12. Shoulder And Elbow Arthroplasty.pdf

PART 

V

RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS

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CHAPTER 

12 

SHOULDER AND ELBOW ARTHROPLASTY Thomas W. Throckmorton

RECONSTRUCTIVE PROCEDURES OF THE SHOULDER History Anatomy and biomechanics Prosthesis design Clinical presentation and radiographic evaluation Preoperative planning Hemiarthroplasty Indications Surgical technique Outcomes Modified hemiarthroplasty: interposition arthroplasty and glenoidplasty (ream and run) Resurfacing hemiarthroplasty Total shoulder arthroplasty Indications Surgical technique Outcomes

570 570 571 574 575 576 576 576 578 580 580 582 582 582 582 584

Reverse total shoulder arthroplasty Indications Surgical technique Outcomes Glenoid bone loss Complications of shoulder arthroplasty Intraoperative complications Postoperative complications Complications of reverse shoulder arthroplasty Revision shoulder arthroplasty Indications Outcomes Other surgical options for failed shoulder arthroplasty Hemiarthroplasty Resection arthroplasty Glenohumeral arthrodesis

RECONSTRUCTIVE PROCEDURES OF THE SHOULDER Prosthetic replacement of the glenohumeral joint has become accepted as a successful treatment for a variety of degenerative conditions around the shoulder. Although less common than hip and knee arthroplasty, multiple studies with longterm follow-up have demonstrated improvements in pain and function with excellent longevity. As experience with primary arthroplasty has accumulated, improved techniques for revision surgery have evolved as well. In the past decade, the emergence of the reverse total shoulder arthroplasty has added another option for the treatment of patients with advanced glenohumeral conditions associated with end-stage rotator cuff dysfunction. This chapter discusses the indications, surgical technique, outcomes, and complications of shoulder arthroplasty.

HISTORY

The earliest known report of shoulder arthroplasty dates back to 1893, when a French surgeon, Péan, substituted a platinum and rubber implant for a glenohumeral joint destroyed by tuberculosis. In the early 1950s, Neer introduced a humeral head prosthesis that he planned to use for complex shoulder fractures. In 1951, he reported his initial results of replacement of the humeral head with an unconstrained cobaltchromium alloy (Vitallium) prosthesis. In 1974, the Neer II humeral prosthesis, which was modified to conform to a

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Rehabilitation after shoulder arthroplasty RECONSTRUCTIVE PROCEDURES OF THE ELBOW Anatomy and biomechanics Types of arthroplasty Debridement arthroplasty Interposition (fascial) arthroplasty Resection and implant arthroplasty of the radial head Total elbow arthroplasty Indications Surgical technique Outcomes Complications Salvage Revision elbow arthroplasty Resection arthroplasty

597 597 598 600 601 602 604 608 609 609 613 614 614 614 615

glenoid component, was introduced. Total shoulder arthroplasty using a constrained articulated unit in patients with loss of the rotator cuff but with a functional deltoid muscle was popular in the early 1970s but had limited success and was abandoned. However, in the early 1990s, Paul Grammont introduced an improved design of a semiconstrained shoulder replacement using a metal sphere implanted into the glenoid and a polyethylene liner and stem into the humerus: the reverse total shoulder arthroplasty. Although implant design factors continue to evolve, the primary features of this prosthesis are retained in current iterations of the reverse arthroplasty. Glenoid components for anatomic total shoulder arthroplasty were initially designed for cementless fixation using screws and porous coating on metal backing with a polyethylene shell. But long-term studies have shown an unacceptably high complication rate, and as such these implants have been largely abandoned. In the 1990s, more emphasis was placed on restoring normal kinematics with anatomic location and orientation of the glenoid joint surface, advanced soft-tissue balancing techniques, and physiologic stabilization of the joint. More recently, research has focused on methods to reduce glenoid wear and loosening, which remains a common mode of late-term failure. Most current glenoid implants are polyethylene and use cement for fixation with either a pegged or keeled configuration on the backside of the component.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

ANATOMY AND BIOMECHANICS

The anatomy of the shoulder joint permits more mobility than any other joint in the body. Although it often is described as a ball-and-socket joint, the large humeral head articulates against and not within the small glenoid cavity. The glenohumeral joint depends on the static and dynamic stabilizers for movement and stability, especially the rotator cuff, which not only stabilizes the glenohumeral joint while allowing greater freedom of motion but also fixes the fulcrum of the upper extremity against which the deltoid can contract and elevate the humerus. The rotator cuff must act simultaneously and synergistically, however, with the deltoid muscle for normal function. Restoration of glenohumeral anatomy is essential for a good functional outcome. Anatomic studies have defined the humeral geometry further and suggested applications to shoulder arthroplasty prosthesis design and surgical techniques (Fig. 12-1 and Table 12-1). The articular surface of the humeral head is essentially spherical, with an arc of approximately 160 degrees covered by articular cartilage. The radius

TABLE 12-1

Anatomic Characteristics of the Shoulder Important for Prosthesis Design GLENOID DIAMETER Superior anteroposterior Inferior anteroposterior Superoinferior (height)

18-30 mm 21-35 mm 30-48 mm

INCLINATION Glenoid Humeral head

Average 4.2 degrees (−7 to 20 degrees) 30-55 degrees

VERSION Glenoid Humeral head

1.5 degrees retroversion (10.5 to 9.5 degrees anteversion) 0-55 degrees retroversion (dependent on measurement method; highly variable among individuals)

SURFACE AREA Glenoid Humeral head

4-6 mm 11-19 mm

CARTILAGE THICKNESS Glenoid Humeral head

2.16 mm 1.44 mm

RADIUS OF CURVATURE Glenoid Humeral head

22-28 mm 23-28 mm (smaller in women than men)

HUMERAL OFFSET Medial (coronal) Posterior (transverse) Head-shaft angle

4-14 mm −2 to 10 mm 30-55 degrees

of curvature is approximately 25 mm and is slightly larger in men than in women. The glenoid articular surface radius of curvature is 2 to 3 mm larger than that of the humeral head. The average neck-shaft angle is 45 degrees (±5 degrees), with a range of 30 to 50 degrees. Murthi et al. found that arthritic shoulders have a flatter neck-shaft angle close to 50 degrees. CT studies found that the normal position of the glenoid surface in relation to the axis of the scapular body ranged from 2 degrees of anteversion to 7 degrees of retroversion. The superior margin of the humeral head articular surface normally is superior to the top of the greater tuberosity by 8 to 10 mm (Fig. 12-2). Restoring the center of rotation for the humeral head in relation to the axis of the humeral diaphysis may play a role in prolonging glenoid fixation and decreasing polyethylene wear. The distance from the lateral base of the coracoid process to the lateral margin of the greater tubero­ sity is called the lateral humeral offset. Maintaining this distance is important because a significant decrease reduces the lever arms for the deltoid and supraspinatus muscles, which weakens abduction and impairs function. A significant increase causes excessive tension on the soft tissues (“overstuffing” of the joint), which results in loss of motion and also likely accelerates polyethylene wear. A biomechanical cadaver study determined that humeral articular malposition of more than 4 mm led to increased subacromial contact and that offset of 8 mm in any direction significantly decreased passive range of motion. The authors suggested that anatomic reconstruction of the humeral head/humeral shaft offset should be within 4 mm of normal to minimize subacromial contact and maximize glenohumeral motion. Based on the clinical success of the Neer II implant, numerous modular designs were developed to improve implant fixation and durability. Detailed studies of shoulder anatomy in the 1990s found not only that normal shoulder anatomy aligned differently than the commonly used prostheses, but also that normal anatomy varied greatly among individuals. Modularity allows a better fit for individual patients because various stem and head sizes can be “mixed and matched” to an individual’s anatomy. Biomechanical studies also showed that shoulder biomechanics are adversely affected by the use of a prosthetic head that is too thick, too thin, or shifted too far from its original position along the plane of the anatomic humeral neck. As a general guideline, the prosthetic head should be within 4 mm of the original humeral head thickness. Other characteristics of shoulder anatomy that are important in prosthesis design are retroversion, head-shaft angle, offset, radius of curvature, and humeral head height. Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees, depending on the method used for measurement. The proximal and the distal axes used to define retroversion have various definitions. For the proximal reference axis, the plane of the articular surface, a line connecting the center of rotation and the central point of the articular surface, and a line from the greater tuberosity to the central point of the articular surface have been used. For the distal reference axis, the trochlear axis, a line between epicondyles, and the forearm itself have been used. The inclination of the proximal humeral articular surface relative to the humeral shaft is the head-shaft angle; it ranges from 30 to 55 degrees, depending on the method of measurement. The humeral offset defines the position of the proximal humeral articular

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS

Neer* 1951 Hemiarthroplasty—Unconstrained

Péan* 1893 Total shoulder arthroplasty (TSA)—Constrained Charnley-THA

Humeral endoprosthesis

Semiconstrained

Unconstrained Neer II (Neer clones) Designed to reproduce normal anatomy Endo or TSA

DANA (Designed After Natural Anatomy) Hooded glenoid

Cup arthroplasty Jónsson (metal), Varian, (Silastic cup), O’Leary-Walker (metal) included an optional glenoid component

English-MacNab Uncemented design Hooded with deep glenoid Mazas Exemplifies qualities of all three methods to semiconstrain a humeral endoprosthesis: • Hooded • Glenoid physically attached to the acromion; acts like a spacer • The deep glenoid acts like a “bowl” to contain the humeral head

DANA (UCLA) and Monospherical (Gristina) Systems require greater bone resection and have more constraint built into the glenoid component St. Georg Primarily used in Europe; Endo or TSA Isoelastic Shoulder implant primarily European use; Endo or TSA

Clayton “Spacer” Polyethylene appliance designed to maintain the interval between the head and the acromion

Bipolar Bateman, Swanson, MacNab Forgiving appliance, fills the glenoid vault, theoretically offers more motion with less stress on the glenoid

Neer hooded Appliance; 200% and 600% glenoid components 600%

St. Georg hooded Neer-type designs Less constraint, modularity to offer better soft-tissue balance and avoid eccentric loading of the glenoid Press-fit, cemented, or bony ingrowth

Bipolar Designed to deal with extensive rotator cuff deficiencies or failed constrained TSAs

In the end it appears that Neer’s original design is as similar to the “modern TSA” as Charnley’s initial THA is to the “modern THA.”

Some of these appliances may still be available; however, they would be hard to find. The benefit-to-risk ratio is poor when weighing the functional improvement against the increased complications.

*On display at the Smithsonian. FIGURE 12-1 Family tree of shoulder arthroplasty prostheses. (Adapted from Gross RM: The history of total shoulder arthroplasty. In Crosby LA, editor: Total shoulder arthroplasty, Rosemont, IL, 2000, American Academy of Orthopaedic Surgeons.)

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

Constrained†

Ball and Socket Trispherical TSA Remarkably similar to Péan’s original TSA The extreme mobility of this appliance minimizes stress at the bony fixation points Floating fulcrum was a problem

Michael Reese

BME

Bickel, Michael Reese, Model BME (Germany), and Stanmore (England) All four of these appliances are of the “captured head” type Breakage, dislocation, and glenoid loosening were all too frequent complications Bickel, Michael Reese, and BME are metal on polyethylene Stanmore originally was metal on metal and later converted to metal on polyethylene

Reverse Ball and Socket Floating socket TSA Reverse bipolar and reverse ball and socket

Fenlin TSA The Fenlin and the Floating Socket are both large-head reverse ball-and-socket Large head design aimed at increasing motion

Neer Mark III Fixed fulcrum reverse ball-and-socket with a rotating stem within the humeral shaft

Kessel Large central screw fixation of the glenoid component, no cement Kölbel TSA Screw fixation to glenoid similar to Péan’s original glenoid fixation

Stanmore

Liverpool TSA Cemented mini “reverse THA”

Delta III Sole survivor, uncemented glenoid surface mount

†Development,

as well as failure, of the constrained TSA came as a result of two false assumptions: (1) most arthritic patients would have deficient rotator cuffs and (2) the function of the rotator cuff could effectively be replaced by a fixed fulcrum. FIGURE 12-1, cont’d

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS F

G

E H

D

C A

M

B

α

I N

FIGURE 12-2 Normal glenohumeral relationships. Humeral offset is depicted by distance F to H, thickness of humeral head from B to C, and center of humeral head at C. Note superior position of humeral head proximal to greater tuberosity (D to E).

surface relative to the humeral shaft; it is measured as the distance from the center of rotation of the proximal humeral articular surface to the central axis of the humeral canal. The medial offset (coronal plane) ranges from 4 to 14 mm, and the anteroposterior offset (transverse plane) ranges from −2 to 10 mm. Reported values for the radius of curvature of the proximal humeral articular surface range from 20 to 30 mm; smaller radii typically are reported in women, and some authors have reported that the radius of curvature is larger in the coronal plane than in the sagittal plane. Replacement of the anatomic humeral head size and position aims to restore normal shoulder biomechanics. Increasing the humeral head thickness by 5 mm has been shown to reduce the range of motion at the glenohumeral joint by 20 to 30 degrees, whereas decreasing the thickness by 5 mm can diminish motion by a similar amount by reducing the surface arc available for differential motion between the humeral head and the glenoid.

PROSTHESIS DESIGN

Most current systems are modular with varying humeral head diameters and neck lengths to allow more accurate coverage of the cut surface of the humeral neck and improve the ability to establish correct position of the joint line. Some designs allow independent sizing of head thickness and head diameter to make soft-tissue balancing easier. Most stems are made of cobalt-chrome or titanium alloy and have proximal porous ingrowth coating to allow insertion without cement. In an effort to match the proximal humeral anatomy as closely as possible, several implant systems offer concentric and offset humeral heads. In an anatomic dissection study, Boileau and Walch found that the center of the humeral head was 2.6 mm posterior and 6.9 mm medial to the center of the

humeral shaft, and Robertson et al., using CT, noted similar measurements of 2.2 mm and 7.4 mm. Anatomic positioning of the humeral head prosthesis is best done with an eccentric locking position of the Morse taper, which allows adjustments to the variable medial offset and any posterior offset. Curiously, postoperative kinematics after total shoulder arthroplasty do not mimic those of the native shoulder. Massimini et al. found that the posterosuperior quadrant of the glenoid is the primary contact location and that the replaced shoulder is not subject to traditional kinematic conceptions. Nevertheless, positioning the head too far superiorly puts additional tension on the overlying supraspinatus tendon and can cause impingement between the head and the acromion. Positioning the head too far inferiorly may cause abutment of the greater tuberosity on the acromion or internal impingement on the rim of the glenoid. Positioning the head too far anterior or posterior can result in abutment of the uncovered humeral neck on the corresponding glenoid rim and excessive tension on the overlying subscapularis and posterior rotator cuff tendons. Most current systems offer humeral heads that are offset by 3 or 4 mm; some allow several discrete positions, and some allow free rotation around the taper. Most stems can be inserted with a press-fit or cemented technique. In a cadaver study, micromotion was found to be significantly less with proximal cement than with press-fit; no difference was found between proximal cementation and full cementation, and full cementation did not increase rotational stability over proximal cementation. One study found a very low rate of radiolucencies around proximal porous coated stems and no clinical signs of loosening. Clinically significant loosening of the humeral component in the absence of infection is uncommon regardless of fixation methods. Cemented all-polyethylene components remain the most frequently used glenoid components, but most now have an increased radius of curvature compared with the humeral head (2 to 6 mm larger) to allow translation during movement and to decrease edge loading. Several studies have shown that translation accompanies glenohumeral rotation after total shoulder arthroplasty. Such translation in a perfectly congruent joint may have a potential for localized wear and loosening (rocking-horse effect); however, increased loosening and polyethylene wear have not been reported to occur when the radii of curvature of the glenoid component and the humeral head are matched within 2 mm. In a multicenter study of 319 total shoulder arthroplasties using the same type of prosthesis, Walch et al. noted fewer radiolucencies with mismatches between the glenoid and humeral head diameters of more than 5.5 mm (6 to 10 mm). They cautioned that the upper limit of mismatch has not been conclusively determined, and thus greater prosthetic mismatches could lead to increased joint translation, accelerated polyethylene wear, and fracture. Current opinion seems to suggest that a glenoid with a radius curvature of 2 to 4 mm larger than the humeral head allows normal translation during rotation without rim loading or risk of loosening (Fig. 12-3). A larger glenoid component results in an increased risk for volumetric polyethylene wear similar to what is seen in hip and knee arthroplasty, but this risk has not been substantiated clinically. However, larger components have been linked with improved stability. In a biomechanical study, Tammachote et al. demonstrated improved stability with

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

CLINICAL PRESENTATION AND RADIOGRAPHIC EVALUATION

A

B FIGURE 12-3 A, When radii of curvature of glenoid component and humeral head conform, translation results in glenoid component rim loading. B, Slight increase in diameter of curvature of glenoid component over that of humeral head allows some translation before rim loading occurs.

increasing sizes of glenoid components. Specifically, transverse plane stability improved 17% between the small and medium components and then improved 10% between the medium and large components. Currently, all-polyethylene glenoid components generally are cemented into place. A biomechanical study found that cemented all-polyethylene designs had an overall stress pattern closer to that of an intact glenoid than did uncemented metal-backed components. In a report of 408 shoulder arthroplasties using a standard glenoid component and followed for more than 2 years, Neer reported that only 3 (0.07%) required reoperation because of glenoid loosening. More recently, Hopkins et al. found that bone quality was important in achieving solid glenoid component fixation. They also stressed the importance of proper implant positioning. Polyethylene glenoid components generally have a single central or offset keel or multiple pegs for fixation into the glenoid vault. The preponderance of biomechanical evidence suggests an advantage to pegged designs, however. Lacroix et al., using a three-dimensional model and finite element analysis, found that bone stresses were not much affected by prosthesis design except at the tip of the central peg or keel. They did conclude, however, that pegged prostheses were better for normal bone, whereas keeled components were better for bone in rheumatoid patients.

The clinical appearance of advanced glenohumeral degeneration was initially described by Neer. Patients typically present with global pain about the shoulder with difficulty performing overhead activities and, often, activities of daily living. On physical examination, diminished active and passive range of motion may be observed and patients may have previously been diagnosed with adhesive capsulitis. In patients with intact rotator cuff tendons, strength is often preserved but may be diminished secondary to pain. Palpable crepitus can often be elicited with passive internal and external rotation of the glenohumeral joint. The acromioclavicular joint and biceps tendon should be carefully evaluated because symptomatic acromioclavicular degeneration and/or biceps tendinitis may also be present. Standard radiographs include anteroposterior views with a 40-degree posterior oblique view in neutral position and internal and external rotation and an axillary lateral view. Radiographs of the opposite, uninvolved shoulder and humerus are helpful in unusual situations, such as when a custom implant is indicated for large humeral or glenoid deficiencies. The radiographic appearance varies with the patient’s pathologic process. Those with osteoarthritis reliably demonstrate subchondral sclerosis and a large osteophyte on the inferior aspect of the humeral head (Fig. 12-4). This so-called “goat’s beard” is pathognomonic of advanced glenohumeral degeneration. These osteophytes can enlarge the humeral head to twice its normal size, resulting in capsular distention. Posterior instability caused by this capsular distention and posterior glenoid erosion may require capsular reefing, augmented glenoid components, or bone grafting at the time of shoulder arthroplasty. This is most common in cases of capsulorrhaphy arthropathy. Joint space narrowing, which is so reliably seen in hip and knee osteoarthritis, is not commonly seen in the shoulder until very late in the disease process owing to the non–weight-bearing position of the shoulder under standard radiography. Axillary lateral radiographs typically demonstrate posterior subluxation of the humeral head on the glenoid, and a wear pattern in the posterior glenoid may be present (Fig. 12-5). Patients with capsulorrhaphy arthropathy have a similar radiographic appearance except that loose bodies and osteophytes tend to be more common and numerous (Fig. 12-6) than in standard osteoarthritis. Malunions of proximal humeral fractures can make shoulder arthroplasty more difficult, occasionally requiring osteotomy. A varus malunion between the head and shaft can complicate positioning of components, but osteotomy usually is unnecessary as newer short-stem and stemless designs allow accommodation of these deformities. Patients with inflammatory arthritis often do not have an inferior osteophyte on radiographs and, instead, demonstrate a more symmetrical pattern of joint space narrowing with periarticular osteopenia. The wear pattern is more commonly central in the glenoid, and posterior subluxation of the humeral head is less common. Cystic change is also common. Rotator cuff tears are more common in patients with rheumatoid arthritis than in patients with osteoarthritis: full-thickness rotator cuff tears have been identified in 25% to 50% of patients undergoing shoulder arthroplasty. Most of these tears are in the superior rotator cuff.

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS biceps tendon. Increased capsular volume posteriorly and capsular contraction anteriorly are usual changes as well. Finally, in patients with precollapse osteonecrosis, MRI is useful for visualizing the area of dead bone and is often the best tool to make the diagnosis (Fig. 12-7). CT is also a valuable asset in the evaluation and preo­ perative planning for patients with advanced glenohumeral degeneration. The scans give an excellent picture of the patient’s glenoid bone stock and the pattern of glenoid wear, which is essential for determining if standard glenoid components can be used or if a bone graft will be needed. Loose bodies may be seen in the axillary or subscapularis recess or attached to the synovium. In the case of malunions or nonunions, three-dimensional reconstruction helps to precisely show the bony deformities and defects before surgery. CT arthrography often is useful to evaluate both the bony architecture of the shoulder and the rotator cuff in patients with contraindications to MRI.

PREOPERATIVE PLANNING

Once the patient is determined to have advanced glenohumeral degeneration and has consented to a shoulder arthroplasty, preoperative planning includes careful evaluation of the radiographs and the CT scans, if obtained. As noted earlier, CT gives a clear view of the glenoid bone stock and wear pattern. Viewing these changes preoperatively allows the surgeon to prepare for the possibility that glenoid bone grafting or glenoid recontouring procedures may be necessary to recenter the subluxed humeral head. The role of preoperative planning based on three-dimensional CT scans to optimize implant position, size, and range of motion is an evolving area of investigation. Most reports have concluded that preoperative planning software using CT scans results in more accurate glenoid component placement with either conventional or patient-specific implants. In particular, shoulders with significant posterior glenoid erosion tend to benefit from implant reaming and targeting systems. In patients who have had previous shoulder surgery, infection can be evaluated by laboratory tests including erythrocyte sedimentation rate, C-reactive protein, and complete blood cell count. Aspiration and culture of glenohumeral joint fluid, holding the culture for at least 14 days to isolate Propionibacterium acnes, is essential if infection is suspected. Electromyography and nerve conduction studies should be obtained preoperatively in patients with suspected deficits. Finally, preoperative medical clearance often is warranted in this typically elderly population. FIGURE 12-4 Subchondral sclerosis and large osteophyte on inferior aspect of humeral head (goat’s beard) are pathognomonic of advanced glenohumeral degeneration.

MRI can be a useful preoperative planning tool in this population. In patients with strength deficits that could be caused by either arthritic pain or a torn rotator cuff, MRI can help determine the status of the tendons. Whereas rotator cuff tendinopathy is common in this setting, full-thickness tears are uncommon and are seen in only about 10% of patients. MRI also typically demonstrates advanced cartilage degeneration and may show numerous other findings, including thinning of the subscapularis and degenerative changes in the

HEMIARTHROPLASTY INDICATIONS

The predominant indication for shoulder hemiarthroplasty is end-stage joint degeneration in a patient with a contraindication to glenoid resurfacing. The preponderance of evidence indicates that total shoulder arthroplasty is superior to hemiarthroplasty regarding pain, function, activity level, longterm survival, and revision rate and, therefore, the glenoid should be resurfaced if at all possible in patients with bipolar arthritis. However, young laborers, patients with glenoid bone stock insufficiency, and patients with high activity levels may benefit more from hemiarthroplasty. Also, rotator cuff tears remain a contraindication to prosthetic glenoid

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

A

B FIGURE 12-5

Axillary radiograph (A) and CT scan (B) showing severe degenerative arthritis.

FIGURE 12-7 Magnetic resonance image showing precollapse osteonecrosis.

FIGURE 12-6 Radiograph showing capsulorrhaphy arthropathy; note numerous loose bodies and osteophytes.

resurfacing. Although excellent pain relief and moderate improvements in function and motion have been reported after total shoulder arthroplasty in patients with irreparable rotator cuff tears, some long-term follow-up studies noted an association between glenoid component loosening and

irreparable rotator cuff tears. Eccentric loading of the glenoid caused by superior migration of the humeral component has been cited as a cause of glenoid loosening (the “rocking-horse effect”). Hemiarthroplasty also can be recommended for patients in whom a massive, long-standing tear of the rotator cuff has caused progressive degenerative changes of the glenohumeral joint (cuff tear arthropathy). In patients with deficient forward elevation, however, reverse total shoulder arthroplasty has

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS posterior reconstruction to provide stability to the implant. The rotator cuff is repaired with sutures placed through the tuberosities before implantation of the humeral component. Although complete repair of the rotator cuff often is impossible, it may be unnecessary for arm elevation. Many patients with full-thickness defects are capable of active overhead arm elevation if sufficient rotator cuff function remains to allow compressive stabilization of the humeral head. Good deltoid function and an adequate coracoacromial arch are key to successful hemiarthroplasty in patients with severe rotator cuff arthropathy. A history of subacromial decompression has been significantly associated with clinically detectable instability and less active elevation after hemiarthroplasty.

HEMIARTHROPLASTY TECHNIQUE 12-1 FIGURE 12-8 Use of humeral head component that is too large results in overstuffing of joint, which can limit range of motion and lead to soft-tissue rupture.

emerged as a more reliable option to reestablish shoulder level function. In patients with cuff tear arthropathy but preserved forward elevation, hemiarthroplasty remains a viable option. Matsen et al. listed five situations in which hemiarthroplasty should be considered: (1) the humeral joint surface is rough, but the cartilaginous surface of the glenoid is intact, and there is sufficient glenoid arc to stabilize the humeral head; (2) there is insufficient bone to support a glenoid component; (3) there is fixed upward displacement of the humeral head relative to the glenoid (as in cuff tear arthropathy or severe rheumatoid arthritis); (4) there is a history of remote joint infection; and (5) heavy demands would be placed on the joint (anticipated heavy loading from occupation, sport, or lower extremity paresis). Contraindications to hemiarthroplasty are recent sepsis, a neuropathic joint, a paralytic disorder of the joint, deficiencies in shoulder cuff and deltoid muscle function, and lack of patient cooperation. Remote pyarthrosis may not be an absolute contraindication, but the operation should be undertaken only after thorough workup to document sterilization of the glenohumeral joint and careful consideration by the surgeon and the patient of all the potential hazards involved.

SURGICAL TECHNIQUE

The goal of hemiarthroplasty is restoration of the humeral articular surface to its normal location and configuration. Because the glenoid is not replaced, the size, radius, and orientation of the prosthetic joint surface must duplicate that of the original biologic humeral head. Radiographs of the contralateral shoulder can provide information about a patient’s normal humeral head anatomy. Care should be taken to avoid a “big head” humeral prosthesis that can “overstuff ” the joint (Fig. 12-8). If it is found to be torn, as much of the rotator cuff as possible should be repaired, emphasizing anterior and

Place the patient in the beach chair position to allow positioning of the patient at the top and edge of the table (Fig. 12-9A). Pad all bony prominences. The medial border of the scapula should be free and off the table, allowing full adduction to gain access to the intramedullary canal. ■ Secure the patient’s head to the headrest, holding the head in a position that avoids hyperextension or tilting of the neck, which can cause compression of the cervical roots. ■ Prepare the arm and drape it widely. We recommend using occlusive dressings to cover the entire surgical field. ■ Make an incision anteriorly, approximately one-third to halfway between the coracoid and the lateral aspect of the acromion (Fig. 12-9B). Carry dissection down to the deltoid and raise medial and lateral flaps to mobilize the deltoid. ■ Open the deltopectoral interval and allow the cephalic vein to fall medially. ■ Perform subdeltoid, subcoracoid, and subacromial releases to release the proximal humerus. In the subcoracoid space, locate the axillary nerve by passing the volar surface of the index finger down along the anterior surface of the subscapularis muscle (Fig. 12-9C). If scarring and adhesions make identification of the nerve difficult, pass an elevator along the anterior surface of the subscapular muscle to create an interval between the muscle and the nerve. Great care must be taken in this step to avoid plunging into the brachial plexus. After the axillary nerve is identified, carefully retract and hold it out of the way, especially during the crucial steps of releasing and resecting the anteroinferior capsule. ■ We prefer to perform a biceps tenodesis before incising the subscapularis. A figure-of-eight stitch is placed between the biceps and pectoralis major tendons. The biceps is then divided and the proximal portion is later resected before making the humeral head osteotomy. ■ Incise the subscapularis 1 cm medial to the lesser tuberosity. Place two retention sutures in the subscapularis to be used as traction sutures when freeing the rest of the tendon from the underlying capsule and scar tissue. At closure, use the sutures to repair the tendon. ■

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

Coracoid process Conjoined tendon

Axillary nerve

A

B

1-mm cotton Dacron tape Superior view of the glenohumeral joint

C

Brown retractor

Darrach retractor

Darrach retractor

D

E

FIGURE 12-9 Hemiarthroplasty technique (see text). A, Beach-chair position with arm extended off table. B, Incision. C, Axillary nerve is identified. D, Coronal Z-plasty is used if external rotation is −20 degrees. E, Darrach retractor is used to lift head of humerus out of glenoid fossa. SEE TECHNIQUE 12-1.

Some authors prefer either a lesser tuberosity osteotomy or a release of the subscapularis directly off of bone. If external rotation is markedly limited, the subscapularis also can be reattached to the proximal humerus more medially to allow increased external rotation. Alternatively, the tendon can be lengthened with a coronal Z-plasty technique (Fig. 12-9D and Table 12-2). ■ Incise the rotator interval, directing the cut medially toward the glenoid. Typically, a large amount of synovial fluid escapes as the joint is entered. ■ Release the anteroinferior capsule from the humerus and externally rotate the arm to bring the inferior aspect of the shoulder capsule into view. Take care to stay directly on bone so as not to injure the axillary nerve during the ■

capsular release. The importance of the inferior capsule release cannot be overstated and must be thoroughly carried out to at least the 7-o’clock position to dislocate the humeral head and gain access to the glenoid. ■ Once the capsule is adequately released, place a large Darrach retractor in the joint and gently externally rotate, adduct, and extend the arm to deliver the humeral head up and out of the glenoid fossa (Fig. 12-9E). If the humeral head cannot be delivered in this fashion, the inferior capsule must be released further. ■ Prepare the humeral canal, using the humeral axis to reference the osteotomy. Initially, open the canal with a high speed burr at the base of the rotator cuff footprint and ream it to a size where appropriate fit is felt. Do not

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Guidelines for Release of Subscapularis Tendon SUBSCAPULARIS TENDON RELEASE Release 1.5 cm medial to insertion Release subperiosteally, reattach medially Subscapularis Z-lengthening

Once the checks have been performed, thoroughly clean the Morse taper, impact the humeral head into position, and reduce the joint for the final time. ■ Perform a tight closure of the rotator interval and the subscapularis with heavy nonabsorbable suture. If the tendon was divided or lengthened, repair and secure it with heavy nonabsorbable sutures to allow immediate passive movement beginning the day after surgery. Place a drain in the deltopectoral interval and close it with No. 0 sutures. Close the skin in standard fashion and place the arm in a soft sterile dressing and a sling while the patient is still upright and before being aroused from anesthesia. ■

PREOPERATIVE RANGE OF MOTION Passive external rotation ≥20 degrees Passive external rotation >−20 degrees and <20 degrees Passive external rotation ≤−20 degrees

Data from Schenk T, Iannotti JP: Prosthetic arthroplasty for glenohumeral arthritis with an intact or repairable rotator cuff: indications, techniques, and results. In Iannotti JP, Williams GR Jr, editors: Disorders of the shoulder: diagnosis and management, Philadelphia, 1999, Lippincott Williams & Wilkins.

use motorized equipment for reaming, and be careful not to overream the canal, which could create a stress riser or cause a fracture. ■ We prefer to use a cutting guide that employs extramedullary referencing, using the axis of the forearm as the reference point. With the cutting guide pinned into position at 30 degrees of retroversion, recheck the cutting angle and confirm that the height is such that the saw will not violate the rotator cuff. ■ Complete the osteotomy with an oscillating saw. If any inferior humeral head osteophyte remains, remove it with a rongeur. ■ After the head cut, broach the humeral canal to the same size as the reamed canal. It is imperative to confirm proper position of the broaches in 30 degrees of retroversion during this step to prevent component malposition. ■ Inspect the glenoid to confirm there is enough glenoid cartilage to provide an adequate bearing surface for the metal humeral head. After this inspection, check the humeral trial stem to ensure it is seated securely within the humeral canal. If so, tap the component stem into position, taking care to keep the stem in 30 degrees of retroversion. ■ If cementing is deemed necessary because of a previous surgical procedure, fracture, osteoporosis, rheumatoid arthritis, or degenerative cysts, place a cement restrictor or a cortical bone plug from the resected humeral head 2 cm inferior to the tip of the prosthesis. ■ Place a trial humeral head and reduce the glenohumeral joint using internal rotation and gentle traction. With the arm in neutral rotation, check the height of the humeral head to confirm anatomic reconstruction. As a rule of thumb, the most superior aspect of the humeral head should be 1 cm superior to the greater tuberosity. ■ Also check the version to confirm that the humeral head rests directly across from the glenoid. With a thumb on the lesser tuberosity, push the humeral head posteriorly and then release it: 50% posterior excursion with immediate “bounce back” of the humeral head is optimal. Evaluate forward elevation and internal rotation.

