Shoulder:Glenohumeral Arthritis/Anatomic Shoulder Arthroplasty - Revision history

Alexandre.laedermann: /* Postoperative Rehabilitation */

2021-08-15T06:52:39Z

Postoperative Rehabilitation

Alexandre.laedermann at 06:48, 15 August 2021

2021-08-15T06:48:56Z

Alexandre.laedermann: /* Biomechanics */

2021-07-28T16:45:12Z

Biomechanics

Alexandre.laedermann: /* Biomechanics */

2021-07-28T16:44:08Z

Biomechanics

Alexandre.laedermann: /* Biomechanics */

2021-07-28T16:41:14Z

Biomechanics

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Alexandre.laedermann: Created page with "==Bullet Points== * ==Key words== ==History== This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see wheth..."

2021-07-28T14:34:46Z

Created page with "==Bullet Points== * ==Key words== ==History== This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see wheth..."

New page

==Bullet Points==

*

==Key words==

==History==
This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.

==Anecdotes==
This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.

==Biomechanics==
===Introduction===The glenohumeral joint is a complex biomechanical entity. In the physiologic state, the shoulder relies on bony anatomy, as well as on static (labrum and ligaments) and dynamic structures (rotator cuff) to adequately balance the force couples applied to the humeral head (1).

The goal of anatomic total shoulder arthroplasty (ATSA) is, therefore, to restore the premorbid state by recreating normal shoulder kinematics. This simple objective can, however, be challenging to achieve, as anatomy is subject to premorbid variations, in addition to distortion secondary to degenerative or traumatic changes (2).

On the contrary, reverse shoulder arthroplasty (RSA) is a non-anatomic procedure that achieves stability through a semi-constrained design and relies on the deltoid and other remaining muscles to move the humerus around a fixed glenosphere. While originally intended to treat patients with cuff tear arthropathy, its indications are continually expending. Since the initial Grammont design, much innovation has been proposed to optimize active and impingement free range of motion.

This chapter provides an overview of the current biomechanical understanding of ATSA. These principles should help surgeons to plan and perform shoulder replacement surgeries in daily practice.

==Indications and Contraindications==
===Indications===
This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.

===Contraindications===
This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.

=Approaches=
===Surgical technique===
The deltopectoral approach consisted of a 10 to 15 cm skin incision being made from the coracoid process toward the deltoid insertion. The infraclavicular fossa (Mohrenheim fossa) is found, the cephalic vein identified and the consistent medial branches, which give the appearance of the Mercedes Benz symbol, are ligated. A self-retaining retractor is used to maintain exposure between the deltoid and pectoralis major. The subacromial bursa was resected to allow the placement of a Hohmann retractor under the deltoid over the top of the coracoid process. The arm was abducted and internally rotated. The subacromial bursa is resected to allow the placement of a Brown-Deltoid retractor.

====Subscapularis Tenotomy====
This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.

====Osteotomy of the Lesser Tuberosity====
The osteotomy is initiated at the bicipital groove with a 2-mm saw blade and then completed with a curved osteotome. An approximately 2.5 cm2 in the coronal plane and 5 mm thick fleck of lesser tuberosity is taken such that the osteotomy entered the joint medially without violating the humeral head.<ref>Giuseffi SA, Wongtriratanachai P, Omae H, Cil A, Zobitz ME, An KN, Sperling JW, Steinmann SP. Biomechanical comparison of lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty. J Shoulder Elbow Surg 2012;21:1087-95.</ref><ref>Ponce BA, Ahluwalia RS, Mazzocca AD, Gobezie RG, Warner JJ, Millett PJ. Biomechanical and clinical evaluation of a novel lesser tuberosity repair technique in total shoulder arthroplasty. J Bone Joint Surg Am 2005;87(Suppl 2):1-8</ref>

A complete release of the subscapularis tendon is then performed and the tendon is pushed in the subscapularis fossa. A glenoid retractor is placed anteriorly. The humeral head is resected with a guide or a free-handed anatomic cut respecting native humeral head version and inclination.

====Subscapularis Repair====
This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.

