Complications Of Shoulder Arthroplasty Research Articles

Complications of shoulder arthroplasty for osteoarthritis with posterior glenoid wear

BackgroundAnatomical total shoulder arthroplasty (TSA) for glenohumeral osteoarthritis (OA) and severe posterior glenoid wear may entail early postoperative complications (recurrence of posterior subluxation, glenoid loosening). To avoid these mechanical problems, reverse shoulder arthroplasty (RSA) has recently been proposed, mainly for its intrinsic stability. Our purpose was to present the results of TSA and RSA in glenohumeral OA with posterior glenoid wear of at least 20°. HypothesisBy virtue of its constrained design, RSA could prevent recurrence of posterior subluxation and limit the occurrence of mechanical complications. Materials and methodsA consecutive series of 23 patients (27 shoulders) were treated for glenohumeral OA with total shoulder prostheses: 19 TSAs and 8 RSAs. Mean age was 70years (range, 47–85years), mean retroversion angle 28° (20°–50°) and mean subluxation index 74% (57–89%). Constant Score, Subjective Shoulder Value (SSV), QuickDASH and Simple Shoulder Test (SST) were measured, and radiological examinations were performed at a mean follow-up of 52months (24–95months). ResultsTSA and RSA patients respectively displayed Constant Scores of 65 and 65, SSV of 79% and 74%, QuickDASH of 16 and 27, and SST of 88 and 78. Two patients underwent surgical revision of TSA because of glenoid loosening; 52% of TSA patients presented complete radiolucent lines and 11% recurrence of posterior subluxation. ConclusionComplications are frequently observed after shoulder arthroplasty for OA with severe glenoid retroversion. RSA could be an alternative to TSA for selected patients, independently of rotator cuff status. Studies on RSA in this specific indication with longer follow-up are now needed. Level of evidenceLevel IV; retrospective case series.

Instability failure in total shoulder arthroplasty

Glenohumeral instability is the second most common complication of shoulder arthroplasty, occurring in 4.9% of cases. Instability following arthroplasty is best classified based on its direction. The unconstrained shoulder arthroplasty can be unstable superiorly, anteriorly, inferiorly, and posteriorly. The causes and incidences of each direction are unique and individualized. The goal of this paper is to identify the cause of different types of total shoulder arthroplasty instability and discuss techniques to avoid such complications.

Subject-specific bone remodelling of the scapula

Finite element analyses, with increasing levels of detail and complexity, are becoming effective tools to evaluate the performance of joint replacement prostheses and to predict the behaviour of bone. As a first step towards the study of the complications of shoulder arthroplasty, the aim of this work was the development and validation of a 3D finite element model of an intact scapula for the prediction of the bone remodelling process based on a previously published model that attempts to follow Wolff's law. The boundary conditions applied include full muscle and joint loads taken from a multibody system of the upper limb based on the same subject whose scapula was here analysed. To validate the bone remodelling simulations, qualitative and quantitative comparisons between the predicted and the specimen's bone density distribution were performed. The results showed that the bone remodelling model was able to successfully reproduce the actual bone density distribution of the analysed scapula.

Pegged versus keeled glenoid components in total shoulder arthroplasty

Loosening of the glenoid component is a common complication in shoulder arthroplasty. We proposed to radiographically and clinically investigate the outcomes of keeled and pegged glenoid components to test the hypothesis that these implants would have equivalent performance. One hundred patients undergoing primary shoulder arthroplasty for osteoarthritis were reviewed. Fifty patients had pegged glenoid components, and fifty had keeled components. Standardized radiographs were taken. Preoperative films classified the severity of degenerative change. The postoperative films were analyzed for radiolucent lines and shift in component position-at-risk signs for loosening. Mean radiographic follow-up was 51.3 months (range, 24-90 months) for the keeled group and 45.7 months (range, 27-98 months) for the pegged group. There were no differences in the degree of preoperative arthritic change between groups. Both groups had significant improvement in motion and pain (P < .001) postoperatively, with no differences in clinical outcome between cohorts (P > or = .20). Initial radiographs showed no radiolucencies around the pegs in 46 implants or around the keel in 49 components. At final follow-up, 10 glenoid implants were found to be at risk for loosening, 6 (12%) in the pegged group and 4 (8%) in the keeled group (P = .74). Initial postoperative radiographs with pegged and keeled components show a low rate of radiolucent lines. These radiolucencies develop over time. However, there is no difference in clinical or radiographic outcomes between pegged and keeled components at intermediate-term follow-up.

