TSA Complications

1. TSA Complications Academic Half Day 2013 Mitch Armstrong

2. Jules Emile Pean 1st TSA in 1893. Tubercular Arthritis in a 30 yo Baker 1st TSA complication (infection) 2yr Also credited with the Pean hemostat 1st vag hysterectomy same yr

4. Overview 40% increase in total shoulders done between 1996 and 2002 compared to previous 10 years (US) Despite increase in volume, ¾ are done by surgeons who perform 1-2/ year Complication and appropriate decision making related to volume of procedures completed (obviously) Overall prevalence of TSA complications relatively unchanged despite increased volume Why do they fail? Multifactorial

5. Arthroplasty Options Hemiarthroplasty Reverse Total Shoulder Total Shoulder

6. Overview • Component loosening • predisposing factors include insufficient glenoid stock and rotator cuff deficiency • 2.9% reoperation rate for loosening (28% with revision) • radiographic lines • presence of radiographic lines does not correlate with symptoms • progression of radiographic line does correlate with symptoms • Subscapularis repair failure   • Malposition of components • Improper soft tissue balancing • failure due to undiagnosed presence of rotator cuff tears • Iatrogenic rotator cuff injury • can occur if humeral neck osteotomy is inferior to level of rotator cuff insertion  • Stiffness • Periprosthetic fracture • Infection • Proprionibacterium acnes (P. acnes)  • has a high bacterial burden around the shoulder  • is a cause for indolent infections and implant failures

7. Overall complication rate after TSA is estimated to be approximately 15%. • Bohsali et al. reviewed 33 articles published between 1996 and 2005 and reported a complication rate of 14.7% in 2540 total shoulder arthroplasties -1) Component loosening 2) Glenohumeral instability 3) Periprosthetic # 4) Rotator cuff tears 5) Infection 6) Implant failure including dissociation of modular prostheses 6) Deltoid weakness or dysfunction. • Chin et al. reported on 431 total shoulder arthroplasties done with cemented all-polyethylene glenoid components between 1990 and 2000, found a 12% complication rate, one reoperation was required because of component loosening. 1) Rotator cuff tearing 2) Glenohumeral instability 3) Periprosthetic humeral fracture. • Bohsali et al. noted complications after TSA tended to occur late in the postoperative course (5 to 10 years after surgery) - Longer term follow-up is necessary to fully elucidate the complication frequencies.

8. Bohsali et al. 2006Complications following unconstrained TSA Bohsali KI, Wirth MA, Rockwood CA Jr: Complications of total shoulder arthroplasty, J Bone Joint Surg 88A:2279, 2006.

9. Component Loosening • Common Problem(6.3%), roughly 1/3 of all complications • Glenoid component loosening > Humeral component loosening Glenoid Component • Radiographic lucent lines at the cement-bone interface reported incidence of 0-100% • Bohsali et al. found 80% at 10 year follow up • Are Radiographic lucent lines a problem? - Presence of lines isn’t problematic but progression is - Correlated with a decrease in function and an increase in pain. • When is Glenoid Component considered loosened radiographically? - Shift in the position - Circumferential radiolucent lines 1.5 mm wide • What to do with Glenoid Loosening? - Asymptomatic patient = observation is indicated - Symptoms of pain, decreased range of motion, and functional disability, further investigation warranted to determine if implant replacement is appropriate.

10. Techniques to prevent loosening • Preservation of native glenoid bone stock, concentric glenoid reaming, metal-backed implants, minimize cement • Keel vs Pegged Glenoid implant - Lazarus et al. reported significant improvements in radiolucency levels and component seating pegged implants compared to keeled. - Gartsman et al. showed increased radiolucent lines around keeled components - Pegged technique more challenging • Metal backed cementless implants show beneficial results in early post op assessment • 5-10 years follow ups show unsatisfactory results - Higher rates of clinical and radiographic signs of failure Component Loosening

