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Glenohumeral Arthrodesis With Locking

Compression Plate

Article in The Journal of hand surgery · April 2016

DOI: 10.1016/j.jhsa.2016.03.004

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 SURGICAL TECHNIQUE

Glenohumeral Arthrodesis With Locking

Compression Plate
Jorge G. Boretto, MD,* Gerardo L. Gallucci, MD,* Pablo De Carli, MD*

Glenohumeral arthrodesis is performed for paralytic disorders. Internal fixation with plates has
been described to diminish the rate of nonunion associated with this procedure. Because plates
are located over the scapular spine and the acromion to add a point of bony union between the
acromion and the humeral head, skin irritation and hardware removal are the main compli-
cations associated with plates. We describe a technique using a locking compression plate
placed under the acromion to decrease complications associated with the hardware without
increasing the risk of nonunion. The technique presented here has 2 biomechanical principles
of fixation: compression and neutralization. Compression by 2 screws allows for a bony union
at the glenohumeral joint, and neutralization by the locking compression plate allows for early
postoperative motion. (J Hand Surg Am. 2016;-(-):-e-. Copyright Ó 2016 by the
American Society for Surgery of the Hand. All rights reserved.)
Key words Glenohumeral arthrodesis, paralytic shoulder, flail shoulder, shoulder arthrodesis.

S
HOULDER ARTHRODESIS WAS FIRST performed to
treat shoulder palsy caused by poliomyelitis and
infection caused mainly by tuberculosis. Extra-
articular arthrodesis (acromiohumeral) was proposed
to avoid the tuberculosis-infected joint. However, as
anti-tubercular drugs become successful, this tech-
nique lost its popularity. To increase the rate of
bony union, articular (glenohumeral) arthrodesis was
associated with extra-articular arthrodesis in past de-
cades. Different types of osteosynthesis, such as wire
loops, tension-band wiring, external fixators, and in-
ternal fixation with screws and plates, have been
proposed to perform fixation between the humerus
and the scapula, with or without the acromion.1,2 In
1970, the AO published a technique using a plate and
From the *Hand and Upper Extremity Surgery Department, Prof. Dr. Carlos Ottolenghi’s
Institute, Orthopaedic and Traumatology Service, Hospital Italiano de Buenos Aires, Buenos
Aires, Argentina.
Received for publication October 23, 2015; accepted in revised form March 19, 2016.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
Corresponding author: Jorge G. Boretto, MD, Hand and Upper Extremity Surgery
Department, Hospital Italiano de Buenos Aires, Potosi 4247, Ciudad Autónoma de Buenos
Aires, C1199ACK, Argentina; e-mail: jorge.boretto@gmail.com.
0363-5023/16/---0001$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2016.03.004
screws to allow for early mobilization without using a
spica cast.3 Although main advantages of this later
technique were its allowance for early mobilization
and the lack of a need for a cast, the need to remove the
hardware has been reported to be as high as 50%
because of skin irritation caused by plate prominence
when it is located over the scapular spine and the
acromion.4e6
ANATOMY
Osseous anatomy
There is a great discrepancy between the diameters of
the humeral head and the glenoid. The average vertical
dimension of the joint portion of the head is 48 mm,
with a radius of curvature of 25 mm. The average
transverse dimension is 45 mm, with a radius of cur-
vature of 22 mm.7 The glenoid has a narrower upper
portion and a wider bottom. The average of the gle-
noid vertical dimension is 35 mm and its transverse
diameter is 25 mm on average. This discrepancy be-
tween the humeral head and the glenoid is solved by
the labrum, which augments the glenoid surface.
The acromion is the other bony structure that is
included in most techniques of arthrodesis to increase
the osseous surface to be united. Normally, there is an
average distance between the acromion and the humeral

