Shoulder arthroplasty


x-rax shoulder arthroplasty


General information about shoulder arthroplasty:
It is very important that the shoulder prosthesis is implanted at the right time. If there is no external rotation, destruction of the humeral head on x-ray and a muscular atrophy, a shoulder arthroplasty can be performed. Then it will delete pain but it won´t restore function and movement. If you wait to long the tendons, joint capsule muscles adhere.
The ideal moment to implant a shoulder prosthesis is, when pain is agonizing, nonoperative treatment failed, external rotation is reduced, but still possible and when on x-ray the shoulder joint space is narrow, but humeral head still has a round contour.
The former attitude "wait until nothing more is possible" is not the right advise, if the prostheses should relief pain and restore movement.
You have to be "just in time".


When to implant a shoulder arthroplasty:
Shoulder arthroplasty is used in situations where the shoulder joint is destructed. Most of the time, when there are complicated fractures or if the shoulder joint is destructed due to arthritis / omarthrosis or humeral head necrosis. If nonoperative treatment, like pain medication, injections, physiotherapy and so on, failed a shoulder arthroplasty is indicated.
Shoulder joint destruction due to rheumatoid arthritis can end into the implantation of a shoulder arthroplasty, also. In patients suffering from a rheumatoid arthritis the bony structures, like glenoid and humeral head, are destructed. Very important, for planning the implantation of a shoulder prosthesis, is to analyze the destruction of the soft tissue in rheumatoid patients. Especially the rotator cuff can be destructed extensively and the cuff is very important for a shoulder arthroplasty to work correctly. Planing a shoulder prostheses for a rheumatoid patient means to account for his age, acivity level and life expectancy. A surface replacement with a cup prostheses is used, often.
Other reasons to implant a shoulder prosthesis are acute humeral head fractures, which are consisting of several segments. Those segments are destroyed so much that it is not advisable to reconstruct the humeral head with an osteosynthesis. In these cases shoulder arthroplasty is used after trauma, directly. Old humeral head fractures and old dislocations of the shoulder, if associated with pain, might also end in a shoulder arthroplasty.
Also, it might be necessary to implant a shoulder prosthesis in rare conditions like a humeral head necrosis. This is a good indication for a shoulder arthroplasty, because the results, pain relief and movement, are very good in this disease, when an artificial shoulder joint has to be implanted. Hemiprostheses and new generation cups are the favourable implants for a humeral head necrosis.
Tumors may destruct the upper third or humeral shaft. This is due to primary bone tumors or metastases. Sometimes in tumors fractures occur due to bone destruction. Within the last years a lot of success was made in chemotherapy and radiation. Surgical therapy, including shoulder arthroplasty, remains the standard therapy for certain conditions of bone tumors of the shoulder. The tumor has to be removed with a maximum of function, as far as possible. Sometimes a shoulder prosthesis can be avoided, performing a tumor resection combined with an osteosynthesis.
Years after an infection of the shoulder - pain and destruction remain, making a shoulder arthroplasty necessary. Even after a few years bacteria could still be there and this has to be taken into consideration planning such a prosthesis.
If there is an acute shoulder infection, missing muscles or extensive nerve damage, the implantation of a shoulder prosthesis does not make sense, in the majority of such cases.
Types of shoulder arthroplasty:
The smallest type of artificial shoulder joint is a cup prosthesis, also called surface replacement. Special types of shoulder cups, with an extended surface are called EAS ( extended articular surface ) or CTA ( cuff tear arthropathy ) cups. They are used when arthritis as well as a defect in the rotator cuff is present and causing pain.
A hemiprothesis consist of a humeral head an a stem, without resurfacing of the glenoid. A hemiprothesis with a glenoid resurfacing is called a total shoulder.
A bipolar prosthesis is a hemiarthroplasty with a double head, for arthritis with big rotator cuff tears.
The reverse shoulder prosthesis is a replacement with is constructed just the other way round. More information here.


How long does a shoulder arthroplasty survive ?
Life expectancy of a shoulderprosthesis is the same as for hip and knee prosthesis. 10 years after implantation about 90 to 95% of the shoulder arthroplasties still work well. 15 years after primary implantation about 86 to 92% are still working - without showing signs of loosening.


Shoulder arthroplasty with or without glenoid component ?
There are no general guidelines, when to implant a glenoid or not. If a total shoulder is implanted, within the first years the results and function are better. The actual results demonstrate that the glenoid component will show a loosening much earlier than a humera
l stem. Which means: shoulder prostheses with glenoid resurfacing have to be changed earlier than hemiprostheses. Whether a glenoid has to be implanted with or without cement will be seen in the future. The exposition during the operation, underlying disease, kind and amount of destruction are the crucial factors for decision.


How to operate a shoulder arthroplasty ?
Shoulder arthroplasty is performed under general anesthesia in beach chair position. The most common used approach is in front of the shoulder. After preparing the skin, muscles and tendons, the shoulder joint is exposed. The humeral head is dislocated and a bony part of this head is removed, tangentially. Rasping the shaft it is prepared for the implantaion of the humeral prosthesis stem. Depending on the above mentioned factors it has to be decided, whether a glenoid is used or not.
Rehabilitation of a shoulder arthroplasty:
The arm is fixed in a sling for about 2 to 4 weeks. The patient remains in hospital for 3 to 7 days. Physiotherapy is necessary for 5 to 7 weeks, on an outpatient basis. Getting out of the sling, active motions are allowed. Sports can be started about 3 month after the operation.


History of shoulder arthroplasty:
J.P. Pean, a Frenchman, was the first to construct an artificial shoulder joint / shoulder prosthesis. This, first arthroplasty, consisted of platinum and ebonite and was implanted in a patient suffering from a shoulder destruction due to tuberculosis. After two years it had to removed because of repeated infections. This case demonstrated, besides unfortunately infections, that a patient could get rid of his pain, if a shoulder arthroplasty is used.
The first step in development of modern shoulder arthroplasty, those protheses contructions that are still used today, was made by the american orthopedic surgeon Charles Neer II around 1951. Motivated to treat complicated humeral head fractures, he developed the basic construction principle for shoulder prostheses, that are still used today. Stellbrink was the first to present glenoid resurfacing. The hemiarthroplasty of Charles Neer ( Neer I model ) was combined with a resurfacing of the glenoid and the "total shoulder" was invented. In 1973 the Neer II model was introduced, which is still used until today.
Second generation models were implanted at the beginning 90th. The second generation of shoulder arthroplasty is characterized by a modular construction, which means that head and shaft are adjustable in an individual way according to size, orientation and inclination.
During the 90th second generation models came on the market. Geometry of the humeral head could be restored much better. From this point glenoid arthroplasty of the shoulder was possible cementless. Special designs, like reverse prosthesis, experienced a revival.
Today third generation shoulder prosthesis are used often.


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