Unconstrained shoulder arthroplasty

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Revision shoulder arthroplasty with a reverse shoulder prosthesis

Introduction

Revision shoulder arthroplasty presents many unique and complex challenges when glenoid bone loss is involved. A distorted and medialized anatomy prevents the proper mechanics of the reverse prosthesis with regard to deltoid tension and ultimate function. This paper highlights one surgeon’s experience using structural allograft for glenoid bone loss.

Patients and methods

In all, 20 patients for a total of 24 surgeries with a medialized glenoid and/or substantial glenoid bone loss of grade IIB or higher were evaluated in this retrospective study. The allograft surgeries were performed as a one-stage procedure except for three patients. Recombinant human bone morphogenetic protein-2 (BMP2) was added to supplement incorporation in all cases. Four patients had two separate allograft procedures. Eight of the allograft procedure were femoral shaft, eleven of the allografts were femoral neck/head, and five of the allograft procedures were from proximal humerus. A graft was considered a success if they had at least 12 months of clinical and radiographic follow-up without subsequent removal of the graft or radiographic failure. Patients with less than 12 months of follow-up were included if the graft was removed or had early failure.

Results

All femoral shaft allografts except one failed, and during revision surgery it was often noted that the graft was cracked where the peripheral screws had been drilled. In nine patients the graft was still in place at last follow-up, seven of these were femoral neck/head allografts. Five grafts were removed secondary to infection. Average follow-up was 24 months (range 5–45 months).

Conclusions

Femoral neck allografts are an option in patients with substantial bone loss. The authors do not recommend use of femoral shaft allografts.

     

Reverse shoulder arthroplasty in revision of failed shoulder arthroplasty—outcome and follow-up

Purpose

The number of shoulder arthroplasties has increased over the last decade, which can partly be explained by the increasing use of the reverse total shoulder arthroplasty technique. However, the options for revision surgery after primary arthroplasty are limited in cases of irreparable rotator cuff deficiency, and tuberosity malunion, nonunion, or resorption. Often, conversion to a reverse design is the only suitable solution. We analysed the functional outcome, complication rate and patient satisfaction after the revision of primary shoulder arthroplasty using an inverse design.

Methods

Over a ten-year period 57 patients underwent revision surgery for failed primary shoulder arthroplasty using a reverse design. Of the 57 patients, 50 (mean age, 64.2 years) were available after an average follow-up of 51 months. Clinical evaluation included the Constant Murley Score, the UCLA score, and the Simple Shoulder Test, whereas radiological evaluation included plain radiographs in standard projections. Patients were also requested to rate their subjective satisfaction of the final outcome as excellent, good, satisfied or dissatisfied.

Results

Compared to the preoperative status, the overall functional outcome measurements based on standardised outcome shoulder scores improved significantly at follow-up. The overall mean Constant Murley score improved from 18.5 to 49.3 points, the mean UCLA score improved from 7.1 to 21.6 points, and the mean simple shoulder test improved from 1.2 to 5.6 points. The average degree of abduction improved from 40 to 93° (p < 0.0001), and the average degree of anterior flexion improved from 47 to 98° (p < 0.0001). The median VAS pain score decreased from 7 to 1. Complications occurred in 12 cases (24 %).A total of 32 (64 %) patients rated their result as good or excellent, six (12 %) as satisfactory and 12 (24 %) as dissatisfied.

Conclusion

In revision shoulder arthroplasty after failed primary shoulder arthroplasty an inverse design can improve the functional outcome, and patient satisfaction is usually high. However, the complication rate of this procedure is also high, and patient selection and other treatment options should be carefully considered.     

Representative survey of frozen shoulder questionnaire responses from the Japan Shoulder Society: What are the appropriate diagnostic terms for primary idiopathic frozen shoulder,stiff shoulder or frozen shoulder?

