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Shoulder Arthroplasty for Orthopaedic Exams
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Shoulder Arthroplasty for Orthopaedic Exams
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Upload Date:
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Transcript:
Language: EN.
Segment:0 .
Good evening, everyone. My name is Amjad madani. I'm just going to be modulating the meeting today. I'm really sorry for the delay. There was a problem for me logging in and I have a slightly technical difficulty. Our presenter today is yeakel.
Honeyball is one of our mentors and he's from Singapore. So he's I think he's really eight hours, I think, ahead of us. So he's early in the morning. Our meeting today is about shoulder arthroplasty and we are going to discuss all the farces related issues regarding that topic. If you have any questions, you just put it on the chat box there on the bottom of your screen.
And now I'm just going to. And transfers you to go there. Good evening, everyone. Thank you for the introduction. My name is Hannibal. I work as an orthopedic specialist in the hip and knee unit in sandboxing hospital Singapore, which is one of the three structured government hospitals here.
Today's topic is the first US exam to open shoulder arthroplasty. The scope of this talk. Includes relevant anatomy. The aims of and the technical challenges encountered in shoulder arthroplasty surgeries. Pros and cons of different surgical approaches used. Different types of arthroplasty options available and its indications, prerequisites and contraindications.
Complications encountered and their management and some evidence that can be quoted in the exam. Late-november rejoint is a mighty axilo ball and socket joint, allowing movement in all three planes. In contrast to the hip joint, which is the other large ball and socket joint in the human body. Nino humeral joined is shallow and provides large range of motion.
This motion comes at the expense of stability, which makes humeral joined the most commonly dislocated joint in the body. Stability of the joint is provided by static and dynamic constraints. You know, general joined stabilizers are one of the most commonly quizzed topics in five past years and trauma examination.
And it is highly likely that each one of you during your exam will be asked about it and you should be able to come up with a structured answer to it. In the arthroplasty scenario, the most important stabilizers of are the static bony constraints and the dynamic concavity compression produced by the rotator cuff.
And deltoid muscles. With regard to the bony anatomy, the scapula is a water 30 degrees in the corona plain, the glenoid is reported seven degrees to the perpendicular of the scapula plain and demonstrate five degrees of superior tilt. And the humeral head is superior inclined with a aircraft and anchor of 130 degrees. And it is positioned eccentrically nine posterior to the central axis, and it is 30 degrees retro water with the epicondyle slap axis.
The core function is compared to a suspension bridge model. The subscapularis tendon forms the anterior pillar and the interest rates, and the third is minor forms the posterior. And even if there is a tear of the press. We need to stand in as long as the pillars of the suspended bridge is intact. The cuff function is maintained. Well, there is a discontinuity of either end of the field.
There will be anterior or posterior translation, and elevation of the shoulder joint will be compromised. This concept of car function should be well understood from the point of view. Coming on to the aims of an atomic shoulder arthroplasty, it is to replicate the normal native anatomy. Restore the center of rotation, offset and muscle tension and regaining the lost range of motion.
This includes replication of the anatomical parameters that was mentioned before, and any mismatch of this anatomical parameters can alter the central propagation and eventually lead to failure of the implant. Technical challenges encountered in shoulder arthroplasty include dealing with a rotator cuff deficient arthritic shoulder and one with a deficient bone stock.
Prosthetic replacement of the shoulder joint with the rotator cuff deficiency request a constrained prosthesis. The lack of tough to constrain the prosthetic humeral head causes superior migration during the initiation of objection, resulting in excessive shear forces causing superior eccentric loading of the glenoid component also referred to as the rocking horse phenomenon.
This will ultimately lead to prosthetic failure. The rivers total shoulder processes was developed to address this need for constraint in the scenario of arthroplasty with rotator cuff deficiency. The processes include two components one large Benoit hemisphere. And a humeral cup which is oriented in the horizontal direction.
The implant design transfers the center of rotation of the humerus, medial and inferior and in effect lengthens the humerus. The transfer of center of rotation has got three effects. One, it would increase the tension of the deltoid and allow for compression between the humeral socket and the sphere, thus stabilizing the prosthetic articulation. No, to me, replacing the glenoid central rotation would allow for enhanced recruitment of the anterior and the posterior deltoid muscle fibers with improved forward elevation and objection.
