Arthritis basics and managment copy

1. Shoulder Arthritis and Management
Puneet Monga
Consultant Orthopaedic Shoulder Surgeon

2. Broadly 2 types of Arthritis
RC Intact RC Torn

3. Shoulder replacements
Broadly 2 types
Anatomical Reverse geometry

4. Making the right
diagnosis….

6. Management
• Early stages
• Analgesia
• Activity modification
• Physiotherapy
• Advanced
• Joint Replacement

7. NJR 2015
= 1 replacement/ surgeon / month
NJR 2016
= Median 13 replacements / surgeon /year

8. Trends; combined data from international shoulder registries-
E Griffiths, P Monga 2016
Proportion of Shoulder Replacements by Type
% anatomic %Reverse %Hemis
FDA Approval for Reverse- 2003

9. Future projections- by 2030
Demand projected to increase by 755.4%
Prediction of increased complication and revision load
Clin Orthop Relat Res. 2015 Jun;473(6):1860-7. doi: 10.1007/s11999-015-4231-z. Epub 2015 Mar 11.
Future patient demand for shoulder arthroplasty by younger patients: national projections.
Padegimas EM1, Maltenfort M, Lazarus MD, Ramsey ML, Williams GR, Namdari S.

10. Understanding the
Trends

11. Increased use of TSR- Influence of
training
Surgeons with fellowship training in shoulder
surgery are more likely to perform TSA over Hemi
arthroplasty for OA

12. Guidelines - AAOS
AAOS recommends TSR over HSA for GH OA
2011

13. Increased use of Reverse- Influence of
training
• Reverse for trauma
• 2005 - 2%
• 2007- 4%
• 2012 - 38%

14. Increased use of Reverse- Influence of
training
• Shoulder Surgeons (fellowship trained)
• 5 times more likely to use arthroplasty
for fractures
• 20 times more likely to use reverse

15. Future projections- by 2030
• Demand projected to increase by 333.3% in <55
year old pts
• Demand projected to increase by 755.4% in >55
year old pts
• Rate of hemiarthroplasty declining by 16% in < 55
year
• Hence prediction of increased revision loadClin Orthop Relat Res. 2015 Jun;473(6):1860-7. doi: 10.1007/s11999-015-4231-z. Epub 2015 Mar 11.
Future patient demand for shoulder arthroplasty by younger patients: national projections.
Padegimas EM1, Maltenfort M, Lazarus MD, Ramsey ML, Williams GR, Namdari S.

16. Evolution and Design

17. • First recorded shoulder arthroplasty
• 1893, Paén, Paris.
• Tubercular arthritis
• Rubber humeral head, Platinum shaft,
attached with a wire. Further wire
attached to Glenoid
• Removed at 2 years
Lugli T: Artificial shoulder joint by Péan (1893). The facts of an exceptional intervention
and the prosthetic method. Clin Orthop 1978; 133: 215-218

18. • Themistocles Gluck
• Romanian Surgeon in Germany
• Second half of 19th Century
• For tuberculosis
• Ivory
• Thought leader
Gluck T: Referat über die Durch das moderne chirugishe Experiment gewonnenen positiven
Resultate betreffend die Nacht und den Ersatz von defecten hoherer Gewebe sowie über die
Verwertung resorbirbarer und lebendiger Tamons in der Chirurgie. Arch Klin Chir 1891; 41: 187-
239

19. First Generation
• Monoblock implants
• 1951 Kruger; Aseptic necrosis
• 1953 Charles Neer Proximal humeral
fractures (1953)
• 1974 Total shoulder replacement for
glenohumeral arthrtis (1974)
Kruger FJ: A vitallium replica arthroplasty on the shoulder: a case report of aseptic necrosis of
the proximal of the humerus. Surgery. 1951; 30: 1005-1011
Neer CS: Articular surface replacement for the humeral head. J bone Joint Surg Am 1955; 37:
215-228

20. Second generation
• Modular Humeral head size
• Did not cater to the variation in anatomy
of the proximal humeral adequately

