Shoulder Arthroplasty Syllabus

2013-09-23

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ICI I

ISTITUTO CLINICO

HUMANITAS

Disclosures and Potential Conflict of Interest

 Consultant:
 LIMA Corporate
 Conmed Linvatec
 Tornier Biologics

 Royalties:
 MD Services

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HUMANITAS

Complications of
Uncemented Metalback
Glenoid Implants:
Personal Experience &
Literature Analysis
A.Castagna, M.Borroni,
G.Delle Rose, C.F.De Biase
IRCCS CLINICAL INSTITUTE HUMANITAS
Milano - Italy

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HUMANITAS

Background

Total shoulder arthroplasty is an effective procedure for:

• Degenerative arthropathy
• Some inflamatory arthropathies
• Certain proximal humeral fractures

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TSA Vs. Hemi
The results of total shoulder arthroplasty
are better than hemiarthroplasty

JBJS 2000

JSES 2007

... BUT ….

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ISTITUTO CLINICO

HUMANITAS

Glenoid Failure
• 60% of failed TSA is the result of loosening
of the glenoid component

JSES 2002

Evolution

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•
•
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•
•
•
•
•

HUMANITAS

1975 English & McNab
1981 Smith & Nephew Cofield
1988 Biomet Biomodular
Kirschner II C
1990 Zimmer Mark 2 Copeland
1993 Biomet Mark 3 Copeland
1994-1998 Biomet Nottingham I - II Wallace
1994 Aequalis Tornier
1994-2002 Randelli - SMR Lima Randelli
1998 Arthrex Univers 3D Habermeyer
2000 Zimmer Sulmesh Gerber

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English & McNab
1975

ISTITUTO CLINICO

HUMANITAS

• 21 glenoid
• FU 3 years
• 1 loosening

CORR 1987

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HUMANITAS

Smith&Nephew Cofield I
1981

• 180 tissue ingrowth glenoid components
• 16% complication of the glenoid
component
• Conforming radius of curvature
• One small central peg
• Main Fixation: screw
CORR 1994

Smith&Nephew Cofield II

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HUMANITAS

•
•
•
•

83 ingrowth total shoulder
Medium FU 9.5 years
33 (39.7%) glenoid loosening
26 (31.3%) glenoid revision

JBJS 2008

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HUMANITAS

•
•
•
•
•

Biomet Biomodular
1988

32 cemented and 26 MB glenoid
FU 5 years
High rate dissociation PE/MB
Same clinical results
Higher rate of radiolucent lines in cemented
group

JBJS 1999

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Biomet Biomodular

HUMANITAS

• 36 TSA in Rheumatoid patients
• Mean FU 132 months (96-168)
• Survivorship: 89% at 10 years
• 1 (2.7%) glenoid loosening
• Cone peg
• Initial fixation: 2 screws

JSES 2010

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Kirschner II C

ISTITUTO CLINICO

HUMANITAS

140 uncemented glenoid;7.5 years FU
16 (11%) Clinical failures
21 (15%) Radiological failures
16 (11%) Fractured screws
53 (38%) Radiolucent line<1 mm
40 (29%) Radiolucent line 1> <2
2 (1.4%) Radiolucent line >2 mm

JBJS 2005

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HUMANITAS

•
•
•
•

Zimmer Mark 2
1993

42 TSA
FU 7.6 years
3 (7.1%) radiological loosening
3 glenoid revision
– 1 PE/MB disassociation (Design change in Mark 3)
– 1 traumatic loosening
– 1 primamry glenoid lossoening

JSES 2004

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•
•
•
•
•
•

Aequalis Tornier
1994

354 total shoulder arthroplasty with a cementless glenoid
Primary fixation was granted by 2 expansion screw
Flat glenoid
Hydroxyapatite on the porous back
Glenoid Complication 16,5%
Glenoid revision 6,4%

2000

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Aequalis Tornier

HUMANITAS

•
•
•
•
•
•

40 double blinded randomized TSA
20 PE cemented - 20 metal back
FU minimum 3 years
Radiolucent lines 85% PE - 25% MB
Revision: 0 PE (0%) - 3 MB (15%)
Failure between 1st-4th year

