NEW HORIZONS IN SHOULDER ARTHROPLASTY
From San Diego Shoulder’s 22nd Annual Arthroscopy/Arthroplasty/Fractures
| SHOULDER ARTHROPLASTY: INDICATIONS AND APPROACHES —Evan L. Flatow, MD, Bernard J.
Lasker Professor of Orthopaedic Surgery, Mount Sinai School of Medicine, and Chief of Shoulder Surgery,
Mount Sinai Hospital, New York City
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| Options for arthroplasty: humeral head replacement; resurfacing (full or partial); stems (standard or fracture);
total shoulder reverse
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| Indications: humeral head replacement—humerus alone diseased (avascular necrosis [AVN]); inadequate glenoid
bone; head-splitting fractures; 4-part fracture dislocation; arthritis in some active patients; rotator cuff deficiency
not requiring reverse arthroplasty; salvage procedures; partial resurfacing—subsegmental AVN; osteochondral
defects; full resurfacing—arthritis in young patients; total shoulder replacement—osteoarthritis [OA] in patients
>50 yr of age; reverse arthroplasty—cuff deficiency; pseudoparalysis; age >70 yr
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 | Fractures: indications for arthroplasty diminish with improved fixation techniques; special fracture stems developed
by Boileu and Walch, DePuy, and Zimmer
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| Deltopectoral approach: through axillary incision in small thin patient; extend incision in heavy patient or for
greater access, eg, for long stem, fracture management; subscapular takedown with tenotomy or lesser tuberosity
osteotomy; capsular releases—essential for glenoid exposure intraoperatively and for adequate range of
motion postoperatively; needed in hemiarthroplasty; release inferior capsule from axillary nerve (using
scalene nerve block), superior capsule, and posterior capsule (exceptions in post-traumatic cases and AVN)
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| Superior approach: initially used by Neer in total shoulder arthroplasty (TSA); indications—in resurfacing and
reverse arthroplasty; rotator cuff revision; possibly, cuff arthropathy
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| TOTAL SHOULDER REPLACEMENT: GLENOID EXPOSURE —Tom R. Norris, MD, Attending Orthopaedic
Surgeon and Co-Director, Shoulder, Elbow and Hand Fellowship, California Pacific Medical Center,
San Francisco
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| Overview: deltopectoral approach; press-fit humeral component; Boileu’s third-generation shoulder arthroplasty
for anatomic fixation; interscalene nerve block (used effectively since 1991); cut coracoacromial ligament
at junction with muscles; open rotator interval; remove spurs from biceps groove; open subscapularis;
leaving tissue attached to lesser tuberosity enables suturing to bone for tendon-to-tendon healing; debride osteophytes;
goal is anatomic resection (rather than replacing enlarged flattened head); exposing glenoid key to
achieving normal version
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| Points on procedure: releasing coracohumeral ligament from upper borders of subscapularis and supraspinatus
allows better mobilization of subscapularis; with Holman retractor protecting axillary nerve, anterior and inferior
capsule elevated from humerus; trimming osteophytes around humeral head exposes anatomic neck;
with rotator cuff protected by circular cutting guide, use saw to remove articular surface; glenoid component—
identification of center of glenoid followed by component placement and trial reduction; design of keeled glenoid
component optimizes impaction of cancellous bone; bone grafting—wafers of bone removed during humeral
osteotomy; wafers facilitate bone grafting in glenoid and calcar of humerus; triple-impaction cementing
technique—cement impacted with thumb and keel impactor, followed by component placement (eliminates
radiolucent lines around glenoid); interference technique—for sizing and placement of long head of biceps in
humeral head
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| THE COPELAND RESURFACING HEAD —Stephen A. Copeland, MD, Consultant Orthopaedic Surgeon, and
Director, Reading Shoulder United, Berkshire Independent Hospital, Reading, United Kingdom
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| Why device developed: shoulder replacement specifically for arthritis then unavailable; problems with cement;
potential prosthetic infection; stress riser at tip of stem (as in hip, risk of shaft fractures in elderly); implanting
stem not possible (consequence of previous surgery); 33% of unsatisfactory shoulder replacements due to
component malposition (revision difficult); potential failure—device should be amenable to revision; 44% of
shoulder replacements by surgeons performing <2 procedures per year; failure rate higher than reported; role
of stems—for fracture reconstruction; not indicated for arthritis; how arthritis affects bone—changes surface,
roughening end of bone; requires resurfacing
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| Changing demands: increased patient expectations (eg, to play sports); needs of younger patients (eg, rheumatoid
arthritis [RA], AVN, osteonecrosis from steroid therapy, trauma)
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| Device designed to: provide stability; avoid bone removal; be cementless (originally press-fit; now hydroxyapatite
coating); mimic anatomy (in version, offset, and inclination); keep instrumentation simple; be easily revised
(with stemmed prosthesis or arthrodesis)
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| Evolution: introduced in 1986; resurfacing intended to reproduce anatomy of shoulder (where original articular
surface was, not where original bone was); incorporation of taper peg in 1989 proved successful (volume of
bone removed by drill hole identical to volume of metal in peg; impaction produces instant mechanical fixation,
followed by biologic fixation); no loosening since hydroxyapatite coating added in 1993; received Food
and Drug Administration (FDA) approval in 2003
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| Indications: arthritis (not fresh fracture); while use as total arthroplasty possible, speaker prefers hemiarthroplasty;
RA; cuff arthropathy; AVN (≤40% of head grafted)
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| Results: most cases OA, followed by RA; constant (functional) scores—OA (TSA, 93; hemi, 91); RA (TSA, 76;
hemi, 71); results vary—OA best; cuff arthropathy worst; revision rate—6.8%, overall since 1986; 0.07%,
primary OA since 1993
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| NONARTHROPLASTY ALTERNATIVES FOR GLENOHUMERAL ARTHRITIS —Brian J. Cole, MD, Associate
Professor, Department of Orthopaedic Surgery, Associate Professor, Department of Anatomy and Cell
Biology, Rush Medical College, and Medical Director, Cartilage Restoration Center, Rush-Presbyterian/St.
