The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 88, Issue 3

Scientific Articles | March 01, 2006

Primary Unconstrained Shoulder Arthroplasty in Patients with a Fixed Anterior Glenohumeral Dislocation

J. Matsoukis, MD¹; W. Tabib, MD¹; P. Guiffault, MD¹; A. Mandelbaum, MD¹; Gilles Walch, MD²; Chantal Némoz, PHD³; Zenia E. Cortés, MD⁴; T. Bradley Edwards, MD⁴

¹ Department of Orthopaedic Surgery, Groupe Hospitalier du Havre, Hôpital Jacques Monod, BP 24, 76083 Le Havre CEDEX, France
² Department of Orthopaedic Surgery, Clinique Sainte Anne Lumière, 85 Cours Albert Thomas, 69003 Lyon, France
³ Department of Biostatistics, Hôpitaux de Lyon, 162 Avenue Lacassagne, 69424 Lyon CEDEX 03, France
⁴ Fondren Orthopedic Group, LLP, 7401 South Main Street, Houston, TX 77030. E-mail address for T.B. Edwards: bemd@fondren.com

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In support of their research for or preparation of this manuscript, one or more of the authors received grants or outside funding from the Tornier Company. In addition, one or more of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity (Tornier Company). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Investigation performed at the Department of Orthopaedic Surgery, Clinique Sainte Anne Lumière, Lyon, France

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J Bone Joint Surg Am, 2006 Mar 01;88(3):547-552. doi: 10.2106/JBJS.E.00368

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Abstract

Background: Reports of shoulder arthroplasty for the treatment of fixed glenohumeral dislocation are rare. The purpose of this study was to analyze the results following shoulder arthroplasty in patients with a fixed anterior shoulder dislocation.

Methods: Eleven patients were evaluated at a minimum of twenty-four months after they underwent an arthroplasty for the treatment of a fixed anterior shoulder dislocation. Four patients underwent a total shoulder arthroplasty, and the remainder were treated with a hemiarthroplasty. Four shoulders had osseous reconstruction of the anterior aspect of the glenoid. The patients were evaluated with use of the Constant score, measurement of active anterior elevation and external rotation, the patient's subjective grading of the result, and a radiographic examination.

Results: The mean Constant score improved from 21.1 points preoperatively to 46.0 points following the arthroplasty, and the mean active anterior elevation improved from 48.6° to 90.0°. The pain component of the Constant score was the most reliably improved parameter, increasing from a mean of 4.8 points preoperatively to a mean of 11.0 points postoperatively. Eight patients reported that the result was excellent or good, and the remaining three considered it to be fair. We observed seven complications in five patients, including four cases of anterior instability of the shoulder. Two of the four patients treated with a total shoulder replacement were seen to have definite loosening of the glenoid component on follow-up radiographs.

Conclusions: Shoulder arthroplasty in patients with a fixed anterior shoulder dislocation is fraught with difficulties and complications. Although arthroplasty reliably relieved shoulder pain in this population, limited functional results should be expected.

Level of Evidence: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

There have been few reports of shoulder arthroplasty for the treatment of fixed glenohumeral dislocation^1,2. The use of shoulder arthroplasty in patients with a locked posterior shoulder dislocation has recently been reported^3,4. Shoulder arthroplasty is challenging in this patient population as concomitant pathological conditions such as fractures of the proximal part of the humerus, fractures of the glenoid, rotator cuff tears, severe soft-tissue contractures, and neurological injuries are common. The purpose of this study was to report the results of shoulder arthroplasty in patients with a fixed anterior glenohumeral dislocation.

Materials and Methods

Materials and Methods | Results | Discussion | References

In a series of 1542 primary shoulder arthroplasties performed between September 1991 and September 1998, and reported on as part of a prospective multicenter study⁵, twelve shoulders (treated by ten different surgeons) were identified as having undergone shoulder arthroplasty for the treatment of a fixed anterior shoulder dislocation (an anterior dislocation of longer than three weeks in duration) (Figs. 1-A and 1-B). One of these patients was unavailable for follow-up because of a disabling cerebrovascular accident. The remaining eleven shoulders are the subjects of this investigation.