JSES 2002

Arthrex Univers 3D

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1998

ISTITUTO CLINICO

HUMANITAS

• 24 patients with cementless glenoid since
1998
• 26% associated with glenoid bone graft
• 95% no radiolucency
• 4% radiolucent line < 1 mm
• Cage screw
• No locked connection between cage and
MB
• No loosening

SECEC 2003

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• 22 TSA

Zimmer Sulmesh

• Mean FU 50.0 months (24-89)

• Multiple layers of highly porous titanium
• 3 (13.6%) failure but with broken peg
• No other loosening

JSES 2010

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Biomet Nottingham
1994/1998

• 90 Biomodular:
– 75.6% (8y) 71.7% (11y)

• 103 Nottingham I
– 81.8% (8y)

• Loosening mainly occured in the
first 4 y
• 34 Nottingham II
– 93.1% (4y)

BMC Muskoloskeletal Disorders 2007

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Our Experience

ISTITUTO CLINICO

HUMANITAS

• We reviewed from 1996 to 2005, 35 consecutive TSA with
SMR MB glenoid:
– 27 (77.1%) primary arthritis
– 5 (14.2%) post traumatic arthritis
– 3 (8.5%) rheumatoid arthritis

• Mean age : 62.7 years (53.9-70.8)

Titanium alloy shell with
hydroxyapatite coating
Convex back side of MB
base-plate. Lima Lto

JBJS Br 2010

Our Experience

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Pre Op: X ray and CT scan
• 77,1%
A1-A2 (slightly or severe concave glenoid)
• 17,1%
B1 (slightly biconcave glenoid)
• 5,7%
B2 (severely biconcave glenoid)

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Our Experience

Mean follow-up of 6.2 years (48-154 months)
Clinical data:
– Constant Score
– Vas
– SST

Radiological data:
– Implant position
– Radiolucent lines (Molè classification)

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Our Experience

ISTITUTO CLINICO

HUMANITAS

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HUMANITAS

SCORE

PREOP

POSTOP

CS

35.2

70.8

VAS

7.8

3.1

SST

8.4

4.4

Our Experience
27 cases (77.1%)
no radiolucent lines

8 cases (22.8%)
radiolucent lines <2mm

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Our Experience

• No PE disassembly
• No glenoid revision or loosening

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Why such different results?

• Shape: convex, not flat
• Polyethylene: material and
sterilization
• Stabilizing system: central
hollow peg, not only screws
• HA also on the peg (not only on
the MB)
• ???

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Why such different results?

• Shape: convex, not flat
• Stabilizing system: central
hollow peg, not only screws
• HA also on the peg (not only
on the MB)
• ???

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Glenoid Stabilization Elements
• 2 screws (first phase)
• Central hollow peg

Post op

5 aa

Discussion

3 poor positioning
of the screws
with no
negative effect

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Open Issues

ISTITUTO CLINICO

HUMANITAS

Polietilene wear

• Component
– Stability
– Disassembly
– Breakage

Metal wear
Osteolysis

• Overstuffing
– Soft tissue tension

Loosening

• Poliethilene wear

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Take Home Message

Glenoid is still the weak point in TSA!
– Needs more investigation, new ideas
– Do not compare pears with apples

… On the other hand ..
– Revision surgery is every day more frequent
– Metal Back glenoid may help to face the revision problems

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Istituto Clinico HUMANITAS

ISTITUTO CLINICO

HUMANITAS

alex.castagna@tin.it

9/22/2013

VuMedi Webinar
Avoiding Complications with
Shoulder Arthroplasty
9-23-2013

Periprosthetic Humeral Fractures
Tom R Norris, MD

Disclosures: Tornier, Inc. consultant, design surgeon, royalties, stock

Risk Factors for PPF
•
•
•
•

Osteopenia-older age, RA
Soft tissue contractures
Polyethylene osteolysis
Cemented, on-growth, in-growth
implant stems
• Stress riser with ipsilateral total elbow
• Technical factors
– Reaming, oversize implant, forceful
rotation
Campbell 1998, Wright, Cofield 1995, Bonutti, Hawkins 1992

Incidence: Humeral fractures in
shoulder arthroplasty
• Intraoperative fractures occurs in 0.6-3%- Primary
• Intraoperative fractures 24.1% - Revision humeral stems
– All intraoperative complications were fractures in RSA series
– Occurred during prosthesis and/or cement removal in revisions.
– Overall, this resulted in decreased patient function and
satisfaction.

