Arthroplasties de l’Epaule

- Indications, Techniques, Résultats- Didier FONTÈS

Institut Main, Epaule et Sport Paris Espace Médical Vauban - Paris VIIe

Indications plus rares que sur les articulations portantes

Anatomie de l’Epaule

w  Grand secteur de Mobilité w  Pas d’emboîtement articulaire w  Stabilité tributaire des parties

molles sujettes à (micro)-traumatismes fréquents (coiffe, labrum)

w  Dysproportion entre glène et tête humérale

Clavicula

Scapula H

umér

us

Supra spinatus

Pectoralis Major

Total Shoulder Reconstruction

w  Components n  Humeral component

l Replaces the ball on top of the upper arm bone.

n  Glenoid component l Replaces the

shoulder socket (part of the scapula).

History

-First procedure (Péan 1892) l  Constrained device design l  Materials: platinum and rubber

n  Stanmore shoulder (1950s) l  Design Features

w  Snap-fit components w  Bone cement for both parts w  Natural glenoid face

l  Influenced by hip replacements w  McKee metal on metal prosthesis

Stanmore Shoulder Copeland, et al

Historical development n  Neer Shoulder

l  Designed by Dr. Charles Neer l  Design features:

w  Unconstrained shoulder replacement w  Humerus component

§  Fixed neck-shaft angle §  No offset of the humeral head

l  Materials: w  Cobalt-Chromium w  Titanium humeral component w  UHMWPE glenoid component.

l  Influenced by developments in hip replacement

Humeral Components CEMENTED

Good for osteopenic bone

Lower risk of intra-operative fracture

More stress-shielding

Hard to revise

PROX POROUS COATED

FULLY POROUS COATED

Higher risk of intra-operative fracture

Less stress-shielding

Easier to revise

Need good bone stock

Need good bone stock

Higher risk intra-operative fracture

More stress

shielding

Hard to revise

Humeral Components PROX POROUS COATED

Higher risk of intra-operative fracture

Less stress-shielding

Easier to revise

Need good bone stock

CEMENTED FULLY POROUS COATED

Good for osteopenic bone

Lower risk of intra-operative fracture

More stress-shielding

Hard to revise

Need good bone stock

Higher risk intra-operative fracture

More stress

shielding

Hard to revise

Humeral Components FULLY POROUS COATED

CEMENTED PROX POROUS COATED

Good for osteopenic bone

Lower risk of intra-operative fracture

More stress-shielding

Hard to revise

Higher risk of intra-operative fracture

Less stress-shielding

Easier to revise

Need good bone stock

Need good bone stock

Higher risk intra-operative fracture

More stress

shielding

Hard to revise

Modeling w  Modeling

n  Finite Element Analysis +  Simple and reliable –  Limited number of nodes –  Time consuming calculation

n  Simplified Elasticity Solution +  Quick, flexible calculation +  Accurate –  Difficult derivation

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Above: An FEA model for a typical glenohumeral interface

Left: An SES solution for stress as a function of displacement into the glenoid component (Święszkowski, W., Bednarz, P. and Prendergast, P. J)

Structural Analysis

Glenohumeral Contact Stresses (700N Applied Force)

Structural Analysis w  Failure Modes

n  Glenohumeral instability l  Most likely failure mode

n  Loosening of glenoid component l  Loss of bone cement adhesion

n  Glenoid component wear l  Polyethylene wear from shear

The Need for Modularity w F-H Offset w B-C Head

thickness w D-E = 8mm Top of humeral

head is higher than greater tuberosity

The Need for Modularity

w Reestablishing normal glenohumeral anatomic relationships is important to ensure optimal results. Iannotti JP; JBJS 74A 1992

Indications d’Arthroplastie de l’Epaule

w Osteoarthritis w Rheumatoid arthritis w Rotator cuff tear arthropathy w Avascular necrosis w Post-traumatic arthritis w Severe proximal humeral fractures

Indications des prothèses de l’épaule

•  Omarthrose centrée : 45 % •  Sequelles de fracture : 14 % •  Polyarthrite rhumatoïde : 10 % •  Ostéonécrose céphalique : 6 % •  Omarthrose excentrée : 5 % •  Fractures de la tête humérale : 20 %

(Etude multicentrique Aequalis (Nice 2000) à propos de 2000 prothèses revues à plus de 2 ans)

Hemiarthroplastie ou cupules céphaliques

Total Shoulder

Reverse Total Shoulder

Options d’Arthroplasties

Omarthrose centrée

w  Classification de Samilson n  Stade 0 : pas d’arthrose n  Stade 1 : osteophyte inf < 3 mm n  Stade 2 : 3 > osteophyte > 7 mm n  Stade 3 : osteophyte > 7 mm + pincement gléno-huméral