21. Third Generation
• Anatomic study; Modeled proximal humerus on a sphere and a cylinder
• Variability in
• Humeral head diameter
• Articular Surface diameter
• Articular surface thickness
• Inclination
• Retroversion
• Posterior offset
• Medial offsetBoileau P, Walch G: Anatomical study of the proximal humerus: Surgical technique consideration and prosthetietic
design rationale. Walch G, Boileau P(ed): Shoulder Arthroplasty. Berlin, Springer, 1999
Robertson DD, Yuan J, Bigliani LU, Flatow E, Yamaguchi K. Three-Dimensional Analysis of the Proximal Part of the

22. Third Generation
• The Anatomic (adaptable) prosthesis.
• Adapt the prosthesis to the patient
• Neck Cut along the patient’s retroversion
• Humeral head Diameter choices
• Neck Shaft Angle choices
• Offset variable and can be dialled in

23. Glenoid resurfacing
• 1974 Neer CS. First report for GH
arthritis
• Keeled Rectangular
• Cemented
• Congruous articular surface Image courtesy: AAOS

24. Glenoid design
• Convex back vs Flat back
• Convex back
• Bone preserving
• Better resistance to shear forces
• Lesser Radioluscent lines
Anglin C, Wyss UP, Pichora DR: Mechanical testing of shoulder prosthesis and
recommendation for glenoid design, J Shoulder Elbow Surg 2000; 9: 323-3331
Image Courtesy: IJSS

25. Glenoid design
• Conforming vs non conforming
• Conforming: minimise wear, stable
• Non conforming: Lack of translation
• 6 to10mm diameter mismatch optimum
Image courtesy: Matsen et al
J Bone Joint Surg Am. 2002 Dec;84-A(12):2186-91.
The influence of glenohumeral prosthetic mismatch on glenoid radiolucent lines: results of a multicenter study.
Walch G1, Edwards TB, Boulahia A, Boileau P, Mole D, Adeleine P.

26. Glenoid design
• Keeled vs Pegged vs Fluted
• Debate still open
• Gartsmann et al-Pegged fewer
radioluscencies
• Gazielly D et al; Keeled better
• Nuttall et al Fluted peg: high early looseningGartsman GM1, Elkousy HA, Warnock KM, Edwards TB, O'Connor DP.Radiographic comparison of pegged and keeled glenoid components.
J Shoulder Elbow Surg. 2005 May-Jun;14(3):252-7.
Nuttall D1, Haines JF, Trail IA The early migration of a partially cemented fluted pegged glenoid component using radiostereometric analysis.
J Shoulder Elbow Surg. 2012 Sep;21(9):1191-6.

27. Glenoid design
• Cemented vs Uncemented
• Metal backed designs Issue:
Glenoid Poly thickness
• High failure rates with traditional
prosthesis
• ?Role in revision and Bone
deficiency
• ? Hybrid models
Image Courtesy: Prof IA Trail
J Shoulder Elbow Surg. 2002 Jul-Aug;11(4):351-9.
Cemented polyethylene versus uncemented metal-backed glenoid components in total shoulder arthroplasty: a
prospective, double-blind, randomized study.
Boileau P, Avidor C, Krishnan SG, Walch G, Kempf JF, Molé D.

28. Getting It Right First
Time

29. Avoiding Complications
…….!

30. • Step 1 Using the Correct implant
• Step 2 Assessment of Bone Stock
• Step 3 Predicting Cuff failure
• Step 4 Performing a good operation

31. Step 1 = Choosing the right Implant
Evolution =

32. Broadly 2 types of Arthritis
RC Intact RC Torn

33. Shoulder replacements
Broadly 2 types
Anatomical Reverse geometry

34. Anatomical Replacements
Resurfacing
Head replacement
Classic Stemmed

35. Modern humeral stem
Kruger FJ: A vitallium replica arthroplasty on the shoulder: a case report of aseptic necrosis of
the proximal of the humerus. Surgery. 1951; 30: 1005-1011
Neer CS: Articular surface replacement for the humeral head. J bone Joint Surg Am 1955; 37:
215-228
Boileau P, Walch G: Anatomical study of the proximal humerus: Surgical technique
consideration and prosthetietic design rationale. Walch G, Boileau P(ed): Shoulder Arthroplasty.
Berlin, Springer, 1999

