Frederick A. Matsen III, Steven B. Lippitt, and Ryan T. Bicknell
DEFINITION
Glenohumeral arthritis is defined as loss of the normal articular cartilage covering of the humeral head and glenoid fossa.
An irreparable rotator cuff defect is one in which a durable attachment of detached cuff tendons to the tuberosity cannot be re-established.
The association of glenohumeral arthritis and irreparable rotator cuff defects occurs in several distinct clinical situations, each of which has unique features and specific treatment options.
The key points in managing these conditions are to define the following:
The pathology
The deficits in comfort and function experienced by the patient
The options for reconstruction
The benefits and risks of each of the treatment options
ANATOMY
The glenohumeral articulation normally is covered with hyaline articular cartilage. The glenoid fossa is a spherical concavity that is deepened because the cartilage is thicker at the periphery and the glenoid rim is surrounded by a fibrocartilaginous labrum. The humeral head is a convexity that fits into this concavity.
The rotator cuff is a synthesis of the tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor with the subjacent glenohumeral capsule.
The rotator cuff tendons insert into the humerus just lateral to the articular cartilage and at the base of the tuberosities.
The spherical proximal humeral convexity is formed by the smooth blending of the cuff tendons with the tuberosities.
The radius of the proximal humeral convexity is the radius of the humeral head plus the thickness of the rotator cuff tendons.
The coracoacromial arch is a spherical concavity consisting of the undersurface of the acromion and the coracoacromial ligament. The proximal humeral convexity fits into this concavity.
The glenohumeral joint is normally stabilized by the concavity compression mechanism:
The rotator cuff muscles compress the humeral head into the glenoid fossa.
The deltoid compresses the proximal humeral convexity into the coracoacromial arch.
PATHOGENESIS
Loss of glenohumeral articular cartilage can be caused by osteoarthritis, rheumatoid arthritis, neurotrophic arthritis, septic arthritis, traumatic arthritis, avascular necrosis, and iatrogenic arthritis.
It also can arise from abrasion of the unprotected humeral head on the undersurface of the coracoacromial arch in chronic rotator cuff deficiency, a situation that often is referred to as rotator cuff tear arthropathy.
Defects in the rotator cuff tendons arise when loads are applied to the tendon insertion that are greater than the strength of the tendon attachment to the tuberosity.
These defects typically begin at the anterior undersurface of the supraspinatus tendon.
Age, systemic disease, corticosteroid injections, and smoking are among the factors that weaken the insertional strength of the rotator cuff tendons, making them more susceptible to tearing and wear.
When the superior rotator cuff is deficient, the radius of the proximal humeral convexity is decreased by the thickness of the cuff tendon.
The loss of the spacer effect of the cuff tendon allows the humeral head to translate superiorly under the active pull of the deltoid until the uncovered head contacts the coracoacromial arch.
The intact coracoacromial arch can provide secondary superior stability to the uncovered humeral head.
The upward translation of the humeral head necessary to contact the arch slackens the deltoid, however, reducing its effectiveness in elevation of the arm.
The coracoacromial arch can be compromised by progressive abrasion with the uncovered humeral head. It also can be compromised by acromioplasty and section of the coracoacromial ligament.
Compromise of the coracoacromial arch coupled with a substantial rotator cuff defect permits anterosuperior escape of the humeral head on deltoid contraction.
This anterosuperior escape eliminates the fulcrum needed for the deltoid to elevate the arm.
The inability of a functioning deltoid to elevate the arm because of slackening and lack of a fulcrum is known as pseudoparalysis.
NATURAL HISTORY
Rotator cuff deficiency and arthritis can occur individually or together.
In most cases of osteoarthritis, the rotator cuff is functionally intact.
In most cases of rheumatoid arthritis, the rotator cuff may be thinned but usually is functionally intact.
In rotator cuff tear arthropathy, the integrity of the cuff, the articular cartilage, and the coracoacromial arch all characteristically degenerate in a progressive manner.