BackgroundPrimary frozen shoulder has unknown etiology and significant restriction of active and passive motion. The distinction between frozen shoulder and stiff shoulder has been unclear. Therefore, the purposes of this study were to perform a survey regarding definition and classification of frozen shoulder proposed by the American Academy of Orthopedic Surgeons (AAOS) among the members of the Japan Shoulder Society (JSS) and to compare the results with those obtained among the members of the American Shoulder and Elbow Surgeons (ASES).MethodsThe Scientific Research Project Committee of the JSS prepared the questionnaire for frozen shoulder and stiff shoulder. Surveys were sent by e-mail on Jan 14, 2016 to JSS registered members and the response dead-line was set on March 13, 2016.ResultsThe number of respondents was 230, including all directors, councilors, and senior doctors. Agreement with the definition of primary frozen shoulder was 67%, the classification of primary or secondary frozen shoulder was 53%, and the 3 divisions of secondary frozen shoulder was 53%. Diagnostic terms for the cases of shoulder stiffness with unknown etiology were as follows: frozen shoulder (31%), stiff shoulder (22%), periarthritis scapulohumeralis (16%), so called “Gojukata” in Japan, which means shoulder problems in their fifties (16%), idiopathic frozen shoulder (6%), primary frozen shoulder (4%), adhesive capsulitis (3%), others (2%).ConclusionThe survey shows lower rates of agreement among the JSS members than the ASES members for the definition of primary frozen shoulder, the classification of primary and secondary frozen shoulder, and the divisions of secondary frozen shoulder. To avoid confusion between stiff shoulder and frozen shoulder, the committee agrees to the ISAKOS recommendation that the term “frozen shoulder” should be used exclusively for primary idiopathic stiff shoulder.     

Does critical shoulder angle predict abduction motion and acromion-tuberosity impingement in reverse shoulder arthroplasty?

BackgroundVirtual planning software for reverse shoulder arthroplasty (RSA) has introduced the ability to optimize implant position in an effort to maximize bony impingement–free motion. Abduction impingement typically occurs between the glenoid and polyethylene or between the tuberosities and the acromion or coracoid. Acromion-tuberosity impingement has been considered less desirable, as it may create additional stress on the acromion. Patients with a large acromion overhang may have higher rates of acromion-tuberosity impingement. As the critical shoulder angle (CSA) represents a larger distance from the glenoid face to the acromion, the purpose of this study was to evaluate the impact of implant selection and position on abduction motion and acromion-tuberosity impingement, with a focus on the association to CSA. We hypothesize that a larger CSA will be associated with less abduction motion and an increase in acromion-tuberosity impingement.MethodsThis is a retrospective cohort case series of 85 consecutive patients who underwent RSA from June 2020 to January 2021. Humeral and glenoid components were implanted virtually (SurgiCase) using a standard protocol for a single implant system (DJO AltiVate Short Stem Reverse) with an inset humeral component. Implant variables analyzed included baseplate location (central vs. inferior glenoid), glenosphere lateralization (10 mm vs. 6 mm), and humeral shell (standard vs. semiconstrained). The maximal degree of abduction and location of impingement were recorded at external rotation of 0°, 45°, and 90°. Implant combinations that resulted in no impingement and no motion were recorded.ResultsIncrease in CSA was associated with acromion-tuberosity impingement for nearly every combination at 0° and 45° external rotation; however, there were no significant associations between CSA and maximum abduction motion. Acromion-tuberosity impingement was associated with central glenosphere placement in all degrees of external rotation (P < .001), use of a 10 mm lateralized glenosphere for 0° (P < .001) and 45° (P = .076), and using a standard polyethylene shell for 0° (P = .032) and 45° external rotation (P = .007). Maximal abduction motion was associated with inferior placement (P < .001), and use of a 10 mm lateralized glenosphere (P < .001) in all positions of external rotation but was not influenced by the polyethylene type.ConclusionIncreased CSA is associated with acromion-tuberosity impingement and can be used to screen for patients at risk for bony impingement in abduction. Placement of the glenosphere centrally and use of a 10 mm lateralized glenosphere were associated with higher rates of acromion-tuberosity impingement. Maximal abduction can be achieved using a 10 mm lateralized glenosphere and inferior placement.     

