Shoulder Arthrodesis

The shoulder joint is the largest and most flexible joint in the body, since the advent of the radial head prosthesis and the total shoulder joint replacement, the humeral head comminuted fracture, rheumatoid arthritis, primary osteoarthritis and traumatic arthritis Shoulder pain and stiffness have rarely been done with fusion. However, shoulder joint tuberculosis, benign tumor resection with extensive destruction and brachial plexus injury, patients who are not suitable for artificial joint replacement still need to do shoulder arthrodesis. Ankle joints, acromioclavicular joints, sterno-lock joints, and scapular chest wall joints are included in the shoulder joint activities. After the ankle joint is merged, the shoulder movement is compensated by the shoulder and chest wall joints. If the chest and shoulder muscles are normal, good function can still be obtained. The shoulder joint function can maximize the function of the hand to meet the needs of daily washing, combing, eating and so on. Rowe pointed out the advantages of reducing abduction and flexion: if the shoulder joint fusion is too large, the upper limb can not be close to the chest wall, and the scapula can be delayed and the serratus muscle strain can be damaged in a long time. When the crowd is crowded, it is easy to be damaged. More affects the stretching movement, and the shoulder rotation is not conducive to writing and eating. Cofield and Briggs found that 71 cases of shoulder fusion study: how much internal rotation determines the function, is the most important factor in the success of surgery. The shoulder joint fusion is divided into anterior and posterior fusion. The posterior fusion is mainly used for extra-articular fusion and is rarely used. Due to the shallow scapula, it is difficult to maintain the close contact between the humeral head and the scapula after the articular cartilage surface is removed. Therefore, the double fusion of the inside and outside of the joint or the metal fixture such as the three-wing nail, the Sterling needle and the screw are often used. Muller et al. advocated the inconvenience of replacing the heavy plaster with a solid metal internal fixation. Difficulties in shoulder fusion are difficult to grasp the angle of fusion during surgery. The ideal location for shoulder fusion can be determined by clinical and preoperative radiographs. Abduction: the angle formed by the humerus and the body; flexion: the angle between the supine upper arm and the ground plane; rotation: maintaining abduction flexion, elbow flexion 90°, the hand is placed between the ipsilateral sternum and the armpit, and the thumb tip can be flexed when the elbow is flexed Touch the bottom line. Preoperative X-ray anterior and posterior radiographs were used to measure the angle of the humerus abduction using the spine as a marker. From the humerus big nodules through the humeral head to the scapula, try to use two guide pins, and take X-rays on the table to determine the fusion angle and the position of the needle. Indication Shoulder joint fixation is suitable for: 1. Shoulder joint tuberculosis, lesion clearance and fusion can be completed at one time. 2. A scapular fracture or defect, unconditional joint replacement. 3. The benign tumor of the proximal humerus is removed, and the artificial joint replacement cannot be performed. 4. Scapular tendon, vestibular rupture and brachial plexus injury that cannot be repaired. Muscle spasm caused by neuropathy or injury, causing severe instability of the joint, affecting the entire limb function, and simple tendon metastasis is not enough to maintain joint stability and restore sufficient effective function. Fixing local joint can improve limb function, and joint should be performed. Fusion. For example, after the anterior horn polio of the spinal cord, the upper limbs can not be lifted. If the shoulder joint is fixed in the functional position, the function of the upper limb can be improved by sliding the shoulder between the shoulders. 5. Shoulder joint replacement failed. 6. Congenital or acquired spinal deformity (such as hemivertebra, scoliosis, lumbar spondylolisthesis, etc.), in order to prevent the development of deformity, early laminectomy can be performed, or after deformity correction. Contraindications Contraindications: 1. There is no activity or fixation between the shoulder wall and the chest wall. This method should not be used. 2. The affected elbow joint and the contralateral shoulder joint have been fixed. 3. The upper limbs are full and cannot reconstruct the function of the hand. Confusion should also be contraindicated if: 1. Patients with osteoarthritis adjacent to the joint should not be used for arthrodesis. If the hip joint is fused, its activity can be compensated by the normal lumbar spine and knee joint to meet the needs of work and life activities. If the lower lumbar or knee joint is already stiff, hip fusion will cause great difficulty to the patient. 