肩关节置换剖析课件

Shoulder ArthroplastyDaniel PenelloUpper Extremity RoundsApril 26,2006Shoulder ArthroplastyDaniel Pe1oLesions of the shoulder requiring arthroplasty are much less common than lesions involving the weight-bearing joints of the body,such as the hip and knee.Lesions of the shoulder requir2肩关节置换剖析课件3The ShoulderoGreatest ROMoNo inherent bony stabilityoRelies on soft tissues for stabilityoMany injuries involve the soft tissues(rotator cuff,labrum)oLittle glenoid bone stockThe ShoulderGreatest ROM4Indications for Shoulder ArthroplastyoOsteoarthritisoRheumatoid arthritisoRotator cuff tear arthropathyoAvascular necrosis oPost-traumatic arthritisoSevere proximal humeral fracturesIndications for Shoulder Arthr5HemiarthroplastyTotal ShoulderReverse Total ShoulderArthroplasty OptionsHemiarthroplastyTotal Shoulder6Surgical ApproachDeltopectoralCoracoidSurgical ApproachDeltopectoral7A little historyo1893-French surgeon Pean inserted platinum and rubber components to replace a shoulder joint destroyed by tuberculosis.o1951-Neer I,Vitallium Hemiarthroplasty prosthesis which resulted in pain relief and good function compared to previous options.A little history1893-French s8o1974-Neer II Prosthesis.Modified Neer I to conform to a glenoid component.oCourtesy of Smith&Nephew1974-Neer II Prosthesis.Modi9o1970s-constrained components were popular,but follow-up reports demonstrated high rates of loosening,particularly of the glenoid component.1970s-constrained component10o1980s Modular humeral components were developed,along with cementless glenoid fixation using polyethylene on a metal backing.1980s Modular humeral compo11Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty:a prospective,double-blind,randomized study.Boileau P,Avidor C,J Shoulder Elbow Surg.2002 Jul-Aug;11(4):351-9.40 Shoulders with 3 year follow up.oMetal-backed 2%radiolucent lines,100%progressive,25%loose in 3 years.Associated with shift and osteolysis.oCemented 80%radiolucent lines,25%progressive.None loose in 3 years.Cemented polyethylene versus u12Other Problems with Metal-Backed Glenoid ComponentsoMetal-backing increased the thickness of the component and often lead to over-stuffing of the joint.oTo avoid over-stuffing the joint,the polyethylene thickness had to be reduced,resulting in accelerated poly wear&failureoPoly-metal disassociation occurred with unacceptable frequency.Other Problems with Metal-Back13Humeral ComponentsCEMENTEDPROX POROUS COATEDFULLY POROUS COATEDGood for osteopenic boneLower risk of intra-operative fractureMore stress-shieldingHard to reviseHigher risk of intra-operative fractureLess stress-shieldingEasier to reviseNeed good bone stockNeed good bone stockHigher risk intra-operative fractureMore stressshieldingHard to revise Humeral ComponentsCEMENTEDPROX14Cemented vs Press-fit Humeral ComponentsoHarris,Jobe and Dai reported less micro-motion with proximally-cemented stems.oFully cemented stems provide no additional benefit or stability over proximally-cemented stems.oSanchez-Sotelo reported a low rate of stem loosening regardless of fixation,but press-fit prostheses developed more radiolucent lines in the first 4 years.Cemented vs Press-fit Humeral 15The Need for ModularityoF-H OffsetoB-C Head thicknessoD-E=8mm Top of humeral head is higher than greater tuberosityThe Need for ModularityF-H Of16The Need for ModularityoReestablishing normal glenohumeral anatomic relationships is important to ensure optimal results.Iannotti JP;JBJS 74A 1992The Need for ModularityReestab17Other Anatomic Variables to ConsideroGlenoid:2 anteversion to 7 retroversionoHumeral Head:20-40 retroversionoAxial CT of the glenohumeral joint is a valuable pre-op planning tool.Other Anatomic Variables to Co18Contraindications to Shoulder ArthroplastyoActive or recent shoulder joint infectionoParalysis with complete loss of rotator cuff and deltoid functionoA neuropathic arthropathyoIrreparable rotator cuff tear is a contraindication to glenoid resurfacing.Contraindications to Shoulder 19OsteoarthritisoIn addition to the universal features of osteoarthritic joints(joint space