Shoulder Arthroplasty
Daniel Penello
Upper Extremity Rounds
April 26, 2006
 Lesions of the shoulder requiring
arthroplasty are much less common
than lesions involving the weightbearing joints of the body, such as
the hip and knee.
The Shoulder
 Greatest ROM
 No inherent bony
stability
 Relies on soft tissues
for stability
 Many injuries involve
the soft tissues
(rotator cuff, labrum)
 Little glenoid bone
stock
Indications for Shoulder
Arthroplasty
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Osteoarthritis
Rheumatoid arthritis
Rotator cuff tear arthropathy
Avascular necrosis
Post-traumatic arthritis
Severe proximal humeral fractures
Arthroplasty Options
Hemiarthroplasty
Reverse Total
Shoulder
Total Shoulder
Surgical Approach
Deltopectoral
Coracoid
A little history
 1893- French surgeon Pean inserted
platinum and rubber components to
replace a shoulder joint destroyed by
tuberculosis.
 1951- Neer I, Vitallium
Hemiarthroplasty prosthesis which
resulted in pain relief and good
function compared to previous
options.
 1974- Neer II Prosthesis. Modified
Neer I to conform to a glenoid
component.

Courtesy of Smith & Nephew
 1970’s - constrained
components were
popular, but follow-up
reports demonstrated
high rates of
loosening, particularly
of the glenoid
component.
 1980’s – Modular humeral
components were developed, along
with cementless glenoid fixation using
polyethylene on a metal backing.
Cemented polyethylene versus uncemented metalbacked glenoid components in total shoulder
arthroplasty: a prospective, double-blind, randomized
study.
Boileau P, Avidor C, J Shoulder Elbow Surg. 2002 Jul-
Aug;11(4):351-9.
40 Shoulders with 3 year follow up.
 Metal-backed – 2% radiolucent lines, 100%
progressive, 25% loose in 3 years. Associated with
shift and osteolysis.

Cemented – 80% radiolucent lines, 25%
progressive. None loose in 3 years.
Other Problems with Metal-Backed
Glenoid Components
 Metal-backing increased the thickness of
the component and often lead to overstuffing of the joint.
 To avoid over-stuffing the joint, the
polyethylene thickness had to be reduced,
resulting in accelerated poly wear & failure
 Poly-metal disassociation occurred with
unacceptable frequency.
Humeral Components
CEMENTED
PROX POROUS
COATED
FULLY POROUS
COATED
Good for
osteopenic bone
Need good
bone stock
Need good bone
stock
Lower risk of
intra-operative
fracture
Higher risk of
intra-operative
fracture
Higher risk
intra-operative
fracture
More stress
More stressshielding
Less stressshielding
Hard to revise
Easier to revise
shielding
Hard to revise
Cemented vs Press-fit Humeral
Components
 Harris, Jobe and Dai reported less micromotion with proximally-cemented stems.
 Fully cemented stems provide no additional
benefit or stability over proximallycemented stems.
 Sanchez-Sotelo reported a low rate of stem
loosening regardless of fixation, but pressfit prostheses developed more radiolucent
lines in the first 4 years.
The Need for Modularity
 F-H Offset
 B-C Head
thickness
 D-E = 8mm
Top of humeral
head is higher
than greater
tuberosity
The Need for Modularity
 Reestablishing normal glenohumeral
anatomic relationships is important to
ensure optimal results.
Iannotti JP; JBJS 74A 1992
Other Anatomic Variables to
Consider
 Glenoid : 2° anteversion
7° retroversion
to
 Humeral Head: 20° - 40° retroversion
 Axial CT of the glenohumeral joint is a
valuable pre-op planning tool.
Contraindications to Shoulder
Arthroplasty
 Active or recent shoulder joint
infection
 Paralysis with complete loss of rotator
cuff and deltoid function
 A neuropathic arthropathy
 Irreparable rotator cuff tear is a
contraindication to glenoid
resurfacing.
Osteoarthritis
 In addition to the universal features of
osteoarthritic joints (joint space narrowing, cyts,
osteophytes…), the shoulder can also
demonstrate
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Posterior glenoid erosion
Flattening of the humeral head
Enlargement of the humeral head
Rotator cuff tears are uncommon in OA
Hemi
vs
Total Shoulder
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Easy procedure
Short Operating time
Less risk of instability
Can be revised to TSA
 More consistent pain
relief
 Better fulcrum for
active motion
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Less reliable pain relief
Progressive Glenoid
erosion may cause
results to deteriorate
over time
Need concentric
glenoid
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Difficult procedure
Longer OR time
Poly wear can cause
loosening of both
components
More Glenoid bone loss
Recommendation based on
Experience
 Neer, 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
Evidence
Kirkley et al, 2000
 42 pts, 3 surgeons (stratified)
 One year follow-up
 No significant difference in WOSI,
ASES, DASH Constant Score or ROM.
 Trend towards better pain relief with
TSA.
 2 Hemi patients crossed over to TSA
after 1 year follow-up.
Recommendations based on
Evidence
Gartsman, 2000
 51 shoulders
 Average f/u of 35 months
 No difference in ASES or UCLA scores.
 Significantly better pain relief with
TSA
 3 pts crossed over to TSA by 35
months
A comparison of pain, strength, range of motion, and
functional outcomes after hemiarthroplasty and total
shoulder arthroplasty in patients with osteoarthritis of the
shoulder. A systematic review and meta-analysis.
Bryant D, Litchfield R; J Bone Joint Surg Am. 2005 Sep;87(9):1947-56.
Included 4 RCT’s
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 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
Evidence

