Mini Medical School _ Focus on Orthopaedics

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1 from The Cleveland Clinic Mini Medical School _ Focus on Orthopaedics Arthritis of the Shoulder: Treatment Options Joseph P. Iannotti MD, PhD Professor and Chairman, Department of Orthopaedic Surgery The Cleveland Clinic Foundation Lerner College of Medicine Appointments: (CARE) or 800/ April 9, 2005 Evaluation of shoulder arthritis History Prior surgery, trauma, steroids, other joints and disease Physical examination Stability Strength Function Pain Imaging studies X-rays, CT scan, MRI Disease specific pathology Each type of arthritis has characteristic features which influence the outcome of shoulder arthroplasty as well as the decision of which type of shoulder arthroplasty to perform. The age of the patient and expected post-operative activity level also influence our decisions.

2 Osteoarthritis Normal x-rays Grade 4 changes Arthroscopy Good bone quality and an intact rotator cuff in 95% of patients Rheumatoid arthritis Rotator cuff tears Peri-articular erosions Osteorosis Glenoid bone loss Rotator cuff tears Weakness Multiple joints involved Non-operative treatment Oral medications Cortisone Viscosupplementation (artificial joint fluid) Nutritional supplements (Glucosamine, Chondroitin Sulfate cartilage extracts) Exercise program Modification of activities Indications for surgery: Failure of non-operative treatment Moderate to severe arthritis Symptoms severe enough to justify surgery Anatomic design Reverse design Surgery to choose Extent and type of arthritis Age and activity level of the patient Young and more active patients get more conservative replacements Allow for more options when they fail Patients with severe arthritis and irreparable rotator cuff tears get either a hemiarthroplasty (when pre-op function is better) or a reverse total shoulder when the function is very poor and they are over the age of 65 years. Anatomic total shoulder replacement: Replaces the humeral head (ball with metal, top) and the glenoid (socket with plastic, bottom) Surgical options Arthroscopic debridement Joint replacement Conservative shoulder arthroplasty Resurfacing of humeral head and soft tissue resurfacing of the glenoid Hemiarthroplasty Total shoulder replacement

3 Arthroscopic debridement and drilling: Patients with moderate arthritis, near-normal joint shape with higher activity level, and failure of non-operative treatment Results of joint replacement Dependent upon: Disease Rotator cuff and deltoid function Capsular contracture Bone quality Surgical technique: Surgeon 20K/year US, Average surgeon does <5 per year Shoulder surgeons at CCF perform 30 to 110 per year for total of more than 300 in 2004) Rehabilitation Prosthetic design Post-operative use Loosening causes pain and bone loss Don t use plastic What else can you use when the socket needs to be resurfaced? Case example 16-year-old RHD healthy female; at age 15 had a tear of the labrum repaired by arthroscopy One year later, severe pain and marked restriction of motion with severe arthritis Nine-month follow-up: Results: 95% of patients with osteoarthritis of the shoulder having a total shoulder replacement will have good to excellent results 85% of patients will have this same result 10 years after the surgery What do you do with the young patient? Plastic wears out Wear particles cause loosening of the parts Why not use soft tissues in all patients? It has to heal to the tissues and this is less reliable than plastic in older people.

4 Shoulder arthritis with an irreparable rotator cuff tear Stable shoulder with shoulderlevel elevation Unstable shoulder with less than shoulder-level elevation Older patient Good deltoid Young patient Heavy labor Poor deltoid Good other shoulder Young patient Good deltoid Hemiarthroplasty utilizing anatomical size humeral head Reverse shoulder Glenohumeral arthrodesis Hemi with muscle transfers Safran and Iannotti Shoulder and Elbow Arthroplasty LWW 2004 CTA head: A special type of metal ball for the patient with arthritis, an irreparable rotator cuff tear and moderate loss of function (below)

5 The reverse shoulder: Summary: Treatment of arthritis of the shoulder Many different options for surgery and non surgical treatment: Selection is based upon: Type of arthritis Severity of the damage to the tissues Patient age and expectations Response to prior treatment notes Patients over the age of 65 that are less active with severe arthritis and a massive irreparable rotator cuff tear and very poor function. Results of the reverse shoulder:

6 notes notes The information provided is for educational use only and may not reflect Cleveland Clinic practice. This information is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. DEPARTMENT OF ORTHOPAEDIC SURGERY 9500 Euclid Avenue Cleveland, Ohio Appointments: (216) 444-HAND (4263) CCF-CARE ( ), Ext Hearing Impaired (TTY) Assistance: (216) Produced by the Department of Patient Education and Health Information The Cleveland Clinic Foundation /05

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