Periprosthetic fractures occurring in total shoulder arthroplasty (TSA) represent challenges both in decision-making as well as surgical management.

These fractures more frequently involve the humerus but can also occur in the scapula. In a few cases with minimal displacement conservative care may be employed.

In most, however, surgical intervention is needed. Depending on the quality of the surrounding bone, the health of the patient, the stability of the existing implant, and the integrity of the surrounding soft tissues, options for management include open reduction and internal fixation, long stem implants, bone grafting, strut and cable fixation, or a combination of these techniques.

In some cases revision arthroplasty is indicated. An approach to surgical decision-making, operative techniques and avoidance of complications will be presented.

In an effort to address the relatively high rate of glenoid component lucent lines, loosening and failure, tantalum/trabecular metal glenoid implant fixation has evolved as it has in hip and knee arthroplasty. Trabecular metal-anchored glenoid implants used in a consecutive patient case series have demonstrated a lower failure rate than traditional all polyethylene cemented glenoids. Although the radiographs of some patients demonstrated small focal areas of lucency, none have become loose, and only two have actually demonstrated glenoid component failure due to a fracture 6 years after the index procedure. One with glenoid loosening was due to polyethylene wear from a massive cuff tear occurring 8 years after the index procedure. Most patients experienced significant improvements in shoulder range of motion and reduction in pain. Trabecular metal-anchored glenoids when carefully implanted do not produce excessive failure rates, but rather result in functional improvements while decreasing operative time.

The age spectrum for patients undergoing shoulder arthroplasty is broadening. Many younger patients now demonstrate shoulder pathology precluding non-arthroplasty reconstruction. The senior population is living longer and “younger”. Therefore, the demands of this patient population to participate in an active lifestyle are growing. Patients with osteoarthritis, cuff tear arthropathy, post-traumatic arthropathy, avascular necrosis, and even forms of inflammatory arthropathy present seeking not only return to simple activities of daily living but the ability to participate in aerobic recreational activities and even work activities which can stretch the limits of shoulder arthroplasty in the physiologic environment of the shoulder.

This presentation will provide an overview of patient demands, concerns and activity level following shoulder arthroplasty. We will provide a prospective of allowable, recommended and discouraged activities depending on the underlying source of pathology in the type of arthroplasty implants employed. An overview of our four phases of rehabilitation protocol will be presented focusing on phase four, “work in sports hardening”.

Experience has demonstrated in the hip and knee, related to total joint replacement arthroplasty, polymethyl methacrylate cement fixation can provide problems in terms of loosening, fragmentation, particulate wear and ultimate failure.

These same problems have been recognised in total shoulder arthroplasty related to cement fixation of the glenoid. While cement fixation of the humeral component has proven much less problematic, there has been a swelling towards avoidance of using cement to secure the humeral component for fear of difficulty if revision is required.

Surprisingly, with the high incidence of lucent lines, bone resorption and frank loosening, representing the most common source of failure in total shoulder arthroplasty, cementless fixation of the glenoid has not been, until now, embraced.

The advent of reverse total shoulder arthroplasty has demonstrated the ability for secure cementless fixation to provide long-lasting secure implant retention in implants which have inherently higher shear and stress forces passing through the implant/bone interface. In anatomic total shoulder arthroplasty a woven tantalum anchor (Trabecular Metal) has proven to demonstrate secure cementless fixation as well.

This presentation will discuss the use of trabecular metal anchored glenoid implants with and without additional screw fixation for anatomic and convertible reverse arthroplasty baseplates. Avoidance of complications with successful long-lasting outcomes requires meticulous surgical attention to detail.

Peri-prosthetic fractures occurring in total shoulder arthroplasty represent surgical challenges both in decision making as well as surgical management.

These fractures can involve both the humerus and scapula. In a few cases with minimal displacement conservative care may be employed.

In most, however, surgical intervention is needed. Depending on the quality of the surrounding bone, the health of the patient, the stability of the existing implant, and the integrity of the surrounding soft tissues, options for management include open reduction and internal fixation, bone grafting, strut and cable fixation, or a combination of these techniques.

In some cases revision arthroplasty is indicated. An approach to surgical decision-making, operative techniques and avoidance of complications will be discussed.

A variety of challenging shoulder pathology will be presented to a panel of expert shoulder surgeons for their diagnostic evaluation, decision making, surgical management and aftercare.

They will discuss the decision making processes and management options to consider in striving to obtain optimal outcomes.

Cement fixation of the glenoid implants in total shoulder arthroplasty has been the norm since the procedure has existed.