====Lesser Osteotomy Repair====
Before placement of the humeral stem, two holes are created with a 2-mm drill bit in the bicipital groove at the superior and inferior aspects of the lesser tuberosity osteotomy. One hole was created in the metaphysis just medial to the lesser tuberosity osteotomy. The sutures are then passed from lateral to medial by entering the bicipital groove, passing around the humeral stem, and exiting medially (Figure 16). A racking hitch is positioned to rest in the bicipital groove. The two sutures are passed through the subscapularis just medial to the lesser tuberosity osteotomy. The needle is removed from each construct to leave two superior and two inferior limbs (Figure 17). Then, one of the superior limbs and one of the inferior limbs were shuttled through the superior racking hitch knot (Figure 18). The suture limbs are passed through a tensioner to remove slack and to tension the repair (Figure 19).

{| class="wikitable"
|-
|[[File:Capture d’écran 2020-03-28 à 08.56.41.png|thumb|Figure 16. Passage of the sutures. A suture with a half racking suture on the end is passed from lateral to medial through the inferior two holes, and (B) a separate suture is passed through the superior hole.]]
|[[File:Capture d’écran 2020-03-28 à 08.57.27.png|thumb|Figure 17. Passage of the sutures through the subscapularis and needle removal. The stem is placed so that the sutures pass around the prosthesis. (A) The sutures are passed through the subscapularis tendon, and (B) the wedged ends are cut to provide access to four free limbs.]]
|-
|[[File:Capture d’écran 2020-03-28 à 08.58.02.png|thumb|Figure 18. Passage of the sutures through the knots. (A) One suture limb from each pair is selected and (B) passed through the half racking suture.]]
|[[File:Capture d’écran 2020-03-28 à 08.58.27.png|thumb|Figure 19. Tensioning of the sutures. The suture limbs passed through the half-racking suture are tensioned. Tensioning is done under visual inspection.]]
|}

===Postoperative Rehabilitation===

====Results====

===Complications===

=References=
<references />

@@ Line 105: / Line 105: @@
 ====Postoperative Rehabilitation====
-This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.
+A sling was worn for 4 weeks following surgery. During the first 4 weeks, these patients only performed active hand, wrist, and elbow exercises, as well as active scapular retraction exercises. At 4 weeks postoperatively, the sling is discontinued and passive forward elevation with a rope and pulley and passive external rotation with a stick were initiated as tolerated. At 8 weeks postoperatively, active assisted progression to active ROM is allowed as tolerated. Strengthening is also routinely started at 8 weeks postoperatively. Activities are allowed as tolerated at 16 weeks postoperatively with a lifetime recommendation for no repetitive lifting over 25 lb (11.3 kg).
 ====Results====

@@ Line 13: / Line 13: @@
 ==Biomechanics==
-#REDIRECT [[Target page name]]
+#REDIRECT [[https://wiki.beemed.com/view/Shoulder:Biomechanics]]
 ===Introduction===
 Anatomy is key to successfully reproduce patient’s physiologic joint kinematics. By virtue of its mobility, the glenohumeral joint is predisposed to instability. One factor affecting stability is the radius of curvature mismatch between the humeral head and glenoid. Further, only 20 to 30% of the humeral head is in contact with the glenoid.<ref name=":20">McPherson EJ, Friedman RJ, An YH, Chokesi R, Dooley RL. Anthropometric study of normal glenohumeral relationships. J Shoulder Elbow Surg. 1997;6(2):105-12</ref> The rotator cuff acts as an essential dynamic stabilizing force centering the humeral in the mid-portion of range of motion and is crucial for anatomic total shoulder arthroplasty to be effective.<ref name=":4">Sharkey NA, Marder RA. The rotator cuff opposes superior translation of the humeral head. Am J Sports Med. 1995;23(3):270-5</ref> The supraspinatus helps to center the humeral head against the force of the deltoid in lower degrees of abduction, while the infraspinatus and teres minor help to clear the greater tuberosity under the coraco-acromial arch when the arm is moved in abduction and external rotation.<ref name=":4" /><ref>Lee SB, Kim KJ, O'Driscoll SW, Morrey BF, An KN. Dynamic glenohumeral stability provided by the rotator cuff muscles in the mid-range and end-range of motion. A study in cadavera. J Bone Joint Surg Am. 2000;82(6):849-57</ref> Lastly, even though the shoulder is not a weight-bearing joint, joint reaction forces as high as 2,4 times body weight have been reported during shoulder rehabilitation.<ref>Bergmann G, Graichen F, Bender A, Rohlmann A, Halder A, Beier A, et al. In vivo gleno-humeral joint loads during forward flexion and abduction. Journal of biomechanics. 2011;44(8):1543-52</ref>