And number three, the humerus central location, which is located more close to the bone sphere in case of a reverse shoulder arthroplasty, would decrease the torque and shear generated and reduce the chance of baseplate loosening. Despite this clinical improvements, several mechanical problems were observed with this design. Hi incidence of scapular noting was observed due to the inferior impingement of the humeral cup on the scapula neck.
The device is associated with limited external rotation, often requiring muscle transfers for. Infuriating the. The center of rotation there is loss of normal. There is no loss of normal control, leading not only to cosmetic concern, but paradoxically decreased deltoid efficiency.
This is due to the altered pool of the deltoid in a mechanically inefficient direction. After excessive, infuriating and mutilating the central. There is also increased risk of microbial stress fracture and break in property with reversible plastic implants. Coming on to the other challenge in shoulder arthroplasty is to how to manage with glenoid bone deficiency.
In osteoarthritis, there is local law concentration and progressive Benoit suffers defamation, typically causing post to bear, resulting in it biconcave. Political strategies in managing glenoid bone defects include eccentric or anteriormente in case of minimal glenoid dysplasia. Bone grafting or metal augment of the defect in conjunction with the placement of the glenoid component.
Biologic glenoid resurfacing procedures, such as in the position of facial Kessler or meniscal allograft tissue, along with Amy arthroplasty. Coming on to the approaches in shoulder arthroplasty. Then typical approach remains the gold standard utility approach. In shoulder arthroplasty. Scapula sparing.
Andrew, superior approach is a good alternative in reverse shoulder arthroplasty in the setting of rotator cuff property as supress bellator's tendon is absent in this condition. It can also be a preferred approach for some surgeons in the setting of a three or four part proximal humerus fractures where the greater tuberosity can be retracted posterior and superior to improve the exposure.
The topical approach is a true into nervous and muscular approach, which reduces bleeding and post-operative pain. Structures are at risk in the tropical approach are axilo ulnar nerve must cutaneous nerve, and indeed it's a complex femoral artery. But the axilo ulnar nerve injury, per say, is more common with the superior approach. Humoral exposure is considered better with the topical approach and in general, superior and superior approach.
The frequently results in inadvertent or a section of the humeral head, resulting in a thicker polyethylene component. Better petrol approach provides better visualization of the inferior glenoid. And better placement of the glenoid component in its inclination and decrease the. Incidents of scapular launching. But approach is considered superior to the typical approach in overall glenoid exposure with good direct visualization of both anterior and the posterior glenoid margins, improving the surgical placement of the glenoid component.
Less inclination of the glenoid is better assist in better petrol approach, and Washington is considered better assisting and superior approach. It made the drawback of the petrol approach is that it requires subscapularis tending to be reflected to get access to the joint. And inadequate or a failed repair can lead to internal weakness and a instability.
And there are three common strategies to manage subscapularis in total shoulder arthroplasty with topical approach. No one is a tenotomy and tendon tendon repair, which is a valid option when the tendon has adequate quality and discussion. Lesser tuberosity osteotomy, which allows for bone to bone healing or repair, and the third, the most commonly used method is a slap video still peel of the attachment of the subscapularis, and we attachment with transocean's repair to the bipedal group.
Now coming on to the options available in arthroplasty. And I have to make shoulder arthroplasty is the preferred surgical option in primary osteoarthritis. Post-traumatic arthritis and inflammatory arthritis and stage four also in the course of the humeral head with glenoid involvement. A functional rotator cuff or a repairable rotator cuff tear is a request for an atomic shoulder arthroplasty.
And if there is suspected weakness of calf muscles on examination, order a preoperative MRI to assess the status of the cuff. The glenoid eroded down to the coracoid process is a contraindication for an atomic shoulder arthroplasty. Imaging with CT scan help in assessing the size and position of the defect and helps in determining the glenoid motion. Indicators for reversal include.
There are property superior escape of the humeral head indicating an incompetent economy art in which situation? Amy arthroplasty is contraindicated a massive symptomatic, irreparable rotator cuff tear in elderly with pseudo paralysis. Three or four part humoral fractures in elderly, where the tuberosity has full potential for healing.
