肩关节置换剖析课件.ppt

1、Shoulder ArthroplastyDaniel PenelloUpper Extremity RoundsApril 26,2006oLesions of the shoulder requiring arthroplasty are much less common than lesions involving the weight-bearing joints of the body,such as the hip and knee.The ShoulderoGreatest ROMoNo inherent bony stabilityoRelies on soft tissues

2、 for stabilityoMany injuries involve the soft tissues(rotator cuff,labrum)oLittle glenoid bone stockIndications for Shoulder ArthroplastyoOsteoarthritisoRheumatoid arthritisoRotator cuff tear arthropathyoAvascular necrosis oPost-traumatic arthritisoSevere proximal humeral fracturesHemiarthroplastyTo

3、tal ShoulderReverse Total ShoulderArthroplasty OptionsSurgical ApproachDeltopectoralCoracoidA little historyo1893-French surgeon Pean inserted platinum and rubber components to replace a shoulder joint destroyed by tuberculosis.o1951-Neer I,Vitallium Hemiarthroplasty prosthesis which resulted in pai

4、n relief and good function compared to previous options.o1974-Neer II Prosthesis.Modified Neer I to conform to a glenoid component.oCourtesy of Smith&Nephewo1970s-constrained components were popular,but follow-up reports demonstrated high rates of loosening,particularly of the glenoid component.o198

5、0s Modular humeral components were developed,along with cementless glenoid fixation using polyethylene on a metal backing.Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty:a prospective,double-blind,randomized study.Boileau P,Avidor C,J Shoulder E

6、lbow Surg.2002 Jul-Aug;11(4):351-9.40 Shoulders with 3 year follow up.oMetal-backed 2%radiolucent lines,100%progressive,25%loose in 3 years.Associated with shift and osteolysis.oCemented 80%radiolucent lines,25%progressive.None loose in 3 years.Other Problems with Metal-Backed Glenoid ComponentsoMet

7、al-backing increased the thickness of the component and often lead to over-stuffing of the joint.oTo avoid over-stuffing the joint,the polyethylene thickness had to be reduced,resulting in accelerated poly wear&failureoPoly-metal disassociation occurred with unacceptable frequency.Humeral Components

8、CEMENTEDPROX POROUS COATEDFULLY POROUS COATEDGood for osteopenic boneLower risk of intra-operative fractureMore stress-shieldingHard to reviseHigher risk of intra-operative fractureLess stress-shieldingEasier to reviseNeed good bone stockNeed good bone stockHigher risk intra-operative fractureMore s

9、tressshieldingHard to revise Cemented vs Press-fit Humeral ComponentsoHarris,Jobe and Dai reported less micro-motion with proximally-cemented stems.oFully cemented stems provide no additional benefit or stability over proximally-cemented stems.oSanchez-Sotelo reported a low rate of stem loosening re

10、gardless of fixation,but press-fit prostheses developed more radiolucent lines in the first 4 years.The Need for ModularityoF-H OffsetoB-C Head thicknessoD-E=8mm Top of humeral head is higher than greater tuberosityThe Need for ModularityoReestablishing normal glenohumeral anatomic relationships is

11、important to ensure optimal results.Iannotti JP;JBJS 74A 1992Other Anatomic Variables to ConsideroGlenoid:2 anteversion to 7 retroversionoHumeral Head:20-40 retroversionoAxial CT of the glenohumeral joint is a valuable pre-op planning tool.Contraindications to Shoulder ArthroplastyoActive or recent

12、shoulder joint infectionoParalysis with complete loss of rotator cuff and deltoid functionoA neuropathic arthropathyoIrreparable rotator cuff tear is a contraindication to glenoid resurfacing.OsteoarthritisoIn addition to the universal features of osteoarthritic joints(joint space narrowing,cyts,ost

13、eophytes),the shoulder can also demonstrateoPosterior glenoid erosionoFlattening of the humeral headoEnlargement of the humeral headoRotator cuff tears are uncommon in OAHemi vs Total ShoulderoEasy procedureoShort Operating timeoLess risk of instabilityoCan be revised to TSAoLess reliable pain relie

14、foProgressive Glenoid erosion may cause results to deteriorate over timeoNeed concentric glenoidoMore consistent pain reliefoBetter fulcrum for active motionoDifficult procedureoLonger OR timeoPoly wear can cause loosening of both componentsoMore Glenoid bone lossRecommendation based on ExperienceoN

15、eer,1998“When the articular surface of the glenoid is good,the results of hemiarthroplasty are similar to those of TSA.Wear on the glenoid has not been a problem if the articular surface was good at the time of surgery and glenohumeral motion was re-established”Recommendations based on EvidenceKirkl

16、ey et al,2000o42 pts,3 surgeons(stratified)oOne year follow-upoNo significant difference in WOSI,ASES,DASH Constant Score or ROM.oTrend towards better pain relief with TSA.o2 Hemi patients crossed over to TSA after 1 year follow-up.Recommendations based on EvidenceGartsman,2000o51 shouldersoAverage

17、f/u of 35 monthsoNo difference in ASES or UCLA scores.oSignificantly better pain relief with TSA o3 pts crossed over to TSA by 35 monthsA comparison of pain,strength,range of motion,and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the

18、shoulder.A systematic review and meta-analysis.Bryant D,Litchfield R;J Bone Joint Surg Am.2005 Sep;87(9):1947-56.Included 4 RCTs Average 2 year follow-up.TSA resulted in significantly improved UCLA scores,pain relief and increased forward elevation(by 13).This meta-analysis concluded that at 2 years

19、 of follow-p,TSA provided a better functional outcome,however the problems of glenoid component loosening in the TSA group and progressive glenoid erosion in the hemi group may affect the eventual long-term outcome.Longer follow-up is necessary Recommendations based on EvidenceoThe results of arthro