• Postoperative fractures occurred in 1.4% – Primary
– All postoperative fractures, as found in most studies, were
secondary to trauma
Zumstein, Pinedo, Old, Boileau. Problems, complications, reoperations, and revisions in 782 reverse total shoulder
arthroplasty: JSES. 2011.
Wright, Cofield: Humeral fractures after shoulder arthroplasty. JBJS Am 1995.
Iannotti, Williams J Arthroplasty 2002
Campbell, Iannotti et al. JSES 1998

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Multiple classification systems

Campbell et al 1998

Classification
• Angulation
– 0-15°
– 16-30 °
– > 30 °

• Displacement
– Mild < 1/3 shaft diameter
– Mod 1/3 to 2/3 shaft diameter
– Severe > 2/3 shaft diameter
Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty. JBJS Am 1995; 77:1340-1346.

Classifications of Humeral PPF
Wright and Cofield-1995
Type

Description

Treatment

A

Above tip of stem

Conservative; functional splint

B

At tip of stem

Poor healing potential with conservative treatment.
In low demand patients, if closed reduction can be obtained, trial of
conservative management for max 90 days; if no evidence of union,
surgical intervention.
For healthy, active patients, immediate surgical intervention.

C

Distal to tip of stem

If closed reduction can be obtained, trial of conservative treatment
for up to 90 days.
If no evidence of healing, surgical intervention.

New category: Planned osteotomies in stem removal or exchange

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Proximal humeral periprosthetic fracture
classifications derive and expanded from the
Johansson 1981 classifications of PPF in the femur

Treatment options
• Non-operative B and C level fractures
•

prolonged healing and delay rehab up to 7
months

• Implant sparing
– ORIF with plate/cables/screws
– Strut allografts cable constructs
• Conversion to long stem
– Biomechanically stronger
– Removal well fixed implant problematic

• Alloprosthetic replacement
Kligman, Roffman 1999, Campbell et al 1998, Wirth, Rockwood 1996
Kelly, Purchase, Kam, Norris 2009, Norris, McElheney 1990

Avoiding Periprosthetic Fx in TSA
•
•
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•

Adequate capsular release
Avoid forceful ER of the arm
Proper patient positioning to allow exposure
Avoid endosteal notching during canal preparation
Avoid aggressive reaming—cortical breach
Avoid underreaming followed by oversized prosthesis
Preoperative templating to avoid overreaming
Beware of patient factors
– RA, osteoporosis/osteopenia, cortical thinning, previous fracture
malunion with deformity

• Creation of humeral windows or humeral unicortical
osteotomy parallel to long axis to facilitate controlled
removal of well-fixed humeral stem during revisions

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Considerations
• Will the fracture heal with non-operative
treatment?
– Fracture location, displacement, component
fixation

• Does the humeral component need to be
exchange for a different type?
• Is there bone support for the prosthesis, or is
auto or allograft support/replacement
necessary?

Stress Shielding + Osteolysis
in implant for revision

High implant, RCT, stress
shielding, and osteolysis

Meticulous use of flexible osteotomes
around the posterior fin at the GT
results successful stem removal without
fracture and preservation of bone stock

Words of caution
– When working proximally,
beware the tuberosities
•
•

It can be easy with the sclerotic, thinned
bone to causes fractures of GT and LT
Cut notches for the fins
– If tri-flange more likely to need
osteotomy 83% vs. 8%
• Phipatanakul J Shoulder Elbow Surg. 2009 SepOct;18(5):724-7

•

If they fracture/When they fracture
– Tag the cuff
– Prepare to fix it at stem implantation
– Use same techniques as hemi for fx

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Tuberosity fixation
• Racking hitch heavy
nonabsorable suture
• Place at cuff insertion to
tuberosity
• Cerclage around
humeral stem
• Tuberosity overlap shaft
• Then held with SSrotator interval closure

Techniques for tuberosity
reconstruction: Racking Hitch Knot

14

Racking hitch suture for tuberosity and
cerclage shaft fracture fixation

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Revision Surgery
10 x risk of fracture than primary!
• Much of revision is implant extraction!
• Inadvertent as well as planned controlled
fractures run risks of unanticipated nerve
injuries