POSTOPERATIVE CARE.  Patients are instructed in a gentle home exercise program with passive forward elevation to 90 degrees and passive external rotation to neutral. Patients typically are discharged from the hospital 1 or 2 days after surgery and are encouraged to use a pillow behind the elbow while recumbent in the sling to support the extremity. Full-time sling immobilization continues for 6 weeks, followed by 6 weeks of sling use only in unprotected environments. Therapy progresses to full passive range of motion by 6 to 12 weeks and to isometric strengthening at 10 weeks.

OUTCOMES

Hemiarthroplasty has been reported to initially relieve pain in 75% to 95% of patients with glenohumeral arthritis and severe rotator cuff deficiency, with more modest improvements in range of motion and strength. However, long-term results have been compromised by persistent pain from glenoid arthrosis, anterosuperior instability, and progressive bone loss. The best results of shoulder hemiarthroplasty are in patients with osteonecrosis, in whom hemiarthroplasty has been reported to provide consistently good pain relief in 90%, with an almost normal range of motion (Table 12-3). Results are not quite as good in patients with rheumatoid arthritis, osteoarthritis, glenoid dysplasia, or posttraumatic glenohumeral arthrosis but are satisfactory in most patients, although range of motion is decreased. In particular, one long-term report found that only 25% of patients were satisfied with stemmed hemiarthroplasty for shoulder osteoarthritis at an average of 17 years follow-up.

MODIFIED HEMIARTHROPLASTY: INTERPOSITION ARTHROPLASTY AND GLENOIDPLASTY (REAM AND RUN)

As it has become clear that glenoid arthritis continues to be a long-term concern for patients undergoing isolated shoulder hemiarthroplasty, some authors have explored various types of glenoid resurfacing procedures, particularly for younger, higher-demand patients. These interposition techniques aim to allow the metal humeral head to articulate with a cushioning surface rather than with the native glenoid in an effort to minimize arthritic progression and subsequent pain. Although most interposition procedures have demonstrated early success, there are few long-term

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY TABLE 12-3

Reported Results of Shoulder Hemiarthroplasty for Rotator Cuff Tear Arthropathy MEAN FOLLOW-UP, YEARS (RANGE) 2 (2-10)

NO PAIN OR MILD POSTOPERATIVE PAIN 11 (61%)

ACTIVE ELEVATION PREOPERATIVE/ POSTOPERATIVE MEAN, DEGREES (RANGE) 66 (44-90)/112 (70-160)

SUCCESSFUL RESULTS NR

STUDY Arntz et al. (1993)

NO. 18

MEAN AGE (RANGE) 71 (54-84)

Williams and Rockwood (1996) Field et al. (1996)

21

72 (59-80)

4 (2-7)

18 (86%)

70 (0-155)/120 (15-160)

18 (86%)

16

74 (62-83)

3 (2-5)

13 (81%)

60 (40-80)/100 (80-130)

10 (62%)

Zuckerman et al. (2000)

15

73 (65-81)

2 (1-5)

7 (47%)

69 (20-140)/86 (45-140)

NR

SanchezSotelo: Mayo Clinic series (2003) Goldberg et al. (2008)

33

69 (50-87)

5 (2-11)

24 (73%)

72 (30-150)/91 (40-165)

22 (67%)

34

72 (48-90)

4 (2-12)

26 (76%)

78 (20-165)/ 111 (40-180)

26 (76%)

COMMENTS Two reoperations for symptomatic glenoid erosion, one for symptomatic instability, one for postoperative traumatic fracture of the acromion No instability or reoperation reported One intraoperative humeral shaft fracture;   4 patients with instability, 2 of whom required reoperation   for subscapularis advancement (1) and resection arthroplasty (1) Eleven of 15 patients satisfied with operation; 1 had anterior instability One intraoperative humeral shaft fracture; 7 patients with anterosuperior instability One patient required reoperation for osteophyte removal; no problems related to implant failure, loosening, infection, or fracture

Modified from Sanchez-Sotelo J: Shoulder arthroplasty for cuff-tear arthropathy. In Morrey BF, editor: Joint replacement arthroplasty, ed 3, Philadelphia, 2003, Churchill Livingstone. NR, Not reported. Copyright of Mayo Foundation.

reports; therefore, further follow-up studies are necessary to better determine their ultimate outcomes. Fascial interposition hemiarthroplasty (biologic resurfacing) has been recommended for use in young, active patients with osteoarthritis. The glenoid is resurfaced using the anterior capsule sewn over the glenoid face or a free fascia lata graft. After humeral osteotomy and removal of osteophytes, the glenoid surface is debrided, slightly increasing the anteversion in the process. If inadequate capsule is present for interposition, a segment of fascia is harvested from the thigh, doubled on itself, and anchored to the center of the glenoid with a suture and to the anteroposterior labrum with heavy suture, such as No. 1 cotton Dacron (Deknatel, Fall River, MA). Good long-term outcomes have been reported with this biologic glenoid resurfacing technique. Other studies, however, have noted a high number of failures and poor

outcomes using Achilles tendon allograft as a resurfacing material with hemiarthroplasty. More recently, lateral meniscal allografts have been used as an interposition material. In this procedure, the anterior and posterior horns of the allograft are sewn to each other to form a circular surface for articulation with the humeral head. The allograft is then laid onto the glenoid and secured, typically with suture anchors (Fig. 12-10). Significant improvements in pain and function have been reported with this procedure. Although joint space narrowing did occur, glenoid erosion did not progress, suggesting that the lateral meniscus may offer some protection against glenoid wear. However, intermediate-term outcomes have been less positive, with results inferior to standard hemiarthroplasty, and enthusiasm for interposition arthroplasty has been waning.

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A

B

C FIGURE 12-10

Lateral meniscal allograft used as interposition material.

A third technique that has been advanced involves concentric reaming of the glenoid combined with shoulder hemiarthroplasty, the “ream and run” procedure. Range-of-motion and Simple Shoulder Test scores were reported to be significantly improved after this procedure, and no shoulder procedures were subsequently revised. However, intermediate- and long-term outcomes are still lacking with this procedure.

RESURFACING HEMIARTHROPLASTY

In an attempt to preserve proximal humeral bone stock, shoulder resurfacing procedures have been developed. Resurfacing implants do not use a stem for intramedullary fixation but instead form a cap over the humeral articular surface and are typically stabilized with a smaller post in the metaphysis (Fig. 12-11). This implant design has been reported to more closely replicate humeral head geometry and reduce eccentric glenoid loading compared with stemmed hemiarthroplasty. Outcomes of humeral resurfacing have generally been successful, with patient satisfaction rates as high as 93% and overall results similar to that of stemmed prostheses. Several series have reported similar success in specific patient cohorts with rheumatoid arthritis, osteoarthritis, and cuff tear arthropathy; however, the reported revision rate of humeral head resurfacing is higher than that of stemmed hemiarthroplasty.

TOTAL SHOULDER ARTHROPLASTY

Total shoulder arthroplasty is a well-established procedure with an excellent long-term track record of pain relief and functional improvements. Long-term results have been reported that are equivalent to those after replacement of the

knee and hip. In a metaanalysis of series that included 646 shoulder arthroplasties done for osteoarthritis, Wilde found that 89% had complete or nearly complete relief of pain; 91% of patients with rheumatoid arthritis reported satisfactory relief.

INDICATIONS

The primary indication for total shoulder arthroplasty is endstage glenohumeral joint degeneration with an intact rotator cuff. This encompasses a number of conditions, including osteoarthritis, rheumatoid arthritis, osteonecrosis, posttraumatic arthritis, and capsulorrhaphy arthropathy. Contraindications to shoulder arthroplasty include active or recent infection and irreparable rotator cuff tears. Paralysis with complete loss of function of the deltoid is also a contraindication. Debilitating medical status and uncorrectable glenohumeral instability are additional contraindications to shoulder arthroplasty. Other patient-specific factors should be considered before total shoulder arthroplasty: morbidly obese patients are known to have a higher rate of medical complications and to incur higher costs; diabetes is reported to correlate with a higher rate of perioperative medical complications; and many elderly patients have concurrent cardiopulmonary disease. Therefore, although perioperative mortality is only approximately 1%, careful medical optimization and patient selection are recommended before shoulder arthroplasty.

SURGICAL TECHNIQUE

Much debate has centered on the relative merits of shoulder hemiarthroplasty and total shoulder arthroplasty.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

FIGURE 12-11

Resurfacing hemiarthroplasty.

The preponderance of evidence in randomized and nonrandomized studies in the literature suggests that although hemiarthroplasty can provide pain relief and increased range of motion in patients with osteoarthritis and a concentric glenoid, total shoulder arthroplasty generally provides superior results in terms of patient satisfaction, function, and strength, especially at longer-term follow-up. A Cochrane Database systemic review of seven studies found that total shoulder arthroplasty is associated with better shoulder function than hemiarthroplasty but does not provide any other significant additional clinical benefits. Mather et al. found that in elderly patients (age ≥ 64 years) with osteoarthritis total shoulder arthroplasty with a cemented glenoid component was more cost effective than hemiarthroplasty in improving quality of life. A multicenter study involving 95 total shoulder arthroplasties and 33 hemiarthroplasties recommended the use of a glenoid component in shoulders with glenoid erosion.

TOTAL SHOULDER ARTHROPLASTY TECHNIQUE 12-2 Approach the glenohumeral joint as described in Technique 12-1. Once the trial broach is tapped into position, remove the retractors from about the humerus. Of note, stemless humeral components for total shoulder arthroplasty have been investigated and have recently been

■

approved by the United States Food and Drug Administration (FDA). ■ Expose the glenoid by placing a Fukuda retractor on the posterior aspect of the glenoid and sublux the humerus posteriorly. ■ Debride the glenoid vault of all remaining labral tissue and articular cartilage. ■ Release the anterior capsule and place a flat Darrach retractor on the anterior glenoid neck to aid exposure. ■ The glenoid is not adequately exposed until the anterior, posterior, superior, and inferior aspects of the glenoid can be seen. Once this is accomplished, inspect the glenoid for wear and bone defects. Typically, there is posterior erosion of the glenoid and the anterior rim of the glenoid needs to be lowered to reestablish correct version (Fig. 12-12). This can be done by eccentric reaming. A preoperative CT scan can aid in understanding glenoid orientation and morphology. ■ Once the glenoid vault is debrided, make a centering hole, typically with a guide. It often is helpful to confirm adequate depth and position of the starting hole with a small curette. After the starting hole is made, proceed with glenoid reaming until the sclerotic bone of the arthritic glenoid is removed and the subchondral plate is seen. With the common posterior wear pattern of osteoarthritis, reaming typically is done in an eccentric fashion so that the anterior lip of the glenoid is planed down. If posterior rim wear is significant and the anterior rim has not been lowered, the component sits excessively retroverted, and anterior glenoid neck perforation is likely. Take care also not to ream too aggressively medially and thereby compromise the glenoid bone stock, as this may result in component subsidence. ■ When reaming is complete, prepare the glenoid for either the pegged or keeled implant. Systems vary in their instrumentation but involve precise placement of the anchoring pegs or keel. To provide secure fixation and reduce the risk of loosening, the glenoid trial must sit securely against the subchondral bone of the glenoid without any rocking after the glenoid is prepared. Cement cannot be used to adjust for poor seating of the glenoid component. ■ Whether using a pegged or keeled component, prepare the glenoid vault for cementing with pulsed lavage to remove debris and blood. Thoroughly dry the peg holes or keel before cementation. ■ Tuberculin syringes are helpful to pressurize the cement. Pack cement into the syringe and then inject it into the peg holes or into the keel. ■ Next, insert the glenoid component and maintain thumb pressure until the cement has hardened. Most shoulder systems also come with an instrument to hold the glenoid component in place while the cement hardens. This method allows excellent pressurization and interdigitation of the cement into the cancellous bone of the glenoid vault, and postoperative radiolucent lines seen with other cementing techniques are minimized (Fig. 12-13). Some systems use a polyethylene or metal ingrowth post to provide a press-fit of the glenoid component, which provides immediate stability so that the component does not rely solely on digital pressure while the cement is curing.

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Area of wear

Bone graft

A

B

C

D

FIGURE 12-12 Problem of and solution for uneven wear and erosion of glenoid. A, Area of wear. B, If glenoid component is inserted without correction of slope, anchoring device passes out of medullary canal; tilt and loss of height also make implant unstable. C and D, Severe erosion is corrected by bone grafting. Piece of humeral head is secured to scapula with 4-mm AO navicular screw. Lesser erosion can be offset by building up low side with acrylic cement or lowering high side. Building up with cement is not recommended because of feared cement loosening. Lowering high side often requires shortening holding device of glenoid component and creates laxity between components, which can make implant temporarily unstable and requires special postoperative care. Glenoid component with thick side is available for moderate uneven erosion. SEE TECHNIQUE 12-2.

Although totally uncemented glenoid components exist, they are associated with higher revision and failure rates. ■ After the cement has hardened, check the broach to ensure that it is still secure within the humeral canal. If so, insert the trial broach and the humeral prosthesis as described in Technique 12-1. Head height, range of motion, and soft-tissue balancing are critical to providing an optimal outcome. Most current systems use modular heads with a variety of diameters and thicknesses. ■ Once the appropriate head is selected, dry the Morse taper and tap the head into position. Reduce the glenohumeral joint and close the wound as described in Technique 12-1.

POSTOPERATIVE CARE.  Postoperative care and rehabilitation are essentially the same as after shoulder hemiarthroplasty (see Technique 12-1) and are governed by protection of the subscapularis repair.

See also Video 12-1.

OUTCOMES

Results after total shoulder arthroplasty have been predictable in producing pain relief and functional improvements for patients with a variety of degenerative glenohumeral conditions, with good results reported in 65% to 95% of patients. Loosening of the glenoid component, however, has been reported in almost half of shoulders at more than 10-year follow-up and is often associated with pain. The best

functional results are obtained in patients with osteoarthritis because the rotator cuff usually is intact and of good quality and the bone stock is typically adequate. In patients with rheumatoid arthritis, the quality of the rotator cuff directly influences the functional result. The durability of total shoulder replacement is similar to that of hip and knee replacements. Results at long-term follow-up in several series have reported 85% component retention at 20 years of follow-up and revision rates for all causes averaging less than 10%. Loosening of the glenoid component has been reported in almost half of shoulders at more than 10-year follow-up and often is associated with pain; however, glenoid component loosening has averaged 4.3% over multiple studies.

OSTEOARTHRITIS

Most total shoulder arthroplasties are done in patients with osteoarthritis or rheumatoid arthritis. Few (<10%) patients with osteoarthritis have complete rotator cuff tears, but contracture of the subscapularis tendon is common. A large multicenter study reported significant improvements in Constant scores and range of motion at 10-year follow-up. Glenoid component survivorship with revision as the end point was 94.5%. In patients older than 80 years, total shoulder arthroplasty remains a reliable option, with 80% attaining an excellent or satisfactory result at an average of 5.5 years, even though there is an increased risk for perioperative medical complications. In patients younger than 50 years, one report with a 20-year minimum follow-up found over 75% component retention, but clinical outcomes tended to decline,

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY stress riser can occur in the humeral diaphysis between the tips of the two humeral components. If shoulder arthroplasty is done first, a short-stem prosthesis should be used; if a longstem component is in place at either joint, the cement column for the second arthroplasty should extend to and include the cement column of the first arthroplasty. If shorter components are used, a long length (approximately 360 mm) of unfilled humerus should be left between the cement columns.

POSTTRAUMATIC ARTHRITIS AND POSTTRAUMATIC SEQUELAE

A

Shoulder arthroplasty for arthritis secondary to chronic displaced fractures and fracture-dislocations of the glenohumeral joint is particularly difficult because of contractures and scarring of the soft tissues, malunion or nonunion of the tuberosities, and possible nerve injuries. Axillary nerve injuries can significantly impair motion and strength because of loss of deltoid function. Anatomic shoulder arthroplasty also has been described for proximal humeral malunions. In a mixed cohort of hemiarthroplasty and total shoulder arthroplasty, an average forward elevation of 109 degrees and improvements in pain were reported. However, postoperative instability because of rotator cuff dysfunction or capsular injury was a common complication.

OSTEONECROSIS

B FIGURE 12-13 A, Degenerative joint disease of left shoulder. B, Total shoulder arthroplasty with cemented glenoid component and noncemented stem. SEE TECHNIQUE 12-2.

ultimately with a large number of unsatisfactory results. The authors recommended caution in performing total shoulder arthroplasty in younger patients.

INFLAMMATORY ARTHRITIS

Total shoulder replacement also is effective in patients with inflammatory arthritis, resulting in significant improvements in pain, range of motion, function, and quality of life. The frequency of perioperative complications in patients with rheumatoid arthritis is similar to that in patients who have total shoulder arthroplasty for other indications; in fact, patients with rheumatoid arthritis have been reported to have shorter average hospital stays and a higher likelihood of routine discharge. Satisfactory pain relief also was reported in 11 shoulders severely affected by juvenile rheumatoid arthritis, although improvements in range of motion were minor. If shoulder and ipsilateral elbow replacements are necessary, the most painful joint should be replaced first. Function may not be significantly improved in patients with severe rheumatoid arthritis until the second joint is replaced. If the shoulder is operated on first, and if a cemented prosthesis is chosen, a cement restrictor or canal plug must be used to prevent cement from entering the distal medullary canal. A

The most common causes of osteonecrosis of the humeral head are corticosteroid use, sickle cell disease, and alcoholism; less common causes include dysbarism, Gaucher disease, and systemic lupus erythematosus. Idiopathic osteonecrosis also is fairly common. Cruess classified osteonecrosis of the humeral head into five stages of increasing severity (Fig. 12-14). Symptomatic progression of the osteonecrosis is almost certain in those with stage IV or stage V. Both total shoulder arthroplasty and hemiarthroplasty have been successful in obtaining subjective improvement in most patients with humeral head osteonecrosis. Most patients with osteonecrosis are relatively young, with good bone quality, and secure press-fit fixation of the humeral component can be obtained. The need for a glenoid component (see section on hemiarthroplasty) is based on the condition of the glenoid fossa, the amount of deformity present, and the degree of articular cartilage loss. In many patients with intact glenoid cartilage, humeral head replacement alone is satisfactory, whereas most patients with stage V disease require a glenoid component because of extensive articular cartilage loss.

CAPSULORRHAPHY ARTHROPATHY AND ARTHROPATHY OF RECURRENT INSTABILITY

Advanced glenohumeral arthritis is a rarely reported late sequela of anterior instability surgery. It is more common after nonanatomic repairs and in younger patients than typical glenohumeral arthritis and is characterized by severe internal rotation contracture and a severely osteophytic arthritis. Excessive soft-tissue tension on the side of the dislocation may produce a fixed subluxation of the humeral head in the posterior direction, requiring release of the iatrogenic soft-tissue contracture to restore joint balance and mobility. Subscapularis lengthening, anterior capsular release, or posterior capsular plication may be required to correct soft

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS

I

II

IV

III

V

FIGURE 12-14 Stages of osteonecrosis of humeral head. Stage I changes are invisible on plain radiographs, and they are not discernible on gross examination. Stage II is marked by sclerotic changes and evidence of bone remodeling, but shape and sphericity of humeral head are maintained. Stage III is differentiated from stage II by presence of subchondral bone collapse or fracture, resulting in loss of humeral head sphericity. In stage IV, humeral head has area of collapsed articular surface; fragment may become displaced intraarticularly. In stage V, there are osteoarthritic changes in the glenoid fossa.

tissue contractures. Although total shoulder arthroplasty can improve function in patients with glenohumeral degeneration associated with shoulder instability or instability surgery, a complication of 40% has been reported, particularly subscapularis insufficiency, with 20% of patients requiring additional surgery.

glenoid resurfacing. Until the introduction of reverse total shoulder arthroplasty, patients with cuff tear arthropathy were generally treated with hemiarthroplasty, which was a durable, if imperfect, solution that provided adequate pain relief but did not restore forward elevation.

REVERSE TOTAL SHOULDER ARTHROPLASTY

The primary indication for reverse total shoulder arthroplasty is a nonfunctional rotator cuff. This encompasses a number of disease processes, including cuff tear arthropathy, pseudoparalysis caused by massive rotator cuff tear without arthritis, multiple failed rotator cuff repairs with poor function and anterosuperior instability, three- and four-part proximal humeral fractures in the elderly, proximal humeral nonunions, greater tuberosity malunions, and failed shoulder hemiarthroplasty with anterosuperior instability. Reverse total shoulder arthroplasty is most appropriate for patients with an intact deltoid, adequate bone stock to support the glenoid component, no evidence of infection, no severe neurologic deficiency (Parkinson disease, Charcot joints, syringomyelia), and no excessive demands on the shoulder joint (Box 12-1). Contraindications include loss or inactivity of the deltoid and excessive glenoid bone loss that would not allow secure implantation of the glenoid component. Some authors have suggested that the procedure is unsuitable for patients younger than 70 years old; however, current opinion has

In 1983, Neer, Craig, and Fukuda described “cuff-tear arthropathy” as a distinct form of osteoarthritis associated with a massive chronic tear of the rotator cuff. Clinically, rotator cuff arthropathy is characterized by pain, poor active motion, near-normal passive motion, crepitus, weakness, and occasionally significant fluid buildup under the deltoid. Radiographic changes include elevation of the humeral head, formation of an acromiohumeral pseudoarticulation, and loss of joint space at the glenohumeral joint. The radiographic pattern of degenerative changes can vary, and not all patients with rotator cuff arthropathy have pain or limited motion. The glenohumeral instability resulting from this condition is manifested as proximal migration of the humerus relative to the glenoid, resulting in erosion of the superior glenoid and the caudal surface of the acromion. Rotator cuff tears have been implicated in early glenoid component loosening in total shoulder replacements, and irreparable tears are generally considered a relative contraindication to prosthetic

INDICATIONS

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY moved more toward accepting use of the reverse prosthesis in younger patients for some end-stage disorders for which there is no other option. Surgeon inexperience is also a relative contraindication to reverse total shoulder arthroplasty.

SURGICAL TECHNIQUE

Biomechanically, the reverse prosthesis works by changing the direction of pull of the deltoid muscle. With standard prostheses, absence of the rotator cuff allows the humeral head to subluxate superiorly during deltoid muscle contraction. The reverse prosthesis corrects this abnormal vector by moving the center of rotation of the arm medially and distally and reestablishing a fulcrum around which the deltoid can pull to restore forward elevation (Fig. 12-15). Because the reverse prosthesis places high shear stresses across the glenoid, several investigators have sought to define the factors most important in maximizing glenoid fixation. Parsons et al. stressed that proper orientation of the baseplate and placement of the screws in optimal position were important for fixation. In particular, they found that superior screws placed at the 12-o’clock position and aimed toward the BOX 12-1 

Indications for Reverse Total Shoulder Arthroplasty Cuff-tear arthropathy Massive rotator cuff tear with pseudoparalysis ■ Severe inflammatory arthritis with a massive cuff tear ■ Failed shoulder arthroplasty ■ Absence of tuberosities (failed hemiarthroplasty for fracture/nonunion) ■ Absence of cuff (failed hemiarthroplasty for cuff-tear arthropathy) ■ Instability ■ Proximal humeral fracture ■ Proximal humeral nonunion ■ Reimplantation for deep periprosthetic infection ■ Reconstruction after tumor removal ■ ■

From Sanchez-Sotelo J: Reverse total shoulder arthroplasty. In Morrey BF, ed: Joint replacement arthroplasty: Basic science, elbow and shoulder, Philadelphia, Wolters Kluwer, 2011, p 277.

A

coracoid were longest. Inferiorly, they found that a screw placed perpendicular to the baseplate yielded longer screw lengths. Others have found that the inferior screw faces the highest shear stress and is key to prevent loosening, whereas others have recommended screw placement in areas with the highest quality bone: the coracoid base, the scapular spine, or the inferior pillar. A device with a lateralized center of rotation was shown to obtain adequate fixation despite a 69% greater moment at the baseplate-glenoid interface. Glenoid wear is common in rotator cuff–deficient conditions. Frankle et al. studied 216 glenoids with plain radiographs and CT scans before operative intervention and found that 37.5% of the glenoids had abnormal morphology. They classified the wear patterns as posterior (17.6%), superior (9.3%), global (6.5%), and anterior (4.2%). These wear patterns were found to affect surgical technique, often requiring placement of the center screw along an alternate center line along the scapular spine. In a later follow-up study of 143 of these patients, all 56 shoulders with abnormal glenoids had center screw placement along an alternative (scapular spine) center line, and 22 had bone grafting procedures; larger glenospheres (36 or 40 mm) also were used more often than in shoulders with normal glenoids. Outcomes were not significantly different between the two groups.

REVERSE TOTAL SHOULDER ARTHROPLASTY TECHNIQUE 12-3 Approach the proximal humerus and prepare it for stem implantation as described in Technique 12-1. Some authors recommend a superior approach, but we prefer the deltopectoral approach because of its versatility and easily extensive nature if exposure is limited. However, there are some important differences in humeral preparation from a total shoulder arthroplasty or hemiarthroplasty. First, because of the common superior subluxation deformity of rotator cuff–deficient shoulders, a larger humeral head cut is often required. Second, some authors

■

B

FIGURE 12-15 A, In a shoulder with no rotator cuff tendons there are few restraints to anterosuperior subluxation of humeral head when patient attempts to raise the arm. Pull of deltoid muscle worsens this by pulling superiorly and medially (arrow). B, With reverse arthroplasty, deltoid muscle lever arm is restored, allowing it to pull the humerus upward and outward into elevation (arrow).

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS advocate placing the stem in neutral version to prevent instability in abduction and external rotation; however, we believe that stem placement in 30 degrees of retroversion is not only acceptable but also preferable to prevent the more common instability in adduction and extension seen with the reverse prosthesis. Although stems were initially cemented in reverse total shoulder arthroplasty, the use of uncemented and shorter stems has been reported with clinical success. Once the glenoid vault is adequately debrided and all four borders are visible, identify the centering point. Move the starting point inferiorly 1 to 2 mm to allow inferior placement of the baseplate to prevent scapular notching. Most authors recommend placing the baseplate with the inferior aspect flush with the inferior surface of the bony glenoid. ■ Place a guide pin through this centering hole using a guide. Take care to place the guide pin in 10 to 15 degrees of inferior tilt, again to prevent scapular notching. ■ Ream the glenoid until the “smiley face” is achieved, with bleeding cancellous bone inferiorly and hard sclerotic bone superiorly (Fig. 12-16). This confirms adequate inferior tilt of the baseplate. ■ Impact the baseplate and secure it with screws. The peripheral screws are ideally placed in the “pillars” of densest cortical bone—the coracoid base, inferior pillar, and scapular spine. We have found screw placement to be inconsistent in the scapular spine; however, fixedangle locking screws can be reliably positioned in the coracoid base and inferior pillar by internally rotating the baseplate approximately 10 degrees. ■ Dry the Morse taper and impact the glenosphere into position. ■ Place the humeral stem is as described in Technique 12-1, using trial components to test for stability and motion. Reduction and dislocation of the glenohumeral joint typically is more difficult than with standard shoulder arthroplasty. Reduction involves a combination of longitudinal traction and forward elevation on the arm. The deltoid tension should be slightly greater than before joint relocation, but take care not to overlengthen the deltoid, which can result in dehiscence and/or acromial fracture. There can be 2 to 3 mm of gapping in the glenohumeral articulation once the joint is reduced without loss of stability. ■ To dislocate the glenohumeral joint, place the dislocation instrument between the bearing surface and glenosphere to disrupt the articulation. Then pull the humerus anteriorly (shoulder extension) to deliver the bearing surface. ■ Once the proper bearing surface is chosen, dry the Morse taper and impact it into position. Reduce the glenohumeral joint for a final time. Close the wound as described in Technique 12-1. Subscapularis repair is especially important in these patients, who often have poor tissue around the shoulder for repair. Closure of the subscapularis has been found to correlate with improved stability.

See also Video 12-2.

POSTOPERATIVE CARE.  Postoperative care is as described for Technique 12-1.

FIGURE 12-16 Glenoid should be reamed until “smiley face” is achieved, with bleeding cancellous bone inferiorly and hard sclerotic bone superiorly. SEE TECHNIQUE 12-3.

OUTCOMES

In the past decade, multiple authors have reported the outcomes of reverse total shoulder arthroplasty done for a number of indications. In general, outcomes vary by etiology, with posttraumatic conditions and revision procedures having worse outcomes and a higher complication rate. Fatty infiltration or absence of the teres minor has also been shown to compromise outcomes. Overall, good and excellent results have been reported in 67% to 82% of patients, with significant increases in functional scores and average forward elevation between 100 and 138 degrees. Long-term survivorship studies have yet to be conducted, but implant survival rates of over 90% at 10 years of follow-up have been reported. Survivorship for glenoid loosening has been reported at 84% over the same period. Although the acceptable postoperative activity level that the reverse prosthesis can tolerate is unknown, a high percentage of patients nevertheless report medium- and high-demand use of the operative limb after surgery.

CUFF TEAR ARTHROPATHY

Several large studies from Europe have reported good results for reverse total shoulder arthroplasty done for rotator cuff arthropathy. In a multicenter study of 80 shoulders observed for an average of 44 months, 96% of patients reported no or minimal pain, and there was an increase in active forward elevation from 73 to 138 degrees. Forty-nine patients (64%) had medial component encroachment and scapular notching, however, without evidence of loosening. Three patients required revision because of progressive loosening of the glenoid component (two patients) or uncoupling of the glenosphere and baseplate (one patient). Another study reported that 78% of 45 patients were satisfied with their results at midterm follow-up (average 40 months); 67% had no or slight pain. Results were significantly better in patients who had primary arthroplasty for cuff tear arthropathy than in patients who had revision of a failed standard arthroplasty. Frankle et al. reported their results with reverse total shoulder arthroplasty at an average 33-month follow-up of 60 patients who had severe rotator cuff deficiency. Significant improvements were found in pain and function scores; 41 (68%) of the 60 patients rated their outcomes as excellent or good, 16 (27%) were satisfied, and 3 (5%) were dissatisfied.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY Seven patients required revision surgery to another reverse total shoulder arthroplasty (5 patients) or hemiarthroplasty (2 patients). Finally, comparative studies have found reverse total shoulder arthroplasty to be superior to hemiarthroplasty for the treatment of cuff tear arthropathy.

ROTATOR CUFF DYSFUNCTION WITHOUT ARTHRITIS

More recently, indications have been expanded from cuff tear arthropathy to include other conditions of rotator cuff insufficiency. Mulieri et al. reported 90% implant survivorship at a little over 4 years after surgery of 72 shoulders with rotator cuff dysfunction without glenohumeral arthritis; 20% of patients had a complication. Ek et al. reported a similar series in a younger patient cohort with clinical improvements that were maintained up to 10 years after surgery; however, the complication rate remained high as in the series reported by Mulieri et al.

PROXIMAL HUMERAL FRACTURES

Several authors have reported the use of reverse total shoulder arthroplasty to treat proximal humeral fractures in the elderly. Results have been satisfactory, with average forward elevation of approximately 100 degrees, but a high rate of scapular notching has been noted. A growing body of evidence supports the use of reverse total shoulder arthroplasty over hemiarthroplasty in the treatment of comminuted proximal humeral fractures in elderly patients; one recent metaanalysis found reverse total shoulder arthroplasty to be superior to hemiarthroplasty for proximal humeral fractures in this population.

RHEUMATOID ARTHRITIS WITH ROTATOR CUFF TEAR

Two studies have reported the use of reverse total shoulder arthroplasty in patients with rheumatoid arthritis. At an average follow-up of 2 years, John et al. reported improvements in all outcomes scores in 17 patients. Scapular notching occurred in roughly one fourth of patients, but there were no radiologic signs of loosening. Holcomb et al. also reported significant improvements in all outcomes measurements in 21 shoulders observed for an average of 3 years. The complication rate was 14%, and 18 patients rated their results as either good or excellent. More recently, Young et al. found similar clinical results but noted a high rate of intraoperative and postoperative fractures in this population.

SALVAGE PROCEDURES

In general, the outcomes of reverse total shoulder arthroplasty for revision of failed shoulder arthroplasty have been less satisfactory than those for primary reverse total shoulder arthroplasty for other conditions. Cuff et al. reported the outcomes of reverse total shoulder arthroplasty in the treatment of 22 shoulders that had either one or two-staged irrigation, debridement, and conversion to reverse total shoulder arthroplasty. There were no recurrent infections and motion was significantly improved; however, the average forward elevation was only 80 degrees. Boileau et al. reported that, although results were not as good as for primary reverse total shoulder arthroplasty, 93% of 40 patients were satisfied with their results. Average forward elevation was 123 degrees at final follow-up, and the complication rate was 12%. The authors

TABLE 12-4

Classification of Glenoid Wear Patterns WALCH ET AL. Type A (central) Type B (posterior) Type C (excessive glenoid retroversion > 25°)

SPERLING ET AL. None Mild (erosion into subchondral bone) Moderate (hemispheric deformation and medialization of subchondral bone) Severe (bone loss extending to the coracoid base)

ANTUNA ET AL. Defects caused by osteolysis/ loosening of polyethylene glenoid implants: Central Peripheral Combined

stressed that reverse total shoulder arthroplasty in patients with more than 90 degrees of forward elevation before surgery risks loss of motion in this plane and decreased patient satisfaction.