Ó 2016 ASSH r Published by Elsevier, Inc. All rights reserved. r 1

2 GLENOHUMERAL ARTHRODESIS
FIGURE 1: A The osseous glenohumeral joint. B Discrepancy between the glenoid and the humeral head when the humerus is raised to
include the acromion in the arthrodesis.
head of 10 mm (6.6e13.8 mm in men and 7.1e11.9
mm in women).8
When the humeral head and the glenoid are pre-
pared for the arthrodesis, both the articular cartilage
and the labrum have to be removed to obtain bloody
osseous surfaces. This preparation leads to a size
discrepancy in the bone surfaces. If in addition to this
the humeral head is raised and in contact with the
acromion, the discrepancy between the glenoid and
the humeral head is even greater (Fig. 1).
There are 2 scapular areas in which the amount of
osseous tissue can permit a good purchase of the
screws. One is the area where the spine of the scapula
is attached to the scapula (the base of the spine); the
second is the lateral border of the scapula in the first 3
to 5 cm from the neck of the glenoid between the
anterior and posterior cortical bone (lateral pillar).
INDICATIONS
1. Total brachial plexus palsy to keep the limited
nerve transfers and/or nerve grafts to elbow
flexion and extension targets.
2. Poor or incomplete shoulder functional recovery
after nerve transfers or nerve graft in brachial
plexus palsy.
3. Irreparable rotator cuff tears associated with long-
lasting deltoid palsy.
4. Pain caused by inferior glenohumeral subluxation
in paralytic disorders.
CONTRAINDICATIONS
1. Bone deficit of the proximal humerus owing to
trauma or tumor resection.
J Hand Surg Am.
2. Active infection of the proximal humerus or the
glenohumeral joint.
3. Paralysis of the upper trapezius and/or the serratus
anterior.
PREOPERATIVE EVALUATION
A careful examination of the scapular muscles has to
be performed to evaluate the function of the upper
portion of the trapezius and the anterior serratus.
Secondarily, the function of the latissimus dorsi, the
rhomboid, and the pectoralis major muscles should
be evaluated.9 Preoperative plain radiographs are
important to assess the glenoid and humeral head bone
stock. It is important to assess the scapular shape,
mainly in cases of brachial plexus palsy in newborns,
because the lateral border of the scapula will be used
to measure not only the intraoperative position of the
arthrodesis but also as a zone of purchase for one of
the screws. In the case of pediatric palsies, some de-
gree of bony deformity could be expected.
TECHNIQUE
Patient positioning
The patient is placed in lateral decubitus with the
involved side up. A silicone roll is used in the
contralateral axilla and the lower extremity that lies
over the table is flexed (hip and knee) and carefully
padded at the level of the head of the fibula to avoid
peroneal nerve compression (Fig. 2).
The entire involved upper extremity is included in
the surgical field and the hand and forearm are dra-
ped. The surgical field should include the scapula up
to the posterior midline in the back. An arm support
r Vol. -, - 2016
 GLENOHUMERAL ARTHRODESIS
FIGURE 2: Patient on the operating table. Care should be taken at the knee to avoid peroneal nerve compression. The involved upper
extremity should be placed in an arm support to be included in the operative field.
FIGURE 3: The shoulder to the midline of the back should be
included in the operative field. The hand is included in the
operative field to define the rotation of the arthrodesis.
is placed in front of the patient to position the
involved hand and forearm (Fig. 3).
Surgical approach
The surgical approach should be enough to expose
the suprascapular fossa, the glenohumeral joint, and
the proximal third of the humerus, and to allow
an evaluation of the correct positioning of the
arthrodesis. Infiltration with 1:1,000 mL dilution of
epinephrine is performed to minimize bleeding.
A superior longitudinal incision is performed fol-
lowing the diaphysial axis of the humerus up to the
supraspinatus fossa. The spine of the scapula and the
acromion are exposed and the upper portion of the
trapezius and the deltoid are detached. The middle
deltoid fibers are split following the same direction of
the approach. Care should be taken during this step and
J Hand Surg Am.
3
the axillary nerve must be identified to ligate the sat-
ellite vessels. Once the proximal humerus is exposed,
the supraspinatus, the infraspinatus, and the teres mi-
nor should be detached. The articular capsule and the
