12 The Postoperative Shoulder 2: Arthroplasty, Arthrodesis and Osteotomy

12 The Postoperative Shoulder 2:

Arthroplasty, Arthrodesis and Osteotomy

T. H. Berquist

T. H. Berquist, MD, FACR

Diagnostic Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA

CONTENTS

12.1 Indications 213

12.2 Preoperative Evaluation 213 12.3 Component Selection 213 12.3.1 Humeral Components 214 12.3.2 Glenoid Components 214

12.4 Hemiarthroplasty versus Total Shoulder Arthroplasty 216

12.5 Postoperative Imaging/Complications 216 12.5.1 Loosening 217

12.5.2 Humeral Component Migration 217 12.5.3 Infection 218

12.5.4 Nerve Injury 218 12.5.5 Fractures 218

References 221

12.1 Indications

Shoulder arthroplasty (glenohumeral joint) has become the technique of choice for patients with articular damage and pain that does not respond to more conservative measures (Arntz et al. 1993; Bell and Geschwend 1986). The procedure is performed to relieve pain and improve function. The most frequent causes of symptoms are rheumatoid arthri- tis, osteoarthritis, avascular necrosis and trauma (Cofi eld 1983; Friedman et al. 1989).

Regardless of the underlying disorder, the prog- nosis and selection of operative approach varies with the extent of joint, bone and soft tissue involve- ment (Cofi eld 1984; Friedman et al. 1989; Hasan et al. 2002).

12.2 Preoperative Evaluation

Both clinical and imaging data must be carefully reviewed prior to selection of components and approaches for shoulder arthroplasty.

The University of California at Los Angeles scor- ing system is commonly used to grade pain, function and strength pre- and postoperatively (Amstatz et al. 1988). The system uses a 10-point scale for each of the areas. Scores in each category are graded as excellent (9–10 points), good (6–8 points), fair (4–

5 points) and poor (1–3 points). Patients with severe pain (1–3 points) are likely to experience the greatest improvement (Friedman et al. 1989).

Preoperative imaging may require a multimodal- ity approach. True AP (anteroposterior), axillary and scapular “Y” views are required to evaluate the joint spaces and osseous abnormalities (Fig. 12.1).

Bone changes may be more accurately assessed with computed tomography (CT), especially changes in the glenoid. Signifi cant bone loss and need for bone grafting must be appreciated preoperatively.

Magnetic resonance imaging (MRI) is useful for evaluating soft tissue support. Arthrograms and/or preoperative aspirations or diagnostic injections are not commonly employed (Berquist 1992; Figgie et al. 1988). Templates are used with radiographs to serve as a guide for component selection and sizing (Fig. 12.2).

12.3 Component Selection

Design choices for shoulder arthroplasty include

constrained, semi-constrained, and anatomic or non-

constrained systems (Alibradi et al. 1988; Amstatz

et al. 1988; Becker 1991; Cofi eld 1983; Lettin et

al. 1982; Post and Jablon 1979; McFarland et

al. 2002). Constrained components are used for

patients with a defi cient rotator cuff and inadequate

12.3.1 Humeral Components

Humeral component design has progressed from metal or silicone cups in the 1980s to new compo- nents used today. The Neer prosthesis has multiple head sizes and 14 types of stems. Bipolar components were designed by Swanson in 1975 for patients with rotator cuff disease. The larger head and unfl exed cup distribute deltoid muscle forces over a larger area of the acromion (Swanson et al. 1989).

Modular humeral components are popular today.

These systems provide fl exibility in matching head and stem confi gurations needed for a given patient.

With some variation, all humeral components have proximal holes for suturing soft tissue or bone frag- ments (Fig. 12.3).

12.3.2 Glenoid Components

Glenoid components may be confi gured completely of polyethylene or have polyethylene articular sur- faces with metal backing. Fixation is accomplished using pegs, fi ns, a keel or cancellous screws. Neer et al. (1982) suggested metal backed components for younger, more active patients. Hooded glenoid components are designed for patients with defi cient rotator cuffs (Fig. 12.4) (Amstatz et al. 1988).

