Shoulder and Elbow Cases to Consider.

Last updated Friday, August 29, 2008

Figure 1a

Figure 1b

Figure 2

Figure 1

Figure 2

Figure 1

Figure 2

Figure 1

Figure 2

Figure 1

Figure 1

Figure 1

Figure 2

Figure 1

Figure 2

Figure 1

Figure 2

Figure 1 - Destruction of the humeral head with an associated soft tissue mass

Figure 2 - Cervicothoracic syrinx

Propionibacterium acnes (P. Acnes) infection after total shoulder arthroplasty

Clinical presentation

1. Infection
   
2. Loosening of components
   
3. Poor glenoid bone stock
   
4. Poor humeral bone stock
   
5. Intra-operative fracture
   
6. Access to glenoid if humeral component well fixed
   
7. Axillary nerve injury due to multiply operated, altered surgical field

Management

Due to the patient’s severe loss of shoulder function with persistent pain and stiffness, we recommended revision surgery to include cultures before antibiotic administration, removal of the glenoid component, possible revision of the humeral component, and debridement with lysis of adhesions.

At surgery the glenoid component was loose. There was a substantial amount of osteolysis of the proximal humerus and glenoid. The glenoid bone was eroded medially. There was no evidence of acute inflammation.

After removal of both the glenoid and humeral components, the remaining glenoid bone was reamed to a conforming concavity after debridement of all fibrous tissue and cement. No prosthetic glenoid component was inserted. No bone graft was performed. A new humeral component was secured in proper position using impaction allograft with Vancomycin-impregnated allograft. (Figure 1b)

Multiple soft tissue and fluid specimens were sent for culture and microscopic examination.  The pathology revealed clusters of gram-positive bacteria. (Figure 2).  5 out of 5 cultures became positive.  Four specimens became positive at 5 days after surgery and one specimen 8 days after surgery.  The patient was started on Ceftriaxone 2 gm IV q24 hours for six weeks via a PICC line followed by amoxicillin 1gm po tid for six weeks.

While the long-term outcome remains to be seen, the patient is making excellent progress with his rehabilitation.

References

1.  Acute deep infection after surgical fixation of proximal humeral fractures
Journal of Shoulder and Elbow Surgery, Volume 16, Issue 4, July-August 2007, Pages 408-412
George S. Athwal, John W. Sperling, Damian M. Rispoli, Robert H. Cofield

2.  Propionibacterium acnes: An agent of prosthetic joint infection and colonization
Journal of Infection, Volume 55, Issue 2, August 2007, Pages 119-124
Valérie Zeller, Ali Ghorbani, Christophe Strady, Philippe Leonard, Patrick Mamoudy, Nicole Desplace

3.  Revision shoulder arthroplasty for glenoid component loosening
Journal of Shoulder and Elbow Surgery, Volume 17, Issue 3, May-June 2008, Pages 371-375
Emilie V. Cheung, John W. Sperling, Robert H. Cofield

4.  Deep infection after rotator cuff repair
Journal of Shoulder and Elbow Surgery, Volume 16, Issue 3, May-June 2007, Pages 306-311
George S. Athwal, John W. Sperling, Damian M. Rispoli, Robert H. Cofield

5.  Revision shoulder arthroplasty with positive intraoperative cultures: The value of preoperative studies and intraoperative histology
Journal of Shoulder and Elbow Surgery, Volume 15, Issue 4, July-August 2006, Pages 402-406
Mark S. Topolski, Patrick Y.K. Chin, John W. Sperling, Robert H. Cofield

Clinical Presentation

This is the radiograph of a 60 year old woman with chronic rheumatoid arthritis who presented to us with problems 4 weeks after left total elbow arthroplasty. She had a similar procedure performed on the opposite side without problem. One week after this surgery she felt a "clunk" in her elbow and then had difficulty moving it without discomfort. Radiographs showed the elbow had dislocated (see figure 1). A closed reduction was performed, but 2 weeks later the dislocation recurred. Open reduction and a soft tissue reconstruction was performed at that time. Now the elbow is again dislocated, swollen and painful on all motion--she keeps it in a splint at all times. Her lateral elbow incision is relatively calm, but the sutures are still in place. She has had two surgeries and one manipulation in less than one month. Her exam indicates ulnar nerve irritation, but she is otherwise neurovascularly intact.

Our concerns included:

1. the patient's loss of elbow function
2. wound status
3. neurovascular status
4. risks of revision of cemented prosthesis in soft rheumatoid bone
5. incisional approaches

Management

Closed reduction was attempted under anesthesia and fluoroscopy. This could not be accomplished.

