Rarely, arthrodesis is done to stabilize the glenohumeral joint after many failed attempts at shoulder reconstruction.. Arthrodesis for failed prosthetic arthroplasty or tumor resection
Trang 1Shoulder arthrodesis is an end-stage salvage option for the failing, painful joint that cannot undergo or has failed reconstruction It is indicated for irreversible and nonreconstructible massive rotator cuff tears and deltoid muscle denervation as well as for detachment
of the deltoid from its origin Rarely, arthrodesis is done to stabilize the glenohumeral joint after many failed attempts at shoulder reconstruction Arthrodesis for failed prosthetic arthroplasty or tumor resection presents additional challenges because of the associated bone loss on the humeral and/or glenoid side of the joint Primary arthrodesis requires rigid internal plate fixation and both an extra- and an intra-articular site of fusion Depending on bone volume and quality needed, the patient may require bracing for 8 to 10 weeks, autogenous or allograft bone grafting, or a vascularized fibular bone graft to reconstruct the bone deficiency, along with prolonged spica cast immobilization The optimal
position for arthrodesis is 20° of forward flexion, 20° of abduction, and 40° of internal rotation, with modifications based on patient
body size or other patient-specific factors Bone fusion is attained
in nearly all patients, with marked pain reduction and improved function Postoperatively, the patient should be able to lift the arm
to near shoulder height and to reach the top of the head, the mouth, the ipsilateral back pocket, and the groin Complications include nonunion, malposition, pain associated with prominent hardware, and periarticular fractures
The development of prosthetic shoulder arthroplasty has nearly eliminated the need for arthrodesis in primary arthritic joints Arthrodesis has become an end-stage salvage pro-cedure for shoulder pain, weakness, and instability not suitable for soft-tissue or prosthetic reconstruction.1
The principal indications include conditions that result in severe and irreparable deltoid and rotator cuff deficiency, caused by irreversible pa-ralysis of these muscles with preser-vation of the scapular muscles In such refractory cases, arthrodesis may offer significant pain reduction
and some functional use of the upper extremity in what would otherwise
be an unsolvable situation
Indications
Currently, shoulder arthrodesis is in-dicated for brachial plexus injury, failed prosthetic arthroplasty, recon-struction after tumor resection, chronic infection, and refractory in-stability and pseudoparalysis of the shoulder secondary to combined ro-tator cuff and deltoid muscle dys-function
Motor vehicle accidents account
Ori Safran, MD
Joseph P Iannotti, MD, PhD
Dr Safran is Senior Orthopaedic
Surgeon, Department of Orthopaedic
Surgery, Hadassah-Hebrew University
Medical School, Jerusalem, Israel Dr.
Iannotti is Professor and Chairman,
Department of Orthopaedic Surgery,
The Cleveland Clinic Foundation,
Cleveland Clinic Lerner School of
Medicine of Case Western Reserve
University, Cleveland, OH.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr Safran and Dr Iannotti.
Reprint requests: Dr Iannotti, The
Cleveland Clinic Foundation, 9500
Euclid Avenue, Cleveland, OH 44195.
J Am Acad Orthop Surg
2006;14:145-153
Copyright 2006 by the American
Academy of Orthopaedic Surgeons.