Your diagnosis? Posterior shoulder dislocation

Accurate diagnosis of posterior shoulder dislocation requires a high index of suspicion in shoulder trauma patients and proper radiographic evaluation. This case highlights the importance of obtaining axillary views in shoulder trauma cases.     

How does gout impact outcomes following primary shoulder arthroplasty?: Gout and shoulder arthroplasty

IntroductionStudies have shown that the overall prevalence of gout has increased. Data shows that patients with gout have worse outcomes following total joint arthroplasty, however studies investigating the effects of gout following primary total shoulder (TSA) and reverse shoulder arthroplasty (RSA) are limited. The purpose of this study was to compare outcomes of patients with and without gout undergoing primary shoulder arthroplasty, evaluating (1) in-hospital length of stay (LOS); (2) medical complications; (3) cost of care.MethodsA retrospective query using a nationwide administrative claims database was performed from January 2005 to March 2014 for all patients who underwent primary TSA and RSA for the treatment of glenohumeral osteoarthritis, yielding a total of 11,414 patients to be included. For the TSA cohort, 7702 patients were identified within the study (n = 1,185) and control (n = 6417) cohorts. Similarly, 3712 patients were identified within the RSA cohorts (gout n = 621 and control n = 3,091). Primary endpoints were in-hospital LOS, 90-day medical complications, and total global 90-day episode of care (EOC) costs. Multivariate logistic regression analyses were used to calculate the odds (OR) of medical complications, whereas Welch's t-tests were used to compare LOS and costs of care. A P value less than .05 was considered statistically significant.ResultsPatients with gout undergoing primary TSA (3- vs. 2-days, P < .0001) and RSA (3- vs. 2-days, P < .0001) had significantly longer in-hospital LOS. Gout patients undergoing either TSA (41.2 vs. 11.3%; OR: 3.30, P < .0001) or RSA had significantly higher incidence and odds (50.6 vs. 17.9%; OR: 2.10, P < .0001) of developing 90-day medical complications compared to their counterparts. Study group patients incurred significantly higher total global 90-day episode of care costs following both TSA ($15,007.84 vs. $13,447.06, P < .0001) and RSA ($19,659.27 vs. $16,783.70, P< .0001).ConclusionThis study demonstrates that patients with gout undergoing primary shoulder arthroplasty have longer in-hospital LOS, in addition to higher rates of complications, and increased costs of care. The study can be used by orthopedic surgeons to educate patients who have gout on complications which may occur following their surgical procedure.Level of EvidenceLevel III, retrospective comparative study.     

Frozen shoulder: a sympathetic dystrophy?

Diagnostic and clinical features of the frozen shoulder syndrome and the Sudeck syndrome are similar in many aspects. Radioisotope bone scan shows an increased uptake in affected areas in both diseases, while native radiographs show a progressive demineralisation. Measurement of bone mineral density (BMD) by quantitative digital radiography objectified these local decalcification processes in an early stage of the frozen shoulder syndrome; 10 of 12 patients with primary frozen shoulder had BMD decreases greater 21% in the humeral head of the affected shoulder compared to the non-affected side. In the immobilised control group with degenerative changes of the rotator cuff, calcifying tendinitis and shoulder instability (n = 12) and in the group of healthy probands (n = 20), the difference between the affected and non-affected side (left and right humerus of the healthy probands) was only more than 21% in one case each. There are several references in the literature that assume frozen shoulder to be an algoneurodystrophic process; our observations support this hypothesis, possibly leading to earlier diagnoses and extended therapeutic management.     

Operative Therapie der „stiff shoulder“

Die Unfallchirurgie - Die Indikation zur operativen Versorgung der ?stiff shoulder“ mithilfe der arthroskopisch gestützten Arthrolyse wird bei Patienten mit persistierenden,...     

Does anterior shoulder balance in adolescent idiopathic scoliosis correlate with posterior shoulder balance clinically and radiographically?