11. Humeral Component Loosening • Makes up 7% of TSA complications • Humeral radiolucent lines not as common as glenoid radiolucent lines • Infection until proven otherwise • May be higher frequency with the use of press-fit humeral stems. • Maynou, Sperling and Matsen identified incomplete radiolucent lines in 18-61% of humeral stems - Prevalence of humeral radiolucencies in each of these studies was high, actual loosening of the component was much less frequent, and few components required revision because of symptomatic loosening. - Humeral component loosening also is diagnosed by a change in implant position or progression of radiolucent lines. Component Loosening

12. Instability • Instability prevalence of 4% and accounting for 30% of all complications • TSA can alter complex balance between soft tissue tensioning and component positioning Anterior Instability • 5% of all complications after total shoulder arthroplasty - Subscapularis failure, glenoid anteversion, malrotation of the humeral component, or anterior deltoid dysfunction. - Can be caused by humeral head that is too small for the joint volume ~ Revision of the humeral head with an appropriate-size implant - Abnormal version cause of anterior instability ~ Revision of the humeral stem should be considered - Torn subscapularis tendon ~ Must be repaired to regain joint stability ~ Unable to repair, then reconstruct with a bone–Achilles tendon allograft * More evidence showing that best option for stability is revision to Reverse TSA

14. Instability Superior Instability • Most common • Associated with dynamic muscle dysfunction, torn or incompetent Supraspinatus, failed rotator cuff repairs, and frank rupture of the rotator cuff • Boyd et al. reported that the amount of proximal humeral migration was independent of the size of the rotator cuff defect, but correlated positively with the association of cuff deficiency and poor preoperative function • Long-term superior migration of the humeral head can result in loosening of the glenoid component • Repair of rotator cuff tears at the time of arthroplasty can help prevent this complication.

15. Posterior Instability • 1) Soft tissue (excess posterior capsule) 2) Component malposition • Proper placement of the humeral and glenoid components is key - soft-tissue balancing ~ anterior soft-tissue envelope is tight and contracted ~ posterior capsule is stretched by the chronic posterior displacement of the humeral head. • Restore normal retroversion, posterior capsular tightening Inferior Instability • Most common after arthroplasty for proximal humeral fractures or tumour • Removal of too much of the proximal humerus - difficulty elevating the arm past the horizontal plane due to of weakness of the deltoid - revision surgery necessary to restore humeral length and regain deltoid strength. Instability

16. Periprosthetic Fracture • With unconstrained TSA – 1.6-2.3% • Intraop #’s more common than postop #’s Intraoperative Fractures • Errors of surgical technique - aggressive reaming (malalignment and cortical perforation) - aggressive impaction of components or eccentric placement - upper extremity manipulation ~ humeral shaft spiral/long oblique #’s caused from too much ER for exposure ~ torsional forces on arm • Cerclage wiring for #’s proximal to tip of prosthesis • Distal #’s require long stemmed prosthesis extending 2 humeral cortical diameters past # - combined deltopectoral and anterolateral approach • Fractures of the glenoid are extremely rare and usually occur in osteopenic bone - CT scan

17. Periprosthetic Fracture Postoperative Fractures • Woman • Rheumatoid Arthritis • Initial non-operative management for fractures proximal to the stem tip • Non-op for fractures with acceptable alignment at the tip of a well-fixed humeral stem • For fractures at the stem tip that had not united by 3 months, then open reduction and internal fixation or • Revision with a long stem was recommended for similar fractures when the humeral component was loose.

18. Rotator Cuff Tear • Incidence of 1% to 2% • Rupture of the subscapularis tendon is most common - associated with multiple operations, overstuffing of the joint, overly aggressive PT involving external rotation, tendon compromise during operation • Symptoms usually are mild and reflect the natural history of rotator cuff disease in the general population. • Miller et al. recommends early intervention with gentle mobilization • Delayed repair may require augmentation of Pec Major transfer • Large tears can cause superior subluxation and eventual loosening of the glenoid component from compression forces on the superior rim of the glenoid

19. Rotator Cuff Tear • Rupture of Posterosuperior RC associated with timing from surgery • - Young et al. 518 TSA • - 100% survivorship at 5 years • - 84% at 10 years • - 43 % at 15 years • Consider preop fatty infiltration • Worse clinical outcomes • Attempts at repair not very successful • Best option- revision to RTSA +/- latissimus dorsi transfer

