A 68-year-old weightlifter with left shoulder pain
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A 68-year-old amateur weightlifter presented with a history of chronic left shoulder pain. He said the pain was constant, worsened over time and with activity, occurred at night and was associated with popping, clicking and weakness.
This condition limited the patient’s ability to exercise at the gym, where he has needed to reduce his workload to lifting 80-pound dumbbells. On exam, he was able to flex to 100° and abduct to 70°. He has 0° external and internal rotation. He had no deficiencies to his rotator cuff on examination within the allowable nonpainful range of motion. His biceps were tender to palpation, however the Speed’s and Yergason’s tests were not grossly positive. His exam was not otherwise notable for any positive findings. Radiographs obtained included anteroposterior, axillary, Bernageau and “scapula Y” views, which revealed severe glenohumeral arthritis, a concentric wear pattern and significant humeral head deformity (Figure 1).
Source: Ian Savage-Elliott, MD
What are your diagnosis and treatment options?
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Humeral head surface replacement arthroplasty for severe shoulder glenohumeral arthritis
A diagnosis of severe left shoulder glenohumeral arthritis was made. A discussion with the patient reviewed operative and nonoperative treatment options, during which nine options were discussed.
The patient stated his pain was significant, but more importantly to him was the functional limitation in the gym, which he considered intolerable, and thusly, he was not amenable to continued observation. Nonoperative interventions for this condition include physical therapy, intra-articular steroid injections and oral medications, all of which the patient had attempted for his pain, but produced little improvement. Biologics are an option; however, there are minimal long-term data for these therapies, and most of these require out-of-pocket costs for patients.
Surgical options
Having previously failed nonoperative management, surgical interventions were also discussed with the patient. The simplest option, arthroscopic debridement with microfracture and excision of osteophytes, may provide good relief; this procedure can be supplemented by glenoid resurfacing with a dermal patch and the possible addition of biceps tenotomy or tenodesis, subacromial decompression and distal clavicle excision. The arthroscopic option is a good one for younger patients, but we have had less success with our older heavy weightlifters, especially when cystic changes are present on both the humerus and glenoid.
More progressive options include traditional shoulder replacement or hemiarthroplasty, both of which may limit his ability to pursue heavy weightlifting at his desired level. A less invasive option is traditional humeral head surface replacement arthroplasty performed through a subscapularis-sparing approach to maintain normal subscapularis function with or without glenoid resurfacing with a biologic graft. After a discussion of the patient’s goals, which included preserving his high activity level and expediting the recovery process, subscapularis-sparing humeral head surface replacement arthroplasty and removal of loose bodies was selected by our patient.
Surgical technique
The patient was taken to the OR and placed in a modified, semi-sitting position. His bony prominences were padded, a bump of blankets was placed under the medial boarder of his scapula and he was prepped and draped. An anterior deltopectoral approach was used. The patient’s deltoid and pectoralis major were both robust and were retracted while protecting the cephalic vein. There was a large loose body in the bicipital groove, which was removed. There was notable bicipital damage distally, which led us to choose to tenodese the biceps to the pectoralis major. The subscapularis was identified with both the 50% and 70% raphes visible. We elected to pursue a 50% split, as previously described by Savoie and colleagues. A horizontal split was made and then the lower tendon was tenotomized. Osteophytes were removed from the inferior humeral head and the head was dislocated anteriorly and inferiorly through the subscapularis tenotomy. The glenoid was inspected and microfractured in the area of the cystic changes. The head was sized and reamed and chamfer cuts were made to it. The permanent prosthesis was implanted with gentle taps. The shoulder was reduced and the motion checked.
The patient’s shoulder motion was measured at 180° flexion, 180° abduction, 90° both external and internal rotation, and 70° external rotation at the side. The wounds were irrigated and the subscapularis repaired with interrupted sutures to close the subscapularis split. External rotation was rechecked and noted to be greater than 60°. The wounds were closed, sterile dressings were applied and the patient was placed in an abduction pillow sling (Figure 2).