Trang 2for most traumatic brachial plexus
injuries These devastating injuries
affect young patients in almost 90%
of cases.2When spontaneous
recov-ery of the deltoid and rotator cuff
muscles does not occur, procedures
such as neurolysis, nerve grafting,
and muscle transfer are warranted in
an effort to reestablish shoulder
function Shoulder arthrodesis may
be considered in the presence of
se-verely restricted shoulder passive
range of motion, significant bone
loss, or failed prior reconstructive
measures.3 Because the trapezius
and levator scapulae muscles are
al-most always intact after traumatic
brachial plexus injury, active arm
abduction can occur through the
scapulothoracic articulation When
the serratus anterior is preserved,
forward elevation of the arm
through scapular rotation is also
pos-sible.4
Severe humeral and glenoid bone
loss, poor deltoid and rotator cuff
function, and refractory instability
(after multiple surgical procedures)
may render functional improvement
or pain relief via revision
arthroplas-ty impossible in patients with failed
shoulder arthroplasty When
arthro-desis is considered for these patients,
special techniques are needed to
compensate for the significant
gle-noid and humeral bone loss
Limb-sparing resection for
malig-nant and locally destructive tumors
of the proximal humerus may result
in significant tissue deficiency The
choice between prosthetic
recon-struction and glenohumeral
arthrode-sis is made based on the quality of the
soft tissue and bone after completion
of the curative resection Frequently,
tissue loss is severe, and arthrodesis
is the only valid option for regaining
shoulder stability.5,6To achieve fusion
in these patients, vascularized
au-tograft or bulk allograft must be used
to compensate for bone deficiency
Patients with the combination of
infection and a painful, damaged
joint present a difficult challenge
Prosthetic reconstruction is
con-traindicated when the septic process
is not eradicated Surgical débride-ment and glenohumeral fusion may yield a painless stable joint in many patients.7
Most unstable shoulder pathology
is managed through one or a combi-nation of the following procedures:
soft-tissue balancing, muscle trans-fer, and bone block With persistent refractory instability after multiple failed stabilization procedures, pa-tients may be left with a painful, dysfunctional shoulder devoid of competent soft-tissue or bony straints Fusion is one option for re-gaining stability and some degree of function in these patients.8
Arthropathy resulting from rota-tor cuff tear alone has not been con-sidered an indication for shoulder fu-sion Currently, patients with a rotator cuff tear may be treated suc-cessfully with shoulder hemiarthro-plasty or reverse total shoulder ar-throplasty with acceptable results
However, in the presence of irrepara-ble rotator cuff tear coinciding with irreparable deficiency of the deltoid muscle or dysfunction, some au-thors recommend fusion.9,10Fusion
is especially advocated in younger patients with demands for substan-tial strength at low angles of shoul-der flexion
Glenohumeral arthrodesis is gen-erally contraindicated in patients who lack functional scapulothoracic motion, which may be caused by pa-ralysis of the trapezius, levator scap-ulae, and serratus anterior muscles
Fusion is a less favorable option in patients at high risk of pseudarthro-sis, such as those with Charcot arthropathy.10-12 Patients with ad-vanced bilateral shoulder disease should not undergo bilateral arthro-desis because positioning cannot be achieved to allow the normal perfor-mance of activities of daily living (ADLs) Finally, elderly patients or those with progressive neurologic disease generally do not achieve sat-isfactory results with shoulder ar-throdesis
Surgical Considerations
A variety of periarticular fusion techniques, fixation methods, and immobilization strategies have been advocated for shoulder arthrodesis
Shoulder Position
The ideal position for shoulder ar-throdesis remains a matter of debate Most surgeons agree that the proper position of shoulder arthrodesis should enable the patient to reach the face for washing, the midline for dressing and hygiene, and the back pocket (Figure 1) It is important to minimize scapular winging in the resting position in order to minimize fatigue and periscapular muscle pain.10
The exact position of fusion re-mains elusive It is difficult to objec-tively and accurately measure the different angles, and the ideal posi-tion depends on patient body size One of the first guidelines was made
in 1942 by a committee of the Amer-ican Orthopaedic Association,13
which recommended 50° of abduc-tion, 15° to 25° of flexion, and 25° of internal rotation This recommenda-tion was later disputed by Rowe,14
who found that the degree of abduc-tion suggested by the committee caused periscapular muscle pain be-cause of excessive loads and winging
of the scapula in the resting position
He explained that excessive abduc-tion shifted the extremity away from the fulcrum of the shoulder, thus weakening its lifting and functional strength Rowe suggested 20° to 25°