20. Infection • Rare (0.5% to 1%) • Devastating complication • Risk factors: Intrinsic– diabetes, RA, SLE, previous surgeries, remote sources of infection Extrinsic- chemotherapy, systemic corticosteriods • Acute < 3 months, Subacute 3 months-1 year, Chronic > 1 year • Clinically look for pain, loose humeral component infected until proven otherwise • WBC, ESR, CRP normal in majority of cases • Propionibacterium acnes most common organism responsible for infection after TSA - avg first culture positive 5.1 days • Acute infection within 30 days post op = I&D + implant retention • Acute hematogenous infection > 30 days post op = I&D + implant retention or 2 stage revision with Abx spacer • Chronic infection = 2 stage revision.

21. Deltoid Muscle Dysfunction Axillary nerve injury or detachment of the deltoid muscle can result in a catastrophic loss of shoulder function Poor outcomes Surgical approaches for total shoulder arthroplasty include deltoid muscle detachment to provide optimal exposure; Neer and Rockwood have advocated the use of an extended deltopectoral approach, which preserves the origin and insertion of the deltoid muscle but still allows excellent exposure for humeral head and glenoid resurfacing.

22. Heterotopic Ossification Heterotopic Ossification 10-45% Males Dx = osteoarthitis Low grade Non-progressive Does not affect outcome

23. Stiffness Depends on indication for arthroplasty Subscap shortening Oversized components Inappropriate rehab Hasan et al. reported that of 139 consecutive patients who were dissatisfied with the outcomes of their total shoulder arthroplasty, stiffness was the most frequent reason (74%).

24. Indications – RC arthropathy, massive RC tears, failed shoulder arthroplasty, fracture • Complications reported 19-68% - Neurologic injury (Axillary most common) - Periprosthetic # - Hematoma (1-20%), meticulous hemostasis - Infection (1-10%) - Scapular notching - Dislocation (2.4-31%) - Baseplate Failure (11-40%) - Acromial Fracture (3.7%) Reverse TSA

25. Left and Right shoulder RC tear arthropathy • PMHx: Angina, MI (2008), HTN, COPD, OSA, GERD, Chronic pain, Anxiety/Depression Case- BL 73 Male

31. Which of the following statements regarding propionibacterium acnes infections after shoulder arthroplasty is incorrect? 1. It is usually associated with fevers 2. Cultures need to be held for 14 days 3. It colonizes the shoulder at increased rates compared to the knee and hip 4. Men have a higher bacterial burden than females 5. It is an important cause of clinical implant failure 

32. PREFERRED RESPONSE ▼ 1 Surgeons need to be aware that P. acnes is a skin bacteria that is responsible for shoulder infections that often have a subtle presentation. Many of the traditional signs of infection such as fever, erythema and severe pain are often not present. Dodson et al describe a case series of 11 patients with P. acnes infections following shoulder arthroplasty stating that it represents a "diagnostic challenge". Traditional signs of infection were often not present. In fact, none of their patients presented with fevers. Initial 3 day cultures were often negative and the mean time to a positive culture was 9 days.Patel et al. looked at colonization rates and bacterial burden and found it to be higher around the shoulder than the hip and knee. The bacterial burden was higher in men than in women.The following responses are true and therefore are incorrect answers:2. It is slow-growing and cultures need to be held longer (14 days).3. It colonizes the shoulder at increased rates compared to knee and hip.4. Men have a higher bacterial burden than females.5. It is an important cause of clinical implant failure. 