labrum should be resected. Careful hemostasis of
the vessels running with the suprascapular nerve at
the level of the spinoglenoid notch should be per-
formed. Finally, the supraspinatus is detached from the
supraspinatus fossa to allow for plate positioning. The
long portion of the biceps tendon should not be de-
tached from the supraglenoid tubercle, to avoid loss of
elbow flexion strength (Fig. 4).
Arthrodesis position, and humeral head and glenoid
osteotomies
Once the glenoid and proximal humerus are free of
soft tissue attachments, the position of the arthrodesis
should be determined. The bony landmarks to define
the correct position are the axis of the humeral
diaphysis and the lateral border of the scapula.
Abduction is determined by forming an angle of 60
between the humeral diaphysis and the lateral edge of
the scapula. Forward flexion is positioned forming a
30 angle between the humeral diaphysis and the
lateral midline of the trunk. All angles are measured
with a handheld goniometer and repeated as many
times as necessary to be sure of the position. Internal
rotation is defined by allowing the hand to reach the
mouth. The helping surgeon has a principal role in
maintaining the position of the upper extremity. After
determining the correct position, parallel cuts are
performed with a sagittal saw at the level of the
glenoid and the humeral head (Fig. 5). Osteotomy at
r Vol. -, - 2016
4 GLENOHUMERAL ARTHRODESIS
FIGURE 4: Through a longitudinal incision, the trapezius, del-
toid, supraspinatus, and infraspinatus are detached to reach the
glenohumeral joint.
the humeral head should be planned to avoid exces-
sive medial translation of the proximal humerus,
which produces a prominent lateral acromion leading
to a disagreeable cosmetic result. Once the parallel
osteotomies are done, there is no risk of losing the
defined abduction and internal rotation; however,
forward flexion should be measured again at the time
of fixation to avoid incorrect positioning.
Internal Fixation
Two principles of internal fixation are applied:
1. Compression using 2 cannulated partially threaded,
6.5-mm screws (Synthes, Oberdorf, Switzerland)
2. Neutralization using a narrow, 4.5-mm, locking
compression plate (Synthes).
The humeral head is centered at the glenoid; ab-
duction and internal rotation are defined by the previ-
ously performed osteotomies and forward flexion is
determined again by measuring it with a handheld
goniometer. The first compression screw with a sup-
porting washer is placed from the lateral aspect of the
humeral head to the base of the scapular spine. The
second compression screw is placed along with a
washer in an anterolateral-superior to posteromedial-
inferior direction from the greater trochanter of the
humerus to the lateral border of the scapula between the
anterior and posterior bony cortex (Fig. 6). For this
step, it is important to have performed previous
dissection of the soft tissues to allow direct visualiza-
tion and palpation of the lateral border of the scapula.
J Hand Surg Am.
FIGURE 5: Parallel osteotomies in the glenoid and humeral head.
Once the 2 compressive screws are placed, motion of
the scapulothoracic joint can be evaluated.
Finally, a 12- to 14-hole, narrow, 4.5-mm locking
compression plate is bent for placement at the
supraspinatus fossa, under the acromion and over the
lateral aspect of the humerus. Three to 4 locking
screws are placed at the supraspinatus fossa. One or 2
more lateral screws have better purchase at the level
of the neck of the glenoid and the base of the spine
than do the medial screws. Four screws are placed at
the level of the proximal humeral diaphysis. Three
more proximal are used as locking screws and the
distal end screw is a cortical screw placed in the
oblique direction to decrease the risk of periprosthetic
fracture.10
Bone graft
A bone graft is not performed in this technique. A
bony union is favored by performing good prepara-
tion of the bony surfaces and compression by means
of the screws.
Closure
The wound is irrigated and meticulous hemostasis is
achieved. Reattachment of the trapezius and the del-
toid muscles are performed via transosseous suture
with a nonabsorbable suture (Fig. 7). A suction drain
is placed deeper into the muscle plane. Dermal and
epidermal layers are closed. A sterile dressing and a
sling are placed.
r Vol. -, - 2016
 GLENOHUMERAL ARTHRODESIS 5

FIGURE 6: Position of the compression screws.