Bone Preservation in Revision
• GOAL: preserve the humeral shaft circumferential
integrity and muscle attachments during stem removal.
• TECHNIQUES:
– Use flexible osteotomes around GT to loosen the implant
sufficiently for an in-line extraction
– Obtain implant specific extraction device to insert on the
top of the humeral stem with an attachable slap hammer -OR–
– stem extractor
– gouges for in-line disimpaction
– longitudinal controlled osteotomy or window

Revision Instruments
be prepared!
•
•
•
•
•
•
•

Wheel burr
Sagittal saw
Flexible osteotomes
Rigid osteotomes
Ultra Drive
Drills (6-9mm)
cement extraction
sets

• System specific
extraction devices
• Reverse cutting
curettes
• Universal extraction
gouges
• Fluoroscopy
• Cerclage cable system
(metallic or polymer)

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Cement Removal
distal to implant if long IM fixation needed

•
•
•
•
•
•

6mm Ultra-Drive plug puller is used to make a central perforation in
the humeral cement mantle.
ALT: use increasing size drills (6-9mm)
Subsequent use of reverse cutting curettes
Caution: cortical perforation can occur and cause injury to the radial
nerve.
Use table so fluoroscopy can be used
Cement can deflect ultra drive and drills out thru weaker cortex!

Component Removal/Utility Instruments

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Cement Removal Instruments

Flexible Osteotomes & Handle

Flat

Radial

Fin

Revision strategies for implant removal
In-Line extraction to preserve shaft

Implant specific extraction device

gouge for in line disimpaction

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Humeral Osteotomy or Window
-For stem removal, a high
speed circular saw is used to
make a controlled
longitudinal humeral
osteotomy.
-Make the early decision to
osteotomize to preserve bone
and avoid additional fractures
and comminution
Preserve muscle attachments,
especially the deltoid
Sperling JW, Cofield RH: Humeral windows in revision shoulder arthroplasty. JSES
2005; 14:258-263.
Increasingly popular: Gohlke, Nicholson, Romeo, Kelly G9MD, Tech Shoulder Elbow

Intra-Operative GT Fx
Inadvertent greater
tuberosity fracture during
disimpaction of a straight
humeral stem with
posterior fin. This can be
avoided by either using
flexible osteotomes to
better expose the fin or
with a controlled
osteotomy in cases with
poor bone stock.
Posterior fin rests with greater tuberosity

Preserve GT

PF HHA for PHF malunited
greater tuberosity over HH and
glenoid arthrosis

There is a malunion of the
greater tuberosity; Despite the
malunion, the patient has
active FF to 115 degrees, and
maintenance of ER.

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Intraoperative GT Fx, Humeral
Osteotomy in revision

Removal of anatomic TSA with RCT, intraoperative greater tuberosity fracture,
and humeral shaft controlled osteotomy, PMMA removal, placement of polymer
cerclage cables and conversion to RSA with racking hitch GT fixation.

Avoid cx in prosthesis selection
No posterior fin-easier insertion
and removal

Short stem as ABX spacer
removable with humeral preservation

Complications-PPF with short stem

OA
Prior HS fracture

Pre-op healed old
humeral shaft fracture

Post op

8 mo

81 yo skier 8 months post-op
Periprosthetic fracture

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Healed 3 m post closed rx

11 mo

Short Stem TSAs
Bypass deformity in proximal humeral MU
Avoids new fracture

Be Prepared
Revision-bone replacement
• Allograft humerus
– R and L available

• Tubular or can create
struts
• Save native deltoid
muscle attachment with
bone and wrap around
allograft prn

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Management of Proximal bone loss
Tubular allograft for additional support and muscle attachments indicated for
humeral deficiency

Humerus – less bow than femur to pass long straight stem
RSA preferred in revisions with cuff and bone loss
Chacon J Bone Am. 2009 Jan;91(1):119-27

Risk of absent proximal bone support

Prosthesis removal for sepsis
radial nerve palsy

Thermal injury

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Etiology radial nerve palsy
• Drill perforate humeral
shaft
• Ultra drive- heat + shaft
perforation
• Cerclage cable for
fracture fixation
• Trephine-heat with
retained stem removal
• Cement extrusion mid
shaft