Some surgeons attempt to improve the comfort and functions of individuals with rotator cuff problems by performing an acromioplasty and coracoacromial ligament section.
Unless cuff function is durably restored, this sacrifice of the coracoacromial arch predisposes the shoulder to anterosuperior escape.
The rotator cuff mechanism can be damaged in the process of humeral head resection during shoulder arthroplasty.
Individuals who have had a shoulder arthroplasty may tear their rotator cuff in a fall or while lifting.
When a prosthesis is used to reconstruct a complex proximal humeral fracture, the tuberosities may fail to unite, resulting in the functional equivalent of rotator cuff deficiency.
PATIENT HISTORY AND PHYSICAL FINDINGS
Rotator cuff tendons fail by some combination of applied load and degeneration (“tear” and “wear”).
There need be no history of a traumatic episode, especially in older individuals who give a history of progressive loss of comfort, strength, and ability to perform functions of their daily living. These are the persons whose condition may progress to cuff tear arthropathy.
By contrast, individuals with acute traumatic rotator cuff tears from the application of substantial load do not typically progress to cuff tear arthropathy.
In patients with massive atraumatic cuff deficiency, it is important to seek historical evidence of factors that may weaken the cuff, such as systemic disease, cortisone injections, antimetabolic medications, and smoking.
Osteoarthritis often presents without a history of injury. Instead, it presents as progressive stiffness, pain, and loss of function.
Rheumatoid arthritis of the shoulder presents in the context of this systemic condition.
Important elements of the history are the patient's selfassessment of shoulder comfort and function (such as the simple shoulder test) and an assessment of the patient's goals for treatment.
The integrity of the principal rotator cuff tendons is determined by the isometric strength of each of the three primary muscles in defined positions.
Supraspinatus integrity: weakness (ie, strength grade 3 or less) indicates a full-thickness supraspinatus tear.
Infraspinatus integrity: weakness (ie, strength grade 3 or less) indicates a large, full-thickness rotator cuff tear, extending into the infraspinatus.
Subscapularis integrity: weakness (ie, strength grade 3 or less) indicates a full-thickness subscapularis tear.
Defects in the rotator cuff often can be palpated just anterior to the acromion while the shoulder is passively rotated.
Chronic cuff defects usually are accompanied by atrophy of the muscles attached to the deficient tendons.
Cuff degeneration often is associated with subacromial crepitus on passive rotation of the humerus beneath the coracoacromial arch.
Cuff tear arthropathy often is associated with a substantial subacromial effusion.
Superior instability is demonstrated by having the patient relax the shoulder, hanging it at the side, and then actively contracting the deltoid while the examiner notes superior translation of the humeral head until it contacts the coracoacromial arch (FIG 1A,B).
Anterosuperior escape is the exaggerated form of superior instability that results when the coracoacromial arch is compromised (FIG 1C,D).
FIG 1 • A,B. Characteristic findings of cuff tear arthropathy, including superior displacement of the humeral head, “femoralization” of the proximal humerus, and “acetabularization” of the coracoacromial arch. In such a case, a conventional hemiarthroplasty, possibly using a special cuff tear arthropathy (CTA) head, may be considered. C,D. Anterosuperior escape of the humeral head resulting from surgical compromise of the coracoacromial arch. In such a case, a conventional arthroplasty will not provide stability, and a Delta (DePuy, Warsaw, IN) or reverse prosthesis may be considered. (Copyright Steven B. Lippitt, MD.
IMAGING AND OTHER DIAGNOSTIC STUDIES
An anteroposterior plain radiograph in the plane of the scapula may reveal:
Decreased acromio–humeral distance, signaling the absence of the normally interposed supraspinatus tendon
“Femoralization” of the proximal humerus (ie, rounding off of the tuberosities so that the proximal humerus is spherical) as well as other changes in humeral anatomy (FIG 2A,B)
“Acetabularization” of the acromion-coracoid-glenoid socket (ie, sculpting of a concavity matching the femoralized proximal humerus)
The amount of superior and medial erosion of the acromion and upper glenoid
A true axillary view (FIG 2C,D) may reveal.
