All authors agree that the presence of a flail shoulder is an indication for glenohumeral arthrodesis. Patients with anterior poliomyelitis, severe proximal root, and irreparable upper trunk brachial plexus lesions and some patients with isolated axillary
nerve paralysis are candidates for glenohumeral arthrodesis.59,61 These patients have good function in their elbows and hands, but are unable to optimize their upper extremity function because of their inability to place their hand in space. If such a patient has good function in the periscapular musculature, particularly the trapezius, levator scapula, and serratus anterior, glenohumeral arthrodesis stabilizes the extremity and allows effective hand function.⁵⁴ Such patients can then fully utilize their upper extremity potential and can work effectively at bench level. In addition, many patients with flail shoulders develop inferior subluxation of the glenohumeral joint owing to periarticular paralysis (Fig. 26-3). This condition is uncomfortable and, in some patients, frankly painful. Such patients often find that they must keep their arm in a sling to avoid injuring it. Painful inferior subluxation of the shoulder provides another indication for stabilization of the glenohumeral joint.

Patients who have the combination of a flail shoulder and flail elbow need both shoulder and elbow reconstruction. In this situation, glenohumeral arthrodesis combined with elbow flexorplasty improves the result of the elbow flexorplasty. Without shoulder stabilization, elbow flexion tends to drive the humerus posteriorly, resulting in shoulder extension, rather than elbow flexion. Arthrodesis of the shoulder in some flexion and abduction helps prevent this phenomenon and optimizes the result that can be achieved with the elbow flexorplasty. Patients with flail shoulders often have a tendency to internally rotate their upper extremity to their chest when some function remains in the powerful internal rotators of the shoulder (pectoralis major, latissimus dorsi) and no function remains in the external rotators. Shoulder stabilization either in the form of arthrodesis or L’Episcopo tendon transfer reduces this undesirable tendency.⁵⁴

There is a wide degree of variability in the disability caused by axillary nerve paralysis, and many patients have virtually full motion following paralysis of the axillary nerve, provided the rotator cuff musculature is undisturbed (endurance is never normal). Patients with isolated paralysis of the axillary nerve can
be treated by either muscle or tendon transfer or glenohumeral arthrodesis. Numerous reports exist in the literature on the value of muscle and muscle tendon transfer to restore shoulder function following paralysis of the axillary nerve.²⁸ It is generally agreed that multiple transfers are necessary to restore deltoid function and that significant problems can occur with gliding of transfers over the acromion. It is often necessary to harvest autogenous tissue, such as fascia lata, to prolong the transfers, and the process of rehabilitation is challenging following such procedures. In author’s experience such transfers are indicated primarily for pediatric patients and adult patients who have only partial paralysis of the axillary nerve.²⁸ However, pediatric patients do well with glenohumeral arthrodesis, and some authors feel they are better able to adapt to the procedure.⁴⁰ If total paralysis of the axillary nerve is present and significant limitation of shoulder function ensues, glenohumeral arthrodesis is recommended by the author, recognizing that the alternative of muscle transfers may be available in carefully selected patients. Glenohumeral arthrodesis is useful in such patients, provided their symptoms justify the procedure. El-Gammal used freefunctioning gracilis transplantation combined with shoulder arthrodesis to restore function in pediatric patients with elbow and shoulder paralysis caused by poliomyelitis.²⁴

En bloc resection of periarticular malignant tumors often requires sacrifice of the rotator cuff or the deltoid, or both. If the resection requires sacrifice of these tissues, reconstruction of the shoulder with an arthroplasty is inadvisable owing to the high risk of instability if an unconstrained prosthesis is used and to the certainty of loosening if a constrained prosthesis is used. Kiss et al. reviewed 91 shoulder resections and found that the best results were achieved when the function of the rotator cuff was preserved.³⁴

Glenohumeral arthrodesis is the procedure of choice to reconstruct the shoulder following wide resection of periarticular malignancies. Specific techniques have been recommended for glenohumeral arthrodesis following tumor resection.³⁹ These include the use of specialized fixation devices and bone-grafting techniques. Vascularized bone grafts and massive allografts are sometimes necessary because of the large defects created by tumor resection.³⁷ These techniques will be discussed later.

Destruction of the shoulder joint by septic arthritis remains an indication for glenohumeral arthrodesis. In the past, tuberculous arthritis was a common indication for glenohumeral arthrodesis. Worldwide, this condition remains prevalent, although in the Western world it has become relatively uncommon. Septic arthritis continues to occur, and when it does, the shoulder joint can be destroyed with resultant pain and limitation of function. Most surgeons would agree that in a young patient with shoulder dysfunction, for this reason, arthrodesis of the shoulder, as opposed to total shoulder arthroplasty, would be indicated. Although total shoulder arthroplasty can be performed in patients with a remote history of sepsis, if there is a recent history of sepsis or if the patient is young, arthrodesis provides a more satisfactory alternative.

