RESULTS AND COMPLICATIONS OF

SHOULDER ARTHROPLASTY

James M. Steinberg, D.O.

Types of Shoulder Arthroplasty

• Hemiarthroplasty: humeral head replacement• Constrained Total Shoulder Arthroplasty:

ball-in-socket• Unconstrained Total Shoulder Arthroplasty:

anatomic or resurfacing• Tissue Ingrowth Total Shoulder Arthroplasty:

bony and fibrous growth into the prosthetic elements

Indications for Shoulder Arthroplasty

• Trauma: typically in three and four part proximal humerus fractures

• Avascular Necrosis of the Humeral Head• Osteoarthritis• Rheumatoid Arthritis

Goal: pain relief and restoration of movement

Hemiarthroplasty

• Neer type of prosthesis has been available for over 40 years

• Utilization in old trauma:- typically provides pain relief but incomplete motion- surgical procedure often difficult due to fibrosis of tissue and bone deformity

Hemiarthroplasty

• Utilization in old trauma: • Tanner & Cofield(1983): 28 shoulders, 89%

pain relief, avg. 112 degrees of active abduction, 1 nerve injury, 3 tuberosity/cuff problems, 2 instability, 1 ectopic bone

• Hawkins et al.(1987): 9 shoulders, 67% pain relief, avg. 140 degrees of active abduction, no complications

Hemiarthroplasty• Utilization in AVN:

- typically provides pain relief and near normal return of movement- rotator cuff and glenoid surface are usually intact

Rutherford & Cofield(1987): 11 shoulders, 100% pain relief, 161 degrees of active abduction, no complications

Hemiarthroplasty• Utilization in osteoarthritis:

• results similar to those found with AVN because the rotator cuff remains intact and a relatively painless articulation is created

• Zuckerman & Cofield(1986): 36 shoulders, 83% pain relief, avg. 132 degrees of active abduction, no complications

Hemiarthroplasty• Utilization in rheumatoid arthritis:

- pain relief often provided- return of motion depends on the extent of disease involvement of the rotator cuff and capsular tissues

• Zuckerman & Cofield(1986): 36 shoulders, 89% pain relief, avg. 106 degrees of active abduction, 1 infection, 1 nerve injury, 1 fracture

Hemiarthroplasty

• Complications are infrequent:- infection- nerve injury- iatrogenic fracture- ectopic bone formation- component failure and loosening

Hemiarthroplasty• Postoperative instability:

- lack of healing of the capsule, rotator cuff, or tuberosities- excessively strong healing with abundant fibrosis

• Careful reconstruction of the capsule and rotator cuff are crucial

• Attention to physical therapy postoperatively• If above are followed, complications are uncommon

Constrained Total Shoulder Arthroplasty

• Ball-in-socket prosthesis• Most studies have found that pain relief is

satisfactory but return of motion, abduction is limited• Complication rate high• Semiconstrained/hooded glenoid components have

been designed- results and complications similar to ball-in-socket device

Constrained Total Shoulder Arthroplasty Results

• Coughlin et al.(1979): 16 shoulders, 100% pain relief, avg. 104 degrees of active abduction, 1 infection and 1 instability

• Lettin et al.(1982): 40 shoulders, 90% pain relief, avg. 70 degrees of active abduction, 3 instability and 10 glenoid loosening

• Gristina & Webb(1982): 20 shoulders, 100% pain relief, avg. 58 degrees of active abduction, 2 instability

Constrained Total Shoulder Arthroplasty Results

• Brostrom et al.(1992): 23 shoulders, 65% pain relief, avg. 35 degrees of active abduction, 1 infection, 1 fracture, 1 instability, 3 glenoid loosening

• Laurence(1991): 71 shoulders, 80% pain relief, avg. 76 degrees of active abduction, 1 instability, 1 glenoid loosening, 4 humeral loosening

Semiconstrained Total Shoulder Arthroplasty Results

• Mazas & de la Caffiniere(1982): 32 shoulders, 91% pain relief, 3 infections, 1 nerve injury, 9 instability, 2 glenoid loosening

