The typical patient requiring shoulder arthrodesis complains of flail shoulder, symptomatic instability, and inability to use the elbow or hand because the shoulder cannot be stabilized. Unless there is a severe brachial plexus injury involving paralysis more distally, the functioning of the elbow and hand is often remarkably good. Examination of the shoulder may reveal atrophy of the deltoid or of the infraspinous or supraspinous fossae. The humeral head may be subluxated inferiorly at rest. Often, there is excessive mobility of the humeral head in the glenoid. In the absence of glenohumeral arthritis, the range of passive motion is often normal, especially in those patients undergoing arthrodesis for paralysis. Muscle testing reveals weakness of internal and external rotators of the shoulder, and weakness or paralysis of the deltoid muscle. In those patients who present for tumor reconstruction, failure of prior rotator cuff or instability surgery, failed arthroplasty, or distant glenohumeral joint infection, the physical examination is usually specific for those conditions. Standard radiographs ordered are anteroposterior, lateral, and axillary views of the glenohumeral joint, giving the surgeon information about the presence or absence of arthritis, any developmental abnormalities of the shoulder, and the adequacy of bone stock if internal fixation is to be used in the surgical arthrodesis. Occasionally, if the neurologic condition of the shoulder girdle muscles is in doubt, an electromyogram of the deltoid, rotator cuff, or scapular muscles may be indicated.

Before shoulder arthrodesis, preparations by the patient, the operating room staff, and the hospital’s rehabilitation personnel are necessary. Patients require some understanding of the operative technique and some insight into how glenohumeral arthrodesis can improve function and increase motion in the presence of a flail shoulder. The concept of the procedure is difficult for many patients. The most practical way to help them understand is to have them speak to a patient who has undergone the procedure. I attempt to provide the patient with the name of a former patient of the same sex, a similar age, and a similar diagnosis.

Shoulder arthrodesis requires a full set of the usual shoulder surgery instruments. In addition, pelvic reconstruction plates are used together with fully threaded cancellous screws (30). Plate-bending devices are required to contour the plate to the specific local anatomy of the individual patient. Curved osteotomes are used for decorticating the surfaces of the glenoid and humeral head and the undersurface of the acromion. Decortication of both the acromial humeral and the glenohumeral surfaces to increase the surface area available for arthrodesis is helpful in achieving solid arthrodesis. The operating room table must be adjustable so that the patient may be placed in a semisitting position intraoperatively. Although there are numerous methods for stabilization of a shoulder arthrodesis, the most popular method today is probably the AO technique with either a single plate or double plate (31).

Postoperative management requires the use of a thermoplastic orthosis appliance suspended from the opposite shoulder, although Riggins (32) has reported, from a small series of patients, that external immobilization is not needed after shoulder arthrodesis with plate fixation. In our institution, these appliances are custommade for each patient and this can be a time-consuming task. Accordingly, the rehabilitation personnel must be aware of the anticipated postoperative requirements of the patient in advance. It is sometimes expeditious to construct the thermoplastic orthosis appliance on the afternoon before or on the morning of surgery so that only minor adjustments are needed in the immediate postoperative period. This can be helpful in reducing patient discomfort.