Yet, an unacceptably high rate of lucent lines, representing prosthetic loosening, and a high rate of resultant failure of fixation of these implants continues to be the single most common cause for revision surgery in total shoulder arthroplasty. Dissatisfaction with a higher than acceptable rate of lucent lines, cement fixation of the glenoid component has led us to evaluate and employ an implant anchored into the glenoid vault with a woven tantalum (trabecular metal) fixation stem. We have employed this implant in patients with healthy bone stock with a minimum 2-year follow-up in well over 100 cases with only one revision performed in a first generation implant due to fatigue fracture. No cases have demonstrated lucency or loosening.

The procedure does require meticulous attention to detail to ensure precise surface and glenoid vault preparation providing complete intraosseous seating of the trabecular metal anchor and flush apposition and support of the polyethylene surface upon the face of the glenoid. This process has reduced surgical preparation time as well as time required for cement setting by an average of 20 minutes per case.

A panel of experts in the field of shoulder surgery/arthroplasty will be presented challenging case studies. They will discuss, dissect and analyze these cases from the perspective of appropriate work-up, clinical management, surgical approach and aftercare. A variety of cases representing the spectrum of pathology not uncommonly presenting to the surgeon caring for complex shoulder conditions will be discussed. Indications for nonsurgical and surgical interventions with consideration for various forms of arthroplasty will be presented and debated by the panel.

Hybrid fixation of total joint arthroplasty has been an accepted form of surgical approach in multiple joints. Principles of implant fixation should focus on durability providing secure long-term function. To date there is no conclusive evidence that pressed fit humeral stem fixation has an advantage over well-secured cemented humeral fixation. In fact, need for revision arthroplasty due to inadequate implant fixation has almost universally revolved around failure of cement fixation and loosening of the glenoid component. A case will be made based on 30 years of experience of one surgeon performing total shoulder arthroplasty using secure modern cement fixation techniques of humeral components. More recently, over the last 10 years, extremely high rate of durable secure glenoid implant fixation has been achieved using tantalum porous anchorage with polyethylene glenoid components. This has resulted in no cases of loosening of glenoid fixation and only 1 case of glenoid component fracture with greater than 95% survivorship over a 10 year period. A combination of well cemented humeral stem and trabecular metal anchorage of the glenoid has provided durable lasting function in primary total shoulder arthroplasty.

The key to management of instability when performing total shoulder arthroplasty is to recognise the potential for instability, and avoid the pitfalls which may lead to it post-operatively. Instability can result from incompetent capsular or rotator cuff soft tissue envelopes. It may also result from muscular imbalances, as well as incompetent bony architecture (severe posterior wear causing extreme retroversion, or anterior glenoid loss from fracture) extreme retroversion or improper placement or fixation of implants.

Keys to providing a stable environment include performing careful soft tissue releases and providing muscular balance about the reconstructed arthroplasty; placement of implants in proper version; appropriate tensioning (height) and sizing (avoiding undersizing or overstuffing) of implants; recognizing incompetent rotator cuff substance or function and providing more stable, constrained implants (reverse total shoulder arthroplasty), when necessary.

Keys to recognizing potential instability, tips and pearls for intra-operative and post-operative surgical management will be provided.

The importance of mitigating pain for patients undergoing total shoulder arthroplasty is extremely relevant for purposes of being able to initiate early functional rehabilitation and activities of daily living. The process, however, does not commence after surgery but rather before surgery. Careful patient education and instruction, including pre-operative exercises to maximise mobility, strength and endurance within the limited range of motion is quite helpful. Adjunctive therapy includes preemptive ultrasound-guided intrascalene regional anesthesia, immediate post-operative peri-incisional injection of liposomal bupivacaine, post-operative use of waterproof Tegaderm^TM dressing to allow warm showers early on in the rehabilitation period, peri-operative use of Cox 2 inhibitors and a gentle, therapist-guided passive exercise program focusing on relaxation techniques. This in combination with patient-controlled analgesic pumps, careful surgical technique providing adequate soft tissue releases and removal of potential pain generators such as the long tendon of the biceps and an arthritic AC joint all contribute to the minimization of the patient's pain experience, and offers relatively early weaning from parenteral narcotics in the first 24 hours, and oral narcotics within the first 7–10 days post-operatively.

Retroversion, also referred to as posterior wear of the glenoid, can make resurfacing the glenoid challenging. However, careful pre-operative planning with three dimensional CT scanning can allow central placement of the glenoid component through removal of some of the anterior bone to allow contained placement and secure fixation within the glenoid vault.

