Difference between revisions of "Shoulder:Glenohumeral Arthritis/Arthrodesis"
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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.<ref>Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951;33B(2):180-91</ref><ref>Cofield RH, Briggs BT. Glenohumeral arthrodesis. Operative and long-term functional results. J Bone Joint Surg Am. 1979;61(5):668-77.</ref> | 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.<ref>Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951;33B(2):180-91</ref><ref>Cofield RH, Briggs BT. Glenohumeral arthrodesis. Operative and long-term functional results. J Bone Joint Surg Am. 1979;61(5):668-77.</ref> | ||
| − | ==Biomechanics== | + | <br /> |
| + | |||
| + | == Biomechanics == | ||
==Surgical Indication== | ==Surgical Indication== | ||
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===Plate Arthrodesis=== | ===Plate Arthrodesis=== | ||
| − | 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. | + | 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 /> | ||
| − | === | + | === Arthroscopic Glenohumeral Arthrodesis +/- O-arm Navigation === |
| − | The | + | Under general anesthesia, the patient is placed on a carbon fiber table in the lateral decubitus position, with circumferential access to the right shoulder and the operative arm draped free (Table 1). The arm is held with 5 to 10 lb of balanced suspension and positioned in 20 to 30 degrees of abduction and 20 degrees of forward flexion. A posterior portal is first established. Notably, in cases of severe glenoid retroversion, it is necessary to place this portal from a more medial approach than the typical posterior portal. An anterior portal is then established with an outside-in technique using a spinal needle as a guide. While the surgeon is viewing from the posterior portal and working from the anterior portal, and then vice versa, an electrocautery probe and a 4.5-mm burr are used to lightly denude the articular surfaces of the humeral head to bleeding subchondral bone. In the setting of significant glenoid bone loss, the glenoid is prepared with a curette and microfracture only to avoid further bone loss (Figure, Video). In cases of glenoid bone loss, we do not attempt to achieve fusion between the humeral head and acromion (extra-articular fusion) because superior translation of the humeral head would lead to a loss of contact with the medialized glenoid. |
| + | A reference with reflective marker spheres is fixed to the spine of the scapula through a mini-open approach (Figure). A sterile draped O-arm is used to obtain a 3-dimensional computed tomography scan with a medium dose of irradiation, and a computer-assisted navigation system is used (Figure). The shoulder is held in a position of 30° of flexion, 20° of abduction, and 40° of internal rotation to mimic the previous position of the arm and the desired position for glenohumeral arthrodesis. With the arm held in the appropriate position, 3 to 4 guidewires for 6.5-mm cannulated screws are percutaneously inserted from the humeral head into the glenoid and from the acromion to the humeral head | ||
| + | 8 with the guidance of intraoperative computer-assisted navigation (Figure) and under direct arthroscopic visualization. Anatomic landmarks are used to avoid injury to the neurovascular structures, particularly the axillary nerve laterally. The wires are then measured and reamed for placement of 6.5-mm cannulated cancellous screws. Before tightening of the screws, cancellous allograft bone chips are placed in the glenohumeral joint under arthroscopy with an osteochondral transfer system. In soft humeral cortical bone washer are used to prevent penetration of the screw head into the proximal humerus.The screws are sequentially tightened to achieve adequate compression of the glenohumeral surfaces. The position of each screw is then verified with the O-arm. | ||
| − | Postoperatively, the arm | + | == Postoperative Rehabilitation == |
| + | Postoperatively, the arm is immobilized in an adjusted abduction brace for 6 to 12 weeks. Then, At 8 weeks, the splint is removed and scapulothoracic motion is allowed. Strengthening is not allowed before 12 weeks, and full activity is allowed when radiographic healing is observed. | ||
==Discussion== | ==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.<ref>Puskas GJ, Lädermann A, Hirsiger S,Hoffmeyer P, Gerber C. Orthop Traumatol Surg Res. 2017;103(6):875-84</ref> | ||
| − | + | == References == | |
| − | |||
| − | |||
| − | |||
| − | ==References== | ||
<references /> | <references /> | ||
Revision as of 16:44, 27 December 2020
Contents
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.