Omarthrose centrée

w  In addition to the universal features of osteoarthritic joints (joint space narrowing, cyts, osteophytes…), the shoulder can also demonstrate n  Posterior glenoid erosion n  Flattening of the humeral head n  Enlargement of the humeral head n  Rotator cuff tears are uncommon in OA

Omarthrose centrée

Omarthrose avec subluxation postérieure

Indications : Anatomic prosthesis

Indication : - Arthritis - Functionnal Cuff muscles

ð Hemi arthroplasty

ð Total Arthroplasty

ANATOMIC PROSTHESIS Global advantage

Les prothèses de l’épaule

Prothèse céphalique (« Aequalis »)

Anatomic: Head + Stem

Global Advantage Global AP ARTHRITIS

Resurfacing head: Global CAP

ARTHRITIS

Les prothèses de l’épaule

Prothèse totale comportant une prothèse humérale et une glène

Prothèse « Aequalis » avec une glène métal-polyéthylène ou toute en polyéthylène cimentée

Hemi versus Total Shoulder

w  Easy procedure w  Short Operating time w  Less risk of instability w  Can be revised to TSA û  Less reliable pain relief û  Progressive Glenoid erosion

may cause results to deteriorate over time

û  Need concentric glenoid

w  More consistent pain relief w  Better fulcrum for active

motion

û  Difficult procedure û  Longer OR time û  Poly wear can cause

loosening of both components û  More Glenoid bone loss

Recommendations based on Evidence

w  The results of arthroplasty in osteoarthritis of the shoulder. Haines JF et al. J Bone Joint Surg Br. 2006 Apr;88(4):496-501

w  Prospective study of 124 shoulder arthroplasties for OA

(Hemi and TSA) w  Similar improvement in pain and function in both groups if

rotator cuff was intact . Better results with Hemi if + rotator cuff tear

w  Hemi à Revision at mean of 1.5 years for glenoid pain w  TSA à Revision at mean of 4.5 years for glenoid loosening

Les indications des prothèses de l’épaule dépendent de l’état de la coiffe

Prothèse totale stable sur omarthrose centrée avec coiffe correcte

Les indications des prothèse de l’épaule dépendent de l’état de la coiffe

Évolution défavorable avec ascension de la prothèse vers l’acromion : coiffe insuffisante

Rotator Cuff Arthropathy

w  One function of the rotator cuff is to depress the humeral head and keep it centered on the glenoid fossa.

w  Massive rotator cuff tears result in proximal migration of the humeral head.

w  This is a contraindication to glenoid resurfacing as it results in eccentric (superior) glenoid loading and early component loosening.

Rotator Cuff Arthropathy

w  Described by Neer, Craig and Fukada in 1983.

w  A distinct form of osteoarthritis associated with a massive chronic rotator cuff tear.

w  Generally, rotator cuff tears

occur in less than 10% of shoulders with OA

Surgical Options

w Hemiarthroplasty with a large head

w Repair of rotator cuff and TSA

w Reverse TSA

Traitement de l’omarthrose excentrée

Bon deltoïde et forme « acétabulaire »

Prothèse céphalique

Bon deltoïde et autres formes

Prothèse inversée mais mauvaise force en rot. ext.

Photos C. Lévigne

Anatomic + CTA Head: Global CTA

Global Advantage CTA

Global AP CTA

CUFF TEAR ARTHROPATHY

Global CAP CTA

CUFF TEAR ARTHROPATHY

Indications : Reversed prosthesis

REVERSED PROSTHESIS Delta 3

Indication : - Cuff tear

Outcomes of Hemiarthroplasty

w Rockwood: 86% satisfactory results after 4 years

w Zuckerman: 93% adequate pain relief and 90% had improved function.

w Sanches-Sotelo: 75% modest improvements in ROM and strength. Good pain relief.

Outcomes of Hemiarthroplasty

w Field et al, and Sanchez-Sotelo reported that impaired deltoid function and previous subacromial decompression (loss of coracoacromial ligament) were significantly associated with clinical shoulder instability post hemiarthroplasty.

Indication : - Cuff tear

REVERSED PROSTHESIS Delta 3

ð Increasing of the lever arm (by medialisation of rotation center)

Initial lever arm

Delta lever arm

ð Center of rotation on glenoid (no lever arm for joint forces)

Developped in 1989

Indications : Reversed prosthesis

Les prothèses de l’épaule Prothèse inversée

(Grammont)

La partie sphérique est fixée sur la glène

Prothèse inversée de Grammont

Reversed : Delta Xtend MASSIVE CUFF TEAR

Delta CTA (3.2)

Delta XTEND

Outcomes of the Reverse Total Shoulder

w  The Reverse Shoulder Prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. A minimum two-year follow-up study of sixty patients.

