week 10 Flashcards
shoulder non-arthroplasty management
-Pain management - NSAIDS
-Intraarticular injections
-Arthroscopic debridement/capsular release
-Rehabilitation
- GHJ, ROM, strengthening (RC); scapular stabilising exercises
shoulder replacement indications
- Advanced OA and RA
-Avascular necrosis
-Traumatic arthritis
-Complete humeral fracture
-Persistent pain an impairment leading to loss of function despite conservative measures
contraindications to shoulder replacement
- Rotator cuff insufficiency
- Deltoid paralysis
- Active infection
- Younger patients
- Neuropathic joint
- People involved in higher activity levels
- Patients who are unable/unwilling to participate in rehabilitation
Types of shoulder surgery
Primary partial
- Partial resurfacing
- Hemi-resurfacing
- Stemmed hemi-shoulder
- Partial mid head
Primary
- Total resurfacing
- Total conventional
- Total reverse
- Total mid head
Revision
- Major total
- Major partial
Classes of partial shoulder replacement explained
Partial resurfacing
- One or more button prostheses to replace part of the articulating surface on one or both sides of the joint
Hemi-resurfacing
- Humeral prothesis that replaces the humeral articular surface only without resecting the head
Partial mid head
- Resection of the humeral head and replacement with a cone stemmed humeral head prothesis
Stemmed hemi-shoulder
- Resection of the humeral head and replacement with a stemmed humeral and humeral head prothesis
classes of TSR explained
Total resurfacing
- Glenoid replacement and humeral prothesis that replaces the humeral articular surface without resecting the head
Total mid head
- Glenoid replacement combined with resection of part of the humeral head and replacement with a cone stemmed humeral head prothesis
Total conventional
- Glenoid replacement combined with resection of the humeral head and replacement with a stemmed humeral head prosthesis and humeral head prothesis
Total reverse
- Glenoid replacement with a glenoid head prothesis combined with resection of the humeral head and replacement with a stemmed humeral prothesis and humeral cup prothesis
types of procedures explained
Hemiarthroplasty
- Part of the glenohumeral joint is replaced, typically the humeral head
- Replacement of only the humeral component
- Indicated when the humeral head is deteriorated or fractured but the glenoid surface is intact
- Surgery of choice if the patients has insufficient glenoid bone to support a glenoid component
- Indicated when arthritis and rotator cuff deficiencies coexist
Anatomical total shoulder replacement
- Humeral head and glenoid are replaced with implants that resemble with implants that resemble the patient’s normal anatomy
Reverse
Ball is placed on the ground and the cup part is placed on the humerus
Glenoid component has a convex spherical articular surface articulating portion of the humeral component is a concave polyethene insert
shoulder arthroplasty surgical approaches
Deltopectoral (anterior)
- Uses deltopectoral interval
- Provides excellent exposure for proximal humerus
- Detach subscapularis and anterior capsule
- Need to do capsular releases for glenoid exposure
- Risks - axillary nerve, cephalic vein
Superior
- Splits the deltoid
- Excellent humeral exposure
- May decrease instability as
- Risks - glenoid component mal-axillary nerve injury
Why chose reverse shoulder arthroplasty
- Developed to address issues encountered while treating end stage glenohumeral arthritis with rotator cuff deficiency
- Best option for elderly with pseudo paresis/pseudo paralysis
○ Pseudo paresis § Active shoulder anterior elevation off less than 90 degrees in the presence of free passive anterior caused by an mRCT (massive rotator cuff tear) ○ Pseudo paralysis § Lack of active anterior shoulder elevation greater than 90 degrees with free passive elevation after an mRCT - Average increase of elevation 56° and 96% reversal of pseudoparesis / pseudoparalysis - Improved outcomes at 20 years post PTSR - Still use same approach as TSR - Anterosuperior approach preferred - Anterior superior humeral escape - Faster rehabilitation and improved post op stability - Deltoid becomes primary elevator of arm - Latissimus transfer
To cement or to not cement?
- In conventional TSA
○ Cementless glenoid components has a significantly higher revision rate than cemented glenoid components
○ Loosening rates between cemented and cementless glenoid components were similar- In reverse TSA
○ Uncemented stems had a significantly higher incidence of early humeral migration and non-progressive radiolucent lines
○ Lower incidence of post-operative fractures of the acromion
○ Functional outcome and range of movement were equivalent in the two groups
- In reverse TSA
Post-surgical instructions/precautions
For TSR:
- Shoulder immobiliser/sling for ~4-6 weeks
- Abduction pillow ~8 weeks
- Limited abduction /ER
- ER to 40° with humerus at 0° adduction
- Place a small pillow or towel roll behind the elbow when in supine
For RTSR:
- Unstable in adduction/extension
- Do not reach behind and push to get up from chair
Revision arthroplasty Aetiology
○ Dislocation (less than 1 year)
○ Loosening of prothesis
○ Rotator cuff disease
○ Mechanical failure
○ Pain
- Risk of revision high in first 5 years post TSR - Higher risk in men and younger individuals
Complications shoulder arthroplasty
from most to least prevalent
- glenoid loosening
- secondary rotator cuff pathology
- GH instability
- stiffness
- neurological complications
- humeral loosening
- intraoperative fracture
- infection
- post op humeral fracture
shoulder arthroplasty innovations
- Stemless implants
- Short stem implants
- Vitamin E polyethylene implants
- 3D printing
- 3D CT scan
- Augmented and mixed reality applications
Prehabilitation shoulder
○ Improved pre-operative measures in pain, posture, joint mobility, muscle strength, and function
○ PT rehab program may delay the need for rTSR surgery
