Difference between revisions of "Shoulder:Glenohumeral Arthritis/Arthrodesis"

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Currently, glenohumeral arthrodesis has its place as a rather rare salvage procedure for selected patients with above diagnoses, malignant tumors or failed shoulder arthroplasty.<ref>Atlan F, Durand S, Fox M, Levy P, Belkheyar Z, Oberlin C. Functional outcome of glenohumeral fusion in brachial plexus palsy: a report of 54 cases. J Hand Surg Am. 2012;37(4):683-8.</ref><ref>Chun JM, Byeon HK. Shoulder arthrodesis with a reconstruction plate. Int Orthop. 2009;33(4):1025-30.</ref><ref>Dimmen S, Madsen JE. Long-term outcome of shoulder arthrodesis performed with plate fixation: 18 patients examined after 3-15 years. Acta Orthop. 2007;78(6):827-33.</ref><ref>Hiersemann K, Patsalis T, Saxler G. Arthroscopy-assisted glenohumeral arthrodesis: a case of uncontrollable shoulder instability Unfallchirurg. 2007;110(5):456-9.</ref><ref>Lädermann A, Denard PJ. Arthroscopic glenohumeral arthrodesis with o-arm navigation Arthrosc Tech, Arthrosc Tech. 2014;27;3(2):e205-9</ref><ref>Morgan, CD Casscells CD. Arthroscopic-assisted glenohumeral arthrodesis. Arthroscopy. 1992;8(2):262-6</ref><ref>Safran O, Iannotti JP. Arthrodesis of the shoulder. J Am Acad Orthop Surg. 2006;14(3):145-53</ref><ref>Thangarajah T, Alexander S, Bayley I, Lambert SM. Glenohumeral arthrodesis for the treatment of recurrent shoulder instability in epileptic patients. Bone Joint J. 2014;96-B(11):1525-9</ref>
 
Currently, glenohumeral arthrodesis has its place as a rather rare salvage procedure for selected patients with above diagnoses, malignant tumors or failed shoulder arthroplasty.<ref>Atlan F, Durand S, Fox M, Levy P, Belkheyar Z, Oberlin C. Functional outcome of glenohumeral fusion in brachial plexus palsy: a report of 54 cases. J Hand Surg Am. 2012;37(4):683-8.</ref><ref>Chun JM, Byeon HK. Shoulder arthrodesis with a reconstruction plate. Int Orthop. 2009;33(4):1025-30.</ref><ref>Dimmen S, Madsen JE. Long-term outcome of shoulder arthrodesis performed with plate fixation: 18 patients examined after 3-15 years. Acta Orthop. 2007;78(6):827-33.</ref><ref>Hiersemann K, Patsalis T, Saxler G. Arthroscopy-assisted glenohumeral arthrodesis: a case of uncontrollable shoulder instability Unfallchirurg. 2007;110(5):456-9.</ref><ref>Lädermann A, Denard PJ. Arthroscopic glenohumeral arthrodesis with o-arm navigation Arthrosc Tech, Arthrosc Tech. 2014;27;3(2):e205-9</ref><ref>Morgan, CD Casscells CD. Arthroscopic-assisted glenohumeral arthrodesis. Arthroscopy. 1992;8(2):262-6</ref><ref>Safran O, Iannotti JP. Arthrodesis of the shoulder. J Am Acad Orthop Surg. 2006;14(3):145-53</ref><ref>Thangarajah T, Alexander S, Bayley I, Lambert SM. Glenohumeral arthrodesis for the treatment of recurrent shoulder instability in epileptic patients. Bone Joint J. 2014;96-B(11):1525-9</ref>
  
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== Surgical Technique ==
+
==Surgical Technique==
  
