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Total Shoulder Arthroplasty

Authors:

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Introduction
  • Replacement of humeral head and glenoid resurfacing
    • cemented all-polyethylene glenoid resurfacing is standard of care
  • Total shoulder arthroplasty unique from THA and TKA in that
    • greater range of motion in the shoulder
    • success depends on proper functioning of the soft tissues
    • glenoid is less constrained
      • leads to greater sheer stresses and is more susceptible to mechanical loosening
  • Factors required for success of TSA
    • rotator cuff intact and functional
      • if rotator cuff is deficient and proximal migration of humerus is seen on x-rays (rotator cuff arthropathy) then glenoid resurfacing is contraindicated 
      • if there is an irreparable rotator cuff deficiency then proceed with hemiarthroplasty or a reverse ball prosthesis
      • an isolated supraspinatus tear without retraction can proceed with TSA 
        • incidence of full thickness rotator cuff tears in patients getting a TSA is 5% to 10%
        • if positive impingement signs on exam, order a pre-operative MRI
    • glenoid bone stock and version
      • if glenoid is eroded down to coracoid process then glenoid resurfacing is contraindicated
      • see Walch classification below
  • Outcomes
    • pain relief most predictive benefit (more predictable than hemiarthroplasty) 
    • reliable range of motion
    • good survival at 10 years (93%)
    • good longevity with cemented and press-fit humeral components
    • worse results for post-capsulorrhaphy arthropathy q
Classification
 
Walch Classification of Glenoid Wear
Type A well-centered 
A1 minor erosion
A2 deeper central erosion
Type B head subluxated posteriorly 
B1 posterior wear
B2 severe biconcave wear
Type C glenoid retroversion of more than 25 degrees (dysplastic in origin)