FIGURE 7: The plate under the acromion. A transosseous suture
is performed to reattach the trapezius and the deltoid muscles.
POSTOPERATIVE FOLLOW-UP AND
REHABILITATION
The skin sutures are removed 2 weeks after surgery.
Active flexion and extension of the elbow as well as
thoracoscapular motion are allowed immediately after
surgery. Weight holding is avoided until 8 to 12 weeks
after surgery. Radiographs are performed every 6
weeks until union is demonstrated.

COMPLICATIONS
Nonunion
Although this complication is no longer frequent, poor
preparation of the glenoid and humeral head can in-
crease the risk of nonunion. In the current technique,
2 parallel osteotomies are performed to allow the
compression screws to have a maximal bony contact
area.

Malpositioning of the arthrodesis

There is no consensus about the optimal position of
the arthrodesis. However, some technical tips must be
highlighted.
 Excessive abduction or forward flexion leads to
periscapular pain and discomfort by traction and
muscle fatigue mainly of the serratus.
 Excessive external rotation prevents the mouth
from being reachable by the hand.
 Excessive internal rotation prevents the mouth
from being reachable by blocking the hand at the
thorax during elbow flexion.
In this technique, the axis of the humerus and the
lateral border of the scapula are used to position the
arthrodesis. Both osseous landmarks are included
in the surgical field under direct visualization, which
FIGURE 8: Postoperative radiograph showing the internal fixa-
tion described in this technique.
allows for measurement of the predetermined posi-
tion with a handheld goniometer.
Hardware prominence
Pain related to the subcutaneous position of the plate
has been reported in up to 50% of patients. Patients are
frequently advised of the possibility of a second pro-
cedure to remove the plate because of pain, promi-
nence, or both.
By placing the plate under the acromion as des-
cribed in this technique, removal of the plate can be
avoided.

J Hand Surg Am. r Vol. -, - 2016

 6 GLENOHUMERAL ARTHRODESIS
Periarthrodesis fracture
Osteopenia of the humerus and elimination of motion
at the glenohumeral joint increase the risk of a peri-
arthrodesis fracture. This complication occurs at the
level of the plate fixation ends or at the entry point of
the most distal screw in the locking plates, and is
attributed to the difference in structural stiffness be-
tween the bone and the plate bone segment. Experi-
mentally, a locked plating construct may cause a
greater periprosthetic fracture risk in bending. To deal
with this type of complication, a nonlocking end
screw is used to enhance the bending strength of the
fixation construct.10
CASE ILLUSTRATION
A right-handed, 67-year-old man had an injury to the
left shoulder 10 months previously. His rotator cuff
rupture was operated on 1 month after the trauma.
At 9 months after surgery, he had no recovery of the
axillary palsy as well as no function of the repaired
rotator cuff. He had no pain at rest but he had a rating
of 8 out of 10 pain on the visual analog scale during
daily activities. Upon examination, the shoulder had
40 forward flexion and 30 abduction; it lacked 16
from full external rotation and internal rotation was
at the L5 level (Video 1). Radiographs showed no
abnormalities. Magnetic resonance imaging exami-
nation showed fatty degeneration in the supraspinatus
and infraspinatus muscles.
Arthrodesis of the shoulder was performed using
the presented technique (Fig. 8). The postoperative
period was uneventful. Postoperative rehabilitation
J Hand Surg Am.
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followed as previously described. At 1 year after
surgery, the patient was free of pain at rest and during
daily activities. Upon examination, forward flexion
was 78 and abduction was 80 , and the patient could
reach the mouth with the hand (Video 2). Finally, at 2
years of postoperative follow-up, the patient had no
pain or discomfort from the hardware.
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