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WHAT IS A SHOULDER RESECTION ARTHROPLASTY?
A shoulder resection arthroplasty is an operation in which the humeral head or the prosthetic material (implants) is removed after complications or failure, usually due to infection. This is a ‘”last-call solution” that is only recommended when there are no other treatment options.
INDICATIONS – WHEN AND WHY IS A SHOULDER RESECTION ARTHROPLASTY NEEDED?
Arthroplasty resection is considered a limb rescue surgical operation after multiple and unsuccessful surgeries, with an impact on the patient’s symptomatology (pain and stiffness). It is often associated with an infection following surgery that has subsequently been treated – unsuccessfully – with revision surgery.
Chronic infection -To cure an infection that has not responded to other treatments or surgery, it is necessary to remove all materials (prostheses or osteosynthesis materials) without repositioning the shoulder. Postoperative total shoulder arthroplasty (TSA) has a frequency of 0-3.9%, whereas reverse total shoulder arthroplasty (RTSA) has a rate of 1-10%.
Shoulder arthroplasty failure, which may be due to implant loosening or material failure. In all these cases, revision (i.e. replacement of the prosthesis) is the most appropriate option, but if bone or soft tissue quality does not allow it, arthroplasty is the next surgical option.
Fracture with inability to recover due to poor bone quality.
Severe inflammatory arthritis, such as rheumatoid arthritis, which causes large bone defects to the extent that the bone is not sufficient to repair or place the implant.
Severe nerve injury combined with one of the above conditions.
FUNCTIONAL RESULTS AFTER SHOULDER RESECTION ARTHROPLASTY
This patient underwent a total shoulder arthroplasty that was infected, requiring removal of materials and placement of antibiotic-impregnated acrylic cement prosthesis (PROSTALAC). Intravenous antibiotics were also administered for several weeks but the infection was not eliminated. Due to the above and severe pain, the patient underwent shoulder resection arthroplasty.
This patient suffered a malunion fracture with a metal screw on the humerus, as well as arthritic lesions (Figure A). He underwent hemiarthroplasty (humerus replacement only) to relieve pain and arthritis (Figure B). An infection was presented, which was initially treated by removal of the material and placement of the PROSTALAC system.
The pain persisted, while it was impossible to fully cure the infection, resulting in a resection of the arthroplasty. An X-ray highlighted the different height of the osteotomy compared to the previous patient.
Six months after surgery, he was relieved of his pain; he could feel his shoulder at 70% normal and he is happy with the results of the surgery. He is also able to raise his hand to 90°.
HOW THE SHOULDER RESECTION ARTHROPLASTY IS COMPLETED
Once the arthroplasty is considered to be the best solution for the treatment of pain, treatment of infection or fracture that is not otherwise treated, the humeral head or the prosthesis (rod and artificial glenoid cavity) is removed. The removal or resection of implants is not followed by their replacement. The space between the arm and the glenoid cavity is left empty until it is filled by scar tissue. Formation of the scar tissue is important for achieving a good functional result. The height of the osteotomy of the humerus (the amount of bone removed) depends on the patient’s history and the type of resection from previous arthroplasty procedures.
THE RESULTS OF RECENT STUDIES ON SHOULDER RESECTION ARTHROPLASTY
Braman JP, Sprague M, Bishop J, Lo IK, Lee EW, Flatow EL. The outcome of shoulder resection arthroplasty for recalcitrant shoulder infections. J Shoulder Elbow Surg. 2006 Sep-Oct; 15 (5): 549-53
This study examined the effects of arthroplasty on shoulder infections that exhibited resistance to pharmaceutical protocols. In seven patients, mean flexion rates were 28° (range 0° – 80°) and mean outer rotation rates were 8° (range 20° to 40°). In this study, all patients reported that they could reach their mouth with the operated limb, while with the other hand their back pocket. All but one patient was pleased with their results.
In conclusion, this resection arthroplasty is a rescue operation when the placement of the prosthesis is not possible.
Debeer P, Plasschaert H, Stuyck J. Resection arthroplasty of the infected shoulder: a salvage procedure for the elderly patient. Acta Orthop Belg. 2006 Apr; 72 (2): 126-30.
This study, in seven elderly patients, concludes that resection arthroplasty is an effective solution for total shoulder arthroplasty infections. The results were excellent in the treatment of infection but the functional results were modest.
Rispoli DM, Sperling JW, Athwal GS, Schleck CD, Cofield RH. Pain relief and functional results after resection of shoulder arthroplasty. J Bone Joint Surg Br. 2007 Sep; 89 (9): 1184-7.
This study reports that pain relief is achieved in 2/3 of patients. Pain relief is not guaranteed, but the shoulder is usually painless at rest, but with many functional limitations.
Muh SJ, Streit JJ, Lenarz CJ, McCrum C, Wanner JP, Shishani Y, Moraga C, Nowinski RJ, Edwards TB, Warner JJ, Walch G, Gobezie R. Resection of arthroplasty for failed shoulder arthroplasty. J Shoulder Elbow Surg. 2013 Feb; 22 (2): 247-52v
A study of 26 patients who underwent resection arthroplasty after failed shoulder arthroplasty (6 cases of total shoulder arthroplasty, 7 cases of semi-arthroplasty, and 13 cases of reverse shoulder arthroplasty).
The authors reported that all patients reported significant improvement in pain. The mean flexion rates were 45° (+/- 30°) and the outer rotation rates were 9° (+/- 13°). The results of this study showed that arthroplasty is effective in relieving pain, even though patients present reduced shoulder functionality.
Also, according to the study, patients undergoing reversible total shoulder arthroplasty have worse outcomes.
CONCLUSIONS
In conclusion, shoulder resection arthroplasty can be considered as the last option after a series of failed surgeries that have preceded and left no alternative for the patient. Arthroplasty resection significantly helps to reduce pain, but does not completely eliminate it.
Postoperatively, the patient may not regain the level of functionality before surgery, but the majority of patients report a significant reduction in pain compared to their preoperative condition.