narrowing,cyts,osteophytes),the shoulder can also demonstrateoPosterior glenoid erosionoFlattening of the humeral headoEnlargement of the humeral headoRotator cuff tears are uncommon in OAOsteoarthritisIn addition to t20Hemi vs Total ShoulderoEasy procedureoShort Operating timeoLess risk of instabilityoCan be revised to TSAoLess reliable pain reliefoProgressive Glenoid erosion may cause results to deteriorate over timeoNeed concentric glenoidoMore consistent pain reliefoBetter fulcrum for active motionoDifficult procedureoLonger OR timeoPoly wear can cause loosening of both componentsoMore Glenoid bone lossHemi vs Total Shoul21Recommendation based on ExperienceoNeer,1998“When the articular surface of the glenoid is good,the results of hemiarthroplasty are similar to those of TSA.Wear on the glenoid has not been a problem if the articular surface was good at the time of surgery and glenohumeral motion was re-established”Recommendation based on Experi22Recommendations based on EvidenceKirkley et al,2000o42 pts,3 surgeons(stratified)oOne year follow-upoNo significant difference in WOSI,ASES,DASH Constant Score or ROM.oTrend towards better pain relief with TSA.o2 Hemi patients crossed over to TSA after 1 year follow-up.Recommendations based on Evide23Recommendations based on EvidenceGartsman,2000o51 shouldersoAverage f/u of 35 monthsoNo difference in ASES or UCLA scores.oSignificantly better pain relief with TSA o3 pts crossed over to TSA by 35 monthsRecommendations based on Evide24A comparison of pain,strength,range of motion,and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder.A systematic review and meta-analysis.Bryant D,Litchfield R;J Bone Joint Surg Am.2005 Sep;87(9):1947-56.Included 4 RCTs Average 2 year follow-up.TSA resulted in significantly improved UCLA scores,pain relief and increased forward elevation(by 13).This meta-analysis concluded that at 2 years of follow-p,TSA provided a better functional outcome,however the problems of glenoid component loosening in the TSA group and progressive glenoid erosion in the hemi group may affect the eventual long-term outcome.Longer follow-up is necessary A comparison of pain,strength25Recommendations based on EvidenceoThe results of arthroplasty in osteoarthritis of the shoulder.Haines JF et al.J Bone Joint Surg Br.2006 Apr;88(4):496-501 oProspective study of 124 shoulder arthroplasties for OA(Hemi and TSA)oSimilar improvement in pain and function in both groups if rotator cuff was intact.Better results with Hemi if+rotator cuff tearoHemi Revision at mean of 1.5 years for glenoid painoTSA Revision at mean of 4.5 years for glenoid looseningRecommendations based on Evide26Technical Issues to ConsideroOA tends to result in posterior glenoid wear/erosion,which,if accepted,will lead to a retroverted glenoid component.oCompensate by anterior reaming or placing the humeral component in LESS retroversion.oFailure to do so will result in Posterior InstabilityTechnical Issues to ConsiderOA27Rheumatoid ArthritisoPeri-articular erosionsoPeri-articular osteopeniaoThin corticesoAdjacent joint involvementRheumatoid ArthritisPeri-artic28Rheumatoid ArthritisoCemented short-stemmed prosthesisoGill,Cofield et al recommend at least 60mm between the cement mantles of ipsilateral shoulder and elbow arthroplasties.oIf this cannot be achieved,join both cement mantles together.Rheumatoid ArthritisCemented 29肩关节置换剖析课件30Rheumatoid ArthritisoGenerally,TSA performed due to destruction of the glenoid articular surface by the disease.oGlenoid erosion may require bone grafting,however,if glenoid is eroded to the level of the coracoid process,glenoid resurfacing is contraindicatedRheumatoid ArthritisGenerally,31Rotator Cuff ArthropathyoDescribed by Neer,Craig and Fukada in 1983.oA distinct form of osteoarthritis associated with a massive chronic rotator cuff tear.oGenerally,rotator cuff tears occur in less than 10%of shoulders with OARotator Cuff ArthropathyDescri32Rotator Cuff ArthropathyoA function of the rotator cuff is to depress the humeral head and keep it centered on the glenoid fossa.oMassive rotator