Under general anesthesia, the patient is placed on a carbon fiber table in the lateral decubitus position, with circumferential access to the right shoulder and the operative arm draped free (Table 1). The arm is held with 5 to 10 lb of balanced suspension and positioned in 20 to 30 degrees of abduction and 20 degrees of forward flexion. A posterior portal is first established. Notably, in cases of severe glenoid retroversion, it is necessary to place this portal from a more medial approach than the typical posterior portal. An anterior portal is then established with an outside-in technique using a spinal needle as a guide. While the surgeon is viewing from the posterior portal and working from the anterior portal, and then vice versa, an electrocautery probe and a 4.5-mm burr are used to lightly denude the articular surfaces of the humeral head to bleeding subchondral bone. In the setting of significant glenoid bone loss, the glenoid is prepared with a curette and microfracture only to avoid further bone loss (Figure, Video). In cases of glenoid bone loss, we do not attempt to achieve fusion between the humeral head and acromion (extra-articular fusion) because superior translation of the humeral head would lead to a loss of contact with the medialized glenoid. A reference with reflective marker spheres is fixed to the spine of the scapula through a mini-open approach (Figure). A sterile draped O-arm is used to obtain a 3-dimensional computed tomography scan with a medium dose of irradiation, and a computer-assisted navigation system is used (Figure). The shoulder is held in a position of 30° of flexion, 20° of abduction, and 40° of internal rotation to mimic the previous position of the arm and the desired position for glenohumeral arthrodesis. With the arm held in the appropriate position, 3 to 4 guidewires for 6.5-mm cannulated screws are percutaneously inserted from the humeral head into the glenoid and from the acromion to the humeral head
8 with the guidance of intraoperative computer-assisted navigation (Figure) and under direct arthroscopic visualization. Anatomic landmarks are used to avoid injury to the neurovascular structures, particularly the axillary nerve laterally. The wires are then measured and reamed for placement of 6.5-mm cannulated cancellous screws. Before tightening of the screws, cancellous allograft bone chips are placed in the glenohumeral joint under arthroscopy with an osteochondral transfer system. In soft humeral cortical bone washer are used to prevent penetration of the screw head into the proximal humerus.The screws are sequentially tightened to achieve adequate compression of the glenohumeral surfaces. The position of each screw is then verified with the O-arm.
Postoperative Rehabilitation
Postoperatively, the arm is immobilized in an adjusted abduction brace for 6 to 12 weeks. Then, At 8 weeks, the splint is removed and scapulothoracic motion is allowed. Strengthening is not allowed before 12 weeks, and full activity is allowed when radiographic healing is observed.
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
- ↑ Charnley J. Compression arthrodesis of the ankle and shoulder. J Bone Joint Surg Br 1951;33B(2):180-91
- ↑ Cofield RH, Briggs BT. Glenohumeral arthrodesis. Operative and long-term functional results. J Bone Joint Surg Am. 1979;61(5):668-77.
- ↑ 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.
- ↑ Chun JM, Byeon HK. Shoulder arthrodesis with a reconstruction plate. Int Orthop. 2009;33(4):1025-30.
- ↑ 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.
- ↑ Hiersemann K, Patsalis T, Saxler G. Arthroscopy-assisted glenohumeral arthrodesis: a case of uncontrollable shoulder instability Unfallchirurg. 2007;110(5):456-9.
- ↑ Lädermann A, Denard PJ. Arthroscopic glenohumeral arthrodesis with o-arm navigation Arthrosc Tech, Arthrosc Tech. 2014;27;3(2):e205-9
- ↑ Morgan, CD Casscells CD. Arthroscopic-assisted glenohumeral arthrodesis. Arthroscopy. 1992;8(2):262-6
- ↑ Safran O, Iannotti JP. Arthrodesis of the shoulder. J Am Acad Orthop Surg. 2006;14(3):145-53
- ↑ 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
- ↑ 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
- ↑ Nagy L, Koch PP, Gerber C.Functional analysis of shoulder arthrodesis. J Shoulder Elbow Surg. 2004;13(4):386-95
- ↑ Puskas GJ, Lädermann A, Hirsiger S,Hoffmeyer P, Gerber C. Orthop Traumatol Surg Res. 2017;103(6):875-84