of abduction (just enough to clear the axilla), 30° of forward flexion, and 45° to 50° of internal rotation to get to the midline of the body Elbow flexion, in his opinion, would allow the patient to reach the head and face.14,15
In contrast, in their review of 71 shoulder fusions, Cofield and Briggs16
found that the amount of abduction and flexion did not correlate with ei-ther periscapular pain or patient sat-isfaction and ADL function They did
Trang 3find a correlation between the
amount of internal rotation and
var-ious ADLs Later studies supported
Rowe’s findings, although they
fa-vored less internal rotation.12,17,18
Groh et al19advocated a lesser degree
of abduction and forward flexion of
10° to 15°, compensated with 45° of
internal rotation, enabling the
pa-tient to reach the mouth, belt buckle,
and contralateral shoulder and axilla
Fusion of the shoulder joint in 20°
of abduction, 20° of forward flexion,
and 40° of internal rotation in most
mesomorphic patients usually
al-lows acceptable position In obese
patients, significantly greater
abduc-tion is both required and
well-toler-ated; the body habitus will not allow
<20° of abduction In all patients, at
the conclusion of the procedure the
surgeon should be able to bring the
hand to the forehead with a
combi-nation of shoulder elevation and
el-bow flexion In addition, the
pa-tient’s arm should be able to rest at
the side without excessive scapular
winging
Extra-articular Versus Intra-articular Fusion
Shoulder arthrodesis may be ac-complished by fusing the glenohu-meral joint, the acromiohuglenohu-meral in-terface, or both Extra-articular fusion involves fusion between the proximal humerus and the undersur-face of the acromion, scapula, and clavicle without entering the gleno-humeral joint Extra-articular fusion alone was one of the first methods of shoulder arthrodesis The technique involved decorticating the upper part of the proximal humerus, the undersurface of the acromion, the lateral portion of the spine of the scapula, and the distal clavicle This procedure was initially advocated for treating tuberculosis patients with glenohumeral joint destruction dur-ing the era in which anti-tuberculosis antibiotics were not available.20 Extra-articular fusions are rarely done as isolated proce-dures today
Intra-articular fusion involves preserving the rotator cuff tendons
without attempting to fuse the hu-merus to the acromion Limited in-ternal fixation is used to preserve most of the bone architecture and soft tissues Some surgeons recom-mend intra-articular fusion for younger patients with glenohumeral joint destruction and intact rotator cuff tendons, with the expectation of possible future revision into shoul-der arthroplasty.21In 1992, Morgan and Casscells22 reported on an arthroscopically assisted intra-articular glenohumeral arthrodesis
in a 39-year-old woman with refrac-tory multidirectional shoulder insta-bility, intractable pain, and deltoid paralysis After aggressive arthro-scopic débridement and decortica-tion of the glenohumeral joint, two cannulated compression screws were inserted across the glenohu-meral joint, followed by an acromio-humeral screw for extra-articular stabilization The patient was placed
in a foam abduction pillow for 4 weeks Radiographs at 10 weeks confirmed solid glenohumeral bony
Figure 1
The arthrodesis position should enable the patient to reach the face and hair for washing and combing (A), the midline for dressing (B), and the back pocket (C).
Trang 4union The patient was pain-free and
able to perform ADLs with the fused
shoulder
Currently, combined extra- and
intra-articular fusion techniques are
most commonly used.4,10,12,16-18,23
Decorticating the humeral head,
gle-noid, and acromion maximizes the
surface area for bone contact,
there-by increasing the probability of
achieving solid fusion
Fixation Methods
Arthrodesis fixation methods
have undergone marked evolution
Historically, postoperative spica
casting for 3 to 4 months was the
only so-called fixation used, and loss
of position was common In 1964,
Charnley and Houston24introduced
external bone compression for
achieving solid fusion of the
shoul-der Later, Beltran et al25introduced
glenohumeral compression screws,
which reduced the length of
postop-erative immobilization to 4 weeks
Subsequently, compression screws
became the accepted standard,12,15,16
but most patients still required
rela-tively prolonged periods of
postoper-ative spica cast immobilization In
the past two decades, the additional
stability provided by the
combina-tion of compression screws and
plates has minimized the need for
strict postoperative immobilization
without a concurrent increase in
nonunion rates; this has become the
accepted standard for glenohumeral
arthrodesis.4,7,8,10,18,23
Richards et al4used a single
con-toured 4.5-mm dynamic
compres-sion plate (DCP) placed over the
spine of the scapula, the acromion,
and the lateral portion of the
humer-al shaft for shoulder arthrodesis in
