反式全肩关节假体置换治疗巨大不可修复肩袖撕裂

目的探讨反式全肩关节置换术（reverse total shoulder arthroplasty,RTSA）治疗巨大不可修复肩袖撕裂的临床治疗效果。 方法对南京中医药大学附属医院2018年5月至2020年1月收治的采取RTSA治疗的13例巨大不可修复肩袖撕裂患者的临床资料进行回顾性分析。记录术前及最后一次随访时患者的肩关节前屈、外展、外旋活动,美国肩肘外科协会评分（American shoulder and elbow surgeons score,ASES）及美国加州大学洛杉矶分校（University of California at Los Angeles,UCLA）评分评估患者肩关节功能。并记录患者发生并发症的情况及影像学检查结果。术前行MR确定肩袖脂肪浸润程度,CT评价肩胛盂骨质情况及有无缺损,术后使用X线评估假体情况。 结果13例患者均随访至少12个月以上。统计术前与术后12个月数据之间的关系,术后12个月肩关节前屈、外展、外旋活动,ASES评分和UCLA评分较术前明显提高,差异具有统计学意义（P<0.01）。随访期内13例患者中有1例患者因局部血肿在术后1周行切开血肿清除引流术,所有患者功能恢复良好。 结论RTSA治疗巨大不可修复肩袖撕裂临床效果良好。     

Anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty for dislocation arthropathy yield comparable functional outcomes with the matched cohort

BackgroundThe aim of this study was to compare outcomes of anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) after prior shoulder stabilization versus matched cohorts without previous stabilization surgery. Hypotheses were as follows: (1) patients undergoing aTSA or rTSA after stabilization procedures would have worse outcomes than matched cohorts and (2) patients undergoing TSA would have better outcomes after soft-tissue stabilization procedures (aTSA_ST or rTSA_ST) than after bony stabilization procedures (aTSA_B or rTSA_B).MethodsRetrospective cohort study was performed comparing (1) 36 patients who underwent aTSA and (2) 32 patients who underwent rTSA with prior shoulder stabilization with 3-to-1 matched cohorts (based on age, gender, and follow-up length) with no prior shoulder instability or surgery. Baseline demographics, perioperative data, adverse events (AEs), radiographic outcomes, functional outcome scores, range of motion (ROM), and patient satisfaction were analyzed. Subgroup analyses compared patients who underwent aTSA_ST or rTSA_ST with patients who underwent aTSA_B or rTSA_B.ResultsThe postoperative AE rate was 8.3% and 4.6% in the aTSA group and matched cohort, respectively (P = .404), with a trend toward a significantly higher incidence of aseptic glenoid loosening in the aTSA group (8.3% vs. 1.9%, P = .067). Functional outcomes, ROM, and patient satisfaction did not differ at follow-up >4 years. In the subgroup analysis, two AEs required reoperation among 25 patients who underwent aTSA_ST versus one among 11 patients who underwent aTSA_B, all related to aseptic loosening. There was a trend toward greater functional outcomes and satisfaction among patients who underwent aTSA_ST. There was a trend toward a clinically significant difference in active abduction at final follow-up favoring aTSA_ST (128 vs. 108 degrees, P = .096).The postoperative AE rate was 6.3% and 4.2% among the rTSA group and matched cohort, respectively (P = .632). Functional outcomes, ROM, and patient satisfaction did not differ at 4-year follow-up. In the subgroup analysis, no AEs were reported among 18 patients who underwent rTSA_ST and 14 patients who underwent rTSA_B. A trend toward greater functional outcomes and patient satisfaction favored patients who underwent rTSA_B, who achieved greater improvements in ROM from baseline and greater ROM in all planes at the final follow-up.ConclusionBoth aTSA and rTSA are reliable options for the treatment of dislocation arthropathy in appropriately selected patients. aTSA and rTSA after prior shoulder stabilization procedures have nearly equal rates of AEs and yield similar clinical and functional outcomes as matched cohorts. There may be an increased risk of glenoid aseptic loosening in aTSA after prior shoulder stabilization. Functional outcomes tend to be greater for patients who underwent aTSA_ST than those for patients who underwent aTSA_B. On the contrary, rTSA may optimize postoperative function when performed for dislocation arthropathy after bony rather than soft-tissue stabilization procedures.Level of evidenceLevel III; Retrospective Cohort Design; Treatment Study     

Going forward with reverse shoulder arthroplasty

Rotator cuff is a vital structure of glenohumeral joint, the dysfunction of which leads to debilitating pain and restricted movement. Arthroplasty using unconstrained anatomical prosthesis for treating these conditions have not been successful in the past. Reverse Shoulder Arthroplasty (RSA) is a novel technique specifically designed to address end stage glenohumeral arthritis in rotator cuff deficient joint. Short and mid-term studies have demonstrated a significant improvement in pain and range of motion of the shoulder joint. However there is a very high complication rate in comparison to total and hemiarthroplasty of shoulder joint. Over the years, there has been a steady increase in RSAs performed, both in volume and the indications for its use. This article discusses the biomechanical aspects, indications and critically reviews the clinical outcome following Reverse Shoulder Arthroplasty.     

