Indications for Total Shoulder Replacement- All you need to know
This talk will focus on the indications for performing total shoulder replacement (TSR) ie a replacement in which both sides of the joint are replaced, in patients with arthritis whose symptoms are not controlled with simple non-operative management strategies.
My name is Gavin Jennings and I am a specialist shoulder surgeon practising at the Royal United Hospital and the Royal National Hospital for Rheumatic Diseases in Bath, UK
This talk was originally presented at the 9th International Clinical Anatomy Course at Padua University, Italy.
The pathologies for which total shoulder replacement may be indicated include primary osteoarthritis, osteoarthritis secondary to conditions such as infection or trauma, inflammatory arthritis, avascular necrosis but certainly not for proximal humeral fractures nor for rotator cuff arthropathy.
There are certain prerequisites required before a Total Shoulder Replacement can be performed. These include the ability to gain access to and expose the glenoid, the presence of adequate glenoid bone stock to be able to support the implanted socket, and an intact rotator cuff. The rotator cuff must be intact as if it subsequently fails to function, the mechanics of the shoulder are changed resulting in early loosening of the glenoid component of the replacement ( the rocking horse effect). This is why TSR’s are not suitable in the management of rotator cuff arthropathy or indeed proximal humeral fractures where there is a high risk of the tuberosities failing to heal to the prosthesis, leaving the shoulder cuff deficient. If these requirements are not met, a hemiarthroplasty (HA) or Reverse Total Shoulder Replacement (RSR) may be the preferred option.
Possible alternatives to shoulder replacement include debridement, biological resurfacing, arthrodesis and suprascapular nerve block.
Arthroscopic debridement has been shown to be effective in 80% of patients, but is less reliable if the joint is incongruent or there are large osteophytes present. A more recent study has confirmed its efficacy, but again not in patients with large ostephytes, grade 4 disease involving humerus and glenoid, or if the remaining joint space is less than 2mm.
Biological resurfacing of the native arthritic glenoid has had some success. Many types of graft been used for the interposition, including those made from decellularised human skin such as the Graft Jacket. Cells are removed maintaining the structure of the extracellular matrix, with the aim of providing a scaffold for the ingrowth of host cells. De Beer reported reasonable mid term results of using an arthroscopic interposition of the graft in younger arthritic shoulders.
Interposition grafts have also been performed along with a hemiarthroplasty with promising early results, but its efficacy has not been born out in the longer term.
Arthrodesis (or fusion) of the joint still has a place in selected patients with arthritis for example if there is paralysis, instability, after failed replacement surgery, tumour resection or traumatic mal-union, or infection.
Ruhmann’s series showed good results of arthrodesis but with a high complication rate.
An example of an arthrodesis is shown here. A recon plate and screws were used to achieve fusion of the humerus with both the acromion and glenoid.
Suprascapular nerve blockade can be used to relieve pain in an arthritic shoulder. In our unit, we perform this initially with LA and steroid and if successful an ablation may be subsequently performed. There is a relative paucity of evidence in the literature on the longer term results of ablation.
When performing shoulder replacement there has long been debate over whether replacing the humeral side alone (a hemiarthroplasty HA) is likely to have as good an outcome as performing a TSR. The modern literature is now overwhelmingly in favour of performing a TSR if the prerequisites described previously have been met.
There is evidence that a TSR is better than a HA even if the rotator cuff is torn as long as the tear can be repaired at the time of the replacement.
In terms of the ability to get to the glenoid, there should be little difficulty for the experienced surgeon.
This slide shows the good access achievable even with the humeral head still in situ,
such as when performing a resurfacing TSR
Historically, there have been concerns over performing TSR in patients with an inflammatory arthritis. This study from the Mayo Clinic shows that as long as the cuff is intact this patient group does better with a TSR.
Rozing had previously shown that the results of TSR in Rheumatoid patients were as good in patients who had a cuff repair as those in which the cuff was intact.
The majority of outcome data refers to stemmed total shoulder replacement but evidence is emerging of the good outcomes achievable with stemless replacements.
Mariotti showed in the short term that the outcomes of stemless were as good as stemmed TSR. In the last seven years there have been a number of short and medium term studies drawing the same conclusion.
In summary, the literature supports the use of TSR in preference to hemiarthroplasty even in the presence of a reparable cuff tear, even in a patient with rheumatoid arthritis.
In other words if a TSR can reliably be done, do it !
Thank you for listening. Please feel free to contact me for any further information