• D-P approach-radial
nerve posterior at
deltoid insertion
Posteriorto
triceps
split nerve
• Safest
isolate
posteriorly

Posterior approach

Radial Nerve!
at risk with the humeral shaft procedures
• In revisions, there is
distorted, scarred anatomy;
nerve can be difficult to
identify in its normal
location along the humerus.
• Release the pectoralis, the
nerve can be traced from a
normal area on the belly of
the latissimus dorsi and
follow it as it courses
posterior to the humeral
spiral groove, then lateral
and distal.
Radial nerve palsy after humeral revision in total elbow arthroplasty. Throckmorton TW, Zarkadas PC,
Sanchez-Sotelo J, Morrey BF. JSES 2011. 20(2), 199-205.

Words of caution
• When making osteotomy
be weary of the risks of
– Uncontrolled extension of
the fracture down the
humerus
– Nerve injury
• Radial nerve is especially at
risk when fixing the
osteotomy/ placing cables
• Radial nerve is straight
posterior at the level of
deltoid

– Suggest getting full
exposure before beginning
osteotomy

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Humeral component unscrewing
due to lack of bone support

Avoid radial nerve
Cerclage racking hitch

Post Operative PHF – Type B
error to wait

Type B fx, obese body habitus

14 weeks after a fall, abundant
callus, 15 degrees varus angulation.
The fracture site is not united.
New lucency formation around the
humeral stem.

Early fixation of Type B fractures allow return to function sooner and lower
chance of nonunion.
Also allow direct examination of stem stability.

ORIF-save the stable implant

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ORIF cortical struts
• Allograft provides
immediate bone
support
• Ultimately increase
bone stock
• Aids in load dispersal
by increasing surface
area

Chandler et. Al Semin Arthroplasty 93: 17/19 fracture treated with allograft struts & cables healed
Haddad et. Al. JBJS 2002: 40 fractures treated with allograft struts secured with cables or plates. 98% union

Longer stem for IM fixation

Post-Operative PPF

Type C displaced
muscle interposition

ORIF -preserve prosthesis

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Many of the problems begin with mid humeral length stems
Bone loss from revision
humeral cemented stem,
sepsis
Then humeral allograft,
Longer IM stem fixation,
PMMA
distal plate for more distal
fracture

Periprosthetic Fractures and how to Avoid or Minimize Complications

Short stems or no stems will reduce
complications with PPF
•
•
•
•
•

Easy to insert/remove
Press fit
Convertible or exchangeable
More proximal PPF
Less interference with TER

Summary
• Periprosthetic fractures 1-3 % primary
• Up to 24% in revision surgery
• Frequently associated with treatment to preserve
or exchange standard humeral stems
• PMMA and in-growth fixation complicate revisions
• Radial nerve at risk in humeral shaft
• More instruments and techniques needed for
revisions-be prepared!
• Short stems will likely decrease potential
complications associated with longer stems

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Thank you

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Avoiding complications with
Reverse Shoulder Arthroplasty

My best tips

VuMedi Webseminar Sept 2013

DISCLOSURE
I receive
Royalties from TORNIER Inc
for patents on Shoulder Prosthesis

Complications in Reverse SA
Complic. rate

Dewilde

Rittmeister
Jacobs
Boulahia
Dewilde
Delloye
Vanhove
Sirveaux
Werner
Frankle
Our series

60%
75%
14.3%
25%
46.2%
80%
8.3%
15%
50%
17%
15.7%

About 516 cases, the average complication rate is 22%

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Total rate of complications
(Intraop + postop)
Primary
arthroplasty

Revision
Arthroplasty

15.3%

64.7%

Intraoperative complications
Primary Arthroplasty:
2.7%

Intraoperative glenoid fracture

- no reaming
- cancellous graft

Intraoperative complications
Revision Arthroplasty
30.9%

Humerus fracture: 28%
cement removal,
osteopenia,
old ladys…
a humeral window
is preferable

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Postoperative complications

Primary
Arthroplasty
12.6%

Revision
Arthroplasty
33.8%

Postoperative complications
Iary Reverse
Arthroplasty
Instability
Infection
PO hum fc
Glen loose
Neuro
Hum loose

