Treatment of cranial cruciate ligament rupture with the ligament ...
Orthopaedic Shoulder Surgeon · 2018-03-19 · arch becomes progressively loaded. C, The result is...
Transcript of Orthopaedic Shoulder Surgeon · 2018-03-19 · arch becomes progressively loaded. C, The result is...
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
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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