Complications in shoulder arthroplasty: an analysis of 485 cases

The aim of this study was to analyse the complication rates of six different shoulder arthroplasty concepts for different diagnoses in the short and midterm. The study included 485 primary shoulder arthroplasties. The mean follow-up of the cohort was 3.5 (1-10) years. Complications were classified into three categories: (1) without reoperation, (2) soft tissue revision and (3) implant revision. In total, 56 complications were recorded (11.6%): 34 (7%) were category 1 complications, 11 (2.3%) were category 2 and 11 (2.3%) were category 3. For the whole cohort the median follow-up was 1.6 years (1-10 years) and the survival rate without any complication was 90.5% (95% CI: 87.9-93.1). Patients rated the result of their surgery in 270 (55.7%) cases as very satisfied, in 148 (30.5%) as satisfied, in 43 (8.9%) as somewhat disappointed and in 24 (4.9%) as disappointed. A relatively low complication rate was found in this study. Long-term observations are necessary to confirm these results.

Shoulder arthroplasty

Shoulder prostheses are now commonly used. Clinical results and patient satisfaction are usually good. The most commonly used types are humeral hemiarthroplasty, unconstrained total shoulder arthroplasty, and semiconstrained inversed shoulder prosthesis. Complications of shoulder arthroplasty depend on the prosthesis type used. The most common complications are prosthetic loosening, glenohumeral instability, periprosthetic fracture, rotator cuff tears, nerve injury, infection, and deltoid muscle dysfunction. Standard radiographs are the basis of both pre- and postoperative imaging. Skeletal scintigraphy has a rather limited role because there is overlap between postoperative changes which may persist for up to 1 year and early loosening and infection. Sonography is most commonly used postoperatively in order to demonstrate complications (hematoma and abscess formation) but may also be useful for the demonstration of rotator cuff tears occurring during follow-up. CT is useful for the demonstration of bone details both pre- and postoperatively. MR imaging is mainly used preoperatively, for instance for demonstration of rotator cuff tears.

Reliability of proximal migration measurements in shoulder arthroplasty

Proximal migration is a complication in shoulder arthroplasty. Quantification of this phenomenon would help in identifying its cause. This study assessed the reliability of 4 methods of measuring proximal migration after shoulder arthroplasty on standard anteroposterior radiographs: the glenohumeral center-to-center measure, the glenohumeral arc measure, the acromiohumeral distance, and the scapular spine-humeral head center (spinohumeral) distance. Radiographs were taken of 12 embalmed shoulders, with matching metal humeral head replacements, in the neutral position and rotated both ways for 20 degrees along the vertical and horizontal axes. The measurements were tested for the reliability of the deviating projections against the neutral position, and an estimate of the interobserver and intraobserver reliability was made. Statistics included a paired t test and the interclass correlation coefficient. The acromiohumeral distance and spinohumeral center method proved most reliable. The spinohumeral center method was the least sensitive for projection errors, although only applicable as a relative measure. The coracoid process base can be used as a tell-tale sign for scapular projection.

Neurovascular injury after shoulder hemiarthroplasty: A case report and review of the literature