The degree of medial glenoid erosion, ie, the amount of glenoid bone stock available for reconstruction
The presence of anterior or posterior glenoid erosion and humeral subluxation, indicating a more complex pattern of instability
An anteroposterior (AP) view of the proximal humerus with the arm in 30 degrees of external rotation with respect to the x-ray beam may reveal:
The approximate size of the humeral medullary cavity that may be used in prosthetic reconstruction
Any humeral deformities that may affect prosthetic reconstruction
We do not routinely use either CT or MRI scans, but they may be useful in clarifying the pathology.
CT scans may help with.
Defining glenoid bone volume and deformities
Defining the glenohumeral relationships
MRI scans may help with.
Determining the condition of the different rotator cuff tendons
Determining the condition of the different rotator cuff muscles
The volume and location of fluid in the joint
Other pathology, such as tumor or avascular necrosis
Factors suggesting that the cuff defect is likely to be irreparable include:
Insidious, atraumatic onset of cuff deficiency
Advanced age of the patient
History of repeated corticosteroid injections
Systemic illness
History of smoking
Previous unsuccessful attempts at rotator cuff repair
Muscle atrophy
Superior displacement or superior instability of the glenohumeral joint
Anterosuperior escape
Pseudoparalysis
FIG 2 • A. Normal glenoid and normal head–glenoid relationship are seen on this AP radiograph in the plane of the scapula. B. Superior glenoid erosion and upward displacement of the head are seen on this AP radiograph in the plane of the scapula. This demonstrates “femoralization” of the proximal humerus and “acetabularization” of the coracoacromial arch. C,D. A proper axillary view will reveal anterior, posterior, or medial glenoid erosion. (Copyright Steven B. Lippitt, MD.)
DIFFERENTIAL DIAGNOSIS
Milwaukee shoulder
Neurotrophic (Charcot) arthropathy
Septic arthritis
Nonseptic inflammatory arthropathy
NONOPERATIVE MANAGEMENT
An acute rotator cuff tear is a matter of relative urgency, but a chronic cuff defect coupled with glenohumeral arthritis provides the opportunity for nonoperative management, including:
Range-of-motion exercises in an attempt to resolve the stiffness that may accompany this condition (eg, the fourquadrant stretching program)
Gentle progressive strengthening exercises for the deltoid and the rotator cuff musculotendinous units that remain intact (eg, the two-hand progressive supine press)
Mild nonnarcotic analgesics may be useful in symptom control.
However, injections of corticosteroids into the shoulder may compromise the integrity of the remaining tendons and increase the risk of infection.
SURGICAL MANAGEMENT
Preoperative Planning
Consideration of surgical management is based on the type of involvement (Table 1), the patient's overall health and wellbeing, and the risk–benefit ratio in trying to meet the patient's goals for treatment.
With each of the procedures, the patient must be wellinformed and give informed consent to the risk of infection, neurovascular injury, pain, stiffness, weakness, fracture, instability, loosening of components, anesthetic complications, and the possible need for revision surgery.
Conventional Hemiarthroplasty, Total Shoulder Arthroplasty, and Special Hemiarthroplasty
Use AP radiograph in the plane of the scapula and axillary view to identify medial, superior, anterior, posterior, or inferior glenoid erosion.
Use AP humeral radiograph to estimate the size and fit of the humeral component (FIG 3).
Give prophylactic antibiotics.
Delta or Reverse Arthroplasty:
Use AP radiograph in the plane of the scapula and transparent glenoid template to estimate the most inferior position of the glenoid that will result in the inferior screw being contained in the thick bone of the scapular axillary border.
Use AP humeral radiograph to estimate the size and fit of the diaphyseal and metaphyseal humeral components.