GLENOID BONE LOSS

Much of the recent debate and investigation surrounding degenerative shoulder conditions has centered on the concept of glenoid wear patterns. Although glenoid defects are more common in revision situations than in primary arthroplasties, they may be present at primary surgery. These wear patterns have been classified by several authors (Table 12-4). Central bone loss is most common in patients with rheumatoid arthritis. Placing a centering hole and evaluating the depth of the glenoid neck are recommended. A depth of less than 1 cm generally does not allow for adequate fixation and typically precludes the use of a glenoid component without bone grafting. Central cavities usually can be filled with local bone graft from the humeral head. Because the glenohumeral joint tends to sublux posteriorly with osteoarthritis, posterior wear patterns are common and can progress to severe bone loss, the so-called B2 glenoid. This eccentric glenoid wear pattern results in a twofold increase in the glenoid component loosening rate compared with concentric wear patterns (A1 and A2 glenoids). Some authorities have advocated placing the glenoid component without bone grafting and compensating for the increased retroversion by anteverting the humeral component so that the sum of the two versions is 30 to 40 degrees; however, a cadaver study determined that compensatory humeral component anteversion does not contribute to stability in the setting of a retroverted glenoid. Alternatively, eccentric reaming of the glenoid has been recommended to correct excess retroversion. Multiple studies have concluded that glenoid retroversion of more than 17 to 18 degrees cannot be corrected with eccentric reaming and that defects of more than 20 degrees typically do not allow placement of a glenoid component. In situations in which eccentric reaming cannot correct abnormal glenoid version, bone grafting or component augmentation is recommended. There are multiple reports of both techniques used in an attempt to correct glenoid version

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS TABLE 12-5

Complications After Unconstrained Total Shoulder Arthroplasties Reported in 33 Series (2540 Shoulders) COMPLICATION COMPONENT LOOSENING Glenoid Humerus INSTABILITY Superior Posterior Anterior PERIPROSTHETIC FRACTURE Intraoperative Postoperative ROTATOR CUFF TEAR NEURAL INJURY INFECTION DELTOID DETACHMENT

% ALL SHOULDERS 6.31 5.3 1.1 4.9 3 1 0.9 1.8 1.1 0.7 1.3 0.8 0.7 0.08

NO. SHOULDERS 161 134 27 124 77 25 22 46 27 19 32 20 19 2

% ALL COMPLICATIONS 39 32 6.5 30 19 6 5 11 6.5 4.6 7.7 4.8 4.6 0.5

Modified from Bohsali KI, Wirth MA, Rockwood CA Jr: Complications of total shoulder arthroplasty, J Bone Joint Surg 88A:2279, 2006.

in anatomic total shoulder arthroplasty. Although no consensus exists regarding the best technique to restore glenoid version, other areas of investigation have centered on the use of patient-specific guides to correct these difficult wear patterns, and improved component positioning has been reported. Finally, in elderly patients with severe posterior glenoid bone loss, reverse total shoulder arthroplasty has been advocated as an alternative to anatomic arthroplasty. For bony defects present at primary or revision reverse total shoulder arthroplasty, placement of the center screw down an alternate scapular spine center line improves the amount of bone stock available for fixation.

COMPLICATIONS OF SHOULDER ARTHROPLASTY

The overall complication rate after total shoulder arthroplasty is estimated to be approximately 15% (Table 12-5). The most commonly reported complications, in order of frequency, are component (primarily glenoid) loosening, glenohumeral instability, rotator cuff tear, periprosthetic fracture, infection, implant failure including dissociation of modular prostheses, and deltoid weakness or dysfunction. A study of over 400 total shoulder arthroplasties done with cemented allpolyethylene glenoid components between 1990 and 2000 found a 12% complication rate, and only one reoperation was required because of component loosening. The most frequent complications in this review were rotator cuff tearing, glenohumeral instability, and periprosthetic humeral fracture. Complications after total shoulder arthroplasty tend to occur late in the postoperative course (5 to 10 years after surgery); component loosening has been reported to occur approximately 8 years after surgery, infection at 12 years, and periprosthetic fractures at 6 years. Reverse total shoulder arthroplasty initially resulted in relatively high complication rates (50%) and some unique complications. In the past decade, with improved techniques and better understanding of the device, the complication rate has fallen (6% recently reported). The most common

complications after reverse total shoulder arthroplasty are scapular notching, hematoma formation, glenoid dissociation such as baseplate failure or aseptic loosening, glenohumeral dislocation, acromial and scapular spine fractures, infection, loosening or dissociation of the humeral component, and nerve injury.

INTRAOPERATIVE COMPLICATIONS

The most common intraoperative complications in shoulder arthroplasty are fracture, usually of the humeral shaft in the mid to distal diaphysis (Fig. 12-17); nerve injury, most often to the axillary nerve; and malpositioning of components. Most often, intraoperative periprosthetic fractures of the humerus or glenoid are caused by errors in surgical technique, such as inadvertent reaming, overzealous impaction, or manipulation of the upper extremity during exposure of the glenoid. Spiral fractures of the humerus usually are caused by excessive external rotation of the shoulder during attempts to improve exposure. Fractures of the humeral shaft often are caused by torque on the arm that produces a spiral fracture of the reamed canal. Overzealous mani­ pulation of the arm during humeral reaming or glenoid exposure has been associated with long oblique and spiral fractures of the humerus. Complete anterior and inferior capsular releases and the use of a bone hook to deliver the proximal humerus out of the glenoid fossa may help minimize torsion forces on the humeral shaft and thereby minimize the risk of fracture. A humeral shaft fracture is most likely at two points in the surgical procedure. During the reaming process, when resistance is met, and if the assistant has a firm hold of the patient’s arm, excessive torque can be generated that generates a spiral fracture. The assistant should be instructed to hold the arm loosely in a supportive position at the elbow. Further, if any resistance is felt, releasing the grip on the patient’s arm and allowing it to rotate with the hand reamer is advisable. The second critical period is during the reduction and dislocation maneuver to test implant stability.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

A

B

C

D

FIGURE 12-17 Periprosthetic humeral fractures. A, Region 1, tuberosity. B, Region 2, proximal metaphysis. C, Region 3, proximal diaphysis. D, Region 4, middiaphysis and distal diaphysis.

Longitudinal distraction must be used, and manual assistance to lift the prosthetic humeral head from the joint cavity prevents the force from being transferred inferiorly into the humeral shaft. Simple cerclage wiring of the proximal end of the humerus and implantation of a standard-size prosthesis usually are sufficient for fractures proximal to the tip of the humeral prosthesis. Autogenous bone graft from the humeral head can be used as a metaphyseal augment after the stem is inserted. We prefer to convert to a longer-stem prosthesis for unstable intraoperative humeral fractures in which standard length stem fixation is compromised. The use of a longer stem prosthesis, extending at least two humeral cortical diameters beyond the most distal extent of the fracture, has several advantages over dynamic compression plating or cerclage wiring alone: the need for secure screw purchase in bone that often is of poor quality is obviated, bending and torsional loads are better tolerated and decrease the risk of implant failure, a rigid and biomechanically sound surgical construct usually can be obtained, the extensile exposure and soft tissue dissection required for plate fixation are avoided, and -stress shielding is minimized. Fractures of the glenoid are extremely rare and usually occur in osteopenic bone. Most often, this complication occurs after the glenoid has been reamed to subchondral bone and the canal has been prepared to receive a keeled prosthesis. Retraction on the anterior or posterior glenoid cortex can produce cortical bone failure. Stable fixation of the fracture is essential to prevent instability of the glenoid component. The glenoid canal also can be penetrated by the handheld burr during preparation of the canal. Good preoperative axillary radiographs or CT scans can help determine if posterior wear of the glenoid is present. Reaming of the glenoid to its neutral version and tilt restores alignment for proper orientation before canal preparation is started. If the cortex

is penetrated, the defect should be bone grafted to prevent cement extrusion. Although nerve injury during total shoulder arthroplasty is rare, it is devastating when it does occur. Most reported instances of permanent axillary nerve injury involved revision surgery or primary surgery in a shoulder that had multiple previous operations. The radial nerve can be injured by an intraoperative humeral shaft fracture and internal fixation of the fracture. Extrusion of cement through a defect in the humeral canal has been reported to result in radial nerve injury; nerve function returned after removal of the cement near the nerve. Most nerve injuries are neurapraxias that recover with time. A complete neurologic examination should be done early in the postoperative period to document any nerve deficits. If no recovery is noted after 6 weeks, an electromyographic examination should be obtained and should be repeated at 3 months. If no recovery has occurred as evident by electromyography at 3 months, exploration of the nerve should be considered. If malposition of the humerus is noted with an uncemented component, it can typically be disimpacted and repositioned. If a cemented component is used, an offset humeral head prosthesis can be used to attempt to correct version. The offset humeral head allows 5 to 7 degrees of version correction in the anterior or posterior direction. However, in reality, a malpositioned cemented humeral stem often requires a lengthy and difficult revision procedure to remove the well-fixed component and replace it in an appropriate position.

POSTOPERATIVE COMPLICATIONS

Postoperative complications include glenoid loosening, glenohumeral instability, rotator cuff tears, periprosthetic fracture, infection, deltoid rupture, tuberosity nonunion or malunion, humeral loosening, impingement, heterotopic

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS bone formation, mechanical failure of components, and loss of motion.

GLENOID LOOSENING

Symptomatic loosening of glenoid or humeral components is the most common problem encountered in total shoulder arthroplasty, accounting for one third of all complications. Loosening of the glenoid component is significantly more common than loosening of the humeral component. Radiographic lucent lines at the cement-bone interface of the glenoid component have been observed in varying degrees in up to 96% of patients in some studies. One metaanalysis found that asymptomatic radiolucent lines occur at a rate of 7% per year, with symptomatic loosening occurring at 1.2% per year, and resultant revision occurring at 0.8% per year. Although some have found no association between radiographic changes and clinical results, progression of the lines has been correlated with a decrease in function and an increase in pain in most patients. A shift in the position of the glenoid component or circumferential radiolucent lines at least 1.5 mm wide are evidence of a loose glenoid component. Injection of the cement under pressurization provided by a syringe and application of cement on the back side of the glenoid component has been reported to improve glenoid component fixation by providing more complete cementation. Radiolucencies tend to evolve late (after 5 years), indicating the need for further technical and prosthetic innovation to improve long-term component durability. Polyethylene debris from glenoid wear has been reported in approximately 20% of revision shoulder arthroplasty cases. In a retrieval study of 52 shoulders undergoing revision surgery after total shoulder arthroplasty, osteolysis was more common when screws had been used for glenoid component fixation and was highly associated with third body wear. Radiolucent lines also were significantly associated with osteolysis. No significant differences were found regarding the presence of particulate debris, however. Another analysis of 78 retrieved glenoid components found that scratching, pitting, and burnishing were the most common modes of glenoid polyethylene wear, mostly in the inferior quadrant, and that radiographic analysis underestimates the amount of clinical glenoid loosening. Others have postulated that the functional malcentering of the humeral head associated with the common posterior subluxation pattern in osteoarthritis can contribute to glenoid wear postoperatively if not corrected at the time of joint replacement. One controversy has been the relative clinical and radiographic performances of pegged glenoid designs and those that use a keel. Multiple authors have concluded that the biomechanical data support pegged glenoid components. Although a randomized controlled trial by Edwards et al. found a significantly higher rate of radiolucencies in keeled implants (46%) than in pegged components (15%), other clinical data have been somewhat mixed. Whereas one radiostereometric analysis found that keeled components demonstrated more migration than pegged implants, another prospective randomized trial using radiostereometric analysis found no difference between pegged and keeled implant micromigration at 2 years of follow-up. More recently, we found no significant differences in clinical or radiographic outcomes between pegged and keeled components at intermediate-term follow-up, indicating that

glenoid lucencies develop over time, most likely as a result of the stresses placed across the bone-cement-polyethylene interface. Arthroscopy has been reported to be useful in evaluating glenoid component loosening. If glenoid loosening is present in an asymptomatic patient, only observation is indicated; however, if loosening is present in a patient who has symptoms of pain, decreased range of motion, and functional disability, further investigation is warranted to determine if implant replacement is appropriate. A painful “clunking” sensation with forward elevation of the arm has been described as a sign of symptomatic glenoid loosening.

HUMERAL LOOSENING

Humeral radiolucent lines are not nearly as common as radiolucent lines around the glenoid component. Radiolucent lines may progress over time to component loosening, which typically is diagnosed by a change in implant position or progression to circumferential radiolucent lines, and is now thought to often indicate indolent infection. Raiss et al., however, suggested that polyethylene wear from the anatomic glenoid component is associated with proximal humeral osteolysis around the humeral component. Although early studies reported humeral radiolucent lines in up to 61% of implants, mostly at the distal stem tip, actual loosening of the component was much less frequent, and few components required revision because of symptomatic loosening. In a more recent study, we found essentially no evidence of loosening and minimal (1 mm) radiolucent lines in 6.5% of proximally coated ingrowth humeral stems at an average of approximately 4 years of follow-up. These results are mirrored in a study of reverse total shoulder arthroplasty, where humeral stem loosening was reported to be less than 1%.

INSTABILITY

Instability is the second leading cause of complications associated with shoulder arthroplasty, with a reported prevalence of 4% and accounting for 30% of all complications. It can occur in any direction and in variable degrees of subluxation and dislocation. In a metaanalysis of 11 series of total shoulder arthroplasties that included 838 patients, Wilde reported a 1.2% incidence of postoperative dislocation over a follow-up period of 20 to 54 months. Approximately 80% of instability complications after total shoulder arthroplasty involve anterior or superior instability. Key to designing treatment for this problem is isolating and understanding the exact cause of the instability. Anterior instability most commonly is associated with subscapularis failure, glenoid anteversion, malrotation of the humeral component, or anterior deltoid dysfunction. Anterior instability secondary to subscapularis rupture generally is a consequence of operative technique, tissue quality, inappropriate physical therapy, or the use of oversized components. Anterior instability also can be caused by the use of a humeral head that is too small for the joint volume (Fig. 12-18). Replacement of the humeral head with an appropriate-size implant, which also can be an offset-type component, can be done to regain stability. If abnormal humeral version is found to be the cause of anterior instability, revision of the stem should be considered. A torn subscapularis tendon is likely underreported and does not correlate with the postoperative physical examination; however, it can contribute to anterior instability and

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

FIGURE 12-18 Humeral head component that is too small can result in anterior instability.

must be repaired to regain joint stability. If the tendon cannot be repaired, reconstruction with a bone–Achilles tendon allograft as a static restraint has been reported to be successful. Concerns about postoperative subscapularis integrity have resulted in a multitude of techniques in addition to subscapularis tenotomy to prevent this complication. One such technique is a lesser tuberosity osteotomy (LTO), in which the bone-tendon unit is resected to access the glenohumeral joint and then fixed at the end of the procedure. However, the biomechanical evidence has been mixed, and clinical series have not demonstrated superiority of one technique over another for subscapularis management. One report suggested that LTO failure may be an underreported complication. Progressive superior migration of the humeral head has been reported in association with dynamic muscle dysfunction, attenuation of the supraspinatus, failed rotator cuff repairs, and frank rupture of the rotator cuff. The amount of proximal humeral migration was found to be independent of the size of the rotator cuff defect but correlated positively with the association of cuff deficiency and poor preoperative function. An imbalance in the force couple between the deltoid and the surgically treated rotator cuff has been implicated in superior migration of the humeral component and may be the result of poor postoperative rehabilitation. Asymptomatic patients should be encouraged to continue rehabilitation and do not require operative intervention; however, longterm superior migration of the humeral head can result in loosening of the glenoid component, and repair of rotator cuff tears at the time of arthroplasty can help prevent this complication. Posterior instability has been attributed most often to malpositioning of the components but may be multifactorial as well. Posterior glenoid erosion with excessive component retroversion and soft-tissue imbalance has been implicated in the development of posterior instability. If the glenoid or humeral component is placed in too much retroversion, posterior instability may occur and revision is recommended. If the capsule is stretched from long-standing posterior wear on the glenoid, it may require imbrication to gain stability.

Patients with posterior glenohumeral subluxation associated with long-standing osteoarthritis or a history of chronic posterior instability, whether recurrent or fixed, are at increased risk for posterior instability after shoulder arthroplasty. Proper use of eccentric reaming, with or without bone grafting, and placement of the humeral and glenoid components has been shown to minimize the risk of this complication, but soft-tissue balancing, as described in the surgical technique for total shoulder arthroplasty, is a critical component of the operation. In most such patients, external rotation is restricted, with tight and contracted anterior structures and an attenuated and stretched posterior capsule. Thus proper attention to component position in addition to softtissue balancing is a crucial step in preventing posterior instability. Inferior instability is related to the loss of normal humeral height and is most common after hemiarthroplasty for proximal humeral fractures. Removal of too much of the proximal humerus, with resultant inferior placement of the humeral head, can lead to inferior instability. Patients usually have difficulty elevating the arm past the horizontal plane because of weakness of the deltoid caused by shortening of the humerus. Revision surgery usually is necessary to restore humeral length and regain deltoid strength.

PERIPROSTHETIC FRACTURE

The reported prevalence of postoperative periprosthetic humeral shaft fractures ranges from 0.5% to 2%. Postoperative humeral shaft fractures are most frequent in women and in patients with rheumatoid arthritis. Wright and Cofield classified periprosthetic humeral shaft fractures into three types. Type A fractures extend proximally from the tip of the prosthesis, type B fractures are centered at the tip of the prosthesis, and type C fractures involve the humeral shaft distal to the prosthesis. Treatment of type A postoperative periprosthetic fractures often require revision arthroplasty and fracture stabilization if the fracture disrupts a large portion of the bone-implant interface and leads to implant loosening. Type B fractures can be treated with a fracture brace if acceptable alignment can be obtained. If union is delayed, open reduction and internal fixation with a plate and screws and cerclage wiring, without prosthesis removal, is recommended; however, it should be stressed that these fractures take an average of 5 to 9 months to heal and the patient should be counseled regarding the extended treatment course from this complication. Type C fractures usually heal with immobilization and can be managed as other fractures of the humeral shaft. Again, extended healing times should be anticipated. Initial nonoperative management has been recommended for fractures proximal to the stem tip and for fractures with acceptable alignment at the tip of a well-fixed humeral stem. For fractures with unacceptable alignment at the stem tip, open reduction and internal fixation has been advocated, particularly if the fracture extends distally. Revision with a long stem is recommended for similar fractures when the humeral component was loose.

ROTATOR CUFF FAILURE

Rotator cuff failure is the fourth most common complication after shoulder arthroplasty, with a reported incidence of 1% to 2%. Rupture of the subscapularis tendon is involved in

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS most rotator cuff tears. Factors reported to be associated with postoperative tears of the subscapularis tendon include multiple operations, overstuffing of the joint, overly aggressive therapy involving external rotation during the early postoperative period, and tendon compromise by lengthening techniques. This secondary rotator cuff dysfunction increases over time and is associated with functional decline of the prosthesis. Preoperative fatty infiltration of the infraspinatus and a glenoid component placed in superior tilt are risk factors for subsequent rotator cuff failure. Symptomatic tears can be repaired in the standard fashion with care to preserve the coracoacromial ligament. Recurrent tears of the superior rotator cuff may result in little improvement in function and motion, however, after operative repair. Large tears cause superior subluxation and eventual loosening of the glenoid component from compression forces on the superior rim of the glenoid (the so-called rocking horse glenoid). Repair of large or massive tears may be impossible. One treatment for this difficult problem involves removing the glenoid component, bone grafting of the glenoid cavity defect, and allowing the humeral prosthesis to migrate superiorly. A competent coracoacromial ligament must be present to provide superior stability if this salvage procedure is done. More recently, conversion to reverse total shoulder arthroplasty has been described, with satisfactory results, although the outcomes of this conversion are not as favorable as those for primary rotator cuff arthropathy.

INFECTION

Infection is rare after both primary anatomic and reverse total shoulder arthroplasty (approximately 2%); male sex and younger age at the time of arthroplasty are risk factors. As with all joint replacements, several factors contribute to the predilection for bacterial seeding, including bacterial adhesion, glycoprotein encapsulation, bacterial resistance to antibiotics, physical properties of the implant such as chemical composition and surface texture, and inhibiting factors from ion elution. The literature also suggests an increased risk of infection in patients with diabetes mellitus, rheumatoid arthritis, systemic lupus erythematosus, and remote sites of infection. Other factors implicated in an increased susceptibility to infection include immunosuppressive chemotherapy, systemic corticosteroids, multiple steroid injections, and previous shoulder surgery. Several reports have linked infection around total joint prostheses to transient bacteremia secondary to dental manipulation, urinary tract infection, pneumonia, and genitourinary instrumentation. As in patients with other total joint arthroplasties, prophylactic antimicrobial coverage should be individualized for each patient and procedure. Propionibacterium acnes is the most commonly isolated organism after shoulder arthroplasty but has a protean presentation and is very difficult to diagnose. A gram-positive, aerotolerant anaerobic rod that lives in the skin (not on the skin), P. acnes has a different behavior and profile than other organisms such as Staphylococcus aureus. Typical inflammatory indices (white blood cell count [WBC], C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]) often are not revealing, and even cultures are not uniformly reliable. The most common symptom is unexplained pain. Because of the organism’s slow-growing nature, cultures

should not be discarded in 3 to 5 days, but should be held for at least 2 weeks to isolate this organism. More recent work has centered on the use of synovial IL-6 measurement as another method to diagnose P. acnes infection. Intraoperative findings of humeral loosening, turbid fluid, and membrane formation all correlate with the likelihood of a positive culture for P. acnes. Intraoperative histopathology has been reported to have very high specificity but only approximately 50% sensitivity for P. acnes infection. A threshold of 10 polymorphonuclear leukocytes per highpower field (rather than 5) to diagnose infection has been suggested to increase the sensitivity of intraoperative pathology without affecting specificity. If the infection is identified early (3 to 6 weeks after surgery) and the organism is gram positive, retention of the components can be considered. One-stage irrigation and debridement with replacement of the humeral head, along with appropriate parenteral antibiotic therapy, has been shown to be effective treatment. If the organism is gram negative or the infection occurs late, removal of the implants and all cement generally is recommended. Placement of an antibiotic-impregnated spacer or beads helps to sterilize the soft-tissue envelope, and a 6-week course of parenteral antibiotics can be followed by implantation of revision components with the use of antibiotics in the cement. In a study of 21 shoulders treated with resection arthroplasty, Sperling et al. reported that six had recurrent infections, six were treated with debridement and prosthesis retention, and three had subsequent infection that required resection arthroplasty. Two had removal of the prosthesis, debridement, and immediate reimplantation; one had reinfection and subsequent resection arthroplasty. Three shoulders with removal of the prosthesis, debridement, and delayed reimplantation had no reinfection. Although the numbers were too small to make any definite conclusions, the authors suggested that delayed reimplantation may be the best option: patients with prostheses had better pain relief and function than those with resection arthroplasty. In clear cases of infection, we routinely remove all components and foreign material, place an antibiotic cement spacer, administer intravenous antibiotics, and follow inflammatory indices (complete blood cell count, ESR, CRP) with the plan for component replantation if the infection is cleared. We obtain an aspiration and culture of glenohumeral joint fluid before replantation. The cultures are held for 14 days to allow for isolation of P. acnes. In selected patients who either refuse or are medically unfit for a revision arthroplasty, use of a functional antibiotic spacer has been reported to obtain satisfactory outcomes.

DELTOID MUSCLE DYSFUNCTION

Deltoid muscle dysfunction caused by axillary nerve injury or detachment of the deltoid muscle can result in a catastrophic loss of shoulder function. Deltoid degeneration after reverse total shoulder arthroplasty has been attributed to an increase in the moment arm in the anterior and middle heads of the deltoid, which reduces the muscle effort required for most activities but can result in attritional stretching of the deltoid with later loss of function. Postoperative fatty infiltration of the deltoid, thought to be secondary to the altered biomechanics of the device, also has been reported to result in inferior clinical outcomes.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

A

B

D

C

E

FIGURE 12-19 Nerot classification of progressive scapular notching. A, Grade 0, no notch. B, Grade 1, small notch. C, Grade 2, notch with condensation (stable). D, Grade 3, evolutive notch (erosion of inferior screw). E, Grade 4, first glenoid loosening.

HETEROTOPIC OSSIFICATION

Heterotopic ossification has been noted to occur after shoulder arthroplasty in 10% to 45% of patients. Male gender and osteoarthritis are risk factors. Bridging heterotopic bone of the glenohumeral joint or glenoacromial space can occur in extreme situations. No correlation is evident, however, between heterotopic ossification and the development of shoulder pain. Heterotopic ossification after total shoulder arthroplasty usually is low grade, is present early in the postoperative period, is nonprogressive, and does not adversely affect clinical results.

STIFFNESS

Many patients who are dissatisfied with the outcomes of their total shoulder arthroplasties cite stiffness as the reason. Postoperative stiffness, typically manifested by loss of forward elevation or external rotation, usually results from oversizing of components, shortening or overtightening of the subscapularis, or insufficient rehabilitation. Treatment involves softtissue balancing procedures to completely mobilize the subscapularis. Excision of the anterior capsule and release of the rotator interval and coracohumeral ligament may be required to accomplish this. If the subscapularis is still tight, a Z-plasty lengthening in the frontal plane may be required. A general rule is that 1 cm of lengthening equals approximately 20 degrees of increased external rotation.

COMPLICATIONS OF REVERSE TOTAL SHOULDER ARTHROPLASTY

Because of its unique configuration, reverse shoulder arthroplasty can result in complications other than those usually

associated with total shoulder arthroplasty. Notching of the scapula is unique to this prosthesis but has variable incidences in the literature; it has been reported in 10% to 96% of reverse arthroplasties. The most common complication after reverse total shoulder arthroplasty is notching of the inferior scapula by the humeral component, an osteolytic reaction caused by impingement of the polyethylene humeral bearing surface, mainly in adduction and external rotation. Nerot classified this notching into four grades, ranging from none to notching severe enough to cause glenoid loosening (Fig. 12-19). In most patients, the notching stabilizes at grade 2 at about 12 months after implantation; however, notching has been shown to result in inferior clinical outcomes and higher rates of radiolucencies at intermediate follow-up. Over the past decade, surgical techniques to decrease the rate of scapular notching have been extensively studied. Several factors have been implicated and technical changes have included placing the baseplate in an inferior position with inferior tilt, usually about 10 to 15 degrees. Levigne et al. found that superior tilt of the glenosphere correlated with scapular notching in their study of 448 shoulders observed for an average of approximately 4 years. Other studies have focused on increasing glenosphere size and lateral offset. Review of the available evidence indicates that inferior placement of the baseplate with inferior tilt are the two most important factors to decrease notching. Kelly et al. recommended placing the initial drill hole 11.5 mm superior to the inferior glenoid rim to optimize baseplate positioning. Use of a more varus stem with a neck-shaft angle of 135 degrees (rather than 155 degrees) and a lateralized glenosphere has been reported to result in lower notching rates as well. Another study noted that a longer scapular neck is associated with a

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS lower notching rate, suggesting that some patient-specific anatomic factors may have a role in this complication. Instability after reverse total shoulder also is a known complication; it occurs primarily in extension and adduction at a rate of approximately 5%. Muscle forces across the joint appear to be the primary determinant of implant stability, and an irreparable subscapularis tendon has been reported to correlate with a higher dislocation rate. Technical factors that can improve stability include use of an inferior offset glenosphere and, when necessary, a constrained polyethylene bearing surface. Interestingly, the use of constrained liners has been reported to result in a comparable level of scapular notching as with unconstrained surfaces. Acromial stress fractures are thought to be caused by increased stress placed on the posterior aspect of the acromion by the configuration of the prosthesis and resultant increased deltoid tension. Radiolucent lines around the glenoid baseplate have been described and have been suggested to result from the offset of the glenosphere at its attachment to the baseplate rather than to loosening. Longer-term follow-up is required to determine the progression or significance of these radiolucent lines. Scapular spine fractures are more common in osteoporotic patients and are associated with the use of a baseplate that relies on a center screw for fixation. As outcomes studies for reverse total shoulder arthroplasty extend into the second decade, there has been concern about polyethylene wear from the semiconstrained articulation. This is particularly true with the use of retentive liners, which have been shown to have increased wear compared with nonretentive bearing surfaces. Future longitudinal studies examining in vivo wear rates and the possible evolution of aseptic loosening patterns will aid in understanding this topic.

REVISION SHOULDER ARTHROPLASTY

The rate of revision of primary shoulder arthroplasties, as reported in the earlier literature, ranged from 0% to 12.5%; however, with longer follow-up, more recently reported revision rates for constrained and unconstrained implants range from 5% to 42%.

INDICATIONS

Revision surgery is technically demanding, and the causes of failure of the primary procedure often are multifactorial, involving soft tissues, bony structures, and the implant. Determining the results of revision arthroplasty is difficult because many reported series of total shoulder arthroplasties include limited discussions of small numbers of revisions along with primary procedures. Nevertheless, the main indication and goal for revision shoulder arthroplasty is pain relief. Restoration of motion, strength, function, and stability are secondary goals because they are less reliably obtained. Dense scarring from previous operations commonly complicates the surgical approach in revision shoulder arthroplasty. Exposure is typically quite difficult, making component implantation less predictable. Foruria et al. described an anteromedial approach to the shoulder in which the anterior deltoid is taken down from the clavicle and acromion, allowing full access to the underlying structures. Meticulous trans­ osseous repair of the deltoid is required at the end of the procedure to prevent dehiscence.

Failed hemiarthroplasty due to glenoid arthritis is an increasingly common indication for revision arthroplasty. Anatomic glenoid component implantation is reliable to relieve pain and improve range of motion, but some authors have noted that preexisting instability and/or subscapularis deficiency often is not correctable with an anatomic revision arthroplasty. Symptomatic loosening of the glenoid component is the most common reason for revision surgery and usually is treated by removal, with or without replacement of the component. Loosening, polyethylene wear or dissociation, and component malposition are the most common causes of glenoid failure. A new component can be cemented in place if adequate glenoid bone stock is available, and the deltoid and rotator cuff muscles are functional. In general, the goal of revision arthroplasty should be to resurface the glenoid to maximize pain relief; however, recurrent glenoid loosening has been reported in 67% of cases. In patients with mild-tomoderate bone loss, replacement of the prosthesis may be possible. Concentric reaming and bone grafting can help provide adequate fixation of the new prosthesis. Reimplantation usually is impossible if bone loss is severe, but removal of the glenoid component may provide satisfactory pain relief. Bone grafting can improve bone stock for later implantation. Another alternative reported to be successful in these situations is conversion to reverse total shoulder arthroplasty; however, complication and reoperation rates are high, and the procedure is technically demanding. Revision of the humeral stem for loosening is uncommon and depends on the type of fixation used. As noted previously, indolent infection should be suspected in cases of isolated humeral stem loosening. In uncemented prostheses, disruption of the remaining ingrowth surface and removal of the component followed by replacement with a cemented or uncemented stem (based on the remaining humeral bone stock) is recommended. When a cemented humeral stem is loose, component removal followed by a cementwithin-cement technique can be used. Alternatively, complete removal of the cement mantle may be accomplished with subsequent placement of an ingrowth stem, if adequate bone stock remains. When a well-fixed stem must be removed, humeral windowing and longitudinal split techniques have been described with high healing and low complication rates.

OUTCOMES

Outcomes after revision of unconstrained shoulder arthroplasties generally are inferior to the outcomes after primary arthroplasty. Dines et al. reviewed the results of 78 revision total shoulder replacements and found that results were significantly better for component revisions than for soft-tissue reconstructions. Although Hattrup reported 70% good and excellent results at an average of 4.5 years after total shoulder arthroplasty for failed hemiarthroplasty, Carroll et al. found a high rate (47%) of unsatisfactory outcomes at 5.5 years of follow-up in a similar group of patients and concluded this procedure is a salvage situation with outcomes inferior to those of primary total shoulder arthroplasty. The versatility of reverse total shoulder arthroplasty makes it an attractive option for revision situations in which the rotator cuff often is not functional. Although a reverse replacement may be the only reasonable option in some patients, the complication rate of revision reverse total

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY shoulder arthroplasty has been reported to be higher than that of primary reverse total shoulder arthroplasty and is typically over 50%; patient satisfaction remains high, however. Although most of these complications are minor, we nevertheless urge caution when undertaking a revision shoulder arthroplasty. When a reverse arthroplasty requires revision, patients should be cautioned that multiple procedures often are necessary but that the prosthesis usually can be salvaged.

OTHER SURGICAL OPTIONS FOR FAILED SHOULDER ARTHROPLASTY HEMIARTHROPLASTY

Hemiarthroplasty is discussed earlier in this chapter.

RESECTION ARTHROPLASTY

Resection arthroplasty may be considered for failed shoulder arthroplasties in patients with resistant infection, intractable pain, or extensive loss of bone or soft tissue that precludes reimplantation of a prosthesis. Successful eradication of recalcitrant shoulder infection has been reported after resection arthroplasty with and without the use of antibiotic spacers. Although the procedure is reliable for pain relief, range of motion and function are generally poor because the fulcrum of the shoulder is lost.

GLENOHUMERAL ARTHRODESIS

Glenohumeral arthrodesis rarely is indicated as a primary procedure for arthritic shoulder conditions but may be appropriate for failed shoulder arthroplasty in patients with severe bone loss, chronic low-grade infection, multiple failed revision arthroplasties, intractable instability, or extensive deficiencies of the deltoid. Techniques for and results of shoulder arthrodesis are discussed in Chapter 13.

