Shoulder resection arthroplasty

Definition

Shoulder resection arthroplasty is surgery performed to repair a shoulder acromioclavicular (AC) joint. The procedure is most commonly recommended for AC joint problems resulting from osteoarthritis or injury.

Purpose

The shoulder consists of three bones: the shoulder blade, the upper arm bone (humerus), and the collarbone (clavicle). The part of the shoulder blade that makes up the roof of the shoulder is called the acromion and the joint where the acromion and the collarbone join is called the acromioclavicular (AC) joint.

Some joints in the body are more likely to develop problems due to normal wear and tear, or deterioration resulting from osteoarthritis, a progressive and degenerative joint disease. The AC joint is a common target for developing osteoarthritis in middle age. This condition can lead to pain and difficulty using the shoulder for everyday activities. Besides osteoarthritis, AC joint disease (arthrosis) may develop from an old injury to the joint such as an acromioclavicular dislocation, which is the disruption of the normal articulation between the acromion and the collarbone. This type of injury is quite common in competitive sports, but can also result from a simple fall on the shoulder.

The goal of shoulder resection arthroplasty is to restore function to an impaired shoulder, with its required motion range, stability, strength, and smoothness.

Demographics

According to the National Ambulatory Medical Care Survey, osteoarthritis is one of the most common confirmed diagnoses in individuals over the age of 65, with the condition starting to develop in middle age.

As for AC joint injuries, they are seen especially in such professional athletes as football or hockey players, and occur most frequently in the second decade of life. Males are more commonly affected than females, with a male-to-female ratio of approximately five to one.

Description

A resection arthroplasty involves the surgical removal of the last 0.5 in (1.3 cm) of the collarbone. This removal leaves a space between the acromion and the cut end of the collarbone where the AC joint used to be. The joint is replaced by scar tissue, which allows movement to occur, but prevents the rubbing of the bone ends. The end result of the surgery is that the flexible connection between the acromion and the collarbone is restored. The procedure is usually performed by making a small 2 in (5 cm) incision in the skin over the AC joint. In some cases, the surgery can be done arthroscopically. In this approach, the surgeon uses an endoscope to look through a small hole into the shoulder joint. The endoscope is an instrument of the size of a pen, consisting of a tube fitted with a light and a miniature video camera, which transmits an image of the joint interior to a television monitor. The surgeon proceeds to remove the segment of collarbone through a small incision with little disruption of the other shoulder structures.

Diagnosis/Preparation

The diagnosis is made by physical exam. Tenderness over the AC joint is usually present, with pain upon compression of the joint. X rays of the AC joint may show narrowing of the joint and bone spurs around the joint. A magnetic resonance imaging (MRI) scan may also be performed. An MRI scan is a special imaging test that uses magnetic waves to create pictures that show the tissues of the shoulder in slices and has the advantage of showing tendons as well as bones. In some cases, an ultrasound test may be also be performed to inspect the soft tissues of the joint.

Prior to arthroplasty surgery, all the standard preoperative blood and urine tests are performed. The patient also meets with the anesthesiologist to discuss any special conditions that may affect the administration of anesthesia.

Aftercare

The rehabilitation following surgery for a simple resection arthroplasty is usually fairly rapid. Patients should expect the soreness to last for three to six weeks. Postoperatively, patients usually have the affected arm in a sling for two weeks. Thereafter, a progressive passive range of shoulder motion exercise is started, usually with range-of-motion exercises that gradually evolve into active stretching and strengthening. The patient's arm remains in the sling between sessions. At six weeks, healing is sufficient to encourage progressive functional use. Physiotherapy usually continues until range of motion and strength are maximized. The therapist may also use massage and other types of hands-on treatments to ease muscle spasm and pain. Heavy physical use of the shoulder is prohibited for an additional six weeks.

Risks

Patients who undergo shoulder resection arthroplasty are susceptible to the same complications associated with any such surgery. These include wound infection, osteomyelitis, soft tissue ossification, and failure of fixation (remaining in place), with recurrent deformity. Symptomatic AC joint arthritis may develop in patients who undergo the surgery as a result of injury.

Specific risks associated with shoulder resection arthroplasty include:

• Fractures. Fractures of the humerus may occur after surgery, although the risk is considered low.
• Shoulder instability. Early shoulder dislocations may occur during the early postoperative period due to soft tissue imbalance or to inadequate postoperative protection; late dislocation may result from glenoid cavity wear.
• Degenerative changes. Progressive degeneration of the AC joint is a common late complication.

Normal results

Shoulder resection arthroplasty is generally very effective in reducing pain and restoring motion of the shoulder.

