COMPARISON OF SURGICAL APPROACHES IN REVERSE ENDOPROSTHETICS OF SHOULDER JOINT

Makarov M.A., Roskidaylo A.A., Panteleev M.V.

Nasonova Rheumatology Research Institute, Moscow, Russia

 COMPARISON OF SURGICAL APPROACHES IN REVERSE ENDOPROSTHETICS OF SHOULDER JOINT

Inflammation of shoulder joint arises in high percentage of patients with rheumatoid arthritis (RA). So, Cuomo et al. state its involvement in 90 % of patients [1]. Shoulder joint lesion in RA is characterized by erosion of articular surfaces with subsequent formation of secondary adhesive capsulitis which manifests in view of progressing loss of its function [2, 3]. The feature of the disease is involvement of shoulder joint and also its rotator cuff into the inflammatory process [2, 4]. The indirect sign is migration of shoulder head upwards. Lacerations of tendons of the rotator cuff are noted in 19-47 % of patients with RA. Finally, a pathologic condition develops that is similar with arthropathy in massive lacerations of the rotator cuff [3, 5, 6].
The uniform efficient method of surgical treatment of such cases is reverse endoprosthetics of shoulder joint. Grammont et al. was the first who performed such surgery for a patient with arthropathy due to massive laceration of the cuff in 1987 [7]. Although Grammont performed this surgery with transacromial approach, the deltopectoral approach became the standard for shoulder endoprosthetics in the end of 1970s. The approach does not affect the deltoid muscle, which provides the function of the reverse implant. At the same time, the approach supposes the dissection and refixation of the subcapsular muscle tendon that decreases the joint stability and slows down the postsurgical rehabilitation. As result, some surgeons started searching the alternative transdeltoid variants of approach to the shoulder joint, considering the destruction of the rotator cuff [8].
It should be historically noted that Thompson (1918) firstly described the transverse dissection of the anterior part of the deltoid muscle near the site of its fixing to the clavicle and to the acromial process of the scapula [9]. Henry described the similar approach [10]. Clubbins [11] offered to dissect the anterior part of the deltoid muscle as addition to the standard approaches in presence of complex deformation of the shoulder joint. The anterior-lateral approach was illustrated by Campbell in Operative Orthopedics Journal in 1939. The illustration showed the differences between superior-lateral and more extended approach, which was described by Cubbins. However it was unclear how the deltoid muscle was dissected and refixed [12]. Neviaser also offered the modification of the transacromial approach [13].
In 1993, Mackenzie described the superior-lateral approach to shoulder joint. The author mentioned the advantages of the approach in comparison with the deltopectoral one: good visualization of glenoid cavity of scapula, and preservation of the cephalic vein [14]. Mole (2011) published the modification of the previously described approach. Some authors offer stratifying the deltoid muscle between its bundles, others – to dissect the clavicular part in subperiosteal manner for better visualization, and to refix it [15].
Study objective – to compare the functional outcomes of patients with rheumatoid arthritis after reverse endoprosthetics of shoulder joint with use of two approaches: anterosuperior (also called as superior lateral) and deltopectoral. 

MATERIALS AND METHODS

37 patients received the reverse endoprosthetics of shoulder joint in the traumatology and orthopedics unit of Nasonova Rheumatology Research Institute in 2008-2018. The patient with anatomical, monopolar and bipolar prostheses were excluded from the study group. Before surgery, all patients received the X-ray examination and computer imaging for estimation of the articular process of scapula and sufficiency of its bone mass. Before surgery, the patients were examined for presence of complaints, volume of motions and condition of the deltoid muscle. Pain was estimated with visual analogue scale (VAS). Shoulder joint function was estimated with ASES. The surgery was conducted with use of two surgical approaches: superior-lateral and deltopectoral. The selection of the approach depended on preferences of the operating surgeon. The endoprostheses Delta X-tend De Puy, Comprehensive Biomet and Reverse Shoulder Zimmer were used.
After 1 year and 3 months, the control examinations were conducted, with estimation of volume of motions, pain (VAS), X-ray images and shoulder joint function (ASES).
The study was conducted in compliance with the ethical standards of the bioethical committee of Nasonova Rheumatology Research Institute developed in compliance with Helsinki Declare of World Medical Organization – Ethical Principles for Medical Research with Human Subjects, 2000, and the Rules for Clinical Practice in the Russian Federation confirmed by the Order of Russian Health Ministry on 19 June 2003, No.266. All participating patients gave their informed consent for participation in the study. 

