SHOULDER
Omarthrosis
The condition manifests itself as pain that worsens when the shoulder is mobilized, whereas at rest there is no pain. However, symptoms may be present at night, with difficulty in sleeping. In addition, loss of joint range of motion may occur. External rotation, flexion and internal rotation of the shoulder are often limited by the pathology.
What is it?
Glenohumeral arthritis is a degenerative disease of the shoulder joint characterized by damage to the articular surfaces of the head of the humerus and/or the glenoid. The disease occurs as the joint ages, and in the presence of concomitant pathologies (rotator cuff disease, inflammatory arthritis, trauma). It occurs more frequently in women. Glenohumeral instability is a risk factor associated with the development of glenohumeral arthritis.
Medacta 2024
On examination of the shoulder, there may be crepitus with a sensation of intra-articular locking and cogwheel motion. A thorough assessment of muscle function is important to determine the type of intervention required. Diagnosis is made by X-ray with projections: anteroposterior, lateral and axial.
X-rays show reduced intrarticular space, sclerosis and subchondral cysts. The state of degeneration and wear of the posterior glenoid bone must be assessed, and any posterior static subluxations of the humeral head detected, in order to understand whether an arthroplasty with reverse prosthesis is necessary.
In the case of a rotator cuff tear, superior migration of the humeral head may be seen, and in more severe cases, acromial erosion. In extreme cases, an acetabulum of the coracoacromial arch is observed.
A CT scan can be useful if the decision to operate is made and preoperative planning is required to optimize the implant type and predict the exact size, shape and position of the implant. In more severe cases, patient-specific instrument analysis software is used.
Treatments
Medacta 2024
Treatment may initially consist of a period of observation, physiotherapy and analgesic treatment with non-steroidal anti-inflammatory drugs, corticosteroids, if symptoms are mild and function preserved. Intra-articular injections can be used to treat painful symptoms. For anti-inflammatory purposes, a cortisone derivative may be ideal, but if symptoms recur, an arthroplasty operation can only be performed three months after the injection. Other products that can be injected to treat painful symptoms are hyaluronic acid, which can lubricate arthritic surfaces, or platelet concentrates. The latter two options need to be discussed with the patient, as evidence remains limited at present. In more severe forms of rheumatoid arthritis, treatment with specific drugs may be necessary, and the patient should be monitored by our rheumatology colleagues. Arthroplasty is indicated in cases of debilitating symptoms lasting a prolonged period, and in some cases of functional impairment.
Anatomic total shoulder arthroplasty is indicated in cases of cartilage degeneration, long-standing pain and intact rotator cuff function. Lack of muscle function, infection and Charcot’s arthropathy are contraindications. The operation involves implanting a concave glenoid and a convex humeral ball. The treatment improves pain symptoms and, with proper muscle function, restores good shoulder function. At 10 years post-op, 92-95% of prostheses do not require revision.
Reverse” total shoulder arthroplasty is classically indicated for irreparable rotator cuff and advanced glenoid pathologies. In recent years, this type of implant has become increasingly preferred, even in the following cases: advanced age, revisions and complex fractures. The reason for this is the reliability of the implant, with better reproducible clinical results and, at the same time, compatibility with a harmonious life. The implant involves a convex part of the glenoid and a concave part of the humerus. It guarantees an improvement in pain symptoms and good function. At 10 years, 90-95% retain good function and do not require revision.
What are the possible complications?
Anatomic total shoulder arthroplasty
Aseptic mobilization of the glenoid component (most frequent complication): often linked to the scarcity of available bone, if severe and symptomatic, it may require implant revision.
Vascular and nerve injuries: despite optimization and knowledge of anatomical structures, certain variations can lead to this type of injury. Vascular injuries can result in haematomas requiring surgical evacuation, and nerve injuries may require nerve revision. Fortunately, complete and permanent injuries are very rare.
Aseptic mobilization of the humeral component: rarer than that of the glenoid, it is linked to risk factors such as inflammatory pathology and infection, and frequently requires further surgery for treatment.
Impairment of subscapularis function: linked to passage through the anterior part of the cuff, this may present as a variable loss of strength in the postoperative period.
Imbalance of static and dynamic stabilization tissues: particularly in the case of previous glenohumeral joint stabilization operations.
Rotator cuff injuries: intra-operatively or post-operatively in the event of conflict with the implant, sometimes necessitating implant revision in a so-called “reverse” implant model.