Treatment of massive irreparable rotator cuff tears without arthritis: a comparison of superior capsular reconstruction,partial rotator cuff repair,and reverse total shoulder arthroplasty

BackgroundTo compare outcomes of superior capsular reconstruction (SCR), partial rotator cuff repair (PR), and reverse total shoulder arthroplasty (rTSA) for massive irreparable rotator cuff tear (MIRCT) without arthritis at more than 2 years follow-up.MethodsA retrospective analysis of prospectively collected data of consecutive patients undergoing surgical treatment for intraoperatively confirmed MIRCT without arthritis using SCR, PR, or rTSA. Preoperative and postoperative data were collected and multivariate analysis performed.ResultsThirty two patients met inclusion criteria for SCR, 24 for PR, and 42 for rTSA (mean follow-up years: SCR 3.2; PR 4.0; rTSA 3.5; P = .02). The rTSA patients were older (66.2 years; SCR 57.3; PR 59.0; P = .0001) and more likely to be female (61.9%; SCR 12.5%; PR 25.0%; P < .001). Intraoperative evaluation demonstrated full thickness subscapularis tear in 37.5% for SCR, 4.2% for PR, and 21.4% for rTSA (P = .01). Pseudoparalysis was present in 18.8% of SCR, 0% of PR, and 14.3% of rTSA patients (P = .08). All groups saw postoperative improvement in strength and patient-reported outcomes (P < .036). SCR and rTSA demonstrated an improved forward elevation range of motion (ROM) postoperatively while PR did not (P = .96). No group experienced improvement in rotation ROM (P > .12). rTSA had worse postoperative ROM in all planes compared to SCR and PR (P < .003). There were no differences between groups in postoperative strength (P > .16) or patient-reported outcomes (American Shoulder and Elbow Surgeons P = .14; visual analog scale P = .86; single assessment numeric evaluation P = .61). Patients were satisfied in 81.2% of SCR cases, 87.5% of PR, and 95.3% of rTSA (P = .33). Three of 32 (9.4%) SCR patients required conversion to rTSA, while 3 of 24 (12.5%) PR patients required reoperation (2 revision repairs; 1 conversion to rTSA). There were 3 additional surgical complications among 42 rTSA patients (7.1%). There were 4 nonsurgical complications in the SCR group and 1 in the rTSA group. One SCR patient and 3 rTSA patients were deceased. Multivariate analysis demonstrated no independent predictors of revision surgery. An increased acromiohumeral interval distance was an independent predictor of improved postoperative strength for all groups (P < .02).ConclusionSCR, PR, and rTSA for the treatment of MIRCT without arthritis all significantly improved postoperative strength and outcomes scores with >80% patient satisfaction but with rTSA having worse postoperative motion and a higher complication rate. There were no independent predictors for revision surgery. SCR, PR and rTSA are all viable operations for MIRCT without arthritis with satisfactory results maintained at 2 years postoperatively.     

Reverse arthroplasty for osteoarthritis and rotator cuff deficiency after previous surgery for recurrent anterior shoulder instability

Purpose

Osteoarthritis in combination with rotator cuff deficiency following previous shoulder stabilisation surgery and after failed surgical treatment for chronic anterior shoulder dislocation is a challenging condition. The aim of this study was to analyse the results of reverse shoulder arthroplasty in such patients.

Methods

Thirteen patients with a median follow-up of 3.5 (range two to eight) years and a median age of 70 (range 48–82) years were included. In all shoulders a tear of at least one rotator cuff tendon in combination with osteoarthritis was present at the time of arthroplasty. The Constant score, shoulder flexion and external and internal rotation with the elbow at the side were documented pre-operatively and at the final follow-up. Pre-operative, immediate post-operative and final follow-up radiographs were analysed. All complications and revisions were documented.

Results

Twelve patients were either satisfied or very satisfied with the procedure. The median Constant score increased from 26 points pre-operatively to 67 points at the final follow-up (p = 0.001). The median shoulder flexion increased significantly from 70° to 130° and internal rotation from two to four points (p = 0.002). External rotation did not change significantly (p = 0.55). Glenoid notching was present in five cases and was graded as mild in three cases and moderate in two. One complication occurred leading to revision surgery.

Conclusions

Reverse arthroplasty leads to high satisfaction rates for patients with osteoarthritis and rotator cuff deficiency who had undergone previous shoulder stabilisation procedures. The improvements in clinical outcome as well as the radiographic results seem to be comparable with those of other studies reporting on the outcome of reverse shoulder arthroplasty for other conditions.     

Cuff tear arthropathy is best treated with a reverse total shoulder arthroplasty

Cuff tear arthropathy is the arthritic eroded collapse of the glenohumeral joint with progressive superior humeral migration in the setting of long-standing rotator cuff insufficiency. The ideal management of cuff tear arthropathy remains elusive. Current arthroplasty options include hemiarthroplasty or reverse shoulder arthroplasty. Proper clinical and radiographic evaluation is essential in decision making in order to optimize outcomes. Acromio-humeral distance (AHD), as measured on plain radiographs, as well as fatty degeneration of the rotator cuff muscles on MRI are reliable tools for decision making. AHD < 7 mm correlates well with complete tear of the supraspinatus while AHD < 5 mm indicates infraspinatus involvement with significant muscular atrophy. Hemiarthroplasty remains an option for providing pain relief; however, continued development of superior migration and glenoid erosion remains a concern. The conversion to reverse total shoulder arthroplasty after hemiarthroplasty can be difficult due to glenoid bone loss. Recent literature supports the use of reverse total shoulder arthroplasty over hemiarthroplasty for cuff tear arthropathy with significant differences in functional outcome. Here, we discuss the radiographic evaluation of cuff tear arthropathy and review the treatment options and why we advocate the use of the reverse prosthesis.