Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

382. Hemiarthroplasty and Total Shoulder Arthroplasty for Glenohumeral Arthritis with an Irreparable Rotator Cuff

Frederick A. Matsen III, Steven B. Lippitt, and Ryan T. Bicknell

DEFINITION

images Glenohumeral arthritis is defined as loss of the normal articular cartilage covering of the humeral head and glenoid fossa.

images An irreparable rotator cuff defect is one in which a durable attachment of detached cuff tendons to the tuberosity cannot be re-established.

images 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.

images The key points in managing these conditions are to define the following:

images The pathology

images The deficits in comfort and function experienced by the patient

images The options for reconstruction

images The benefits and risks of each of the treatment options

ANATOMY

images 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.

images The rotator cuff is a synthesis of the tendons of the subscapularis, supraspinatus, infraspinatus, and teres minor with the subjacent glenohumeral capsule.

images The rotator cuff tendons insert into the humerus just lateral to the articular cartilage and at the base of the tuberosities.

images The spherical proximal humeral convexity is formed by the smooth blending of the cuff tendons with the tuberosities.

images The radius of the proximal humeral convexity is the radius of the humeral head plus the thickness of the rotator cuff tendons.

images 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.

images The glenohumeral joint is normally stabilized by the concavity compression mechanism:

images The rotator cuff muscles compress the humeral head into the glenoid fossa.

images The deltoid compresses the proximal humeral convexity into the coracoacromial arch.

PATHOGENESIS

images Loss of glenohumeral articular cartilage can be caused by osteoarthritis, rheumatoid arthritis, neurotrophic arthritis, septic arthritis, traumatic arthritis, avascular necrosis, and iatrogenic arthritis.

images 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.

images 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.

images These defects typically begin at the anterior undersurface of the supraspinatus tendon.

images 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.

images When the superior rotator cuff is deficient, the radius of the proximal humeral convexity is decreased by the thickness of the cuff tendon.

images 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.

images The intact coracoacromial arch can provide secondary superior stability to the uncovered humeral head.

images The upward translation of the humeral head necessary to contact the arch slackens the deltoid, however, reducing its effectiveness in elevation of the arm.

images 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.

images Compromise of the coracoacromial arch coupled with a substantial rotator cuff defect permits anterosuperior escape of the humeral head on deltoid contraction.

images This anterosuperior escape eliminates the fulcrum needed for the deltoid to elevate the arm.

images The inability of a functioning deltoid to elevate the arm because of slackening and lack of a fulcrum is known as pseudoparalysis.

NATURAL HISTORY

images Rotator cuff deficiency and arthritis can occur individually or together.

images In most cases of osteoarthritis, the rotator cuff is functionally intact.

images In most cases of rheumatoid arthritis, the rotator cuff may be thinned but usually is functionally intact.

images In rotator cuff tear arthropathy, the integrity of the cuff, the articular cartilage, and the coracoacromial arch all characteristically degenerate in a progressive manner.

images Some surgeons attempt to improve the comfort and functions of individuals with rotator cuff problems by performing an acromioplasty and coracoacromial ligament section.

images Unless cuff function is durably restored, this sacrifice of the coracoacromial arch predisposes the shoulder to anterosuperior escape.

images The rotator cuff mechanism can be damaged in the process of humeral head resection during shoulder arthroplasty.

images Individuals who have had a shoulder arthroplasty may tear their rotator cuff in a fall or while lifting.

images 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

images Rotator cuff tendons fail by some combination of applied load and degeneration (“tear” and “wear”).

images 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.

images By contrast, individuals with acute traumatic rotator cuff tears from the application of substantial load do not typically progress to cuff tear arthropathy.

images 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.

images Osteoarthritis often presents without a history of injury. Instead, it presents as progressive stiffness, pain, and loss of function.

images Rheumatoid arthritis of the shoulder presents in the context of this systemic condition.

images 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.

images The integrity of the principal rotator cuff tendons is determined by the isometric strength of each of the three primary muscles in defined positions.

images Supraspinatus integrity: weakness (ie, strength grade 3 or less) indicates a full-thickness supraspinatus tear.

images Infraspinatus integrity: weakness (ie, strength grade 3 or less) indicates a large, full-thickness rotator cuff tear, extending into the infraspinatus.