Frankle M, Siegel S, J Bone Joint Surg Am. 2005 Aug;87(8):1697-705 w  Average age = 70 w  Improved ASES scores w  Improved ROM Flex: 55 à 105° Abd: 41 à 102° q  17% Complication rate

7 failures à 5 revised to new Reverse TSA à 2 revised to Hemiarthroplasties

Rheumatoid Arthritis

w  Peri-articular erosions w  Peri-articular osteopenia w  Thin cortices w  Adjacent joint involvement

Rheumatoid Arthritis

w Cemented short-stemmed prosthesis w Gill, Cofield et al recommend at least 60mm

between the cement mantles of ipsilateral shoulder and elbow arthroplasties.

w  If this cannot be achieved, join both cement mantles together.

Rheumatoid Arthritis

w Generally, TSA performed due to destruction of the glenoid articular surface by the disease.

w Glenoid erosion may require bone grafting, however, if glenoid is eroded to the level of the coracoid process, glenoid resurfacing is contraindicated

Traitement de la polyarthrite rhumatoïde

•  Bonne coiffe et glène peu usée

Bons résultats

•  Coiffe dégénérative ou glène détruite

Objectif antalgique

Osteonecrosis

Causes: q Corticosteroids q Alcoholism q Sickle cell disease q Lupus q Idiopathic

Osteonecrosis

w Usually young patients with adequate bone stock.

w Prefer proximally porous-coated, press-fit humeral prosthesis.

ü  less stress-shielding ü  easier to revise if necessary q Only resurface glenoid in stage V

osteonecrosis (glenoid erosion).

Glène intacte

Prothèse céphalique

Glène altérée

Prothèse totale

Photos C. Lévigne

Osteonecrosis

Nécrose de la tête humérale après traitement orthopédique d’une fracture

Nécrose de la tête humérale après traitement orthopédique d’une fracture

Post-Traumatic Arthritis

w Due to fractures treated conservatively w May have mal-union of tuberosities,

distorting normal anatomic landmarks w 12% of patients have axillary nerve palsies

(Neer). w Many have soft-tissue contractures and

muscle weakness

FRACTURES

Fracture stem: Global Fx FRACTURES

Les prothèses pour le traitement des fractures de la tête humérale

Les prothèses pour le traitement des fractures de la tête humérale

Difficultés pour rétablir : - Une hauteur correcte - Une rétroversion correcte - Trochiter et trochin en bonne place Conditions indispensables pour avoir un bon résultat fonctionnel

Après 70 ans

Fractures comminutives

Prothèses céphaliques

Protocole de Rééducation

Protocole de Rééducation Amélioration possible même après la deuxième année

Les résultats fonctionnels sont bons Amélioration fonctionnelle dans les arthropathies chroniques :

90 % des patients satisfaits pour les principales étiologies

70 % seulement pour les séquelles de fractures

Résultats des prothèses de l’épaule

Résultats des prothèses de l’épaule

Complications

w  Instability 1.2% n  Malposition (Excessive Retro/Anteversion)

n  Head too small n  Head too low (post fracture) n  Subscap rupture

Complications

w Rotator Cuff Tear 2%

§  Results in superior migration of humerus and glenoid loosening

Les descellements glénoïdiens sont fréquents (Liseré fréquent après 5 ans mais souvent asymptomatique)

Complications

Le « notching » des Prothèses inversées

Complications

Complications

w  Infection 0.5% §  Staph Aureus,

Propionibacter acnes §  More common after revision

surgery

Complications

w Heterotopic Ossification 10 -45% n  Males n  Dx = osteoarthitis n  Low grade n  Non-progressive n  Does not affect outcome

Sperling, Cofield et al

Complications

w Stiffness n  Depends on indication for arthroplasty n  Subscap shortening n  Oversized components n  Inappropriate rehab

Complications

w Periprosthetic Fracture w Material breakage w  Intra-op 1% w Post-op 0.5 – 2% Most common in RA 85% women Glenoid fractures are rare

Complications

w Periprosthetic Fracture w Material breakage w  Intra-op 1% w Post-op 0.5 – 2% Most common in RA 85% women Glenoid fractures are rare

Complications

w Axillary nerve injury §  Rare §  Higher risk during revision

surgery §  Usually a neuropraxia reversible

Ultimate Bail -Outs

w Excision Arthroplasty w Reversed arthroplasty w Shoulder Arthrodesis

Conclusion

w  Grande modularité dans l’offre prothétique w  L’état de la coiffe des rotateurs dicte l’indication et

conditionne le pronostic w  Bilan systématique par Arthroscanner ou IRM w  Le résultat des d’autant meilleur que l’on a pas tardé

à poser l’indication