Since shoulder replacement was introduced for the treatment of complex proximal humeral fractures by Neer et al 13 Neer II, C. Brown Jr., T. McLaughlin H. Fracture of the neck of the humerus with dislocation of the head fragment. Am J Surg. 1953; 85: 252-258 Abstract Full Text PDF PubMed Scopus (107) Google Scholar in 1951, its use has grown exponentially. 2 Aval S.M. Durand Jr., P. Shankwiler J.A. Neurovascular injuries to the athlete's shoulder: part I. J Am Acad Orthop Surg. 2007; 15: 249-256 PubMed Google Scholar Neer and Morrison 14 Neer II, C. Morrison D. Glenoid bone-grafting in total shoulder arthroplasty. J Bone Joint Surg Am. 1988; 70: 1154-1162 PubMed Google Scholar reported that replacement of the shoulder joint is one of the most technically demanding of the current joint replacement procedures. Despite its clinical success, complications do occur. 15 Norris T. Iannotti J. A prospective outcome study comparing humeral head replacement and total shoulder replacement for primary osteoarthritis of the shoulder. Presented at the 12th Opening Meeting of the American Shoulder and Elbow Surgeons. Ga, AtlantaFebruary 1996 Google Scholar , 16 Passannante A. Spinal anesthesia and permanent neurologic deficit after interscalene block. Anesth Analg. 1996; 82: 873-874 PubMed Google Scholar , 23 Stableforth P. Four-part fractures of the neck of the humerus. J Bone Joint Surg Br. 1984; 66: 104-108 PubMed Google Scholar Although neurologic injury is a rare complication, with an estimated incidence of 1% to 4% in shoulder arthroplasty cases, 6 Cofield R. Complications of shoulder arthroplasty. Instructional Course Lecture No. 317. Presented at the American Academy of Orthopaedic Surgeons Annual Meeting. Calif, San FranciscoFebruary 1993 Google Scholar , 11 Lynch N.M. Cofield R.H. Silbert P.I. Hermann R.C. Neurologic complications after total shoulder arthroplasty. J Shoulder Elbow Surg. 1996; 5: 53-61 Abstract Full Text PDF PubMed Scopus (166) Google Scholar we are unaware of definite data on the prevalence of vascular or combined neurovascular injury. We present a patient who had complete transection of the axillary artery and the distal posterior cord after shoulder hemiarthroplasty.

Shoulder hemiarthroplasty for acute fractures of the proximal humerus: A minimum five-year follow-up

Significant discrepancy in the functional outcome of hemiarthroplasty for proximal humerus fractures has been reported with short or mid-term follow-up. This study reports the long-term results and rate of complications of shoulder arthroplasty in the treatment of proximal humerus fractures. The review comprised 57 patients (44 women, 13 men) who underwent hemiarthroplasty between 1976 and 1996 as treatment of a proximal humerus fracture and who had a minimum 5-year follow-up (mean, 10.3 years). The mean patient age was 66 years at the time of surgery (range, 23-89 years). According to a modified Neer result rating system, results were satisfactory in 27 patients and unsatisfactory in 30. The mean active elevation was 100 degrees (range, 20 degrees -180 degrees ) and external rotation was 30 degrees (range, 0 degrees -90 degrees ). At the most recent follow-up, 9 patients (16%) had moderate or severe pain and 2 required implant revision or removal. The study data suggest that patients undergoing arthroplasty as treatment of an acute fracture of the proximal humerus may achieve satisfactory long-term pain relief; however, the result for overall shoulder motion is less predictable. In view of these results, current indications, surgical technique, and postoperative treatment may need to be revisited.

Intramedullary reaming for press-fit fixation of a humeral component removes cortical bone asymmetrically

Periprosthetic humeral fractures are major complications of shoulder arthroplasty. Bone removal during surgical reaming is a risk factor for these fractures. Although it is recognized that the endosteal surface of the humerus is asymmetrical whereas the reamers are symmetrical, to our knowledge, the effect of cylindrical reaming on the pattern of cortical bone removal during reaming has not been previously studied. The medullary canals of 10 cadaveric humeri (mean age, 73 years) were reamed in a manner similar to that used during humeral arthroplasty. Cortical dimensions were obtained from computed tomography scans before and after reaming. In unreamed humeri, the anterior-posterior endocortical diameter was 20% smaller than the medial-lateral diameter. The average medial-lateral diameter (15.6 +/- 2.3 mm) was significantly greater than the anterior-posterior diameter (12.5 +/- 1.9 mm) at 13 cm distal to the tuberosity (P < .00005). Successive cylindrical reaming preferentially thinned the anterior and posterior cortices. This bone loss would not be apparent on anterior-posterior radiographs. Intramedullary reaming to obtain substantial cortical contact asymmetrically removes cortical bone in a manner that may increase the risk of periprosthetic fracture.

