SHOULDER ARTHROPLASTY
Featuring selections from San Diego Shoulder Institute’s Arthroscopy, Arthroplasty, Fractures
| INDICATIONS AND TECHNIQUES—Jon J.P. Warner, MD, Associate Professor of Orthopaedic Surgery,
Harvard Medical School, and Chief, The Harvard Shoulder Service, Massachusetts General Hospital, Boston,
MA
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| Lessons from Neer: factors that affect outcome—pathoanatomy; implant selection; surgeon; surgical technique;
Neer’s experience—804 cases (139 total shoulder arthroplasty [TSA]; 165 hemiarthroplasty); expected
≥90% excellent outcome using simple monoblock prosthesis; radiolucent lines common, but revision relatively
uncommon; 10- to 15-yr survival rate high; equivalent data unavailable for second- and third-generation prostheses
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| Causes of failure: errors in component placement and sizing common; incorrect humeral head placement (glenoid
loosening; rotator cuff tears); component geometry—head too large (subscapular failure; glenoid erosion;
rotator cuff tears); head too high (converts much of cuff into adductor; pulls against supraspinatus); head too
small (internal impingement; loosening; polyethylene wear)
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| Preferred technique: protects subscapularis tendon; bone-to-bone repair; osteotomizing lesser tuberosity creates
stronger construct; sutures placed around stem (stem reinforces sutures)
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| Newer options: biologic resurfacing; meniscal allografts; speaker’s experience—26 Achilles tendon allografts
over 6 yr (failure rate 64%; 100% in younger patients with arthritis); 3 meniscal allografts (all failed)
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| Speaker’s results: 373 TSAs in 6 yr; satisfaction rate in 191 patients at 1 yr (98% “happy”; 80% said shoulder
better; 35% said shoulder normal)
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| Inside the shoulder: end result of procedure affects durability, ie, whether kinematics normal; 3-dimensional
flouroscopic analysis of humeral head–glenoid contact on motion shows pattern duplicates normal
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| Surgeon experience and outcomes: failure rate higher for surgeons who perform fewer procedures
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| TIPS FOR GLENOID EXPOSURE—Evan L. Flatow, MD, Lasker Professor and Chairman, Department of Orthopaedic
Surgery, Mount Sinai School of Medicine, and Chief of Shoulder Surgery, Orthopaedic Surgery Service,
Mount Sinai Hospital, New York, NY
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| Exposing glenoid: full visibility needed for end-on approaches; straight drills and reamers recommended; angled
drills and reamers harder to control for precise preparation
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| Hemiarthroplasty vs TSA: no difference in need for adequate capsular releases to achieve good result (to allow
adequate kinematics and to avoid excessive pressure and excentric loading on glenoid)
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| Anesthesia: regional anesthesia produces relaxation but not paralysis; permits aggressive capsular releases using
electrocautery at low setting (twitches indicate proximity to nerve)
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| Proper positioning: placing patient off side of table allows arm to be moved into desired positions; speaker
uses pneumatic device to hold arm in precise position for glenoid exposure
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| Capsular releases: essential for 3 reasons—motion and kinematics; gliding of rotator cuff and subscapularis;
exposure; release—scar and capsule from humeral neck; rotator cuff muscles (subscapularis; supraspinatus)
from coracoid base and glenoid rim; in osteoarthritic shoulder—release superior capsule, anterior capsule, and
inferior capsule; separate inferior capsule from axillary nerve (pain relief achieved by freeing adhesions from
nerves)
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| Surgical points: trimming osteophytes before glenoid exposure provides more working room; reverse
arthroplasty—more room needed for placing screws and for reverse component movement; posterior exposure
may require release of triceps origin; superior approach allows more access to glenoid to treat rotator cuff tear
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| SHOULDER ARTHROPLASTY vs HEMIARTHROPLASTY: WHERE IS THE AXILLARY NERVE?—T.