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Figs. 1-A and 1-B: Fig. 1-A Anteroposterior radiograph demonstrating subcoracoid dislocation with a fracture of the greater tuberosity. Fig. 1-B Axial computed tomography scan revealing anterior dislocation and a fracture of the greater tuberosity.

Three patients were men, and eight were women. The mean age was 67.3 years (range, forty-five to eighty-four years) at the time of the shoulder dislocation and 69.3 years (range, forty-six years to eighty-seven years) at the time of the shoulder arthroplasty. All dislocations were traumatic, and no patient had a history of a seizure disorder. Three patients had had a prior attempt at open reduction and stabilization, and all three had a recurrent, fixed dislocation within two weeks after that procedure. Two of the three patients had undergone an open reduction and a coracoid process transfer, and the other patient had undergone an open reduction and a Bankart-type stabilization. The time interval from the index operation to the shoulder arthroplasty was thirteen months for one of the patients who had a coracoid transfer, twelve months for the other who had a coracoid transfer, and ten months for the patient who had the Bankart repair. The reason for the prolonged time interval between the operations is unclear, as all three of the initial surgical procedures were performed at outlying institutions.

All patients in this series underwent primary shoulder arthroplasty with cement and use of the Aequalis prosthesis (Tornier, Montbonnot, France). Seven shoulders were treated with a hemiarthroplasty, and four were treated with a total shoulder arthroplasty. All of the glenoid implants of the total shoulder replacements were cemented keeled flat-back components. The indication for total shoulder arthroplasty was grossly abnormal glenoid articular cartilage found at the time of surgery. All patients had an extensive capsular release, consisting of release of the anterior, inferior, and posterior aspects of the capsule from the glenoid with use of electrocautery. Additionally, the rotator interval, including the coracohumeral and superior glenohumeral ligaments, was released. In two patients, a fracture of the greater tuberosity resulting from the initial trauma was fixed with number-5 braided polyester sutures. In four patients, anterior glenoid insufficiency (loss of greater than one-third of the anterior-to-posterior diameter of the glenoid), as judged by the operating surgeon, was reconstructed with autogenous tricortical iliac crest bone graft fixed to the glenoid from anterior to posterior with use of one or two bicortical 4.5-mm partially threaded malleolar screws. All components were placed in what was judged to be anatomic orientation; there were no attempts to intentionally change prosthetic version to provide better glenohumeral stability in this series. Three patients had an isolated supraspinatus tear, one patient had an isolated subscapularis tear, and one patient had tears of both the supraspinatus and the subscapularis. As these tears were judged to be irreparable, no attempt was made to repair them.

Preoperatively, all patients were evaluated with a Constant score⁶, which was then adjusted for age and gender and expressed as a percentage of normal⁷. Additionally, active forward flexion in the plane of the scapula and external rotation with the arm at the side were recorded preoperatively. The postoperative evaluation consisted of determination of the Constant score and the adjusted Constant score as well as measurement of the same mobility parameters as were evaluated preoperatively. In addition, a subjective result, graded as excellent, good, fair, or poor on the basis of the patient's response regarding whether he or she was very satisfied, somewhat satisfied, somewhat disappointed, or very disappointed with the shoulder, was documented. Radiographic evaluation with anteroposterior shoulder views in neutral, humeral internal and external rotation views, and an axillary view was performed at the time of the latest follow-up.

Results

Materials and Methods | Results | Discussion | References

The patients were followed for an average 47.7 months (range, twenty-four to eighty-six months). The results of the preoperative and postoperative evaluations are shown in Table I. Eight patients reported that the result was excellent or good, and three patients reported that it was fair. We observed seven complications in five shoulders, two of which required a reoperation. Four shoulders demonstrated recurrent anterior instability (Fig. 2), and two of the four patients treated with a total shoulder arthroplasty demonstrated glenoid loosening.

