Arthrodesis Shoulder

Indications

 

Indications have narrowed

- due to success of shoulder arthroplasty

 

1. Chronic infections of GHJ

2. Stabilization in paralytic disorders

3. Post-traumatic brachial plexus palsy

4. Salvage of failed GHJ Arthroplasty

- may need bone graft procedures

5. Arthritic diseases unsuitable for arthroplasty / young patient

6. Stabilization after resection for neoplastic lesions

 

Contra-Indications

 

Ipsilateral elbow fusion

Contralateral shoulder arthrodesis

Paralysis of scapula-stabilisers (no movement possible)

Charcot arthropathy (low chance union)

 

Advantages

 

Permanent solution

 

Disadvantages

 

Loss of movement at shoulder

Difficulty with activities at head level or behind the back 

Perineal care

Feeding

Loss of movement at other joints 2° prolonged immobilisation

 

Results

 

80-95% patient satisfaction

 

Union rates ~ 95%

 

Aims

 

Rowe 1974 Requisites after Shoulder Arthrodesis

 

1.  Hand should reach face / head / mid-line of the body anteriorly & posteriorly

- thumb to chin

- reach axilla, mouth and belt buckle

- combination of forward flexion and elbow flexion

 

2.  Shoulder be comfortable at rest / scapula should not be prominent

- arm should hang by side with scapula flat against thorax

- no winging

 

Position

 

Rockwood et al JBJS Am April 2001

- Abduction 10-15°

- Flexion 10-15°

- Internal Rotation 45°

 

Issues

1.  Technically difficult to obtain correct position intra-operatively

2.  IR most important to later function

3.  Position in reference to trunk not scapula

4.  Avoid excessive abduction & flexion

- forces the scapula to rotate & wing at rest

- leads to fatigue & discomfort

 

Principles

 

1. Need painless, supple joints above & below

2. Rigidly stabilise congruent vascular cancellous surfaces under compression

3. Bone graft & splint as needed 

 

Options

 

Intra-articular / glenohumeral

 

Extra-articular /  acromio-humeral

 

Combined

 

Principles

 

Approach

 

A.  Posterior

- detach deltoid from spine

- between IS and TM

 

B.  Anterior

- detach deltoid from clavicle

 

Technique

- denude GHJ cartilage

- denude superior humeral head and undersurface acromion

- arthrodesis between humeral head and glenoid / acromion

- temporarily fix with steinman pins GHJ and acromion-humerus

- check position / ROM / no winging

- if satisfactory, insert GHJ and acromial-humeral compression screws

- humerus - acromial plate if anterior approach

- humerus - scapular spine plate if posterior approach

 

Complications

 

Early skin breakdown

Loss elbow flexion

Non-union

Mal-union

Painful metalwork

Breakage of metalwork

Suprascapular nerve entrapment

AC joint OA

 

Results

 

Cofield & Briggs JBJS 1979

- 71 fused shoulders

- average 9 year follow up

- 96% union rate

- 75% adequate pain relief

- 70% good functional result