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Span fracture with standard length prosthesis (2-3 cortical diameters) or long-stem prosthesis. Cement in distal canal to engage prosthesis (do NOT let cement escape from fracture site). Cortical strut allograft + cerclage.
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Average 4.2 of 38 Ratings
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In which of the following clinical circumstances would it be appropriate to eccentrically ream the anterior glenoid?
72-year-old male undergoing a shoulder arthroplasty due to rotator cuff arthropathy
65-year-old female with a glenoid retroversion of 13-degrees undergoing shoulder arthroplasty
70-year-old female with humeral anteversion of 13-degrees undergoing shoulder arthroplasty
65-year-old female with glenoid retroversion of 25-degrees undergoing shoulder arthroplasty
59-year-old male with significant glenoid bone stock deficiency and severe osteoarthritis
Select Answer to see Preferred Response
The surgeon should consider eccentrically reaming the anterior glenoid when performing a total shoulder arthroplasty on a patient with a retroverted glenoid due to posterior deficiency associated with osteoarthritic changes which is most consistent with answer choice #2.
Normal version of the glenoid is 0-3 degrees of retroversion, but when doing a total shoulder the goal should be to place the glenoid component in neutral to slight anteversion. Reaming the anterior glenoid to neutral is a technique to be considered by the operative surgeon when presented with a patient undergoing total shoulder arthroplasty with a retroverted glenoid, as failure to perform this step increases the chance for glenoid loosening. If reaming down the anterior glenoid will take away too much bone stock (down to the coracoid process), one may consider bone grafting the posterior glenoid. To perform a total shoulder arthroplasty patients will need a functioning rotator cuff and appropriate glenoid bone stock.
Clavert et al. performed cadaveric analysis to simulate glenoid retroversion of greater than 15 degrees and found that retroversion to this degree cannot be safely corrected with eccentric anterior reaming when using a glenoid component with peripheral pegs due to penetration into the glenoid vault.
Nowak et al. used 3D-CT models of patients with advanced shoulder osteoarthritis with varying degrees of glenoid retroversion and simulated glenoid resurfacing. They found that smaller size glenoid components may allow for greater version correction when using in-line pegged components, as they would be less likely to result in peg penetration.
Illustration A shows >25 degrees of glenoid retroversion seen by axial radiograph of the shoulder in a patient with advanced osteoarthritis. In this case, anterior glenoid reaming is not the correct answer and a posterior glenoid allograft reconstruction would be appropriate.
Answer 1: This patient should undergo a reverse total shoulder due to the lack of rotator cuff where anterior glenoid reaming is not applicable.
Answers 3: Eccentric reaming is not a useful adjunct when the humerus is anteverted
Answer 4: Excessive glenoid retroversion requires allograft reconstruction of the posterior defect instead of anterior glenoid reaming
Answer 5: Eccentric reaming is contraindicated when bone stock is insufficient to allow it.
Clavert P, Millett PJ, Warner JJ
J Shoulder Elbow Surg. 2007 Nov-Dec;16(6):843-8. PMID: 18061118 (Link to Abstract)
Nowak DD, Bahu MJ, Gardner TR, Dyrszka MD, Levine WN, Bigliani LU, Ahmad CS
J Shoulder Elbow Surg. 2009 Sep-Oct;18(5):680-8.. PMID: 19487133 (Link to Abstract)
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Average 3.0 of 36 Ratings
Which of the following preoperative factors is a contraindication to total shoulder arthroplasty?
Passive external rotation less than 10 degrees
Eccentric posterior glenoid erosion
A 2-cm full-thickness supraspinatus tendon tear
A preganglionic brachial plexus injury
A preganglionic brachial plexus palsy, otherwise known as a root avulsion injury, presents with a flail arm and has a poor prognosis for recovery of motor function. Patients with brachial plexus palsies are not candidates for total shoulder arthroplasty due to the substantial motor and sensory deficits associated with these injuries.