Pseudo-obstruction; a rare complication of shoulder arthroplasty

Acute pseudo-obstruction of the colon (Ogilvie’s syndrome) is a recognized complication following lower limb arthroplasty, pelvic and spinal surgery. If unrecognized it may result in massive colonic dilatation that may lead to life threatening perforation. An 84 year-old female patient experienced pseudo-obstruction following shoulder arthroplasty. She improved with non-operative treatment. To our knowledge this has not been described before. Therefore this potentially life-threatening complication should also be considered in upper limb surgery if the clinical picture suggests pseudo-obstruction.

Résultats de la résection arthroplastique dans les arthroplasties d’épaule infectée

Purpose of the study Infection is a rare complication of shoulder arthroplasty. Various therapeutic solutions have been proposed: antibiotics alone, one-stage or two-stage reimplantation, surgical or arthroscopic cleaning without prosthesis removal, scapulohumeral arthrodesis or simple arthroscopic resection. We evaluated the mid-term clinical outcome after resection arthroplasty for the treatment of infected shoulder arthroplasty. Material and methods The series included ten infected arthroplasties in ten patients. Mean duration of implantation was two years seven months (range nine months to five years). Bacteriological diagnosis was established from intraoperative articular samples or systematic samples taken during surgical revision procedures: meti-S Staphylococcus aureus strains (n = 4), coagulase-negative Staphylococcus (n = 5 including three S. epidermidis) Streptococcus mitis (n = 1) and Citrobacter koseri (n = 1). The mean Constant score before revision was 58 (range 23-77). Subjective patient satisfaction before surgical revision was rated good in six cases, fair in one and poor in three. Surgery associated removal of the implant, complete resection of the cement, resection of the fistular tracts, wide debridement of infected tissues and total synovectomy. Results Patients were seen at an average follow-up of three years eight months. The objective functional outcome measured with the Constant score was only fair, 28 points (range 20.6-36), and corres-ponded to a loss of 29 points compared with the preoperative score. This was explained mainly by lower scores for joint motion, function and muscle force but with persistently satisfactory scores for pain. All patients remained pain-free (daytime and nighttime). Patient satisfaction was rated good for two, fair for five and mediocre for three. Clinical and biological proof of eradicated infection was obtained in all patients. Discussion Infection remains a serious devastating problem for shoulder arthroplasty with an important functional impact. Resection only has a modest clinical effect. Precise identification of the causal germ with institution of adapted antibiotic therapy is required for eradication of the infection. Early diagnosis is probably the most important parameter affecting clinical outcome and surgical options. Functional results after resection arthroplasty are modest. This procedure should be reserved for patients with reduced functional demands. Improved management of the infectious load and reduction of diagnostic delay should help improve functional outcome ad favor use of stow-stage procedures for reinsertion.

Complications of total shoulder arthroplasty: Are they fewer or different?

There has been significant evolution of total shoulder arthroplasty design and improvement in technique over the past 25 years, but there is no information available as to whether this has translated into lower complication rates or different sorts of complications. The purpose of this study was to determine the contemporary complications and their frequency. Between 1990 and 2000, 431 total shoulder arthroplasties were performed with a cemented all-polyethylene glenoid component. Follow-up averaged 4.2 years. Complications were categorized by type as early or late and as minor, major, or major requiring reoperation. In total, 53 surgical complications occurred in 53 patients (12%). Of these, 32 were major complications (7.4%), with 17 of these requiring reoperation. Index complications in order of frequency included rotator cuff tearing, postoperative glenohumeral instability, and periprosthetic humeral fracture. Notably, glenoid and humeral component loosening requiring reoperation occurred in only 1 shoulder. Developing a complication was unrelated to diagnosis, previous surgery, age, sex, humeral head size, or cementing or not cementing the humeral component. Data from the contemporary patient group suggest that there are fewer complications of shoulder arthroplasty and less need for reoperation. Especially striking is the near absence of component revision because of loosening or other mechanical factors. Periprosthetic humeral fractures are more common; the explanation for this warrants further study.