Purpose

Patients with adolescent idiopathic scoliosis (AIS) often present with a disfiguring shoulder imbalance. Shoulder balance (Sh.B) is of significant importance to the patient’s self-perception. Previous studies have correlated Sh.B with respect to only the clinical posterior view correlated with radiographs. It is important, however, to address Sh.B with respect to anterior view of the patients’ shoulders as if patients were viewing in a mirror. In this study, we evaluated the anterior Sh.B and correlated it with posterior Sh.B clinically and radiographically in Lenke type 1 and 2 curves.

Method

An online scoliosis database was queried to identify 74 AIS patients with Lenke 1 (n = 55, age 15.28 ± 3.35) and 2 (n = 19, age 15.66 ± 3.72) curves with a complete set of PA radiographs and anterior and posterior photos. Radiographic measures for Sh.B included Cobb angles, T1 tilt, first rib angle, and clavicle-rib intersection angle. Clinical measures for Sh.B included inner shoulder angle, outer shoulder angle, and axillary fold angle. Regression analysis with Pearson’s correlation and ANOVA for statistical significance was used for analysis.

Results

For Lenke 1 curves, there was moderate statistically significant correlation between anterior and posterior clinical Sh.B (R = 0.35–0.41). There was only weak to moderate correlation between radiographic and clinical measures. For Lenke 2 curves, there was a weak to moderate correlation between anterior and posterior clinical Sh.B (R = 0.25–0.45), though not statistically significant. There was no statistically significant correlation between any radiographic measures and posterior Sh.B. There was, however, moderate and significant correlation between radiographic measures and anterior Sh.B.

Conclusion

There is no strong correlation between anterior and posterior clinical Sh.B, and surgeons should evaluate both sides in planning deformity correction, especially in Lenke 2 curves. None of the radiographic measures showed strong correlation (R > 0.8) with anterior or posterior clinical Sh.B. A stronger correlation existed between radiographic measures and anterior Sh.B measurements compared with posterior clinical Sh.B measurements in Lenke 2 curves further necessitating anterior evaluation in this group.     

Four-part posterior fracture – dislocations of the shoulder

Ten patients who had been treated by limited open reduction and percutaneous stabilization for four-part posterior fracture-dislocation of the shoulder were followed-up for an average of 3.2 years postoperatively. According to the criteria of Neer, the result was excellent in nine patients, with an average Constant score of 95.7. There was one failure who showed complete avascular necrosis. All patients with excellent results had at least 1 mm of the neck portion of the head fragment intact. Received: 19 May 1998     

An unusual cause of shoulder pain and dysfunction of the shoulder girdle: Parsonage–Turner syndrome—case report

Parsonage–Turner syndrome (PTS) is a rare disorder consisting of a complex aggregate of signs and symptoms with an acute onset of pain followed by muscle weakness in a separate peripheral nerve distribution, dysesthesias, and numbness. Although the etiology of PTS is unclear, it is reported in various clinical situations, including postoperatively, postinfectious, posttraumatic, and postvaccination. We report a case of a 27-year-old man that presented to our outpatient clinic with a throbbing acute shoulder pain and motor weakness over several months that did not improve after 2 years. At the time of consultation, he complained of left-sided neck pain radiating to the left deltoid muscle and axilla as well as left shoulder blade pain with shoulder girdle muscle weakness. Repeated electrodiagnostic studies revealed denervation limited to the supraspinatus and infraspinatus muscles without evidence of cervical radiculopathy. He was diagnosed with PTS. The authors review patient presentation, physical examination, and workup needed for diagnosis of PTS to help physicians diagnose and treat this complex syndrome.     

