Shoulder fusion - difficult for surgeon and patient

Long-Term Outcomes of Glenohumeral Arthrodesis

These authors reviewed 29 patients with primary glenohumeral arthrodesis performed between 1992
and 2009. Surgical indications included rotator cuff arthropathy and pseudoparalysis (n = 7), neurologic injuries (n = 12), chronic infection (n = 3), recurrent dislocations (n = 3), and proximal humeral or shoulder girdle tumors (n = 4). Surgical fixation techniques included plates and screws in 18 patients and screws only in 11 patients.

All patients were examined, with a mean follow-up of 12 years (range, 2 to 22 years). Twelve patients (41%) had postoperative complications, including 6 periprosthetic fractures, 7 nonunions, and 3 infections. Eleven patients (38%) required additional surgical procedures after arthrodesis, including revision internal fixation to achieve glenohumeral fusion after nonunions (n = 7), irrigation and debridement with antibiotic treatment for deep infections (n = 2), open reduction and internal fixation to treat fracture (n = 2), and implant removal to treat symptomatic patients (n = 3). Patients experienced reasonable overall pain relief. The mean postoperative scores were 35 points for the Subjective Shoulder Value, 58 points for the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and 54 points for the Short Form-36. Eighty-seven percent of patients reported postoperative limitations. Patients with neurologic injuries had worse functional outcomes.

Comment: Shoulder arthrodesis is not commonly performed, but it is procedure that should be considered in patients with deltoid paralysis and in young patients with intractable instability. 

In young patients, we use a reasonably cosmetic technique that preserves the deltoid and most of the cuff muscles. The shoulder is approached through a standard deltopectoral incision. The subscapularis is incised from the lesser tuberosity to be closed at the end of the case. The cartilage is removed from the humeral and glenoid articular surfaces.

The undersurface of the acromion is curetted. 

 While some advocate fusing at higher angles of elevation, we've found that fusion in the 0,0,60 position is most comfortable because it allows the scapula to be in an anatomic position when the arm is at rest by the side. This position also enables the surgeon to use a sling rather than a cast or brace for postoperative immobilization.

Fixation is achieved by three screws placed from the humerus into the solid bone of the glenoid.

Fixation is augmented by placing an iliac crest autograft between the acromion and the humeral head.

 When stability cannot be achieved in the manner described above, a contoured plate is added from the scapular spine to the lateral humerus.

Non-union and fracture can complicate shoulder fusion. We also encounter patients whose shoulder was fused in too much abduction, too much flexion or too much external rotation. In these cases a corrective osteotomy may be needed

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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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