And in failed arthroplasty, when all other options have been exhausted. Reverse shoulder arthroplasty is ideally suited for low functional demand patients with physiological age of more than 70 and sufficient bone stock for the placement of the sphere. A walking deltoid muscle and an intact actually nerve is a prerequisite for reverse shoulder arthroplasty.
Amy arthroplasty is indicated for proximal humeral fractures in elderly not suitable for open addiction, internal fixation and osteonecrosis of the humeral head, with Benoit sparing that is early stages of a course of the humeral head. It is an alternative option in primary glenoid arthritis with deficient calf, but with an intact coracoacromial ligament to prevent and superior escape of the humeral head, in which case a hemiarthroplasty with a large size humeral head is utilized.
Another indication is Blu ray, with inadequate bone stock for the placement of the component young active patients is a relatively. A relative indication where there is high chance of early glimmer component loosening in total shoulder arthroplasty. Me in 1988 stated in his original paper that and I quote when articular surface of the glenoid is good.
Results of Amy arthroplasty, you see data, anatomy, shoulder, arthroplasty. Bear on the glenoid was not a problem when the articular surface was good at the time of surgery. And humoral motion is re-established. I am put. Humeral head resurfacing is an attractive option in patients with. Arthritis associated with proximal humeral deformity that otherwise would require a corrective osteotomy replacement stem implant and also in patients with ibs-c lateral shoulder arthroplasty.
Coming on with the common complications. Infection rates after shoulder arthroplasty is relatively low. Less than 0.5% It is difficult to identify prosthetic joint infections. Preoperatively has large number of patients with operatively cultures do not show abnormality in their preoperative examination and investigation studies.
This may be due to high prevalence of slow growing microorganisms like propionibacterium acne. No state implantation is the treatment of choice for most deep infections after shoulder arthroplasty. Rate of the infection after pre-implantation is low, but functional brazils are oftentimes compromised by stiffness and calf dysfunction. There is a reporter six times greater risk of infection after shoulder arthroplasty when compared to total shoulder arthroplasty infection rates reported at around 3.8% The rate of instability after shoulder arthroplasty is estimated to be $5.
A.d. instability is associated usually with subscapularis deficiency because of failure or inefficient repair. In the management of a instability, then direct primary tendon repair is associated with high failure rate, usually requests and allograft augmentation, or epicondyle is major transfer. Austerity and stability is resistant to treatment, and there is a 60% chance of persistent instability this condition.
And more surgeons would favor the wasting and unstable shoulder arthroplasty to reverse arthroplasty. Intra operatively fractures especially common in rheumatoid arthritis when there is coexisting osteopenia and usually happens when the humerus is externally rotated for exposure. Prevention by careful and extensive soft tissue releases before applying any caution on the shaft will prevent this complication.
Also, humeral periprosthetic fractures may be treated surgically if the implant is well fixed and the fracture line is located at or distal to the tip of the prosthesis. Otherwise, surgery is required and may involve internal fixation with small clutch wires, blades and bone strips, with or without the revision of the humerus component. Kaplan watching is the most is the most common complication observed in shoulder arthroplasty implant design factors that can produce Kaplan watching include lateralized implant designs.
Decreasing next angle from the initial 155 degrees in the original Grumman processes to the current design angle of 1.35 degrees, inferior eccentricity and inferior tilt of the sphere may mitigate addiction and impingement and launching. Now, coming on to New evidence that can be quoted in the exam, this study is a systemic review of literature of total shoulder arthroplasty versus hemiarthroplasty for arthritis.
With long follow up of minimum seven years. Uh, 18 studies, 1,958 patients with 360 hemiarthroplasty and 142 total shoulder arthroplasty patients. We shouldn't rate was higher in the hemiarthroplasty group when compared to total shoulder arthroplasty. There is statistically significant improved range of movement inflection. Objection external rotation in the total shoulder arthroplasty group.
Main score was also better in the total shoulder arthroplasty complication of was slightly higher in the total shoulder arthroplasty group. So the authors concluded that the total shoulder arthroplasty presence needs less, reduce remission rates, better pain scores and range of motion, but a trend to result in more complications.