Luke’s Medical Center, Chicago
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| Introduction: presentation looks at applying techniques used in knee to glenohumeral joint; grade 4 lesions—full-
thickness cartilage loss reaching to or through subchondral bone; designation of grade 4 articular cartilage lesions
in shoulder derived from Outerbridge classification in knee; grade 4 lesion incidence ≈5%; most well tolerated;
etiologies—posttraumatic; glenohumeral surgery; genetic; AVN; osteochondritis dissecans (OCD)
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| Patient evaluation: history—ask about shoulder surgery; findings—pain in mid-range of motion; pain with loading;
mechanical symptoms (if subchondral bone violated); pain with barometric changes; other pathology
may be source of pain; arthroscopy—gold standard; to determine defect, size, and depth; look for treatable comorbidities
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| Therapeutic approaches: palliative (debridement and lavage); tissue repair (marrow stimulation; microfracture
drilling); reparative-restorative (autogenous chondrocyte implantation [ACI]); biologic restorative (osteochondral
allograft or autograft); investigational (radiofrequency); patient selection—<40 yr of age; impaired
by problem; match level of demand to treatment (eg, for low demand, arthroscopic debridement; for high demand,
more aggressive options [symptom relief insufficient]); rule out other pathology as source of symptoms
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| Treatment options: primary repair—for OCD, post-traumatic defects; may require rigid mechanical fixation;
arthroscopic techniques—for superficial defect; debridement; creating “vertical shoulders” around defect may
provide protection and prevent progression; perform thermal synovectomy; remove loose bodies; possible
capsular release; results—debridement (88% had some pain relief at 28 mo); thermal chondroplasty (heat injures
or kills chondrocytes to depth of ≈250 µ; cell death less with monopolar device; radiofrequency (risks
destruction to subchondral bone and beyond)
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| Other alternatives: marrow stimulation—first-line treatment for superficial defects; void calcified layer; space
holes 2 to 3 mm apart to induce bleeding; experience with therapy limited (patients had reduced pain); osteochondral
autograft—more invasive; second-line treatment after failed marrow stimulation; restores subchondral
bone; obtain graft from knee; probably requires arthrotomy; osteochondral allograft—for large deep
lesions; posttraumatic defects; AVN; indicated in younger and older patients; harvested aseptically without
secondary sterilization; risk of infection despite 14-day culture; implantation recommended before 28 days,
preferably within 14 to 21 days; likely best biologic alternative; autologous chondrocyte implantation—for lesions
2 to 6 cm2 (preferably superficial and contained) in relatively young patients; currently, only clinical cell-
based technology; tertiary solution; biologic resurfacing—interpositional grafts; for bipolar lesions, young arthritic
patients; best current candidates (previous suture-anchor stabilization, possibly with radiofrequency);
options include meniscal allograft (designed to decrease load across joint or to act as interface between humerus
and glenoid, not as artifical labrum to prevent instability); radiofrequency—may have role in future
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| SHOULDER ARTHROPLASTY IN YOUNG PATIENTS —Dr. Flatow
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| Level of activity: young patients with significant shoulder disease may refuse to give up physically challenging
sports; others may agree to curtail activities but unable to do so
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| Favorable results: meta-analysis of 3 randomized prospective studies showed benefits of TSA; Flatow and Bigliani
had poor experience with hemiarthroplasty in comparison study; TSA remains only proven reliable treatment
for advanced glenohumeral arthritis; glenoid loosening—rare with appropriate implantation and
rehabilitation (based on >14-yr follow-up of Neer’s results); loose glenoids well tolerated (during “autohemiarthroplasty”,
glenoid migration resolves on its own); revision uncommon—reported rates of loosening not same
as rates of revision; long-term survival—Thornhill found 73% survival at 20 yr, with many performed using inferior
techniques by today’s standards; Mayo study—at 20-yr follow-up, 84% of TSAs intact vs 74% of hemiarthroplasties
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| Reasons to expect better results: improvements in understanding of anatomy and its surgical application; improved
glenoid design (eg, decreased contact stresses, more accurate sizing); better cement techniques (impaction
grafting); development of “trabecular metal”; “magic peg” glenoid
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| Improvements in stem: intramedullary (IM) nail-like approach to avoid removing cancellous bone; cement
problems—osteolysis and particle disease make revision more difficult in young patients; uncemented technologies
under investigation, with goal of increasing survival in younger patients
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Educational Objectives
| The goal of this program is to educate orthopaedists about current developments in the field of shoulder arthroplasty.