20、plasty in osteoarthritis of the shoulder.Haines JF et al.J Bone Joint Surg Br.2006 Apr;88(4):496-501 oProspective study of 124 shoulder arthroplasties for OA(Hemi and TSA)oSimilar improvement in pain and function in both groups if rotator cuff was intact.Better results with Hemi if+rotator cuff tear

21、oHemi Revision at mean of 1.5 years for glenoid painoTSA Revision at mean of 4.5 years for glenoid looseningTechnical Issues to ConsideroOA tends to result in posterior glenoid wear/erosion,which,if accepted,will lead to a retroverted glenoid component.oCompensate by anterior reaming or placing the

22、humeral component in LESS retroversion.oFailure to do so will result in Posterior InstabilityRheumatoid ArthritisoPeri-articular erosionsoPeri-articular osteopeniaoThin corticesoAdjacent joint involvementRheumatoid ArthritisoCemented short-stemmed prosthesisoGill,Cofield et al recommend at least 60m

23、m between the cement mantles of ipsilateral shoulder and elbow arthroplasties.oIf this cannot be achieved,join both cement mantles together.Rheumatoid ArthritisoGenerally,TSA performed due to destruction of the glenoid articular surface by the disease.oGlenoid erosion may require bone grafting,howev

24、er,if glenoid is eroded to the level of the coracoid process,glenoid resurfacing is contraindicatedRotator Cuff ArthropathyoDescribed by Neer,Craig and Fukada in 1983.oA distinct form of osteoarthritis associated with a massive chronic rotator cuff tear.oGenerally,rotator cuff tears occur in less th

25、an 10%of shoulders with OARotator Cuff ArthropathyoA function of the rotator cuff is to depress the humeral head and keep it centered on the glenoid fossa.oMassive rotator cuff tears result in proximal migration of the humeral head.oThis is a contraindication to glenoid resurfacing as it results in

26、eccentric(superior)glenoid loading and early component loosening.Surgical OptionsoHemiarthroplasty with a large head oRepair of rotator cuff and TSAoReverse TSA o“Clayton Spacer”Outcomes of HemiarthroplastyoRockwood:86%satisfactory results after 4 yearsoZuckerman:93%adequate pain relief and 90%had i

27、mproved function for ADLs.oSanches-Sotelo:75%modest improvements in ROM and strength for ADLs.Good pain relief.Outcomes of HemiarthroplastyoField et al,and Sanchez-Sotelo reported that impaired deltoid function and previous subacromial decompression (loss of coracoacromial ligament)were significantl

28、y associated with clinical shoulder instability post hemiarthroplasty.Reverse Total Shoulder ArthroplastyoLateralizes the centre of rotation and places the deltoid at a mechanical advantage.oMore inherent stability and prevents proximal migration of humeral head.Outcomes of the Reverse Total Shoulde

29、roThe Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency.A minimum two-year follow-up study of sixty patients.Frankle M,Siegel S,J Bone Joint Surg Am.2005 Aug;87(8):1697-705 oAverage age=70oImproved ASES scoresoImproved ROM Flex:55 105 Abd:41 102 o1

30、7%Complication rateo 7 failures 5 revised to new Reverse TSA 2 revised to HemiarthroplastiesOutcomes of the Reverse TSA(Delta III prosthesis)oTreatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis.Werner CM,

31、Glbart M,J Bone Joint Surg Am.2005 Jul;87(7):1476-86.o58 consecutive patients,average age=68o41 cases were revisionsoFollow up=38 monthsoImproved Constant Score,Pain reduction and improved ROM.ROM:Flex:42 100 Abd:43 90o50%complication rate(including minor)oIf a 1 surgery =18%re-operation rateoIf a R

32、evision surgery=39%re-operation rateReverse Total Shoulder Arthroplasty is Hard to ReviseoLittle Glenoid bone stock once component is removed.OsteonecrosisCauses:oCorticosteroidsoAlcoholismoSickle cell dieseseoLupusoIdiopathicOsteonecrosisoUsually young patients with adequate bone stock.oPrefer prox

33、imally porous-coated,press-fit humeral prosthesis.o less stress-shieldingo easier to revise if necessaryoOnly resurface glenoid in stage V osteonecrosis(glenoid erosion).Post-Traumatic ArthritisoDue to fractures treated conservativelyoMay have mal-union of tuberosities,distorting normal anatomic lan

34、dmarkso12%of patients have axillary nerve palsies(Neer).oMany have soft-tissue contractures and muscle weaknessChoice of ProsthesisConsideroPatient ageoCondition of glenoid surface and bone stockoAxillary nerve palsy is a relative contraindication to arthroplastyComplicationsoInstability 1.2%o Exces

35、sive Retro/Anteversiono Head too smallo Head too low(post fracture)o Subscap ruptureComplicationsoRotator Cuff Tear 2%oResults in superior migration of humerus and glenoid looseningoGlenoid looseningComplicationsoInfection 0.5%oStaph AureusoMore common after revision surgeryComplicationsoHeterotopic

36、 Ossification 10-45%o Males o Dx=osteoarthitiso Low gradeo Non-progressiveo Does not affect outcomeSperling,Cofield et alComplicationsoStiffnessoDepends on indication for arthroplastyoSubscap shorteningoOversized componentsoInappropriate rehabComplicationsoPeriprosthetic FractureoIntra-op 1%oPost-op 0.5-2%oMost common in RAo85%womenoGlenoid fractures are rareComplicationsoAxillary nerve injuryoRareoHigher risk during revision surgeryoUsually a neuropraxiaUltimate Bail-OutsoExcision ArthroplastyoShoulder Arthrodesis