@@ Line 14: / Line 14: @@
 ==Biomechanics==
 #REDIRECT [[https://wiki.beemed.com/view/Shoulder:Biomechanics]]
 ===Introduction===
 Anatomy is key to successfully reproduce patient’s physiologic joint kinematics. By virtue of its mobility, the glenohumeral joint is predisposed to instability. One factor affecting stability is the radius of curvature mismatch between the humeral head and glenoid. Further, only 20 to 30% of the humeral head is in contact with the glenoid.<ref name=":20">McPherson EJ, Friedman RJ, An YH, Chokesi R, Dooley RL. Anthropometric study of normal glenohumeral relationships. J Shoulder Elbow Surg. 1997;6(2):105-12</ref> The rotator cuff acts as an essential dynamic stabilizing force centering the humeral in the mid-portion of range of motion and is crucial for anatomic total shoulder arthroplasty to be effective.<ref name=":4">Sharkey NA, Marder RA. The rotator cuff opposes superior translation of the humeral head. Am J Sports Med. 1995;23(3):270-5</ref> The supraspinatus helps to center the humeral head against the force of the deltoid in lower degrees of abduction, while the infraspinatus and teres minor help to clear the greater tuberosity under the coraco-acromial arch when the arm is moved in abduction and external rotation.<ref name=":4" /><ref>Lee SB, Kim KJ, O'Driscoll SW, Morrey BF, An KN. Dynamic glenohumeral stability provided by the rotator cuff muscles in the mid-range and end-range of motion. A study in cadavera. J Bone Joint Surg Am. 2000;82(6):849-57</ref> Lastly, even though the shoulder is not a weight-bearing joint, joint reaction forces as high as 2,4 times body weight have been reported during shoulder rehabilitation.<ref>Bergmann G, Graichen F, Bender A, Rohlmann A, Halder A, Beier A, et al. In vivo gleno-humeral joint loads during forward flexion and abduction. Journal of biomechanics. 2011;44(8):1543-52</ref>
@@ Line 66: / Line 67: @@
 Proper implantation technique avoiding superior inclination or retroversion is thought to be crucial to avoid edge-loading causing micromotion and subsequent breakdown at the bone-implant interface, ultimately leading to aseptic loosening.<ref name=":23" /><ref>Karelse A, Van Tongel A, Verstraeten T, Poncet D, De Wilde LF. Rocking-horse phenomenon of the glenoid component: the importance of inclination. J Shoulder Elbow Surg. 2015;24(7):1142-8</ref> For the same reason, an intact cuff is also mandatory to conserve physiologic joint kinematics and therefore limit polyethylene wear.<ref>Braun S, Schroeder S, Mueller U, Sonntag R, Buelhoff M, Kretzer JP. Influence of joint kinematics on polyethylene wear in anatomic shoulder joint arthroplasty. J Shoulder Elbow Surg. 2018;27(9):1679-85</ref> While most current anatomic total shoulder arthroplasty heads are metallic, experimental studies suggest that a change towards ceramic heads could reduce polyethylene wear rate by up to 26.7%.<ref>Mueller U, Braun S, Schroeder S, Schroeder M, Sonntag R, Jaeger S, Kretzer JP. Influence of humeral head material on wear performance in anatomic shoulder joint arthroplasty. J Shoulder Elbow Surg. 2017;26(10):1756-64</ref> A wide range of onlay all-polyethylene glenoid shapes (pear-shaped versus elliptic) and sizes are currently available on the market, with no current consensus on optimal designs regarding back-surface (flat versus curved), anchorage (keel versus peg) or level of conformity.<ref>Junaid S, Sanghavi S, Anglin C, Bull A, Emery R, Amis AA, Hansen Ul. Treatment of the Fixation Surface Improves Glenoid Prosthesis Longevity in vitro. Journal of biomechanics. 2017;61:81-7</ref> Further, a recent cadaveric study comparing inlay (implanted into the bone socket and therefore allowing for circumferential bone support) with onlay components revealed superior outcome regarding joint reaction forces and fatigue failure in favor of the inlay design.<ref>Gagliano JR, Helms SM, Colbath GP, Przestrzelski BT, Hawkins RJ, DesJardins JD. A comparison of onlay versus inlay glenoid component loosening in total shoulder arthroplasty. J Shoulder Elbow Surg. 2017;26(7):1113-20</ref> There is also renewed interest towards metal-back glenoids in response to the reported encouraging survival rates of modern designs.<ref>Castagna A, Randelli M, Garofalo R, Maradei L, Giardella A, Borroni M. Mid-term results of a metal-backed glenoid component in total shoulder replacement. J Bone Joint Surg Br. 2010;92(10):1410-5</ref> While the theoretical benefit of more stable fixation and easy conversion to reverse shoulder arthroplasty seems appealing, long-term outcomes are awaited based on the long list of retrieved pre-existing metal-back designs.<ref>Castagna A, Garofalo R. Journey of the glenoid in anatomic total shoulder replacement. Shoulder Elbow. 2019;11(2):140-8</ref>