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=== Plate Arthrodesis ===
+
===Plate Arthrodesis===
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A lateral deltoid splitting approach with partial deltoid release from the lateral acromion is used.<ref>Puskas GJ, Lädermann A, Hirsiger S, Hoffmeyer P, Gerber C. Revision rate after screw or plate arthrodesis of the glenohumeral joint. Orthop Traumatol Surg Res. 2017;103(6):875-84</ref> The incision is extended proximally along the scapular spine. Care is taken not to harm the axillary nerve and its course over the fixation plate is documented. The residual rotator cuff is excised and the biceps underwent tenotomy. The undersurface of the acromion is decorticated. The glenohumeral joint is exposed and if hardware from previous surgeries are in place, it is removed. The articular surfaces of the glenoid and humeral head are denuded of remaining cartilage. To determine the position of arthrodesis, the arm is placed in the position favored by the patient, usually in the desired position of about 35 to 45 degrees of abduction, 15 to 30 degrees of flexion and 30 to 40 degrees of internal rotation.<ref>Nagy L, Koch PP, Gerber C.Functional analysis of shoulder arthrodesis. J Shoulder Elbow Surg. 2004;13(4):386-95 </ref> However, most important is the intraoperative functional testing: if the patient could reach mouth and belt with his hand, the position is accepted. For plate arthrodesis, an 8 to 16-hole 4.5 reconstruction plate (Synthes, Oberdorf, Switzerland) was contoured to fit across the superior aspect of the acromion down to the humerus after temporary K-wire fixation. The plate was fixed proximally to the acromion and scapular spine and distally to the humerus with 4.5 cortical screws. Long partial threaded 6.5 cancellous screws are used for glenohumeral transfixation. The acromion can be partially osteotomized in order to get a larger humeroscapular contact area. With large glenohumeral defects, grafting can be additionally performed either with autologous bone from the ipsilateral iliac crest (one case), allograft rhBMP-2, or a combination of the two.  
+
A lateral deltoid splitting approach with partial deltoid release from the lateral acromion is used.<ref>Puskas GJ, Lädermann A, Hirsiger S, Hoffmeyer P, Gerber C. Revision rate after screw or plate arthrodesis of the glenohumeral joint. Orthop Traumatol Surg Res. 2017;103(6):875-84</ref> The incision is extended proximally along the scapular spine. Care is taken not to harm the axillary nerve and its course over the fixation plate is documented. The residual rotator cuff is excised and the biceps underwent tenotomy. The undersurface of the acromion is decorticated. The glenohumeral joint is exposed and if hardware from previous surgeries are in place, it is removed. The articular surfaces of the glenoid and humeral head are denuded of remaining cartilage. To determine the position of arthrodesis, the arm is placed in the position favored by the patient, usually in the desired position of about 35 to 45 degrees of abduction, 15 to 30 degrees of flexion and 30 to 40 degrees of internal rotation.<ref>Nagy L, Koch PP, Gerber C.Functional analysis of shoulder arthrodesis. J Shoulder Elbow Surg. 2004;13(4):386-95 </ref> However, most important is the intraoperative functional testing: if the patient could reach mouth and belt with his hand, the position is accepted. For plate arthrodesis, an 8 to 16-hole 4.5 reconstruction plate is contoured to fit across the superior aspect of the acromion down to the humerus after temporary K-wire fixation. The plate was fixed proximally to the acromion and scapular spine and distally to the humerus with 4.5 cortical screws. Long partial threaded 6.5 cancellous screws are used for glenohumeral transfixation. The acromion can be partially osteotomized in order to get a larger humeroscapular contact area. With large glenohumeral defects, grafting can be additionally performed either with autologous bone from the ipsilateral iliac crest (one case), allograft rhBMP-2, or a combination of the two.  
 
<br />
 
<br />
  
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=== Screw Arthrodesis ===
+
===Screw Arthrodesis===
 
The debridement of the glenohumeral cartilage is performed arthroscopically as the first step of the operation. For screw arthrodesis, threaded K-wires are placed through the glenohumeral joint for preliminary fixation, overdrilled and cannulated, terminally threaded 6.5 or 7.0 cancellous screws are inserted. In soft humeral cortical bone washer are used to prevent penetration of the screw head into the proximal humerus.
 
The debridement of the glenohumeral cartilage is performed arthroscopically as the first step of the operation. For screw arthrodesis, threaded K-wires are placed through the glenohumeral joint for preliminary fixation, overdrilled and cannulated, terminally threaded 6.5 or 7.0 cancellous screws are inserted. In soft humeral cortical bone washer are used to prevent penetration of the screw head into the proximal humerus.
  

Revision as of 16:29, 27 December 2020


Bullet Points[edit | edit source]

Key words[edit | edit source]

Glenohumeral joint; Shoulder; Fusion; Plate arthrodesis; Screw.