Surgical technique

Superior-lateral approach

The surgery was conducted under anesthesia (intubation, conduction or combined analgesia) in “beach chair” position, with shoulder joint free from supports, and the forearm freely lying on the side table. The head was fixed in the special head holder. A skin incision (8-10 cm) was initiated beside the acromial-clavicular joint and was along the longitudinal axis of the upper extremity. After subcutaneous fat mobilization, the deltoid muscle was visualized. With the clamp, the deltoid muscle was stratified at the level of anterior portion (Fig. 1).

Figure 1. The virtual model of superolateral approach to shoulder joint. The copy from the article by Mole et al. 2011 [15]

   

The shoulder head and the scarry subacromial bursa were visualized. The resection of the acromial-clavicular joint, described by some authors, was performed very rarely. The clavicular portion of the deltoid muscle with its subsequent refixation was realized in 3 cases.

Deltopectoral approach

A skin incision of 8 cm in the plane of the deltopectoral furrow was made in position on the surgical table in the manner similar with the above mentioned one. After incision of skin and subcutaneous fat, v. cefalica was exposed and abducted inwards or was ligated. A deep penetration was made between fibers of deltoid and pectoralis major. Aponeurosis was dissected along the incision. A transverse incision was made for dissection of m. subscapularis over the distance of 1-1.5 cm from the site of its fixation to lesser tubercle of humeri, with opening the joint capsule. At that, the shoulder was rotated outwards. 

Rehabilitation

The upper extremity was fixed in the triangular bandage or in the abduction split with 30 degrees during 6 weeks after surgery for all patients. All patients with the superior-lateral approach initiated the development of passive motions on the second day after surgery after X-ray examination of the operated joint. The device for passive development of motions (Arthromot) was used (Fig. 2, 3).

Figure 2. Training of passive motions with Arthromot device



Figure 3. The X-ray image of shoulder joint after surgery

For all patients with the deltopectoral approach it is recommended to refrain from active motions in shoulder joint during 6 weeks after surgery. Then the restoration of volume of passive and then active motions was realized. The postsurgical limitations were associated with refixation of the tendon of the subscapular muscle and possible inconsistence due to early rehabilitation. Also it was found that patients of this group demonstrated more intense pain syndrome in early postsurgical period that did not allow initiating the passive training of motions in the operated joint with use of Arthromot. 

Statistical analysis

The statistical analysis was conducted with Statistica 8.0 for Windows (StatSoft Inc., USA). The descriptive statistical methods were used. T-test was used for dependent and independent samples. 