In contrast, patients with a preoperative loss of passive external rotation, posterior glenoid erosion, a reparable full-thickness rotator cuff tear isolated to the supraspinatus tendon, and inflammatory arthritis are not contraindicated for a total shoulder arthroplasty.
Iannotti et al. performed a Level I prospective study in 118 patients who underwent either a total shoulder arthroplasty or a shoulder hemiarthroplasty for primary osteoarthritis. The presence of a reparable full-thickness rotator cuff tear did not adversely affect outcomes in either group but rather provided better active external rotation in the cohort receiving total shoulder arthroplasties. The authors concluded that a reparable tear of supraspinatus is not a contraindication to the use of a glenoid component.
Norris et al. compared outcomes of total shoulder arthroplasty and hemiarthroplasty performed for primary osteoarthritis in 160 patients. There were no differences in postoperative pain, function, ASES scores, or range of motion between groups for patients with reparable rotator cuff tears. The authors concluded that minor thinning and small tears of the rotator cuff can be adequately addressed at the time of surgery without adversely affecting outcomes.
Illustration A is a cervical T2 axial MRI which shows a cervical root avulsion, a form of preganglionic brachial plexus injury. Notice the perineural hyperintensity.
Answers 1, 2, & 3 are not contraindications to total shoulder arthroplasty and were found by Iannotti et al. to have either no effect or improved outcomes when a total shoulder arthroplasty was performed over a hemiarthroplasty.
Answer 4 is an indication, not a contraindication, to a total shoulder arthroplasty when sufficient bone stock is present to support a glenoid component.
Iannotti JP, Norris TR.
J Bone Joint Surg Am. 2003 Feb;85-A(2):251-8. PMID: 12571302 (Link to Abstract)
Norris TR, Iannotti JP
J Shoulder Elbow Surg. 2002 Mar-Apr;11(2):130-5. PMID: 11988723 (Link to Abstract)
Average 4.0 of 8 Ratings
Which of the following statements regarding propionibacterium acnes infections after shoulder arthroplasty is incorrect?
It is usually associated with fevers
Cultures need to be held for 14 days
It colonizes the shoulder at increased rates compared to the knee and hip
Men have a higher bacterial burden than females
It is an important cause of clinical implant failure
Surgeons need to be aware that P. acnes is a skin bacteria that is responsible for shoulder infections that often have a subtle presentation. Many of the traditional signs of infection such as fever, erythema and severe pain are often not present.
Dodson et al describe a case series of 11 patients with P. acnes infections following shoulder arthroplasty stating that it represents a "diagnostic challenge". Traditional signs of infection were often not present. In fact, none of their patients presented with fevers. Initial 3 day cultures were often negative and the mean time to a positive culture was 9 days.
Patel et al. looked at colonization rates and bacterial burden and found it to be higher around the shoulder than the hip and knee. The bacterial burden was higher in men than in women.
The following responses are true and therefore are incorrect answers:
2. It is slow-growing and cultures need to be held longer (14 days).
3. It colonizes the shoulder at increased rates compared to knee and hip.
4. Men have a higher bacterial burden than females.
5. It is an important cause of clinical implant failure.
Dodson CC, Craig EV, Cordasco FA, Dines DM, Dines JS, Dicarlo E, Brause BD, Warren RF.
J Shoulder Elbow Surg. 2010 Mar;19(2):303-7. Epub 2009 Nov 1. PMID: 19884021 (Link to Abstract)
Patel A, Calfee RP, Plante M, Fischer SA, Green A.
J Shoulder Elbow Surg. 2009 Nov-Dec;18(6):897-902. Epub 2009 Apr 11. PMID: 19362854 (Link to Abstract)
Average 3.0 of 31 Ratings
During a total shoulder arthoplasty (TSA), which of the following technical maneuvers would most likely place the rotator cuff tendons at risk of injury?