Since the scapula is not a fixed skeletal structure and moves substantially on the chest wall, the actual degree of posterior wear (retroversion) frequently is the result of extraneous biomechanical forces and structures. For example, the degree of kyphosis and shape of the rib cage can have a substantial impact on the relative position of the glenoid surface as it articulates with the humerus. Attempts to totally equalise this through implant augmentation have not, to date, been shown to be effective, and in some cases can be destabilising. Restoration of enough alignment to place the implant centrally can be achieved without need for augmentation even in some very hypoplastic glenoids. The technique for this straight-forward approach will be presented, including pre-surgical planning, in some cases, patient specific instrumentation, with demonstration of functional outcomes.

Total shoulder arthroplasty has been shown to be a very effective means of restoring function in all forms of arthritic shoulders. However, much as with any form of arthroplasty, problems and complications can and do occur. These include infection, nerve injury, anesthetic complications, peri-prosthetic fracture, instability and dislocation, nerve and vascular injury, loosening, loss of mobility, and contracture or stiffness, and implant related failures.

Careful pre-operative planning, intra-operative technical execution, and post-operative rehabilitation all designed to meet the needs and demands of the specific patient can help identify potential sources of complications pre-operatively and avoid them post-operatively. Understanding the specific complexities of the type of arthritis being addressed, the strengths and weaknesses, limitations and need for adjustments to the local anatomy can help the surgeon execute the total shoulder arthroplasty with minimal likelihood for post-operative complications. Awareness of patient's own flora and application of appropriate antibiotic prophylaxis can help identify patients at risk for infection.

Although it is impossible to fully eliminate the occurrence of complications, a majority can be avoided through attention to detail.

Introduction and Aims: Rotational malalignment following fracture of the distal radius results in subluxation of the distal radioulnar joint, alteration of the normal contact area of the ulnar head in the sigmoid notch of the radius, arthrosis, pain, limited pronation and supination and dysfunction. This paper describes the technique for restoration of appropriate rotation, as well as length and angulation following malunion.

Method: Eleven cases of derotational osteotomy of the distal radius with low-profile plate fixation have been performed for correction of rotational malalignment with restoration of appropriate articular tilt, length and alignment. In eight cases, the articular surface of the distal ulna was found to be too degenerated to salvage the distal radioulnar joint and resection of the distal ulna with soft tissue reconstruction was performed.

Results: Healing of the osteotomy of the distal radius was achieved in all 11 patients. None of the patients undergoing distal resection demonstrated instability of the distal radioulnar joint but one demonstrated distal radioulnar impingement. One patient with a preserved ulnar head demonstrated ulnocarpal abutment and required late secondary ulna head resection. Pre-operative pronation/supination arc was 40 degrees and postoperative arc was 130 degrees. In eight of the 11, pain was rated as zero on a 10-point scale, while the other three ranged between two and five on the same scale. At a two-year follow-up, grip strength measured 80% of the contralateral side while total range of motion measured 76% of the contralateral side. All 11 patients were functional at daily household activities, five out of seven previously working patients were back to work, and all patients felt that their post-operative status was a significant improvement over their pre-operative status.

Conclusion: Rotatory malpositioning following distal radius fracture provides significant disability. Derotational osteotomy can be effective in restoring pronation and supination, diminishing pain and increasing function. Late treatment may also require resection of the distal ulnar articular surface due to post-traumatic arthrosis. Soft tissue stabilisation at the time of osteotomy provides stability of the distal radioulnar joint in the majority of cases.

Internal rotation contracture/tightness presents a functional problem for the patient and a technical challenge for the surgeon performing total shoulder arthroplasty most commonly occurring in cases of osteoarthritis. Internal rotation contractures result from a number of physiologic and biomechanical conditions. Osteophytes, which form around the head and neck of the humerus and glenoid provide a mechanical block to external rotation, which occurs over time. The inability to pass through a full excursion of external rotation tightens the anterior capsular structures over time and causes a contracture of the musculotendinous units (subscapularis and pectoralis major), responsible for internal rotation. The osteophytes themselves also change the vector of pull of the internal rotators and cause them to be “tented” anteriorly. Hence the issues causing an internal rotation contracture and inhibiting external rotation following total shoulder arthroplasty include a mechanical bone block, diminished tissue compliance and abnormal tendon excursion. Management of this problem has frequently been focused predominantly on fractional lengthening the subscapularis tendon, but all components must be addressed at the time of surgery to make sure that a functional range of motion in external rotation can be achieved following reconstruction. This video details the assessment of each of these components and their management.