2. Among the same joints of the limbs, one side has a strong straight, and the contralateral side should not be subjected to arthrodesis. If the hip joints are fused on both sides, it will be very difficult to get up, lie, walk and sit. 3. Children's articular cartilage is rich, joint fusion is not easy to cause bone fusion, but also easy to damage the epiphysis, affecting growth and development; at the same time, children in the limb development stage and muscle sustained action, the fusion joint can be deformed again. Therefore, children under the age of 12 should not undergo arthrodesis. Preoperative preparation 1. Arthrodesis may actually include a series of operations such as lesion removal, joint fusion, bone transplantation, and correction of deformity, so it is a complicated operation. Therefore, the surgical plan should be determined according to these surgical requirements, comprehensive consideration, try to get a surgery, a cut to solve the problem, in order to achieve the best results at the least cost. 2. Loss of activity after joint fusion can cause the patient's ideological concerns, and should be dispelled before surgery: the fusion of a joint that affects the function of the limb will improve the function of the entire limb. 3. The joints of the shoulders, hips and other large joints have more bleeding during the operation, and there is a possibility of shock. A certain amount of blood should be reserved before surgery. When the elbow and knee joints are operated, the inflatable tourniquet is used to keep the field clear for the operation. 4. Inflammatory joint disease (such as tuberculosis, suppurative) should be applied preoperative antibiotics or anti-tuberculosis drugs to control the infection or prevent the recurrence of the resting lesion. 5. If the joint has soft tissue contracture, the deformity will not be easily corrected during the operation, and the joint will be difficult to reset. It is difficult to maintain stability even if it is barely repositioned; if it is strongly corrected during surgery, it will cause damage to nerves, blood vessels, etc. Postoperative muscle spasm, and even cause complications such as dislocation. Therefore, traction should be performed before surgery to overcome contracture as much as possible; and design the steps to relieve contracture during surgery. 6. Prepare the T-plate before surgery so that the upper shoulder "person" is fixed at the end of the operation. 7. Preoperative clinical X-ray film measurement angle, when necessary, prepare for X-ray film. Surgical procedure Incision The anterior medial approach of the shoulder joint was used. 2. Exposing the joint Cut the skin, subcutaneous tissue and deep fascia, find the cephalic vein from the deltoid and pectoralis major intervertebral space, lift up and down with a rubber strip, and branch and ligature it (or cut the triangle 0.5cm outside the cephalic vein) Muscle fibers, using the triangular muscle fiber strip to protect the cephalic vein). The deltoid muscle was cut and retracted 0.5 cm below the starting point of the clavicle and the shoulder. The pectoralis major and the cephalic vein were retracted inward to reveal the condyle. The biceps on the condyle were cut 1 cm below the condyle. The short head and the diaphragm are combined with the iliac crest, or the condyle is cut with a bone knife, and the tendon is flipped down together to reveal the arteriovenous, brachial plexus, and subscapularis muscles in the deep joint. The external rotation of the upper arm strained the subscapularis muscle and was cut at 0.5 cm from the proximal humerus. Retract the scapularis muscles inward, cut the transverse ligaments, lift the long head of the biceps, cut the sac of the switch, and expose the humeral head and shoulder blades. 3. Excision of cartilage surface and joint fusion The external arm is dislocated to dislocate the joint, and the cartilage surface of the humeral head and the scapula is removed. After the reduction, the rough bone surface is in close contact, and the 1 or 2 Sterling needles pass through the big nodules through the humeral head to the shoulder blade, and are fixed at the abduction 20°, the flexion 30°, and the internal rotation 40°. The sacral sacral nodule is opened. Three methods of bone graft fusion can be used: 1 subperiosteal peeling off the shoulder and the lateral part of the scapula, chiseling into a rough surface, cutting a part of the scapula with a bone knife, gently pressing the distal end to cause a green branch fracture, embedded in the split In the humeral large nodule, the two nodules were worn by the two spurs to the scapular neck and fixed more firmly. 2 The scapula and the distal clavicle caused the green branch fracture to be embedded in the humeral nodule and fixed by compression screws. 3 Dissipate the scapula and pay attention to the scapular transverse artery and the superior scapular nerve in the scapula. Use a bone knife to cut a bone from the scapula and insert it into the sacral nodule to form a shoulder peak. Inter-section bridge connection, screw pressure fixed. 4. Suture incision Strictly stop bleeding, infiltrate the incision with isotonic saline, maintain a fixed position, fill the cancellous bone in the gap, sew back the biceps short head and the diaphragm joint, or fix the severed condyle in situ with a screw. The slit is layered and sutured. Cut the Sterling needle to retract the needle to the skin. Move the patient's upper body to the head of the bed and sleep on a wooden or stainless steel T-shaped plate. The headrest is placed on the cross-arm of the T-shaped plate and immediately fixed on the shoulder with a "human" plaster (including general anesthesia). After the plaster is hardened, the T-shaped plate is taken out. Some people advocate the use of an exhibition stand to fix 10 to 14 days after surgery, and change the shoulder "person" word plaster when the line is removed. 5. Horse-shaped incision for shoulder fusion If a saber-cut incision is used to make a shoulder joint fusion, the acromioclavicular joint is used as the midpoint, and the deltoid muscle is peeled off from the apex of the deltoid, the scapula and the clavicle. Open the scapula and the humeral head. This is easy to expose and saves time.