14 patients Postoperatively, patients
were placed in a spica cast for an
av-erage of 8 weeks All patients
achieved solid fusion; the two who
had only acromiohumeral fusion
re-mained stable and asymptomatic
Five years later, Richards et al23
re-ported their use of a single 4.5-mm
pelvic reconstruction plate on 11
pa-tients with brachial plexus palsy who underwent shoulder arthrode-sis; they were immobilized postoper-atively in a spica cast for 6 weeks
All achieved union by 5 months
The authors concluded that the more malleable reconstruction plate provided sufficient stability, a high union rate, and minimal skin prob-lems
Stark et al18used a long DCP in 15 patients undergoing arthrodesis, with no postoperative immobiliza-tion aside from an abducimmobiliza-tion pillow
Fusion was achieved in 14 of 15 pa-tients, and extremity position was lost in only one patient, in whom fixation was inadequate Four pa-tients had local skin irritation and pain, with two ultimately requiring removal of the screws but not the plate Clare et al10recommended the routine use of a 4.5-mm reconstruc-tion plate but favored the 4.5-mm DCP plate for patients weighing more than 100 kg Use of the ex-tremity was allowed as soon as tol-erated Routine use of compression screws traversing the plate and crossing the glenohumeral joint were used by all authors
External fixators also have been used in shoulder arthrodesis Charn-ley and Houston24used an external fixator, achieving union in 18 of 19 patients, most with tuberculous joint destruction Postoperatively, spica casts were used for additional stability in all patients Johnson et
al26 and, later, Kocialkowski and Wallace,27reported using a combina-tion of compression glenohumeral screws and an external fixator
Johnson et al26 used a Hoffman ex-ternal fixator and compression screws in four patients without addi-tional immobilization, and all fused
The fixator was removed 7 to 14 weeks after surgery; the authors re-ported only one pin tract infection (which responded to antibiotics and local wound care) and one fracture after frame removal Nagano et al28
reported on 11 patients who under-went shoulder arthrodesis for
brachi-al plexus injury using an externbrachi-al fixator and temporary internal fixa-tion All patients had solid fusion within 3 months, and the external fixator was removed 3 months after surgery No complications were re-ported
Technique
Preoperative planning is crucial for successful arthrodesis Often, shoulder arthrodesis is performed af-ter several failed previous surgical attempts or in conjunction with a radical bone and soft-tissue resec-tion Extensive bone loss may exist because of injury, infection, osteoly-sis after shoulder arthroplasty, or tu-mor resection Consideration should
be given to careful assessment of re-maining bone stock and soft-tissue deficiencies Small cancellous bone deficiencies may be managed with local or iliac cancellous bone graft More substantial deficits may re-quire a structural graft, such as a tri-cortical iliac graft, structural al-lograft, or vascularized fibular graft The patient is anesthetized using
a combination of a scalene block and general anesthesia, followed by su-pine beach chair positioning An in-cision is made over the spine of the scapula, curving it anteriorly over the midacromion toward the antero-lateral corner of the acromion, then continuing over the lateral aspect of the arm toward the deltoid tuberos-ity The deltopectoral interval is identified and developed The
anteri-or and middle panteri-ortions of the deltoid are detached from the lateral third of the clavicle, anterior acromion, and lateral acromion The deltoid is then retracted laterally and distally, hinged on its neurovascular pedicle The subscapularis tendon is sharply dissected from the lesser tuberosity, and the supraspinatus tendon is ex-cised from its musculotendinous junction to the greater tuberosity The glenoid is prepared by remov-ing its articular cartilage and cuttremov-ing its bony surface flat and parallel with its original plane The humeral
Trang 5head is placed in contact with the
prepared glenoid fossa, and the arm
is placed in the preferred position
and temporarily held in place by two
Steinmann pins Proper positioning
is examined by taking the arm
through a range of scapulothoracic
motion, verifying a functional range
With the arm in the correct position,
an oscillating saw is used to cut the
medial portion of the humeral head
The undersurface of the acromion is
cut to a flat decorticated surface, and
the superior portion of the humeral
head is cut parallel with it (Figure 2,
A and B)
A 4.5-mm pelvic reconstruction
plate is contoured to accommodate
the spine of the scapula, the lateral
surface of the acromion, and the
lat-eral portion of the proximal
humer-us Under fluoroscopic guidance,
two partially threaded cancellous
screws are placed through the
hu-meral head into the glenoid surface
and neck; at least one is placed
through the plate One or two
simi-lar screws are inserted through the
