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Shoulder Arthrodesis 23800

 

synonyms: shoulder fusion, shoulder arthrodesis

Shoulder Arthrodesis Indications

Shoulder Arthrodesis Contraindications

  • Lack of functional scapulothoracic motion
  • Trapezius, levator scapulae, serratus anterior paralysis
  • Charcot arthropathy
  • Previous ipsilateral shoulder arthrodesis
  • Elderaly patients
  • Progressive neurologic disease

Shoulder Arthrodesis Alternatives

Shoulder Arthrodesis Pre-op Planning / Special Considerations

  • Fusion position = 20°of abduction, 20° of forward flexion, and 40° of internal rotation in patients with normal body habitus. (Safran O, JAAOS, 2006;14:145)
  • Pre-operative xrays and CT scan should evaluated for any bony deficiencies and pre-operative surgical plan should be created.

Shoulder Arthrodesis Technique

  • Pre-op antibiotic
  • Anesthesia: GETA +/- scalene block
  • Beach chair position
  • All bony prominences well padded.
  • Incision over the scapular spine curving anterioly toward the anterolateral acromion and contining toward the deltoid tuberosity.
  • Identify deltopectoral interval (interval can be found by palpating medial edge of deltoid insertion into clavicle or finding fat layer in interval surrounding cephalic vein.)
  • Detach the anterior and middle third of the deltoid from the acromion and distal clavicle.
  • Incise clavipectoral fascia adjacent to the conjoined tendon up to the coracoacromial ligament.
  • Release upper 1/3 of pectoralis tendon if needed for exposure.
  • Release subscapularis and anterior capsule as one unit 2cm from the lesser tuberosity insertion. Ensure long-head of biceps tendon is not injured in the proximal aspects of the release.
  • Incise rotator interval medially to the level of the coracoid process.
  • Release the supraspinatus tendon from its greater tuberosity insertion.
  • Tag subscapularis with sutures.
  • Dislocate humeral head by hyperextending and externally rotating arm.
  • Remove marginal osteophytes.
  • Expose the glenoid and shape it to a flat surface in its anatomical plane. (Glenoid inclination is variable, but averages @4.25 degrees superior (range -7 to 15.8); Glenoid version averages 1.23 degrees of retroversion.)
  • The humeral head is temporary pinned in place with Steinman pins in the chosed position of fusion. 20°of abduction, 20° of forward flexion, and 40° of internal rotation in patients with normal body habitus. Verify that the hand can be brought to the forehead with a combinationof shoulder elevation and elbow flexion and the patient’s arm rests at the side without excessive scapular winging in the chosed position.
  • The humeral head is then cut with a oscillating saw to provide maximal bony contact with the prepared glenoid in the position of fusion.
  • The undersurface of the acromoin cut to a flat surface.
  • The superior humeral head is cut to match the undersurface of the acroimion.
  • 4.5mm pelvic reconstuction plate is contoured to the scapular spine, over the acromion and down the lateral proximal humerus.
  • The plate is then fixed using standard AO technique. Place at least two lag screws from the lateral proximal humerus into the glenoid.
  • Pack fusion site with bone graft/demineralized bone matrix.
  • Repair subacapularis to the lesser tuberosity.
  • Repair deltoid to the acromion and distal clavicle.
  • Irrigate.
  • Close in layers.
  • Place in shoulder immobilizer with adbuction pillow.

Shoulder Arthrodesis Complications

  • Nonunion: 0-20% (Safran O, JAAOS, 2006;14:145). Treated with bone graft +/- revision of fixation.
  • Malunion: Treated with ostetomy distal to fusion site. (Groh GI, JBJS 1997;79A:881).
  • Fracture
  • Infection
  • Continued pain
  • Painfull hardware
  • Scapulothoracic muscle pain, loss of motion

Shoulder Arthrodesis Follow-up care

  • Remain in shoulder immobizer with abduction pillow until radiograhic signs of fusion are evident. (3-4 months)
  • Start scapular exercises for strenght and ROM after radiographic fusion.

Shoulder Arthrodesis Outcomes

  • 38% pain free, 36% had mild pain, 23% moderate pain, 3% severe pain. 70% can lift moderate weights, dress themselves, tend to personal hygiene,and eat using the fused extremity. Only 21% can use their arm for light work at shoulder level. 82% find their arthrodesis to be functionally beneficial. (Cofield RH, JBJS 1979;61A:668).

Shoulder Arthrodesis Review References