33. During a total shoulder arthoplasty (TSA), which of the following technical maneuvers would most likely place the rotator cuff tendons at risk of injury? 1. Excessive retraction on the deltoid muscle during a delto-pectoral approach 2. Palpation of the rotator cuff insertion prior to humeral head resection 3. A humeral cut with 30 degrees of retroversion 4. Excessive bone removal with the humeral neck osteotomy 5. A humeral cut with 45 degrees of inclination 

34. PREFERRED RESPONSE ▼ 4 The rotator cuff tendons can be inadvertantly cut or detached during a TSA if the head cut is made either too distally or in excessive retroversion. Pearl et al studied the placement of humeral component position during TSA by studying 21 cadaveric specimens. Their results supported that retroversion of the proximal humerus is highly variable, ranging from 10 degrees to 55 degrees and mean of 29.8 degrees. They recommend anatomic reconstruction of the retroversion angle based on patient anatomy. They also stress palpation of the rotator cuff insertion prior to humeral head resection to avoid inadvertant cuff injury.Illustrations A shows example of an appropriate osteotomy which is made proximal to both the greater and less tuberosities. Illustration B shows the footprint of the rotator cuff insertion relative to the correct humeral cut during a TSA.Incorrect Answers:Choice 1- Excessive retraction on the deltoid muscle could cause injury to the axillary nerve, but will not injure the rotator cuff.Choices 2- This step is encouraged to spare the rotator cuff insertions before humeral head osteotomyChoice 3- A head cut in 30 degrees of retroversion is normalChoice 5- Excessive inclination may take too much medial bone, but if appropriately placed, would not risk injuring the rotator cuff insertion. 

36.  A 65 year-old man has progressive debilitating pain and crepitus in his shoulder. Active forward elevation is 120 degrees and external rotation strength is good. Radiograph and CT scan are shown in Figures A and B. Which treatment will likely give him the best outcome in 3 years. 1. Arthroscopic capsular release 2. Humeral head arthroplasty with glenoid bone grafting followed by staged glenoid component implantation 3. Hemiarthroplasty 4. Reverse total shoulder replacement 5. Total shoulder arthroplasty 

37. PREFERRED RESPONSE ▼ 5 The patient has advanced glenohumeral arthritis with a functioning rotator cuff and adequate glenoid bone stock for immediate glenoid component implantation. A total shoulder replacement will give the patient the best chance at better outcomes as observed in the cited studies by Gartsman and Bryant when compared to hemiarthroplasty alone for glenohumeral arthritis. A reverse total shoulder would be an appropriate option for a patient with cuff tear arthropathy. Hemiarthroplasties have been shown to have inferior outcomes to TSA’s for glenoihumeral arthritis due to painful articulation of the humeral component on arthritic glenoid. Capsular release would aid a frozen shoulder.

38. References: Sperling JW, Hawkins RJ, WalchG,Zuckerman JD. Complications in Total Shoulder Arthroplasty. 2013. JBJS, 95-6 Bohsali KI, Wirth MA, Rockwood CA. Complications of Total Shoulder Arthroplasty. 2006. JBJS, 85-10. Chin PY, Sperling JW, Cofield RH, Schleck C. Complications of total shoulder arthroplasty: are they fewer or different? J Shoulder Elbow Surg. 2006;15:19-22. Gartsman GM, Elkousy HA, Warnock KM, Edwards TB, O’Connor DP. Radio- graphic comparison of pegged and keeled glenoid components. J Shoulder Elbow Surg. 2005;14:252-7. Lazarus MD, Jensen KL, Southworth C, Matsen FA 3rd. The radiographic eval- uation of keeled and pegged glenoid component insertion. J Bone Joint Surg Am. 2002;84:1174-82. Sperling JW, Cofield RH, Steinmann SP. Shoulder arthroplasty for osteoarthri- tis secondary to glenoid dysplasia. J Bone Joint Surg Am. 2002;84:541-6. Maynou C, Petroff E, Mestdagh H, Dubois HH, Lerue O. [Clinical and radio- logic outcome of humeral implants in shoulder arthroplasty]. ActaOrthop Belg. 1999;65:57-64. French. Matsen FA 3rd, Iannotti JP, Rockwood CA Jr. Humeral fixation by press-fitting of a tapered metaphyseal stem: a prospective radiographic study. J Bone Joint Surg Am. 2003;85:304-8. Boyd AD Jr, Thomas WH, Scott RD, Sledge CB, Thornhill TS. Total shoulder ar- throplasty versus hemiarthroplasty. Indications for glenoid resurfacing. J Arthro- plasty. 1990;5:329-36.