In proximal humerus fracture. There is this meta analysis published in 2016, meta analysis of seven studies. Comparing Amy arthroplasty with Bush in proximal humeral fractures, the shoulder scored a range of deflection and abduction and tuberosity healing.
Also, favorable results in favor of rubber shoulder arthroplasty only, unfavorable results in reverse shoulder arthroplasty when compared to him, he was in range of external rotation. rubber shoulder coming onto the proffer trial rubber shoulder arthroplasty was not considered a management option in proper trial one, which was published in 2015, and all the ongoing proper trial to grant compares.
Randomized the comparison of reverse shoulder, arthroplasty, Amy, arthroplasty and non-surgical care. This study is a more homogeneous study where only acute three or four part fractures of the proximal humerus are included, and only age group that is considered is over the age of 65. The study has started in December 2017, and Gore expected to go until 2023, with the result expected to be published in 2024.
Study participants of 380. And with this study, we might have the result of which is better for a proximal humeral fracture management. Thank you. Thank you very much, GQ. This was a very, very good and comprehensive talk.
I think you covered almost everything about shoulder arthroplasty and this is you made a very good point about the focus on something topic related to the farc, because our main focus here is FARC as an aspect of this topic. The most important thing is that you covered on the basic science, and I have to emphasize that your basic science is a crucial part, especially the basic science of the normal shoulder, the basic anatomy of the normal shoulder.
And then you have to emphasis on the approaches and you cover that really, really quite well. Then the basic science of the total shoulder arthroplasty and then the barsaat anatomy of the rotator cuff. The rotator cuff is important in stabilizing the shoulder and then the basic science or the questions of the reverse shoulder. And then you provide it a very beautiful evidence.
I have one question here from the group here with three. Rahm was asking what is the total shoulder replacement in inflammatory arthritis? I presume he meant to say, what are the options? OK, so that actually was mentioned in the talk in inflammatory arthritis with reasonably good bones talk a anatomy shoulder replacement is the preferred option.
Yeah, thank you very much, management option for patients who have now had a reverse shoulder, also prostate and the post-operative, I discovered that the patient I do iatrogenic axilo ulnar nerve claw palsy, what is the management option in this situation? Just run. Yeah so in case of a petrol approach, the actually nerve injury appears to be more dense.
And if you are using a superior approach, it appears to be a partial axilo policy. So the function might not be that much fully compromised. I'm not sure about the management of axilo ulnar nerve injury, where after as a complication of shoulder the plastic might have to look up, if I may.
Based on the standard nerve injuries that you would expect to see in trauma, the question will be is this a very nerve injury, which is neuropathy, a type injury versus a direct cut type injury? So you need to have a think about what was the cause of your nerve injury. If you think it's a pyrexia type injury, it's reasonable to treat this expectantly with the view that this is going to get better.
If there's no improvement in symptoms in about four weeks, 4 to six weeks, then you can proceed to nerve conduction study to confirm if this is a complete injury or an incomplete injury and how it is progressing. If if you direct cut and a proper eye to join the injury, then in that case, you need to have a chat with your plastic service or your peripheral nerve injury service if it's during the operation.
But that case, my advice is tag the nerve you will say in your exam you you do not have microscopically available. You would rather this has been dealt with by a dedicated peripheral nerve injury service, so you'll tag the nerve. So the location can be found easily. Carefully document where it is in your notes and then look at the times. Call your peripheral nerve surgeon service if it's in a second different center within the same center.
You can have the patient still asleep while your colleague comes to you in the theater and you have a discussion with one, then they will do a direct repair or nerve graft, depending on how badly damaged it is. OK I hope. Yeah, thank you very much, Juan. I think the question in the Viper stations and other pathology and to make sure replacement X-ray then complicated by axilo inevitable and its management.
That was the question. That's why I ask it either anatomic or reverse and postoperative, complicated by axilo. So the options are if you got a zillionaire injury with tenotomy shoulder replacement and you're going to revise to reverse that, you have to either transfer the pec major or you have to transfer the upper trapezius to replace the function of the deltoid.