Bradley Edwards, MD, Fondren Orthopedic Clinic, and Texas Orthopaedic Hospital, Houston
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| Hemiarthroplasty vs TSA: studies compared in primary osteoarthritis; small prospective randomized study—
TSA superior in Ambulatory Surgical Centers (ASCs) and University of California Los Angeles (UCLA)
scores, patient satisfaction, and function and strength; statistically, pain relief better with TSA; retrospective
multicenter study—609 arthroplasties at 2-yr follow-up; except for strength, total Constance score, range of
motion (ROM), and patient satisfaction better with TSA; complications equal (revision for loosening in TSA;
conversion to total for glenoid erosion in hemiarthroplasty); other diagnoses—studies found TSA better (if rotator
cuff intact) in rheumatoid arthritis and posttraumatic arthritis; osteonecrosis (procedures equal in early
stages; TSA in severe humeral head collapse); speaker’s practice—hemiarthroplasty preferred when TSA contraindicated,
eg, inadequate glenoid bone stock, early stage osteonecrosis, massive rotator cuff tears (when reverse
arthroplasty contraindicated), and chondrolysis after arthroscopy in younger patients
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| Axillary nerve: 3 key points in TSA—ability to locate nerve; when nerve at risk; how to avoid injuring nerve
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 | Anatomy: terminal branch of posterior cord of brachial plexus; innervates deltoid and teres minor muscles; sensory
branch innervates inferior glenohumeral joint capsule; terminates in superior lateral brachial cutaneous
nerve root
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| Surgical steps: standard deltopectoral approach; suture ligation of anterior humeral circumflex; forward flex
arm in neutral-to-slight internal rotation; dissect under vessels, using Metzenbaum scissors to spread, exposing
axillary nerve just inferior to subscapularis; perform subscapularis tenotomy along anatomic neck;
release superior aspect of subscapularis tendon by releasing superior glenohumeral ligament, followed by
middle glenohumeral ligament, paralleling anterior glenoid
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| When nerve at risk: releasing inferior glenohumeral ligament—inferior third of subscapularis tendon muscular;
place scissors in plane between muscular portion and adjacent capsule; extend release to level of glenoid;
releasing inferior capsule—using electrocautery, release capsule just off inferior glenoid rim; “stay
on bone” to protect nerve
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| EXPOSURE AND EXPERIENCE WITH A CONTOURED ARTIFICIAL PROSTHETIC RESURFACING
SYSTEM—James E. Tibone, MD, Clinical Professor of Orthopaedic Surgery, Keck School of Medicine at the
University of Southern California, Los Angeles
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| Arthrosurface HemiCAP: titanium screw; cobalt chrome head; joined with Morse taper; 25-mm to 40-mm
sizes
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| Indications: avascular necrosis; focal articular cartilage lesions; osteoarthritis (OA) with concentric glenoid;
large Hill-Sachs lesions; reverse Hill-Sachs lesions
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| Advantages in OA: more anatomic; saves bone stock; easier technically; no cement; easier to revise; outpatient
procedure
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| Surgical approach: anterior through deltopectoral interval; expose subscapularis tendon; perform biceps tenotomy;
cut subscapularis and anterior capsule ≈1 cm from lesser tuberosity; expose glenoid, performing adequate
releases; deliver humeral head into wound; remove osteophytes
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| Inserting prosthesis: center 4 prongs of drill guide on humeral head; insert guide pin into center of head; use
step drill to create hole for screw; tap bone; insert 32-mm screw down to indicated depth; insert trial cap to ensure
screw at proper depth; measure 4 quadrants of head curvature to determine reamer size; score to mark
starting point for reamer; reach high speed before gently pressing reamer; insert trial prosthesis; clean Morse
taper; insert prosthesis
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| Postoperative rehabilitation: same as hemiarthroplasty or TSA; protect subscapularis tendon repair; limit rotation
6 wk; start other motions immediately; return to sports in 3 to 6 mo
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| Complications: intraoperative—head fragmentation during reaming and conversion to hemiarthroplasty;
postoperative—one acute deep infection; no dislocations or neurologic complications; revision—8 per 1000
to TSA
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| Radiographic results: solid fixation; no radial lucency, osteolysis, or device migration reported
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| Clinical results: 76% to ≈80% improvement on subjective outcome scores; pain relief similar to hemiarthroplasty,
but ROM better
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| SUBSCAPULARIS REPAIR AFTER SHOULDER ARTHROPLASTY: BIOMECHANICAL AND CLINICAL
VALIDATION OF A NOVEL TECHNIQUE—Sumant Krishnan, MD, Clinical Assistant Professor of Orthopaedic
Surgery, University of Texas Southwestern Medical Center, and Attending Orthopaedic Surgeon, The W.B. Carrell
Clinic, Dallas, TX
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| Biomechanical study: involved 15 human cadavers; tenotomy—5 underwent mid-tendon tenotomy and suture
repair; osteotomy—subscapularis released with “fleck” of lesser tuberosity bone in 10; 5 repaired with single row
of sutures surrounding bone fleck; 5 repaired with double row of sutures (extra row added along anatomic neck;
sutures passed mattress-fashion at bone-tendon junction of subscapularis and bone fleck); findings—on rotation,
double-row repair prevented rotation of bone fleck; modes of failure—tenotomy failed in tendon; single-row repair
failure variable; double-row repairs transferred any failure to host bone
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| Clinical study: retrospective review of 100 TSAs using bone fleck in osteotomy and double-row repair; followed
≥24 mo; findings—79% able to perform lift-off test; 86% performed belly press; 8 of 10 patients able to
tuck shirt into back of pants (internal rotation behind their body); x-rays showed anatomic healing of bone fleck
in 97 cases (3 healed to humeral shaft); no subscapularis failures
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| Conclusion: double-row repair increases subscapularis insertional contact area and increases footprint restoration
of subscapularis without medializing tendon itself; provides improved and reproducible subscapularis integrity;
procedure now performed in >400 TSAs