Positioning
All procedures can be performed in the beach chair position. This position is comfortable and safe for the patient, and allows good access for the anesthesiologist and the surgeon.
The patient is positioned and secured with the glenohumeral joint at the edge of the operating table.
The forequarter is doubly prepped, and the arm is draped so it can be moved freely.
Approach
Although some surgeons advocate a deltoid-incising lateral approach, we prefer the deltopectoral approach, because it is effective, familiar, versatile, safe, and extensile.
Each procedure strives to completely preserve and protect the deltoid and the axillary nerve.
Each procedure includes a complete mobilization of the humeroscapular motion interface with resection of all scar, suture, and suture anchors from previous surgical procedures, and hypertrophic bursa.
This débridement permits complete assessment of the surgical anatomy.
The integrity of the acromion and coracoacromial ligament is assessed and preserved.
The subscapularis and subjacent capsule are incised from their attachment to the humerus at the lesser tuberosity.
A 360-degree subscapularis release is carried out while the axillary nerve is protected.
One of two types of reconstruction is selected.
Anatomic arthroplasty, with one of the following:
Hemiarthoplasty using a conventional prosthesis
Total glenohumeral arthroplasty
Hemiarthroplasty with a special head (eg, Delta CTA [cuff tear arthropathy; DePuy, Inc., Warsaw, IN])
Delta or reverse arthroplasty
At the conclusion of the arthroplasty, the subscapularis is repaired to the bone of the cut humeral surface adjacent to the lesser tuberosity using six sutures of no. 2 nonabsorbable suture passed through drill holes.
A suction drain is placed just anterior to the subscapularis and led out through a long subcutaneous track to exit the skin of the lateral arm.
Dry sterile dressings are applied.
Continuous passive motion is used for 36 hours for all reconstructions except for the Delta or reverse arthroplasty.
After the Delta arthroplasty, the arm is immobilized for 36 hours.
FIG 3 • Templating view of the humerus taken with the arm in 30 degrees of external rotation with respect to the x-ray beam and with a magnification marker. (Copyright Steven B. Lippitt, MD.)
TECHNIQUES
CONVENTIONAL HEMIARTHROPLASTY, TOTAL SHOULDER ARTHROPLASTY, AND SPECIAL HEMIARTHROPLASTY
Incision and Approach
Create a deltopectoral incision.
Lyse adhesions and remove bursa from the humeroscapular motion interface.
Verify irreparability of the rotator cuff tear and resect useless tendon tissue. If useful cuff elements remain, tag for later reattachment.
Incise susbscapularis and capsule from insertion to lesser tuberosity, preserving maximal length of tendon.
Release inferior capsule from humerus.
Identify axillary nerve.
Perform a 360-degree subscapularis release.
Humeral Preparation and
Implant Sizing
Insert progressively larger reamers into the canal, stopping at the first endocortical bite (TECH FIG 1A).
Resect the humeral head in 30 degrees of retroversion and 45 degrees with the long axis of the shaft (TECH FIG 1B).
Measure height and diameter of the curvature of the resected head (TECH FIG 1C).
Mince bone of the humeral head to make autogenous graft.
If the glenoid is rough and eroded medially, but not superiorly, and if the infraspinatus and subscapularis are intact or robustly reconstructable, and if the patient has soft glenoid bone (as in rheumatoid arthritis), consider inserting a prosthetic glenoid component.
Using minced autogenous bone from the humeral head, perform impaction autografting of the humeral canal so that the prosthetic stem will achieve a snug press-fit (TECH FIG 1D).
If a partial rotator cuff repair can be carried out, perform that before definitive sizing of component, because repair may diminish the room available for the prosthesis (TECH FIG 1E).
If glenoid arthroplasty has been performed, select the humeral head prosthesis with the appropriate diameter of curvature for the glenoid.
If glenoid arthroplasty has not been performed, select the humeral head prosthesis with the diameter equal to that of the resected head.