That is the recent evidence, which is from a 2018 may. I will just post the paper for you guys. If you if anyone is interested to see. Thank you very much, guys. Then if you have to.
Segment:0 .
Good evening, everyone. My name is Amjad madani. I'm just going to be modulating the meeting today. I'm really sorry for the delay. There was a problem for me logging in and I have a slightly technical difficulty. Our presenter today is yeakel.
Honeyball is one of our mentors and he's from Singapore. So he's I think he's really eight hours, I think, ahead of us. So he's early in the morning. Our meeting today is about shoulder arthroplasty and we are going to discuss all the farces related issues regarding that topic. If you have any questions, you just put it on the chat box there on the bottom of your screen.
And now I'm just going to. And transfers you to go there. Good evening, everyone. Thank you for the introduction. My name is Hannibal. I work as an orthopedic specialist in the hip and knee unit in sandboxing hospital Singapore, which is one of the three structured government hospitals here.
Today's topic is the first US exam to open shoulder arthroplasty. The scope of this talk. Includes relevant anatomy. The aims of and the technical challenges encountered in shoulder arthroplasty surgeries. Pros and cons of different surgical approaches used. Different types of arthroplasty options available and its indications, prerequisites and contraindications.
Complications encountered and their management and some evidence that can be quoted in the exam. Late-november rejoint is a mighty axilo ball and socket joint, allowing movement in all three planes. In contrast to the hip joint, which is the other large ball and socket joint in the human body. Nino humeral joined is shallow and provides large range of motion.
This motion comes at the expense of stability, which makes humeral joined the most commonly dislocated joint in the body. Stability of the joint is provided by static and dynamic constraints. You know, general joined stabilizers are one of the most commonly quizzed topics in five past years and trauma examination.
And it is highly likely that each one of you during your exam will be asked about it and you should be able to come up with a structured answer to it. In the arthroplasty scenario, the most important stabilizers of are the static bony constraints and the dynamic concavity compression produced by the rotator cuff.
And deltoid muscles. With regard to the bony anatomy, the scapula is a water 30 degrees in the corona plain, the glenoid is reported seven degrees to the perpendicular of the scapula plain and demonstrate five degrees of superior tilt. And the humeral head is superior inclined with a aircraft and anchor of 130 degrees. And it is positioned eccentrically nine posterior to the central axis, and it is 30 degrees retro water with the epicondyle slap axis.
The core function is compared to a suspension bridge model. The subscapularis tendon forms the anterior pillar and the interest rates, and the third is minor forms the posterior. And even if there is a tear of the press. We need to stand in as long as the pillars of the suspended bridge is intact. The cuff function is maintained. Well, there is a discontinuity of either end of the field.
There will be anterior or posterior translation, and elevation of the shoulder joint will be compromised. This concept of car function should be well understood from the point of view. Coming on to the aims of an atomic shoulder arthroplasty, it is to replicate the normal native anatomy. Restore the center of rotation, offset and muscle tension and regaining the lost range of motion.
This includes replication of the anatomical parameters that was mentioned before, and any mismatch of this anatomical parameters can alter the central propagation and eventually lead to failure of the implant. Technical challenges encountered in shoulder arthroplasty include dealing with a rotator cuff deficient arthritic shoulder and one with a deficient bone stock.
Prosthetic replacement of the shoulder joint with the rotator cuff deficiency request a constrained prosthesis. The lack of tough to constrain the prosthetic humeral head causes superior migration during the initiation of objection, resulting in excessive shear forces causing superior eccentric loading of the glenoid component also referred to as the rocking horse phenomenon.
This will ultimately lead to prosthetic failure. The rivers total shoulder processes was developed to address this need for constraint in the scenario of arthroplasty with rotator cuff deficiency. The processes include two components one large Benoit hemisphere. And a humeral cup which is oriented in the horizontal direction.
The implant design transfers the center of rotation of the humerus, medial and inferior and in effect lengthens the humerus. The transfer of center of rotation has got three effects. One, it would increase the tension of the deltoid and allow for compression between the humeral socket and the sphere, thus stabilizing the prosthetic articulation. No, to me, replacing the glenoid central rotation would allow for enhanced recruitment of the anterior and the posterior deltoid muscle fibers with improved forward elevation and objection.