Total shoulder arthroplasty — current problems and possible solutions

The concept and design of a cemented unconstrained total shoulder arthroplasty (TSA), introduced by Charles Neer II 25 years ago, has been successful in the management of degenerative and inflammatory conditions of the shoulder, controlling pain and, in many patients, significantly improving function. The clinical outcome is very much determined by the nature and severity of the pathology, as well as by the surgeon's experience and ability to correctly locate and fix the components. Total shoulder arthroplasty is a technically difficult procedure with perhaps a greater potential for technical errors and complications compared with other commonly performed arthroplasties. Current systems are modular on the humeral side, with varying head diameters and neck lengths, allowing more accurate coverage of the cut surface of the humeral neck and improved ability to establish the position of the joint line within the requirements of correct soft tissue tension and balance. Cemented all-polyethylene glenoid components remain the most favored, but the majority now have an increased radius of curvature compared with their corresponding humeral head, to allow translation during movement. Aseptic glenoid component loosening is the most frequently encountered long-term complication and is hastened by conforming prostheses, incorrect positioning, rotator cuff tears, and capsular contractures, but is protected by secure glenoid fixation. Cemented one-piece metal-backed glenoids have been disappointing, but non-cemented glenoids are being trialed with promising early results, although they have introduced their own particular problems of rapid polyethylene wear and component dissociation. Although cemented humeral components have a very low incidence of symptomatic loosening, most surgeons currently use press-fit designs supplemented with metaphyseal porous coating for osseous integration. Based on increased understanding of the morphology of the upper humerus, current designs are evolving with increased modularity, allowing the surgeon to choose the appropriate size, inclination, offset and version of the humeral component. These changes will, it is hoped, result in improved functional recovery and increased survivorship of the glenoid component. Received for publication on April 15, 1998; accepted on July 31, 1998     

Does diabetes affect functional outcomes after shoulder arthroplasty?

ObjectivesThe purpose of this study was to assess whether diabetes affects functional and physical outcomes following shoulder arthroplastyMethodsA cohort of 140 patients were tested preoperatively, at an early follow-up visit (between 3-6 months) and at late follow-up visit (between 1-3 years) following shoulder arthroplasty. The American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form measured shoulder pain and function and the Short-Form-12 (SF-12) measured physical health status. Shoulder goniometry and dynamometry were used to assess motion and strength. Diabetic status was self-reported.ResultsThere were significant improvements in function and physical health status for both diabetic and nondiabetic patients at the late follow-up visit. For patients with diabetes, shoulder function (ASES: 0-30) improved from 5 (5) to 18 (6) scores (p < 0.001) and physical health status improved from 27 (6) to 38 (8) scores (p < 0.001). For patients without diabetes, shoulder function improved from 8 (5) to 19 (8) scores (p < 0.001) and physical health status improved from 31 (8) to 40 (12) scores (p < 0.001). No significant differences between diabetic and nondiabetic patients was detected at the late follow-up.ConclusionPatients with diabetes achieve large clinical benefits from shoulder arthroplasty, with follow-up outcomes equally positive to those without diabetes. Future prospective studies with a larger sample size of patients with diabetes are needed to confirm the results of this study.Level of evidenceII     

Is shoulder arthroplasty an option for charcot arthropathy?

Introduction

Charcot arthropathy is a rare cause of debilitating joint destruction. Shoulder arthroplasty for Charcot arthropathy is challenging secondary to local bone and soft tissue loss, lack of protective sensation, and altered muscle control. The purpose of this study is to review the outcomes, complications, and survivorship of shoulder arthroplasty for Charcot arthropathy.

Methods

Between January 2000 and December 2011, ten shoulders with Charcot arthropathy were treated with shoulder arthroplasty at our Institution (six hemiarthroplasty, one total shoulder arthroplasty, three reverse shoulder arthroplasty). Shoulders were followed for a minimum of two years or until re-operation. Outcomes measures included pain, range of motion, complications, and reoperation.

Results

Shoulder arthroplasty improved pain to a mean score of 2.6 at follow up. However, gains in range of motion were not as substantial, with mean elevation of only 105°. External rotation improved from 20 to 43°. Subjectively, six of the ten patients rated the result as much better or better. Two shoulders underwent revision surgery at an average of five months after index arthroplasty.

Conclusion

Shoulder arthroplasty for the treatment of the sequelae of a Charcot joint is a reasonable treatment option to provide substantial pain relief and improved motion. The relative indications of hemiarthroplasty, total shoulder arthroplasty, and reverse shoulder arthroplasty for this particular condition continue to evolve.