36. Glenoid design
• Convex back vs Flat back
• Conforming vs non
conforming
Anglin C, Wyss UP, Pichora DR: Mechanical testing of shoulder prosthesis and recommendation for glenoid design, J Shoulder Elbow Surg 2000; 9: 323-3331J Bone Joint
Surg Am. 2002 Dec;84-A(12):2186-91.
The influence of glenohumeral prosthetic mismatch on glenoid radiolucent lines: results of a multicenter study.
Walch G1, Edwards TB, Boulahia A, Boileau P, Mole D, Adeleine PGartsman GM1, Elkousy HA, Warnock KM, Edwards TB, O'Connor DP.Radiographic comparison of
pegged and keeled glenoid components.
J Shoulder Elbow Surg. 2005 May-Jun;14(3):252-7.Nuttall D1, Haines JF, Trail IA The early migration of a partially cemented fluted pegged glenoid component using
radiostereometric analysis. J Shoulder Elbow Surg. 2012 Sep;21(9):1191-6. Gazielly D, El-abaid R: comparitive results of three types of polythelene cemented glenoid
componenets. Recul de 2 à 10 Ans. Paris, Sauramps Medical, 2001, 483-488
Image Courtesy: IJSS
Image courtesy: Matsen et al
• Keeled vs Pegged vs Fluted
• Cemented vs Uncemented
“Convex Back, Non conforming, cemented All-poly pegged”

37. Reverse geometry
• Many unsuccessful attempts at reverse
geometry
• Paul Grammont 1985 pioneered new generation
reverse
Grammont’s Idea The Story of Paul Grammont’s Functional Surgery Concept and the Development of the Reverse Principle Emmanuel Baulot MD,
Franc¸ois Sirveaux MD, Pascal Boileau MD
Clin Orthop Relat Res (2011) 469:2425–2431

38. Glenoid Notching

39. Notching solution
Design changes

40. Notching solution- Offset
Increasing offset - bone / metal

41. Notching- solution
Surgical technique

42. Step 2- Assessment of Bone Stock

43. Walch Classification

44. Assessing the Glenoid
• CT
• 3D printing
• PSI

45. Current Imaging

46. “3D Printing represents a quantum jump in defining and
assessing Orthopaedic osteology”
- Al Najjer, Monga; June2014

47. Patient Specific Instrumentation

48. Custom Jig

49. 3D Printed Custom Implant
Puneet Monga
Wrightington Hospital

50. Implantation

51. Step 3- Predicting Cuff Failure

52. RA- Cuff failure/ loose Glenoid

53. Staged Implantation

54. Predicting cuff failure
• Anatomical TSR in young pt with debatable cuff
quality?
• Anatomical TSR in cuff intact Patients > 80 years ?
Gazielly DF, Scarlat MM, Verborgt O. Long-term survival of the glenoid components in total shoulder replacement for
arthritis. Int Orthop. 2015 Feb;39(2):285-9. doi: 10.1007/s00264-014-2637-y. Epub 2014 Dec 24.

55. Step 4- Performing a good operation

56. Better outcomes in high volume centres / surgeons
Jain N, Pietrobon R, Hocker S, et al; The relationship between surgeon and hospital volume and
outcomes for shoulder arthroplasty. J Bone Joint Surg Am. 2004 Mar;86-A(3):496-505.
Hammond JW, Queale WS, Kim TK, et al; Surgeon experience and clinical and economic outcomes for
shoulder arthroplasty. J Bone Joint Surg Am. 2003 Dec;85-A(12):2318-24.

58. Preferred Fixation

59. Bone Loss / Revision

60. Learning from
Revisions

61. “No Object is so beautiful that, under certain
conditions, it will not look ugly”
- Oscar Wilde