The results of arthroplasty in osteoarthritis of the
shoulder. Haines JF et al. J Bone Joint Surg Br. 2006 Apr;88(4):496-501
 Prospective study of 124 shoulder arthroplasties for OA
(Hemi and TSA)
 Similar improvement in pain and function in both groups
if rotator cuff was intact . Better results with Hemi if +
rotator cuff tear
 Hemi  Revision at mean of 1.5 years for glenoid
pain
 TSA  Revision at mean of 4.5 years for glenoid
loosening
Technical Issues to Consider
 OA tends to result in posterior glenoid
wear/erosion, which, if accepted, will
lead to a retroverted glenoid
component.
 Compensate by anterior reaming or
placing the humeral component in
LESS retroversion.
 Failure to do so will result in Posterior
Instability
Rheumatoid Arthritis
 Peri-articular erosions
 Peri-articular
osteopenia
 Thin cortices
 Adjacent joint
involvement
Rheumatoid Arthritis
 Cemented short-stemmed prosthesis
 Gill, Cofield et al recommend at least
60mm between the cement mantles
of ipsilateral shoulder and elbow
arthroplasties.
 If this cannot be achieved, join both
cement mantles together.
Rheumatoid Arthritis
 Generally, TSA performed due to
destruction of the glenoid articular
surface by the disease.
 Glenoid erosion may require bone
grafting, however, if glenoid is eroded
to the level of the coracoid process,
glenoid resurfacing is contraindicated
Rotator Cuff Arthropathy
 Described by Neer, Craig and Fukada
in 1983.
 A distinct form of osteoarthritis
associated with a massive chronic
rotator cuff tear.
 Generally, rotator cuff tears occur in
less than 10% of shoulders with OA
Rotator Cuff Arthropathy
 A function of the rotator cuff is to depress
the humeral head and keep it centered on
the glenoid fossa.
 Massive rotator cuff tears result in proximal
migration of the humeral head.
 This is a contraindication to glenoid
resurfacing as it results in eccentric
(superior) glenoid loading and early
component loosening.
Surgical Options
 Hemiarthroplasty with a large head
 Repair of rotator cuff and TSA
 Reverse TSA
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“Clayton Spacer”
Outcomes of Hemiarthroplasty
 Rockwood: 86% satisfactory results
after 4 years
 Zuckerman: 93% adequate pain
relief and 90% had improved function
for ADL’s.
 Sanches-Sotelo: 75% modest
improvements in ROM and strength
for ADL’s. Good pain relief.
Outcomes of Hemiarthroplasty
 Field et al, and Sanchez-Sotelo
reported that impaired deltoid
function and previous subacromial
decompression (loss of
coracoacromial ligament) were
significantly associated with clinical
shoulder instability post
hemiarthroplasty.
Reverse Total Shoulder Arthroplasty
 Lateralizes the centre of
rotation and places the
deltoid at a mechanical
advantage.
 More inherent stability
and prevents proximal
migration of humeral
head.
Outcomes of the Reverse Total
Shoulder