Component Placement
With the trial component in position, resect any prominent tuberosity that may abut against the coracoacromial arch on elevation of the arm (TECH FIG 2A,B).
Consider a special humeral head (eg, CTA head) to cover the area of the greater tuberosity (TECH FIG 2C).
TECH FIG 1 • A. Reaming the humerus until the first endocortical bite is achieved. B. Marking the humeral osteotomy at 45 degrees with the reamed axis of the shaft and in 30 degrees of retroversion. Care must be taken to protect the rotator cuff in making the osteotomy. C. Measuring the resected head to determine the diameter of curvature and the height. D. Impaction grafting of the medullary canal to achieve a secure press-fit without jeopardizing the strength of the diaphyseal cortex. E. Partial repair of the rotator cuff to the edge of the resected humerus. (Copyright Steven B. Lippitt, MD.)
Select the humeral head height that, on trial reduction, allows 40 degrees of external rotation with the subscapularis approximated, 50% posterior translation on the posterior drawer test, and 60 degrees of internal rotation when the arm is abducted to 90 degrees (TECH FIG 2D–G).
Place six no. 2 nonabsorbable sutures in the anterior humeral neck cut for reattachment of the subscapularis (TECH FIG 2H).
Assemble the definitive humeral prosthesis.
Insert the prosthesis in the impaction-grafted medullary canal.
Final Contouring and Wound Closure
Ensure smooth passage of the proximal humerus beneath the coracoacromial arch. If abutment occurs, perform smoothing on the humeral side, preserving the integrity of the arch.
Repair the subscapularis.
Insert drain.
Close the deltopectoral interval.
Perform subcutaneous and skin closure.
Apply sterile dressings.
TECH FIG 2 • A,B. Smoothing of the greater tuberosity lateral to the articular surface of the prosthetic humeral head. C. Cuff tear arthropathy (CTA) head prosthesis, providing a smooth lateral articulation for the shoulder with irreparable cuff deficiency. D–G. Balancing the soft tissue tension: 40 degrees of external rotation (D), 50% posterior translation (E,F), and 60 degrees of internal rotation in 90 degrees of abduction (G). H. Preparing for subscapularis reattachment to the cut edge of the humerus. (Copyright Steven B. Lippitt, MD.)
DELTA OR REVERSE ARTHROPLASTY
Incision and Approach
Make a deltopectoral incision.
Lyse adhesions and remove bursa from the humeroscapular motion interface, protecting deltoid, acromion, and residual cuff tissue.
Verify irreparability of the rotator cuff tear and resect useless tendon tissue.
Tag any potentially reparable elements of the cuff that are identified, for later use.
Incise the subscapularis and capsule from insertion to lesser tuberosity, preserving maximal length of the tendon.
Release the inferior capsule from the humerus.
Identify the axillary nerve.
Perform a 360-degree subscapularis release.
Humeral Preparation
Insert humeral resection guide stem into medullary canal (TECH FIG 3A).
Resect humeral head in zero degrees of retroversion (TECH FIG 3B).
When the arm is pulled distally, the plane of the humeral cut should pass just below the inferior glenoid.
Glenoid Preparation
Dissect the capsule from the anterior glenoid down to and around the inferior pole so that the upper axillary border of the scapula can be palpated and seen, releasing the origin of the long head of the triceps as necessary.
Check radiographs and exposed glenoid to identify abnormal glenoid anatomy (eg, superior, inferior, anterior, posterior, inferior or medial erosion, as well as defects from previous surgery [such as earlier arthroplasty]).
Note the relation of the inferior glenoid lip to the axillary border of the scapula.
Remove the labrum and cartilage from the glenoid.
Mark a point 13 mm anterior to the posterior rim of the glenoid and 19 mm superior to the inferior glenoid rim.
Drill the guidewire into the glenoid at this point (TECH FIG 4A).
