Orthopaedic Shoulder Surgeon · 2018-03-19 · arch becomes progressively loaded. C, The result is...
Transcript of Orthopaedic Shoulder Surgeon · 2018-03-19 · arch becomes progressively loaded. C, The result is...
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Shoulder replacementMr. Devinder Garewal
Orthopaedic Shoulder Surgeon
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Overview
• Anatomy & biomechanics
• Clinical & radiological assessment
• Considerations for replacement
• Prosthetic options
• Operative approach
• Anaesthetic considerations
• Post-operative considerations
• Rehabilitation
• Results
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Shoulder
• Unique ball & socket joint
• Great range of motion due to large humeral head and small glenoid socket
• Potentially unstable design is stabilised by action of rotator cuff
• Concavity compression: cuff compresses the humeral articular surface into the glenoid cavity
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Common shoulder pathologies
• Rotator cuff tear arthropathy
• Degenerative joint disease
• Inflammatory arthritis
• Avascular necrosis
• Trauma & post traumatic arthritis
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Clinical evaluation
• Range
• Cuff integrity
• Imaging:
• Plain XRs
• CT
• Ultrasound
• MRI
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869Chapter 16 Glenohumeral Arthritis and Its Management
FIGURE 16-98: Rotator cuff tear arthropathy with acetabular-
ization of the coracoacromial arch and upper glenoid. FIGURE 16-99: Rotator cuff tear arthropathy with femoraliza-
tion of the proximal humerus and actetabularization of the
coracoacromial arch and upper glenoid.
FIGURE 16-100: Cuff tear arthropathy. Superior medial erosion
(dotted red line) typical of cuff tear arthropathy. (From Matsen
FA III, Lippitt SB. Shoulder Surgery: Principles and Proce-
dures. Philadelphia: Saunders; 2004:426.)
FIGURE 16-101: Acromial traction spur. A, Normal position.
B, As the humeral head moves upwards, the coracoacromial
arch becomes progressively loaded. C, The result is a traction
spur in the coracoacromial ligament. Because it lies within the
substance of the ligament, this spur does not encroach on the
rotator cuff, even though it might look impressive on the radio-
graph. D, Rotator cuff tear arthroplasty. (From Matsen FA III,
Lippitt SB. Shoulder Surgery: Principles and Procedures. Phila-
delphia: Saunders; 2004:280.)
C
A
D
B
Downloaded from ClinicalKey.com.au at Royal Australasian College of Surgeons JC December 28, 2016.For personal use only. No other uses without permission. Copyright ©2016. Elsevier Inc. All rights reserved.
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CT
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Assessment of cuff
• Clinical
• Intra-operative
• CT
• Soft tissue windows
• Sagittal view looking at muscle bulk & fat
• MRI
• Gold standard
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Shoulder Replacements
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History
• First performed 1894
• Charles Neer was the pioneer of modern shoulder replacements
• 1951: hemi-arthroplasty (for fractures)
• 1973: designed glenoid component to make first Total Shoulder Replacement
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Total Shoulder Replacement
• Replace glenoid with either:
• plastic (PE) which requires cement for fixation or
• a metal component that requires screws
• Replace humerus with stem/head (uncemented or cemented)
• Requires intact rotator cuff muscles to balance the shoulder replacement and provide function to move the joint
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PE glenoid
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Metal back glenoid
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Humeral stem
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Total shoulder replacement
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Reverse shoulder replacement
• Gaining popularity
• Increasing world wide use
• Glenoid and humeral components are reversed
• Relies on deltoid
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Reverse shoulder replacement
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Reverse shoulder replacement
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Operative considerations
• Position
• Monitoring
• Pain relief
• Arm holder
• Approach
• Discharge planning
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Pre-operative considerations
• Beach chair for replacement• Replacement: beach chair
• Scopes: upright V lateral
• Inter-scalene block• Excellent intra-op and post-op pain control
• Monitoring• Arterial line
• Secure airway
• Antibiotics
• TXA
• DVT prophylaxis• Mechanical
• Chemical
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Position
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Arm holder
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Deltopectoral approachSurgical Approach
Deltopectoral
Coracoid
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Post-operative care
• Should be minimal!
• Pain relief
• Oral analgesia nocte and for 2/52 post op
• IV Abs (2 doses)
• Post op XR
• Leave dressings intact 2/52
• Can shower out of sling
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Rehabilitation
• Sling 4 weeks
• Can’t drive for 6 weeks
• Early movement (within safe zone)
• Protect subscapularis in anatomic shoulder replacement
• Scapular control
• Optimise cuff & deltoid function
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Joint registry (2004-)
• 11.1% increase in last 12 months
• 115.5% increase since 2008
• 40% anatomic, 60% reverse (28,193 replacements)
• 70% of replacements 2016 were reverse SRs
• At 9 years, 11.3% revision for aSRs & 7.0% revision for rSRs
• Common reasons for revision include: instability/dislocation, cuff insufficiency, loosening, pain
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Thank you