acromion into the humeral head,
with at least one through the plate
An additional screw is placed
through the plate and spine of the
scapula into the base of the glenoid
neck The remaining screws are
placed through the plate into the
spine of the scapula and proximal
humerus using a standard AO
tech-nique (Figure 2, C and D) The fusion
site is packed with local morcellized
bone using pieces of bone removed
during humeral and acromial
prepa-ration The subscapularis is then
re-paired to the lesser tuberosity The
deltoid is reattached to the clavicle
and to the anterior and lateral
por-tions of the acromion through bone
holes, as well as to the trapezius
fas-cia
In the presence of severe bone
stock deficiency (eg, after failed
ar-throplasty), augmentation of the
bone stock is needed In these cases,
bone contact may be improved by
using the tuberosities as a local
vas-cularized bone graft; they are fixed to
the fusion region between the gle-noid and neck Further stability may
be achieved by adding a structural graft of tricortical iliac bone or al-lograft between the lateral humeral shaft and the decorticated undersur-face of the acromion A pelvic recon-struction plate is used to fix the al-lograft in place (Figure 3)
When >6 cm of the proximal hu-meral shaft is missing, vascularized fibular grafts are used to replace the absent segment, along with addi-tional iliac bone graft or allograft For optimal docking, the fibular graft should be 4 to 5 cm longer than the humeral length needed The distal 3
cm of the fibular graft is stripped of its soft tissue and is either placed in
the humeral medullary canal or at-tached to the humeral outer cortex and fixed with cortical screws The proximal part of the fibular graft is keyed into a trough burred within the glenoid fossa The construct is stabilized with a 4.5-cm pelvic recon-struction plate Partially threaded cancellous screws are placed through the fibula into the glenoid (Figures 4 and 5) After stable fixation is achieved, the fibular graft is revascu-larized Thereafter, augmentation is done with autologous graft or frac-tionated bone marrow aspirate mixed with demineralized cortical fibers and cancellous chips The material is used to fill the space between the proximal fibula, the glenoid, and the
Figure 2
Stages of bone preparation and fixation A, The medial aspect of the humeral head
is cut parallel with the glenoid surface The glenohumeral pins are removed before
completing the cut B, The undersurface of the acromion and superior surface of the humeral head are cut in parallel C, A 4.5-mm pelvic reconstruction plate is used
to firmly stabilize the arthrodesis Partially threaded screws are used to compress
the humerus to the glenoid and acromion D, Anteroposterior radiograph taken a
few weeks after arthrodesis (Panels A, B, and C copyright Cleveland Clinic Foundation, 2003.)
Trang 6undersurface of the acromion.
After surgery, the shoulder is
im-mobilized using a Southern
Califor-nia Orthopaedic Institute (SCOI)
brace (DonJoy, Vista, CA), abduction
pillow, or spica cast The extent of
immobilization depends on the
qual-ity and quantqual-ity of bone as well as
the stability of the fixation In a
pri-mary fusion with good bone stock
and stable fixation, the SCOI brace
or abduction pillow is used for 8 to
10 weeks In complex cases with
poor bone quality, poor fixation, or
structural grafting, the patient is
im-mobilized in a spica cast for 3 to 4
months or until there is
radiograph-ic evidence of fusion When it is dif-ficult to determine bony fusion on radiographs, computed tomography scan reconstructions may be neces-sary Scapular exercises for range of motion and strength are started after radiographic signs of fusion are found
Functional Results
The objective of shoulder arthrode-sis is a painless, functional
extremi-ty sufficient for most ADLs Studies indicate that most patients report
marked pain relief after surgery, al-though few are completely pain-free Hawkins and Neer12 reported that only 4 of their 16 patients were pain-free, whereas 9 needed analgesics on
a daily basis for moderate or severe pain Cofield and Briggs16 reported better pain control in their series Of the 65 patients, 25 (38%),were pain free, 24 (36%) had mild pain, 15 (23%) had moderate pain, and only 2 (3%) had severe pain Of the 17 pa-tients with moderate or severe pain,
10 (59%) had pain located to the sur-gical area, 5 (29%) had pain in the periscapular region, and 2 (12%) had diffuse pain Extremity function was limited by pain in most of the pa-tients with moderate or severe pain Rouholamin et al29described ex-cellent pain relief in 10 of 15 pa-tients with brachial plexus injury
Figure 3
A 65-year-old man presented with failed humeral arthroplasty of the right shoulder,
an irreparable rotator cuff tear, and impaired deltoid muscle function
A,Preoperative anteroposterior radiograph demonstrating noticeable prosthetic
loosening B, Postoperative anteroposterior radiograph after application of a pelvic
reconstruction plate C and D, Functional range of motion was achieved.