cuff tears result in proximal migration of the humeral head.oThis is a contraindication to glenoid resurfacing as it results in eccentric(superior)glenoid loading and early component loosening.Rotator Cuff ArthropathyA func33Surgical OptionsoHemiarthroplasty with a large head oRepair of rotator cuff and TSAoReverse TSA o“Clayton Spacer”Surgical Options34Outcomes of HemiarthroplastyoRockwood:86%satisfactory results after 4 yearsoZuckerman:93%adequate pain relief and 90%had improved function for ADLs.oSanches-Sotelo:75%modest improvements in ROM and strength for ADLs.Good pain relief.Outcomes of HemiarthroplastyRo35Outcomes of HemiarthroplastyoField et al,and Sanchez-Sotelo reported that impaired deltoid function and previous subacromial decompression (loss of coracoacromial ligament)were significantly associated with clinical shoulder instability post hemiarthroplasty.Outcomes of HemiarthroplastyFi36Reverse Total Shoulder ArthroplastyoLateralizes the centre of rotation and places the deltoid at a mechanical advantage.oMore inherent stability and prevents proximal migration of humeral head.Reverse Total Shoulder Arthrop37Outcomes of the Reverse Total ShoulderoThe Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency.A minimum two-year follow-up study of sixty patients.Frankle M,Siegel S,J Bone Joint Surg Am.2005 Aug;87(8):1697-705 oAverage age=70oImproved ASES scoresoImproved ROM Flex:55 105 Abd:41 102 o17%Complication rateo 7 failures 5 revised to new Reverse TSA 2 revised to HemiarthroplastiesOutcomes of the Reverse Total 38Outcomes of the Reverse TSA(Delta III prosthesis)oTreatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis.Werner CM,Glbart M,J Bone Joint Surg Am.2005 Jul;87(7):1476-86.o58 consecutive patients,average age=68o41 cases were revisionsoFollow up=38 monthsoImproved Constant Score,Pain reduction and improved ROM.ROM:Flex:42 100 Abd:43 90o50%complication rate(including minor)oIf a 1 surgery =18%re-operation rateoIf a Revision surgery=39%re-operation rateOutcomes of the Reverse TSA(D39Reverse Total Shoulder Arthroplasty is Hard to ReviseoLittle Glenoid bone stock once component is removed.Reverse Total Shoulder Arthrop40OsteonecrosisCauses:oCorticosteroidsoAlcoholismoSickle cell dieseseoLupusoIdiopathicOsteonecrosisCauses:41OsteonecrosisoUsually young patients with adequate bone stock.oPrefer proximally porous-coated,press-fit humeral prosthesis.o less stress-shieldingo easier to revise if necessaryoOnly resurface glenoid in stage V osteonecrosis(glenoid erosion).OsteonecrosisUsually young pat42Post-Traumatic ArthritisoDue to fractures treated conservativelyoMay have mal-union of tuberosities,distorting normal anatomic landmarkso12%of patients have axillary nerve palsies(Neer).oMany have soft-tissue contractures and muscle weaknessPost-Traumatic ArthritisDue to43Choice of ProsthesisConsideroPatient ageoCondition of glenoid surface and bone stockoAxillary nerve palsy is a relative contraindication to arthroplastyChoice of ProsthesisConsider44ComplicationsoInstability 1.2%o Excessive Retro/Anteversiono Head too smallo Head too low(post fracture)o Subscap ruptureComplicationsInstability 1.2%45ComplicationsoRotator Cuff Tear 2%oResults in superior migration of humerus and glenoid looseningoGlenoid looseningComplicationsRotator Cuff Tear46ComplicationsoInfection 0.5%oStaph AureusoMore common after revision surgeryComplicationsInfection 0.5%47ComplicationsoHeterotopic Ossification 10-45%o Males o Dx=osteoarthitiso Low gradeo Non-progressiveo Does not affect outcomeSperling,Cofield et alComplicationsHeterotopic Ossif48ComplicationsoStiffnessoDepends on indication for arthroplastyoSubscap shorteningoOversized componentsoInappropriate rehabComplicationsStiffness49ComplicationsoPeriprosthetic FractureoIntra-op 1%oPost-op 0.5-2%oMost common in RAo85%womenoGlenoid fractures are rareComplicationsPeriprosthetic Fr50ComplicationsoAxillary nerve injuryoRareoHigher risk during revision surgeryoUsually a neuropraxiaComplicationsAxillary nerve in51Ultimate Bail-OutsoExcision ArthroplastyoShoulder ArthrodesisUltimate Bail-Outs52