REHABILITATION AFTER SHOULDER ARTHROPLASTY

Few comparative data are available regarding rehabilitation protocols after shoulder arthroplasty. Most surgeons have their own protocols, but, in general, the goals for rehabilitation are restoration of function and motion (Box 12-2). Recovering motion and strengthening the anterior deltoid and external rotators are of greatest importance. Of particular importance in anatomic replacements is protecting the subscapularis repair, and most protocols are governed by this premise. Patients with poorly functioning deltoid and rotator cuff muscles are placed in the limited-goals category and are given an exercise program aimed at achieving a more modest range of motion. A sling or immobilizer is applied immediately after surgery and is worn for the first 6 weeks when not performing physical therapy. Most patients begin early passive and activeassisted range of motion, including pendulum, isometric elbow, and wrist and hand exercises. At 6 weeks, the sling or immobilizer is removed and gentle activities in front of the body are permitted. Pulley exercises for overhead motion and exercises for external rotation are initiated at this point as well. Passive forward elevation, internal rotation, and external rotation should be maximized before isometric strengthening is initiated at 6 weeks. Active internal rotation and passive external rotation are limited to protect the subscapularis repair for 12 weeks. Patients should be cautioned to avoid

BOX 12-2

Rehabilitation Protocol After Shoulder Arthroplasty POD1 to 6 weeks—AA/PROM only ■ Forward elevation—in the plane of the scapula as tolerated, up to 90 degrees ■ Internal rotation, with upper arm at side, to chest ■ External rotation, with upper arm at side, 0-20 degrees ■ Pendulum exercises five times per day ■ AA→AROM for elbow, wrist, and hand ■ 6-12 weeks—continue AA/PROM ■ Forward elevation to full ■ External rotation to 30 degrees ■ Wand and overhead pulley ■ Isometric strengthening for flexion, extension, external rotation, and abduction in neutral position only ■ At 12 weeks—start AROM/dynamic strengthening ■ Continue AROM, stretches, and TheraBand strengthening ■ Progress strengthening ■ Progress to home program ■

AAROM, Active-assisted range of motion; AROM, active range of motion; POD, postoperative day; PROM, passive range of motion.

using their arm to push themselves up in bed or from a chair because this requires forceful contraction of the subscapularis. Unrestricted activity is permitted at 12 weeks, but patients are cautioned not to participate in contact sports or do any aggressive weight training. If any residual tightness is present at 12 to 16 weeks, aggressive stretching should be started. Range of motion usually is approximately two thirds of normal after completion of a rehabilitation program. The rehabilitation protocol should be modified as necessary in circumstances requiring rotator cuff repair or revision. A home-based program of rehabilitation after total shoulder arthroplasty also can be effective (Table 12-6). Patients are instructed in the first sequence of exercises while in the hospital, and these are practiced with a relative or friend in three or four sessions with a physical therapist. At 5 weeks, patients return for a single physical therapy session for instruction in the newer exercises. Serial radiographs are made annually to ensure that no signs of component failure are present. Patients with rheumatoid arthritis, traumatic arthritis, or osteonecrosis may be at risk for failure to regain motion and for complications with tendon, particularly subscapularis, healing.

RECONSTRUCTIVE PROCEDURES OF THE ELBOW Elbow arthroplasty has been described in multiple forms over time. Debridement procedures, soft-tissue interposition, and prosthetic arthroplasty have all been reported. Semiconstrained total elbow arthroplasty, in particular, has a wellstudied track record of pain relief and restoration of function for activities of daily living in low-demand patients. However, the procedure is associated with a relatively high complication rate and is not as durable as replacements of the hip,

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ANATOMY AND BIOMECHANICS

In the normal elbow joint, stability is maintained by the combination of highly congruent joint geometry, capsuloligamentous integrity, and balanced intact musculature. The biceps, brachialis, anconeus, and triceps muscles are especially important. The medial collateral ligament complex consists of anterior, posterior, and transverse components (Fig. 12-20A). The anterior bundle is the most easily identifiable and is the major portion of the medial collateral ligament complex. The anterior bundle inserts along the medial aspect of the coronoid process (sublime tubercle) and is taut with the elbow in flexion and extension. The posterior bundle is taut during flexion.

TABLE 12-6

Home-Based Exercise Program for Rehabilitation After Total Shoulder Arthroplasty EXERCISE Active hand, forearm, elbow motion Passive shoulder motion Assisted pulley for elevation Active-assisted motion and stretching with wand/cane: flexion-extension, elevationadduction Isometrics for light strengthening Strengthening with TheraBand*

DAYS AFTER SURGERY 1

WEEKS AFTER SURGERY

1 21 35

3 5

35

5 10

*The Hygenic Corp., Akron, Ohio. From Boardman ND III, Cofield RH, Bengtson KA, et al: Rehabilitation after total shoulder arthroplasty, J Arthroplasty 6:483, 2001.

The lateral ligament complex consists of the radial collateral ligament, the lateral ulnar collateral ligament, the accessory lateral collateral ligament, and the annular ligament (Fig. 12-20B). The radial collateral ligament arises from the lateral epicondyle and inserts into the annular ligament along with fibers of the capsule. The lateral ulnar collateral ligament consists of posterior fibers of the radial collateral ligament, which extend superficially to and across the annular ligament, inserting on the crista supinatorius (supinator crest) of the ulna. The accessory lateral collateral ligament arises from the lateral epicondyle and inserts into the inferior margin of the annular ligament. It is taut when the elbow is stressed in varus. The annular ligament arises and inserts on the anterior and posterior margins of the lesser sigmoid notch of the ulna and stabilizes the radial head adjacent to the ulna. Of these, the lateral ulnar collateral ligament is most crucial to maintaining elbow stability. In extension, the anterior capsule provides approximately 70% of soft-tissue restraint to distraction. Valgus stress in extension is divided equally among the medial collateral ligament, capsule, and joint surface. Varus stress in extension is limited equally by the joint articulation, lateral collateral ligament, and capsule. In flexion, the medial collateral ligament complex provides a soft-tissue restraint to distraction and is the prime stabilizing structure resisting valgus stress, with the radial head providing a secondary restraint. The joint articulation provides about 75% of the stability and resistance to varus stressing with the elbow flexed. Most activities involving the elbow produce valgus forces. An intact medial collateral ligament and intact radial head are essential to prevent dislocation of the normal elbow joint. The ulnohumeral joint maintains stability as the elbow flexes and extends, whereas the radiocapitellar joint resists valgus stress and transmits vertical loading forces of pushing and lifting. The elbow is composed of two independent uniaxial joints. One is the ulnohumeral joint, which is a hinged, or ginglymoid, joint. The other consists of the radiocapitellar and proximal radioulnar articulations, a pivoted, or trochoid, joint, allowing 2 degrees of freedom in the elbow joint. This articulation has been termed a trochoginglymoid joint, or “sloppy” hinge.

Radial collateral ligament Annular ligament Anterior bundle

Accessory collateral ligament

Posterior bundle

A

Transverse ligament

B

Lateral ulnar collateral ligament

FIGURE 12-20 Collateral ligaments of elbow. A, Classic representation of medial collateral ligament complex consisting of anterior and posterior oblique bundle and transverse component. B, Typical pattern of more variable radial collateral ligament complex consists of contribution from humerus to ulna, which Morrey termed lateral ulnar collateral ligament.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

FIGURE 12-21 Axis of rotation of elbow in flexion and extension is through center of trochlea, collinear with distal anterior cortex of humerus.

Motion in the elbow involves rotation of the ulna around the humerus during flexion and extension and rotation of the radius around the ulna during supination and pronation. The instant center of flexion and extension for the elbow is at the center of concentric circles formed by the lateral projection of the capitellum and trochlea of the distal humerus, is 2 to 3 mm in diameter, and is located in the center of the trochlea when viewed from the lateral aspect (Fig. 12-21). The axis of rotation of the elbow lies anterior to the humeral midline and on a line drawn along the anterior cortex of the humerus. The carrying angle of the elbow varies from 11 degrees of valgus with the elbow in full extension to 6 degrees of varus with the elbow in full flexion (Fig. 12-22). The joint surfaces slide until the extremes of full flexion and extension are reached, and then bony impingement occurs. The transverse axis of rotation of the radiocapitellar joint coincides with the ulnohumeral axis. The longitudinal axis of the forearm passes through the radial head proximally and the ulnar head distally and is oblique to the longitudinal axes of the radius and ulna. The normal range of motion of the elbow is from 0 degrees (full extension) to approximately 150 degrees (full flexion). The anatomic restraints of elbow motion include the geometry of the joint; the surrounding bone, capsule, ligaments, and muscles; impaction of the olecranon process on the olecranon fossa; and impaction of the radial head against the radial fossa. Rotation is limited by passive resistance of the stretched muscles and the ligaments and impingement of the flexor pollicis longus against the finger flexors. The contact surfaces of the elbow change with different elbow positions. In full extension, the contact surfaces are on the inferomedial aspect of the ulna. In other positions, most of the joint contact occurs along the trochlear notch, which passes from posterolateral to anteromedial. Electromyographic studies of elbow muscle activity show that the brachialis is active in most ranges of elbow motion and is the “workhorse” of flexion. The forces around the elbow joint also have been extensively studied. Static analyses of the muscle and joint reaction

FIGURE 12-22 Carrying angle of elbow changes from valgus angle in full extension to varus angle in full flexion. (Redrawn from Morrey BF, Chao EYS: Passive motion of the elbow joint, J Bone Joint Surg 58A:501, 1976.)

forces suggest that the joint forces are greatest in extension, the flexed elbow being able to tolerate higher loads than the extended elbow. Joint forces also are found to be greatest in pronation. Twisting moments around the humeral axis can be quite high, especially when loads are applied to the hand with the elbow flexed (Fig. 12-23). Maximal elbow flexion strength occurs at 90 degrees, whereas about one third to one half the maximal lifting force can be generated with the elbow in an extended or a 30-degree flexed position. A force three times the body weight can be developed in the elbow joint during strenuous lifting. As the forces on the elbow are directed toward the anterior or the posterior margins of the joint, the weight-bearing surfaces decrease, maximal compressive forces are elevated, and the stress distribution becomes uneven. For the most part, joint compression forces along the mediolateral plane that cause valgus or varus stress are small compared with the forces in the sagittal plane directed anteriorly or posteriorly. Forces at the distal humerus are greatest in a posterior and proximal direction, causing anterior tilting of a distal humeral component and absorption of the anterior cortex of the humerus when prostheses loosen or when anterior bone grafting is not used. With the elbow extended and axially loaded, approximately 40% of the stress is on the ulnohumeral joint, with 60% on the radiocapitellar joint. Considerable rotatory torque is developed at the distal humerus when the elbow is flexed to 90 degrees and force is applied to the hand from the side. Tensile forces on the medial collateral ligament can approach two times the body weight,

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External force

Radial head compression

Medial ligament tension

Inward rotation

FIGURE 12-23

A

Forces at elbow during inward rotation.

B

FIGURE 12-24 A, Forearm bones in equilibrium against humerus during flexion, no collateral tension. B, Forces concentrate on lateral edge of coronoid process after radial head excision. Medial ligament tension prevents valgus deformity.

and compressive forces on the radial head can approach three times the body weight. If the radial head is excised, radiocapitellar force is transmitted to the ulna, and the medial collateral ligament tension adds to the ulnohumeral force, which may concentrate the entire load on the lateral edge of the coronoid articular surface (Fig. 12-24). This may apply a force of nine times the body weight to the medial collateral ligament and is associated with progression of ulnohumeral joint

degeneration. These forces are applied to the ulnar and humeral components of a prosthetic arthroplasty if the radial head is resected and not replaced. Suggested goals for the ideal elbow arthroplasty include a painless, stable, mobile, durable, revisable, and reproducible prosthesis. It should preserve the olecranon, have a carrying angle, sacrifice as little bone as possible, provide stable fixation on the supporting bone, be free of moving or multiple parts, be durable and biologically inert, leave minimal dead space, be relatively easy to implant, be readily available without need for custom implants, and provide joint stability and a good range of movement. The main problems in design have been achievement of long-term bony fixation without loosening, minimization of polyethylene wear, and the development of satisfactory materials able to withstand high loads in active patients.

TYPES OF ARTHROPLASTY

Three types of arthroplasties are discussed in this chapter: debridement, interpositional, and prosthetic. Depending on the rigidity of humeral component fixation to the ulnar component, the implant arthroplasties are designated as constrained, semiconstrained, and unconstrained. Constrained, metal-to-metal prostheses include the Stanmore, Dee, McKee, GSB I (Gschwend, Scheier, and Bähler), and Mazas designs and generally have a metal-to-metal hinge with polymethyl methacrylate bone cement fixation. These implants have been largely abandoned, and the technique of their implantation is not described here. The semiconstrained prostheses are two-part or threepart prostheses that have a metal-to-high-density polyethylene articulation, which may be connected with a locking pin or with a snap-fit device. The semiconstrained hinged prostheses have built-in laxity to provide for dissipation of forces. The GSB III, HSS-Osteonics, Coonrad-Morrey, Nexel, and Discovery prostheses are examples of semiconstrained devices (Fig. 12-25). The linked prostheses are highly versatile because they do not depend on intact ligamentous structures for stability. As such, they can be applied to a number of end-stage pathologies, including posttraumatic arthritis, chronic instability, and tumor reconstruction. The unconstrained prostheses are two- or three-part devices consisting of metal articulating with high-density polyethylene. They usually do not have a snap-fit, link, or pin connection. Some designs consist of a resurfacing device, and some have stems for the humeral component. The unconstrained implant arthroplasties include the capitellocondylar (Ewald), London, Kudo, Ishizuki, Lowe-Miller, Wadsworth, Souter-Strathclyde, and Latitude designs. Of note, the Latitude is a hybrid device that can be converted to a semiconstrained articulation with a locking ring. Early to mid-term follow-up of this prosthesis has found outcomes and overall complication rates comparable with other implants, but disengagement of the radial head component occurred in almost one third of elbows. Most of these prostheses represent an attempt to anatomically duplicate the articular surfaces of the elbow. They restore the joint’s anterior offset from the humerus and have a single center of rotation. All resurfacing or unconstrained prostheses require normal intact ligaments and anterior capsule and appropriate static alignment. If bone loss or capsuloligamentous destruction is extensive, an unconstrained prosthesis generally cannot be used.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

FIGURE 12-25 Right, GSB III elbow prosthesis. Middle, HSSOsteonics linked semiconstrained total elbow prosthesis. Left, Coonrad semiconstrained elbow prosthesis. (Right from Herren DB, O’Driscoll SW, An KN: Role of collateral ligaments in the GSB-linked total elbow prosthesis, J Shoulder Elbow Surg 10:260, 2001; middle from Kraay MJ, Figgie MP, Inglis AE, et al: Primary semiconstrained total arthroplasty: survival analysis of 113 consecutive cases, J Bone Joint Surg 76B:636, 1994.)

Early clinical reports of experience with many of the prosthetic designs were preliminary evaluations of small numbers of patients, with no standardized method of assessment. Some reports mixed different prostheses and included patients with traumatic arthritis, osteoarthritis, and rheumatoid arthritis. These factors have limited the objective comparison of the different implants. More recent reports allow better understanding of the advantages and limitations of the various prosthetic designs.

DEBRIDEMENT ARTHROPLASTY

Debridement arthroplasty for degenerative elbow conditions is recommended for younger, higher-demand patients who may not be able to comply with the lifting restrictions associated with total elbow replacement. A lateral approach or combined medial and lateral approaches can be used to remove loose bodies and to debride osteophytes in a painful, stiff osteoarthritic elbow. A medial approach has been recommended because of the frequent concomitant ulnar nerve symptoms and the importance of evaluating for and removing osteophytes from the medial edge of the coronoid and olecranon rather than their respective processes (see Technique 12-4). Arthroscopic debridement also has been described; this is discussed more fully in Chapter 52.

DEBRIDEMENT ARTHROPLASTY TECHNIQUE 12-4 (WADA ET AL.) With the patient supine and the involved extremity on an arm board, make a curved posteromedial incision along the distal border of the pronator teres, passing 1 cm

■

posterior to the medial epicondyle and extending 4 cm proximal to the olecranon process (Fig. 12-26A and B). Protect the sensory branches before ulnar nerve isolation and decompression. ■ Elevate the flexor-pronator origin and anterior capsule to expose the anterior humeroulnar and radiocapitellar joints (Fig. 12-26C). ■ Use rongeurs or chisels to remove osteophytes from the coronoid process, the medial edge of the coronoid, the coronoid fossa, and the radial fossa. If needed for osteophyte excision, retract the anterior band of the medial collateral ligament medially, but preserve it (Fig. 12-26D). ■ Elevate the ulnar nerve, excise the posterior bundle of the medial collateral ligament, and elevate the triceps posteriorly for debridement of the posterior humeroulnar joint and the olecranon fossa (Fig. 12-26E). ■ Dissect between the triceps and the brachioradialis to expose the lateral condyle and joint capsule (Fig. 12-26F). ■ Expose the radial head by opening longitudinally the radial collateral ligament. ■ Elevate the anterior joint capsule subperiosteally and remove any osteophytes. ■ Alternatively, carefully elevate the muscular fibers of the brachioradialis, extensor carpi radialis longus, and brachialis off the anterior joint capsule before excising the capsule and performing the joint debridement. ■ Preserve the lateral ulnar collateral ligament by keeping the capsular dissection anterior to a line connecting the midpoint of the lateral epicondyle to the midportion of the radiocapitellar joint. ■ Carry the dissection posterior to the lateral epicondyle and proximally along the anterior border of the triceps laterally to expose the posterior fat pad and the olecranon fossa (Fig. 12-26G). Loose bodies and osteophytes often are encountered posteriorly, and dissection distal to the lateral epicondyle into the posterior radiocapitellar joint is required for completion of the lateral debridement. ■ Copiously irrigate the joint after satisfactory motion has been obtained. ■ Obtain hemostasis as much as possible and cover raw cancellous bone surfaces with paraffin. ■ If the flexor-pronator group has been detached, approximate it to a soft-tissue cuff or to bone through drill holes. ■ Manage the ulnar nerve according to its behavior through the elbow range of motion achieved. If there is minimal tension on the nerve throughout the motion arc and the nerve is not forcefully subluxing over the medial epicondyle, simply leave it decompressed in situ. If ulnar nerve subluxation is forceful or nerve tension is excessive with elbow flexion, perform an anterior transposition procedure. ■ Place suction drains and close the incisions in routine fashion.

POSTOPERATIVE CARE.  Physical therapy is begun on postoperative day 1, and the drains are removed. Static splints frequently are used to prevent the recurrence of an elbow flexion contracture.

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Biceps muscle

Brachialis muscle Triceps muscle Ulnar nerve Ulnar nerve

Triceps muscle

A

D

Medial epicondyle

Ulnar nerve

Posterior oblique bundle Anterior oblique bundle

B

C

E

F

Humeral head of flexor carpi ulnaris muscle

Medial epicondyle

G FIGURE 12-26 Debridement arthroplasty of elbow (see text). A and B, Incision. C, Elevation of flexor-pronator origin. D, Exposure of anterior elbow compartment. E, Excision of posterior oblique bundle and posterior capsule. F, Exposure of anterior, medial, and posterior aspects of ulnohumeral joint. G, Exposure and excision of osteophytes on lateral aspect of olecranon and olecranon fossa. SEE TECHNIQUE 12-4.

More recently, some authors have advocated arthroscopic elbow debridement for degenerative conditions. Adams et al. reported 42 elbows followed for a minimum of 2 years after arthroscopic debridement and capsular release for osteoarthritis. The authors reported significant gains in flexion, extension, supination, pain, and Mayo Elbow Performance Scores. Complications were uncommon, and 81% of patients achieved good or excellent results. Although these early reports have been promising with this so-called osteocapsular arthroplasty, further study is needed to determine the longterm effectiveness of this procedure.

INTERPOSITION (FASCIAL) ARTHROPLASTY Interposition arthroplasty is another intervention to treat degenerative elbow conditions in patients who have a contraindication to implant placement. The primary indication may be loss of motion or incapacitating pain or both. Loss of motion can be caused by inflammatory or degenerative arthritis, sepsis, burns, or trauma. Ankylosis can be bony or fibrous. Incapacitating pain in a young, active patient may be the most compelling indication. If the pain and restriction of motion are the results of sepsis, a careful preoperative

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY evaluation must determine that the sepsis has been under control. The best indication for interposition arthroplasty is painful, posttraumatic loss of motion in the absence of infection. Because interposition arthroplasty does not inherently contribute to elbow stability, instability is not a good indication for this procedure. Identification of appropriate patients for interposition arthroplasty is difficult and involves an evaluation of the underlying pathologic process and the motivation of the patient. To achieve success, the condition of the soft tissues surrounding the elbow must be as normal as possible. Weak, atrophic muscles; thin, delicate skin; and extensive scarring or adherence of skin to underlying bone prevent a satisfactory result. The forearm musculature must be in good condition so that postoperative strength and stability can be achieved through the rehabilitation of these muscles. Furthermore, it is important to preserve as much bone stock as possible and to maintain the integrity of the capsuloligamentous and muscular soft tissues surrounding the elbow joint. Interposition arthroplasty can be considered in younger patients with posttraumatic arthritis (Fig. 12-27). It can be effective in these patients and remains an alternative to total elbow arthroplasty. The addition of distraction devices is helpful but not required.

INTERPOSITION ARTHROPLASTY TECHNIQUE 12-5 Beginning proximal to the elbow joint, make an incision 15 to 20 cm long on the posterior aspect of the arm and forearm just medial to the midline of the limb. ■ Elevate the deep fascia laterally 2 to 3 cm and expose the broad aponeurosis of the triceps muscle (Fig. 12-28A). ■ To approach the joint, one of two methods can be used. In the first, enter the Kocher interval and carry the dissection along the lateral head of the triceps, taking care not to proceed so proximally as to endanger the radial nerve. ■ In the second method, a triceps-splitting midline approach can be used. ■ After either approach, with a periosteal elevator, strip the periosteum from the distal third of the posterior surface of the humerus, retract it medially and laterally, and expose the radial head and olecranon (Fig. 12-28B). ■ If the joint is fused, osteotomize the fusion between the olecranon and humerus and between the radial head and humerus, carefully protecting the ulnar nerve. ■ Flex the joint and displace the radius and ulna medially. ■ Fashion the distal end of the humerus into one condyle convex from anteriorly to posteriorly (Fig. 12-28C). Although no attempt is made to reproduce the contours of the capitellum and trochlea, some mediolateral stability can be achieved if the distal humerus is shaped into an inverted V. ■ With a curved chisel, excise superficial bone to deepen and lengthen the trochlear notch of the ulna and cut away the head of the radius to the level of the distal part of this notch (Fig. 12-28D). ■

Smooth all surfaces with a rasp. Prepare an Achilles tendon allograft by folding it in half crosswise with its smooth surface on the inside and anchor its folded edge to the anterior part of the capsule with three sutures, one on each side and one in the middle. Other authors prefer to use an acellular dermis matrix patch, which can be prepared in a similar way. ■ Place the proximal half of the fascia over the newly fashioned humeral condyle and with interrupted sutures fasten the medial and lateral edges of this half to the adjacent soft tissues well over the medial and lateral borders of the humerus; if the soft tissues are insufficient, secure the fascia by sutures passed through holes drilled in these borders. ■ As an alternative, use suture anchors to expedite the attachment of the fascia to the humerus and olecranon and the attachment of the capsuloligamentous tissues to the humerus. ■ Place the distal half of the fascia over the trochlear notch and suture it in place (Fig. 12-28E). (In the presence of synostosis between the proximal radius and ulna, excise enough bone to permit free rotation of the radius.) ■ Insert a fold of the same fascia between the radius and ulna and invest the radial head, or place a separate sheet of fascia around the head and fix it with a purse-string suture. ■ Reduce the joint and, with the elbow flexed to 90 degrees, close the capsule from distally to proximally. Apply a longarm posterior splint or cast with the elbow in 90 degrees of flexion. ■ ■

POSTOPERATIVE CARE.  The elbow is immobilized in 90 degrees of flexion on an elbow splint or in a cast for 10 to 14 days to prevent rotation. When the wound has healed completely, a posterior elbow splint with straps and buckles is applied. This splint is removed for 1 to 2 hours three or four times a day for active exercises to develop the flexors and extensors of the elbow and the flexors of the fingers. At 3 weeks after surgery, the splint can be discarded during the day and a sling is used as necessary for support, but the splint should be worn at night until a useful range of motion in the elbow and good strength in the muscles have been regained; this usually is at 8 weeks after surgery. The patient must continue active exercises for at least 6 months. Maximal strength and motion usually are regained within 2 years after surgery.

The prognosis after elbow interposition remains guarded. Larson and Morrey reported that only 29% of 45 patients achieved a good or excellent result on 45 elbows at 6-year follow-up, although there were significant improvements in pain, motion, and functional scores. Preoperative instability was associated with worse functional outcomes. The functional results and the radiographic appearance of the elbow after interpositional arthroplasty correlate poorly (see Fig. 12-27). In general, the fair and poor results of fascial arthroplasty have been caused by persistent pain, loss of motion (reankylosis), and excessive instability. Complications of fascial arthroplasty in the elbow include bony absorption, triceps rupture, heterotopic bone

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A

B

C

D FIGURE 12-27

A and B, After fascial arthroplasty. C, Extension 20 years after surgery. D, Flexion 20 years after surgery.

formation, instability, infection, and seroma formation in the thigh donor site if fascia lata is used for interposition material. Bony absorption may occur at the distal humeral condyles and may contribute to instability. Triceps rupture, which may be related to the surgical exposure, is an uncommon complication of fascial arthroplasty. It can be minimized or prevented by using approaches that preserve the triceps insertion, such as those described above. Excessive heterotopic bone formation limits motion. Although excision of the heterotopic bone may improve motion, bone formation may recur, regardless of most methods used to prevent it. Treatment of infection after fascial arthroplasty of the elbow should be prompt and aggressive. If the infection is superficial or if cellulitis develops, oral antibiotics, elevation of the elbow, and immobilization may allow resolution. If the deeper structures are infected, open drainage and

debridement or excision of the fascial graft may be required. If autogenous fascia lata is used as a graft material, hematoma and seroma formation in the thigh donor site frequently resolve over weeks and rarely require drainage. If drainage is required, aseptic technique is used and needle aspiration may be sufficient. Pain, reankylosis, or instability may cause the procedure to fail. Deterioration may also occur with time. Revision of the fascial arthroplasty may be helpful if the exact nature of the failure can be identified and reasonable success has been reported with revision.

RESECTION AND IMPLANT ARTHROPLASTY OF THE RADIAL HEAD

Radial head resection is a commonly used procedure for symptomatic radiocapitellar dysfunction. The typical indications for radial head resection include isolated radiocapitellar

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

Hand

Forearm

Forearm

Olecranon tip

Olecranon Humerus

Humerus

Medial epicondyle Triceps fascia reflected Triceps aponeurosis

Hemostats holding triceps fascia

A

B

Anterior capsule Olecranon tip

Triceps fascia

Triceps fascia

Olecranon reshaped

Anterior capsule Reshaped humeral condyle Gauze Gauze

C

Reshaped humeral condyle

D

Ulnar nerve

Humeral condyle covered with fascia lata

E FIGURE 12-28

A-E, Operative technique of fascial arthroplasty. SEE TECHNIQUE 12-5.

arthritis, mechanical block to pronation-supination in the posttraumatic elbow, and inflammatory arthritis in association with a debridement procedure. Radial head resection also has been described for acute comminuted radial head fractures. Although clinical outcomes at 15 to 17 years of follow-up were good to excellent, posttraumatic changes including elbow and wrist arthrosis, proximal radial migration, and a valgus carrying angle were noted. The radial head

is an important secondary stabilizer to valgus stress; therefore we recommend ensuring the lateral collateral ligament complex is intact when considering radial head resection to prevent postoperative instability. Because of the high incidence of injury to the lateral collateral ligament complex, radial head replacement is most often used in the treatment of comminuted radial head fractures, but it also can be used for other disorders of the radial

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A

B

C FIGURE 12-29

A, Elbow fracture-dislocation. B and C, After radial head implant.

head, such as elbow instability and deformity. Silicone (Silastic) implants were introduced in the early 1980s, with good results reported initially; however, longer-term follow-up data indicated problems with failure of the prosthesis and silicone synovitis. Because of the problems associated with silicone radial head replacements, most currently used radial head prostheses are metal, which have been reported to be durable and help to maintain valgus stability of the elbow after radial head replacement for trauma.

RADIAL HEAD ARTHROPLASTY

Radial head fractures associated with elbow dislocations frequently are comminuted and nonreconstructible and are

initially excised. In this situation, the lateral ulnar collateral ligament often is injured, with concomitant elbow instability. More complex associated injury patterns include either a low coronoid fracture or a medial collateral ligament rupture. In these situations, a radial head implant is recommended to help stabilize the joint. If the radial head is fractured and the distal radioulnar joint is dislocated, proximal migration of the radius after simple radial head excision may be minimized by a radial head implant. In each of these situations, a radial head implant may be indicated to stabilize the elbow joint and allow range-of-motion exercises to begin early (Fig. 12-29). Attempts to prevent recurrent elbow dislocation, proximal migration of the radius, and excessive instability after

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY Full extension (no “edge binding”)

90° flexion (some “edge binding”)

FIGURE 12-30 Radial head implant (see text). Threedimensional CT scans used to determine plane defined by distal margins of articular surface of radial head. Arrow 1, Central ridge of coronoid process. Arrow 2, Lateral edge of coronoid process. (From Doornberg JN, Linzel DS, Zurakowski D, et al: Reference points for radial head prosthesis size, J Hand Surg 31A:53, 2006.)

certain elbow and forearm axis injuries have led to an evolution of radial head prosthetic designs. Although prosthetic replacement of the radial head after acute fractures of the radial head and after radial head excision and elbow synovectomy is controversial, it is reasonable to consider this procedure after injury or disease has caused significant instability of the elbow joint, radial forearm axis, and distal radioulnar joint. In particular, outcomes of comminuted radial head fractures treated with radial head arthroplasty have been reported to be superior to open reduction internal fixation at short-term follow-up. The many types of radial head implants now available have evolved from a monoblock design to modular prostheses, some of which incorporate bipolar features and different materials that may lessen the likelihood of capitellar wear from the prosthesis. Recent investigation into radial head arthroplasty has focused on implant sizing. An oversized radial head implant can increase tension on the interosseous membrane with subsequent risk of stiffness and pain, and one report found that more than 2 mm of lengthening can increase radiocapitellar contact pressures. Therefore a radial head replacement should be close to an anatomic substitute. Generally, the proximal edge of the radial head is 0.9 mm distal to the lateral coronoid edge, but patient variability might make imaging of the contralateral elbow useful for sizing purposes. To prevent overstuffing the radiocapitellar joint, the proximal edge of the prosthesis should be level with the lateral coronoid edge (Fig. 12-30). Moon et al. found that overstuffing of the radial head implant can decrease the ipsilateral ulnar variance, an indicator that can be used during

FIGURE 12-31 Radial head implant (see text). Implant should be checked for stability during elbow motion to ensure that any potential edge binding of implant and capitellum does not occur.

surgery to judge correct sizing, and Athwal et al. reported that gapping in the lateral ulnohumeral joint line is a reliable indicator of radial head overlengthening. Changes in the medial ulnohumeral joint line, however, were apparent only after 6 mm of overlengthening. After correctly sizing the implant, appropriate reattachment of the lateral ligamentous complex also is necessary to prevent edge binding of the radial head prosthesis (Fig. 12-31). In theory, a bipolar implant may help reduce this problem. The results of complex radial head fractures treated with a variety of monoblock and bipolar prostheses are encouraging, although long-term results of significant numbers of patients are pending. In general, the results seem to be good to excellent in 80% of patients, with 10% to 20% reduction in strength. The pain relief is excellent, elbow extension-flexion and pronation-supination arcs are within 10 to 20 degrees of normal values, and maintenance of ulnohumeral joint stability is generally successful. One mid-term to long-term concern is a lack of implant durability because of loosening of the stem with either ingrowth or cemented components. Reported in almost one third of press-fit radial head arthroplasties, the loosening causes significant proximal radial osteolysis and generally necessitates removal.

RADIAL HEAD ARTHROPLASTY TECHNIQUE 12-6 Position the patient supine or in the lateral position with the affected elbow up. Prepare and drape the arm to expose the elbow with the arm across the chest. Use a pneumatic tourniquet.

■

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS BOX 12-3

Distal humerus

Mayo Elbow Performance Score Radial head implant

Pain (45 points) ■ None (45 points) ■ Mild (30 points) ■ Moderate (15 points) ■ Severe (0 points) Range of Motion (20 points) ■ Arc > 100 degrees (20 points) ■ Arc 50 to 100 degrees (15 points) ■ Arc < 50 degrees (5 points)

Ulna

Annular ligament Radial shaft with head resected

FIGURE 12-32 Radial head implant (see text). Annular ligament is incised transversely to allow end-on view of canal for implant placement. SEE TECHNIQUE 12-6.