Postoperative care
Postoperatively, the patient remained in the abduction pillow sling for 1-week full time and 3 weeks at night due to restless sleep. He started a progressive home program at 1 week and physical therapy 3 weeks after his first postoperative visit. At his 2-month follow-up he was cleared for normal activity, at which time he had 130° flexion, 100° abduction and 60° external and internal rotation. An axillary radiograph confirmed excellent balance of the shoulder and no anterior translation of the prosthesis. Ultrasound showed an intact and robust subscapularis tendon, and he had resumed heavy weightlifting, which is consistent with an intact subscapularis (Figure 3).
Discussion
The main goals of any replacement surgery are to relieve pain and improve function. Preserving the majority of the subscapularis insertion allows patients more rapid rehabilitation and return to activity while minimizing the risk of subscapularis insufficiency. Surface replacement arthroplasty offers the advantage of maintaining native shoulder version, inclination and offset. It also minimizes complications related to stem insertion. One of the main causes of patient dissatisfaction after arthroplasty is activity restriction. Revision to total shoulder arthroplasty can also be undertaken without any bony augmentation given the minimal bone loss from the index surgery.
There are numerous potential complications of stemless humeral resurfacing arthroplasty, including overstuffing leading to abnormal joint kinematics, challenges with glenoid exposure, compressive strain at the implant surface and a potential for bone resorption beneath the central implant. However, for younger, more active patients, it offers the opportunity to return to full activity. Nicholas D. Iagulli, MD, and colleagues studied results of surface replacement arthroplasty by this article’s senior author in 52 patients older than 60 years who underwent the procedure with a mean follow-up of 6 years. Patients had a mean subjective shoulder value of 92%. Three patients restricted their activity, and one revision was performed secondary to pain. All but one patient stated they were happy with the result and would have the procedure again.
Partial tendon preservation
The subscapularis-sparing approach to humeral head replacement has been described in the literature. The technique relies on identifying the lower muscle tendon raphe approximately one-half to two-thirds inferior to the superior border of the tendon. Thus, the upper half to 70% of the tendon is preserved while allowing complete access to the humeral head in this mini-open approach. Therefore, patients can undergo quicker rehabilitation postoperatively. The senior author conducted a prospective case series to evaluate this approach with minimum 2-year follow-up in 50 patients. At 4 weeks postoperatively, all patients had negative belly-press and lift-off testing. Nineteen patients underwent postoperative MRI, and 24 patients underwent ultrasound evaluation with all imaging revealing an intact subscapularis tendon attachment and no patients had atrophy of the muscle belly. Of the 43 patients who followed up at 2 years, there were no failures (rupture or atrophy) using this approach. Criticisms of the approach are the lack of full exposure of the glenoid and fears of long-term weakening of the subscapularis, which has a blood supply that is primarily located at the proximal aspect.
Approach aids activity resumption
We present the case of an active 68-year-old man who underwent humeral head surface replacement through a mini-open, subscapularis-sparing approach. We believe these modified approaches to arthroplasty that allow patients to resume full activity in an expedited time-frame will continue to grow in popularity as the long-term outcomes of these techniques become validated. While patients may require subsequent procedures in their lifetime, the ability to heal quickly and resume full activity without significant pain negates two of the main patient impediments to shoulder arthroplasty.
- References:
- Iagulli ND, et al. Orthop J Sports Med. 2014;doi:10.1177/2325967113519407.
- Savoie FH, et al. J Shoulder Elbow Surg. 2015;doi.org/10.1016/j.jse.2014.07.020.
- For more information:
- Ian Savage-Elliott, MD, is a chief resident, and Felix H. Savoie III, MD, FAAOS, FAOA, is Ray Haddad Professor and chair of the department of orthopaedic surgery at Tulane University. They can be reached at 1415 Tulane Ave., New Orleans, LA 70112. Savage-Elliott’s email: iansavageelliott@gmail.com. Savoie’s email: fsavoie@tulane.edu.
- Edited by Travis Frantz, MD, and Ian Savage-Elliott, MD. Frantz is a sports medicine and shoulder fellow at TRIA Orthopaedic Center in Minneapolis. He completed his orthopedic surgery residency at The Ohio State University Wexner Medical Center in Columbus, Ohio. Savage-Elliott is a chief resident in the department of orthopedic surgery at Tulane University Medical Center in New Orleans. He will pursue fellowship training in foot and ankle and sports medicine following residency completion. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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