
literature review. Injury Extra. 36. 90–95. 10.1016/[Link].2004.08.025.
Cooke, Stephen & Hackney, Roger. (2005). Bilateral posterior four-part fracture–dislocations of the shoulders following electric shock: A case report and
literature review. Injury Extra. 36. 90–95. 10.1016/[Link].2004.08.025.
Cooke, Stephen & Hackney, Roger. (2005). Bilateral posterior four-part fracture–dislocations of the shoulders following electric shock: A case report and
literature review. Injury Extra. 36. 90–95. 10.1016/[Link].2004.08.025.
Case Report
Five days following admission he underwent bilateral shoulder hemiarthroplasties
(Neer prosthesis).
Post-operatively he was immobilized in poly-slings for 1 week after which passive
mobilisation with the physiotherapists was commenced.
At 4 weeks he started assisted-active mobilisation progressing to active after 2
months.
Post-operative X-rays are shown in Fig. 3.
Cooke, Stephen & Hackney, Roger. (2005). Bilateral posterior four-part fracture–dislocations of the shoulders following electric shock: A case report and
literature review. Injury Extra. 36. 90–95. 10.1016/[Link].2004.08.025.
Cooke, Stephen & Hackney, Roger. (2005). Bilateral posterior four-part fracture–dislocations of the shoulders following electric shock: A case report and
literature review. Injury Extra. 36. 90–95. 10.1016/[Link].2004.08.025.
Case Report
At 3-month follow-up his pain had significantly decreased.
Active abduction was to 60o on the right and 80o on the left.
He was having difficulty in operating above shoulder height.
Physiotherapy was continuing and it was advised to increase exercised to maximise
strength and range of movement.
There was no loss of power on examination.
Cooke, Stephen & Hackney, Roger. (2005). Bilateral posterior four-part fracture–dislocations of the shoulders following electric shock: A case report and
literature review. Injury Extra. 36. 90–95. 10.1016/[Link].2004.08.025.
INTRODUCTION
The primary goals of shoulder arthroplasty are to provide pain relief,
stability, and restore motion (Bogdan A. Matache, P. Lapner)
Advisability and specific procedure 4P:
Problem (include: bone, deltoid, cuff, nerve, and skin tissues)
Patient (Rehabilitation, Comorbid, etc)
Physician (“The surgeon is the method,” and “Experience is
the great teacher”)
Procedure (the problem, patient, and physician)
Rockwood and Matsens The Shoulder
Prosthetic
Resurfacing
TYPES
Biology
Hemiarthroplasty Resurfacing
Total Shoulder
Arthroplasty
Reverse Total
Shoulder Arthroplasty
Rockwood and Matsens The Shoulder, Orthobullets offline
HEMIARTHROPLASTY
Replacing only humeral articular surface
Prosthetic Resurfacing: humeral head arthroplasty with a non-stemmed, metal
prosthesis
Biologic Resurfacing (interpositional allografting/Ream and run
arthroplasty): Concept of putting soft tissue in glenoid to reduce symptoms
Rockwood and Matsens The Shoulder, Orthobullets offline
HEMIARTHROPLASTY
Rockwood and Matsens The Shoulder
HEMIARTHROPLASTY
Primary arthritis
Deficient rotator cuff
Glenoid intact
Rotator cuff arthropathy
Osteonecrosis without glenoid involvement
Proximal humerus fracture
Rockwood and Matsens The Shoulder, Orthobullets offline
HEMIARTHROPLASTY
Prosthetic Resurfacing Biologic Resurfacing
Abnormal anatomy Young patients
Rotator cuff arthropathy
Dysplasia Glenohumeral narrowing following
- Developmental hemiarthroplasty
- Secondary
Glenohumeral arthritis following
arthroscopic stabilization procedures
Fracture
- Proximal malunion
- Stem implantation block
Facia lata
Meniscal Allograft
Achilles Allograft
Acellular Dermal Matrix
Orthobullets offline
TOTAL SHOULDER ARTHROPLASTY
Humeral hemiarthroplasty combined with a prosthetic glenoid component
Rockwood and Matsens The Shoulder
TOTAL SHOULDER ARTHROPLASTY
Pain and inability perform activities of daily living
Posterior humeral head dislocation
Glenoid chondral wear
Rotator cuff intact and functional
Rockwood and Matsens The Shoulder, Orthobullets offline
TOTAL SHOULDER ARTHROPLASTY
Sanchez-Sotelo J. (2011). Total shoulder arthroplasty. The open orthopaedics journal, 5, 106–114. [Link]
REVERSE
TOTAL SHOULDER ARTHROPLASTY
Convex glenoid (hemispheric ball) and concave humerus (articulating
cup) to reconstruct the glenohumeral joint
Porous-coated
baseplate
Humeral PE
Socket
Humeral Glenosphere
stem
Miller's Review of Orthopaedics, 6th ed
REVERSE
TOTAL SHOULDER ARTHROPLASTY
Clinical Condition Patient Characteristic
CTA (cuff tear arthropaty) Low functional demand
Pseudoparalysis Sufficient glenoid bone stock
Antero-superior escape Working deltoid muscle
Acute 3 or 4-parts proximal humerus Physiological age >70
fracture in elderly
Rotator cuff insufficiency
Failed arthroplasty
Rheumatoid arthritis
Orthobullets offline
Wong, T. T., & Kazam, J. K. (2016). Shoulder Arthroplasty , from In- dications to
Complications : What the Radiologist Needs to Know 1. 192–208.