Begin the incision superior to the lateral epicondyle and extend it distally approximately 6 cm across the joint in the interval between the extensor carpi ulnaris and the anconeus. ■ Develop the interval between these two muscles and expose the lateral capsule of the elbow. Often the lateral capsular structures are stripped from the lateral epicondyle, and the interval created from the trauma should allow removal of bone fragments and exposure of the radial neck. ■ Incise the annular ligament transversely and cut the radial neck just proximal to the fracture site (Fig. 12-32). ■ Prepare the proximal radial medullary canal with burrs or rasps to accept the implant stem. ■ Cut the surface of the proximal radius evenly so that contact between it and the collar of the prosthesis is complete. ■ Achieve a tight fit of the stem in the medullary canal and ensure that contact with the capitellum is satisfactory. Avoid excessive compression of the implant. ■ Carry the forearm through a range of flexion, extension, and rotation to observe the relationship between the capitellum and the implant in anteroposterior and lateral projections. ■ After the use of a trial prosthesis has shown satisfactory contact between the capitellum and the prosthesis and a good fit in the radial medullary canal, insert the final prosthesis. ■ Make drill holes or use a suture anchor at the capitellar rotation center to reattach lateral capsular structures, ■

Stability (10 points) ■ Stable (10 points) ■ Moderately unstable (5 points) ■ Grossly unstable (0 points) Function (25 points) ■ Able to comb hair (5 points) ■ Able to feed oneself (5 points) ■ Able to perform personal hygiene tasks (5 points) ■ Able to put on shirt (5 points) ■ Able to put on shoes (5 points) ■ Maximal total = 100 points Outcomes classification: 90-100 = excellent, 75-89 = good, 60-74 = fair, <60 = poor.

including the lateral ulnar collateral ligament to its isometric point with the ulnohumeral joint held reduced. ■ Close the wound in layers and protect the elbow with a compression dressing in 90 degrees of flexion.

POSTOPERATIVE CARE.  The dressing is removed 3 to 5 days after surgery. A small dressing is left in place thereafter, and gentle active motion of the elbow is begun. Aggressive physical therapy should be avoided. If other injuries are present, including distal radioulnar dislocation, ligamentous injuries, or elbow instability, immobilization of the elbow is continued for 2 weeks with gentle passive range of motion thereafter. Mobilization after radioulnar disruption depends on the management of the distal radioulnar joint and its temporary fixation with pins. Active motion is begun under supervision at approximately 6 weeks after surgery.

TOTAL ELBOW ARTHROPLASTY

Total elbow arthroplasty is among the best studied procedures in orthopaedic surgery. Multiple authors have reported their outcomes with various implant types. The method of evaluating the results of elbow implant arthroplasty is becoming standardized, and rating systems have been established by Morrey et al., the American Shoulder and Elbow Surgeons (ASES), Inglis and Pellicci, and Ewald. The Mayo Elbow Performance Score, which takes into account pain, motion, stability, and daily function, is most commonly used to compare various operative procedures on the elbow (Box 12-3).

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

INDICATIONS

The goals of reconstructive elbow surgery are to restore function through pain relief and restoration of motion and stability. When evaluating candidates for elbow arthroplasty, two factors must be considered: patient selection and implant selection. A stable, painless elbow with preservation of motion in the middle or functional range usually does not require arthroplasty. Although many indications and relative indications have been reported, deformity and dysfunction without pain are not indications for surgery. Similarly, weakness and discomfort caused by instability may be relative indications, especially in patients with posttraumatic arthritis. The primary indications for total elbow arthroplasty are pain and/or instability. Rheumatoid arthritis with radiographic evidence of joint destruction, which is too far advanced to benefit from radial head excision and synovectomy, especially in patients with painful instability and painful stiffness that limit activities, is generally considered to be an indication. Elderly patients with an unreconstructable intraarticular distal humeral fracture or end-stage posttraumatic arthritis also are acceptable candidates for total elbow replacement. Bony or fibrous ankylosis with the elbow in a poorly functioning position is another indication for elbow arthroplasty. In patients with rheumatoid arthritis, arthroplasty should be considered only after medical treatment has failed and the disease has advanced to show bony changes, which is beyond the stage at which synovectomy would be beneficial. The best candidate for total elbow replacement has been described as a patient with severely painful and disabling rheumatoid arthritis with altered articular architecture; however, the decision to proceed with arthroplasty must be made cautiously because of the high complication rate. Patients with rheumatoid arthritis who have limitation of motion, ankylosis, instability, or incapacitating pain generally do better after implant arthroplasty than do patients with posttraumatic arthritis. Selection of the type of prosthetic implant depends to a great extent on the state of the capsuloligamentous structures around the elbow and the integrity of the musculature and the amount of bone remaining at the elbow joint. Generally, the more bone remaining and the more stable the joint, the more suitable the joint is for replacement with a resurfacing or unconstrained prosthetic implant. More constrained prosthetic designs should be selected for patients with injury to the stabilizing ligaments and capsule of the joint, atrophic musculature, and loss of considerable bone stock. Ewald suggested that one absolute contraindication to prosthetic elbow implant arthroplasty is a history of previous elbow sepsis. Because of the design of his capitellocondylar implant, he also considered a previous fascial or other interpositional arthroplasty and previous hinged arthroplasty to be absolute contraindications to the use of the capitellocondylar device. Relative contraindications to the use of an unconstrained resurfacing arthroplasty included excessive bone loss, as in giant rheumatoid cysts, deficiency of the trochlear notch of the ulna, and posttraumatic or degenerative arthritis. Coonrad and Moorey considered infection, excessive use of the elbow, ankylosis of the ipsilateral shoulder, and the presence of neurotrophic joints to be contraindications. Kudo et al. concluded that extensive bone loss on either side of the joint and poorly functioning flexor and

extensor mechanisms were contraindications. Morrey et al. reported that no consistently reliable total prosthetic arthroplasty is available for patients with posttraumatic degenerative arthritis in the elbow. However, in these salvage situations this does not always represent an absolute contraindication to total elbow arthroplasty.

SURGICAL TECHNIQUE SEMICONSTRAINED (LINKED) TOTAL ELBOW ARTHROPLASTY

Most semiconstrained hinged prostheses use a highmolecular-weight polyethylene bushing and titanium humeral and ulnar components. They are designed with 7 degrees of rotary and side-to-side laxity. Humeral and ulnar stems match the shapes of the medullary canals. The triangular humeral stem is flattened near the base at the inferior flatter and wider portion of the medullary canal of the humerus. The large medullary stem enhances rigid fixation. The stem contour and distal anterior flange increase resistance to torque. Careful bone removal in the intercondylar area of the humerus is necessary to allow a tight fit of the humeral prosthesis. The humeral and ulnar components typically are joined with a linking mechanism that, if necessary, can be disarticulated. The axis of rotation of these prostheses are near the anatomic center when the device is properly implanted. Because the components are relatively large, a disadvantage in smaller patients is that they occasionally require manufacture of custom components.

COONRAD-MORREY PROSTHESIS TECHNIQUE 12-7 Place the patient supine with the affected arm in front of the chest and with a sandbag beneath the ipsilateral shoulder (Fig. 12-33A). When preparing and draping the arm, leave the entire elbow area and forearm exposed so that the prosthesis can be inserted properly. Use a sterile tourniquet and exsanguinate the limb by elevating it for several minutes before inflating the tourniquet. ■ Use a straight posteromedial incision. ■ Identify the ulnar nerve, gently mobilize and protect it, and transpose it anteriorly after the operation. ■ Carefully elevate the triceps mechanism in continuity with the periosteum over the proximal ulna and olecranon to avoid transection or separation of the triceps mechanism (Fig. 12-33B). ■ Reflect the triceps mechanism to the radial side of the olecranon to expose the proximal ulna. Some authors prefer to keep the triceps insertion intact to avoid the risk of weakness and rupture after surgery—the so-called triceps-on approach. These techniques include either a Kocher approach with partial elevation of the triceps insertion or the para-olecranon approach described by Studer et al. One comparative report found that total elbow arthroplasty performed with the triceps-on technique resulted in similar outcomes and cement mantle quality as the triceps-off approach and with no risk of tendon rupture. As such, we prefer a triceps-on ■

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS Sharpey fibers Medial epicondyle Ulnar crest

Motor branch of ulnar nerve

A

Ulnar nerve

Flexor carpi ulnaris muscle

B

C

F

D

G

H

E

I

FIGURE 12-33 A-R, Coonrad-Morrey total elbow arthroplasty. (Redrawn from Coonrad RW, Morrey BJ: Coonrad/Morrey total elbow: surgical technique, Warsaw, IN, 1988, Zimmer USA.) SEE TECHNIQUE 12-7.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY

J

K

L

M

N

O

P

Q

R FIGURE 12-33, cont’d

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS technique if possible when performing total elbow arthroplasty. ■ Release the collateral ligaments on each side of the elbow. ■ Rotate the forearm laterally to dislocate the elbow and allow exposure of the distal humerus. ■ Remove the midportion of the trochlea with an oscillating saw to allow access to the medullary canal of the humerus (Fig. 12-33C). Identify the canal with a burr applied to the roof of the olecranon fossa (Fig. 12-33D). ■ Remove the cortex of the olecranon fossa and open the medullary canal to a size sufficient to allow a twist reamer (Fig. 12-33E). ■ Preserve the medial and lateral portions of the supracondylar columns during the preparation of the distal humerus. Use the medial and lateral supracondylar columns for reference during the bone preparation to ensure satisfactory orientation and alignment. ■ Place the alignment stem down the medullary canal with a T-handle (Fig. 12-33F). ■ Remove the handle and apply the cutting block with the appropriate right or left placement of the side arm of the cutting block. Allow the side arm to rest on the capitellum to provide for the proper depth of the cut (Fig. 12-33G). ■ Use an oscillating saw to remove the trochlear and capitellar bone to correspond with the size of the appropriate cutting block. If the bone is osteoporotic, score the cortex with electrocautery, using the cutting block as a guide. ■ Remove any remaining bone after the cut with a rongeur. Avoid injury to the medial and lateral supracondylar columns to avoid fracture. Remove the bone carefully, small amounts at a time, repeatedly inserting the trial prosthesis until the margins of the prosthesis are exactly level with the epicondylar articular surface margins on the capitellar and trochlear sides. Also ensure that the rotational center of the trial prosthesis corresponds to the native center of rotation of the elbow. ■ Hollow the flattened areas of the distal humerus to allow a precise fit of the shoulders of the humeral stem by curettage of cancellous bone from the epicondylar and distal flaring portions of the humerus. This should allow satisfactory cement fixation (Fig. 12-33H). ■ Remove the tip of the olecranon. ■ Use a high-speed burr and remove subchondral and cancellous bone to allow identification of the ulnar medullary canal. ■ Remove additional bone from the tip of the olecranon to form a notch for placement of the serial reamers to be introduced down the medullary canal of the ulna (Fig. 12-33I). Use the appropriate right or left ulnar rasps as needed. ■ Select the appropriate size rasp and use a burr to remove the subchondral bone gently around the coronoid process (Fig. 12-33J). ■ After the proximal ulna and distal humerus have been prepared, insert a trial prosthesis and evaluate the elbow for complete flexion and extension. ■ If there is a limitation to full extension, release the anterior capsule and evaluate the trial components again until the elbow can be straightened.

Before inserting the final prosthesis with polymethyl methacrylate, use the trial prosthesis to determine if the radial head impinges on the prosthesis. If it is present, resect the radial head. ■ Fashion a bone graft from the previously cut trochlea to be placed behind the anterior humeral flange during component implantation. The graft usually is 2 to 3 mm thick, 1.5 cm long, and 1 cm wide. Elevate the brachialis from the anterior humerus to provide a bed for placement of the bone graft. ■ Clean the medullary canals of the humerus and ulna with a pulsatile lavage irrigating system and dry the canals. ■ Place cement restrictors in the humeral and ulnar canals. ■ Use a cement gun with flexible tubing to insert the cement into the canals (Fig. 12-33K). Inject the cement early in the polymerization process. Inject the cement into the ulna, leaving 1 to 2 cm of medullary canal unfilled to allow for back flow of the cement. ■ Insert the ulnar component first as far distally as the coronoid process. Align the center of the ulnar component with the center of the greater sigmoid notch (Fig. 12-33L). Remove the excess cement from around the ulnar component. ■ Insert cement into the humeral canal, leaving about 1 cm of canal unfilled to allow for back flow of cement (Fig. 12-33M). ■ While the cement is still soft, place the humeral component down to a point that allows articulation of the device and the placement of the axis pin. Place the bone graft against the distal humerus beneath the soft tissue (Fig. 12-33N). At this point, the bone graft is partially covered by the anterior flange of the humeral component. ■ Articulate the humeral device by placing the axis pin through the humerus and ulna. Secure it with a split locking ring (Fig. 12-33O). There will be a confirmatory click when the locking device engages. ■ Impact the humeral component into the humerus so that the axis of rotation of the prosthesis is at the level of the normal anatomic axis of rotation (Fig. 12-33P and Q). This usually is accomplished when the base of the anterior flange is flush with the anterior bone of the olecranon fossa. ■ Check the bone graft to ensure that it is still behind the anterior humeral flange and secure between it and humerus. ■ Place the arm in maximal extension while the cement hardens. While this occurs, carefully remove excess cement. ■ Deflate the tourniquet and obtain hemostasis. Leave a drain in the depths of the wound. ■ If the triceps was released during the approach, drill holes in an X configuration through the olecranon to accept the sutures to repair the triceps mechanism with a locking running stitch (Fig. 12-33R). Also place a transverse suture through the olecranon and tie it over the top of the approximated triceps to provide additional fixation. Close the remainder of the triceps with absorbable suture. ■

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY Apply a compression dressing with the elbow in full extension and a long anterior splint to minimize pressure on the posterior incision.

■

See also Videos 12-3 and 12-4.

POSTOPERATIVE CARE.  The extremity is elevated overnight with the elbow above the shoulder. The drains and compressive dressing are removed the day after surgery. A light dressing is then applied, and passive elbow flexion and extension are allowed as tolerated. A sling is used, and instructions in the activities of daily living are provided by an occupational therapist. To protect the repaired triceps, active elbow extension must be avoided for 3 months. In patients who had a triceps-on approach, passive range of motion can be initiated early through a comfortable arc as tolerated. Strengthening exercises are avoided, and the patient is encouraged to avoid lifting more than 5 lb with the involved arm for the first 3 months after surgery. Thereafter, lifting is restricted to 10 pounds. Despite these recommendations, most patients, particularly young men and those with posttraumatic disorders, have been shown to engage in higher demand activities, despite receiving these instructions.

OUTCOMES

Long-term (10 to 20 years) outcomes of semiconstrained and unconstrained total elbow implant arthroplasty are now available; 5- and 10-year survival rates have been reported at 90% and 81%, respectively, in a study of the Norwegian joint arthroplasty database; a separate study found a 67% survival rate at 20 years. In the review of results for implant arthroplasty, several generalizations seem appropriate. If the available published reports of semiconstrained and unconstrained arthroplasties are considered, an average of 75% satisfactory results have been achieved. Furthermore, quality of life indices have been reported to be improved after total elbow arthroplasty. If reports of the earlier hinged designs are excluded, the satisfactory results approach 90%. The best results from total elbow arthroplasty are obtained when the procedure is done for rheumatoid arthritis, where satisfactory results average about 90%. In contrast, total elbow arthroplasty for posttraumatic sequelae is generally less successful.

UNCONSTRAINED TOTAL ELBOW ARTHROPLASTY

Numerous unconstrained total elbow implants have been in use, most with various modifications. With unconstrained “surface replacement” arthroplasties, an overall average of nearly 85% satisfactory results has been reported, and 90% of patients may achieve satisfactory results when patient selection and surgical techniques are satisfactory. Patients with rheumatoid arthritis constitute the largest group treated with unconstrained prostheses. Aseptic loosening was found in 10% of 522 Souter-Strathclyde implants used in patients with inflammatory arthritis at average follow-up of 6.6 years. Aside from aseptic loosening, the survivorship was 96% and 84% at 5 and 10 years. Trail et al., after their experience with 309 Souter-Strathclyde total elbow arthroplasties in rheumatoid patients, recommended that a longer

humeral component be used because 25 of their 32 revisions were for humeral component loosening. Despite lucency rates of 100% and 8.9% for humeral and ulnar components, a 90% survival rate at 16 years with an average Mayo score improvement from 43 to 77 was reported with the use of Kudo type 3 total elbow implants. Ulnar nerve palsy, deep infection, wound complications, stiffness, and instability are common problems encountered with all these devices. The more prevailing concern underlying all these implants and other unlinked implants more recently introduced into the market is the high rate of radiographic lucencies around the humeral and ulnar components. Multiple recent reports have found that a semiconstrained device demonstrated better longevity than unconstrained replacements.

SEMICONSTRAINED TOTAL ELBOW ARTHROPLASTY

Semiconstrained total elbow replacement for rheumatoid arthritis has been well studied. Early reports indicated good results in about 85% of patients, with implant survival of 92%, although complication rates were relatively high (14%). A more recent comparison of the outcomes of unconstrained and semiconstrained total elbow arthroplasties for rheumatoid arthritis reported a 93% survivorship at 5 years and 76% at 10 years for the unconstrained device. In contrast, the semiconstrained device had 100% retention at 5 years. The unconstrained device had high rates of loosening (18%) and instability (9%) that accounted for the inferior survival rate. Other reports also have found an advantage to semiconstrained designs over unconstrained implants. Total elbow arthroplasty for distal humeral fractures in the elderly has been shown to be effective in properly selected patients. Patients older than age 65 years with small bone fragments or poor bone quality and significant comorbid factors, such as rheumatoid arthritis, osteoporosis, diabetes mellitus, and conditions requiring steroids, have had superior outcomes at short-term follow-up with total elbow replacement as opposed to fixation. A multicenter, randomized prospective study comparing internal fixation with total elbow arthroplasty for displaced intraarticular distal humeral fractures in the elderly found that arthroplasty resulted in improved functional outcomes at 2 years; however, inferior results were reported in younger patients (average age, 23 years) with fractures caused by gunshot wounds. Posttraumatic arthritis also is an indication for total elbow arthroplasty that has been expanding. At an average of 68 months after total elbow arthroplasty, 83% of 41 patients with posttraumatic arthritis had good or excellent results. Failures were typically attributed to overuse of the implant in this younger, more active population. A recent update on this series with an average follow-up of 9 years found 70% component retention at 15 years; 68% of patients had good or excellent results. Other authors have reported their experiences with total elbow arthroplasties for posttraumatic sequelae. In general, a stable and functional elbow can be achieved, but implant longevity, particularly when performed in younger patients, remains a concern; caution is recommended when considering total elbow arthroplasties for this condition in patients under 60 years of age. Failed elbow procedures of any type may be an indication for implant arthroplasty as a revision. Suggested indications

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS for arthroplasty include intractable pain with radiographic evidence of destruction of the radiohumeral and humeroulnar joints, instability, failed synovectomy with radial head excision, and loss of bone stock caused by tumor, trauma, or infection. Patients with primary tumors generally have better results than patients with metastatic lesions.

COMPLICATIONS

An overall complication rate in total elbow arthroplasty of 43% has been reported, including an 18% revision rate and 15% “permanent” complications. Perioperative mortality has been reported to be 0.6% and is most commonly caused by cardiac complications. The reported incidence of infection varies from 0% to 11.5% and averages 5% to 6%. Patients with rheumatoid arthritis have higher infection rates than those with posttraumatic sequelae. In particular, persistent wound drainage is highly indicative of deep infection and predicts the likelihood of subsequent component resection. In an analysis of the failure mechanisms of total elbow arthroplasty for posttraumatic arthritis, it was found that in the early term (<5 years), infection was the primary mode of failure; at between 5 and 10 years, bushing wear was the most common complication; and in the late term (>10 years), complications were uncommon but involved component loosening or fracture. Wear of the polyethylene bearing surface has also been reported after total elbow arthroplasty but accounts for a minority of revision procedures. Factors associated with the development of bushing wear were younger patient age, male sex, posttraumatic arthritis, preoperative elbow deformity, supracondylar nonunion, and high activity levels. Implant malalignment has also been implicated in a biomechanical model. Osteolytic reaction similar to that seen in total hip and knee replacements has been found in total elbow replacement. In a retrieval study of 16 elbows, multiple modes of wear were observed, including asymmetric thinning of the humeral and ulnar bearing surfaces and metal-on-metal debris. In another study, polyethylene particles, cement, and metal debris were all found at the time of total elbow revision. The authors suggested that osteolysis in total elbow arthroplasty is therefore a multifactorial process. A principal complication of unconstrained total elbow arthroplasty has been loosening, usually of the humeral component (Table 12-7). For semiconstrained prostheses, loosening of the humeral component, previously the most common cause for revision, has been reduced to less than 5% overall with improvements in prosthesis design, changes in operative technique, and better understanding of the anatomy and function of the elbow. In particular, one study noted that use of a shorter (4 inch) stem in semiconstrained total elbow arthroplasty resulted in earlier time to revision than longer (6 inch) stems. Nevertheless, humeral stem loosening remained uncommon at a rate of approximately 2% at an average of 7 years of follow-up. Ulnar component loosening and osteolysis increased with the addition of a polymethylmethacrylate precoat in the 1990s but has decreased since the surface finish was changed to a plasma spray preparation. Instability in the form of dislocation or subluxation is the most common complication requiring revision of unconstrained prostheses and has been reported to occur in between 9% and 10% of total elbow arthroplasties. True dislocation

TABLE 12-7

Complications of Implant Elbow Arthroplasty AVERAGE (%) RARELY REQUIRING SURGERY Nerve paresthesias Wound problems Fracture, humerus Fracture, ulna

11 14 5 5

USUALLY REQUIRING SURGERY Nerve entrapment* Triceps problems Ankylosis*

3 4 4

USUALLY REQUIRING REVISION Loosening (semiconstrained) Instability (unconstrained) Infection Fracture and loosening*

5 9 7 5

Average percentage from published reports. *Rarely reported by most authors.

occurs in fewer than 5% of unlinked implants and is dependent on surgical technique. Appropriate tensioning of the medial and lateral ligament complexes and preservation of the anterior capsule and triceps can help avoid this complication. A number of measures have been recommended to minimize the occurrence of other complications of elbow implant arthroplasty, especially infection and problems with the triceps, ulnar nerve, and wound healing. These include the use of a straight incision medial to the olecranon tip, detachment of the triceps in continuity from the olecranon without division of the tendon or the use of a triceps-on approach, anterior transposition of the ulnar nerve, drainage of the wound with at least one suction drain, and initial splinting of the elbow in full extension.

SALVAGE

REVISION ELBOW ARTHROPLASTY

Initial results of revision elbow arthroplasty were poor with a high complication rate and an equally high rate of unsatisfactory outcomes; however, with improved surgical technique and understanding of the failure modes of these implants, more recent outcomes have been more promising. Nevertheless, revision total elbow arthroplasty remains a difficult salvage situation and patients should be counseled as to the end-stage nature of their disorders before intervention so that expectations are properly set. Wolfe et al. identified preoperative risk factors for infection after total elbow arthroplasty, including previous elbow surgery or infection, psychiatric illness, and class IV rheumatoid arthritis. Postoperative risk factors included wound drainage, spontaneous drainage after 10 days, and reoperation for any reason. For deep infection after elbow implant arthroplasty, removal of the implant and all cement has been recommended. For superficial infection, Wolfe et al.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY recommended debridement with salvage of the implant, resection arthroplasty, or elbow arthrodesis. In patients with gross loosening of the implant, salvage attempts were not worthwhile. In patients with no implant loosening, however, salvage was possible. Aggressive measures were used to stabilize the soft tissues, including excision of sinus tracts; debridement of thinned skin and exposed bone; and the use of skin grafts, rotation flaps, and muscle pedicle flaps. Salvage of an infected elbow prosthesis by serial debridement and antibiotic therapy has been described, and successful singlestage exchange arthroplasty. In a later report by Yamaguchi, Adams, and Morrey, 25 patients with postoperative infections were grouped according to the treatment they received. In group I, the implant was retained using antibiotics and serial debridement, which included exchange of the polyethylene bushings. In group II, the implant was removed and reimplantation was done either immediately or as a delayed procedure. In group III, resection arthroplasty was done. The infection was successfully treated in 7 of the 14 patients in group I. The results depended on the causative organism. Less satisfactory outcomes were seen in patients infected with Staphylococcus epidermidis. In group II, 4 of 6 patients had successful reimplantation of a prosthesis. In group III, none of the 5 patients had signs of infection at latest follow-up. Resection arthroplasty had a more predictable outcome in medically “frail” patients and in patients with reduced demands for the elbow. More recent reports have found success with a two-stage revision technique of initial resection followed by delayed component replantation. Infection can be eradicated in 72% to 88% of patients with fair to good results. Advancements in design and improvements in cementing techniques should help to minimize loosening. Selection of appropriate patients for elbow implant arthroplasty (who have a low level of activity, such as patients with rheumatoid arthritis) also may help to minimize loosening. Prosthetic designs that allow valgus and varus and rotational motion at the coupling of the semiconstrained devices help to dissipate the forces at the elbow. Symptomatic loosening of an elbow prosthesis can be treated by revision using a different type of prosthesis, removal of the prosthesis creating a resection arthroplasty, revision of the remaining bone to create an interposition arthroplasty, or arthrodesis. Because of scarring, contractures, and poor bone quality, revision surgery for elbow prostheses can be exceedingly difficult. Of particular concern when revising the humeral component is the proximity of the radial nerve. When proximal dissection is warranted, typically to remove a well-fixed humeral stem, we recommend formally identifying and protecting the radial nerve over simple palpation. Various types of bone grafting procedures have been used in revisions for component loosening, including impaction grafting, strut allografts, and allograft-prosthesis constructs. Eight of 12 implants revised with impaction bone grafting were reported to be intact at 6 years in one series and good to excellent results were found in 15 of 16 patients in another. Strut allograft reconstruction improved Mayo Elbow Performance scores in 21 patients, but complications were frequent (36%), and allograft-prosthesis constructs were reported to be successful in relieving pain in approximately 70% of patients, although functional gains were minimal. Graft healing and incorporation occurred in 92% of cases, with a similar complication rate as strut grafting procedures.

Periprosthetic fractures have also been reported after total elbow arthroplasty: humeral component fractures occur in 0.65% of implants and ulnar component fractures in 1.2%. Athwal and Morrey reported 26 elbows that had revision because of component fracture. At 5-year follow-up, the average Mayo Elbow Performance score was 82 but complications were frequent (62%). Dislocation of the prosthetic components, uncoupling of the articulating device, or fracture of a prosthetic component can cause failure of an implant elbow arthroplasty. If the coupling device of a prosthesis fails, it should be revised by replacement of the polyethylene component. Similarly, if a component fractures or dislocates, it should be replaced by revision surgery. Revision surgery requires careful handling of the soft tissues and bone. Gaps in bone may require the use of custom prostheses or allografts to achieve satisfactory results. In the absence of infection, satisfactory results can be achieved in as many as 85% of revisions in patients without documented infection and with “sufficient bone stock” and adequate soft tissues. Revision elbow arthroplasty is a salvage procedure that, when successful, is superior functionally to resection arthroplasty or arthrodesis.

RESECTION ARTHROPLASTY

Resection arthroplasty is rarely indicated. Resection of the elbow joint may cause nearly incapacitating instability, and, if bone resorption occurs at the sites of resection, the instability is worsened. Resection arthroplasty has been used in the treatment of refractory sepsis, elbow ankylosis after sepsis or trauma, and rheumatoid arthritis. Impressive improvement may be seen in some patients when the joint is resected for ankylosis. Currently, the indications for resection arthroplasty include refractory sepsis, either primary infection or after elbow arthroplasty, and salvage of a failed implant elbow arthroplasty. Although disability scores remain high after the procedure, Zarkadas et al. found resection arthroplasty to be a reasonable solution to a persistently infected total elbow replacement.

ELBOW RESECTION ARTHROPLASTY TECHNIQUE 12-8 (CAMPBELL) With the patient supine, make a longitudinal posterior incision curving to the radial side of the olecranon. ■ Dissect the subcutaneous tissues and mobilize skin flaps from the triceps aponeurosis. ■ Elevate and invert a V-shaped tongue or flap of the triceps aponeurosis, leaving the triceps tendon attached distally to the tip of the olecranon (Fig. 12-34A). As in total elbow arthroplasty, a triceps-on approach may also be considered. ■ Split the triceps muscle longitudinally and expose the distal humerus subperiosteally. ■ With a rongeur, remove the distal end of the humerus to form a convex surface when seen from the lateral side. Some stability can be preserved if the lower end of the ■

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Humerus Ulna olecranon with tip removed Olecranon

A

Flap

B

Ulna

C

FIGURE 12-34 Campbell technique for resection arthroplasty. A, Distally based triceps tongue is left attached to olecranon. B, Triceps muscle is interposed between reshaped surfaces. C, Closure of triceps tongue in V-Y position to release posterior contracture. SEE TECHNIQUE 12-8.

humerus is shaped into an inverted V. Remove the articular surface from the semilunar notch of the ulna, forming a concave recess. If this is left with a slight convexity to fit the humeral inverted V, the joint has more mediolateral stability. ■ Resect a small portion of the coronoid process. In total, remove approximately 2 cm of bone from the distal humerus and 1 cm from the articular surface of the olecranon. ■ If the radiocapitellar joint is normal, do not debride it. If the joint is diseased, excise the radial head and reshape the capitellum, leaving the proximal radioulnar joint intact. ■ Attach the triceps muscle to the anterior capsule as an interposition material (Fig. 12-34B) and close the triceps aponeurosis (Fig. 12-34C). ■ If an extension contracture is present before surgery, advance triceps aponeurosis distally to release this contracture and close the wound in a V-Y configuration. ■ Release the tourniquet and obtain hemostasis. ■ Close the remainder of the wound in layers. Leave suction drainage tubes in the depths of the wound as necessary, depending on the amount of bleeding on the muscle surface. ■ Apply a posterior splint or long arm cast.

POSTOPERATIVE CARE.  The elbow is immobilized for approximately 3 weeks. Active range-of-motion exercises are begun and increased as pain and swelling permit.

REFERENCES RECONSTRUCTIVE PROCEDURES OF THE SHOULDER HISTORY, ANATOMY, PROSTHESIS DESIGN Farmer KW, Hammond JW, Queale WS, et al: Shoulder arthroplasty versus hip and knee arthroplasties: a comparison of outcomes, Clin Orthop Relat Res 455:183, 2007. Hendel MD, Bryan JA, Barsoum WK, et al: Comparison of patient-specific instruments with standard surgical instruments in determining glenoid component position: a randomized prospective clinical trial, J Bone Joint Surg 94A:2167, 2012.

Hoenecke HR Jr, Hermida JC, Flores-Hernandez C, D’Lima DD: Accuracy of CT-based measurements of glenoid version for total shoulder arthroplasty, J Shoulder Elbow Surg 19:166, 2010. Hoenecke HR Jr, Tibor LM, Elias DW, et al: A quantitative three-dimensional templating method for shoulder arthroplasty: biomechanical validation in cadavers, J Shoulder Elbow Surg 21:1377, 2012. Iannotti J, Baker J, Rodriguez E, et al: Three-dimensional preoperative planning software and a novel information transfer technique technology improve glenoid component positioning, J Bone Joint Surg 96A:e71, 2014. Iannotti JP, Weiner S, Rodriguez E, et al: Three-dimensional imaging and templating improve glenoid implant positioning, J Bone Joint Surg 97A:651, 2015. Karelse A, Leuridan S, Van Tongel A, et al: A glenoid reaming study: how accurate are current reaming techniques?, J Shoulder Elbow Surg 23:1120, 2014. Kircher J, Wiedemann M, Magosch P, et al: Improved accuracy of glenoid positioning in total shouler arthroplasty with intraoperative navigation: a prospective-randomized clinical study, J Shoulder Elbow Surg 18:515, 2009. Laver L, Garrigues GE: Avoiding superior tilt in reverse shoulder arthroplasty: a review of the literature and technical recommendations, J Shoulder Elbow Surg 23:1582, 2014. Levy JC, Everding NG, Frankle MA, Keppler LJ: Accuracy of patient-specific guided glenoid baseplate positioning for reverse shoulder arthroplasty, J Shoulder Elbow Surg 23:1563, 2014. Massimini DF, Li G, Warner JP: Glenohumeral contact kinematics in patients after total shoulder arthroplasty, J Bone Joint Surg 92A:916, 2010. Nguyen D, Ferreira LM, Brownhill JR, et al: Improved accuracy of computer assisted glenoid implantation in total shoulder arthroplasty: an in-vitro randomized controlled trial, J Shoulder Elbow Surg 18:907, 2009. Scallise JJ, Codsi MJ, Bryan J, et al: The influence of three-dimensional computed tomography images of the shoulder in preoperative planning for total shoulder arthroplasty, J Bone Joint Surg 90A:2438, 2008. Tammachote N, Sperling JW, Berglund LJ, et al: The effect of glenoid component size on the stability of total shoulder arthroplasty, J Shoulder Elbow Surg 16(3 Suppl):S102, 2007. Taunton MJ, McIntosh AL, Sperling JW, Cofield RH: Total shoulder arthroplasty with a metal-backed, bone-ingrowth glenoid component: medium to long-term results, J Bone Joint Surg 90A:2180, 2008. Throckmorton TW, Gulotta LV, Bonnarens FO, et al: Patient-specific targeting guides compared with traditional instrumentation for glenoid component placement in shoulder arthroplasty: a multi-surgeon study in 70 arthritic cadaver specimens, J Shoulder Elbow Surg 24:965, 2015. Throckmorton TW, Zarkadas PC, Sperling JW, Cofield RH: Radiographic stability of ingrowth humeral stems in total shoulder arthroplasty, Clin Orthop Relat Res 468:2122, 2010.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY Venne G, Rasquinha Bj, Pichora D, et al: Comparing conventional and computer-assisted surgery baseplate and screw placement in reverse shoulder arthroplasty, J Shoulder Elbow Surg 24:1112, 2015.