Surgical technique includes: resection of all obstructive osteophytes which block rotation and which cause abnormal tendon excursion; adequate head removal and shaping to provide restoration of an anatomical arc of curvature of the humeral head in continuity with the metaphyseal support base, adequate release of upper pectoralis major tendon tightness, release of capsular contractures and adhesions about the subscapularis muscle and tendon; and fractional lengthening of the subscapularis muscle-tendon itself to allow adequate healthy reattachment of the subscapularis tendon to the more superior aspects of the rotator cuff without allowing anterior instability to occur. Attention to the myotendinous junction rather than thinning the tendon itself has proven to be important in achieving a healthy tendon attachment without significant attenuation. Appropriate seating of the humeral head in anatomic version is also important to prevent unnatural distention of the anterior structures. These surgical techniques should help the surgeon provide an anatomic restoration of motion and function.

Septic arthritis of the shoulder or an infected arthroplasty are rare events, but when they do occur present difficult clinical challenges. Little can be found in the existing literature to provide guidance in managing these problems. Certainly early signs of infection are best treated aggressively with irrigation, debridement and appropriate intravenous antibiotic therapy. Early aggressive management can sometimes prevent formal septic arthritis, when a prosthetic implant is well seated may preclude development of deep infection and need for removal.

However, in the face of definitive septic arthritis or sepsis around a prosthetic shoulder implant, aggressive debridement including removal of infected bone, cartilage, and complete removal of prosthetic implants and cement has been shown to be the most reliable means of eradicating infection. Unfortunately, the resultant void leaves the patient with a fairly useless shoulder. Treatment options historically have included resection arthroplasty, late arthrodesis and more recently late attempts at prosthetic reconstruction.

Eight patients have been treated with staged exchange prosthetic replacement utilising tobramycin impregnated methacrylate spacers, shaped and fitted to the patient’s anatomy at the time of extensive debridement. Intravenous antibiotic therapy followed for a minimum of three months. At the end of six months the patients were evaluated for any clinical or laboratory signs of infection. When none were encountered, exchange prosthetic reconstruction was performed utilising standard implants fixed with antibiotic impregnated methyl methacrylate cement. There were three primary infections, (one following rotator cuff surgery) and five patients with infected total shoulder or hemiarthroplasties. Organisms included staph aureus in six patients and staph epidermatitis in two. No organism was methacillin resistant. Three patients had a revision to a total shoulder arthroplasty while five underwent hemiarthroplasty of the humerus with local capsular flap fascial covering of the glenoid.

All eight patients demonstrated substantial pain relief and improvement in function. Motion in all cases was significantly limited with total overhead elevation averaging approximately 70° with only one patient achieving 120°.

Staged exchange prosthetic replacement of the shoulder appears to be a satisfactory salvage procedure for managing sepsis both primarily and following shoulder arthroplasty with evidence of good pain relief but with significant limitations in motion and strength.

Management of arthropathy of the glenohumeral joint has undergone an evolution from neglect to arthrodesis to arthroplasty over the past 30 years. Indications for total shoulder arthroplasty include severely symptomatic glenohumeral arthritis resulting from rheumatoid arthritis, osteoarthritis, a variety of inflammatory arthropathies, post-traumatic arthritis, chronic or multiple recurrent dislocation arthropathy, cuff tear arthropathy and even septic arthritis.

Each form of arthropathy has its own special indications and nuances regarding the successful performance of arthroplasty. With good bone stock and a healthy soft tissue envelope (comprised of deltoid, scapula support musculature and rotator cuff tendons), resurfacing of both the proximal humerus and glenoid has proven to be a very successful surgical procedure, affording reduction in pain, improved motion and function. This procedure has undergone an evolution from the early prosthesis designed by Dr. Charles Neer to the many modular prosthetic devices now available, providing the capability to closely resemble native anatomy in the form of size, version, and angulation. Although the prostheses themselves focus on the restoration of articular surfaces, the key to a successful operation lies in the appropriate tensioning of the soft tissues and recreation of a functional dynamic soft tissue envelope. When bone stock is limited (most commonly involving the glenoid or the glenoid neck), hemiarthroplasty with or without fascial resurfacing of the glenoid has been shown to be helpful.

In cuff deficient patients mobilisation and transfer of tendons around a hemiarthroplasty to provide stability and limited motion has proven to be a good alternative to total shoulder replacement. In the face of infection, debridement and staged reconstruction using an antibiotic impregnated methacrylate spacer with later exchange for a hemi- or total shoulder arthroplasty has been a successful solution and alternative to arthrodesis. Resection arthroplasty and/or arthrodesis are rarely indicated in the active individual but may prove to be viable “bail out” procedures in the patient with chronic infection, low demand or deltoid paralysis.

Arthroscopic debridement of a moderately arthritic joint in young patients has recently been described but its long-term efficacy and has yet to be demonstrated.

Participants should take away from this session an understanding of the indications and contraindications for total shoulder arthroplasty as well as appropriate alternatives in a variety of challenging clinical entities.