And number three, the humerus central location, which is located more close to the bone sphere in case of a reverse shoulder arthroplasty, would decrease the torque and shear generated and reduce the chance of baseplate loosening. Despite this clinical improvements, several mechanical problems were observed with this design. Hi incidence of scapular noting was observed due to the inferior impingement of the humeral cup on the scapula neck.
The device is associated with limited external rotation, often requiring muscle transfers for. Infuriating the. The center of rotation there is loss of normal. There is no loss of normal control, leading not only to cosmetic concern, but paradoxically decreased deltoid efficiency.
This is due to the altered pool of the deltoid in a mechanically inefficient direction. After excessive, infuriating and mutilating the central. There is also increased risk of microbial stress fracture and break in property with reversible plastic implants. Coming on to the other challenge in shoulder arthroplasty is to how to manage with glenoid bone deficiency.
In osteoarthritis, there is local law concentration and progressive Benoit suffers defamation, typically causing post to bear, resulting in it biconcave. Political strategies in managing glenoid bone defects include eccentric or anteriormente in case of minimal glenoid dysplasia. Bone grafting or metal augment of the defect in conjunction with the placement of the glenoid component.
Biologic glenoid resurfacing procedures, such as in the position of facial Kessler or meniscal allograft tissue, along with Amy arthroplasty. Coming on to the approaches in shoulder arthroplasty. Then typical approach remains the gold standard utility approach. In shoulder arthroplasty. Scapula sparing.
Andrew, superior approach is a good alternative in reverse shoulder arthroplasty in the setting of rotator cuff property as supress bellator's tendon is absent in this condition. It can also be a preferred approach for some surgeons in the setting of a three or four part proximal humerus fractures where the greater tuberosity can be retracted posterior and superior to improve the exposure.
The topical approach is a true into nervous and muscular approach, which reduces bleeding and post-operative pain. Structures are at risk in the tropical approach are axilo ulnar nerve must cutaneous nerve, and indeed it's a complex femoral artery. But the axilo ulnar nerve injury, per say, is more common with the superior approach. Humoral exposure is considered better with the topical approach and in general, superior and superior approach.
The frequently results in inadvertent or a section of the humeral head, resulting in a thicker polyethylene component. Better petrol approach provides better visualization of the inferior glenoid. And better placement of the glenoid component in its inclination and decrease the. Incidents of scapular launching. But approach is considered superior to the typical approach in overall glenoid exposure with good direct visualization of both anterior and the posterior glenoid margins, improving the surgical placement of the glenoid component.
Less inclination of the glenoid is better assist in better petrol approach, and Washington is considered better assisting and superior approach. It made the drawback of the petrol approach is that it requires subscapularis tending to be reflected to get access to the joint. And inadequate or a failed repair can lead to internal weakness and a instability.
And there are three common strategies to manage subscapularis in total shoulder arthroplasty with topical approach. No one is a tenotomy and tendon tendon repair, which is a valid option when the tendon has adequate quality and discussion. Lesser tuberosity osteotomy, which allows for bone to bone healing or repair, and the third, the most commonly used method is a slap video still peel of the attachment of the subscapularis, and we attachment with transocean's repair to the bipedal group.
Now coming on to the options available in arthroplasty. And I have to make shoulder arthroplasty is the preferred surgical option in primary osteoarthritis. Post-traumatic arthritis and inflammatory arthritis and stage four also in the course of the humeral head with glenoid involvement. A functional rotator cuff or a repairable rotator cuff tear is a request for an atomic shoulder arthroplasty.
And if there is suspected weakness of calf muscles on examination, order a preoperative MRI to assess the status of the cuff. The glenoid eroded down to the coracoid process is a contraindication for an atomic shoulder arthroplasty. Imaging with CT scan help in assessing the size and position of the defect and helps in determining the glenoid motion. Indicators for reversal include.
There are property superior escape of the humeral head indicating an incompetent economy art in which situation? Amy arthroplasty is contraindicated a massive symptomatic, irreparable rotator cuff tear in elderly with pseudo paralysis. Three or four part humoral fractures in elderly, where the tuberosity has full potential for healing.