HEMIARTHROPLASTY Adams JE, Sperling JW, Schleck CD, et al: Outcomes of shoulder arthroplasty in Olmstead County, Minnesota: a population-based study, Clin Orthop Relat Res 455:176, 2007. Al-Hadithy N, Domos P, Sewell MD, et al: Cementless surface replacement arthroplasty of the shoulder for osteoarthritis: results of fifty Mark III Copeland prosthesis from an independent center with four-year mean follow-up, J Shoulder Elbow Surg 21:1776, 2012. Bailie DS, Llinas PJ, Ellenbecker TS: Cementless humeral resufacing arthroplasty in active patients less than fifty-five years of age, J Bone Joint Surg 90A:110, 2008. Bonnevialle N, Mansat P, Mansat M, Bonnevialle P: Hemiarthroplasty for osteoarthritis in shoulder with dysplastic morphology, J Shoulder Elbow Surg 20:378, 2011. Buchner M, Eschbach N, Loew M: Comparison of the short-term functional results after surface replacement and total shoulder arthroplasty for osteoarthritis of the shoulder: a matched-pair analysis, Arch Orthop Trauma Surg 128:347, 2008. Duan X, Zhang W, Dong X, et al: Total shoulder arthroplasty versus hemiarthroplasty in patients with shoulder osteoarthritis: a meta-analysis of randomized controlled trials, Semin Arthritis Rheum 43:297, 2013. Elhassan B, Ozbaydar M, Diller D, et al: Soft-tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old, J Bone Joint Surg 91A:419, 2009. Gadea F, Alami G, Pape G, et al: Shoulder hemiarthroplaslty: outcomes and long-term survival analysis according to etiology, Orthop Traumatol Surg Res 98:659, 2012. Goldberg SS, Bell JE, Kim HJ, et al: Hemiarthroplasty for the rotator cuffdeficient shoulder, J Bone Joint Surg 90A:554, 2008. Hammond G, Tibone JE, McGarry MH, et al: Biomechanical comparison of anatomic humeral head resurfacing and hemiarthroplasty in functional glenohumeral positions, J Bone Joint Surg 94A:68, 2012. Hammond LC, Lin EC, Harwood DP, et al: Clinical outcomes of hemiarthroplasty and biological resurfacing in patients aged younger than 50 years, J Shoulder Elbow Surg 22:1345, 2013. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ: Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis: Two to fifteen-year outcomes, J Bone Joint Surg 89A:727, 2007. Krishnan SG, Reineck JR, Nowinski RJ, et al: Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis: Surgical technique, J Bone Joint Surg 90A(Suppl 2 Pt 1):9, 2008. Lebon J, Delclaux S, Bonnevialle N, et al: Stemmed hemiarthroplasty versus resurfacing in primary shoulder osteoarthritis: a single-center retrospective series of 78 patients, Orthop Traumatol Surg Res 100(6 Suppl):S327, 2014. Levine WN, Fischer CR, Nguyen D, et al: Long-term follow-up of shoulder hemiarthroplasty for glenohumeral osteoarthritis, J Bone Joint Surg 94A:e164, 2012. Lynch JR, Franta AK, Montgomery WH Jr, et al: Self-assessed outcome at two to four years after shoulder hemiarthroplasty with concentric glenoid reaming, J Bone Joint Surg 89A:1284, 2007. Mather RC 3rd, Watters TS, Orlando LA, et al: Cost effectiveness analysis of hemiarthroplasty and total shoulder arthroplasty, J Shoulder Elbow Surg 19:325, 2010. Mullett H, Levy O, Rag D, et al: Copeland surface replacement of the shoulder: results of an hydroxyapatite-coated cementless implant in patients over 80 years of age, J Bone Joint Surg 89B:1466, 2007. Nicholson GP, Goldstein JL, Romeo AA, et al: Lateral meniscus allograft biologic glenoid arthroplasty in total shoulder arthroplasty for young shoulders with degenerative joint disease, J Should Elbow Surg 16(5 Suppl):S261, 2007. Pfahler M, Jena F, Neyton LK, et al: Hemiarthroplasty versus total shoulder prosthesis: results of cemented glenoid components, J Shoulder Elbow Surg 15:154, 2006.

Sandow MJ, David H, Bentall SJ: Hemiarthroplasty vs total shoulder replacement for rotator cuff intact osteoarthritis: how do they fare after a decade? J Shoulder Elbow Surg 22:877, 2013. Shrivastava N, Szabo RM: Copeland EAS hemi-resurfacing arthroplasty for rotator cuff tear arthropathy: preliminary results, J Surg Orthop Adv 18:189, 2009. Singh JA, Sperling J, Buchbinder R, McMaken K: Surgery for shoulder osteoarthritis: a Cochrane systematic review, J Rheumatol 38:598, 2011. Themistocleous GS, Zalavras CG, Zachos VC, et al: Biologic resurfacing of the glenoid using a meniscal allograft, Tech Hand Up Extrem Surg 10:145, 2006. Wirth MA: Humeral head arthroplasty and meniscal allograft resurfacing of the glenoid, J Bone Joint Surg 91A:1109, 2009.

TOTAL SHOULDER ARTHROPLASTY Bartelt R, Sperling JW, Schleck DC, Cofield RH: Shoulder arthroplasty in patients aged fifty-five years of younger with osteoarthritis, J Shoulder Elbow Surg 20:123, 2011. Boileau P, Moineau G, Morin-Salvo N, et al: Metal-backed glenoid implant with polyethylene insert is not a viable long-term therapeutic option, J Shoulder Elbow Surg 24:1534, 2015. Cadet ER, Kok P, Greiwe RM, et al: Intermediate and long-term follow-up of total shoulder arthroplasty for the management of postcapsulorrhaphy arthropathy, J Shoulder Elbow Surg 23:1301, 2014. Churchill RS: Stemless shoulder arthroplasty: current status, J Shoulder Elbow Surg 23:1409, 2014. Clitherow HD, Frampton CM, Astley TM: Effect of glenoid cementation on total shoulder arthroplasty for degenerative arthritis of the shoulder: a review of the New Zealand National Joint Registry, J Shoulder Elbow Surg 23:775, 2014. Farng E, Zingmond D, Krenek L, Soohoo NF: Factors predicting complication rates after primary shoulder arthroplasty, J Shoulder Elbow Surg 20:557, 2011. Feeley BT, Fealy S, Dines DM, et al: Hemiarthroplasty and total shoulder arthroplasty for avascular necrosis of the humeral head, J Shoulder Elbow Surg 17:689, 2008. Foruria AM, Sperling JW, Ankem HK, et al: Total shoulder replacement for osteoarthritis in patients 80 years of age and older, J Bone Joint Surg 92B:970, 2010. Gerber C, Lingenfelter EJ, Reischl N, et al: Single-stage bilateral total shoulder arthroplasty: a preliminary study, J Bone Joint Surg 88B:751, 2006. Gerber C, Pennington SD, Yian EH, et al: Lesser tuberosity osteotomy for total shoulder arthroplasty: surgical technique, J Bone Joint Surg 88(Suppl 1 part 1):170, 2006. Griffin JW, Novicoff WM, Browne JA, Brockmeier SF: Morbid obesity in total shoulder arthroplasty: risk, outcomes, and cost analysis, J Shoulder Elbow Surg 23:1444, 2014. Huguet D, DeClercq G, Rio B, et al: Results of a new stemless shoulder prosthesis: radiologic proof of maintained fixation and stability after a minimum of three years’ follow-up, J Shoulder Elbow Surg 19847, 2010. Jacobson JA, Duquin TR, Sanchez-Sotelo J, et al: Anatomic shoulder arthroplasty for treatment of proximal humerus malunions, J Shoulder Elbow Surg 23:1232, 2014. Jolles BM, Grosso P, Bogoch ER: Shoulder arthroplasty for patients with juvenile idiopathic arthritis, J Arthroplasty 22:876, 2007. Keller J, Bak S, Bigliani LU, Levine WN: Glenoid replacement in total shoulder arthroplasty, Orthopedics 29:221, 2006. Krishnan SG, Nowinski RJ, Harrison D, Burkhead WZ: Humeral hemiarthroplasty with biologic resurfacing of the glenoid for glenohumeral arthritis: Two to fifteen-year outcomes, J Bone Joint Surg 89A:727, 2007. Lehmann L, Magosch P, Mauermann E, et al: Total shoulder arthroplasty in dislocation arthropathy, Int Orthop 34:1219, 2010. Matsoukis J, Tabib W, Guiffault P, et al: Primary unconstrained shoulder arthroplasty in patients with a fixed anterior glenohumeral dislocation, J Bone Joint Surg 88A:547, 2006.

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS Nyffeler RW, Meyer D, Sheikh R, et al: The effect of cementing technique on structural fixation of pegged glenoid components in total shoulder arthroplasty, J Shoulder Elbow Surg 15:106, 2006. Ponce BA, Menendez ME, Oladeji LO, Soldado F: Diabetes as a risk factor for poorer early postoperative outcomes after shoulder arthroplasty, J Shoulder Elbow Surg 23:671, 2014. Roche C, Angibaud L, Flurin PH, et al: Glenoid loosening in response to dynamic multi-axis eccentric loading: a comparison between keeled and pegged designs with an equivalent radial mismatch, Bull Hosp Jt Dis 63:88, 2006. Schoch BS, Barlow JD, Schleck C, et al: Shoulder arthroplasty for posttraumatic osteonecrosis of the humeral head, J Shoulder Elbow Surg 2015. [Epub ahead of print]. Schoch B, Schleck C, Cofield RH, Sperling JW: Shoulder arthroplasty in patients younger than 50 years: minimum 20-year follow-up, J Shoulder Elbow Surg 24:705, 2015. Schumann K, Flury MP, Schwyzer HK, et al: Sports activity after anatomic total shoulder arthroplasty, Am J Sports Med 38:2097, 2010. Sperling JW, Cofield RH, Schleck CD, Harmsen WS: Total shoulder arthroplasty versus hemiarthroplasty for rheumatoid arthritis of the shoulder: results of 303 consecutive cases, J Shoulder Elbow Surg 16:683, 2007. Throckmorton TW, Zarkadas PC, Sperling JW, Cofield RH: Radiographic stability of ingrowth humeral stems in total shoulder arthroplasty, Clin Orthop Relat Res 468:2122, 2010. Waterman BR, Dunn JC, Bader J, et al: Thirty-day morbidity and mortality after elective total shoulder arthroplasty: patient-based and surgical risk factors, J Shoulder Elbow Surg 24:24, 2015. Young A, Walch G, Boileau P, et al: A multicentre study of the long-term results of using a flat-back polyethylene glenoid component in shoulder replacement for primary osteoarthritis, J Bone Joint Surg 93B:210, 2011.

REVERSE SHOULDER ARTHROPLASTY Boileau P, Chuinard C, Roussanne Y, et al: Reverse shoulder arthroplasty combined with a modified latissimus dorsi and teres major tendon transfer for shoulder pseudoparalysis associated with dropping arm, Clin Orthop Relat Res 466:584, 2008. Boileau P, Gonzalez JF, Chuinard C, et al: Reverse total shoulder arthroplasty after failed rotator cuff surgery, J Shoulder Elbow Surg 18:600, 2009. Boileau P, Watkinson D, Hatzidakis AM, et al: Neer Award 2005. The Grammont reverse shoulder prosthesis: results in cuff tear arthritis, fracture sequelae, and revision arthroplasty, J Shoulder Elbow Surg 15:527, 2006. Boyle MJ, Youn SM, Frampton CM, Ball CM: Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures, J Shoulder Elbow Surg 22:32, 2013. Bufquin T, Hersan A, Hubert L, Massin P: Reverse shoulder arthroplasty for the treatment of three- and four-part fractures of the proximal humerus in the elderly: a prospective review of 43 cases with a short-term follow-up, J Bone Joint Surg 89B:516, 2007. Chebli C, Huber P, Watling J, et al: Factors affecting fixation of the glenoid component of a reverse total shoulder prosthesis, J Shoulder Elbow Surg 17:323, 2007. Cuff DJ, Pupello DR: Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of fractures in elderly patients, J Bone Joint Surg 95A:2050, 2013. Cuff D, Pupello D, Virani N, et al: Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency, J Bone Joint Surg 90A:1244, 2008. DeWilde L, Walch G: Humeral prosthetic failure of reversed total shoulder arthroplasty: a report of three cases, J Shoulder Elbow Surg 15:260, 2006. Distefano JG, Park AY, Nguyen TQ, et al: Optimal screw placement for base plate fixation in reverse total shoulder arthroplasty, J Shoulder Elbow Surg 20:467, 2011. Drake GN, O’Connor DP, Edwards TB: Indications for reverse total shoulder arthroplasty in rotator cuff disease, Clin Orthop Relat Res 468:1526, 2010. Edwards TB, Williams MD, Labriola JE, et al: Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty, J Shoulder Elbow Surg 18:892, 2009. Ek ET, Neukom L, Catanzaro S, Gerber C: Reverse total shoulder arthroplasty for massive irreparable rotator cuff tears in patients younger than

65 years old: results after five to fifteen years, J Shoulder Elbow Surg 22:1199, 2013. Favre P, Sussmann PS, Gerber C: The effect of component positioning on intrinsic stability of the reverse shoulder arthroplasty, J Shoulder Elbow Surg 19:550, 2010. Ferrell JR, Trinh TQ, Fischer RA: Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: a systematic review, J Orthop Trauma 29:60, 2015. Frankle M, Levy JC, Pupello D, et al: The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: a minimum two-year follow-up study of sixty patients: surgical technique, J Bone Joint Surg 88A:178, 2006. Frankle MA, Teramoto A, Luo ZP, et al: Glenoid morphology in reverse shoulder arthroplasty: classification and surgical implications, J Shoulder Elbow Surg 18:874, 2009. Giuseffi SA, Streubel P, Sperling J, Sanchez-Sotelo J: Short-stem uncemented primary reverse shoulder arthroplasty: clinical and radiological outcomes, Bone Joint J 96-B:526, 2014. Guery J, Favard L, Sirveaux F, et al: Reverse total shoulder arthroplasty: survivorship analysis of eighty replacements followed for five to ten years, J Bone Joint Surg 88A:1742, 2006. Holcomb JO, Hebert DJ, Mighell MA, et al: Reverse shoulder arthroplasty in patients with rheumatoid arthritis, J Shoulder Elbow Surg 19:1076, 2010. Hussey MM, Steen BM, Cusick MC, et al: The effects of glenoid wear patterns on patients with osteoarthritis in total shoulder arthroplasty: an assessment of outcomes and value, J Shoulder Elbow Surg 24:682, 2015. John M, Pap G, Angst F, et al: Short-term results after reverse shoulder arthroplasty (Delta III) in patients with rheumatoid arthritis and irreparable rotator cuff tear, Int Orthop 34:71, 2010. Klika BJ, Wooten CW, Sperling JW, et al: Structural bone grafting for glenoid deficiency in primary total shoulder arthroplasty, J Shoulder Elbow Surg 23:1066, 2014. Lawrence TM, Ahmadi S, Sanchez-Sotelo J, et al: Patient reported activities after reverse shoulder arthroplasty: part II, J Shoulder Elbow Surg 21:1464, 2012. Leung B, Horodyski M, Struk AM, Wright TW: Functional outcome of hemiarthroplasty compared with reverse total shoulder arthroplasty in the treatment of rotator cuff tear arthropathy, J Shoulder Elbow Surg 21:319, 2012. Martin TG, Iannotti JP: Reverse total shoulder arthroplasty for acute fractures and failed management after proximal humeral fractures, Orthop Clin North Am 39:451, 2008. McFarland EG, Sanguanjit P, Tasaki A, et al: The reverse shoulder prosthesis: a review of imaging features and complications, Skeletal Radiol 35:488, 2006. Middernacht B, De Roo PJ, Van Maele G, De Wilde LF: Consequences of scapular anatomy for reversed shoulder arthroplasty, Clin Orthop Relat Res 466:1410, 2008. Mizuno N, Denard PJ, Raiss P, Walch G: Reverse total shoulder arthroplasty for primary glenohumeral osteoarthritis in patients with a biconcave glenoid, J Bone Joint Surg 95A:1297, 2013. Mulieri P, Dunning P, Klein S, et al: Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis, J Bone Joint Surg 92A:2544, 2010. Nolan BM, Ankerson E, Wiater JM: Reverse total shoulder arthroplasty improves function in cuff tear arthropathy, Clin Orthop Relat Res 469:2476–2482, 2011. Parsons BO, Gruson KI, Accousti KJ, et al: Optimal rotation and screw positioning for initial glenosphere baseplate fixation in reverse shoulder arthroplasty, J Shoulder Elbow Surg 18:886, 2009. Roche CP, Diep P, Hamilton MA, et al: Impact of inferior glenoid tilt, humeral retroversion, bone grafting, and design parameters on muscle length and deltoid wrapping in reverse shoulder arthroplasty, Bull Hosp Jt Dis 71:284, 2013. Sabesan V, Callanan M, Ho J, Iannotti JP: Clinical and radiographic outcomes of total shoulder arthroplasty with bone graft for osteoarthritis with severe glenoid bone loss, J Bone Joint Surg 95A:1290, 2013.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY Sabesan V, Callanan M, Sharma V, Iannotti JP: Correction of acquired glenoid bone loss in osteoarthritis with a standard versus an augmented glenoid component, J Shoulder Elbow Surg 23:964, 2014. Sanchez-Sotelo J: Reverse total shoulder arthroplasty, Clin Anat 22:172, 2009. Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V: Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study, J Shoulder Elbow Surg 23:1419, 2014. Stechel A, Fuhrmann U, Irlenbusch L, et al: Reverse shoulder arthroplasty in cuff tear arthritis, fracture sequelae, and revision arthroplasty, Acta Orthop 81:367, 2010. Stephens SP, Paisley KC, Giveans MR, Wirth MA: The effect of proximal humeral bone loss on revision reverse total shoulder arthroplasty, J Shoulder Elbow Surg 24:1519, 2015. Walch G, Boileau P, Noel E: Shoulder arthroplasty: evolving techniques and indications, Joint Bone Spine 77:501, 2010. Wall B, Nové-Josserand L, O’Connor DP, et al: Reverse total shoulder arthroplasty: a review of results according to etiology, J Bone Joint Surg 89A:1476, 2007. Wall B, Walch G: Reverse shoulder arthroplasty for the treatment of proximal humerus fractures, Hand Clin 23:425, 2007. Wang J, Zhu Y, Zhang F, et al: Meta-analysis suggests that reverse shoulder arthroplasty in proximal humerus fractures is a better option than hemiarthroplasty in the elderly, Int Orthop 2015 Jun 24. [Epub ahead of print] Young AA, Smith MM, Bacle G, et al: Early results of reverse shoulder arthroplasty in patients with rheumatoid arthritis, J Bone Joint Surg 93A:1915, 2011. Young SW, Zhu M, Walker CG, Poon PC: Comparison of functional outcomes of reverse shoulder arthroplasty with those of hemiarthroplasty in the treatment of cuff-tear arthropathy: a matched-pair analysis, J Bone Joint Surg 95A:910, 2013.

COMPLICATIONS AND REVISION Ackland DC, Roshan-Zamir S, Richardson M, Pandy MG: Moment arms of the shoulder musculature after reverse total shoulder arthroplasty, J Bone Joint Surg 92A:1221, 2010. Athwal GS, Sperling JW, Rispoli DM, Cofield RH: Periprosthetic humeral fractures during shoulder arthroplasty, J Bone Joint Surg 91A:594, 2009. Bohsali KI, Wirth MA, Rockwood CA Jr: Current concepts review: complications of total shoulder arthroplasty, J Bone Joint Surg 88A:2279, 2006. Boileau P, Melis B, Duperron D, et al: Revision surgery of reverse shoulder arthroplasty, J Shoulder Elbow Surg 22:1359, 2013. Bonnevialle N, Melis B, Neyton L, et al: Aseptic glenoid loosening or failure in total shoulder arthroplasty: revision with glenoid reimplantation, J Shoulder Elbow Surg 22:745, 2013. Buckley T, Miller R, Nicandri G, et al: Analysis of subscapularis integrity and function after lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using ultrasound and validated clinical outcome measures, J Shoulder Elbow Surg 23:1309, 2014. Carpenter S, Pinkas D, Newton MD, et al: Wear rates of retentive versus nonretentive reverse total shoulder arthroplasty liners in an in vitro wear simulation, J Shoulder Elbow Surg 24:1372, 2015. Chin PY, Sperling JW, Cofield RH, et al: Complications of total shoulder arthroplasty: are they fewer or different?, J Shoulder Elbow Surg 15:19, 2006. Chou J, Malak SF, Anderson IA, et al: Biomechanical evaluation of different designs of glenospheres in the SMR reverse total shoulder prosthesis: range of motion and risk of notching, J Shoulder Elbow Surg 18:354, 2009. Clouthier AL, Hetzler MA, Fedorak G, et al: Factors affecting the stability of reverse shoulder arthroplasty: a biomechanical study, J Shoulder Elbow Surg 22:439, 2013. de Wilde LF, Poncet D, Middernacht B, Ekelund A: Prosthetic overhang is the most effective way to prevent scapular conflict in a reverse total shoulder prosthesis, Acta Orthop 81:719, 2010.

Dines JS, Fealy S, Strauss EJ, et al: Outcomes analysis of revision total shoulder replacement, J Bone Joint Surg 88:1494, 2006. Edwards TB, Labriola JE, Stanley RJ, et al: Radiographic comparison of pegged and keeled glenoid components using modern cementing techniques: a prospective randomized study, J Shoulder Elbow Surg 19:251, 2010. Erickson BJ, Frank RM, Harris JD, et al: The influence of humeral head inclination in reverse total shoulder arthroplasty: a systematic review, J Shoulder Elbow Surg 24:988, 2015. Fishman MP, Budge MD, Moravek JE Jr, et al: Biomechanical testing of small versus large lesser tuberosity osteotomies: effect on gap formation and ultimate failure load, J Shoulder Elbow Surg 23:470, 2014. Florschütz AV, Lane PD, Crosby LA: Infection after primary anatomic versus primary reverse total shoulder arthroplasty, J Shoulder Elbow Surg 24:1296, 2015. Foruria AM, Oh LS, Sperling JW, Cofield RH: Anteromedial approach for shoulder arthroplasty: current indications, complications, and results, J Shoulder Elbow Surg 19:734, 2010. Fox TJ, Foruria AM, Klika BJ, et al: Radiographic survival in total shoulder arthroplasty, J Shoulder Elbow Surg 22:1221, 2013. Gerber C, Pennington SD, Yian EH, et al: Lesser tuberosity osteotomy for total shoulder arthroplasty. Surgical technique, J Bone Joint Surg Am 88(Suppl 1 Pt 2):170, 2006. Gillespie R, Lyons R, Lazarus M: Eccentric reaming in total shoulder arthroplasty: a cadaveric study, Orthopedics 32:21, 2009. Gilot G, Alvarez-Pinzon AM, Wright TW, et al: The incidence of radiographic aseptic loosening of the humeral component in reverse total shoulder arthroplasty, J Shoulder Elbow Surg 24:1555, 2015. Giuseffi SA, Wongtriratanachai P, Omae H, et al: Biomechanical comparison of lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty, J Shoulder Elbow Surg 21:1087, 2012. Greiner SH, Back DA, Herrmann S, et al: Degenerative changes of the deltoid muscle have impact on clinical outcome after reversed total shoulder arthroplasty, Arch Orthop Trauma Surg 130:177, 2010. Groh GI, Groh GM: Complication rates, reoperation rates, and the learning curve in reverse shoulder arthroplasty, J Shoulder Elbow Surg 23:388, 2014. Grosso MJ, Frangiamore Sj, Ricchetti ET, et al: Sensitivity of frozen section histology for identifying Propionibacterium acnes infections in revision shoulder arthroplasty, J Bone Joint Surg 96A:442, 2014. Gutiérrez S, Comiskey CA 4th, Luo ZP, et al: Range of impingement-free abduction in adduction deficit after reverse total shoulder arthroplasty: hierarchy of surgical and implant-design-related factors, J Bone Joint Surg 90A:2606, 2008. Gutiérrez S, Keller TS, Levy JC, et al: Hierarchy of stability factors in reverse shoulder arthroplasty, Clin Orthop Relat Res 466:670, 2008. Gutiérrrez S, Levy JC, Frankle MA, et al: Evaluation of abduction range of motion and avoidance of inferior scapular impingement in a reverse shoulder model, J Shoulder Elbow Surg 17:608, 2008. Habermeyer P, Magosch P, Lichtenberg S: Recentering the humeral head for glenoid deficiency in total shoulder arthroplasty, Clin Orthop Relat Res 457:124, 2007. Hattrup SJ: Revision total shoulder arthroplasty for painful humeral head replacement with glenoid arthrosis, J Shoulder Elbow Surg 18:220, 2009. Hoffelner T, Moroder P, Auffarth A, et al: Outcomes after shoulder arthroplasty revision with glenoid reconstruction and bone grafting, Int Orthop 38:775, 2014. Jackson JC, Cil A, Smith J, Steinmann SP: Integrity and function of the subscapularis after total shoulder arthroplasty, J Shoulder Elbow Surg 19:1085, 2010. Kelly JD 2nd, Humphrey CS, Norris TR: Optimizing glenosphere position and fixation in reverse shoulder arthroplasty, part one: the twelve-mm rule, J Shoulder Elbow Surg 17:589, 2008. Kelly JD 2nd, Zhao JX, Hobgood ER, Norris TR: Clinical results of revision shoulder arthroplasty using the reverse prosthesis, J Shoulder Elbow Surg 21:1516, 2012. Kempton LB, Ankerson E, Wiater JM: A complication-based learning curve from 200 reverse shoulder arthroplasties, Clin Orthop Relat Res 469:2496, 2011.

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS Kempton LB, Balasubramaniam M, Ankerson E, Wiater JM: A radiographic analysis of the effects of prosthetic design on scapular notching following reverse total shoulder arthroplasty, J Shoulder Elbow Surg 20:571, 2011. Kepler CK, Nho SJ, Ala OL, et al: Comparison of early and delayed failed total shoulder arthroplasty, Acta Orthop Belg 75:297, 2009. Klein SM, Dunning P, Mulieri P, et al: Effects of acquired glenoid bone defects on surgical technique and clinical outcomes in reverse shoulder arthroplasty, J Bone Joint Surg 92A:1144, 2010. Kowalsky MS, Galatz LM, Shia DS, et al: The relationship between scapular notching and reverse shoulder arthroplasty prosthesis design, J Shoulder Elbow Surg 21:1430, 2012. Lévigne C, Garret J, Boileau P, et al: Scapular notching in reverse shoulder arthroplasty: is it important to avoid it and how?, Clin Orthop Relat Res 469:2512–2520, 2011. Lévigne, Boileau P, Favard L, et al: Scapular notching in reverse shoulder arthroplasty, J Shoulder Elbow Surg 17:925, 2008. Levy JC, Triplet J, Everding N: Use of a functional antibiotic spacer in treating infected shoulder arthroplasty, Orthopedics 38:e512, 2015. Melis B, Bonnevialle N, Neyton L, et al: Glenoid loosening and failure in anatomical total shoulder arthroplasty: is revision with a reverse shoulder arthroplasty a reliable option? J Shoulder Elbow Surg 21:342, 2012. Middernacht B, De Wilde L, Molé D, et al: Glenosphere disengagement: a potentially serious default in reverse shoulder surgery, Clin Orthop Relat Res 466:892, 2008. Muh Sj, Streit JJ, Lenarz CJ, et al: Resection arthroplasty for failed shoulder arthroplasty, J Shoulder Elbow Surg 22:247, 2013. Nam D, Kepler CK, Neviaser AS, et al: Reverse total shoulder arthroplasty: current concepts, results, and wear analysis, J Bone Joint Surg 92A(Suppl 2):23, 2010. Nam D, Kepler CK, Nho SJ, et al: Observations on retrieved humeral polyethylene components from reverse total shoulder arthroplasty, J Shoulder Elbow Surg 19:1003, 2010. Nho SJ, Nam D, Ala OL, et al: Observations on retrieved glenoid components from total shoulder arthroplasty, J Shoulder Elbow Surg 18:371, 2009. Nicholson GP, Strauss EJ, Sherman SL: Scapular notching: recognition and strategies to minimize clinical impact, Clin Orthop Relat Res 469:2521– 2530, 2011. Nowark DD, Gardner TR, Bigliani LU, et al: Interobserver and intraobserver reliability of the Walch classification in primary glenohumeral arthritis, J Shoulder Elbow Surg 19:180, 2010. Nuttall D, Haines JF, Trail II: A study of the micromovement of pegged and keeled glenoid components using radiostereometric analysis, J Shoulder Elbow Surg 16(Suppl 3):S65, 2007. Nyffeler RW, Skeikh R, Atkinson TS, et al: Effects of glenoid component version on humeral head displacement and joint reaction forces: an experimental study, J Shoulder Elbow Surg 15:625, 2006. Otto RJ, Virani NA, Levy JC, et al: Scapular fractures after reverse shoulder arthroplasty: evaluation of risk factors and the reliability of a proposed classification, J Shoulder Elbow Surg 22:1514, 2013. Paisley KC, Kraeutler MJ, Lazarus MD, et al: Relationship of scapular neck length to scapular notching after reverse total shoulder arthroplasty by use of plain radiographs, J Shoulder Elbow Surg 23:882, 2014. Papadonikolakis A, Neradilek MB, Matsen FA 3rd: Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012, J Bone Joint Surg 95A:2205, 2013. Pottinger P, Butler-Wu S, Neradilek MB, et al: Prognostic factors for bacterial cultures positive for Propionibacterium acnes and other organisms in a large series of revision shoulder arthroplasties performed for stiffness, pain, or loosening, J Bone Joint Surg 94A:2075, 2012. Rahme H, Mattson P, Wikblad L, et al: Stability of cemented in-line pegged glenoid compared with keeled glenoid components in total shoulder arthroplasty, J Bone Joint Surg 91A:1965, 2009. Raiss P, Edwards TB, Deutsch A, et al: Radiographic changes around humeral components in shoulder arthroplasty, J Bone Joint Surg 96A:e54, 2014.

Sahota S, Sperling JW, Cofield Rh: Humeral windows and longitudinal splits for component removal in revision shoulder arthroplasty, J Shoulder Elbow Surg 23:1485, 2014. Saltzman BM, Chalmers PN, Gupta AK, et al: Complication rates comparing primary with revision reverse total shoulder arthroplasty, J Shoulder Elbow Surg 23:1647, 2014. Sassoon AA, Rhee PC, Schleck CD, et al: Revision total shoulder arthroplasty for painful glenoid arthrosis after humeral head replacement: the nontraumatic shoulder, J Shoulder Elbow Surg 21:1484, 2012. Scalise JJ, Ciccone J, Iannotti JP: Clinical, radiographic, and ultrasonographic comparison of subscapularis tenotomy and lesser tuberosity osteotomy for total shoulder arthroplasty, J Bone Joint Surg 92A:1627, 2010. Schmidt CC, Jarrett CD, Brown BT, et al: Effect of lesser tuberosity osteotomy size and repair construct during total shoulder arthroplasty, J Shoulder Elbow Surg 23:117, 2014. Seebauer L: Total reverse shoulder arthroplasty: European lessons and future trends, Am J Orthop 36(12 Suppl 1):22, 2007. Shi LL, Jiang JJ, Ek ET, Higgins LD: Failure of the lesser tuberosity osteotomy after total shoulder arthroplasty, J Shoulder Elbow Surg 24:203–209, 2015. Simovitch RW, Helmy N, Zumstein MA, Gerber C: Impact of fatty infiltration of the teres minor muscle on the outcome of reverse total shoulder arthroplasty, J Bone Joint Surg 89A:934, 2007. Simovitch RW, Zumstein MA, Lohri E, et al: Predictors of scapular notching in patients managed with the Delta III reverse total shoulder replacement, J Bone Joint Surg 89A:588, 2007. Throckmorton TW, Zarkadas PC, Sperling JW, Cofield RH: Pegged versus keeled glenoid components in total shoulder arthroplasty, J Shoulder Elbow Surg 19:726, 2010. Throckmorton TW, Zarkadas PC, Sperling JW, Cofield RH: Radiographic stability of ingrowth humeral stems in total shoulder arthroplasty, Clin Orthop Relat Res 468:2122, 2010. Trappey GJ 4th, O’Connor DP, Edwards TB: What are the instability and infection rates after reverse shoulder arthroplasty? Clin Orthop Relat Res 469:2505, 2011. Verhelst L, Stuyck J, Bellemans J, Debeer P: Resection arthroplasty of the shoulder as a salvage procedure for deep shoulder infection: does the use of a cement spacer improve outcome? J Shoulder Elbow Surg 20:1224, 2011. von Eisenhart-Rothe R, Müller-Gerbl M, Wiedermann E, et al: Functional malcentering of the humeral head and asymmetric long-term stress on the glenoid: potential reasons for glenoid loosening in total shoulder arthroplasty, J Shoulder Elbow Surg 17:695, 2008. Young AA, Walch G, Pape G, et al: Secondary rotator cuff dysfunction following total shoulder arthroplasty for primary glenohumeral osteoarthritis: results of a multicenter study with more than five years of follow-up, J Bone Joint Surg 94A:685, 2012.

