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Shoulder Arthrodesis

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Topic updated on 09/15/15 2:08pm
Introduction
  • The goal of shoulder arthrodesis is to provide a stable base for the upper extremity optimizing hand and elbow function
    • it remains an important treatment option in appropriately selected patients
  • Indications
    • stabilization of paralytic disorders
    • brachial plexus palsy
    • irreparable deltoid and rotator cuff deficiency with arthropathy
    • salvage of a failed total shoulder arthroplasty
    • reconstruction after tumor resection
    • painful ankylosis after chronic infection
    • recurrent shoulder instability which has failed previous repair attempts
    • paralytic disorders in infancy
  • Contraindications
    • ipsilateral elbow arthrodesis
    • contralateral shoulder arthrodesis
    • lack of functional scapulothoracic motion
    • trapezius, levator scapulae, or serratus anterior paralysis
    • Charcot arthropathy during acute inflammatory stage (Eichenholtz 0-2)
    • elderly patients
    • progressive neurologic disease
Anatomy
  • Glenohumeral articulation
    • a relatively small amount of surface area exists allowing for predictable fusion
    • to increase the available fusion area, decortication of both the glenohumeral articular surface and the articulation between the humeral head and the undersurface of the acromion is performed
    • only the glenoid fossa and base of the coracoid provide sufficient strength for fixation
Presentation
  • Symptoms
    • specific to the underlying condition necessitating arthrodesis
    • symptomatic dysfunction of the glenohumeral joint
Imaging
  • Radiographs
    • recommended views
      • AP, lateral, and axillary views to assess bone stock available for fusion and deformities
  • CT
    • better to evaluate glenoid bone loss especially in the setting of failed arthroplasty
Studies
  • EMG
    • indicated when the neurologic condition of the scapular muscles is ill-defined
Surgical Technique
  • Approach
    • S-shaped skin incision beginning over the scapular spine, traversing anteriorly over the acromion, and extending down the anterolateral aspect of the arm
  • Fusion position
    • goal is to allow patients to reach their mouths for feeding 
      • think "30°-30°-30°" 
        • 20°-30° of abduction
        • 20°-30° of forward flexion
        • 20°-30° of internal rotation
  • Technique
    • rotator cuff is resected from the proximal humerus and the biceps tendon is tenodesed
    • glenoid and humeral head articular surfaces and the undersurface of the acromion are decorticated
    • arm is placed into the position of fusion (30°-30°-30°)
    • a 10-hole, 4.5 mm pelvic reconstruction plate is contoured along the spine of the scapula, over the acromion, and down the shaft of the humerus
    • compression screws are placed through the plate across the glenohumeral articular surface into the glenoid fossa
    • the plate is anchored to the scapular spine with a screw into the base of the coracoid
  • Postoperative care
    • a thermoplastic orthosis is applied the day after surgery and is maintained for 6 weeks
    • at 6 weeks, may transition to a sling if there are no radiographic signs of loosening
    • at 3 months, mobilization exercises and thoracoscapular strengthening are commenced if no radiographic signs of loosening are present
    • expected recovery period is 6-12 months
Complications
  • Infection
  • Nonunion
  • Malposition
  • Prominent hardware
  • Humeral shaft fracture

 

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Qbank (2 Questions)

TAG
(OBQ11.69) Which of the following patients would benefit most from a glenohumeral arthrodesis? Topic Review Topic

1. A 74-year-old man with AVN of the proximal humerus
2. A 24-year-old woman with recurrent instability after an arthroscopic procedure for multi-directional instability
3. A 30-year-old laborer with a paralysis of the deltoid and rotator cuff muscles
4. A 70-year-old patient with removal of an infected primary total shoulder arthroplasty
5. A 20-year-old man patient with cleidocranial dysostosis

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TAG
(OBQ06.241) A 45-year-old man has paralysis of his deltoid and rotator cuff as the result of a motorcycle injury. His neurologic injury has not improved in the 5 years since the injury, but he does have some use of his hand and wrist. What is the most appropriate treatment? Topic Review Topic

1. Levator scapulae and rhomboid tendon transfer
2. Total shoulder replacement
3. Reverse total shoulder replacement
4. Shoulder arthrodesis
5. Latissimus dorsi transfer

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