And in failed arthroplasty, when all other options have been exhausted. Reverse shoulder arthroplasty is ideally suited for low functional demand patients with physiological age of more than 70 and sufficient bone stock for the placement of the sphere. A walking deltoid muscle and an intact actually nerve is a prerequisite for reverse shoulder arthroplasty.
Amy arthroplasty is indicated for proximal humeral fractures in elderly not suitable for open addiction, internal fixation and osteonecrosis of the humeral head, with Benoit sparing that is early stages of a course of the humeral head. It is an alternative option in primary glenoid arthritis with deficient calf, but with an intact coracoacromial ligament to prevent and superior escape of the humeral head, in which case a hemiarthroplasty with a large size humeral head is utilized.
Another indication is Blu ray, with inadequate bone stock for the placement of the component young active patients is a relatively. A relative indication where there is high chance of early glimmer component loosening in total shoulder arthroplasty. Me in 1988 stated in his original paper that and I quote when articular surface of the glenoid is good.
Results of Amy arthroplasty, you see data, anatomy, shoulder, arthroplasty. Bear on the glenoid was not a problem when the articular surface was good at the time of surgery. And humoral motion is re-established. I am put. Humeral head resurfacing is an attractive option in patients with. Arthritis associated with proximal humeral deformity that otherwise would require a corrective osteotomy replacement stem implant and also in patients with ibs-c lateral shoulder arthroplasty.
Coming on with the common complications. Infection rates after shoulder arthroplasty is relatively low. Less than 0.5% It is difficult to identify prosthetic joint infections. Preoperatively has large number of patients with operatively cultures do not show abnormality in their preoperative examination and investigation studies.
This may be due to high prevalence of slow growing microorganisms like propionibacterium acne. No state implantation is the treatment of choice for most deep infections after shoulder arthroplasty. Rate of the infection after pre-implantation is low, but functional brazils are oftentimes compromised by stiffness and calf dysfunction. There is a reporter six times greater risk of infection after shoulder arthroplasty when compared to total shoulder arthroplasty infection rates reported at around 3.8% The rate of instability after shoulder arthroplasty is estimated to be $5.
A.d. instability is associated usually with subscapularis deficiency because of failure or inefficient repair. In the management of a instability, then direct primary tendon repair is associated with high failure rate, usually requests and allograft augmentation, or epicondyle is major transfer. Austerity and stability is resistant to treatment, and there is a 60% chance of persistent instability this condition.
And more surgeons would favor the wasting and unstable shoulder arthroplasty to reverse arthroplasty. Intra operatively fractures especially common in rheumatoid arthritis when there is coexisting osteopenia and usually happens when the humerus is externally rotated for exposure. Prevention by careful and extensive soft tissue releases before applying any caution on the shaft will prevent this complication.
Also, humeral periprosthetic fractures may be treated surgically if the implant is well fixed and the fracture line is located at or distal to the tip of the prosthesis. Otherwise, surgery is required and may involve internal fixation with small clutch wires, blades and bone strips, with or without the revision of the humerus component. Kaplan watching is the most is the most common complication observed in shoulder arthroplasty implant design factors that can produce Kaplan watching include lateralized implant designs.
Decreasing next angle from the initial 155 degrees in the original Grumman processes to the current design angle of 1.35 degrees, inferior eccentricity and inferior tilt of the sphere may mitigate addiction and impingement and launching. Now, coming on to New evidence that can be quoted in the exam, this study is a systemic review of literature of total shoulder arthroplasty versus hemiarthroplasty for arthritis.
With long follow up of minimum seven years. Uh, 18 studies, 1,958 patients with 360 hemiarthroplasty and 142 total shoulder arthroplasty patients. We shouldn't rate was higher in the hemiarthroplasty group when compared to total shoulder arthroplasty. There is statistically significant improved range of movement inflection. Objection external rotation in the total shoulder arthroplasty group.
Main score was also better in the total shoulder arthroplasty complication of was slightly higher in the total shoulder arthroplasty group. So the authors concluded that the total shoulder arthroplasty presence needs less, reduce remission rates, better pain scores and range of motion, but a trend to result in more complications.