Fig. 12.2. Anteroposterior radiograph with overlaid humeral component template

Fig. 12.1a, b. Preoperative radiographs. a Anteroposterior view of the shoulder shows advanced degenerative arthritis with loss of humeral acromial space due to a chronic rotator cuff tear. b Displaced fracture of the humeral head with high incidence of avascular necrosis. Indication for hemiarthroplasty

a b

soft tissue support (Post 1987; Grammont and

Baulot 1993; Rittmeister and Kerschbaumer

2001). These systems have limited indications and

an unacceptably high rate of loosening so they are

rarely used today (Post 1979). Therefore, we will

emphasize nonconstrained designs.

a

c

b

d

Fig. 12.3a–d. Humeral components. a Standard Cofi eld humeral stems (courtesy of Smith Nephew Richards, Memphis, TN). b–d Modular heads (b), humeral neck on end (c) and with partially porous coated humeral stem assembled (d) Biomodular Total Shoulder (Courtesy of Biomet, Warsaw, IN)

a b

Fig. 12.4a, b. Glenoid components. a Metal backed glenoid component with fi xation screws and two thicknesses of polyethylene insert (courtesy of Biomet, Warsaw, IN). b D.A.N.A (designed after natural anatomy; Howmedica, Rutherford, N.J.) total shoulder with non-modular humeral components and hooded (arrows) and standard (open arrows) polyethylene glenoid components

12.5 Postoperative Imaging/Complications

Imaging of patients after shoulder arthroplasty plays a signifi cant role in their evaluation. Routine radiographs are obtained 2, 6 and 12 months after the procedure and then yearly assuming there are no indications of complications. Most authors sug- gest AP, axillary and scapular “Y” views for screening (Amstatz et al. 1988; Berquist 1996). This series is adequate for most patients with hemiarthroplasty.

However, proper evaluation of the glenoid compo- nent and certain humeral components is suboptimal unless the shoulder is fl uoroscopically positioned to provide optimal evaluation of implant bone inter- faces (Fig. 12.7). Serial radiographs are still the most useful method for evaluating subtle changes over time (Berquist 1996). In patients with suspected complications, additional studies may be indicated (Westhoff et al. 2002), Speling et al. 2002).

Fig. 12.5. Anteroposterior view of the shoulder after hemi- arthroplasty with a modular humeral component. Head size (H) can be modifi ed. Note the two holes for soft tissue attachment (arrows)

Fig. 12.6. a Anteroposterior view of the shoulder shows avascular necrosis of the humeral head. The glenoid shows no major defects. b Hemiarthroplasty was performed using a modular component

a b

Complications related to shoulder arthroplasty vary with the type of prosthesis (constrained, semi- constrained, unconstrained, hemiarthroplasty) and underlying condition (bone, soft tissue integrity) (Barrett et al. 1987; Cofi eld 1984; Frich et al.

1991; Neer et al. 1982). Table 12.1 summarizes com- plications of total shoulder arthroplasty. Complica- tion rates in various reports range from 9%–38%

(Weiss et al. 1990).

Table 12.1. Complications of total shoulder arthroplasty

Complication Incidence (%)

Glenoid component loosening 3–15 Humeral component loosening 5 Humeral subsidence 7 Subluxation/dislocation 6 Superior migration of humerus 22

Neural injury 1–2

Infection 1–3

Humeral fracture 1.6

Fig. 12.7a, b. Cofi eld total shoulder arthroplasty. a The anteroposte- rior (AP) view does not adequately demonstrate the glenoid component interfaces. b Fluoroscopically posi- tioned AP shows the glenoid position optimally. Note slight lucency at the humeral tip (arrow) raising the ques- tion of toggling due to humeral com- ponent loosening

a b

12.5.1 Loosening

Glenoid component loosening is the most frequent complication of shoulder arthroplasty (3%–15% for unconstrained components; average 4.7%) (Bell

and Geschwend 1986; Cofi eld 1984; Franklin et al. 1988) (Fig. 12.8). Humeral component loosening occurs in about 5% (range 1%–7%) of patients (see Fig. 12.7). Lucent lines at the bone cement interface are common with component loosening (Fig. 12.8).