History[edit | edit source]

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Anecdotes[edit | edit source]

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Introduction

Glenohumeral arthrodesis used to be a favored surgical treatment option for patients with paralysis of the shoulder due to an underlying neurological pathology, massive rotator cuff tears, fracture sequelae, chronic instability, osteoarthritis, rheumatoid arthritis and infection.[1][2]

Biomechanics

Surgical Indication

Currently, glenohumeral arthrodesis has its place as a rather rare salvage procedure for selected patients with above diagnoses, malignant tumors or failed shoulder arthroplasty.[3][4][5][6][7][8][9][10]

Surgical Technique

Plate Arthrodesis

A lateral deltoid splitting approach with partial deltoid release from the lateral acromion is used.[11] The incision is extended proximally along the scapular spine. Care is taken not to harm the axillary nerve and its course over the fixation plate is documented. The residual rotator cuff is excised and the biceps underwent tenotomy. The undersurface of the acromion is decorticated. The glenohumeral joint is exposed and if hardware from previous surgeries are in place, it is removed. The articular surfaces of the glenoid and humeral head are denuded of remaining cartilage. To determine the position of arthrodesis, the arm is placed in the position favored by the patient, usually in the desired position of about 35 to 45 degrees of abduction, 15 to 30 degrees of flexion and 30 to 40 degrees of internal rotation.[12] However, most important is the intraoperative functional testing: if the patient could reach mouth and belt with his hand, the position is accepted. For plate arthrodesis, an 8 to 16-hole 4.5 reconstruction plate is contoured to fit across the superior aspect of the acromion down to the humerus after temporary K-wire fixation. The plate was fixed proximally to the acromion and scapular spine and distally to the humerus with 4.5 cortical screws. Long partial threaded 6.5 cancellous screws are used for glenohumeral transfixation. The acromion can be partially osteotomized in order to get a larger humeroscapular contact area. With large glenohumeral defects, grafting can be additionally performed either with autologous bone from the ipsilateral iliac crest (one case), allograft rhBMP-2, or a combination of the two.

Screw Arthrodesis

The debridement of the glenohumeral cartilage is performed arthroscopically as the first step of the operation. For screw arthrodesis, threaded K-wires are placed through the glenohumeral joint for preliminary fixation, overdrilled and cannulated, terminally threaded 6.5 or 7.0 cancellous screws are inserted. In soft humeral cortical bone washer are used to prevent penetration of the screw head into the proximal humerus.


Postoperatively, the arm was immobilized in an adjusted abduction brace for 6 to 12 weeks.

Discussion

In selected patients, glenohumeral arthrodesis can significantly reduce pain and achieve at best a reasonable function and subjective satisfaction rate. Revision rates favor plate over isolated screw fixation.[13]


References

  1. ↑ Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951;33B(2):180-91
  2. ↑ Cofield RH, Briggs BT. Glenohumeral arthrodesis. Operative and long-term functional results. J Bone Joint Surg Am. 1979;61(5):668-77.
  3. ↑ Atlan F, Durand S, Fox M, Levy P, Belkheyar Z, Oberlin C. Functional outcome of glenohumeral fusion in brachial plexus palsy: a report of 54 cases. J Hand Surg Am. 2012;37(4):683-8.
  4. ↑ Chun JM, Byeon HK. Shoulder arthrodesis with a reconstruction plate. Int Orthop. 2009;33(4):1025-30.
  5. ↑ Dimmen S, Madsen JE. Long-term outcome of shoulder arthrodesis performed with plate fixation: 18 patients examined after 3-15 years. Acta Orthop. 2007;78(6):827-33.
  6. ↑ Hiersemann K, Patsalis T, Saxler G. Arthroscopy-assisted glenohumeral arthrodesis: a case of uncontrollable shoulder instability Unfallchirurg. 2007;110(5):456-9.
  7. ↑ Lädermann A, Denard PJ. Arthroscopic glenohumeral arthrodesis with o-arm navigation Arthrosc Tech, Arthrosc Tech. 2014;27;3(2):e205-9
  8. ↑ Morgan, CD Casscells CD. Arthroscopic-assisted glenohumeral arthrodesis. Arthroscopy. 1992;8(2):262-6
  9. ↑ Safran O, Iannotti JP. Arthrodesis of the shoulder. J Am Acad Orthop Surg. 2006;14(3):145-53
  10. ↑ Thangarajah T, Alexander S, Bayley I, Lambert SM. Glenohumeral arthrodesis for the treatment of recurrent shoulder instability in epileptic patients. Bone Joint J. 2014;96-B(11):1525-9
  11. ↑ Puskas GJ, Lädermann A, Hirsiger S, Hoffmeyer P, Gerber C. Revision rate after screw or plate arthrodesis of the glenohumeral joint. Orthop Traumatol Surg Res. 2017;103(6):875-84
  12. ↑ Nagy L, Koch PP, Gerber C.Functional analysis of shoulder arthrodesis. J Shoulder Elbow Surg. 2004;13(4):386-95
  13. ↑ Puskas GJ, Lädermann A, Hirsiger S,Hoffmeyer P, Gerber C. Orthop Traumatol Surg Res. 2017;103(6):875-84
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