The effect of shoulder arthroplasty on humeral strength: An in vitro biomechanical investigation

Periprosthetic humeral fractures are a serious complication of shoulder arthroplasty. While adequate reaming of the canal and insertion of an oversized implant optimizes fit, such maneuvers also weaken the bone and predispose it to fracture. The impact of the humeral arthroplasty was assessed in vitro on human cadaveric specimens. Strain gauges were attached to the distal diaphyses and the specimens were mounted in a torsion-loading fixture throughout the tests. An initial series examined the effect of reaming of the canal to its clinically appropriate diameter using uniaxial strain gauges. A second series utilized strain rosettes to evaluate the cumulative effects of reaming, broaching, and implant insertion. Reaming of the canal to its clinically appropriate diameter significantly increased (P=0.007) uniaxial strain measurements by a mean of 30% with five of eight specimens showing increases of over 49% on at least one of four diaphyseal locations. In the second series, the surface strain was significantly affected by arthroplasty (P<0.008). Post-hoc analysis showed that the maximum in-plane shear strain following implant insertion was significantly increased relative to strain levels following reaming and broaching (P<0.009). The direction of the principal strain axes did not significantly change (P>0.46). Unexpected decreases in some strain measurements were observed as the arthroplasty procedure progressed perhaps reflecting overt mechanical failure within the humeral shaft. The strain increase following reaming suggests a reduction in torsional strength by over 33% which is further reduced following broaching and implant insertion. For the practicing surgeon, post-operative strength can be adversely affected by both canal preparation and implant insertion.

Glenoid cementing may generate sufficient heat to endanger the surrounding bone.

Glenoid loosening is a common complication of shoulder arthroplasty. One possible cause is bone necrosis from the exothermic reaction of polymethylmethacrylate. The relationship between the amount of cement used in glenoid fixation and the risk of thermal injury to bone was examined. Glenoid arthroplasty was done on 17 fresh cadaver scapulas, recording the amount of cement used. The bone surface temperature during cement curing was measured using infrared thermography. Using these data and published thresholds for thermal necrosis, the frontal plane area of bone that would be at risk for necrosis in vivo was estimated. The average weight of cement implanted was 5.35 g (2.65-8.08 g). The maximum temperature recorded averaged 64.7 degree C (48.2 degree-76.8 degree C). The area of bone at risk correlated with the amount of cement used. This study indicates that potentially dangerous amounts of heat may be generated during cementing of glenoid components.

Stress shielding and bone resorption in shoulder arthroplasty

The radiographs of 64 patients with 70 humeral head replacements were reviewed for signs of stress shielding. Of these, 49 were implanted for rheumatoid arthritis and 21 for osteoarthritis. The radiographic follow-up averaged 5.3 years. Measurements of cortex thickness were performed in 4 regions along the stem of the implant, and the differences between the postoperative radiograph and the radiograph at follow-up were calculated. The size of the stem in relation to the diameter of the humerus was calculated with the use of validated measures, resulting in the relative stem size. In 6 patients (9%) a significant reduction in cortical thickness was observed in the proximal-lateral region of the humeral stem, 5 in rheumatoid patients and 1 in an osteoarthritic patient. In the stress shielding group, the relative stem size was found to be significantly higher than that in the non-stress shielding group (0.58 vs 0.48). Osteoporosis, especially present in rheumatoid arthritis, could well be a risk factor. It was concluded that stress shielding is a long-term complication of shoulder arthroplasty and that the relative stem size is an important factor in its genesis. (J Shoulder Elbow Surg 2003;12:35-39)

Pulmonary embolism following shoulder arthroplasty.

While there have been numerous reports concerning the risk of pulmonary embolism after knee and hip arthroplasty, no such information is available for shoulder arthroplasty, as far as we know. The purpose of this study was to determine the prevalence of pulmonary embolism following shoulder arthroplasty. A review of 2885 consecutive patients who underwent primary shoulder arthroplasty at our institution between June 30, 1981, and June 30, 2001, was performed to identify all patients who sustained a pulmonary embolism. During this time-period, five patients sustained a pulmonary embolism following shoulder arthroplasty. Three of the five presented with symptoms that were originally attributed to causes other than pulmonary embolism. None of the patients sustained a fatal pulmonary embolism. The data from this study demonstrate that pulmonary embolism is an uncommon complication of shoulder arthroplasty and that surgeons should have a high degree of suspicion if patients have respiratory difficulty following shoulder arthroplasty.