Figure 4
Arthrodesis with large proximal humeral bone deficiency The fibular graft is 4
to 5 cm longer than the humeral length needed, for optimal docking The proximal part of the fibular graft is keyed into a burred trough in the glenoid The trough is fashioned to optimize bone contact and allow sufficient abduction (Copyright Cleveland Clinic Foundation, 2003.)
Trang 7who underwent shoulder fusion.
Three patients reported aching with
prolonged use of the arm; the pain
was relieved with rest Two patients
with preoperatively diagnosed
neu-rogenic pain continued to have pain
Excellent pain relief also was
report-ed by Rybka et al30in their series of
41 patients with rheumatoid
arthri-tis Only four patients reported
tran-sitory pain, which was thought to be
caused by increased strain on the
periscapular muscles In a recent
study, Wick et al7reported marked
pain reduction after arthrodesis in 15
patients with septic arthritis
Four-teen of the 15 patients had active
in-fection (positive cultures) at the time
of arthrodesis Ninety percent of
pa-tients reported marked pain
reduc-tion; however, no patient was
pain-free
Functional outcome after
shoul-der arthrodesis has lagged behind
pain improvement Of the 17
pa-tients in the Hawkins and Neer
study,125 functioned reasonably well
at head level (eg, hair combing, face
washing), while 4 others had great
difficulty Fourteen patients could
use their hands satisfactorily at
waist level, but only 3 could reach
the hand behind the back for
hy-giene Overall, 7 of the 17 patients
were dissatisfied because of
func-tional disability Wick et al7 found
that patients were unable to reach
behind the back, and most of them
had difficulty with ADLs around the
face In contrast, Cofield and
Briggs16reported that, of the 65
pa-tients available for follow-up, 70%
could lift moderate weights, dress
themselves, tend to personal
hy-giene, and eat using the extremity
with the fused shoulder Although
only 21% could use their arm for
light work at shoulder level, 82%
found their arthrodesis to be
func-tionally beneficial
Richards and colleagues4,23 and
Rouholamin et al29 reported
func-tional results similar to those of
Cofield and Briggs.16All of their
pa-tients (except those with distal
ex-tremity paralysis or amputees) could easily reach the mouth Although none of Richards’ patients could per-form overhead work, all were satis-fied with their functional improve-ment Hawkins and Neer12reported that no patient was able to work overhead or with the arms abducted (eg, hammering, painting, climbing a ladder) Four of 17 patients could not return to jobs requiring manual la-bor Five of the 17 patients returned
to manual labor, but not at their
pre-injury level It is worth noting that Hawkins and Neer12 as well as Cofield and Briggs16found extreme internal rotation to be detrimental for shoulder function
Complications
Among the complications of shoul-der arthrodesis are nonunion, mal-positioning of the fused shoulder, perifusion fractures, infection, con-tinued pain, and soft-tissue irritation
Figure 5
A 21-year-old man presented several years after resection of the right proximal humerus for osteogenic sarcoma The proximal humerus was reconstructed with
segmental allograft and a custom-made total shoulder prosthesis A, Preoperative
anteroposterior radiograph demonstrating dislocation of the shoulder arthroplasty
as well as a recent periprosthetic fracture, necessitating shoulder arthrodesis
B,Postoperative radiograph demonstrating a long vascularized fibular graft compensating for a deficient humerus and arthrodesis of the acromion, glenoid,
and fibula C and D, Functional range of motion was achieved after fusion.