REHABILITATION
Goal is a 150-degree range of assisted elevation prior to hospital discharge
Immediately after
surgery
WHEN??
On the day of
surgery
under instructions given by the surgeon or
Rockwood and Matsens The Shoulder
REHABILITATION
First 36 hours after surgery
Prevents adhesions
Squeeze ball to reduce swelling
Rockwood and Matsens The Shoulder
REHABILITATION
Rockwood and Matsens The Shoulder
REHABILITATION
6 weeks
5 times a day
Warn for ecchymosis (subsides in 2 weeks) Rockwood and Matsens The Shoulder
REHABILITATION
Rockwood and Matsens The Shoulder
REHABILITATION
Rockwood and Matsens The Shoulder
REHABILITATION
After 6 weeks
Strengthening exercise
Starting with 1 lbs until 2 lbs
Rockwood and Matsens The Shoulder
REHABILITATION
Repeat strengthening 20 times
Slow and steady
Added progressively
Golf and tennis may started 3 – 6 months
Avoid impact activity
Follow up progress to successful rehabilitation
Rockwood and Matsens The Shoulder
QUESTION AND ANSWER
A 60-year-old man has chronic shoulder pain and weakness.
Radiographs show moderate glenohumeral arthritis and narrowing of
the acromio-humeral distance. He is scheduled to undergo either
hemiarthroplasty or total shoulder arthroplasty. His postoperative
function will be most affected by which of the following factors?
1. The integrity of the rotator cuff
2. The integrity of the coracoacromial ligament
3. The presence of glenoid wear
4. The presence of an inferior head osteophyte
5. The extent of AC joint arthritis
1. The integrity of the rotator cuff
With conventional arthroplasty, the functional outcomes are dependent
on the integrity of the rotator cuff. Narrowing of the acromio-humeral
distance indicates superior migration of the humeral head which is
often seen in cases of rotator cuff deficiency. Further imaging studies
such as an MRI or CT arthrogram may be indicated to evaluate the
status of the rotator cuff. If there is an irrepairable rotator cuff tear,
total shoulder arthroplasty is contra-indicated. In that case, the
treatment options include hemiarthroplasty (with limited functional
outcomes) or more recently, reverse total shoulder arthroplasty
A 62-year-old man complains of shoulder pain for 2 years. He has had 1 course of intra-
articular sodium hyaluronate and 6 weeks of physical therapy with little relief.
Examination reveals diminished arm flexion and abduction secondary to pain. Radiographs
of his shoulder are shown in Figures A and B. According to the American Academy of
Orthopaedic Surgeons Clinical Practice Guidelines, what is the next best step?
1. Humeral head replacement
arthroplasty
2. Hemiarthroplasty and ream-and-run
glenoid procedure
3. Cuff tear arthropathy (CTA) prosthesis
4. Total shoulder arthroplasty with a
metal-backed cemented glenoid
component
5. Total shoulder arthroplasty with an
all-polyethylene cemented glenoid
component
5. Total shoulder arthroplasty with an all-
polyethylene cemented glenoid
component
This patient has end-stage glenohumeral osteoarthritis (GH OA). According to the
AAOS CPG, total shoulder arthroplasty (TSA) is recommended using an all-
polyethylene cemented glenoid component.
TSA is indicated for cases of end-stage GH OA. It is preferred to hemiarthroplasty. It
is contraindicated in cases with insufficient glenoid bone stock (glenoid wear to the
level of the coracoid), rotator cuff arthropathy or irreparable cuff tears and deltoid
dysfunction. It provides good pain relief and has good survival at 10 years (>90%)
Which of the following is considered a contraindication to
the use of a reverse total shoulder arthroplasty?
1. Prior shoulder joint infection
2. Pseudoparalysis
3. Prior partial acromioplasty
4. Absent glenohumeral joint space narrowing
5. Axillary neuropathy
5. Axillary neuropathy
The reverse total shoulder arthroplasty depends on a functional deltoid muscle which
is innervated by the axillary nerve to restore elevation for the patient.
Pseudoparalysis is an indication for a reverse shoulder arthroplasty. Acromioplasty
has not been correlated with poor results with a reverse shoulder arthroplasty. As
long as the patient does not have an active infection, prior infections are not a
contraindication. Patients can still have pain and pseudoparalysis from a chronic
rotator cuff tear, despite having normal cartilage, and they will still benefit from a
reverse total shoulder arthroplasty if other treatments have failed
THANK
YOU