RESULTS

37 patients were observed, including 3 patients with diagnosis of juvenile rheumatoid arthritis (8.1 %), 1 – with psoriatic arthritis (2.7 %), 1 – Sjogren syndrome (2.7 %), 7 – with osteoarthrosis (18.9 %), 1 – with systemic lupus erythematosus (2.7 %), 24 – with rheumatoid arthritis (64.8 %). There were 5 men (13.5 %) and 32 women (86.5 %). The mean age was 53.1 ± 6.2 (26-72). The injury to the dominating hand prevailed (25 patients, 67.5 %). Delta X-tend De Puy (for 32 patients), Comprehensive Biomet (for 3 patients) and Reverse Shoulder Zimmer (for 2 patients) prostheses were used.
The patients were divided into two groups according to a type of a surgical approach. The group of the superolateral approach (SLA) included 29 patients, the group of the deltopectoral approach – 8 (DPA). The clinical examination showed that all patients of the study group had the deficiency of volume of motions and insufficiency of tendons of the rotator cuff. The strength of the deltoid muscle (test with resistance) was satisfactory in all patients. The range of motions before surgery was: abduction 38.1º ± 10.8º, flexion 62.4º ± 11.6º, external rotation 6.5º ± 8.8º, internal rotation 16.5º ± 5.6º. The mean VAS was 72 ± 7.4 mm before surgery. The mean ASES was 25 ± 4.7. The examination of these values identified that the patients of both groups did not have any reliable statistical differences in gender, age, range of motions, pain and ASES (p ≤ 0.05).
Three months after surgery, the first control examination showed that all values were higher in the group of the superolateral approach that was confirmed statistically. Three months later, the range of motions in the group of the superolateral approach was: abduction 120 ± 4.4 (p = 0.02), flexion 140 ± 6.1 (p = 0.014), external rotation 22 ± 8.2 (p = 0.012), internal rotation 20 ± 3.4 (p = 0.85). The mean VAS decreased – 20 ± 2.2 mm (p = 0.03). The mean ASES was 51 ± 7.6 (p = 0.02).
12 months after surgery, the second control examination identified that all examined values were comparable in the groups of the superolateral and deltopectoral approaches. After 12 months, the range of motions in the group of the superolateral approach was: abduction 160 ± 3.8 (p = 0.01), flexion 158 ± 8.6 (p = 0.014), external rotation 22 ± 9.2 (p = 0.017), internal rotation 24 ± 8.4 (p = 0.02). The mean VAS was 14 ± 3.2 mm (p = 0.028). The mean ASES was 76 ± 6.7 (p = 0.015). 

Complications

In our study, complications appeared in 4 patients among 37 (10.8 %). It was two times lower than the middle rate of complications (19 %) according to results of foreign studies. The first case included the postsurgical adduction contracture of shoulder joint due to insufficient rehabilitation. The first case included the transient plexitis of brachial plexus with disordered sensitivity in distal regions of the upper extremity. Plexitis was completely corrected with conservative therapy. Two cases included the recurrent dislocations of shoulder. One case required for revision surgery with realignment of glenoid component (glenosphere). The subsequent follow-up and the control examinations showed the defiguration in the plane of the deltoid muscle due to an injury to anterior bundle of the deltoid muscle (Fig. 4).
The metaanalysis of foreign studies showed the rate of dislocations of 1.7 %. However they did not identify any purulent complications, fractures of great tubercle, of acromion and coracoids and articular processes of scapula. Also we did not find any signs of loosening of the glenoid component in the control examination [16].

Figure 4. The postsurgical scar with deltoid muscle defect

  

DISCUSSION

In our study, the amount of cases (37 patients) was comparable to other studies (Lädermann – 35 patients). However the study by the foreign author showed more smooth distribution into the subgroups of superolateral and deltopectoral approaches: 17 and 18 patients correspondingly. There were more women in both studies: 86.6 % and 77 % correspondingly. The injury to the dominating hand was more common in our study – 67.5 % and 51 % correspondingly. In our study, no patients had previous surgery for shoulder joint as compared to the study by Lädermann (61 %). The mean age in the European study was significantly higher than in our study: 78 and 53.1 years correspondingly. The presurgical range of motions was more limited in our study: flexion 62.4º and 95º, external rotation 6.5º and 19º correspondingly. The mean value of pain was comparable – 72 and 69 mm correspondingly. The mean ASES was 25 in our study. ASES was not used in the study by Lädermann.
The dynamic observation showed some similar trends. By the 3d month of the follow-up, the pain decreased similarly in the group of the deltopectoral approach and in the group of the superolateral approach. The increase in the range of motions was noted. However the movements were wider in the group of the superolateral approach, like in our study (p = 0.01). By 12th month of the follow-up, there were not any differences in the groups of the deltopectoral and superolateral approaches [17]. 

CONCLUSION

Our observations allowed making the conclusion that the use of the superolateral approach for reverse endoprosthetics of shoulder joint resulted in the decreasing level of pain in early postsurgical period and initiation of early rehabilitation of patients (training of motions in the operated joint), but without any reliable differences in functional results in 12 months. 

Information on financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.

REFERENCES:

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