Trang 8caused by prominent fixation
devic-es The frequency of these
complica-tions is related to the quality and
quantity of bone available for fusion
as well as to the condition of the
soft-tissue envelope
Nonunion
In most series, the rate of
20%.4,7,8,12,16,23,30The relatively small
number of patients in most studies,
along with the complexity of the
ini-tial diagnosis, makes it difficult to
compare results between studies
With modern fixation methods,
however, the nonunion rate is
clos-er to 10%, with the exception of
fu-sion after septic arthritis, which
re-mains at 20%.7
Most reported nonunions were
symptomatic, painful, and required
further treatment Revision surgery
with secondary bone grafting and/or
refixation achieved union in most
patients Only a small percentage of
patients demonstrated partial fusion
of either the glenohumeral or the
acromiohumeral articulation In
nearly all cases, the fusion mass was
stable, the shoulder was functional,
and no further treatment was
neces-sary
Malposition of the Fused
Shoulder
It is difficult to define
malposi-tion because no consensus exists as
to optimal position However,
sever-al guidelines may assist in making
this assessment Painful winging of
the scapula with the arm in the
rest-ing position is a functional
defini-tion of malposidefini-tion associated with
excessive abduction or flexion of the
fusion In addition, in the absence of
other causes, inability to reach the
face or anterior midline is most
like-ly the result of rotational
malposi-tion of the arthrodesis Surgical
cor-rection should be sought when the
malposition causes scapular pain or
leads to dysfunction in ADLs A
closing wedge corrective osteotomy
distal to the fusion mass combined
with plate fixation and grafting is recommended for managing a signif-icant and symptomatic malposi-tioned fusion.10Groh et al19reported that osteotomy markedly improved pain and function in all nine patients who underwent corrective
osteoto-my for malpositioned shoulder fu-sion
Periarthrodesis Fractures
Elimination of motion at the gle-nohumeral joint combined with lo-cal osteopenia increases the proba-bility that relatively minor trauma will cause fracture around the ar-throdesis Typically, fracture occurs distal to the fusion mass either at the point at which the plate fixation ends or at the entry point of the most distal compression screws
Cofield and Briggs16 reported on eight postoperative humeral frac-tures in their series of 71 patients, with most occurring in paralytic pa-tients All fractures healed with ex-ternal immobilization In their se-ries of 41 patients, Rybka et al30
reported only one late postoperative humeral neck fracture, which oc-curred after a fall 1.5 years after sur-gery No fractures were reported by Richards and colleagues4,23 or by Stark et al.18Nondisplaced humeral fractures are managed with immobi-lization; displaced or unstable frac-tures require internal fixation for solid union to occur.17
Prominence of Fixation Device
The superficial location of inter-nal fixation devices, particularly compression screws and plates, may cause local skin problems and skin penetration Typically, this occurs over the spine of the scapula and acromion because of a poor soft-tissue envelope secondary to muscle atrophy and multiple surgeries In many cases, partial or complete re-moval of the fixation device after consolidation of the fusion mass is necessary to solve the problem
Cofield and Briggs16 reported late
screw removal in 17 of 71 shoulder operations (compression screws were used) Higher rates of soft-tissue prominence have been reported when DCP plates were used Rich-ards et al4had to remove eight DCP plates from their 14 patients (57%) Stark et al18reported four symptom-atic plate removals in 15 patients In the later study by Richards et al,23
lower rates of metal-related symp-toms were reported when recon-struction plates were used However,
in a series using only reconstruction plates for fixation, local discomfort
or prominence necessitated hard-ware removal in five of eight pa-tients.8
Summary
Shoulder arthrodesis is an end-stage salvage procedure for managing pain and loss of function when other joint-sparing reconstructive options have been exhausted It is an alterna-tive to resection arthroplasty in the patient who desires the ability to lift
to chest or shoulder level A solid fu-sion achieves good pain relief and ac-ceptable ADL function in most pa-tients Return to work is less consistently achieved, however Both the surgeon and the patient should be aware of the limitations of shoulder arthrodesis and set realistic goals With proper indications and surgical techniques, solid shoulder fusion and a satisfactory result are achieved in the vast majority of
cas-es, with improvement in pain and functional outcome
References
Evidence-based Medicine: Evidence-based reports consist of level III (case-contracted studies) or level IV (case series) only
Citation numbers printed in bold
type indicate references published
within the past 5 years
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Trang 9shoulder fusion in the era of
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