Indications
  • Indications 
    • pain (anterior to posterior), especially at night, and inability to perform activities of daily living
    • glenoid chondral wear to bone   
      • preferred over hemiarthroplasty for osteoarthritis and inflammatory arthritis
    • posterior humeral head subluxation
  • Contraindications
    • insufficient glenoid bone stock
    • rotator cuff arthropathy
    • deltoid dysfunction
    • irreparable rotator cuff (hemiarthroplasty or reverse total shoulder are preferable) q 
      • risk of loosening of the glenoid prosthesis is high ("rocking horse" phenomenon)
    • active infection
    • brachial plexus palsy
Preoperative Imaging
  • Radiographs
    • true AP
      • determine extent of arthritis and look for superior migration of humerus
    • axillary view
      • look for posterior wear of glenoid
  • CT scan
    • obtain CT scan to determine glenoid version and glenoid bone stock
  • MRI
    • evaluate rotator cuff condition
Approach
  • Deltopectoral
    • detach the subscapularis and capsule from anterior humerus
    • dislocate shoulder anteriorly
    • tight shoulders may require release of the upper half of the pectoralis tendon to increase exposure and dislocation
      • pectoralis major tendon passes on top of the biceps tendon to attach to the humerus
  • Complications
    • axillary nerve damage is the most common complication
      • axillary nerve and posterior humeral circumflex artery pass beneath the glenohumeral joint in the quadrilateral space 
Technical considerations
  • Capsule
    • anterior capsule contracture (passive ER < 40°)
      • treatment
        • anterior release and Z-lengthening
    • posterior capsule stretching
      • treatment
        • volume-reducing procedure (plication of posterior capsule)
  • Glenoid deficiency and retroversion
    • glenoid deficiency q 
      • treatment
        • build up with iliac crest autograft or part of the resected humerus 
        • do not use cement to build up the deficiency
    • retroverted glenoid  
      • treatment
        • build up posterior glenoid with allograft
        • eccentrically ream anterior glenoid
  • Glenoid component
    • convex superior to flat
    • recreate neutral version
    • peg design is biomechanically superior to keel design
    • polyethylene-backed components superior to metal-backed components
      • glenoid not large enough to accommodate both metal and PE
    • uncemented glenoid has a lower rate of loosening
    • conforming vs. nonconforming
      • both have advantages and neither is superior
      • conforming is more stable but leads to rim stress and radiolucencies
      • nonconforming leads to increased polyethylene wear
  • Humeral stem fixation
    • cemented stem or uncemented porous-coated implants 
    • position of humeral stem should be 25-45° of retroversion   
      • if position of glenoid retroversion is required, then the humeral stem should be less retroverted to avoid posterior dislocation
    • avoid valgus positioning of humeral stem
    • avoid overstuffing the humeral head
      • increases joint reaction forces and tension on the rotator cuff
      • the top of the humeral head should be 5 to 8 mm superior to the top of the greater tuberosity
    • intraoperative humerus fracture
      • greater tuberosity fracture
        • treatment
          • if minimally displaced, insert a standard humeral prosthesis with suture fixation and autogenous cancellous bone grafting of the greater tuberosity fracture
      • humeral shaft fracture
        • treatment
          • remove prosthesis and add longer stem with cement and reinforce with cerclage wiring
Rehabilitation
  • Passive or active-assisted motion only during early rehab
    •  limiting factor in early postoperative rehabilitation is risk of injury to the subscapularis tendon repair q 
  • Progress to ER isometrics
  • Limit passive external rotation
    • risk of tear and pull-off of subscapularis tendon from anterior humerus
      • tear leads to anterior shoulder instability (most common form of instability after TSA)
      • treatment of subscapularis pull-off is early exploration and repair of tendon
      • test for pull-off of subscapularis
        • weak belly-press test
        • inability to put hand in back pants pockets or tuck shirt behind the back
      • avoid pushing out of chair during acute rehab
  • IR eccentric and isometric
Complications
  • Glenoid loosening
    • most common cause of TSA failure (30% of primary OA revisions)
    • risk factors
      • insufficient glenoid bone stock
      • rotator cuff deficiency
    • 2.9% reoperation rate for loosening (28% with revision)
    • radiographic lines
      • presence of radiographic lines does not correlate with symptoms
      • progression of a radiographic line does correlate with symptoms
        • progression present in 50% of patients as early as 3 to 4 years after TSA
      • radiolucency around the glenoid does not always correlate with clinical failure
        • at 3- and 7-year follow-up did not correlate with poor functional outcomes or pain
  • Humeral stem loosening
    • more common in RA and osteonecrosis
    • rule out infection
  • Subscapularis repair failure q  
  • Malposition of components
  • Improper soft tissue balancing
    • failure due to undiagnosed presence of rotator cuff tears
  • Iatrogenic rotator cuff injury
    • can occur if humeral neck osteotomy is inferior to level of rotator cuff insertion 
  • Stiffness
  • Infection
    • may have normal aspiration results
    • culture
      • arthroscopic tissue culture more sensitive (100% sensitive and specific) than fluoroscopically guided aspiration (17% sensitivity, 100% specific)
    • Propionibacterium acnes (P. acnes) 
      • most common cause of indolent infections and implant failures
        • infection rate 1-2% after primary TSA
      • characteristics
        • gram positive, facultative, aerotolerant, anaerobic rod that ferments lactose to propionic acid
        • has high bacterial burden around the shoulder 
        • forms biofilm within 18-90h (found on implant surface and on synovial tissue) >> planktonic (explains why aspiration is only 17% sensitive)
        • P. acnes PJI more common in males 
      • presentation
        • initial pain & stiffness
        • later swelling & redness
      • diagnosis
        • use anaerobic culture bottles, keep for 10-14days (mean time to detection 6 days)
        • 16s rRNA PCR
        • imaging (XR, CT, ultrasound) positive for subluxation/loosening in 24% of cases
        • if implant is removed, sonicate implant (to dislodge bacteria from surface) for sonication culture
      • treatment
        • early infection (<6 weeks) can be treated with open irrigation and debridement
        • late infection (>6 weeks) should be treated by explant and 2-stage reimplantation after IV antibiotic (penicillin G, ceftriaxone, clindamycin, vanco) x 6wk, followed by 2-6mths of PO antibiotic
  • Neurologic injury
    • axillary nerve is most commonly injured
    • musculocutaneous nerve can be injured by retractor placement under conjoint tendon
  • Periprosthetic fracture
    • acceptable fragment alignment ≤ 20° flexion/extension, ≤ 30° varus/valgus, ≤ 20° rotation malalignment
    • see table below
Wright & Cofield Classification of Periprosthetic fracture  
Type  Characteristics Treatment of Intraoperative Fracture Treatment of Postop Fracture
Type A Centered near the tip of the stem and extends proximally Span fracture with standard length prosthesis (2-3 cortical diameters) or long-stem prosthesis. Transosseous sutures for tuberosity fractures
Usually min displaced/angulated (treat nonop). If significant overlap between prox-distal fragments, treat as if stem loose and revise to long stem prosthesis.
Type B Centered at the tip of the stem and extends distally. 

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. 

Revise to long-stem prosthesis. Cement in distal canal to engage prosthesis 
Type C Located distal to the tip of the stem. Long-stem prosthesis, or if close to olecranon fossa, plate+screws ± cerclage wire, strut allograft ORIF (plate overlap prosthesis by 2 cortical diameters to avoid stress riser)
 

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Technique Guides (1)
Questions (11)

(OBQ12.172) In which of the following clinical circumstances would it be appropriate to eccentrically ream the anterior glenoid? Review Topic

QID:4532
1

72-year-old male undergoing a shoulder arthroplasty due to rotator cuff arthropathy

3%

(92/3325)

2

65-year-old female with a glenoid retroversion of 13-degrees undergoing shoulder arthroplasty

36%

(1193/3325)

3

70-year-old female with humeral anteversion of 13-degrees undergoing shoulder arthroplasty

7%

(231/3325)

4

65-year-old female with glenoid retroversion of 25-degrees undergoing shoulder arthroplasty

45%

(1482/3325)

5

59-year-old male with significant glenoid bone stock deficiency and severe osteoarthritis

8%

(273/3325)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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.