-==Indications and Contraindications==
+==Treatment==
-===Indications===
+===Clinical Practice Guideline===
 This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.
-===Contraindications===
+===Conservative (Nonoperative) Treatment===
 This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.
-=Approaches=
+===Surgical (Operative) Treatment===
-===Surgical technique===
+====Approaches====
 The deltopectoral approach consisted of a 10 to 15 cm skin incision being made from the coracoid process toward the deltoid insertion. The infraclavicular fossa (Mohrenheim fossa) is found, the cephalic vein identified and the consistent medial branches, which give the appearance of the Mercedes Benz symbol, are ligated. A self-retaining retractor is used to maintain exposure between the deltoid and pectoralis major. The subacromial bursa was resected to allow the placement of a Hohmann retractor under the deltoid over the top of the coracoid process. The arm was abducted and internally rotated. The subacromial bursa is resected to allow the placement of a Brown-Deltoid retractor.
-====Subscapularis Tenotomy====
+======Subscapularis Tenotomy======
 This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.
-====Osteotomy of the Lesser Tuberosity====
+======Osteotomy of the Lesser Tuberosity======
 The osteotomy is initiated at the bicipital groove with a 2-mm saw blade and then completed with a curved osteotome. An approximately 2.5 cm2 in the coronal plane and 5 mm thick fleck of lesser tuberosity is taken such that the osteotomy entered the joint medially without violating the humeral head.<ref>Giuseffi SA, Wongtriratanachai P, Omae H, Cil A, Zobitz ME, An KN, Sperling JW, Steinmann SP. Biomechanical comparison of lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty. J Shoulder Elbow Surg 2012;21:1087-95.</ref><ref>Ponce BA, Ahluwalia RS, Mazzocca AD, Gobezie RG, Warner JJ, Millett PJ. Biomechanical and clinical evaluation of a novel lesser tuberosity repair technique in total shoulder arthroplasty. J Bone Joint Surg Am 2005;87(Suppl 2):1-8</ref>
 A complete release of the subscapularis tendon is then performed and the tendon is pushed in the subscapularis fossa. A glenoid retractor is placed anteriorly. The humeral head is resected with a guide or a free-handed anatomic cut respecting native humeral head version and inclination.
-====Subscapularis Repair====
+======Subscapularis Repair======
 This subsection does not exist. You can ask for it to be created, but consider checking the search results below to see whether the topic is already covered.
-====Lesser Osteotomy Repair====
+======Lesser Osteotomy Repair======
 Before placement of the humeral stem, two holes are created with a 2-mm drill bit in the bicipital groove at the superior and inferior aspects of the lesser tuberosity osteotomy. One hole was created in the metaphysis just medial to the lesser tuberosity osteotomy. The sutures are then passed from lateral to medial by entering the bicipital groove, passing around the humeral stem, and exiting medially (Figure 16). A racking hitch is positioned to rest in the bicipital groove. The two sutures are passed through the subscapularis just medial to the lesser tuberosity osteotomy. The needle is removed from each construct to leave two superior and two inferior limbs (Figure 17). Then, one of the superior limbs and one of the inferior limbs were shuttled through the superior racking hitch knot (Figure 18). The suture limbs are passed through a tensioner to remove slack and to tension the repair (Figure 19).
@@ Line 100: / Line 104: @@
 |}
-===Postoperative Rehabilitation===
+====Postoperative Rehabilitation====
 ====Results====
-===Complications===
+====Complications====
 =References=
 <references />