The Reverse Shoulder Prosthesis for glenohumeral arthritis
associated with severe rotator cuff deficiency. A minimum twoyear follow-up study of sixty patients.
Frankle M, Siegel S, J Bone Joint Surg Am. 2005
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Aug;87(8):1697-705
Average age = 70
Improved ASES scores
Improved ROM
Flex:
Abd:
55  105°
41  102°
17% Complication rate
7 failures  5 revised to new Reverse TSA
 2 revised to Hemiarthroplasties
Outcomes of the Reverse TSA
(Delta III prosthesis)
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Treatment of painful pseudoparesis due to irreparable
rotator cuff dysfunction with the Delta III reverse-balland-socket total shoulder prosthesis.
Werner CM, Glbart M, J Bone Joint Surg Am. 2005
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Jul;87(7):1476-86.
58 consecutive patients, average age = 68
41 cases were revisions
Follow up = 38 months
Improved Constant Score, Pain reduction and improved ROM.
ROM: Flex: 42  100°
Abd: 43  90°
50% complication rate (including minor)
If a 1° surgery
= 18% re-operation rate
If a Revision surgery= 39% re-operation rate
Reverse Total Shoulder Arthroplasty
is Hard to Revise
 Little Glenoid bone
stock once
component is
removed.
Osteonecrosis
Causes:
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Corticosteroids
Alcoholism
Sickle cell diesese
Lupus
Idiopathic
Osteonecrosis
 Usually young patients with adequate
bone stock.
 Prefer proximally porous-coated,
press-fit humeral prosthesis.

less stress-shielding

easier to revise if necessary
 Only resurface glenoid in stage V
osteonecrosis (glenoid erosion).
Post-Traumatic Arthritis
 Due to fractures treated
conservatively
 May have mal-union of tuberosities,
distorting normal anatomic landmarks
 12% of patients have axillary nerve
palsies (Neer).
 Many have soft-tissue contractures
and muscle weakness
Choice of Prosthesis
Consider
 Patient age
 Condition of glenoid surface and bone
stock
 Axillary nerve palsy is a relative
contraindication to arthroplasty
Complications
 Instability 1.2%
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Excessive Retro/Anteversion
Head too small
Head too low (post fracture)
Subscap rupture
Complications
 Rotator Cuff Tear 2%
 Results in superior migration of
humerus and glenoid loosening
 Glenoid loosening
Complications
 Infection
0.5%
 Staph Aureus
 More common after revision surgery
Complications
 Heterotopic Ossification
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10 -45%
Males
Dx = osteoarthitis
Low grade
Non-progressive
Does not affect outcome
Sperling, Cofield et al
Complications
 Stiffness
 Depends on indication for
arthroplasty
 Subscap shortening
 Oversized components
 Inappropriate rehab
Complications
 Periprosthetic Fracture
 Intra-op 1%
 Post-op 0.5 - 2%
 Most common in RA
 85% women
 Glenoid fractures are rare
Complications
 Axillary nerve injury
 Rare
 Higher risk during revision surgery
 Usually a neuropraxia
Ultimate Bail -Outs
 Excision Arthroplasty
 Shoulder Arthrodesis
Thank You