Thursday, February 4, 2016

Shoulder fusion - conversion to reverse?

Once an arthrodesis, always an arthrodesis?

These authors present four patients (2 men, 2 women; age 46-66 years) with a longstanding shoulder arthrodesis (5-11 years) and periscapular pain. The shoulders were fused in 60 to 80 degrees of abduction, 20 to 40 degrees of flexion, and 40 to 50 degrees of internal rotation. Preoperative EMG showed activity in at least the posterior or middle parts of the deltoid, or both.

The patients were satisfied; the Constant-Murley scores were modestly improved from 15-21 to 30-60; rotation was somewhat increase. Pain did not disappear but decreased considerably, from visual analog scale 8-10 to 0-4. No dislocations were noted.

Comment: It is interesting that these shoulders had been fused in extreme positions of abduction and moderate flexion so that substantial winging of the scapula would have been necessary  for the patient to adduct the arm to a rest position by the side. Because such positions of fusion are usually productive of periscapular pain and difficulties lying flat or sitting in a firm-backed chair, our preferred position of fusion is 0-15 degrees of flexion, 0-15 degrees of abduction and sufficient internal rotation so that the hand can easily reach the mouth and zipper.

While shoulder arthrodesis is not commonly performed these days, it remains an alternative. The position of arthrodesis needs to be carefully considered in light of the discussion above, which is in contrast to the ‘conventionally recommended’ position. In performing an arthrodesis, our current technique seeks to preserve the deltoid by avoiding an acromiohumeral plate (in the event that subsequent conversion to an arthroplasty may be considered down the line). 


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