RECONSTRUCTIVE PROCEDURES OF THE ELBOW IMPLANT ARTHROPLASTY Aldridge JM III, Lightdale NR, Mallon WJ, et al: Total elbow arthroplasty with the Coonrad/Coonrad-Morrey prosthesis: a 10- to 31-year survival analysis, J Bone Joint Surg 88B:509, 2006. Athwal GS, Frank SG, Frewal R, et al: Determination of correct implant size in radial head arthroplasty to avoid overlengthening: surgical technique, J Bone Joint Surg 92A(Suppl 1 Pt 2):250, 2010. Athwal GS, Morrey BF: Revision total elbow arthroplasty for prosthetic fractures, J Bone Joint Surg 88A:2017, 2006. Barlow JD, Morrey BF, O’Driscoll SW, et al: Activities after total elbow arthroplasty, J Shoulder Elbow Surg 22:787, 2013. Barthel PY, Mansat P, Sirveaux F, et al: Is total elbow arthroplasty indicated in the treatment of traumatic sequelae? 19 cases of Coonrad-Morrey(®) reviewed at a mean follow-up of 5.2 years, Orthop Traumatol Surg Res 100:113, 2014. Bennett JB, Mehlhoff TL: Total elbow arthroplasty: surgical technique, J Hand Surg Am 34:933, 2009. Brownhill JR, Pollock JW, Ferreira LM, et al: The effect of implant malalignment on joint loading in total elbow arthroplasty: an in vitro study, J Shoulder Elbow Surg 21:1032, 2012.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY Calfee R, Madom I, Weiss APC: Radial head arthroplasty, J Hand Surg 31A:314, 2006. Celli A, Morrey BF: Total elbow arthroplasty in patients forty years of age or less, J Bone Joint Surg 91A:1414, 2009. Chapman CB, Su BW, Sinicropi SM, et al: Vitallium radial head prosthesis for acute and chronic elbow fractures and fracture-dislocations involving the radial head, J Shoulder Elbow Surg 15:463, 2006. Cheung EV, Adams RA, Morrey BF: Reimplantation of a total elbow prosthesis following resection arthroplasty for infection, J Bone Joint Surg 90A:589, 2008. Cohn M, Glait SA, Sapienza A, Kwon YW: Radiocapitellar joint contact pressures following radial head arthroplasty, J Hand Surg Am 39:1566, 2014. Dachs RP, Fleming MA, Chivers DA, et al: Total elbow arthroplasty: outcomes after triceps-detaching and triceps-sparing approaches, J Shoulder Elbow Surg 24:339, 2015. Day JS, Baxter RM, Ramsey ML, et al: Characterization of wear debris in total elbow arthroplasty, J Shoulder Elbow Surg 22:924, 2013. Demiralp B, Komurcu M, Ozturk C, et al: Total elbow arthroplasty in patients who have elbow fractures caused by gunshot injuries: 8- to 12-year follow-up study, Arch Orthop Trauma Surg 129:17, 2008. Doornberg JN, Linzel DS, Zurakowski D, et al: Reference points for radial head prosthesis size, J Hand Surg 31A:53, 2006. Dotzis A, Cochu G, Mabit C, et al: Comminuted fractures of the radial head treated by the Judet floating radial head prosthesis, J Bone Joint Surg 88B:760, 2006. Flinkkilä T, Kaisto T, Sirniö K, et al: Short- to mid-term results of metallic press-fit radial head arthroplasty in unstable injuries of the elbow, J Bone Joint Surg 94B:805, 2012. Frank SG, Grewal R, Johnson J, et al: Determination of correct implant size in radial head arthroplasty to avoid overlengthening, J Bone Joint Surg 91A:1738, 2009. Gille J, Ince A, González O, et al: Single-stage revision of peri-prosthetic infection following total elbow replacement, J Bone Joint Surg 88B:1341, 2006. Goldberg SH, Urban RM, Jacobs JJ, et al: Modes of wear after semiconstrained total elbow arthroplasty, J Bone Joint Surg 90A:609, 2008. Grewal R, MacDermid JC, Faber KJ, et al: Comminuted radial head fractures treated with a modular metallic radial head arthroplasty: study of outcomes, J Bone Joint Surg 88A:2192, 2006. Jenkins PJ, Watts AC, Norwood T, et al: Total elbow replacement:outcome of 1,146 arthroplasties from the Scottish Arthroplasty Project, Acta Orthop 84:119, 2013. Jensen CH, Jacobsen S, Ratchke M, et al: The GSB III elbow prosthesis in rheumatoid arthritis: a 2- to 9-year follow-up, Acta Orthop 77:143, 2006. Jeon JH, Morrey BF, Anakwenze OA, Tran NV: Incidence and implications of early postoperative wound complications after total elbow arthroplasty, J Shoulder Elbow Surg 20:857, 2011. Jeon JH, Morrey BF, Sanchez-Sotelo J: Ulnar component surface finish influenced the outcome of primary Coonrad-Morrey total elbow arthroplasty, J Shoulder Elbow Surg 21:1229, 2012. Lanting BA, Ferreira LM, Johnson JA, et al: Radial head implant diameter: a biomechanical assessment of the forgotten dimension, Clin Biomech (Bristol, Avon) 30:444, 2015. Larson AN, Adams RA, Morrey BF: Revision interposition arthroplasty of the elbow, J Bone Joint Surg 92B:1273, 2010. Larson AN, Morrey BF: Interposition arthroplasty with an Achilles tendon allograft as a salvage procedure for the elbow, J Bone Joint Surg 90A:2714, 2008. Li N, Chen S: Open reduction and internal-fixation versus radial head replacement in treatment of Mason type III radial head fractures, Eur J Orthop Surg Traumatol 24:851, 2014. Mansat P, Bonnevialle N, Rongieres M, et al: Experience with the Coonrad-Morrey total elbow arthroplasty: 78 consecutive total elbow arthroplasties reviewed with an average 5 years of follow-up, J Shoulder Elbow Surg 22:1461, 2013. Marra G, Morrey BF, Gallay SH, et al: Fracture and nonunion of the olecranon in total elbow arthroplasty, J Shoulder Elbow Surg 15:486, 2006.

McKee MD, Veillette CJ, Hall JA, et al: A multicenter, prospective, randomized, controlled trial of open reduction-internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients, J Shoulder Elbow Surg 18:3, 2009. Moon JG, Hong JH, Bither N, Shon WY: Can ulnar variance be used to detect overstuffing after radial head arthroplasty?, Clin Orthop Relat Res 472:727, 2014. Morrey BF, Sanchez-Sotelo J: Approaches for elbow arthroplasty: how to handle the triceps, J Shoulder Elbow Surg 20(Suppl 2):S90, 2011. Morrey ME, Sanchez-Sotelo J, Abdel MP, Morrey BF: Allograftprosthetic composite reconstruction for massive bone loss including catastrophic failure in total elbow arthroplasty, J Bone Joint Surg 95A:1117, 2013. Morrey BF, Schneeberger AG: Total elbow arthroplasty for posttraumatic arthrosis, Instr Course Lect 58:495, 2009. Mukka S, Berg G, Hassany HR, et al: Semiconstrained total elbow arthroplasty for rheumatoid arthritis patients: clinical and radiological results of 1-8 years follow-up, Arch Orthop Trauma Surg 135:595, 2015. Park SE, Kim JY, Cho SW, et al: Complications and revision rate compared by type of total elbow arthroplasty, J Shoulder Elbow Surg 22:1121, 2013. Peach CA, Nicoletti S, Lawrence TM, Stanley D: Two-stage revision for the treatment of the infected total elbow arthroplasty, Bone Joint J 95-B:1681, 2013. Plaschke HC, Thillemann TM, Brorson S, Olsen BS: Implant survival after total elbow arthroplasty: a retrospective study of 324 procedures performed from 1980 to 2008, J Shoulder Elbow Surg 23:829, 2014. Puskas GJ, Morrey BF, Sanchez-Sotelo J: Aseptic loosening rate of the humeral stem in the Coonrad-Morrey total elbow arthroplasty. Does size matter? J Shoulder Elbow Surg 23:76, 2014. Qureshi F, Draviaraj KP, Stanley D: The Kudo 5 total elbow replacement in the treatment of the rheumatoid elbow: results at a minimum of ten years, J Bone Joint Surg 92B:1416, 2010. Rhee YG, Cho NS, Parke CS: Impaction grafting in revision total elbow arthroplasty due to aseptic loosening and bone loss, J Bone Joint Surg 95A:e741, 2013. Sanchez-Sotelo J, Morrey BF: Total elbow arthroplasty, J Am Acad Orthop Surg 19:121, 2011. Schneeberger AG, Meyer DC, Yian EH: Coonrad-Morrey total elbow replacement for primary and revision surgery: a 2- to 7.5-year follow-up study, J Shoulder Elbow Surg 16(Suppl 3):S47, 2007. Schöni M, Drerup S, Angst F, et al: Long-term survival of GSB III elbow prostheses and risk factors for revisions, Arch Orthop Trauma Surg 133:1415, 2013. Spormann C, Achermann Y, Simmen BR, et al: Treatment strategies for periprosthetic infections after primary elbow arthroplasty, J Shoulder Elbow Surg 21:992, 2012. Studer A, Athwal GS, McDermid JC, et al: The lateral para-olecranon approach for total elbow arthroplasty, J Hand Surg Am 38:2219, 2013. Thillemann TM, Olsen BS, Johannsen HV, et al: Long-term results with the Kudo type 3 total elbow arthroplasty, J Shoulder Elbow Surg 15:485, 2006. Throckmorton TW, Zarkadas PC, Sanchez-Sotelo J, Morrey BF: Radial nerve palsy after humeral revision in total elbow arthroplasty, J Shoulder Elbow Surg 20:199, 2011. Throckmorton TW, Zarkadas P, Sanchez-Sotelo J, Morrey B: Failure patterns after linked semiconstrained total elbow arthroplasty for posttraumatic arthritis, J Bone Joint Surg 92A:1432, 2010. Wagener ML, de Vos M, Hannink G, et al: Mid-term clinical results of a modern convertible total elbow arthroplasty, Bone Joint J 97-B:681, 2015.

RESECTION ARTHROPLASTY Chauhan A, Palmer BA, Baratz ME: Arthroscopically assisted elbow interposition arthroplasty without hinged external fixation: surgical technique and patient outcomes, J Shoulder Elbow Surg 24:947, 2015. Cheung EV, Adams RA, Morrey BF: Reimplantation of a total elbow prosthesis following resection arthroplasty for infection, J Bone Joint Surg 90A:589, 2008.

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PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS Iftimie PP, Calmet Garcia J, de Loyola Garcia Forcada I, et al: Resection arthroplasty for radial head fractures: long-term follow-up, J Shoulder Elbow Surg 20:45, 2011. Larson AN, Adams RA, Morrey BF: Revision interposition arthroplasty of the elbow, J Bone Joint Surg 92B:1273, 2010. Rhee YG, Cho NS, Park JG, Song JH: Resection arthroplasty for periprosthetic infection after total elbow arthroplasty, J Shoulder Elbow Surg 25:105, 2016. Yalcinkaya M, Bagatur AE, Erdogan S, Zorer G: Resection arthroplasty for Mason type III radial head fractures yield good clinical but poor radiological results in the long term, Orthopedics 36:e1358, 2013.

Zarkadas PC, Cass B, Throckmorton T, et al: Long-term outcome of resection arthroplasty for the failed total elbow arthroplasty, J Bone Joint Surg Am 92:2576, 2010.

The complete list of references is available online at expertconsult .inkling.com.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY 622.e1

SUPPLEMENTAL REFERENCES RECONSTRUCTIVE PROCEDURES OF THE SHOULDER HISTORY, ANATOMY, PROSTHESIS DESIGN Albee FH: Restoration of shoulder function in cases of loss of head and upper portion of humerus, Surg Gynecol Obstet 32:1, 1921. Boileau P, Walch G: The three-dimensional geometry of the proximal humerus: implications for surgical technique and prosthetic design, J Bone Joint Surg 79B:857, 1997. Churchill RS, Brems JJ: Kotschi H: Glenoid size, inclination, and version: an anatomic study, J Shoulder Elbow Surg 10:327, 2001. Fukuda K, Chen CM, Cofield RH, et al: Biomechanical analysis of stability and fixation strength of total shoulder prostheses, Orthopedics 11:141, 1988. Gartsman GM, Russell JA, Gaenslen E: Modular shoulder arthroplasty, J Shoulder Elbow Surg 6:333, 1997. Gristina AC, Webb LX: Proximal humeral and monospherical glenoid replacement: surgical technique, Rutherford, NJ, 1982, Howmedica. Gross RM: The history of total shoulder arthroplasty. In Crosby LA, editor: Total shoulder arthroplasty, Rosemont, IL, 2000, American Academy of Orthopaedic Surgeons. Harris TE, Jobe CM, Dai QG: Fixation of proximal humeral prostheses and rotational micromotion, J Shoulder Elbow Surg 9:205, 2000. Hopkins AR, Hansen UN, Amis AA, Emery R: The effects of glenoid component alignment variations on cement mantle stresses in total shoulder arthroplasty, J Shoulder Elbow Surg 13:668, 2004. Jobe CM, Iannotti JP: Limits imposed on glenohumeral motion by joint geometry, J Shoulder Elbow Surg 4:281, 1995. Jones L: Reconstructive operation for nonreducible fractures of the head of the humerus, Ann Surg 97:217, 1933. Kronberg M, Broström LA, Soderlund V: Retroversion of the humeral head in the normal shoulder and its relationship to the normal range of motion, Clin Orthop Relat Res 253:113, 1990. Lacroix D, Murphy LA, Prendergast PJ: Three-dimensional finite element analysis of glenoid replacement prostheses: a comparison of keeled and pegged anchorage systems, J Biomech Eng 122:430, 2000. Lazarus MD, Jensen KL, Southworth C, Matsen FA: The radiographic evaluation of keeled and pegged glenoid component insertion, J Bone Joint Surg 84A:1174, 2002. Lettin AWF, Copeland SA, Scales JT: The Stanmore total shoulder replacement, J Bone Joint Surg 64B:47, 1982. Levy O, Copeland SA: Cementless surface replacement arthroplasty of the shoulder: 5- to 10-year results with the Copeland Mark 2 prosthesis, J Bone Joint Surg 83B:213, 2001. Martin SD, Zurakowski D, Thornhill TS: Uncemented glenoid component in total shoulder arthroplasty. Survivorship and outcomes, J Bone Joint Surg Am 87:1284, 2005. Murphy LA, Prendergast PJ, Resch H: Structural analysis of an offset-keel design glenoid component compared with a center-keel design, J Shoulder Elbow Surg 10:568, 2001. Neer CS II, Watson KC, Stanton FJ: Recent experience in total shoulder replacement, J Bone Joint Surg 64A:319, 1982. Pearl ML, Volk AG: Coronal plane geometry of the proximal humerus relevant to prosthetic arthroplasty, J Shoulder Elbow Surg 5:320, 1996. Robertson DD, Yuan J, Bigliani LU, et al: Three-dimensional analysis of the proximal part of the humerus: relevance to arthroplasty, J Bone Joint Surg 82A:1594, 2000. Rockwood C, Jenson KL, Wirth MA: Total shoulder arthroplasty vs. hemiarthroplasty in patients with osteoarthritis, Orthop Trans 19:821, 1995-1996. Soslowsky LJ, Malicky DM, Blasier RB: Active and passive factors in inferior glenohumeral stabilization: a biomechanical model, J Shoulder Elbow Surg 6:371, 1997. Stone KD, Grabowski JJ, Cofield RH, et al: Stress analyses of glenoid components in total shoulder arthroplasty, J Shoulder Elbow Surg 8:151, 1999. Walch G, Boileau P: Prosthetic adaptability: a new concept for shoulder arthroplasty, J Shoulder Elbow Surg 8:443, 1999.

HEMIARTHROPLASTY Alund M, Hoe-Hansen C, Tillander B, et al: Outcome after cup hemiarthroplasty in the rheumatoid shoulder: a retrospective evaluation of 39 patients followed for 2 to 6 years, Acta Orthop Scand 71:180, 2000. Arntz CT, Jackins S, Matsen FA 3rd: Prosthetic replacement of the shoulder for the treatment of defects in the rotator cuff and the surface of the glenohumeral joint, J Bone Joint Surg 75A:485, 1993. Baumgarten KM, Lashgari CJ, Yamaguchi K: Glenoid resurfacing in shoulder arthroplasty: indications and contraindications, Instr Course Lect 53:3, 2004. Bigliani LU, Bauer GS, Murthi AM: Humeral head replacement: techniques and soft tissue preparation, Instr Course Lect 52:11, 2002. Bishop JY, Flatow EL: Humeral head replacement versus total shoulder arthroplasty: clinical outcomes—a review, J Shoulder Elbow Surg 14(1 Suppl S):141S, 2005. Boyd AD, Thomas WH, Scott RD, et al: Total shoulder arthroplasty versus hemiarthroplasty, J Arthroplasty 5:329, 1990. Bryant D, Litchfield R, Sandow M, et al: A comparison of pain, strength, range of motion, and functional outcomes after hemiarthroplasty and total shoulder arthroplasty in patients with osteoarthritis of the shoulder: a systematic review and meta-analysis, J Bone Joint Surg 87A:1947, 2005. Burkhead WZ Jr, Hutton KS: Biologic resurfacing of the glenoid with hemiarthroplasty of the shoulder, J Shoulder Elbow Surg 4:263, 1995. Edwards TB, Kadakia NR, Boulahia A, et al: A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study, J Shoulder Elbow Surg 12:207, 2003. Fama G, Edwards TB, Boulahia A, et al: The role of concomitant biceps tenodesis in shoulder arthroplasty for primary osteoarthritis: results of a multicentric study, Orthopedics 27:401, 2004. Field LD, Dines DM, Zabinski SJ, et al: Hemiarthroplasty of the shoulder for rotator cuff arthropathy, J Shoulder Elbow Surg 6:18, 1997. Levy O, Copeland SA: Cementless surface replacement arthroplasty (Copeland CSRA) for osteoarthritis of the shoulder, J Shoulder Elbow Surg 13:266, 2004. Levy O, Funk L, Sforza G, Copeland SA: Copeland surface replacement arthroplasty of the shoulder in rheumatoid arthritis, J Bone Joint Surg Am 86:512, 2004. Lo IK, Litchfield RB, Griffin S, et al: Quality-of-life outcome following hemiarthroplasty or total shoulder arthroplasty in patients with osteoarthritis: a prospective, randomized trial, J Bone Joint Surg 87A:2178, 2005. Neer CS II: Articular replacement for the humeral head, J Bone Joint Surg 37A:215, 1955. Neer CS II: Prosthetic replacement of the humeral head: indications and operative technique, Surg Clin North Am 43:1581, 1963. Neer CS II: Shoulder prosthetics (indications, hemi vs TSA, outcome, factors affecting outcome). Paper presced at the AAOS annual meeting, Kiawah Island, SC, 1998. Neer CS II, Craig EV, Fukuda H: Cuff-tear arthropathy, J Bone Joint Surg 65A:1232, 1983. Parsons IM IV, Millett PJ, Warner JJ: Glenoid wear after shoulder hemiarthroplasty: quantitative radiographic analysis, Clin Orthop Relat Res 421:120, 2004. Sanchez-Sotelo J, Cofield RH, Rowland CM: Shoulder hemiarthroplasty for glenohumeral arthritis associated with severe rotator cuff deficiency, J Bone Joint Surg 83A:2001, 1814. Smith KL, Matsen FA III: Total shoulder arthroplasty versus hemiarthroplasty: current trends, Orthop Clin North Am 29:491, 1998. Sperling JW, Cofield RH, Rowland CM: Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less: long-term results, J Bone Joint Surg 80A:464, 1998. Sperling JW, Cofield RH, Rowland CM: Minimum fifteen-year follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger, J Shoulder Elbow Surg 13:604, 2004. Williams GR Jr, Rockwood CA Jr: Hemiarthroplasty in rotator cuff-deficient shoulders, J Shoulder Elbow Surg 5:362, 1996. Zuckerman JD, Scott AJ, Gallagher MA: Hemiarthroplasty for cuff tear arthropathy, J Shoulder Elbow Surg 9:169, 2000.

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622.e2 PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS TOTAL SHOULDER ARTHROPLASTY Antuna SA, Sperling JW, Cofield RH, Rowland CM: Glenoid revision surgery after total shoulder arthroplasty, J Shoulder Elbow Surg 10:217, 2001. Arroyo JS: Surgical technique and results. In Crosby LA, editor: Total shoulder arthroplasty, Rosemont, IL, 2000, American Academy of Orthopaedic Surgeons. Barrett WP, Thornhill TS, Thomas WH, et al: Nonconstrained total shoulder arthroplasty in patients with polyarticular rheumatoid arthritis, J Arthroplasty 4:91, 1989. Baumgarten KM, Lashgari CJ, Yamaguchi K: Glenoid resurfacing in shoulder arthroplasty: indications and contraindications, Instr Course Lect 53:3, 2004. Bell RH, Noble JS: The management of significant glenoid deficiency in total shoulder arthroplasty, J Shoulder Elbow Surg 9:248, 2000. Boardman ND III, Cofield RH, Bengtson KA, et al: Rehabilitation after total shoulder arthroplasty, J Arthroplasty 16:483, 2001. Boileau P, Avidor C, Krishnan SG, et al: Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a prospective, double-blind, randomized study, J Shoulder Elbow Surg 11:351, 2002. Brems JJ: Rehabilitation following total shoulder arthroplasty, Clin Orthop Relat Res 307:70, 1994. Brenner BC, Ferlic DC, Clayton ML, et al: Survivorship of unconstrained total shoulder arthroplasty, J Bone Joint Surg 71A:1289, 1989. Brown DD, Friedman RJ: Postoperative rehabilitation following total shoulder arthroplasty, Orthop Clin North Am 29:535, 1998. Burroughs PL, Gearen PF, Petty WR, et al: Shoulder arthroplasty in the young patient, J Arthroplasty 18:792, 2003. Cameron B, Galatz L, Williams GR Jr: Factors affecting the outcome of total shoulder arthroplasty, Am J Orthop 30:613, 2001. Cofield RH: Total shoulder arthroplasty with the Neer prosthesis, J Bone Joint Surg 66A:899, 1984. Cofield RH: Uncemented total shoulder arthroplasty, Clin Orthop Relat Res 307:86, 1994. Cofield RH: Total shoulder replacement: managing bone deficiencies. In Craig EV, editor: Master techniques in orthopaedic surgery: the shoulder, Philadelphia, 1995, Lippincott. Collins DN, Harryman DT 2nd, Wirth MA: Shoulder arthroplasty for the treatment of inflammatory arthritis, J Bone Joint Surg Am 86:2489, 2004. Collins D, Tencer A, Sidles J, Matsen F: Edge displacement and deformation of glenoid components in response to eccentric loading: the effect of preparation of the glenoid bone, J Bone Joint Surg 74A:501, 1992. Craig EV: Total shoulder replacement. In Chapman M, editor: Operative orthopaedics, ed 2, Philadelphia, 1993, Lippincott. Cruess RL: Steroid-induced osteonecrosis of the head of the humerus: natural history and management, J Bone Joint Surg 58B:313, 1976. Cushner MA, Friedman RJ: Osteonecrosis of the humeral head, J Am Acad Orthop Surg 5:339, 1997. Deshmukh AV, Koris M, Zrakowski D, Thornhill TS: Total shoulder arthroplasty: long-term survivorship, functional outcome, and quality of life, J Shoulder Elbow Surg 14:471, 2005. Dutta AK, Matthys G, Burkhead WZ: Glenoid resurfacing in shoulder arthroplasty, Instr Course Lect 52:29, 2002. Fenlin JM Jr, Frieman BG: Indications, technique, and results of total shoulder arthroplasty in osteoarthritis, Orthop Clin North Am 29:423, 1998. Figgie HE III, Inglis AE, Goldberg VM, et al: An analysis of factors affecting the long-term results of total shoulder arthroplasty in inflammatory arthritis, J Arthroplasty 3:123, 1988. Flatow EL, Bigliani LU: Tips of the trade: locating and protecting the axillary nerve in shoulder surgery: the tug test, Orthop Rev 21:503, 1992. Friedman RJ, Ewald F: Arthroplasty of the ipsilateral shoulder and elbow in patients who have rheumatoid arthritis, J Bone Joint Surg 69A:661, 1988. Friedman RJ, Thornhill TS, Thomas WH, et al: Non-constrained total shoulder replacement in patients who have rheumatoid arthritis and class IV function, J Bone Joint Surg 71A:494, 1989. Gagey O, Spraut JM, Vinh TS: Posterolateral approach of the shoulder: assessment of 50 cases, J Shoulder Elbow Surg 10:47, 2001.

Gartsman GM, Elkousy HA, Warnock KM, et al: Radiographic comparison of pegged and keeled glenoid components, J Shoulder Elbow Surg 14:252, 2005. Gartsman GM, Roddey TS, Hammerman SM: Shoulder arthroplasty with or without resurfacing of the glenoid in patients who have osteoarthritis, J Bone Joint Surg 82A:26, 2000. Gerber A, Ghalambor N, Warner JJ: Instability of shoulder arthroplasty: balancing mobility and stability, Orthop Clin North Am 32:661, 2001. Gill DRJ, Cofield RH, Morrey BF: Ipsilateral total shoulder and elbow arthroplasties in patients who have rheumatoid arthritis, J Bone Joint Surg 81A:1128, 1999. Green A, Norris TR: Shoulder arthroplasty for advanced glenohumeral arthritis after anterior instability repair, J Shoulder Elbow Surg 10:539, 2001. Hattrup SJ, Cofield RH: Osteonecrosis of the humeral head: results of replacement, J Shoulder Elbow Surg 9:177, 2000. Hayes PR, Flatow EL: Total shoulder arthroplasty in the young patient, Instr Course Lect 50:73, 2000. Hill JM: Indications. In Crosby LA, editor: Total shoulder arthroplasty, Rosemont, IL, 2000, American Academy of Orthopaedic Surgeons. Hill JM, Norris TR: Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid, J Bone Joint Surg 83A:877, 2001. Iannotti JP, Norris TR: Influence of preoperative factors on outcome of shoulder arthroplasty for glenohumeral osteoarthritis, J Bone Joint Surg 85A:251, 2003. Iannotti JP, Williams GR: Total shoulder arthroplasty: factors influencing prosthetic design, Orthop Clin North Am 29:377, 1998. Ibarra C, Craig EV: Soft-tissue balancing in total shoulder arthroplasty, Orthop Clin North Am 29:415, 1998. Ibarra C, Dines DM, McLaughlin JA: Glenoid replacement in total shoulder arthroplasty, Orthop Clin North Am 29:403, 1998. Inglis AE, Inglis AE Jr: Ipsilateral total shoulder arthroplasty and total elbow replacement arthroplasty: a caveat, J Arthroplasty 15:123, 2000. Kelly JD Jr, Norris TR: Decision making in glenohumeral arthroplasty, J Arthroplasty 18:75, 2003. Kocialkowski A, Wallace WA: One-stage arthroplasty of the ipsilateral shoulder and elbow, J Bone Joint Surg 72B:520, 1990. L’Insalata JC, Pagnani MJ, Warren RF, et al: Humeral head osteonecrosis: clinical course and radiographic predictors of outcome, J Shoulder Elbow Surg 5:355, 1996. Martin SD, Zurakowski D, Thornhill TS: Uncemented glenoid component in total shoulder arthroplasty: survivorship and outcomes, J Bone Joint Surg 87A:1284, 2005. Matsen FA III, Rockwood CA Jr, Wirth MA, et al: Glenohumeral arthritis and its management. In Rockwood CA Jr, Matsen FA III, Wirth MA, et al, editors: The shoulder, ed 3, Philadelphia, 2004, Saunders. Maynou C, Petroff E, Mestdagh H, et al: Clinical and radiologic outcome of humeral implants in shoulder arthroplasty, Acta Orthop Belg 65:57, 1999. Mileti J, Boardman ND III, Sperling JW, et al: Radiographic analysis of polyethylene glenoid components using modern cementing techniques, J Shoulder Elbow Surg 13:492, 2004. Neer CS II, Morrison DS: Glenoid bone-grafting in total shoulder arthroplasty, J Bone Joint Surg 70A:1154, 1988. Norris TR, Iannotti JP: Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study, J Shoulder Elbow Surg 11:130, 2002. Norris TR, Lachiewicz PF: Modern cement technique and the survivorship of total shoulder arthroplasty, Clin Orthop Relat Res 328:76, 1996. Nwakama AC, Cofield RH, Kavanagh BF, et al: Semiconstrained total shoulder arthroplasty for glenohumeral arthritis and massive rotator cuff tearing, J Shoulder Elbow Surg 9:302, 2000. Pearl ML, Romeo AA, Wirth MA, et al: Decision making in contemporary shoulder arthroplasty, Instr Course Lect 54:69, 2005. Pollock RG, Deliz ED, McIlveen SJ, et al: Prosthetic replacement in rotator cuff–deficient shoulders, J Shoulder Elbow Surg 1:173, 1992. Post M, Haskell SS, Jablon M: Total shoulder replacement with a constrained prosthesis, J Bone Joint Surg 62A:327, 1980.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY 622.e3 Rozing PM, Brand R: Rotator cuff repair during shoulder arthroplasty in rheumatoid arthritis, J Arthroplasty 13:311, 1998. Rutherford MD, Cofield RH: Osteonecrosis of the shoulder, Orthop Trans 11:239, 1987. Sanchez-Sotelo J, O’Driscoll SW, Torchia ME, et al: Radiographic assessment of cemented humeral components in shoulder arthroplasty, J Shoulder Elbow Surg 10:526, 2001. Shapiro J, Zuckerman JD: Glenohumeral arthroplasty: indications and preoperative considerations, Instr Course Lect 51:3, 2002. Sperling JW, Antuna SA, Sanchez-Sotelo J, et al: Shoulder arthroplasty for arthritis after instability surgery, J Bone Joint Surg 84A:1775, 2002. Steinmann SP, Cofield RH: Bone grafting for glenoid deficiency in total shoulder replacement, J Shoulder Elbow Surg 9:361, 2000. Torchia ME, Cofield RH, Settergren CR: Total shoulder arthroplasty with the Neer prosthesis: long-term results, J Shoulder Elbow Surg 6:495, 1997. Waldman BJ, Figgie MP: Indications, technique, and results of total shoulder arthroplasty in rheumatoid arthritis, Orthop Clin North Am 29:435, 1998. Wallace AL, Phillips RL, MacDougal GA, et al: Resurfacing of the glenoid in total shoulder arthroplasty: a comparison, at a mean of five years, of prostheses inserted with and without cement, J Bone Joint Surg 81A:510, 1999. Watson KC: Total shoulder replacement, Tech Orthop 3:81, 1989. Weiss AP, Adams MA, Moore JR, et al: Unconstrained shoulder arthroplasty: a five-year average follow-up study, Clin Orthop Relat Res 257:86, 1990. Wilde AH: Shoulder arthroplasty: what is it good for and how good is it? In Matsen FA, Fu FH, Hawkins RJ, editors: The shoulder: a balance of mobility and stability, Rosemont, IL, 1992, American Academy of Orthopaedic Surgeons. Williams GR, Abboud JA: Total shoulder arthroplasty: glenoid component design, J Shoulder Elbow Surg 14(1 Suppl S):122S, 2005.

REVERSE SHOULDER ARTHROPLASTY Boulahia A, Edwards TB, Walch G, et al: Early results of a reverse design prosthesis in the treatment of arthritis of the shoulder in elderly patients with a large rotator cuff tear, Orthopedics 25:129, 2002. DeWilde L, Mombert M, Van Petegem P, et al: Revision of shoulder replacement with a reversed shoulder prosthesis (Delta III): report of five cases, Acta Orthop Belg 67:348, 2001. Frankle M, Levy JC, Pupello D, et al: The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency: a minimum two-year follow-up study of sixty patients, J Bone Joint Surg 87A:1697, 2005. Harman M, Frankle M, Vasey M, Banks S: Initial glenoid component fixation in “reverse” total shoulder arthroplasty: a biomechanical evaluation, J Shoulder Elbow Surg 14(1 Suppl S):162S, 2005. Laudicina L, D’Ambrosia R: Management of irreparable rotator cuff tears and glenohumeral arthritis, Orthopedics 28:382, 2005. Mahfouz M, Nicholson G, Komistek R, et al: In vivo determination of the dynamics of normal, rotator cuff-deficient, total, and reverse replacement shoulders, J Bone Joint Surg 87(Suppl 2):107, 2005. Seebauer L, Walter W, Keyl W: Reverse total shoulder arthroplasty for the treatment of defect arthropathy, Oper Orthop Traumatol 17:1, 2005. Sirveaux F, Favrd L, Oudet D, et al: Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff: results of a multicentre study of 80 shoulders, J Bone Joint Surg 86B:388, 2004. Vanhove B, Beugnies A: Grammont’s reverse shoulder prosthesis for rotator cuff arthropathy: a retrospective study of 32 cases, Acta Orthop Belg 70:219, 2004. Werner CM, Steinmann PA, Gilbart M, et al: Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis, J Bone Joint Surg 87A: 1476, 2005.

