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Arthroplasty of the Shoulder

- Discussion: 

     - Total Shoulder Arthroplasty:    (considerations: hemiarthroplasty vs TSA)
     - Reverse arthroplasty

- Indications:
     - indicated for end stage DJD or RA shoulder involvement;
     - contra-indications to shoulder arthroplasty include combined rotator cuff / deltoid paralysis
            and recent joint infection;
            - in these rare circumstances, arthrodesis may be considered;
     - may occur as a consequence of recurrent shoulder instability;
     - infection control
     - references:
            - Shoulder Arthroplasty in Patients with a Prior Anterior Shoulder Dislocation. Results of a Multicenter Study.
            - Dislocation arthropathy of the shoulder 

- Exam:

     - note the degree both preoperatively and postoperatively of scapulothoracic to glenohumeral motion;
     - as noted by Friedman RJ (1997), patients with DJD of the shoulder reverse the normal 1:2 ratio of
            scapulothoracic to glenohumeral motion ratio (this is not changed w/ arthroplasty);
     - excessive external rotation:
            - may indicated deficiency of subscapularis
     - restricted external rotation:
            - may indicated severe wear of the posterior glenoid, in which case the glenoid may have to be
                       reamed to a more neutral version;
     - reference
             - Prospective analysis of total shoulder arthroplasty biomechanics.

- Radiographs:
     - AP radiograph in internal and external rotation
     - axillary view to assess glenoid deficiencies;
            - even if glenoid appears normal on the axillary view, any posterior subluxation may indicate excessive
                       poserior glenoid wear;
     - CT scan:
            - may allow better assesment of the glenoid version and possible posterior glenoid erosion;
            - ref: The use of computerized tomography in the measurement of glenoid version.
     - osteoarthritic changes:
            - prominent osteophyte at the inferior margin of the humeral head or glenoid is characteristic;
            - mild arthrosis: inferior osteophyte less than 3 mm in length;
            - moderate arthrosis: inferior osteophyte between 3-5 mm in length, irregularity of the joint line and subchondral sclerosis;
            - severe arthrosis: inferior osteophyte measuring more than 5 mm or if there is joint incongruity;

- Surgical Technique:      
     - anterior approach to shoulder
     - hemiarthroplasty  - preparation and insertion of hemiarthroplasty
     - total shoulder arthroplasty:
             - glenoid component:
             - total shoulder arthroplasty - video
             - technical considerations with fracture
             - reverse arthroplasty

- Post Operative Rehab:
      - immediate begin an active assisted range-of-motion program emphasizing forward elevation and external rotation to the side;
      - active strengthening should not begin for 6 weeks postoperatively to allow the subscapularis tendon repair time to heal;
      - reference:
               - Rehabilitation after total shoulder arthroplasty.
               - Is a formal physical therapy program necessary after total shoulder arthroplasty for osteoarthritis?

- Complications of Shoulder Arthroplasty