Lucent lines alone may not be signifi cant. Serial radiographs that demonstrate lucent lines that progress or exceed 2 mm in width are a more accu- rate indication of loosening. Progressive superior humeral migration has also been associated with increased incidence of glenoid component loosen- ing (Berquist 1996; Craig 1988; Weiss 1990).

12.5.2 Humeral Component Migration

Subsidence (sinking of the humeral component into the shaft) occurs in about 7% of cases (Alibradi et al. 1988). Superior migration (Fig. 12.9), subluxation and dislocation of the humeral head (Fig. 12.10) have all been reported. Subluxation or dislocation occurs in up to 6% of patients (range 1%–18%). Superior humeral migration occurs in 22%–53% of patients.

Humeral migration does not necessarily cause symp- toms. It may be related to rotator cuff defi ciency or failed cuff repair (Fig. 12.9) (Barrett et al. 1987;

Boyd et al. 1991). Rotator cuff tears are confi rmed

in about one fourth of patients (Boyd et al. 1991).

12.5.3 Infection

Infection is an uncommon complication of shoulder arthroplasty. Deep infection occurs in less than 1% of unconstrained and 2%–3% of constrained prosthesis.

Infection after hemiarthroplasty is rare (Alibradi et al. 1988; Cofi eld 1991).

Routine radiographic features of infection include areas of bone destruction, obvious loosening, endos- teal scalloping and periosteal new bone formation (Fig. 12.11) (Berquist 1992). Radionuclide scans are also useful. Technetium–99m scans may be posi- tive in normal patients for up to 1 year after surgery.

Combined technetium-99m with labeled white blood cells (indium-111 or technetium) is more accurate.

Combined arthrography with intra-articular tech- netium-99m sulfur colloid may be even more useful.

Joint aspiration can be performed as part of the latter procedure (Maxon et al. 1989; Magnuson et al. 1988).

12.5.4 Nerve Injury

Nerve injury is more common in patients with previ- ous trauma or surgery where scar tissue compromises surgical dissection (Craig 1988). The incidence is nev- ertheless still low (1%–2%) (Cofi eld 1991). Imaging may be accomplished with MRI depending upon the type of implant and extent of metal artifact.

12.5.5 Fractures

Fractures of the humeral shaft are uncommon (1.6%) (Bonutto and Hawkins 1992). Fractures occur during or after surgery. Conservative therapy

Lucent lines are common in 1 and 5, but more signifi cant in 2–4. b Same patient 6 years later; there is increased width of lucent line on zones 1–3 due to loosening

a b

Fig. 12.9. Shoulder arthroplasty with progressive superior humeral migration and reduced humero-acromial space. Con- sistent measurement assures evaluation of progression on serial radiographs. The center of the humeral head (+) and glenoid (+) are connected by horizontal lines to a line perpendicular to the humeral component to measure change

Fig. 12.10a–c. Dislocation. Modular total shoulder arthroplasty with anterior dis- location seen on anteroposterior (a), axillary (b) and scapular “Y” views (c) b

Fig. 12.11. Infected, loose hemiarthroplasty. Anteroposterior view demon- strates irregular lucency at the bone cement interface around the entire component. There is periosteal new bone (arrows) and a cement fracture (arrowhead) due to loosening

Fig. 12.13. Anteroposterior view of a healed proximal humeral fracture (arrows) revised with a long stem humeral component

Fig. 12.12. a Antero- posterior view of a Cofi eld arthroplasty with fracture at the tip of the humeral stem. b After reduc- tion with Dall-Miles cables

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