Shoulder replacementMr. Devinder Garewal

Orthopaedic Shoulder Surgeon

Overview

• Anatomy & biomechanics

• Clinical & radiological assessment

• Considerations for replacement

• Prosthetic options

• Operative approach

• Anaesthetic considerations

• Post-operative considerations

• Rehabilitation

• Results

Shoulder

• Unique ball & socket joint

• Great range of motion due to large humeral head and small glenoid socket

• Potentially unstable design is stabilised by action of rotator cuff

• Concavity compression: cuff compresses the humeral articular surface into the glenoid cavity

Common shoulder pathologies

• Rotator cuff tear arthropathy

• Degenerative joint disease

• Inflammatory arthritis

• Avascular necrosis

• Trauma & post traumatic arthritis

Clinical evaluation

• Range

• Cuff integrity

• Imaging:

• Plain XRs

• CT

• Ultrasound

• MRI

869Chapter 16 Glenohumeral Arthritis and Its Management

FIGURE 16-98: Rotator cuff tear arthropathy with acetabular-

ization of the coracoacromial arch and upper glenoid. FIGURE 16-99: Rotator cuff tear arthropathy with femoraliza-

tion of the proximal humerus and actetabularization of the

coracoacromial arch and upper glenoid.

FIGURE 16-100: Cuff tear arthropathy. Superior medial erosion

(dotted red line) typical of cuff tear arthropathy. (From Matsen

FA III, Lippitt SB. Shoulder Surgery: Principles and Proce-

dures. Philadelphia: Saunders; 2004:426.)

FIGURE 16-101: Acromial traction spur. A, Normal position.

B, As the humeral head moves upwards, the coracoacromial

arch becomes progressively loaded. C, The result is a traction

spur in the coracoacromial ligament. Because it lies within the

substance of the ligament, this spur does not encroach on the

rotator cuff, even though it might look impressive on the radio-

graph. D, Rotator cuff tear arthroplasty. (From Matsen FA III,

Lippitt SB. Shoulder Surgery: Principles and Procedures. Phila-

delphia: Saunders; 2004:280.)

C

A

D

B

Downloaded from ClinicalKey.com.au at Royal Australasian College of Surgeons JC December 28, 2016.For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.

CT

Assessment of cuff

• Clinical

• Intra-operative

• CT

• Soft tissue windows

• Sagittal view looking at muscle bulk & fat

• MRI

• Gold standard

Shoulder Replacements

History

• First performed 1894

• Charles Neer was the pioneer of modern shoulder replacements

• 1951: hemi-arthroplasty (for fractures)

• 1973: designed glenoid component to make first Total Shoulder Replacement

Total Shoulder Replacement

• Replace glenoid with either:

• plastic (PE) which requires cement for fixation or

• a metal component that requires screws

• Replace humerus with stem/head (uncemented or cemented)

• Requires intact rotator cuff muscles to balance the shoulder replacement and provide function to move the joint

PE glenoid

Metal back glenoid

Humeral stem

Total shoulder replacement

Reverse shoulder replacement

• Gaining popularity

• Increasing world wide use

• Glenoid and humeral components are reversed

• Relies on deltoid

Reverse shoulder replacement

Reverse shoulder replacement

Operative considerations

• Position

• Monitoring

• Pain relief

• Arm holder

• Approach

• Discharge planning

Pre-operative considerations

• Beach chair for replacement• Replacement: beach chair

• Scopes: upright V lateral

• Inter-scalene block• Excellent intra-op and post-op pain control

• Monitoring• Arterial line

• Secure airway

• Antibiotics

• TXA

• DVT prophylaxis• Mechanical

• Chemical

Position

Arm holder

Deltopectoral approachSurgical Approach

Deltopectoral

Coracoid

Post-operative care

• Should be minimal!

• Pain relief

• Oral analgesia nocte and for 2/52 post op

• IV Abs (2 doses)

• Post op XR

• Leave dressings intact 2/52

• Can shower out of sling

Rehabilitation

• Sling 4 weeks

• Can’t drive for 6 weeks

• Early movement (within safe zone)

• Protect subscapularis in anatomic shoulder replacement

• Scapular control

• Optimise cuff & deltoid function

Joint registry (2004-)

• 11.1% increase in last 12 months

• 115.5% increase since 2008

• 40% anatomic, 60% reverse (28,193 replacements)

• 70% of replacements 2016 were reverse SRs

• At 9 years, 11.3% revision for aSRs & 7.0% revision for rSRs

• Common reasons for revision include: instability/dislocation, cuff insufficiency, loosening, pain

Thank you