After hearing and assimilating this program, the orthopaedic surgeon will be better able to:
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| 1. Identify indications for shoulder arthroplasty and several surgical approaches.
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| 2. Employ glenoid exposure in total shoulder replacement.
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| 3. Evaluate the Copeland resurfacing head.
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| 4. Adopt nonarthroplasty alternatives for managing glenohumeral arthritis.
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| 5. Assess the role of shoulder arthroplasty in young patients.
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Suggested Reading
Alford JW et al: Cartilage restoration, part 1: basic science.historical perspective, patient evaluation, and treatment
options. Am J Sports Med 33:295, 2005; Alford JW et al: Cartilage restoration, part 2: techniques, outcomes,
and future directions. Am J Sports Med 33:443, 2005; Bishop JY et al: Humeral head replacement versus
total shoulder arthroplasty: clinical outcomes. J Shoulder Elbow Surg 14:141S, 2005; Bishop JY et al: Interscalene
regional anesthesia for shoulder surgery. J Bone Joint Surg Am 87:974, 2005; Bishop JY et al: Management
of glenohumeral arthritis: a role for arthroscopy? Orthop Clin North Am 34:559, 2003; Cole BJ et al:
Allograft meniscal transplantation: background, techniques, and results. Instr Course Lect52:383, 2003; Review.
Freedman KB et al: Marrow stimulating technique to augment meniscus repair. Arthroscopy 19:794, 2003;
Hayes PR et al: Total shoulder arthroplasty in the young patient. Instr Course Lect 50:73, 2001; Review. Iannotti
JP et al: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis. J
Bone Joint Surg Am 85-A:251, 2003; Kelly JD Jr et al: Decision making in glenohumeral arthroplasty. J Arthroplasty
18:75, 2003; Klepps S et al: Incidence of early radiolucent glenoid lines in patients having total shoulder
replacements. Clin Orthop Relat Res:118, 2005; Levine WN et al: Hemiarthroplasty for glenohumeral osteoarthritis:
results correlated to degree of glenoid wear. J Shoulder Elbow Surg 6:449, 1997; Levy O et al: Cementless
surface replacement arthroplasty (Copeland CSRA) for osteoarthritis of the shoulder. J Shoulder Elbow Surg
13:266, 2004; Levy O et al: Cementless surface replacement arthroplasty of the shoulder. 5- to 10-year results
with the Copeland mark-2 prosthesis. J Bone Joint Surg Br 83:213, 2001; Levy O et al: Copeland surface replacement
arthroplasty of the shoulder in rheumatoid arthritis. J Bone Joint Surg Am 86-A:512, 2004; McCarty LP 3rd
et al: Nonarthroplasty treatment of glenohumeral cartilage lesions. Arthroscopy 21:1131, 2005; Norris TR et al:
Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow
Surg 11:130, 2002; Thomas SR et al: Geometrical analysis of Copeland surface replacement shoulder arthroplasty
in relation to normal anatomy. J Shoulder Elbow Surg 14:186, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant
financial relationship with the manufacturer or provider of any commercial product or service discussed.
The following has been disclosed: Dr. Flatow—Zimmer, Inc; Dr. Cole—Tornier, US (consultant); Dr.
Copeland—Biomet (royalties)
Drs. Flatow, Norris, Copeland, and Cole were recorded at the 22nd Annual Arthroscopy/Arthroplasty/Fractures,
sponsored by San Diego Shoulder in La Jolla, California, on June 22-25, 2005. The Audio-Digest Foundation
thanks the speakers and the sponsor for their cooperation in the production of this program.
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