Shoulder Arthroplasty Syllabus

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Disclosures and Potential Conflict of Interest

Royalties:

MD Services

Consultant:

LIMA Corporate

Conmed Linvatec

Tornier Biologics

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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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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

JSES 2007

JBJS 2000

... BUT ….

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Glenoid Failure

•60% of failed TSA is the result of loosening

of the glenoid component

JSES 2002

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Evolution

•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

•21 glenoid

•FU 3 years

•1 loosening

CORR 1987

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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

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•83 ingrowth total shoulder

•Medium FU 9.5 years

•33 (39.7%) glenoid loosening

•26 (31.3%) glenoid revision

JBJS 2008

Smith&Nephew Cofield II

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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

•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

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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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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•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

Aequalis Tornier

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Arthrex Univers 3D

1998

•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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Zimmer Sulmesh

•22 TSA

•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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•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)

Our Experience

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Mean follow-up of 6.2 years (48-154 months)

Clinical data:

–Constant Score

–Vas

–SST

Radiological data:

–Implant position

–Radiolucent lines (Molè classification)

Our Experience

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SCORE PREOP POSTOP

CS 35.2 70.8

VAS 7.8 3.1

SST 8.4 4.4

Our Experience

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27 cases (77.1%)

no radiolucent lines

8 cases (22.8%)

radiolucent lines <2mm

Our Experience

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•No PE disassembly

•No glenoid revision or loosening

Our Experience

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•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)

•???

Why such different results?

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•Shape: convex, not flat

•Stabilizing system: central

hollow peg, not only screws

•HA also on the peg (not only

on the MB)

•???

Why such different results?

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Glenoid Stabilization Elements

•2 screws (first phase)

•Central hollow peg

Discussion

Post op 5 aa

3 poor positioning

of the screws

with no

negative effect

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•Component

–Stability

–Disassembly

–Breakage

•Overstuffing

–Soft tissue tension

•Poliethilene wear

Open Issues

Polietilene wear

Metal wear

Osteolysis

Loosening

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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

alex.castagna@tin.it

9/22/2013

1

Periprosthetic Humeral Fractures

Avoiding Complications with

Shoulder Arthroplasty

9-23-2013

Tom R Norris, MD

VuMedi Webinar

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

•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

Meticulous use of flexible osteotomes

around the posterior fin at the GT

results successful stem removal without

fracture and preservation of bone stock

High implant, RCT, stress

shielding, and osteolysis

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 Sep-

Oct;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 SS-

rotator interval closure

14

Techniques for tuberosity

reconstruction: Racking Hitch Knot

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

Fin

Radial

Flat

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

81 yo skier 8 months post-op

Periprosthetic fracture

Pre-op healed old

humeral shaft fracture

OA

Prior HS fracture Post op 8 mo

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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

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

Tubular allograft for additional support and muscle attachments indicated for

humeral deficiency

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

Posterior triceps split

Posterior approach

•D-P approach-radial

nerve posterior at

deltoid insertion

•Safest to isolate nerve

posteriorly

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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Bone loss from revision

humeral cemented stem,

sepsis

Then humeral allograft,

Longer IM stem fixation,

PMMA

distal plate for more distal

fracture

Many of the problems begin with mid humeral length stems

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

Periprosthetic Fractures and how to Avoid or Minimize Complications

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

9/16/2013

1

Avoiding complications with

Reverse Shoulder Arthroplasty

My best tips

VuMedi Webseminar Sept 2013

I receive

Royalties from TORNIER Inc

for patents on Shoulder Prosthesis

DISCLOSURE

Complications in Reverse SA

About 516 cases, the average complication rate is 22%

15.7%

Our series

Frankle

50%

Werner

Sirveaux

8.3%

Vanhove

Delloye

46.2%

Dewilde

Boulahia

14.3%

Jacobs

Rittmeister

60%

Dewilde

Complic. rate

75%

25%

80%

15%

17%

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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

Revision

Arthroplasty

33.8%

Primary

Arthroplasty

12.6%

Postoperative complications

Instability 3.3%

Infection 3%

PO hum fc 2.6%

Glen loose 1.3%

Neuro 0.8%

Hum loose 0.6%

Iary Reverse

Arthroplasty

Instability 10.6%

Hum pb 10.6%

Infection 6.4%

Hematoma 2.1%

Glen pb 1%

Revision

Arthroplasty

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

A B C D

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!

small cut generous cut

c c

H

P

… 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

Laedermann

JSES 2008





H

C C

R

A B

Rather than to check the « tension »

of the deltoid,, better to respect the

length of the Humerus.

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)

1996

Superior tilt

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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Cohort 1 Cohort 2

Infection 8 1

Dislocation 15 4

Glenoid loosening 2 2

Spine fracture 2 2

Neuro complic 5 7

Humeral loosening 0 1

TOTAL complic 32 =16% 17 =9%

Revisions 11 cases

4.5%

7 cases

2.9%

Avoiding complications: experience

1995-2003 2003-2007

P= 0.07

lowering

the sphere

cohort 1 cohort 2 P =

Notch Gr 0, 1 49.3% 82.3%

p= 0.012

Notch Gr 3,4 30% 8.7%

Whatabout Notching ?

Position of the sphere influences notching

Excentric sphere gives

more inferior clearance

+4mm

Lowered design

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Cohort 1

95-03

152 c; fu: 41m

Cohort 2

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%

Influence of excentric sphere

on notching

glenoid lateralization (Boileau)

An other way to limit notching:

Revision Arthroplasty decreased

(dramatically)

First cohort Second cohort

22,5 %

(54 cases)

7 %

(17 cases)

Revision

Arthroplasty

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Summary

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

The rate of complication depends on

definition, etiology, intra vs postop, surgeon experience

Thank you