Instability after arthroplasty: The shoulder

Shoulder instability after total shoulder arthroplasty may be classified as posterior, anterior, superior, or inferior. Basic causes include malposition of the components, incorrect version of the glenoid or humeral cuts, soft tissue contractures or laxity, and cuff deficiency. These may be present as isolated or as combined deficiencies. As always, avoidance is best, but instability is the commonest complication of shoulder arthroplasty and must be dealt with correctly. Recognition of the anatomic cause is crucial. Proper evaluation with radiographs, computed tomography, and magnetic resonance imaging is crucial to the treatment algorithm. Normally the glenoid is nearly perpendicular to the scapular spine, whereas the humeral head is retroverted about 30° with respect to the transepicondylar axis. After defining the anatomic problem, proper component positioning, elimination of contractures, plication of capsular laxity, and establishing cuff integrity ensure the best opportunity for a stable shoulder. Copyright 2002, Elsevier Science (USA). All rights reserved.

Arthroscopy for failed shoulder arthroplasty

Purpose: It was the purpose of this study to describe the specifics of technique and results of arthroscopic evaluation and treatment of failed shoulder arthroplasties in 10 patients with early and late complications of shoulder arthroplasty. Type of Study: Case series. Materials and Methods: Ten patients (2 bilateral) underwent 13 arthroscopies after poor results following shoulder arthroplasty. The arthroscopic diagnoses ranged from rotator cuff tears in 5 shoulders, fibrosis and scarring of the long head of the biceps in 5 shoulders, impingement and biceps tendinitis in 1 shoulder, and capsular contracture in 1 shoulder. We performed 4 mini-open rotator cuff repairs, 1 open rotator cuff repair with revision of the humeral component, 5 arthroscopic debridements of the long head of the biceps, 2 arthroscopic decompressions with biceps tenodesis, and 1 arthroscopic capsular release. Results: Before arthroscopy, the preoperative Hospital for Special Surgery (HSS) scores were 6 fair and 6 poor. At latest follow-up, there were 3 excellent, 4 good, and 5 fair results. There was a statistically significant improvement in HSS scores and range of motion for all patients in this study. All patients were satisfied with the results of the procedure. There were no infections or wound problems and neurovascular status was unaltered after arthroscopy. There was 1 intraoperative complication, a periprosthetic humerus fracture after manipulation in an osteoporotic woman with rheumatoid arthritis. Conclusion: Arthroscopy proved to be a reliable diagnostic and therapeutic tool in dealing with some of the postoperative complications encountered both early and late after shoulder arthroplasty. Careful attention to surgical technique, including use of blunt trocars, traction, and intraoperative prophylactic antibiotics, can minimize complications of arthroscopy in this setting.Arthroscopy: The Journal of Arthroscopic and Related surgery, Vol 16, No 6 (September), 2000: pp 606–612

Periprosthetic fractures in total shoulder replacement

Periprosthetic fracture is an uncommon complication of shoulder arthroplasty. Over an 18-year period, we identified 38 fractures occurring either during or subsequent to a shoulder arthroplasty. Among intraoperative fractures, the humeral shaft was involved in nine cases, the greater tuberosity in five, the proximal humeral metaphysis in two, the glenoid in four, and the coracoid process in two. Postoperative fractures involved the humeral shaft in 15 cases and the coracoid process in one. Thirty-three fractures occurred in women compared with five in men. Rheumatoid arthritis was the most common diagnosis. Our results suggest that intraoperative shaft fractures occurring at or below the stem tip can be successfully managed by using a long stem implant to bypass the fracture. Supplementary cerclage wires or cables are added if additional stabilization is needed. Eleven of the 15 postoperative shaft fractures were initially treated with a cast or brace. Nonoperative treatment led to union in 6 of the 11 (54.5%), but failed in 5. We recommend a trial of closed treatment if a satisfactory reduction can be obtained and maintained. If acceptable alignment cannot be achieved, or if delayed or nonunion develops, recommended surgical options include internal fixation with a plate if the prosthesis is well fixed, or revision with a long-stem prosthesis. Three of the four intraoperative glenoid fractures precluded glenoid resurfacing. Except for a nonunion in one case, greater tuberosity fractures did not impact the ultimate clinical outcome. Coracoid process fractures were also not clinically significant.