images Subscapularis integrity: weakness (ie, strength grade 3 or less) indicates a full-thickness subscapularis tear.

images Defects in the rotator cuff often can be palpated just anterior to the acromion while the shoulder is passively rotated.

images Chronic cuff defects usually are accompanied by atrophy of the muscles attached to the deficient tendons.

images Cuff degeneration often is associated with subacromial crepitus on passive rotation of the humerus beneath the coracoacromial arch.

images Cuff tear arthropathy often is associated with a substantial subacromial effusion.

images 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).

images Anterosuperior escape is the exaggerated form of superior instability that results when the coracoacromial arch is compromised (FIG 1C,D).

images

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

images An anteroposterior plain radiograph in the plane of the scapula may reveal:

images Decreased acromio–humeral distance, signaling the absence of the normally interposed supraspinatus tendon

images “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)

images “Acetabularization” of the acromion-coracoid-glenoid socket (ie, sculpting of a concavity matching the femoralized proximal humerus)

images The amount of superior and medial erosion of the acromion and upper glenoid

images A true axillary view (FIG 2C,D) may reveal.

images The degree of medial glenoid erosion, ie, the amount of glenoid bone stock available for reconstruction

images The presence of anterior or posterior glenoid erosion and humeral subluxation, indicating a more complex pattern of instability

images 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:

images The approximate size of the humeral medullary cavity that may be used in prosthetic reconstruction

images Any humeral deformities that may affect prosthetic reconstruction

images We do not routinely use either CT or MRI scans, but they may be useful in clarifying the pathology.

images CT scans may help with.

images Defining glenoid bone volume and deformities

images Defining the glenohumeral relationships

images MRI scans may help with.

images Determining the condition of the different rotator cuff tendons

images Determining the condition of the different rotator cuff muscles

images The volume and location of fluid in the joint

images Other pathology, such as tumor or avascular necrosis

images Factors suggesting that the cuff defect is likely to be irreparable include:

images Insidious, atraumatic onset of cuff deficiency

images Advanced age of the patient

images History of repeated corticosteroid injections

images Systemic illness

images History of smoking

images Previous unsuccessful attempts at rotator cuff repair

images Muscle atrophy

images Superior displacement or superior instability of the glenohumeral joint

images Anterosuperior escape

images Pseudoparalysis

images

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

images Milwaukee shoulder

images Neurotrophic (Charcot) arthropathy

images Septic arthritis

images Nonseptic inflammatory arthropathy

NONOPERATIVE MANAGEMENT

images 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:

images Range-of-motion exercises in an attempt to resolve the stiffness that may accompany this condition (eg, the fourquadrant stretching program)

images Gentle progressive strengthening exercises for the deltoid and the rotator cuff musculotendinous units that remain intact (eg, the two-hand progressive supine press)

images Mild nonnarcotic analgesics may be useful in symptom control.

images 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

images 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.

images 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

images Use AP radiograph in the plane of the scapula and axillary view to identify medial, superior, anterior, posterior, or inferior glenoid erosion.

images Use AP humeral radiograph to estimate the size and fit of the humeral component (FIG 3).

images Give prophylactic antibiotics.

Delta or Reverse Arthroplasty:

images 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.

images Use AP humeral radiograph to estimate the size and fit of the diaphyseal and metaphyseal humeral components.

Positioning

images 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.

images The patient is positioned and secured with the glenohumeral joint at the edge of the operating table.

images The forequarter is doubly prepped, and the arm is draped so it can be moved freely.

Approach

images Although some surgeons advocate a deltoid-incising lateral approach, we prefer the deltopectoral approach, because it is effective, familiar, versatile, safe, and extensile.

images Each procedure strives to completely preserve and protect the deltoid and the axillary nerve.

images 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.

images

images This débridement permits complete assessment of the surgical anatomy.

images The integrity of the acromion and coracoacromial ligament is assessed and preserved.

images The subscapularis and subjacent capsule are incised from their attachment to the humerus at the lesser tuberosity.

images A 360-degree subscapularis release is carried out while the axillary nerve is protected.

images One of two types of reconstruction is selected.