Incorrect Answers:
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.

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(OBQ12.241) Which of the following preoperative factors is a contraindication to total shoulder arthroplasty? Review Topic

QID:4601
1

Passive external rotation less than 10 degrees

1%

(26/2669)

2

Eccentric posterior glenoid erosion

2%

(43/2669)

3

A 2-cm full-thickness supraspinatus tendon tear

19%

(505/2669)

4

Inflammatory arthritis

2%

(60/2669)

5

A preganglionic brachial plexus injury

76%

(2030/2669)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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.

Incorrect Answers:
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.

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(OBQ11.50) Which of the following statements regarding propionibacterium acnes infections after shoulder arthroplasty is incorrect? Review Topic

QID:3473
1

It is usually associated with fevers

80%

(1948/2431)

2

Cultures need to be held for 14 days

7%

(178/2431)

3

It colonizes the shoulder at increased rates compared to the knee and hip

5%

(111/2431)

4

Men have a higher bacterial burden than females

4%

(103/2431)

5

It is an important cause of clinical implant failure

3%

(81/2431)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.


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(OBQ11.252) During a total shoulder arthoplasty (TSA), which of the following technical maneuvers would most likely place the rotator cuff tendons at risk of injury? Review Topic

QID:3675
1

Excessive retraction on the deltoid muscle during a delto-pectoral approach

2%

(43/2378)

2

Palpation of the rotator cuff insertion prior to humeral head resection

0%

(10/2378)

3

A humeral cut with 30 degrees of retroversion

7%

(156/2378)

4

Excessive bone removal with the humeral neck osteotomy

77%

(1829/2378)

5

A humeral cut with 45 degrees of inclination

14%

(328/2378)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

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.

Incorrect Answers:
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.

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(OBQ09.85) 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. Review Topic

QID:2898
FIGURES:
1

Arthroscopic capsular release

0%

(9/2209)

2

Humeral head arthroplasty with glenoid bone grafting followed by staged glenoid component implantation

4%

(82/2209)

3

Hemiarthroplasty

2%

(55/2209)

4

Reverse total shoulder replacement

4%

(89/2209)

5

Total shoulder arthroplasty

89%

(1966/2209)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

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.

Incorrect Answers:
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.


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Question COMMENTS (3)

(OBQ09.219) 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? Review Topic

QID:3032
1

long head biceps rupture

3%

(16/476)

2

supraspinatus rupture

4%

(20/476)

3

subscapularis rupture

89%

(424/476)

4

infraspinatus rupture

1%

(3/476)

5

labral tear

2%

(10/476)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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.


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(OBQ08.12) The placement of a standard all-polyethylene glenoid component for shoulder arthroplasty is contraindicated in which of the following scenarios? Review Topic

QID:398
1

Irreparable rotator cuff tear

59%

(239/406)

2

Previous glenoid resurfacing

16%

(66/406)

3

Rheumatoid arthritis

17%

(67/406)

4

Osteoarthritis

0%

(0/406)

5

Osteoporosis

8%

(32/406)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.


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(OBQ08.24) During the initial rehabilitation phase following total shoulder arthroplasty through a delto-pectoral approach, motion and strengthening are typically restricted because of which factor? Review Topic

QID:410
1

Protection of the subscapularis tendon

91%

(1533/1689)

2

Protect of the supraspinatus tendon

3%

(49/1689)

3

Risk of dislocation

5%

(82/1689)

4

Risk of loosening

1%

(13/1689)

5

Intra-articular effusion

0%

(5/1689)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.


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(OBQ07.27) Which of the following factors has the greatest influence on early postoperative restrictions following total shoulder arthroplasty through a deltopectoral approach? Review Topic

QID:688
1

Release of the superior border of the pectoralis

3%

(11/405)

2

Strength of the capsular repair

9%

(38/405)

3

Strength of the subscapularis repair

82%

(334/405)

4

Presence of glenoid retroversion

2%

(8/405)

5

Quality of the patients' bone

3%

(12/405)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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.


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Question COMMENTS (2)

(OBQ06.153) 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? Review Topic

QID:339
FIGURES:
1

rule out infection

3%

(10/338)

2

bone grafting of the glenoid

83%

(279/338)

3

rotator cuff repair

3%

(11/338)

4

acromioplasty

5%

(18/338)

5

humeral head biopsy

5%

(17/338)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

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.


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(OBQ04.66) 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? Review Topic

QID:1171
1

Brachial neuritis

0%

(1/329)

2

Long head of biceps rupture

0%

(1/329)

3

Subscapularis insufficiency

89%

(292/329)

4

Subscapularis nerve palsy

7%

(22/329)

5

Standard postoperative recovery

3%

(10/329)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

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.

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