Place the metaglene of the Delta prosthesis (TECH FIG 4B) over this guidewire, with the peg laterally, to verify the appropriateness of this center point.
The inferior aspect of the metaglene should align with a line extended from the axillary border of the scapula.
When the rim of the metaglene is flush with the extrapolated axillary border, remove the metaglene and drill a central hole with the step drill (TECH FIG 4C).
Ream the glenoid conservatively, removing only enough bone to make the surface relatively flat and making sure the reamer handle remains perpendicular to the face of the glenoid (TECH FIG 4D).
Metaglene Placement
Insert the metaglene peg into the central hole (TECH FIG 5A).
Palpate the anterior and posterior aspects of the axillary border of the scapula and rotate the metaglene so the inferior screw hole is centered over the axillary border.
Recall that the inferior locking screw makes a 16-degree angle with the central peg.
Using a drill guide, drill a hole for the inferior locking screw, checking frequently to ensure that the drill is in bone by pushing on the drill while it is not rotating.
Use a 2-mm drill bit unless the bone is hard (TECH FIG 5B).
At least 36 mm of intraosseous drilling should be achieved.
If not, re-examine rotation of the metaglene with respect to the axillary border (TECH FIG 5C).
Screw Fixation
Insert the inferior locking screw (TECH FIG 6A).
Drill and insert the superior locking screw using similar technique (TECH FIG 6B,C).
TECH FIG 3 • A. Humeral resection guide inserted for cut at 0 degree of retroversion. B. Resected humerus after removal of osteophytes. (Copyright Frederick A. Matsen, MD.)
TECH FIG 4 • A. The glenoid guidewire is inserted 19 mm up from the inferior edge of the glenoid and 13 mm anterior to the posterior glenoid border. B. The Delta prosthesis.. From left to right: humeral stem, polyethylene cup, glenosphere, and metaglene. C. A step drill is inserted over the guidewire. D. Glenoid reaming is performed conservatively to preserve bone stock. (Copyright Frederick A. Matsen, MD.)
TECH FIG 5 • A. Inserting the metaglene, noting its flush position with the inferior glenoid. B. Drill guide aligned with the axillary border of the scapula. C. Verifying the intraosseous position of the inferior drill hole by direct palpation. (Copyright Frederick A. Matsen, MD.)
TECH FIG 6 • A. Desired location of the inferior screw in the axillary border of the scapula. B. Drilling the superior hole using a fixed-angle guide. C. Inserting the superior screw. D. Drilling the anterior hole using a variable-angle guide. E. Inserting anterior screw. F. The desired position of the anterior screw exiting deep in the subscapularis fossa. G. Four screws in place in the metaglene. (Copyright Frederick A. Matsen, MD.)
Drill and insert the anterior nonlocking screw, guiding orientation by palpating the anterior glenoid neck (TECH FIG 6D–F).
Drill and insert the posterior nonlocking screw (TECH FIG 6G).
Once screws have been placed, check the security of metaglene fixation.
Insert a trial glenosphere onto the metaglene.
Inspect the inferior aspect of the glenoid, removing any bone that may abut against the humeral polyethylene component.
Adequacy of bone resection can be verified by placing a trial polyethylene humeral component over the glenosphere and making sure it can be adducted fully, recalling that the humeral cup makes a 65-degree angle with the humeral shaft.
Humeral Preparation
Prepare the humeral canal in a manner that preserves bone stock by insertion of progressively larger reamers until cortical contact is just achieved (TECH FIG 7A,B).
Insert a trial stem with a metaphyseal reamer guide in 0 degrees of rotation (TECH FIG 7C).
Ream the metaphysis until bone purchase is achieved (TECH FIG 7D).
Trial Placement
Perform trial reduction of the prepared humerus (without trial components) to see if the reamed metaphysis can be reduced to the glenosphere, indicating that the humeral resection is adequate (TECH FIG 8A).