images Anatomic arthroplasty, with one of the following:

images Hemiarthoplasty using a conventional prosthesis

images Total glenohumeral arthroplasty

images Hemiarthroplasty with a special head (eg, Delta CTA [cuff tear arthropathy; DePuy, Inc., Warsaw, IN])

images Delta or reverse arthroplasty

images 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.

images 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.

images Dry sterile dressings are applied.

images Continuous passive motion is used for 36 hours for all reconstructions except for the Delta or reverse arthroplasty.

images After the Delta arthroplasty, the arm is immobilized for 36 hours.

images

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

images Create a deltopectoral incision.

images Lyse adhesions and remove bursa from the humeroscapular motion interface.

images Verify irreparability of the rotator cuff tear and resect useless tendon tissue. If useful cuff elements remain, tag for later reattachment.

images Incise susbscapularis and capsule from insertion to lesser tuberosity, preserving maximal length of tendon.

images Release inferior capsule from humerus.

images Identify axillary nerve.

images Perform a 360-degree subscapularis release.

Humeral Preparation and

Implant Sizing

images Insert progressively larger reamers into the canal, stopping at the first endocortical bite (TECH FIG 1A).

images Resect the humeral head in 30 degrees of retroversion and 45 degrees with the long axis of the shaft (TECH FIG 1B).

images Measure height and diameter of the curvature of the resected head (TECH FIG 1C).

images Mince bone of the humeral head to make autogenous graft.

images 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.

images 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).

images 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).

images If glenoid arthroplasty has been performed, select the humeral head prosthesis with the appropriate diameter of curvature for the glenoid.

images If glenoid arthroplasty has not been performed, select the humeral head prosthesis with the diameter equal to that of the resected head.

Component Placement

images 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).

images Consider a special humeral head (eg, CTA head) to cover the area of the greater tuberosity (TECH FIG 2C).

images

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.)

images 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 2DG).

images Place six no. 2 nonabsorbable sutures in the anterior humeral neck cut for reattachment of the subscapularis (TECH FIG 2H).

images Assemble the definitive humeral prosthesis.

images Insert the prosthesis in the impaction-grafted medullary canal.

Final Contouring and Wound Closure

images 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.

images Repair the subscapularis.

images Insert drain.

images Close the deltopectoral interval.

images Perform subcutaneous and skin closure.

images Apply sterile dressings.

images

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

images Make a deltopectoral incision.

images Lyse adhesions and remove bursa from the humeroscapular motion interface, protecting deltoid, acromion, and residual cuff tissue.

images Verify irreparability of the rotator cuff tear and resect useless tendon tissue.

images Tag any potentially reparable elements of the cuff that are identified, for later use.

images Incise the subscapularis and capsule from insertion to lesser tuberosity, preserving maximal length of the tendon.

images Release the inferior capsule from the humerus.

images Identify the axillary nerve.

images Perform a 360-degree subscapularis release.

Humeral Preparation

images Insert humeral resection guide stem into medullary canal (TECH FIG 3A).

images Resect humeral head in zero degrees of retroversion (TECH FIG 3B).

images When the arm is pulled distally, the plane of the humeral cut should pass just below the inferior glenoid.

Glenoid Preparation

images 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.

images 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]).

images Note the relation of the inferior glenoid lip to the axillary border of the scapula.

images Remove the labrum and cartilage from the glenoid.

images Mark a point 13 mm anterior to the posterior rim of the glenoid and 19 mm superior to the inferior glenoid rim.

images Drill the guidewire into the glenoid at this point (TECH FIG 4A).

images 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.

images The inferior aspect of the metaglene should align with a line extended from the axillary border of the scapula.

images 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).

images 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

images Insert the metaglene peg into the central hole (TECH FIG 5A).

images 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.

images Recall that the inferior locking screw makes a 16-degree angle with the central peg.

images 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.

images Use a 2-mm drill bit unless the bone is hard (TECH FIG 5B).

images At least 36 mm of intraosseous drilling should be achieved.

images If not, re-examine rotation of the metaglene with respect to the axillary border (TECH FIG 5C).

