Arthritis basics and managment copy

Arthritis basics and managment copy

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  Shoulder Arthritis andManagement Puneet Monga Consultant Orthopaedic Shoulder Surgeon
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  Broadly 2 typesof Arthritis RC Intact RC Torn
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  Shoulder replacements Broadly 2types Anatomical Reverse geometry
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  Making the right diagnosis….
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  Management • Early stages •Analgesia • Activity modification • Physiotherapy • Advanced • Joint Replacement
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  NJR 2015 = 1replacement/ surgeon / month NJR 2016 = Median 13 replacements / surgeon /year
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  Trends; combined datafrom international shoulder registries- E Griffiths, P Monga 2016 Proportion of Shoulder Replacements by Type % anatomic %Reverse %Hemis FDA Approval for Reverse- 2003
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  Future projections- by2030 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.
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  Understanding the Trends
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  Increased use ofTSR- Influence of training Surgeons with fellowship training in shoulder surgery are more likely to perform TSA over Hemi arthroplasty for OA
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  Guidelines - AAOS AAOSrecommends TSR over HSA for GH OA 2011
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  Increased use ofReverse- Influence of training • Reverse for trauma • 2005 - 2% • 2007- 4% • 2012 - 38%
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  Increased use ofReverse- Influence of training • Shoulder Surgeons (fellowship trained) • 5 times more likely to use arthroplasty for fractures • 20 times more likely to use reverse
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  Future projections- by2030 • 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.
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  Evolution and Design
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  • First recordedshoulder 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
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  • 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
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  First Generation • Monoblockimplants • 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
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  Second generation • ModularHumeral head size • Did not cater to the variation in anatomy of the proximal humeral adequately
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  Third Generation • Anatomicstudy; 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
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  Third Generation • TheAnatomic (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
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  Glenoid resurfacing • 1974Neer CS. First report for GH arthritis • Keeled Rectangular • Cemented • Congruous articular surface Image courtesy: AAOS
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  Glenoid design • Convexback 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
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  Glenoid design • Conformingvs 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.
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  Glenoid design • Keeledvs 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.
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  Glenoid design • Cementedvs 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.
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  Getting It RightFirst Time
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  Avoiding Complications …….!
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  • Step 1Using the Correct implant • Step 2 Assessment of Bone Stock • Step 3 Predicting Cuff failure • Step 4 Performing a good operation
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  Step 1 =Choosing the right Implant Evolution =
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  Broadly 2 typesof Arthritis RC Intact RC Torn
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  Shoulder replacements Broadly 2types Anatomical Reverse geometry
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  Anatomical Replacements Resurfacing Head replacement ClassicStemmed
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  Modern humeral stem KrugerFJ: 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
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  Glenoid design • Convexback 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”
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  Reverse geometry • Manyunsuccessful 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
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  Glenoid Notching
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  Notching solution Design changes
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  Notching solution- Offset Increasingoffset - bone / metal
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  Notching- solution Surgical technique
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  Step 2- Assessmentof Bone Stock
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  Walch Classification
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  Assessing the Glenoid •CT • 3D printing • PSI
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  Current Imaging
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  “3D Printing representsa quantum jump in defining and assessing Orthopaedic osteology” - Al Najjer, Monga; June2014
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  Patient Specific Instrumentation
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  Custom Jig
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  3D Printed CustomImplant Puneet Monga Wrightington Hospital
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  Implantation
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  Step 3- PredictingCuff Failure
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  RA- Cuff failure/loose Glenoid
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  Staged Implantation
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  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.
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  Step 4- Performinga good operation
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  Better outcomes inhigh 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.
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  Preferred Fixation
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  Bone Loss /Revision
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  Learning from Revisions
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  “No Object isso beautiful that, under certain conditions, it will not look ugly” - Oscar Wilde