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Arthrodesis of the Shoulder

- See: Brachial Plexus Injury

- Indications:
      - shoulder paralysis:
          - may include paralytic dislocation or combined rotator cuff / deltoid paralysis (in which case shoulder arthroplasty would be contra-indicated);
          - as a requirement for shoulder fusion, the muscles of forearm and hand need to be functional as do the serratus anterior and trapezius;
                 - the later muscles need to be strong inorder to control scapulothoracic motion after the fusion;
      - degenerative or rheumatoid arthritis;

- Functional Position:
    - fusion should allow the patient to reach the face as well as the back pocket;
    - when trapezius and serratus anterior function is acceptable, position in:
          - abduction:
                - recommendations have ranged from 15 deg to 45 deg;
                - historically recommended positions for shoulder fusion have ranged from 30-45 deg;
                - abduction beyond 45 deg may be associated with pain and winging of the scapula;
                - when serratus anterior is paralyzed, the shoulder should be fused in no more than 30 deg of abduction;
                       - otherwise, the weight of the arm may depress the lateral part of the scapula and overstretch and  weaken the trapezius;
          - flexion: less than 10-30 deg;
          - internal rotation: 20-45 deg;
                - allows patient to reach contra-lateral should, belt, and mouth;
                - deg of rotation can be the most important factor determining extremity function;
     - references:
          - A functional analysis of shoulder fusions.
          - Re-evaluation of the position of the arm in arthrodesis of the shoulder in the adult.  

- Technical Considerations:
    - incision: begin at the scapular spine, continue across the anterior aspect of the acromion, and down the anterior aspect of the proximal part of the humeral shaft;
          - deltoid is detached from the anterior aspect of the acromion, and the fibers are split distally;
          - rotator cuff is excised, the articular surfaces of the glenoid and humeral head are removed, and the undersurface of the acromion is decorticated;
    - attempt both intra-articular fusion (glenohumeral) and extra-articular fusion (acromio-humeral) fusion;
    - if glenohumeral contact is inadequate w/ the superior placement of the humeral head, a partial osteotomy of the acromion can be performed at the junction with the scapular spine;
            - acromion is then displaced downward, hinging at the AC joint;
    - plate is contoured against the scapular spine, over the acromion, and against the proximal humerus;

- Post Op Evaluation:
    - motion of scapula then compensates for the lack of motion in joint;
    - single most important cause of complications following shoulder arthrodesis is malposition, either too much flexion or too much abduction, which results in periscapular pain;

- Arthrodesis in Children:
    - indicatioins:
         - children w/ paralysis of shoulder girdle muscles w/ subluxation or dislocation (as might occur in Polio) inorder to stabilize the flail shoulder;
    - prerequisites for procedure:
          - functional results are related to neurologic status of distal arm & hand, & therefore normal function of forearm & hand is a prerequisite;
          - strong trapezius & serratus anterior muscles are required in order to allow for increased scapulothoracic movement;
    - optimal age is controversial;
           - since it is difficult to predict the final position, some delay shoulder arthrodesis until skeletal maturity;
    - pseudoarthrosis: may occur in 20%;
           - solid fusion is technically difficult to achieve in children because of the amount of cartilage in pediatric humeral head;
           - care must be taken to preserve the proximal humeral growth plate in skeletally immature patient;
     - optimal position of arthrodesis:
           - abduction: 15 deg (but 45 deg as been recommended historically);
                  - excessive abduction should be avoided, because excessive scapular winging can result;
                  - there may be loss of 10-20 degrees of abduction during first 12 months in young children;
           - flexion: 25 deg;
           - internal rotation: 25 deg

A functional analysis of shoulder fusions.

Glenohumeral arthrodesis. Operative and long-term functional results.

Early arthrodesis for a flail shoulder in young children.

A simplified compression arthrodesis of the shoulder.

Shoulder arthrodesis using a pelvic-reconstruction plate. A report of eleven cases.

Arthrodesis of the shoulder in children

Treatment of Complications of Shoulder Arthrodesis.
A simple method of shoulder arthrodesis.

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