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| EVALUATION AND DECISIONS IN REVISION INSTABILITY SURGERY—Felix H. Savoie III, MD, Professor
of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, LA
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| Factors in failure: patient factors; surgeon factors; rehabilitation factors
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| Ligament quality: Ehlers-Danlos syndrome contraindication to stabilization; congenital hyperelasticity depends
on rehabilitation; multiple dislocations not contra-indication
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| Bone structure: significant bone loss must be replaced; engaging Hill-Sachs lesion relative consideration
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| Healing ability: nutrition; consider family history; quality of diet
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| Posture: correctable; scapular rehabilitation and core strengthening exercises; bracing (static; dynamic;
AlignMed S3 brace)
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| Cooperativeness: young patients may be uncooperative
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| Indications: history of original injury; compare initial and current examination
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| Evaluation: bone and tissue loss on x-ray, computed tomography (CT), and magnetic resonance imaging (MRI)
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| Technique: vertical shift; anchor placement; knot tying; address all pathologies
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| Rehabilitation factors: focus—core strength; scapula; high-speed training
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| Effort: required of patient
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| Cost: significant; sports may offer alternative
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| Instructions: most therapists rehabilitate to activities of daily living; will not protect shoulder in athletic activities
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| How speaker approaches failed instability
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| History: original injury; family history; reason for original surgical decision; operative notes; mechanism and
timing of failure; current status; patient’s current goal
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| Evaluation: motion (determines release); position of apprehension; sulcus sign in neutral, abduction, and external
rotation; radiographs; MRI or CT arthrography (oblique, sagittal, and 3-dimensional views of glenoid);
neurologic
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| Surgery: extensive diagnostic arthroscopy; complete release; aggressive vertical shift and repair (mattress sutures);
possible posterior sutures; interval plication with arm at 90° external rotation; Latarjet procedure indications
(40% glenoid loss; otherwise, soft-tissue reconstruction)
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| Rehabilitation: early scapular rehabilitation (taping; S3 or S4 bracing if cost permits)
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| Results: 33 failed instability surgeries evaluated; 97% remained stable; motion ≥90% of opposite shoulder; pain
relief inconsistent
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Suggested Reading
Antuna SA et al: Glenoid revision surgery after total shoulder arthroplasty. J Shoulder Elbow Surg 10:217,
2001; Bryant D et al: A comparison of pain, strength, ROM, and functional outcomes after hemiarthroplasty and
total shoulder arthroplasty in patients with osteoarthritis of the shoulder. A systematic review and meta-analysis. J
Bone Joint Surg Am 87:1947, 2005; Chin PY et al: Complications of total shoulder arthroplasty: are they fewer
or different? J Shoulder Elbow Surg 15:19, 2006; Edwards TB et al: A comparison of hemiarthroplasty and total
shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study. J
Shoulder Elbow Surg 12:207, 2003; Gartsman GM et al: Shoulder arthroplasty with or without resurfacing of
the glenoid in patients who have osteoarthritis. J Bone Joint Surg Am 82:26, 2000; Jain N et al: The relationship
between surgeon and hospital volume and outcomes for shoulder arthroplasty. J Bone Joint Surg Am 86-A:496,
2004; Matsoukis J et al: Primary unconstrained shoulder arthroplasty in patients with a fixed anterior glenohumeral
dislocation. J Bone Joint Surg Am 88:547, 2006; Sanchez-Sotelo J et al: Instability after shoulder arthroplasty:
results of surgical treatment. J Bone Joint Surg Am 85-A:622, 2003; Savoie FH 3rd et al: Anterior
superior instability with rotator cuff tearing: SLAC lesion. Orthop Clin North Am 32:457, 2001; Savoie FH 3rd
et al: Straight anterior instability: Lesions of the middle glenohumeral ligament. Arthroscopy 17:229, 2001;
Sperling JW et al: Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in
patients aged fifty years or younger. J Shoulder Elbow Surg 13:604, 2004; Sperling JW et al: Shoulder arthroplasty
for arthritis after instability surgery. J Bone Joint Surg Am 84-A:1775, 2002; Tammachote N et al: The
effect of glenoid component size on the stability of total shoulder arthroplasty. J Shoulder Elbow Surg 16:S102,
2007.
Educational Objectives
| The goal of this program is to improve the performance of shoulder arthroplasty. After hearing and assimilating
this program, the orthopaedic surgeon will be better able to:
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| Identify the indications and techniques for shoulder arthroplasty
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| Perform glenoid exposure.
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| Avoid axillary nerve injury during total shoulder arthroplasty (TSA).
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| Evaluate employing a fleck of bone and double-row suture repair in performing an osteotomy during TSA.
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| Revise failed surgery for shoulder instability.
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Faculty Disclosure
In adherence to the ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
releveant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not
a proprietary business or commercial interest. For this program the following has been disclosed: Dr. Warner—
Zimmer (royalty); Dr. Edwards—Tornier, Inc (consultant); Kinamed, Inc (consultant; Dr. Krishnan—Tornier, Inc
(consultant; institutional and research); DePuy Mitek, Inc (consultant; institutional and research)
Acknowledgements
The speakers were recorded at Arthroscopy, Arthroplasty, Fractures, sponsored by the San Diego Shoulder Institute
in San Diego, CA, June 20-23, 2007. The Audio-Digest Foundation thanks the speakers and the San Diego
Shoulder Institute for their cooperation in the production of this program.
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