Open reduction was attempted after ulnar nerve dissection through a new posteriormedial approach. A stable reduction could not be achieved. Revision to constrained total elbow was accomplished with minor penetrations of ulna and humerus in process of cement removal. Post operative range was 0-135 degrees. Neurovascular status intact. See post operative radiograph (figure 2).

Clinical presentation

This is the radiograph of the right shoulder of a 50 year old woman who presented with a chronic atrophic non-union of her humerus (see figure 1). She sustained the subtuberous fracture in a fall 6 months ago. She was treated with closed reduction and sling immobilization. At 6 weeks mobilization was started, however over the ensuing months she had progressively increasing pain in her arm.

At her consultation visit with us, examination revealed pain and crepitance on movement of the arm. There was no evidence of sepsis or neurovascular impairment. Her general health was excellent.

Our concerns included:

1. The loss of bone around the fracture site.
2. The local osteopenia.
3. The method of internal fixation (if a prosthesis was not used).
4. The challenge of obtaining union between the tuberosities and humeral shaft if a prosthesis was used.

Management

In our view the primary problem here was not the articular surface nor the length of the bone, but rather the challenge of getting the tuberosities to heal to the shaft. We elected a method of treatment which respected the compromised bone quality and which maximized the contact between bone of the proximal and distal fragments. On these bases, neither interpositional bone graft, metallic internal fixation nor a prosthesis was used. The shoulder was approached through a deltopectoral incision to protect the deltoid muscle. The distal aspect of the proximal fragment was carefully carved to receive and interlock with the proximal end of the distal fragment. The insertion of the peg of the humeral shaft in to the hole in the head was secured with six large (#5) non nonabsorbable sutures passed through holes in the proximal shaft and then through the proximal humeral metaphysis, out the cuff insertion and around the tuberosities. Iliac crest autograft was added around the non-union site. The fixation was robust, so early gentle active motion was started immediately.

Radiographs taken 6 months later show a united fracture (see figure 2). The arm is one inch short and the deltoid lag is resolved. The patient is now pain free, has good use of the shoulder, and is pleased.

Clinical presentation

This is the radiograph of a 25 year old male with a history of recurrent anterior dislocations of his right shoulder (see figure 1). His original dislocation occurred 5 years ago following a seizure. Unfortunately over the ensuing two years his seizures were poorly controlled resulting in further dislocations. Over the last three years he has had two surgical procedures (a Bankart repair and a revision Bankart repair with soft tissue augmentation), but continues to have instability whenever his arm is brought into abduction and minimal external rotation. Due to the dislocations he is unable to work or perform normal daily activities above shoulder level. His epilepsy is well controlled on medication.

On examination the patient was very apprehensive with his arm in abduction and in thirty degrees of external rotation. With his arm by the side he could externally rotate to sixty degrees without discomfort in comparison to eighty degrees on the other side.He had a functioning rotator cuff and subscapularis. He had no evidence of ligamentous laxity,a negative sulcus sign and a negative jerk test.

Our concerns include:

1. Significant deficiency of the anterior / inferior glenoid.
2. Early degenerative change of the glenohumeral joint.
3. The history of seizures.
4. The failure of two previous repairs.

Management

Despite early degenerative changes on X-ray, the patient's primary functional problem was instability. Examination under anesthesia revealed that there was no effective anterior glenoid lip on the load and shift test. Surgical findings confirmed the lack of an anterior inferior glenoid lip, a large recurrent Bankart lesion, a large Hill-Sachs defect, and early degenerative changes. The subscapularis was intact.

We concluded that a robust reconstruction of the anterior glenoid was essential to stabilizing this shoulder and that the patient's history demonstrated that this could not be accomplished with soft tissue procedures. Thus we reconstructed the anterior glenoid using a contoured iliac crest graft with capsule interposed between the graft and the humeral head.

One year following surgery, the bone graft remains stable (see figure 2) and the patient uses the shoulder for daily activities without apprehension, instability, or complaints of pain.

Clinical presentation

This is the radiograph of a fifty year old woman with rheumatoid arthritis who presented to our unit with a complex shoulder history (see figure 1). Six years previously she underwent a right total shoulder replacement and did well until four years later, when she fractured her humerus below the stem of the prosthesis in an automobile accident. The fracture was treated with open reduction and internal fixation of the humerus using a plate and screws. Postoperatively, however, the arm became infected with staph aureus, requiring removal of the internal fixation and prosthesis and the insertion of antibiotic-impregnated cement beads around and within the humeral shaft. At the time of presentation to us, the patient's chief complaint was pain and inability to use her arm due to weakness and instability. She answered "no" to all 12 questions of the Simple Shoulder Test. There was no clinical evidence of infection, a sedimentation rate of 25, and the shaft fracture appeared healed. Her main question was whether a new joint could be re-inserted.