Excessive retraction on the deltoid muscle during a delto-pectoral approach
Palpation of the rotator cuff insertion prior to humeral head resection
A humeral cut with 30 degrees of retroversion
Excessive bone removal with the humeral neck osteotomy
A humeral cut with 45 degrees of inclination
The rotator cuff tendons can be inadvertantly cut or detached during a TSA if the head cut is made either too distally or in excessive retroversion.
Pearl et al studied the placement of humeral component position during TSA by studying 21 cadaveric specimens. Their results supported that retroversion of the proximal humerus is highly variable, ranging from 10 degrees to 55 degrees and mean of 29.8 degrees. They recommend anatomic reconstruction of the retroversion angle based on patient anatomy. They also stress palpation of the rotator cuff insertion prior to humeral head resection to avoid inadvertant cuff injury.
Illustrations A shows example of an appropriate osteotomy which is made proximal to both the greater and less tuberosities. Illustration B shows the footprint of the rotator cuff insertion relative to the correct humeral cut during a TSA.
Choice 1- Excessive retraction on the deltoid muscle could cause injury to the axillary nerve, but will not injure the rotator cuff.
Choices 2- This step is encouraged to spare the rotator cuff insertions before humeral head osteotomy
Choice 3- A head cut in 30 degrees of retroversion is normal
Choice 5- Excessive inclination may take too much medial bone, but if appropriately placed, would not risk injuring the rotator cuff insertion.
Pearl ML, Volk AG.
J Shoulder Elbow Surg. 1995 Jul-Aug;4(4):286-9. PMID: 8542372 (Link to Abstract)
Average 4.0 of 21 Ratings
A 65 year-old man has progressive debilitating pain and crepitus in his shoulder. Active forward elevation is 120 degrees and external rotation strength is normal. Radiograph and CT scan are shown in Figures A and B. Which treatment will likely give him the best outcome in 3 years.
Arthroscopic capsular release
Humeral head arthroplasty with glenoid bone grafting followed by staged glenoid component implantation
Reverse total shoulder replacement
Total shoulder arthroplasty
This patient has advanced glenohumeral humeral arthritis. The treatment that will lead to the best outcomes for this patient is a total shoulder arthroplasty (TSA).
Use of TSA to treat glenohumeral arthritis has been associated with improved functional outcomes compared to hemiarthroplasty of the shoulder. Resurfacing of the glenoid should not be completed if there is insufficient glenoid bone stock. This patient has adequate bone stock, although there is evidence of posterior subluxation of the humeral head.
Bryant et al. conducted a meta-analysis to compare outcomes between total shoulder arthroplasty (TSA) and hemiarthroplasty. The TSA demonstrated better functional outcomes (pain, UCLA shoulder score, forward elevation on exam) compared to hemiarthroplasty at a minimum of 2 years.
Gartsman et al. prospectively evaluated outcome differences between TSA and hemiarthroplasty for shoulder osteoarthritis. At an average follow up of 35 months, the authors found that TSA provided greater pain relief, greater patient satisfaction, function and strength compared to hemiarthroplasty.
Figure A shows an AP radiograph of the shoulder with evidence of osteoarthritis of the shoulder. Figure B shows an axial CT scan reconstruction of the same shoulder with posterior glenoid erosion.
Answer 1: Capsular release will not address the degenerative changes within the joint itself.
Answer 2: While a hemiarthroplasty could be completed, evidence of posterior glenoid erosion is supportive of the use of a total shoulder arthroplasty. Bone grafting is indicated if there is greater than 20-25% posterior glenoid deficiency. Use of a total shoulder arthroplasty is associated with decreased need for revision surgery compared to hemiarthroplasty at short term follow up
Answer 3: Hemiarthroplasty outcomes are not as good as with TSA
Answer 4: Because this patient’s rotator cuff is intact, a reverse TSA is not indicated.
