Shoulder Arthrodesis

Indications
Indications stabilization of paralytic disorders brachial plexus palsy irreparable deltoid and rotator cuff deficiency with arthropathy failed total shoulder arthroplasty salvage reconstruction after tumor resection painful ankylosis after chronic infection recurrent shoulder instability which has failed previous repair attempts paralytic disorders in infancy Contraindications ipsilateral elbow arthrodesis lack of functional scapulothoracic motion trapezius, levator scapulae, serratus anterior paralysis Charcot arthropathy elderly patients progressive neurologic disease
Technique
Fusion position goal is to have patient get his hand to his mouth to feed himself think 30°-30°-30° 20°-30° of abduction 20°-30° of forward flexion 20°-30° of internal rotation

TAG

(OBQ11.69) Which of the following patients would benefit most from a glenohumeral arthrodesis? Topic

Review Topic

1. A 74-year-old man with AVN of the proximal humerus
2. A 24-year-old woman with recurrent instability after an arthroscopic procedure for multi-directional instability
3. A 30-year-old laborer with a paralysis of the deltoid and rotator cuff muscles
4. A 70-year-old patient with removal of an infected primary total shoulder arthroplasty
5. A 20-year-old man patient with cleidocranial dysostosis

PREFERRED RESPONSE ▶

DISCUSSION: A glenohumeral arthrodesis would be most beneficial to a patient with a flail shoulder but intact elbow and hand function. This is especially important for a laborer. It will allow the patient to have a stable base upon which to be able to use the hand. The position of arthrodesis is described in the review topic, and the goal is to position the shoulder so that the hand can reach the patient's mouth for feeding and groin for hygiene.

According to Clare et al. the indications include posttraumatic paralysis of the deltoid muscle and rotator cuff, brachial plexus injuries, chronic infection, failed revision arthroplasty, severe refractory instability, and bone deficiency following tumor resection.

The review by Safran & Iannotti noted marked improvements in pain and function in appropriately selected patients. Complications include nonunion, malposition, pain associated with prominent hardware, and periarticular fractures.

Incorrect Responses:
1. Hemiarthoplasty may be better for a younger patient with AVN.
2. Continued therapy and revision arthroscopic or open stabilization would be better choices.
4. Once the infection is treated, a second-stage re-implantation of a TSA, hemiarthroplasty or reverse TSA would be a better option.
5. Patients with cleidocranial dysostosis may benefit from scapulo-thoracic arthrodesis, not glenohumeral.

REFERENCES:

1. Safran O, Iannotti JP. Arthrodesis of the shoulder. J Am Acad Orthop Surg. 2006 Mar;14(3):145-53. Review. PMID:16520365 (Link to Abstract)

2. Clare DJ, Wirth MA, Groh GI, Rockwood CA Jr. Shoulder arthrodesis. J Bone Joint Surg Am. 2001 Apr;83-A(4):593-600. PMID:11315792 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Dave Marcu MD, Ben Taylor MD,

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TAG

(OBQ06.241) A 45-year-old man has paralysis of his deltoid and rotator cuff as the result of a motorcycle injury. His neurologic injury has not improved in the 5 years since the injury, but he does have some use of his hand and wrist. What is the most appropriate treatment? Topic

Review Topic

1. Levator scapulae and rhomboid tendon transfer
2. Total shoulder replacement
3. Reverse total shoulder replacement
4. Shoulder arthrodesis
5. Latissimus dorsi transfer

PREFERRED RESPONSE ▶

DISCUSSION: A young patient with a flail shoulder but functional use of his hand is a good candidate for glenohumeral arthrodesis. The shoulder needs to be fused in a position of function, with mid-abduction and enough forward flexion and internal rotation so that his hand can reach his mouth. A typical arthrodesis position would be roughly 40 degrees of abduction, 35 degrees of foward elevation, and 20 degrees of internal rotation.

Rühmann et al. reviewed 43 cases of shoulder arthrodesis performed for indications such as paralysis (32 [74%]), osteoarthritis or humeral head necrosis (15 [35%]), infection (7 [16%]), and persistent shoulder instability. The article has a surgical technique section that states, “In relation to the thorax, the following arm positions were selected for arthrodesis (range): abduction, 20° to 60°; anteversion, 20° to 40°; internal rotation 0° to 50°; and no external rotation.”

Incorrect Answers:
1. Eden-Lange procedure is used to treat chronic lateral scapular winging. It involves the lateral transfer of the levator scapulae, rhomboid major, and rhomboid minor to substitute for each part of the trapezius.
2. A total shoulder is contra-indicated in a patient without rotator cuff function.
3. A reverse TSA is contra-indicated in patients without deltoid funtion.
5. Latissimus transfer is used to improve overhead motion in patients with irrepairable rotator cuff tears.

REFERENCES:

1. Rühmann O, Schmolke S, Bohnsack M, Flamme C, Wirth CJ. Shoulder arthrodesis: Indications, technique, results and complications. J Shoulder Elbow Surg 2005; 14:38-50. PMID:15723012 (Link to Abstract)

Question Authors:

Patrick McCulloch MD, Michael Hughes MD, John Badylak MD,

Please Rate Educational Value!

4.0

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Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Safran O, Iannotti JP. Arthrodesis of the shoulder. J Am Acad Orthop Surg. 2006 Mar;14(3):145-53. Review. PMID:16520365 (Link to Abstract)
Clare DJ, Wirth MA, Groh GI, Rockwood CA Jr. Shoulder arthrodesis. J Bone Joint Surg Am. 2001 Apr;83-A(4):593-600. PMID:11315792 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Rühmann O, Schmolke S, Bohnsack M, Flamme C, Wirth CJ. Shoulder arthrodesis: Indications, technique, results and complications. J Shoulder Elbow Surg 2005; 14:38-50. PMID:15723012 (Link to Abstract)

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