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TABLE I Data on the Patients

	Age (yr)						Preop. Constant Score			Preop. Active Motion (deg)				Postop. Constant Score			Postop. Active Motion (deg)
Case	At 1st Disloc.	At Op.	Concomitant Lesions	Type of Procedure^*	Concomitant Procedures	Absolute (Points)	Adjusted (%)	Elevation	External Rotation	Durat. of Follow-up (mo)	Absolute (Points)	Adjusted (%)	Elevation	External Rotation	Subjective Result	Complications	Reoperation
1	45	46	Supraspinatus tear, subscapularis tear	Hemi	Glenoid bone graft	26	32	10	0	34	39	49	75	0	Excellent
2	65	66	Subscapularis tear	Total		15	21	60	40	67	32	46	90	30	Good	Anterior dislocation, glenoid loosening	Glenoid component removal
3	66	66	Glenoid fracture, supraspinatus tear	Total		36	51	75	20	86	13	19	50	0	Fair	Anterior subluxation, glenoid loosening
4	70	82	Supraspinatus tear	Total		33	47	70	20	52	49	50	10	10	Good	Anterior dislocation
5	70	71		Hemi	Glenoid bone graft	19	27	30	20	24	42	60	80	20	Fair	Anterior dislocation
6	71	71	Supraspinatus tear	Hemi		12.5	18	70	25	44	76.5	110	170	35	Good
7	77	77	Greater tuberosity fracture	Hemi	Open reduction and internal fixation of greater tuberosity	29	41	60	10	51	36	54	90	20	Fair
8	84	87		Hemi		19	29	80	0	30	51	79	130	15	Excellent
9	67	68		Hemi	Glenoid bone graft	34	34	30	0	32	66	66	145	20	Good	Bone graft migration	Screw removal
10	72	72	Glenoid fracture, greater tuberosity fracture, axillary nerve palsy	Total	Glenoid bone graft, open reduction and internal fixation of greater tuberosity	0	0	30	10	51	37	54	40	60	Good
11	53	56	Incomplete brachial plexus palsy	Hemi		9	10	20	0	54	64	71	110	70	Good
Mean	67.3	69.3				21.1	28.2	48.6	13.2	47.7	46.0	59.8	90.0	25.5

Hemi = hemiarthroplasty, and total = total shoulder arthroplasty

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TABLE I Data on the Patients

	Age (yr)						Preop. Constant Score			Preop. Active Motion (deg)				Postop. Constant Score			Postop. Active Motion (deg)
Case	At 1st Disloc.	At Op.	Concomitant Lesions	Type of Procedure^*	Concomitant Procedures	Absolute (Points)	Adjusted (%)	Elevation	External Rotation	Durat. of Follow-up (mo)	Absolute (Points)	Adjusted (%)	Elevation	External Rotation	Subjective Result	Complications	Reoperation
1	45	46	Supraspinatus tear, subscapularis tear	Hemi	Glenoid bone graft	26	32	10	0	34	39	49	75	0	Excellent
2	65	66	Subscapularis tear	Total		15	21	60	40	67	32	46	90	30	Good	Anterior dislocation, glenoid loosening	Glenoid component removal
3	66	66	Glenoid fracture, supraspinatus tear	Total		36	51	75	20	86	13	19	50	0	Fair	Anterior subluxation, glenoid loosening
4	70	82	Supraspinatus tear	Total		33	47	70	20	52	49	50	10	10	Good	Anterior dislocation
5	70	71		Hemi	Glenoid bone graft	19	27	30	20	24	42	60	80	20	Fair	Anterior dislocation
6	71	71	Supraspinatus tear	Hemi		12.5	18	70	25	44	76.5	110	170	35	Good
7	77	77	Greater tuberosity fracture	Hemi	Open reduction and internal fixation of greater tuberosity	29	41	60	10	51	36	54	90	20	Fair
8	84	87		Hemi		19	29	80	0	30	51	79	130	15	Excellent
9	67	68		Hemi	Glenoid bone graft	34	34	30	0	32	66	66	145	20	Good	Bone graft migration	Screw removal
10	72	72	Glenoid fracture, greater tuberosity fracture, axillary nerve palsy	Total	Glenoid bone graft, open reduction and internal fixation of greater tuberosity	0	0	30	10	51	37	54	40	60	Good
11	53	56	Incomplete brachial plexus palsy	Hemi		9	10	20	0	54	64	71	110	70	Good
Mean	67.3	69.3				21.1	28.2	48.6	13.2	47.7	46.0	59.8	90.0	25.5