• Amstutz et al.(1988): 10 shoulders, 100% pain relief, avg. 85 degrees of active abduction, 1 fracture, 1 glenoid loosening

Constrained Total Shoulder Arthroplasty

• Complications:- infection- fracture- nerve injury- ectopic bone formation- dislocations- component loosening or material failure

Constrained Total Shoulder Arthroplasty

• Majority of complications are instability and glenoid component loosening

• Most dislocations and component failure require revision

• Based on the high complication rate and lack of return of abduction, its use is rarely indicated

Unconstrained Total Shoulder Arthroplasty

• Neer type of unconstrained TSA is the standard implant which others must be compared

• Indicated in patients with OA, RA, and arthritis secondary to a previous trauma

• No or slight pain is present in 90% of patients treated

Unconstrained Total Shoulder Arthroplasty

• Patients with diagnosis of RA typically only have a return of active abduction about one half normal

• Patients with diagnosis of OA typically only have a return of active abduction about three-fourths normal

Unconstrained Total Shoulder Arthroplasty Results

• Neer et al.(1982): 194 shoulders, clinical ratings; 101 excellent, 28 satisfactory, 21 unsatisfactory, 43 limited rehabilitation, 1 infection, 1 fracture, 6 instability, 7 impingement/cuff/tuberosity problem

• Cofield(1984): 73 shoulders, 92% pain relief, avg. 120 degrees of elevation, avg. 48 degrees of external rotation, 1 nerve injury, 6 impingement/cuff/tuberosity problem, 3 glenoid loosening

• Barrett et al.(1989): 140 shoulders, 93% pain relief, avg. 90 degrees of elevation, avg. 40 degrees of external rotation, 2 nerve injury, 4 instability, 3 impingement/ cuff/tuberosity problem

Unconstrained Total Shoulder Arthroplasty Results

• Hawkins et al.(1989): 70 shoulders, 90% pain relief, avg. 131 degrees of elevation, avg. 36 degrees of external rotation, 4 fracture, 1 instability, 2 impingement/cuff/tuberosity problem, 2 glenoid loosening

• Boyd et al.(1991): 131 shoulders, 95% pain relief, avg. 100 degrees of elevation, avg. 33 degrees of external rotation, 2 fracture, 1 nerve injury, 2 instability, 1 glenoid loosening

Unconstrained Total Shoulder Arthroplasty

Complications:-rotator cuff or tuberosity difficulties-instability-glenoid loosening-infection-intraoperative or postoperative fracture-nerve injury-ectopic bone formation

Unconstrained Total Shoulder Arthroplasty

• Review of 1046 Neer total shoulder replacement the complication rate was 12%, majority being an impingement/ cuff/ tuberosity problem

• Results are substantially better than the results of constrained or semiconstrained

• Rate of revision is low, most commonly for glenoid loosening

Tissue Ingrowth Total Shoulder Arthroplasty

• Developed by English & Macnab• Components are porous and allow for tissue

ingrowth• Glenoid component has superior extension and

therefore acts as a semiconstrained device• Pain relief was satisfactory in 85-90% of patients• Return of movement limited• Important to have adequate bone and joint stability

Tissue Ingrowth Total Shoulder Arthroplasty Results

• Faludi & Weiland(1983): 13 shoulders, avg. 75 degrees of active abduction, 1 infection, 2 fractures, 1 instability

• McElwin & English(1987): 13 shoulders, 85% pain relief, avg. 56 degrees of active abduction, 1 fracture, 1 instabilty, 3 component failures, 2 glenoid loosening

• Mayo Clinic(83-86): 32 shoulders, 96% pain relief, avg. 145 degrees of active abduction, 1 infection, 2 glenoid loosening, 1 humeral loosening

Tissue Ingrowth Total Shoulder Arthroplasty

Complications: slightly more common than in unconstrained implants-fracture-instability-component failure-component loosening

Summary

• Hemiarthroplasty is effective in acute fractures, (3 and 4 part), and in AVN of the humeral head

• If there is moderate glenoid involvement an unconstrained total shoulder arthroplasty is the better choice

• Little indication for constrained or semiconstrained devices

• With adequate bone, tissue ingrowth systems may be a viable alternative to cemented unconstrained systems