Morbidity and mortality rates

In a recent four-year follow-up study on shoulder arthroplasty patients, all patients experienced relief from pain. Functional improvement was good in 77% of patients. Average shoulder abduction improved from 37–79° and forward flexion from 52–93°. No deaths resulting from shoulder resection arthroplasty have ever been reported.

Alternatives

Non-surgical treatments

Doctors commonly attempt to treat AC joint problems using conservative treatments. Patients may be prescribed such anti-inflammatory medications as aspirin or ibuprofen. Treatment also may include such diseasemodifying drugs as methotrexate, sulfasalazine and gold injections. Researchers are also working on biologic agents that can interrupt the progress of osteoarthritis. These agents target specific chemicals in the body to prevent them from acting on the joints. Resting the sore joint and applying ice to it can also ease pain and inflammation. Injections of cortisone into the joint may also be prescribed. Cortisone is a strong steroidal medication that decreases inflammation and reduces pain. The effects of the drug are temporary, but it provides effective relief in the short term. Physicians may also prescribe sessions with a physical or occupational therapist, who may use various treatments to relieve inflammation of the AC joint, including heat and ice.

Surgical alternatives

Alternative surgical approaches include replacing the entire shoulder joint with a prosthesis (total shoulder arthroplasty) or replacing the head of the humerus (hemiarthroplasty).

See also Arthroplasty ; Shoulder joint replacement .

Resources

BOOKS

Friedman, R. J. Arthroplasty of the Shoulder. New York: Thieme Medical Pub., 1994.

Lajtai, G., S. J. Snyder, G. Applegate, G. Aitzetmuller, and C. Gerber, eds. Shoulder Arthroscopy and MRI-Techniques. New York: Springer Verlag, 2003.

Walch, G., and P. Boileau., eds. Shoulder Arthroplasty. New York: Springer Verlag, 1999.

Wallace, W. A., ed. Joint Replacement in the Shoulder and Elbow. London: Edward Arnold Pub., 1998.

PERIODICALS

Iannotti, J. P., and T. R. Norris. "Influence of Preoperative Factors on Outcome of Shoulder Arthroplasty for Glenohumeral Osteoarthritis." Journal of Bone and Joint Surgery 85 (February 2003): 251–258.

Mileti, J., J. W. Sperling, and R. H. Cofield. "Shoulder Arthroplasty for the Treatment of Postinfectious Glenohumeral Arthritis." Journal of Bone and Joint Surgery 85 (April 2003): 619–614.

Nagels, J., M. Stokdijk, and P. M. Rozing. "Stress Shielding and Bone Resorption in Shoulder Arthroplasty." Journal of Shoulder and Elbow Surgery 12 (January–February 2003): 35–39.

Sanchez-Sotelo, J., J. W. Sperling, C. M. Rowland, and R. H. Cofield. "Instability after Shoulder Arthroplasty: Results of Surgical Treatment." Journal of Bone and Joint Surgery 85 (April 2003): 622–631.

Sofka, C. M., and R. S. Adler. "Sonographic Evaluation of Shoulder Arthroplasty." American Journal of Roentgenology 180 (April 2003): 1117–1120.

Woodruff, J., P. Cohen, and G. Bradley. "Arthroplasty of the Shoulder in Rheumatoid Arthritis with Rotator Cuff Dysfunction." International Orthopaedics 27 (2003): 7–10.

ORGANIZATIONS

American Academy of Orthopaedic Surgeons. 6300 North River Road, Rosemont, Illinois 60018-4262. (847) 823-7186. http://www.aaos.org .

American Shoulder and Elbow Surgeons (ASES). 6300 North River Road, Suite 727, Rosemont, IL, 60018-4226. (847) 698-1629. http://www.ases-assn.org .

OTHER

"Arthroplasty of the Shoulder." Wheeless' Textbook of Orthopaedics. http://www.ortho-u.net/orthoo/44.htm .

"Rehabilitation After Shoulder Arthroplasty." University of Washington Orthopaedics and Sports Medicine. <http://www.orthop.washington.edu/shoulder_elbow/roughness/mana ement/rehab/01> .

Monique Laberge, PhD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Shoulder resection arthroplasty is performed in a hospital. It is performed by experienced orthopedic surgeons who are specialists in AC joint problems. Some medical centers specialize in joint surgery and tend to have higher success rates than less specialized centers.

QUESTIONS TO ASK THE DOCTOR

• How can I regain the use of my shoulder?
• What will it take to make my shoulder healthy again?
• Why do I have problems with my shoulder?
• What surgical procedures do you follow?
• How many shoulder resection arthroplasties do you perform each year?
• Will surgery on my shoulder allow me to resume my activities?