Bryant D, Litchfield R, Sandow M, Gartsman GM, Guyatt G, Kirkley A
J Bone Joint Surg Am. 2005 Sep;87(9):1947-56. PMID: 16140808 (Link to Abstract)
Gartsman GM, Roddey TS, Hammerman SM.
J Bone Joint Surg Am. 2000 Jan;82(1):26-34. PMID: 10653081 (Link to Abstract)
Average 4.0 of 17 Ratings
A 62-year-old man undergoes a total shoulder arthroplasty for osteoarthritis. He accidently uses his operative arm to rise from a chair 3 weeks after surgery and thereafter complains of anterior shoulder pain. Radiographs are significant for anterior dislocation of the prosthesis. What is the most likely mechanism for this complication?
long head biceps rupture
The primary restriction after total shoulder arthroplasty (TSA) is passive external rotation, as well as active internal rotation, to protect the subscapularis repair. This patient fired his subscapularis rising from the chair.
According to Wirth and Rockwood, rupture of the subscapularis was seen in all cases of anterior dislocation following TSA.
Wirth MA, Rockwood CA Jr.
J Bone Joint Surg Am. 1996 Apr;78(4):603-16. PMID: 8609143 (Link to Abstract)
Average 4.0 of 15 Ratings
The placement of a standard all-polyethylene glenoid component for shoulder arthroplasty is contraindicated in which of the following scenarios?
Irreparable rotator cuff tear
Previous glenoid resurfacing
Significant irreparable rotator cuff tears represent a contraindication to standard total shoulder arthroplasty.
Options in a rotator cuff deficient patient include no glenoid resurfacing (hemiarthroplasty) or placement of a reverse total shoulder, but not a standard all-poly or metal-backed poly glenoid component.
If a patient has an irreparable rotator cuff tear, they will have abnormal mechanics and often develop degenerative changes referred to as rotator cuff arthropathy. The abnormal mechanics will persist even after standard total shoulder arthoplasty components are placed, with the head levering on the superior glenoid (the "rocking horse” phenomenon) which may loosen the glenoid component. In this situation, a hemiarthroplasty or a reverse total shoulder arthroplasty would be preferrable.
Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd.
J Arthroplasty. 1988;3(1):39-46. PMID: 3361319 (Link to Abstract)
Antuna SA, Sperling JW, Cofield RH, Rowland CM.
J Shoulder Elbow Surg. 2001 May-Jun;10(3):217-24. PMID: 11408901 (Link to Abstract)
Average 2.0 of 48 Ratings
During the initial rehabilitation phase following total shoulder arthroplasty through a delto-pectoral approach, motion and strengthening are typically restricted because of which factor?
Protection of the subscapularis tendon
Protect of the supraspinatus tendon
Risk of dislocation
Risk of loosening
Through a delto-pectoral approach, the subscapularis is taken down off the humerus. This may be done trans-tendon, directly off bone, or with a lesser tuberosity osteotomy. In any case, passive external rotation past 30 degrees and active internal rotation past the plane of the body are usually restricted for several weeks to allow healing.
Miller BS, Joseph TA, Noonan TJ, Horan MP, Hawkins RJ.
J Shoulder Elbow Surg. 2005 Sep-Oct;14(5):492-6. PMID: 16194740 (Link to Abstract)
Burroughs PL, Gearen PF, Petty WR, Wright TW.
J Arthroplasty. 2003 Sep;18(6):792-8. PMID: 14513456 (Link to Abstract)
Which of the following factors has the greatest influence on early postoperative restrictions following total shoulder arthroplasty through a deltopectoral approach?
Release of the superior border of the pectoralis
Strength of the capsular repair
Strength of the subscapularis repair
Presence of glenoid retroversion
Quality of the patients' bone
Using the deltopectoral approach for total shoulder arthroplasty requires that the subscapularis is taken down. This can be performed trans-tendon, taking the tendon off bone, or with a lesser tuberosity osteotomy. Regardless, excessive early passive external rotation and active internal rotation past the plane of the body are rarely permitted during the first 6 weeks.