Stiffness: often linked to scar adhesions, it requires a longer and more intensive period of rehabilitation than physiotherapy, and rarely requires surgical revision of the scars.
Infection: can be acute or chronic, and is most often caused by Cutibacterium acne or Staphylococci. The Cutibacterium acne germ often manifests itself as a low-intensity infection that persists over time. It is a commensal skin germ, present in all individuals, but can enter the surgical site as a pathogen. In the event of symptoms and/or radiological signs of osteolysis, further investigations may be required, and revision or replacement of the prosthesis in one or more stages may be necessary.
Periprosthetic fractures: intraoperative fractures, often limited to small fractures, may require a period of protected mobilization with slower rehabilitation; they are rarely fractures requiring a specific implant or stabilization by intraoperative osteosynthesis. Similarly, post-operative fractures need to be assessed according to their severity, in order to decide whether they should be treated conservatively or surgically.
Reverse total shoulder arthroplasty
“Notching of the scapular neck: very frequent (44-96%), but a much less frequent source of symptoms and revisions. New implants and techniques considerably reduce its occurrence in the postoperative period.
Dislocation: reported in 2 to 3.4% of cases, this is the most frequent cause of treatment failure. Correct positioning of the implant, refixation of the subscapularis (where possible) and correct use of the splint during the first 6 weeks post-operatively can help reduce the risk and avoid this complication.
Aseptic mobilization of the glenoid component: this is more frequent when the reverse prosthesis is implanted as a revision of the anatomical prosthesis (up to 25% at 5 years in the case of revision). It may require a two-stage revision with reconstruction of the glenoid bone mass using an autologous or heterologous bone implant.
Deep-seated infections: occur in 1-2% of cases. The most common germs are Cutibacterium acne and staphylococci. Risk factors include young age and male gender, revision procedures and arthroplasty in trumatological cases.
Fractures of the scapula (acromion and spina): these are more frequent due to the biomechanics of the prosthesis, which exploits the activity of the deltoid. According to the literature, 4% can be a source of pain, and treatment can be conservative in around half of cases.
Axillary nerve neuroapraxia: up to 0.5-1%, but often temporary.
The first day after surgery
The operation is performed under general anesthesia, possibly combined with a nerve block in the arm. A prophylactic antibiotic is administered 30 minutes before the surgical incision.
The operation takes around 2 hours. An incision is made in the front of the shoulder. It can be about 8-10 cm long.
After the operation, the abduction splint chosen by the surgeon is applied to the operated shoulder. Tingling and a feeling of numbness in the hand are quite common after surgery, but disappear within a few days.
Post-operative physiotherapy
Rehabilitation includes :
- an abduction splint for 6 weeks for the whole day, except when dressing and bandaging.
- no load for 10 to 12 weeks.
- in the case of biceps tenodesis, no flexion and supination against resistance for 10-12 weeks
- weeks 1 and 2 post-op: elbow and hand mobilization only and pendulum mobilization of the arm
- postoperative weeks 3 and 4: passive mobilization of the arm with imposed limitations, 90° abduction and flexion of the arm, 10° external rotation and internal rotation limited by the tummy.
- Post-operative weeks 5 and 6: assisted active mobilization of the arm with imposed limitations, 90° arm abduction and flexion, 10° external rotation and internal rotation limited by the abdomen.
- After six weeks: Between the sixth and twelfth week, after medical assessment, it is possible to stop using the splint and begin active movements independently, although it is important to ensure that there is no load on the arm. The aim is to increase arm amplitudes.
- Between the third and sixth months: progressive muscle strengthening. Resumption of sporting activities is gradual, depending on the type of sport. Sports involving involuntary, sudden efforts are started in the fifth and sixth months.
Wound control and treatment
The dressing should be changed every three days. Disinfection and dressing changes must be carried out carefully, using sterile instruments (tablets, tweezers if necessary).
Sutures are removed on the 15th day by a doctor or specialized nurse.
Home help from a medical-social center for various activities can be organized.
When will you be back in business?
Do not drive the vehicle for the first six weeks. During this period, you can travel as a passenger on short car journeys or use public transport.
Your return to work and sport is determined by your progress. You are expected to be off work for six to eight weeks. Walking is recommended, but other sports can be resumed on medical advice.
Medical examination
Dr. Fornaciari will perform a clinical check-up at six weeks and at the third, sixth and twelfth months. Each meeting includes an assessment of clinical status and a decision on the progress of physiotherapy treatment. These appointments are scheduled at the time of discharge and return home.
