Shoulder arthroplasty

This video shows the implantation of a shoulder prosthesis
 
History:
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 a patient suffering fram a shoulder destruction due to tuberculosis. 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 gerneration 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.

 

Fields of application:
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 used.
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.
 

Implantation of a shoulder cup prostheses
Other reasons to implant a shoulder prostheses 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 and 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 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 are destructiong the upper third or humeral shaft, often. This is due to primary bone tumors or metastases. Sometimes fractures occur due to tumeral 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. The tumor has to be removed with a maximum of function, as far as possible. Sometimes a shoulder prosthesis can be avoided, performing a tumorr esection combined with an osteosyntheses.
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.
 

Bipolar shoulder prosthesis 1 = stem; 2 = interior head; 3 = outer head

 

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.

 

Survival time:
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 work. 15 years after primary implantation about 86 to 92% are still working - without showing signs of loosening.

 

General information:
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.
 

Cementing of the glenoid component in a total shoulder

 

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 lossening much earlier than a humeral 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 xposition during the operation, underlying disease, kind and amount of destruction are the crucial factors for decision.

 

Operation:
Shoulder arthroplasty is performed in general anesthesia in beach chair position. The most common used approach is in front of the shoulder. After preparing 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.
 

Reverse prothesis: a glenosphere is implanted

 

For very young patients there special implants like cups and for patients suffering from an arthritis of the shoulder with a huge rotator cuff tear special protheses like the reverse implants are used.

 

Rehabilitation:
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.

 

For more information: go to our website www.shoulderprosthesis.com

 

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Other themes & sites arround the shoulder:

Diseases of the shoulder ( german ): http://www.schulterinfo.de , http://www.schulter.info

Diseases of the shoulder ( english ): http://www.shoulderinformation.com

Shoulder arthroplasty: http://www.schulterprothesen.net , http://www.schulterprothesen.com , http://www.shoulderprosthesis.com , http://www.prothesenatlas.de

Frozen shoulder ( german ): http://www.schultersteife.de

Shoulder specialists ( german ): http://www.schulterspezialisten.de

Shoulder examination ( german ): http://www.schulteruntersuchung.de

Shoulder videos ( german ): http://www.schultervideo.de