The Norris article is a multicenter cohort study reporting results of shoulder arthroplasty. Total shoulder arthroplasty and hemiarthroplasty for treatment of primary osteoarthritis result in good or excellent pain relief, improvement in function, and patient satisfaction in 95% of cases. The most common intraoperative complications were intraoperative fractures.
The Cameron paper is a review article that evaluates the factors affecting the outcome of total shoulder arthroplasties, including rehabilitation.
Cameron B, Galatz L, Williams GR Jr.
Am J Orthop (Belle Mead NJ). 2001 Aug;30(8):613-23. PMID: 11520017 (Link to Abstract)
Average 3.0 of 16 Ratings
A 75-year-old right-hand dominant female has persistent right shoulder pain for the past 5 years. An axial CT scan is shown in the Figure A. If a total shoulder arthroplasty is planned, what other procedure must be performed based on this patient's imaging?
rule out infection
bone grafting of the glenoid
rotator cuff repair
humeral head biopsy
The patient is being considered for total shoulder arthroplasty, but the axial CT scan demonstrates significant glenoid retroversion and loss of glenoid bone stock. This patient is at risk for glenoid component failure because of significant bone loss. Not resurfacing the glenoid and performing a hemiarthroplasty is an option. If the glenoid is going to be re-surfaced as the question states, posterior glenoid bone grafting should be performed.
Steinmann et al reported on using the cut autologous humeral head to fashion a bone graft for the glenoid in 28 patients. While there was some component loosening, they found that the overall results were similar to other series of total shoulders. According to Hill et al, despite the finding that eight shoulders had an unsatisfactory functional result at the time of longterm follow-up, corticocancellous grafting of the glenoid successfully restored glenoid version and volume in fourteen of the seventeen shoulders in the present study. They noted that patients with glenoid deficiency often have associated glenohumeral instability, which may affect the results of total shoulder arthroplasty. Boyd et al did a retrospective review of their arthoplasties with and without the use of a glenoid component and found progressive glenoid loosening in 12% of total should arthroplasties but no correlation with pain relief or range of motion was noted.
Steinmann SP, Cofield RH.
J Shoulder Elbow Surg. 2000 Sep-Oct;9(5):361-7. PMID: 11075317 (Link to Abstract)
Hill JM, Norris TR.
J Bone Joint Surg Am. 2001 Jun;83-A(6):877-83. PMID: 11407796 (Link to Abstract)
Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS.
J Arthroplasty. 1990 Dec;5(4):329-36. PMID: 2290089 (Link to Abstract)
A 72-year-old male who underwent right total shoulder arthroplasty 8 months ago is unable to lift his right hand off his back and has weakness with internal rotation. What is the most likely diagnosis?
Long head of biceps rupture
Subscapularis nerve palsy
Standard postoperative recovery
The patient is unable to internally rotate and has a positive lift-off test (inability to lift off hand from behind back), all significant for subscapularis insufficiency which may happen after any anterior approach to the shoulder with takedown of the subscapularis. Subscapular insufficiency may occur with failure of tendon repair or permanent changes to the subscapularis muscle. Clinical findings include internal rotation weakness, increased passive external rotation, weakness to belly press, and an abnormal subscapularis lift-off test (Video A demonstrates lift-off test).
Scheibel et al reports on 25 patients (primary and revision) who underwent open shoulder stabilization with an inverted L-shaped tenotomy approach which lead to atrophy and fatty infiltration on MRI resulting in postoperative subscapularis muscle insufficiency.
Scheibel M, Tsynman A, Magosch P, Schroeder RJ, Habermeyer P.
Am J Sports Med. 2006 Oct;34(10):1586-93. Epub 2006 Jun 26. PMID: 16801689 (Link to Abstract)
Average 3.0 of 9 Ratings
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