Screw Fixation

images Insert the inferior locking screw (TECH FIG 6A).

images Drill and insert the superior locking screw using similar technique (TECH FIG 6B,C).

images

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.)

images

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.)

images

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.)

images

images

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.)

images Drill and insert the anterior nonlocking screw, guiding orientation by palpating the anterior glenoid neck (TECH FIG 6DF).

images Drill and insert the posterior nonlocking screw (TECH FIG 6G).

images Once screws have been placed, check the security of metaglene fixation.

images Insert a trial glenosphere onto the metaglene.

images Inspect the inferior aspect of the glenoid, removing any bone that may abut against the humeral polyethylene component.

images 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

images 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).

images Insert a trial stem with a metaphyseal reamer guide in 0 degrees of rotation (TECH FIG 7C).

images Ream the metaphysis until bone purchase is achieved (TECH FIG 7D).

Trial Placement

images 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).

images Assemble and insert the trial humeral component in 0 degrees of retroversion with a 3-mm trial plastic component (TECH FIG 8B).

images Reduce the joint (TECH FIG 8C,D) and check for.

images Medial abutment of plastic against the axillary border of the glenoid

images Stability

images Range of motion

images Minimal (<2 mm) distraction on distal traction

images If the joint cannot be reduced, consider lowering the humeral component position by sequentially resecting small amounts of humeral bone.

images

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.)

images

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

images Insert the glenosphere into the metaglene, making sure it is aligned to avoid cross-threading and making sure it is fully seated.

images Securely assemble the definitive humeral component with a strong crescent wrench.

images Brush and irrigate the humeral medullary canal.

images Insert a cement restrictor 13 cm distal to the lateral aspect of the humeral cut.

images Place six drill holes and no. 2 nonabsorbable sutures in the anterior neck cut for later reattachment of the subscapularis.

images Repair the posterior cuff, if possible.

images Cement the assembled humeral component in 0 degrees of retroversion without a polyethylene insert.

images 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.

images Insert the definitive polyethylene component, making sure it seats fully.

images Irrigate the wound completely.

images Reduce the joint.

Wound Closure

images Repair the subscapularis to sutures previously placed at the anterior neck cut.

images Place a suction drain.

images Close the deltopectoral interval, close the subcutaneous layer, and close the skin with staples.

images Apply dry sterile dressings and an axillary pad.

PEARLS AND PITFALLS

images

images

FIG 4  Continuous passive motion. (Copyright Steven B. Lippitt, MD.)

POSTOPERATIVE CARE

images Hemiarthroplasty with a conventional prosthesis, total glenohumeral arthroplasty, or hemiarthroplasty with a special head (eg, CTA)

images 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).

images Elevation of the arm to 140 degrees is achieved before the patient leaves the medical center.

images For 6 weeks, external rotation is limited to what was easily achievable on the operating table.

images Gentle progressive strengthening exercises, including the supine press, usually are started at 6 weeks.

images Delta or reverse arthroplast.

images Institute hand-gripping and active elbow flexion postoperatively.

images Motion is withheld for 36 hours to minimize the risk of hematoma formation.

images 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.

images Avoid lifting anything heavier than 1 pound for 3 months.

OUTCOMES

images The highly variable patient characteristics, shoulder pathology, and surgical techniques make general statements about functional and prosthetic survival difficult.

images For this reason, a conservative approach to surgery is advised.

COMPLICATIONS

images Systemic perioperativ.

images Anesthetic complications

images Deep venous thrombosis

images Atelectasis

images Cardiac events

images Local perioperativ.

images Intraoperative fracture of humerus, glenoid, acromion

images Axillary nerve or plexus injury

images Deltoid injury

images Postoperativ.

images Hematoma

images Infection

images Dislocation

images Failure of tissue repair

images Fracture of humerus, glenoid, acromion

images Prosthetic loosening

images Pain

images Weakness

images Failure to regain function

REFERENCES

· Boileau P, Watkinson D, et al. Neer Award 2005. The Grammont reverse shoulder prosthesis: Results in cuff tear arthritis, fracture sequelae, and revision arthroplasty. J Shoulder Elbow Surg 2006;15: 527–540.

· Boileau P, Watkinson DJ, et al. Grammont reverse prosthesis: Design, rationale, and biomechanics. J Shoulder Elbow Surg 2005;14 (1 Suppl S):147S–161S.

· Frankle M, Levy JC, et al. The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: a minimum two-year follow-up study of sixty patients' surgical technique. J Bone Joint Surg Am 2006;88A(Suppl 1 Pt 2):178–190.

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