In proximal humerus fracture. There is this meta analysis published in 2016, meta analysis of seven studies. Comparing Amy arthroplasty with Bush in proximal humeral fractures, the shoulder scored a range of deflection and abduction and tuberosity healing.
Also, favorable results in favor of rubber shoulder arthroplasty only, unfavorable results in reverse shoulder arthroplasty when compared to him, he was in range of external rotation. rubber shoulder coming onto the proffer trial rubber shoulder arthroplasty was not considered a management option in proper trial one, which was published in 2015, and all the ongoing proper trial to grant compares.
Randomized the comparison of reverse shoulder, arthroplasty, Amy, arthroplasty and non-surgical care. This study is a more homogeneous study where only acute three or four part fractures of the proximal humerus are included, and only age group that is considered is over the age of 65. The study has started in December 2017, and Gore expected to go until 2023, with the result expected to be published in 2024.
Study participants of 380. And with this study, we might have the result of which is better for a proximal humeral fracture management. Thank you. Thank you very much, GQ. This was a very, very good and comprehensive talk.
I think you covered almost everything about shoulder arthroplasty and this is you made a very good point about the focus on something topic related to the farc, because our main focus here is FARC as an aspect of this topic. The most important thing is that you covered on the basic science, and I have to emphasize that your basic science is a crucial part, especially the basic science of the normal shoulder, the basic anatomy of the normal shoulder.
And then you have to emphasis on the approaches and you cover that really, really quite well. Then the basic science of the total shoulder arthroplasty and then the barsaat anatomy of the rotator cuff. The rotator cuff is important in stabilizing the shoulder and then the basic science or the questions of the reverse shoulder. And then you provide it a very beautiful evidence.
I have one question here from the group here with three. Rahm was asking what is the total shoulder replacement in inflammatory arthritis? I presume he meant to say, what are the options? OK, so that actually was mentioned in the talk in inflammatory arthritis with reasonably good bones talk a anatomy shoulder replacement is the preferred option.
Yeah, thank you very much, management option for patients who have now had a reverse shoulder, also prostate and the post-operative, I discovered that the patient I do iatrogenic axilo ulnar nerve claw palsy, what is the management option in this situation? Just run. Yeah so in case of a petrol approach, the actually nerve injury appears to be more dense.
And if you are using a superior approach, it appears to be a partial axilo policy. So the function might not be that much fully compromised. I'm not sure about the management of axilo ulnar nerve injury, where after as a complication of shoulder the plastic might have to look up, if I may.
Based on the standard nerve injuries that you would expect to see in trauma, the question will be is this a very nerve injury, which is neuropathy, a type injury versus a direct cut type injury? So you need to have a think about what was the cause of your nerve injury. If you think it's a pyrexia type injury, it's reasonable to treat this expectantly with the view that this is going to get better.
If there's no improvement in symptoms in about four weeks, 4 to six weeks, then you can proceed to nerve conduction study to confirm if this is a complete injury or an incomplete injury and how it is progressing. If if you direct cut and a proper eye to join the injury, then in that case, you need to have a chat with your plastic service or your peripheral nerve injury service if it's during the operation.
But that case, my advice is tag the nerve you will say in your exam you you do not have microscopically available. You would rather this has been dealt with by a dedicated peripheral nerve injury service, so you'll tag the nerve. So the location can be found easily. Carefully document where it is in your notes and then look at the times. Call your peripheral nerve surgeon service if it's in a second different center within the same center.
You can have the patient still asleep while your colleague comes to you in the theater and you have a discussion with one, then they will do a direct repair or nerve graft, depending on how badly damaged it is. OK I hope. Yeah, thank you very much, Juan. I think the question in the Viper stations and other pathology and to make sure replacement X-ray then complicated by axilo inevitable and its management.
That was the question. That's why I ask it either anatomic or reverse and postoperative, complicated by axilo. So the options are if you got a zillionaire injury with tenotomy shoulder replacement and you're going to revise to reverse that, you have to either transfer the pec major or you have to transfer the upper trapezius to replace the function of the deltoid.
That is the recent evidence, which is from a 2018 may. I will just post the paper for you guys. If you if anyone is interested to see. Thank you very much, guys. Then if you have to.
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