Wick et al. reported the long-term results after infection in 15 patients. Complications occurred in five patients. The complication rate was lower in patients less than 50 years of age and in those patients who had fewer than four previous operations.⁷⁹

The author of this study has seen several patients who have had multiple unsuccessful shoulder arthroplasties. Although the results of shoulder arthroplasty are generally good, there are some patients in whom loosening, sepsis, and implant breakage occur. These patients often have severe loss of humeral and glenoid bone stock (Fig. 26-4). In this situation the surgeon must choose between attempting a repeat revision of the shoulder arthroplasty and reconstruction of the shoulder joint by arthrodesis. The results of revision total shoulder arthroplasty are suboptimal when compared with the results of primary arthroplasty. The decision between these two alternatives must be made on the basis of the patient’s age, the presence or absence of active sepsis, the bone stock that remains in the proximal humerus and glenoid, the symptoms the patient is experiencing, the quality and function of the rotator cuff and the deltoid, and the technical experience and expertise of the surgeon. In several patients who were significantly disabled the author has carried out glenohumeral arthrodesis following failed total shoulder arthroplasty and found it to be a helpful procedure for the patient. It is his belief that glenohumeral arthrodesis must be considered when the reconstructive surgeon is confronted with a patient with a history of multiple failed total shoulder arthroplasties.

Scalise and Iannotti reviewed seven patients who had arthrodesis following failed prosthetic shoulder arthroplasty. Four of the seven patients had undergone additional bonegrafting procedures in order to obtain union. The results of the study suggested that arthrodesis could achieve satisfactory clinical outcomes and that the patient should be aware of the frequent need for additional surgical procedures to obtain fusion.⁶⁹ Conversely, Sperling and Cofield reported
their experience performing total shoulder arthroplasty after attempted shoulder arthrodesis in three patients.⁷³

Virtually, all patients with shoulder instability can be treated by soft tissue or bony reconstructive procedures to stabilize the glenohumeral joint. Rarely, a patient will present with chronic shoulder instability after multiple attempts at surgical stabilization. If every surgical therapeutic alternative has been exhausted, the patient’s shoulder remains symptomatically unstable, and the patient does not wish to wear a thoracobrachial support, then arthrodesis can be indicated to restore shoulder stability. In this situation, careful assessment of the patient’s psychologic makeup must be carried out and one must be certain the patient has a full understanding of the implications of the procedure. Diaz et al. report arthrodesis to be a viable treatment option for this group of patients.²⁰ The author considers arthrodesis for such patients if secondary osteoarthritic changes have begun to develop in the glenohumeral joint. These patients, however, may continue to experience problems and may not function at as high a level as other patients undergoing arthrodesis. Much has been written about the difficulties in managing such patients.⁵⁵,⁶³

Severe shoulder dysfunction can result from massive rotator cuff tears.²³ Most rotator cuff tears can be managed by coracoacromial decompression and repair of the cuff. In patients who have massive rotator cuff tears that cannot be repaired, some authors have reported good results with debridement of the cuff tear and coracoacromial decompression.⁶⁰ Longstanding rotator cuff tears can lead to cuff tear arthropathy as reported by Neer et al.⁴⁹ This difficult pathologic entity can be treated by prosthetic arthroplasty with limited goals. Glenohumeral arthrodesis should be kept in mind as a possible alternative form of reconstruction in such patients when the technical skill of the surgeon or the available tissues do not permit cuff reconstruction and the patient is sufficiently symptomatic to exchange the loss of glenohumeral motion for the relief of pain. In author’s experience, this situation rarely, if ever, develops.

Glenohumeral arthrodesis is rarely indicated for post-traumatic deformity. Most patients with post-traumatic deformities, such as osteonecrosis of the humeral head, chronic fracture dislocations, tuberosity impingement, and a malunion of the proximal humerus, are best treated by shoulder reconstruction using either osteotomy, arthroplasty, or a combination of both. If these procedures are not possible, then glenohumeral arthrodesis can be considered.

The presence of glenohumeral osteoarthritis in an otherwise normal shoulder is an indication for total shoulder arthroplasty. However, almost all patients with glenohumeral osteoarthritis are of sufficient age that they are excellent candidates for total shoulder arthroplasty. If the patient were to develop osteoarthritis at a relatively young age, then glenohumeral arthrodesis might be considered,³ particularly if the patient was a laborer and modified work was not available to him or her. The results of total shoulder arthroplasty are so much superior that arthrodesis is rarely indicated for patients with this diagnosis.

Patients with rheumatoid arthritis affecting the glenohumeral joint commonly have multiple problems in their upper extremity. Glenohumeral arthrodesis is recognized as a procedure that can decrease pain arising in the glenohumeral joint.³²,⁵³,⁶⁷ Obliteration of glenohumeral motion has a negative influence on the upper extremity function. Frequently both upper extremities are involved. It is believed that patients with rheumatoid arthritis are much more effectively treated by total shoulder arthroplasty.²⁵ Favorable reports of the combination of shoulder and elbow arthroplasty have appeared in the literature, and the author of this study would advocate this method of reconstruction for such patients.