Arthrodesis

 

 

Shoulder arthrodesisShoulder arthrodesis lateral

 

Indications

 

Indications have narrowed due to the success of shoulder arthroplasty

 

1. Chronic infection

2. Obstetric brachial plexus injury

3. Post-traumatic brachial plexus injury

4. Salvage of failed GHJ arthroplasty

5. Arthritic diseases unsuitable for arthroplasty / young patient

6. Tumour resection

7. Instability in epilepsy patients / severe MDI

 

Contra-Indications

 

Ipsilateral elbow fusion

Contralateral shoulder arthrodesis

Paralysis of scapula-stabilisers - necessary for function following arthrodesis

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

 

Goals

 

1.  Hand should reach

- mouth

- waist

- belt buckle

- back pocket

 

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

- arm should hang by side with scapula flat against thorax

- no winging

 

Position

 

Ideal

- abduction 10-15°

- flexion 10-15°

- internal rotation 45°

 

Issues

1.  Technically difficult to obtain correct position intra-operatively

2.  Internal rotation 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

 

Options

 

Intra-articular  - glenohumeral compression screws +/- acromiohumeral screws

 

Extra-articular - plate along spine of scapula / acromion and lateral humerus

 

Combined

 

Open Technique

 

Shoulder arthrodesis APShoulder arthrodesis lateral

 

Technique

 

Vumedi open arthrodesis surgical technique video

 

Approach

- midline incision over spine / acromion /  down to deltoid tuberosity

- posterior approach - detach deltoid from spine, interval between IS and TM

- anterior approach  - detach deltoid from clavicle

- protect axillary nerve

 

Preparation

- resect rotator interval

- denude GHJ cartilage

- denude superior humeral head and undersurface acromion

- temporarily fix with steinman pins GHJ and acromio-humeral

- check position / ROM / no winging

- nsert GHJ and acromial-humeral compression screws

- supplement with pelvic reconstruction 12 - 14 hole plate scapular spine / acromion / humerus

- bone graft

- careful deltoid repair in case of future conversion to reverse TSR

- spica / shoulder abduction sling

 

Arthroscopic Technique

 

Arthroscopy Technique

 

Complications

 

Nonunion

 

Infection

 

Fracture of humerus below fusion

 

Prominent hardware

 

Results

 

Brachial plexus injury

 

Atlan et al. J Hand Surg Am 2012

- 54 patients with brachial plexus palsy

- fusion rate 76% after one procedure

- 94% after second operation

- abduction 45 degrees in 75% patients

- rotation 45 degrees in 65% patients

 

Epilepsy

 

Thangarajah et al. J Bone Joint 2014

- 6 patients with epilepsy and chronic instability

- all cases achieved union and prevented instability

 

Failed total shoulder replacement

 

Scalise et al JBJS Am 2008

- 7 patients

- 4/7 required additional procedures to obtain union

- 2/7 persistent non-union

- extremely challenging

 

Conversion to Reverse TSR

 

Alta et al. JSES 2016

- takedown of 4 patients with scapula pain

- EMG evidence of deltoid function

- some improvements in pain and ROM