Our concerns include:

1. Had the humeral shaft fracture united?
2. Was there still residual infection?
3. Was it possible to revise this to a hemiarthroplasty?
4. Could a humeral stem be inserted all the way down the humeral shaft?

Management

After thorough discussion of the risks with the patient, she decided to have us explore the shoulder with the possibility of inserting a prosthesis if there was no evidence of sepsis. Without preoperative antibiotics, the shoulder was exposed through the previous deltopectoral incision. A large amount of residual scar tissue was identified yet there was no macro or microscopic evidence of underlying sepsis. After cultures were obtained, intravenous antibiotics were administered. The shaft appeared to be solidly healed. Although our initial plan was to insert a long stemmed component; removal of the beads from the intact shaft proved impossible. Rather than splitting the humerus to remove the remaining beads, we cut down the stem of a prosthesis to fit the available space in the medullary canal. A solid press fit was achieved without additional cement. This prosthesis provided a smooth and stable articulation with the remaining glenoid.

Forty-eight hours after surgery the patient was discharged with a comfortable shoulder which she could elevate to 140 degrees and externally rotate to forty degrees. She was pleased and already more functional than at the time of admission.

Clinical presentation

This is the radiograph of a 70 year old woman with spondylo-epiphyseal dysplasia who has had severe limitation of her right shoulder motion since birth. Over the last few years she has progressively experienced severe pain which prevents her from using this arm and from sleeping. She also uses a wheel chair for ambulation because of dysplastic involvement of her spine, hips and knees. Her left shoulder remains relatively unaffected.

On examination her right shoulder is relatively fixed in internal rotation. Any use or motion of the joint is painful for her and produces crepitance. Her attitude is very positive.

Our concerns include :

1. Marked disuse osteopenia.
2. The technical difficulty of a shoulder arthroplasty.
3. The potential for improved function after an arthroplasty due to the chronicity of her condition.
4. The feasibility and potential benefit of an arthrodesis.

Management

The patient clearly identified pain at rest and on use of her shoulder as her primary problem; she had thoroughly adapted to the loss of motion. Because of her serviceable left arm and her need for a strong right shoulder for transfers and wheel chair ambulation, we recommended a shoulder arthrodesis using internal fixation for immediate return to function.

At surgery the virtual absence of glenohumeral motion was verified. The shoulder was fused in the same position it had assumed for 70 years: slight flexion and abduction with 45 degrees of internal rotation. The arthrodesis was secured with a pelvic reconstruction plate. She began using her arm on the first post operative day. Three months after surgery the shoulder was essentially painless and allowed function in the necessary activities of daily living.

Clinical presentation

This is the radiograph of a 45 year old man who presented to our clinic with a painful left shoulder of 5 months duration (see figure 1). His chronic anterior dislocation apparently resulted from a fall after an epileptic seizure. An unsuccessful attempt had been made 1 month earlier to reduce the dislocation in the emergency room. His current complaint was disabling pain and limited range of motion.

On examination the patient held his right shoulder in fixed internal rotation. Obvious asymmetry was present around the shoulder girdle when compared to the contralateral side. His humeral head could be palpated anteriorly and inferiorly and any form of shoulder movement caused severe pain. His axillary nerve was functioning and his remaining neurovascular examination was normal. The patient had a history of alcoholism and epilepsy poorly controlled by medication.

Our concerns include :

1. The patients' general health and well-being.
2. The possibility of maintaining a reduction following an open procedure.
3. The condition and viability of his humeral head.
4. If a hemiarthroplasty was necessary, what soft tissues would maintain stability in this patient.
5. Would there be a need for a bony procedure around the glenoid to establish stability?

Management

Despite the patient's history of alcoholism and poorly controlled epilepsy we thought it appropriate to try to treat the patient and his shoulder due to his chronic disabling pain.

No attempt was made to perform a closed reduction due to the chronicity of the dislocation.

A routine deltopectoral incision was made exposing the subscapularis and dislocated humeral head. Care was then taken to identify and protect the axillary nerve. It was impossible to openly reduce the humeral head due to a large Hill Sachs lesion involving at least 50% of the articular surface and severe contracture of the posterior structures.

Due to the humeral head destruction yet an intact glenoid, a decision was made to perform a hemiarthroplasty rather than a TSA. An extensive release of the posterior capsule and cuff was performed before inserting the humeral component. This was then reduced with difficulty and showed signs of anterior subluxation when the arm was rotated away from neutral. The component was therefore placed in some 45 degrees of retroversion and a more extensive posterior release was performed around the glenoid. We did not feel the necessity to place an anterior bone block on the glenoid although this would be a possibility if instability persisted.