COMPLICATIONS AND REVISION Antuna SA, Sperling JW, Cofield RH, et al: Glenoid revision shoulder after total shoulder arthroplasty, J Shoulder Elbow Surg 10:217, 2001.

Bonutti PM, Hawkins RJ: Fracture of the humeral shaft associated with total replacement arthroplasty of the shoulder, J Bone Joint Surg 74A:617, 1992. Bonutti PM, Hawkins RJ: Saddemi S: Arthroscopic assessment of glenoid component loosening after total shoulder arthroplasty, Arthroscopy 9:272, 1993. Brems JJ: Complications of shoulder arthroplasty: infections, instability, and loosening, Instr Course Lect 51:29, 2002. Brown TD, Bigliani LU: Complications with humeral head replacement, Orthop Clin North Am 31:77, 2000. Cameron B, Iannotti JP: Periprosthetic fractures of the humerus and scapula: management and prevention, Orthop Clin North Am 30:305, 1999. Campbell JT, Moore RS, Iannotti JP, et al: Periprosthetic humeral fractures: mechanisms of fracture and treatment options, J Shoulder Elbow Surg 7:406, 1998. Carroll RM, Izquierdo R, Vazquez M, et al: Conversion of painful hemi­ arthroplasty to total shoulder arthroplasty: long-term results, J Shoulder Elbow Surg 13:599, 2004. Coste JS, Reig S, Trojani C, et al: The management of infection in arthroplasty of the shoulder, J Bone Joint Surg 86B:65, 2004. Crosby LA: Complications. In Crosby LA, editor: Total shoulder arthroplasty, Rosemont, IL, 2000, American Academy of Orthopaedic Surgeons. Fink B, Sallen V, Guderian H, et al: Resection interposition arthroplasty of the shoulder affected by inflammatory arthritis, J Shoulder Elbow Surg 10:365, 2001. Franklin JL, Barrett WP, Jackins SE, et al: Glenoid loosening in total shoulder arthroplasty: association with rotator cuff deficiency, J Arthroplasty 3:39, 1988. Gartsman GM, Elkousy HA, Warnock KM, et al: Radiographic comparison of pegged and keeled glenoid components, J Shoulder Elbow Surg 14:252, 2005. Hasan SS, Leith JM, Campbell B, et al: Characteristics of unsatisfactory shoulder arthroplasties, J Shoulder Elbow Surg 11:431, 2002. Hawkins RJ, Greis PE, Bonutti PM: Treatment of symptomatic glenoid loosening following unco shoulder arthroplasty, Orthopedics 22:230, 1999. Hennigan SP, Iannotti JP: Instability after prosthetic arthroplasty of the shoulder, Orthop Clin North Am 32:649, 2001. Hersch JC, Dines JM: Arthroscopy for failed shoulder arthroplasty, Arthroscopy 16:606, 2000. Kjaersgaard-Andersen P, Frich LH, Søjbjerg JO, et al: Heterotopic bone formation following total shoulder arthroplasty, J Arthroplasty 4:99, 1989. Klimkiewica JJ, Iannotti JP, Rubash HE, et al: Aseptic loosening of the humeral component in total shoulder arthroplasty, J Shoulder Elbow Surg 7:422, 1998. Klingman M, Roffman M: Humeral fracture following shoulder arthroplasty, Orthopedics 22:511, 1999. Kørsgaard-Andersen P, Frich LH, Søjberg JO, et al: Heterotopic bone formation following total shoulder arthroplasty, J Arthroplasty 4:99, 1989. Krakauer JD, Cofield RH: Periprosthetic fractures in total shoulder arthroplasty, Op Tech Orthop 4:243, 1994. Kumar S, Sperling JW, Haidukewych GH, Cofield RH: Periprosthetic humeral fractures after shoulder arthroplasty, J Bone Joint Surg 86A:680, 2004. Lazarus MD, Jensen KL, Southworth C, Matsen FA 3rd: The radiographic evaluation of keeled and pegged glenoid component insertion, J Bone Joint Surg Am 84:1174, 2002. Loebenberg MI, Zuckerman JD: An articulating interval spacer in the treatment of an infected total shoulder arthroplasty, J Shoulder Elbow Surg 13:476, 2004. Lynch NM, Cofield RH, Silbert PL, et al: Neurologic complications after total shoulder arthroplasty, J Shoulder Elbow Surg 5:53, 1996. Milbrink J, Wigren A: Resection arthroplasty of the shoulder, Scand J Rheumatol 19:432, 1990. Moeckel BH, Altchek DW, Warren RF, et al: Instability of the shoulder after arthroplasty, J Bone Joint Surg 75A:492, 1993. Murthi AM, Vosburgh CL, Neviaser TJ: The incidence of pathologic changes of the long head of the biceps tendon, J Shoulder Elbow Surg 9:382, 2000. Neer CS II, Kirby RM: Revision of humeral head and total shoulder arthroplasties, Clin Orthop Relat Res 170:189, 1982.

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622.e4 PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS Neer CS, Rockwood CA: Fractures and dislocations of the shoulder. In Rockwood CA, Green DP, editors: Fractures, Philadelphia, 1984, Lippincott. Norris TR, Lipson SR: Management of the unstable prosthetic shoulder arthroplasty, Instr Course Lect 47:141, 1998. Peterson SA, Hawkins RJ: Revision of failed total shoulder arthroplasty, Orthop Clin North Am 29:519, 1998. Sanchez-Sotelo J, Sperling JW, Rowland CM, et al: Instability after shoulder arthroplasty: results of surgical treatment, J Bone Joint Surg 85A:622, 2003. Spencer EE Jr, Valdevit A, Kambic H, et al: The effect of humeral component anteversion on shoulder stability with glenoid component retroversion, J Bone Joint Surg Am 87:808, 2005. Sperling JW, Cofield RH: Revision total shoulder arthroplasty for the treatment of glenoid arthrosis, J Bone Joint Surg 80A:860, 1998. Sperling JW, Cofield RH, Rowland CM: Heterotopic ossification after total shoulder arthroplasty, J Arthroplasty 15:179, 2000. Sperling JW, Kozak TK, Hanssen AD, et al: Infection after total shoulder arthroplasty, Clin Orthop Relat Res 382:206, 2001. Wallace AL, Walsh WR, Sonnabend DH: Dissociation of the glenoid component in cementless total shoulder arthroplasty, J Shoulder Elbow Surg 8:81, 1999. Wiater JM, Levine WN: Revision shoulder arthroplasty. In Crosby LA, editor: Total shoulder arthroplasty, Rosemont, IL, 2000, American Academy of Orthopaedic Surgeons. Williams GR Jr, Wong KL, Pepe MD, et al: The effect of articular malposition after total shoulder arthroplasty on glenohumeral translations, range of motion, and subacromial impingement, J Shoulder Elbow Surg 10:399, 2001. Wirth MA, Rockwood CA: Complications of total shoulder replacement arthroplasty, J Bone Joint Surg 78A:603, 1996. Worland RL, Kim DY, Arredondo J: Periprosthetic humeral fractures: management and classification, J Shoulder Elbow Surg 8:590, 1999. Wright TW, Cofield RH: Humeral fractures after shoulder arthroplasty, J Bone Joint Surg 77A:1340, 1995.

RECONSTRUCTIVE PROCEDURES OF THE ELBOW HISTORY

Coonrad RW: History of total elbow arthroplasty. In Inglis AE, editor: American Academy of Orthopaedic Surgeons, Symposium on total joint replacement of the upper extremity, St. Louis, 1982, Mosby. Dee R: Elbow arthroplasty, Proc R Soc Med 62:1031, 1969. Dee R: Rheumatologic and degenerative disorders of the elbow. In Dee R, Mango E, Hurst LC, editors: Principles of orthopaedic practice, New York, 1988, McGraw-Hill. Dee R, Ries M: Nonprosthetic elbow reconstruction, Contemp Orthop 14:37, 1978. Ewald FC, et al: Reconstructive surgery and rehabilitation of the elbow. In Kelley WN, Harris ED Jr, Ruddy S, et al, editors: Textbook of rheumatology, vol 2, Philadelphia, 1981, Saunders. Inglis AE, Ranawat CS, Straub LR: Synovectomy and debridement of the elbow in rheumatoid arthritis, J Bone Joint Surg 53A:652, 1971. Kasten MD, Skinner HB: Total elbow arthroplasty, Clin Orthop Relat Res 290:177, 1993. Mills R, Rush J: Skin arthroplasty of the elbow, Aust NZ J Surg 41:179, 1971. Morrey BF: Elbow reconstructive surgery. In Chapman MW, editor: Operative orthopaedics, Philadelphia, 1988, Lippincott. Morrey BF, editor: Reconstructive surgery of the joints, New York, 1996, Churchill Livingstone. Smith FM: Surgery of the elbow, ed 2, Philadelphia, 1972, Saunders. Wadsworth TG, editor: The elbow, Edinburgh, 1982, Churchill Livingstone.

ANATOMY AND BIOMECHANICS Amis AA, Dowson D, Wright V: Elbow joint force predictions for some strenuous isometric actions, J Biomech 13:765, 1980. Amis AA, Dowson D, Wright V, et al: The derivation of elbow joint forces and their relation to prosthesis design, J Med Eng Tech 3:229, 1979. Bryan RS, Morrey BF: Extensive posterior exposure of the elbow: a tricepssparing approach, Clin Orthop Relat Res 166:188, 1982.

King GJW, Glauser SJ, Westreich A, et al: In vitro stability of an unconstrained total elbow prosthesis, J Arthroplasty 8:291, 1993. King GJW, Itoi E, Niebur GL, et al: Motion and laxity of the capitellocondylar total elbow prosthesis, J Bone Joint Surg 76A:1000, 1994. Lewis G: The elbow joint and its total arthroplasty: I. A state-of-the-art review, Biomed Mat Eng 6:353, 1996. Lewis G, Clark MC, Harber MS: The elbow joint and its total arthroplasty: II. Finite element study, Biomed Mat Eng 6:367, 1996. London JT: Kinematics of the elbow, J Bone Joint Surg 63A:529, 1981. Lowe LW, Miller AJ, Alum RL, Higginson DW: The development of an unconstrained elbow arthroplasty: a clinical review, J Bone Joint Surg 66B:243, 1984. Mehlnoff TL, Bennett JB, Tullos HS: Silastic prosthetic replacement for severe fractures of the radial head: long term results. Paper presented at the Fiftyseventh annual meeting of the American Academy of Orthopaedic Surgeons, New Orleans, 1990. Morrey BF, Askew LJ, An KN: Strength function after elbow arthroplasty, Clin Orthop Relat Res 234:43, 1988. Morrey BF, Askew LJ, An KN, et al: A biomechanical study of normal functional elbow motion, J Bone Joint Surg 63A:87, 1981. Morrey BF, Chao EYS: Passive motion of the elbow joint, J Bone Joint Surg 58A:501, 1976. O’Driscoll SW, An K, Korinek S, et al: Kinematics of semi-constrained total elbow arthroplasty, J Bone Joint Surg 74B:297, 1992. Schwab GH, Bennett JB, Woods GW, et al: Biomechanics of elbow instability: the role of the medial collateral ligament, Clin Orthop Relat Res 146:42, 1980. Shuind F, O’Driscoll S, Korinek S, et al: Loose-hinge total elbow arthroplasty, J Arthroplasty 10:670, 1995.

IMPLANT ARTHROPLASTY Antuna SA, Morrey BF, Adams RA, et al: Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: long-term outcome and complications, J Bone Joint Surg 84A:2168, 2002. Birkedal JP, Deal DN, Ruch DS: Loss of flexion after radial head replacement, J Shoulder Elbow Surg 13:208, 2004. Blaine TA, Adams R, Morrey BF: Total elbow arthroplasty after interposition arthroplasty for elbow arthritis, J Bone Joint Surg 87A:286, 2005. Brady O, Quinlan W: The Guildford elbow, J Hand Surg 18B:389, 1993. Bryan RS: Total replacement of the elbow joint, Arch Surg 112:1092, 1977. Burnett R, Fyfe IS: Souter-Strathclyde arthroplasty of the rheumatoid elbow, Acta Orthop Scand 62:52, 1991. Celli A, Arash A, Adams RA, et al: Triceps insufficiency following total elbow arthroplasty, J Bone Joint Surg 87A:1957, 2005. Cobb TK, Morrey BF: Use of distraction arthroplasty in unstable fracture dislocations of the elbow, Clin Orthop Relat Res 312:201, 1995. Cobb TK, Morrey BF: Total elbow arthroplasty as primary treatment for distal humeral fractures in elderly patients, J Bone Joint Surg 79A:826, 1997. Connor PM, Morrey BF: Total elbow arthroplasty in patients who have juvenile rheumatoid arthritis, J Bone Joint Surg 80A:678, 1998. Coonrad RW, Morrey BJ: Coonrad/Morrey total elbow: surgical technique, Warsaw, IN, 1988, Zimmer USA. Davis RF, Weiland AJ, Hungerford DS, et al: Nonconstrained total elbow arthoplasty, Clin Orthop 171:156, 1982. Dee R: Total replacement arthroplasty of the elbow for rheumatoid arthritis, J Bone Joint Surg 54B:88, 1972. Dee R: Total replacement of the elbow joint, Orthop Clin North Am 4:415, 1973. Dee R: Elbow replacement with the R. Dee prosthesis, Acta Orthop Belg 41:477, 1975. Dee R: Reconstructive surgery following total elbow endoprosthesis, Clin Orthop Relat Res 170:196, 1982. Dent CM, Hoy G, Stanley JK: Revision of failed total elbow arthroplasty, J Bone Joint Surg 77B:691, 1995. Ewald FC: Total elbow replacement, Orthop Clin North Am 6:685, 1975. Ewald FC, Jacobs MA: Total elbow arthroplasty, Clin Orthop Relat Res 182:137, 1984.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY 622.e5 Ewald FC, Simmons ED, Sullivan JA, et al: Capitellocondylar total elbow replacement in rheumatoid arthritis, J Bone Joint Surg 75A:498, 1993. Faber KJ, Cordy ME, Milne AD, et al: Advanced cement technique improves fixation in elbow arthroplasty, Clin Orthop Relat Res 334:150, 1997. Ferlic DC, Clayton ML: Salvage of failed total elbow arthroplasty, J Shoulder Elbow Surg 4:290, 1995. Figgie HE III, Inglis AE, Ranawat CS, et al: Results of total elbow arthroplasty as a salvage procedure for failed elbow reconstructive operations, Clin Orthop Relat Res 219:185, 1987. Figgie MP, Inglis AE, Mow CS, et al: Total elbow arthroplasty for complete ankylosis of the elbow, J Bone Joint Surg 71A:513, 1989. Foulkes GD, Mitsunaga MM: Allograft salvage of failed total elbow arthroplasty, Clin Orthop Relat Res 296:113, 1993. Frankle MA, Herscovici D, DiPasquale TE, et al: A comparison of open reduction and internal fixation and primary total elbow arthroplasty in the treatment of intraarticular distal humerus fractures in women older than age 65, J Orthop Trauma 17:473, 2003. Friedman RJ, Lee DE, Ewald FC: Nonconstrained total elbow arthroplasty: development and results in patients with functional class IV rheumatoid arthritis, J Arthroplasty 4:31, 1989. Goldberg VM, Figgie HE III, Inglis AE, Figgie MP: Current concepts review: total elbow arthroplasty, J Bone Joint Surg 70A:778, 1988. Gschwend N, Loehr J, Ivosevic-Radovanovic D, et al: Semiconstrained elbow prostheses with special reference to the GSB III prosthesis, Clin Orthop Relat Res 232:104, 1988. Gschwend N, Scheier NH, Bähler AR: Long-term results of GSB III elbow arthroplasty, J Bone Joint Surg 81B:1005, 1999. Gschwend N, Simmen BR, Matejovsky Z: Late complications in elbow arthroplasty, J Shoulder Elbow Surg 5:86, 1996. Gutow AP, Wolfe SW: Infection following total elbow arthroplasty, Hand Clin 10:521, 1994. Hanyu T, Nakazono K: Ishimkawa H: Humeral shaft fracture after a total elbow arthroplasty, J Shoulder Elbow Surg 7:541, 1998. Harrington IJ, Sekyi-Otu A, Barrington TW, et al: The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review, J Trauma 50:46, 2001. Harrington IJ, Tountas AA: Replacement of the radial head in the treatment of unstable elbow fractures, Injury 12:405, 1981. Hildebrand KA, Patterson SD, Regan WD, et al: Functional outcome of semiconstrained total elbow arthroplasty, J Bone Joint Surg 82A:1379, 2000. Ikavalko M, Belt EA, Kautiainen H, et al: Revisions for aseptic loosening in Souter-Strathclyde elbow arthroplasty: incidence of revisions of different components used in 522 consecutive cases, Acta Orthop Scand 73:257, 2002. Inglis AE: Revision surgery following a failed total elbow arthroplasty, Clin Orthop Relat Res 170:213, 1982. Inglis AE, Inglis AE Jr, Figgie MM, et al: Total elbow arthroplasty for flail and unstable elbows, J Shoulder Elbow Surg 6:29, 1997. Inglis AE, Pellici PM: Total elbow replacement, J Bone Joint Surg 62A:1252, 1980. Jensen SL, Deutch SR, Olsen BS, et al: Laxity of the elbow after experimental excision of the radial head and division of the medial collateral ligament: efficacy of ligament repair and radial head prosthetic replacement: a cadaver study, J Bone Joint Surg 85B:1006, 2003. Kamineni S, Morrey BF: Proximal ulnar reconstruction with strut allograft in revision total elbow arthroplasty, J Bone Joint Surg Am 86:1223, 2004. Kamineni S, Morrey BF: Distal humeral fractures treated with noncustom total elbow replacement: surgical technique, J Bone Joint Surg 87A(Suppl 1 pt 1):41, 2005. Kay RM, Eckardt JJ: Total elbow allograft for twice-failed total elbow arthroplasty, Clin Orthop Relat Res 303:135, 1994. Kelly EW, Coghlan J, Bell S: Five- to thirteen-year follow-up of the GSB III total elbow arthroplasty, J Shoulder Elbow Surg 13:434, 2004. Khatri M, Stirrat AN: Souter-Strathclyde total elbow arthroplasty in rheumatoid arthritis: medium-term results, J Bone Joint Surg 87B:950, 2005. King GJW, Adams RA, Morrey BF: Total elbow arthroplasty: revision with use of a noncustom semiconstrained prosthesis, J Bone Joint Surg 79A: 394, 1997.

King GJW, Zarzour ZDS, Rath DA, et al: Metallic radial head arthroplasty improves valgus stability of the elbow, Clin Orthop Relat Res 368:114, 1999. Knight DJ, Rymaszewski LA, Amis AA, et al: Primary replacement of the fractured radial head with a metal prosthesis, J Bone Joint Surg 75B:572, 1993. Kozak TK, Adams RA, Morrey BF: Total elbow arthroplasty in primary osteoarthritis of the elbow, J Arthroplasty 13:837, 1998. Kraay MJ, Figgie MP, Inglis AE, et al: Primary semiconstrained total elbow arthroplasty, J Bone Joint Surg 76B:636, 1994. Kudo H: Nonconstrained elbow arthroplasty for mutilans deformity in rheumatoid arthritis, J Bone Joint Surg 80B:234, 1998. Kudo H, Iwano K: Total elbow arthroplasty with a non-constrained surfacereplacement prosthesis in patients who have rheumatoid arthritis: a longterm follow-up study, J Bone Joint Surg 72A:355, 1990. Kudo H, Iwano K, Nishino J: Cementless or hybrid total elbow arthroplasty with titanium-alloy implants, J Arthroplasty 9:269, 1994. Kudo H, Iwano K, Nishino J: Total elbow arthroplasty with use of a nonconstrained humeral component inserted without cement in patients who have rheumatoid arthritis, J Bone Joint Surg 81A:1268, 1999. Kudo H, Iwano K, Watanabe S: Total replacement of the rheumatoid elbow with a hingeless prosthesis, J Bone Joint Surg 62A:277, 1980. Lee DH: Impaction allograft bone-grafting for revision total elbow arthroplasty, J Bone Joint Surg 81A:1008, 1999. Lee BP, Adams RA, Morrey BF: Polyethylene wear after total elbow arthroplasty, J Bone Joint Surg 87A:1080, 2005. Little CP, Graham AJ, Carr AJ: Total elbow arthroplasty: a systematic review of the literature in the English language until the end of 2003, J Bone Joint Surg 87B:437, 2005. Little CP, Graham AJ, Karatzas G, et al: Outcomes of total elbow arthroplasty for rheumatoid arthritis: comparative study of three implants, J Bone Joint Surg 87A:2439, 2005. Loebenberg MI, Adams R, O’Driscoll SW, et al: Impaction grafting in revision total elbow arthroplasty, J Bone Joint Surg 87A:99, 2005. London JT: Resurfacing total elbow arthroplasty, Orthop Trans 2:217, 1978. Lyall HA, Cohen B, Clatworthy M, et al: Results of the Souter-Strathclyde total elbow arthroplasty in patients with rheumatoid arthritis, J Arthroplasty 9:279, 1994. MacAusland WR: Replacement of the lower end of the humerus with a prosthesis: a report of four cases, West J Surg Obstet Gynecol 62:557, 1954. Mackay I, FitzGerald B, Miller JH: Silastic radial head prosthesis in rheumatoid arthritis, Acta Orthop Scand 53:63, 1982. Malone AA, Taylor AJN, Fyfe IS: Successful outcome of the Souter-Strathclyde elbow arthroplasty, J Shoulder Elbow Surg 13:548, 2004. Mansat P, Adams RA, Morrey BF: Allograft-prosthesis composite for revision of catastrophic failure of total elbow arthroplasty, J Bone Joint Surg Am 86:724, 2004. Morrey BF, Adams RA: Semiconstrained arthroplasty for the treatment of rheumatoid arthritis of the elbow, J Bone Joint Surg 74A:479, 1992. Morrey BF, Askew RPT, Chao EY: Silastic prosthetic replacement for the radial head, J Bone Joint Surg 63A:454, 1981. Morrey BF, Bryan RS: Infection after total elbow arthroplasty, J Bone Joint Surg 65A:330, 1983. Morrey BF, Bryan RS, Dobyns JH, et al: Total elbow arthroplasty: a five-year experience at the Mayo Clinic, J Bone Joint Surg 63A:1050, 1981. Morrey BF, Chao EY: Biomechanical study of the elbow following excision of the radial head, J Bone Joint Surg 61A:63, 1979. O’Driscoll SW, King GJ: Treatment of instability after total elbow arthroplasty, Orthop Clin North Am 32:679, 2001. Phillips NJ, Ali A, Stanley D: Treatment of primary degenerative arthritis of the elbow by ulnohumeral arthroplasty: a long-term follow-up, J Bone Joint Surg 85B:347, 2003. Pierce TD, Herndon JH: The triceps-preserving approach to total elbow arthroplasty, Clin Orthop Relat Res 354:144, 1998. Pöll RG, Rozing PM: Use of the Souter-Strathclyde total elbow prosthesis in patients who have rheumatoid arthritis, J Bone Joint Surg 73A:1227, 1991. Pritchard RW: Long-term follow-up study: semi-constrained elbow prosthesis, Orthopedics 4:151, 1981.

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622.e6 PART V  RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS Pritchard RW: Anatomic surface elbow arthroplasty: a preliminary report, Clin Orthop Relat Res 179:223, 1983. Pritchard RW: Total elbow joint arthroplasty in patients with rheumatoid arthritis, Semin Arthritis Rheum 21:24, 1991. Ramsey ML, Adams RA, Morrey BF: Instability of the elbow treated with semiconstrained total elbow arthroplasty, J Bone Joint Surg 81A:38, 1999. Renfree KJ, Dell PC, Kozin SH, Wright TW: Total elbow arthroplasty with massive composite allografts, J Shoulder Elbow Surg 13:313, 2004. Ruth JT, Wilde AH: Capitellocondylar total elbow replacement, J Bone Joint Surg 74A:95, 1992. Sanchez-Sotelo J, Morrey BF: Total elbow arthroplasty, J Am Acad Orthop Surg 19:121, 2011. Sanchez-Sotelo J, O’Driscoll S, Morrey BF: Periprosthetic humeral fractures after total elbow arthroplasty: treatment with implant revision and strut allograft augmentation, J Bone Joint Surg 84A:2002, 1642. Schemitsch EH, Ewald FC, Thornhill TS: Results of total elbow arthroplasty after excision of the radial head and synovectomy in patients who had rheumatoid arthritis, J Bone Joint Surg 78A:1996, 1541. Schlein AP: Semiconstrained total elbow arthroplasty, Clin Orthop Relat Res 121:222, 1976. Schneeberger AG, Hertel R, Gerber C: Total elbow replacement with the GSB III prosthesis, J Shoulder Elbow Surg 9:135, 2000. Souter WA: Arthroplasty of the elbow: with particular reference to metallic hinge arthroplasty in rheumatoid patients, Orthop Clin North Am 4:395, 1973. Sperling JW, Pritchard DJ, Morrey BF: Total elbow arthroplasty after resection of tumors at the elbow, Clin Orthop Relat Res 367:256, 1999. Street DM, Stevens PS: A humeral replacement prosthesis for the elbow: results in ten elbows, J Bone Joint Surg 56A:1147, 1974. Swanson AB, Jaeger SH, LaRochelle D: Comminuted fractures of the radial head: the role of silicone-implant replacement arthroplasty, J Bone Joint Surg 63A:1039, 1981. Swanson AB, Swanson G, Masada K, et al: Constrained total elbow arthroplasty, J Arthroplasty 6:203, 1991. Tanaka N, Kudo H, Iwano K, et al: Kudo total elbow arthroplasty in patients with rheumatoid arthritis: a long-term follow-up study, J Bone Joint Surg 83A:1506, 2001. Trail IA, Nuttal D, Stanley JK: Comparison of survivorship between standard and long-stem Souter-Strathclyde total elbow arthroplasty, J Shoulder Elbow Surg 11:373, 2002. Trail IA, Nuttal D, Stanley JK: Survivorship and radiological analysis of the standard Souter-Strathclyde total elbow arthroplasty, J Bone Joint Surg 81B:80, 1999. Trepman E, Ewald FC: Early failure of silicone radial head implants in the rheumatoid elbow, J Arthroplasty 6:59, 1991. Trepman E, Vella IM, Ewald FC: Radial head replacement in capitellocondylar total elbow arthroplasty, J Arthroplasty 6:67, 1991. van der Lugt JC, Geskus RB, Rozing PM: Primary Souter-Strathclyde total elbow prosthesis in rheumatoid arthritis: surgical technique, J Bone Joint Surg 87A(Suppl 1 pt 1):67, 2005. Van Glabbeek F, Van Riet RP, Baumfield JA, et al: Detrimental effects of overstuffing or understuffing with a radial head replacement in the medial collateral-ligament deficient elbow, J Bone Joint Surg 86A:2629, 2004. Wadsworth TG: A new technique of total elbow replacement, Eng Med 10:69, 1980. Weiland AJ, Weiss APC, Wills RP, et al: Capitellocondylar total elbow replacement: a long-term follow-up study, J Bone Joint Surg 71A:217, 1989. Wolfe SW, Figgie MP, Inglis AE, et al: Management of infection about total elbow prostheses, J Bone Joint Surg 72A:198, 1990. Wretenberg PF, Mikhail WE: Late dislocation after total elbow arthroplasty, J Shoulder Elbow Surg 8:178, 1999. Wright TW, Hastings H: Total elbow arthroplasty failure due to overuse, C-ring failure, and/or bushing wear, J Shoulder Elbow Surg 14:65, 2005. Yamaguchi K, Adams RA, Morrey BF: Infection after total elbow arthroplasty, J Bone Joint Surg 80A:481, 1998.

Yamaguchi K, Adams RA, Morrey BF: Semiconstrained total elbow arthroplasty in the context of treated previous infection, J Shoulder Elbow Surg 8:461, 1999. Yanni ON, Fearn CB, Gallannaugh SC, Joshi R: The Roper-Tuke total elbow arthroplasty: 4- to 10-year results of an unconstrained prosthesis, J Bone Joint Surg 82B:705, 2000.

RESECTION ARTHROPLASTY

Albee FH: Arthroplasty of the elbow, J Bone Joint Surg 15:979, 1933. Baer WS: Preliminary report of animal membrane in producing mobility in ankylosed joint, Am J Orthop Surg 7:3, 1909. Baer WS: Arthroplasty with the aid of animal membrane, Am J Orthop Surg 16:1, 1918. Buzby BF: End results of excision of the elbow, Ann Surg 103:625, 1936. Campbell WC: Arthroplasties, J Orthop Surg 19:430, 1921. Campbell WC: Arthroplasty of the elbow, Ann Surg 76:615, 1922. Campbell WC: Mobilization of joints with bony ankylosis: an analysis of 110 cases, JAMA 93:976, 1924. Campbell WC: Operative orthopaedics, St. Louis, 1939, Mosby. Cheng SL, Morrey BF: Treatment of the mobile, painful arthritic elbow by distraction interposition arthroplasty, J Bone Joint Surg 82B:233, 2000. Froimson AI, Silva JE, Richey D: Cutis arthroplasty of the elbow, J Bone Joint Surg 58A:863, 1976. Hass J: Functional arthroplasty, J Bone Joint Surg 26:297, 1944. Hausman MR, Birnbaum PS: Interposition elbow arthroplasty, Tech Hand Up Extrem Surg 8:181, 2004. Henderson MS: What are the real results of arthroplasty?, Am J Orthop Surg 16:30, 1918. Henderson MS: Arthroplasty, Minn Med 8:97, 1925. Hurri L, Pulkki T, Vainio K: Arthroplasty of the elbow in rheumatoid arthritis, Acta Chir Scand 127:459, 1964. Ikävalko M, Belt EA, Kautiainen H, et al: Revisions for aseptic loosening in Souter-Strathclyde elbow arthroplasty: incidence of revisions of different components used in 522 consecutive cases, Acta Orthop Scand 73:257, 2002. Knight RA, Van Zandt IL: Arthroplasty of the elbow: an end-result study, J Bone Joint Surg 34A:610, 1952. Lee DH: Posttraumatic elbow arthritis and arthroplasty, Orthop Clin North Am 30:141, 1999. Lexer E: Über Gelenktransplantationen, Arch Klink Chir 90:263, 1909. Ljung P, Larsson K, Rydholm U: Interposition arthroplasty of the elbow with rheumatoid arthritis, J Shoulder Elbow Surg 5:81, 1996. MacAusland WR: The mobilization of elbow by free fascia transplantation with report of 31 cases, Surg Gynecol Obstet 33:223, 1921. MacAusland WR: Arthroplasty of the elbow, N Engl J Med 235:97, 1947. Morrey BF: Posttraumatic contracture of the elbow: operative treatment, including distraction arthroplasty, J Bone Joint Surg 72A:601, 1990. Murphy JB: Ankylosis: arthroplasty, clinical and experimental, JAMA 44:1573, 1905. Murphy JB: Arthroplasty, Ann Surg 57:593, 1913. Oka Y: Debridement arthroplasty for osteoarthrosis of the elbow: 50 patients followed mean 5 ears, Acta Orthop Scand 71:185, 2000. Oka Y, Ohta K, Saitoh I: Debridement arthroplasty for osteoarthritis of the elbow, Clin Orthop Relat Res 351:127, 1998. Ollier L: Traité des résections et des opérations conservatrices qu’on peut pratiques sur le systéme osseux, Paris, 1885-1889, Masson. Payr E: Über die operative mobilizierung ankylosierter Gelenke, Munch Med Wochenschr 37:1921, 1910. Putti V: Arthroplasty, J Orthop Surg 19:419, 1921. Silva JF: Old dislocations of the elbow, Ann R Coll Surg Engl 22:363, 1958. Speed JS, Smith H: Arthroplasty: a review of the past ten years, Int Abstr Surg Gynecol Obstet 70:224, 1940. Tsuge K, Mizuseki T: Debridement arthroplasty for advanced primary osteoarthritis of the elbow, J Bone Joint Surg 76B:641, 1994. Tsuge K, Murakami T, Yasunaga Y, et al: Arthroplasty of the elbow: twenty years’ experience of a new approach, J Bone Joint Surg 69B:116, 1987.

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CHAPTER 12  SHOULDER AND ELBOW ARTHROPLASTY 622.e7 Uuspaa V: Anatomical interposition arthroplasty with dermal graft: a study of 51 elbow arthroplasties on 48 rheumatoid patients, Z Rheumatol 46:132, 1987. Vainio K: Arthroplasty of the elbow and hand in rheumatoid arthritis: a study of 131 operations. In Chapchal G, editor: Synovectomy and arthroplasty in rheumatoid arthritis, Stuttgart, 1967, Thieme. Verneuil A: De la creation d’une fausse articulation par section ou resection partielle de l’os maxillaire inferieur, comme moyen de remedier l’ankylose orale de fausse de la machoire inferieur, Arch Gen Med 15:284, 1860.

Wada T, Isogai S, Ishii S, et al: Debridement arthroplasty for primary osteoarthritis of the elbow, J Bone Joint Surg 86A:233, 2004. Wada T, Isogai S, Ishii S, et al: Debridement arthroplasty for primary osteoarthritis of the elbow: surgical technique, J Bone Joint Surg 87A(Suppl 1 part 1):95, 2005. Wright PE, Stewart MJ: Fascial arthroplasty of the elbow. In Morrey BF, editor: The elbow and its disorders, Philadelphia, 1985, Saunders.

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