3.3%
3%
2.6%
1.3%
0.8%
0.6%

Revision
Arthroplasty
Instability
Hum pb
Infection
Hematoma
Glen pb

10.6%
10.6%
6.4%
2.1%
1%

How to avoid infections ?
Reoperations are at risk +++

- Cement with Antibiotics (R Gobezie)
- Two stages surgery in case of doubt
(cultures & spacer for 6 weeks)

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How to avoid infections ?
Systematic cultures for any reoperation
if more than one positive
=> oral ATB for 6 weeks

How to avoid instability
with DP approach
- Use a 42 mm glenosphere

- Correct deltoid tension
- Subscapularis repair
and protection

What is deltoid « tension »?
An intraop subjective criteria (conjoint tendon’s
tension, difficult to reduce , no pistonning, complete
adduction…..)

which depends on :
etiology (Post Trauma Arthr, Rev Arthrop…. are stiffer)
anesthesia (degree of sleep, interscalene block)

Therefore assessment of deltoid length is a better
objective approach than deltoid tension

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Deltoid length
-position of the glenosphere
-height of the stem

you really control only few factors !
- Position of the glenosphere in the vertical plan (you don’t choose)
- Glenosphere size (3§ or 42 mm) (arm > 300 mm = 1%)
- Eccentric glenosphere (2 to 4 mm)
- Stem height (cut, spacer, poly) several cm: >10%
Key!

generous cut

small cut

A

B

C

D

H
P

c

c

… if CH = CP, average arm lengthening is 2.4 cm
=> deltoid tension is OK
Laedermann - JSES 2008

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Ideally the metallic top
of the prosthesis should
be just above the GT

Rather than to check the « tension »
of the deltoid,, better to respect the
length of the Humerus.

A

H

B
R





Laedermann
JSES 2008
C
C

If deltoid length is insufficient => instability

29cm

33cm

How
to avoid
glenoid
loosening

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Glenoid loosening
causes
• superior tilt, central post not in the
native glenoid (technical error)
- insufficient glenoid bone stock
(excessive indication)

Superior tilt

1996

central Post not in the native glenoid

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Insufficient glenoid bone stock

If insufficient glenoid bone stock
better to do 2 stage surgery

Influence of learning curve
- 2 consecutive cohorts of 240 Reverse SA
implanted by the same two surgeons (LNJ & GW):
• Sept 1995 -> June 2003 (8y)

(J Bone Joint Surg Am. 2007).

• July 2003 -> March 2007 (4y)

(J Shoulder Elbow Surg. 2012)

To evaluate if surgeon’s experience
modifies complications ?

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Avoiding complications: experience
Cohort 1

Cohort 2

1995-2003

2003-2007

Infection

8

1

Dislocation

15

4

Glenoid loosening

2

2

Spine fracture

2

2

Neuro complic

5

7

Humeral loosening

0

TOTAL complic

Revisions

1

16%

32 =

9%

P= 0.07

17 =

11 cases

7 cases

4.5%

2.9%

Whatabout Notching ?
Position of the sphere influences notching

cohort 1

cohort 2

Notch Gr 0, 1

49.3%

82.3%

Notch Gr 3,4

30%

8.7%

P=

p= 0.012

lowering
the sphere

Excentric sphere gives
more inferior clearance

+4mm

Lowered design

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Influence of excentric sphere
on notching
Cohort 2

Cohort 1
95-03

152 c; fu: 41m

03-07
198 c; fu: 40m

Cohort 3

07-08
52 c; fu: 30m

Notch 0-1

49.3%

82.3%

85.7%

Notch 3-4

30%

8.7%

2.4%

An other way to limit notching:

glenoid lateralization (Boileau)

Revision Arthroplasty decreased
(dramatically)

Revision
Arthroplasty

First cohort

Second cohort

22,5
%
(54 cases)

(17 cases)

7%

10

9/16/2013

Summary
The rate of complication depends on
definition, etiology, intra vs postop, surgeon experience

The main complications are: instability, infection
intraoperative fracture and glenoid loosening

Although notching is not a real complication, it is a concern
that can be addressed by improving surgical technique

Thank you

11
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