synonyms: shoulder fusion, shoulder arthrodesis
Shoulder Arthrodesis Indications
Shoulder Arthrodesis Contraindications
- Lack of functional scapulothoracic motion
- Trapezius, levator scapulae, serratus anterior paralysis
- Charcot arthropathy
- Previous ipsilateral shoulder arthrodesis
- Elderaly patients
- Progressive neurologic disease
Shoulder Arthrodesis Alternatives
Shoulder Arthrodesis Pre-op Planning / Special Considerations
- Fusion position = 20°of abduction, 20° of forward flexion, and 40° of internal rotation in patients with normal body habitus. (Safran O, JAAOS, 2006;14:145)
- Pre-operative xrays and CT scan should evaluated for any bony deficiencies and pre-operative surgical plan should be created.
Shoulder Arthrodesis Technique
- Pre-op antibiotic
- Anesthesia: GETA +/- scalene block
- Beach chair position
- All bony prominences well padded.
- Incision over the scapular spine curving anterioly toward the anterolateral acromion and contining toward the deltoid tuberosity.
- Identify deltopectoral interval (interval can be found by palpating medial edge of deltoid insertion into clavicle or finding fat layer in interval surrounding cephalic vein.)
- Detach the anterior and middle third of the deltoid from the acromion and distal clavicle.
- Incise clavipectoral fascia adjacent to the conjoined tendon up to the coracoacromial ligament.
- Release upper 1/3 of pectoralis tendon if needed for exposure.
- Release subscapularis and anterior capsule as one unit 2cm from the lesser tuberosity insertion. Ensure long-head of biceps tendon is not injured in the proximal aspects of the release.
- Incise rotator interval medially to the level of the coracoid process.
- Release the supraspinatus tendon from its greater tuberosity insertion.
- Tag subscapularis with sutures.
- Dislocate humeral head by hyperextending and externally rotating arm.
- Remove marginal osteophytes.
- Expose the glenoid and shape it to a flat surface in its anatomical plane. (Glenoid inclination is variable, but averages @4.25 degrees superior (range -7 to 15.8); Glenoid version averages 1.23 degrees of retroversion.)
- The humeral head is temporary pinned in place with Steinman pins in the chosed position of fusion. 20°of abduction, 20° of forward flexion, and 40° of internal rotation in patients with normal body habitus. Verify that the hand can be brought to the forehead with a combinationof shoulder elevation and elbow flexion and the patient’s arm rests at the side without excessive scapular winging in the chosed position.
- The humeral head is then cut with a oscillating saw to provide maximal bony contact with the prepared glenoid in the position of fusion.
- The undersurface of the acromoin cut to a flat surface.
- The superior humeral head is cut to match the undersurface of the acroimion.
- 4.5mm pelvic reconstuction plate is contoured to the scapular spine, over the acromion and down the lateral proximal humerus.
- The plate is then fixed using standard AO technique. Place at least two lag screws from the lateral proximal humerus into the glenoid.
- Pack fusion site with bone graft/demineralized bone matrix.
- Repair subacapularis to the lesser tuberosity.
- Repair deltoid to the acromion and distal clavicle.
- Close in layers.
- Place in shoulder immobilizer with adbuction pillow.
Shoulder Arthrodesis Complications
- Nonunion: 0-20% (Safran O, JAAOS, 2006;14:145). Treated with bone graft +/- revision of fixation.
- Malunion: Treated with ostetomy distal to fusion site. (Groh GI, JBJS 1997;79A:881).
- Continued pain
- Painfull hardware
- Scapulothoracic muscle pain, loss of motion
Shoulder Arthrodesis Follow-up care
- Remain in shoulder immobizer with abduction pillow until radiograhic signs of fusion are evident. (3-4 months)
- Start scapular exercises for strenght and ROM after radiographic fusion.
Shoulder Arthrodesis Outcomes
- 38% pain free, 36% had mild pain, 23% moderate pain, 3% severe pain. 70% can lift moderate weights, dress themselves, tend to personal hygiene,and eat using the fused extremity. Only 21% can use their arm for light work at shoulder level. 82% find their arthrodesis to be functionally beneficial. (Cofield RH, JBJS 1979;61A:668).
Shoulder Arthrodesis Review References
- Lee D, Operative Techniques: Shoulder and Elbow Surgery: Book, Website and DVD, 1e, 2010
- Craig EV, The Shoulder (Master Techniques in Orthopaedic Surgery), 2012
- Williams GR, Operative Techniques in Shoulder and Elbow Surgery, 2010
- Zuckerman JD, Advanced Reconstruction Shoulder (American Academy of Orthopaedic Surgeons), 2007
- Richards RR: Glenohumeral arthrodesis, in Iannotti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA: Lippincott Williams & Wilkins, 1999, pp 501-520
- (Safran O, JAAOS, 2006;14:145)