Hemi = hemiarthroplasty, and total = total shoulder arthroplasty

One patient had an incomplete radiolucency around the humeral component, which did not appear to have progressed on serial radiographs made during the follow-up period. There was no evidence of humeral stem migration during the follow-up period. Three glenoid components were associated with a radiolucent line, and two of the lines were progressive. The patient who had supraspinatus and subscapularis tears had superior migration of the humeral component.

Discussion

Materials and Methods | Results | Discussion | References

The results of this review demonstrate the challenge involved in treating patients with a chronically fixed anterior glenohumeral dislocation. Although unconstrained arthroplasty provided substantial functional gains, the high complication rate is further evidence of the technical challenge presented by these cases.

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Fig. 2: Anteroposterior radiograph showing recurrent anterior instability after hemiarthroplasty.

Although there have been several reports on fixed glenohumeral dislocations in the literature, few have presented the results of arthroplasty in this patient population^1,3,4,8-10. Our clinical results demonstrate that these patients, although reasonably satisfied with the outcome, fare poorly compared with patients who undergo arthroplasty for primary osteoarthritis¹¹. There were substantial gains in shoulder-specific outcome parameters following the arthroplasty, but ultimately function was only 60% of normal for the patients' age and gender as determined with the adjusted Constant score.

In addition to the compromised clinical results, complications occurred in nearly half of the shoulders in this series, illustrating the technically difficult nature of arthroplasty in these individuals. Recurrent instability was a major problem despite attempts at anterior glenoid reconstruction. Perhaps the addition of a pectoralis major transfer, as described by Galatz et al.¹², may alter the incidence of recurrent anterior instability in patients with a subscapularis tear; however, we have no personal experience with this technique in this scenario, and only one of our patients with postoperative instability had a subscapularis tear. Another possible solution to the postoperative instability encountered following unconstrained shoulder arthroplasty is to place the humeral component in increased retroversion. The converse of this was tested by Spencer et al., who placed the humeral component in excessive anteversion in cadaveric specimens in which the glenoid was in excessive retroversion¹³. In this laboratory model, changing the version of the humeral component did not favorably affect glenohumeral stability. Finally, allograft reconstruction has been described in revision surgery in patients with subscapularis failure following shoulder arthoplasty¹⁴. Perhaps one of these techniques used in combination with an unconstrained shoulder arthroplasty would be effective as a primary procedure in this patient population, but we have no experience with these techniques.

Another complication that we encountered was failure of the glenoid component, which occurred in two of the four patients treated with total shoulder replacement. Both of those patients had an irreparable rotator cuff tear, which further validates the identification, originally by Franklin et al.¹⁵, of such large tears as a contraindication to unconstrained total shoulder arthroplasty. Currently, we do not recommend prosthetic resurfacing of the glenoid in patients with an irreparable rotator cuff tear and a fixed anterior dislocation regardless of the condition of the glenoid articular cartilage.

We recognize that our multicenter case-control study has weaknesses. Surgical techniques and assessments of results cannot be completely standardized in such a study. Despite these limitations, our case series is the largest in which the results of unconstrained shoulder arthroplasty for the treatment of fixed anterior shoulder dislocation were reported. Our investigation involved multiple comparisons with multiple factors that could potentially influence the results. Because of the relative rarity of the condition, we did not study a sufficient number of subjects to perform a meaningful statistical analysis.