Assemble and insert the trial humeral component in 0 degrees of retroversion with a 3-mm trial plastic component (TECH FIG 8B).
Reduce the joint (TECH FIG 8C,D) and check for.
Medial abutment of plastic against the axillary border of the glenoid
Stability
Range of motion
Minimal (<2 mm) distraction on distal traction
If the joint cannot be reduced, consider lowering the humeral component position by sequentially resecting small amounts of humeral bone.
TECH FIG 7 • A. Medullary reaming of the humerus using a lateral starting point. B. Reamed medullary canal of the humerus. C. Inserting the metaphyseal reaming guide in 0 degrees of retroversion to the depth appropriate for the 36-mm prosthesis. D. Reaming the metaphysis over the metaphyseal reaming guide. (Copyright Frederick A. Matsen, MD.)
TECH FIG 8 • A. Trial reduction of the humerus. B. Insertion of a trial humeral component. C,D. Reducing the trial components. (Copyright Frederick A. Matsen, MD.)
Final Component Placement
Insert the glenosphere into the metaglene, making sure it is aligned to avoid cross-threading and making sure it is fully seated.
Securely assemble the definitive humeral component with a strong crescent wrench.
Brush and irrigate the humeral medullary canal.
Insert a cement restrictor 13 cm distal to the lateral aspect of the humeral cut.
Place six drill holes and no. 2 nonabsorbable sutures in the anterior neck cut for later reattachment of the subscapularis.
Repair the posterior cuff, if possible.
Cement the assembled humeral component in 0 degrees of retroversion without a polyethylene insert.
Trial different heights of polyethylene liners, starting with 3 mm, reducing shoulder to discover the height that allows for reduction but less than 2 mm of distraction, checking again for abutment of adducted plastic against the lateral glenoid bone inferiorly.
Insert the definitive polyethylene component, making sure it seats fully.
Irrigate the wound completely.
Reduce the joint.
Wound Closure
Repair the subscapularis to sutures previously placed at the anterior neck cut.
Place a suction drain.
Close the deltopectoral interval, close the subcutaneous layer, and close the skin with staples.
Apply dry sterile dressings and an axillary pad.
PEARLS AND PITFALLS
FIG 4 • Continuous passive motion. (Copyright Steven B. Lippitt, MD.)
POSTOPERATIVE CARE
Hemiarthroplasty with a conventional prosthesis, total glenohumeral arthroplasty, or hemiarthroplasty with a special head (eg, CTA)
Institute a continuous passive motion (FIG 4) and early active assisted motion protocol as soon as possible postoperatively (unless major partial cuff repair has been carried out).
Elevation of the arm to 140 degrees is achieved before the patient leaves the medical center.
For 6 weeks, external rotation is limited to what was easily achievable on the operating table.
Gentle progressive strengthening exercises, including the supine press, usually are started at 6 weeks.
Delta or reverse arthroplast.
Institute hand-gripping and active elbow flexion postoperatively.
Motion is withheld for 36 hours to minimize the risk of hematoma formation.
Gentle activities, such as eating, are started at 36 hours, followed by the slow, progressive addition of other activities, reminding the patient of the need for the shoulder bones and muscles to have time to remodel to their new loading patterns.
Avoid lifting anything heavier than 1 pound for 3 months.
OUTCOMES
The highly variable patient characteristics, shoulder pathology, and surgical techniques make general statements about functional and prosthetic survival difficult.
For this reason, a conservative approach to surgery is advised.
COMPLICATIONS
Systemic perioperativ.
Anesthetic complications
Deep venous thrombosis
Atelectasis
Cardiac events
Local perioperativ.
Intraoperative fracture of humerus, glenoid, acromion
Axillary nerve or plexus injury
Deltoid injury
Postoperativ.
Hematoma
Infection
Dislocation
Failure of tissue repair
Fracture of humerus, glenoid, acromion
Prosthetic loosening
Pain
Weakness
Failure to regain function
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