Due to concerns of patient compliance and the potential for instability post-operatively he was placed in a shoulder immobilizer for 6 weeks.

The current radiographs are shown demonstrating a located humeral head and a small amount of heterotopic ossification which commonly occurs following a chronic dislocation (see figure 2). No further episodes of instability have occurred at 6 months follow-up and the patient is currently satisfied with the result.

Clinical presentation

This is the radiograph of a 50 year old, otherwise normal woman who presented with a comminuted fracture of her proximal humerus sustained in a fall (see figure 1). She had a normal neurovascular examination.

Our concerns include :

1. Could this fracture be successfully managed non-operatively?
2. If operative intervention were necessary, what would be the best method of internal fixation?

Management

The fracture was managed nonoperatively. At 6 weeks the radiographs (see figure 2) showed early callous and the position remained acceptable so gentle motion was commenced. Twelve months later the fracture was solidly united. She had full use of her arm and a full range of movement both of her shoulder and elbow.

Clinical presentation

This 45 year old female presented with a one-year history of gradually increasing left shoulder pain and gradual loss of range of motion (see figure 1). The patient recalled an injury about one year prior to presentation when some boxes she was carrying were forced into her shoulder by a closing door.

On examination no soft tissue mass was present around her shoulder region.There was tenderness to palpation over her anterior deltoid. There was loss of motion of the affected shoulder particularly involving external rotation and forward elevation. Her neurovascular examination was unremarkable.

Her general health and overall physical examination was normal expect for a past history of benign thyroid nodules.

Our concerns include :

• Establishing an accurate diagnosis of the bony / soft tissue lesion.
• What further investigations were necessary?
• Possible management strategies depending on the diagnosis.

Management

Our differential diagnosis from history and radiographic appearance included myositis ossificans, high grade surface osteosarcoma, and parosteal osteosarcoma. Further studies used to help differentiate and stage the lesion included a CT scan of her shoulder and chest, MRI of her shoulder, technetium bone scan and appropriate blood workup.

Following these studies an open biopsy was performed through the anterior edge of the deltoid which could be later sacrificed if a formal resection was required. Biopsy confirmed the diagnosis of "parosteal osteosarcoma".

The options of management were then discussed at length with the patient and included:

1. Limb salvage via a proximal humeral allograft
2. Shoulder disarticulation
3. Tikhof-Lindberg
4. Allograft arthrodesis
5. Mega-prosthesis

A mutual decision was made to perform a limb salvage procedure via a proximal humeral allograft and a cemented long stem Neer prosthesis as seen in the current radiograph (see figure 2). This was performed through an extended anterior deltopectoral approach. Adequate margins were achieved by resecting the proximal 1/3 of the humerus including part of the cuff and part of deltoid, pectoralis major, latissimus dorsi, and teres major. Neurovascular structures were able to be preserved.

The remaing cuff and capsule were reattached to the allograft. The deltoid insertion to the humerus was preserved. Microscopic pathology revealed adequate margins.

Clinical presentation

A 43 year old right-hand-dominant male, with a history of a nonspecific injury to his left shoulder while skiing 15 years ago, presented to the University of Washington Shoulder and Elbow Service complaining of crepitus in his left shoulder. Approximately 3 to 4 weeks prior to presentation, the patient noted acute onset of painless and progressive left shoulder swelling. The patient's past medical and surgical histories were otherwise unremarkable.

Physical examination was remarkable for a 10 x 15 cm nontender mass in the anterolateral aspect of his left shoulder. Neurovascular examination was remarkable only for a vague, nondermatomal decrease in pinprick sensation in his left upper extremity. Proprioception and vibration sensation were preserved.

Plain radiographs of the left shoulder revealed destruction of the humeral head with an associated soft tissue mass (see figure 1).

Laboratory tests were unremarkable.

Management

The differential diagnosis included Charcot joint, septic arthritis, and neoplasm. The patient was taken to the operating room for open biopsy of his left shoulder mass. Cultures were negative. Histological examination showed chronic inflammation, reactive new bone formation, and fibrosis suggestive of neuropathic arthropathy. Subsequently, the patient had an MRI of the cervical spine which demonstrated a cervicothoracic syrinx (see figure 2).

The patient was evaluated by the Neurosurgery Service and underwent a syringoperitoneal shunt.

Since arthroplasty and arthrodesis in this group of patients have a historically high failure rate, no further surgical intervention in planned. The patient has been educated as to the disease process as well as conservative treatment to maximize his function.