In summary, shoulder arthroplasty in patients with a fixed anterior glenohumeral dislocation is technically challenging and fraught with potential complications. Despite acceptable patient satisfaction and substantial gains in pain relief and function, the results in our group of patients did not approach those expected following total shoulder arthroplasty for the treatment of primary osteoarthritis. ?

References

Materials and Methods | Results | Discussion | References

Pritchett JW, Clark JM. Prosthetic replacement for chronic unreduced dislocations of the shoulder. Clin Orthop Relat Res. 1987;216: 89-93.21689 1987 [PubMed]

Rowe CR, Zarins B. Chronic unreduced dislocations of the shoulder. J Bone Joint Surg Am. 1982;64: 494-505.64494 1982 [PubMed]

Cheng SL, Mackay MB, Richards RR. Treatment of locked posterior fracture-dislocations of the shoulder by total shoulder arthroplasty. J Shoulder Elbow Surg. 1997;6: 11-7.611 1997 [PubMed][CrossRef]

Sperling JW, Pring M, Antuna SA, Cofield RH. Shoulder arthroplasty for locked posterior dislocation of the shoulder. J Shoulder Elbow Surg. 2004; 13: 522-7.13522 2004 [PubMed][CrossRef]

Walch G, Boulahia A, Boileau P, Kempf JF. Presentation of the multicentric study. In: Walch G, Boileau P, Molé D, editors. 2000 prosthéses d'epaule...recul de 2 à 10 ans. Paris: Sauramps Medical; 2001. p 13-20.13 2001

Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;214: 160-4.214160 1987

Constant CR. Assessment of shoulder function. In: Gazielly DF, Gleyze P, Thomas T, editors. The cuff. Paris: Elsevier; 1997. p 39-44.39 1997

Hawkins RJ, Neer CS 2nd, Pianta RM, Mendoza FX. Locked posterior dislocations of the shoulder. J Bone Joint Surg Am. 1987;69: 9-18.699 1987

Schulz TJ, Jacobs B, Patterson RL Jr. Unrecognized dislocations of the shoulder. J Trauma. 1969;9: 1009-23.91009 1969 [PubMed][CrossRef]

Walch G, Boileau P, Martin B, Dejour H. [Unreduced posterior luxations and fractures-luxations of the shoulder. Apropos of 30 cases]. Rev Chir Orthop Reparatrice Appar Mot. 1990;76: 546-58. French.76546 1990 [PubMed]

Lafosse L, Kempf JF. Omarthrose primitive: resultants cliniques et radiologiques. In: Walch G, Boileau P, Molé D, editors. 2000 prosthéses d'epaule...recul de 2 à 10 ans. Paris: Sauramps Medical; 2001. p 73-85.73 2001

Galatz LM, Connor PM, Calfee RP, Hsu JC, Yamaguchi K. Pectoralis major transfer for anterior-superior subluxation in massive rotator cuff insufficiency. J Shoulder Elbow Surg. 2003;12: 1-5.121 2003 [PubMed][CrossRef]

Spencer EE Jr, Valdevit A, Kambic H, Brems JJ, Iannotti JP. The effect of humeral component anteversion on shoulder stability with glenoid component retroversion. J Bone Joint Surg Am. 2005;87: 808-14.87808 2005 [CrossRef]

Moeckel BH, Altchek DW, Warren RF, Wickiewicz TL, Dines DM. Instability of the shoulder after arthroplasty. J Bone Joint Surg Am. 1993;75: 492-7.75492 1993 [PubMed]

Franklin JL, Barrett WP, Jackins SE, Matsen FA 3rd. Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency. J Arthroplasty. 1988;3: 39-46.339 1988 [PubMed][CrossRef]

Topics

shoulder dislocations ; shoulder replacement arthroplasty

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J. Matsoukis, W. Tabib, P. Guiffault, A. Mandelbaum, Gilles Walch, Chantal Némoz, Zenia E. Cortés, T. Bradley Edwards; Primary Unconstrained Shoulder Arthroplasty in Patients with a Fixed Anterior Glenohumeral Dislocation. The Journal of Bone & Joint Surgery. 2006 Mar;88(3):547-552.

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