Surgical management of shoulder arthritis

Shoulder arthritis is a painful and functionally limiting condition. Importantly, the overarching diagnosis of shoulder arthritis encompasses a cascade of pathologies affecting the bony and soft tissue structures of the shoulder. Although many surgical and non-surgical management options are available, effective utilization of these treatments is dependent upon careful diagnosis and consideration of the complex anatomy of the glenohumeral joint. This review considers what is known about this increasingly common condition and the spectrum of treatments available.     

Reverse polarity shoulder replacement: Current concepts and review of literature

Shoulder replacement in cuff tear arthropathy (CTA) is an unsolved challenge. CTA poses a soft tissue deficiency in an arthritic glenohumeral joint which the anatomical total shoulder replacement and hemiarthroplasty cannot reliably provide stability, range of movement, function or satisfactory long term outcome. In the past two decades since the introduction of the reverse shoulder replacement, the prosthesis has evolved and has shown promising results. It is a partially constraint joint by virtue of its design features. The reversal of the concavity and convexity of the joint to the proximal humerus and the glenoid, respectively, also shifts and improves its center of rotation onto the osseous surface of the glenoid with less exposure to shear stress. It is a successful pain relieving procedure, offering good outcome in patients with irreparable massive rotator cuff tear with or without osteoarthritis. Consequently, this has led to wider use and expansion of its indication to include more complex elective and trauma cases. Whereas originally used in the more elderly patients, there is increasingly more demand in the younger patients. It is important to have good quality long term data to support these increasing indications. Therefore, we review the literature on the concepts of reverse shoulder replacement and the contemporary evidence.     

类风湿性关节炎肩关节病变的影像学测量

[目的]调查类风湿性关节炎( rheumatoid arthritis,RA)患者的肩关节功能及影像学改变,了解该类人群中肩关节病变现状,分析肩关节破坏的相关因素,为RA肩部疾病的预防和治疗提供临床依据.[方法]随机选择RA患者,记录发病年龄、病程,采用ASES肩关节评分量表评测肩关节功能;拍摄肩关节正位X线片,进行Larson分期,测量肩关节内侧距离(MD)、肩关节上移指数(UI)、肩关节内移指数(MI)、大结节关节面间距(GA),分析Larson分期与上述数据间的相关性.[结果]2010年3月～2010年11月,60人入选本研究,平均年龄(51.34±14.14)岁,男6人,女54人.ASES评分(72.69±24.76)分;完成116肩摄X线片,无明显骨性破坏的肩关节(Larson 0 ～1期)MD为(7.55±0.55) cm,UI为1.38±0.10,MI为1.04±0.29,GA为(0.60±0.22) cm.Larson 分期与ASES评分呈显著负相关(r=-0.028 3,P=0.001),与反映肩关节内移的MD、MI呈显著负相关(r=-0.177,P=0.029和r=-0.438,P＜0.001);与UI无显著相关性(r=-0.062,P=0.253);与GA呈显著负相关(r=-0.369,P＜0.001).与病程和年龄呈显著正相关(r=0.534和r=0.390,P＜0.001),与患病年龄无显著相关性(r =0.091,P=0.165).[结论]肩关节受累在RA患者中广泛存在,其受累程度随着病程增加而增加,随着破坏程度的加剧肩关节旋转中心发生内移,但是尚不明确旋转中心上移与骨性破坏是否同步发展.     

Reverse shoulder arthroplasty for proximal humerus fractures

A reverse shoulder arthroplasty is a consideration for the treatment of comminuted four-part proximal humerus fractures in elderly patients. While a reverse TSA should not replace other treatment modalities, it is indicated in elderly patients with fractures that are not amenable to fixation. Immediate stability and relative independence from tuberosity healing are clear advantages, but the complication rate is substantially higher. Larger studies are necessary to clarify appropriate indications.     

The antero-superior exposure for total shoulder replacement

Surgical Principles The survivorship of total shoulder replacement appears to depend to a large extent on glenoid fixation. Therefore a surgical exposure which provides optimum visualization of the glenoid surface during its preparation will enhance the precision of the bone cuts and presumably the accuracy of component fixation. Whether such improvement will lengthen longevity of the arthroplasty is the subject of a separate study.     

Short stem shoulder replacement

Context:

It is agreed that it is important to anatomically reproduce the proximal humeral anatomy when performing a prosthetic shoulder replacement. This can be difficult with a long stemmed prosthesis, in particular if there is little relationship of the metaphysis to the humeral shaft. The ‘short stem’ prosthesis can deal with this problem.

Aims:

A prospective study assessed the results of total shoulder arthroplasty using a short stem humeral prosthesis, a ceramic humeral head, and a pegged cemented polyethylene glenoid.

Materials and methods:

Patients with primary shoulder osteoarthritis were recruited into this prospective trial and pre-operatively had the ASES, Constant, SPADI, and DASH scores recorded. The patients were clinically reviewed at the two weeks, eight weeks, one year, and two year mark with completion of a data form. Radiological evaluation was at the eight week, one year and two year follow-up. At the one and two year follow-up the satisfaction rating, the range of passive and active motion, Constant, ASES, SPADI, DASH and pain results were recorded and analysed with SPPS 20.

Results:

During the study period 97 short stem, ceramic head total shoulder replacements were carried out. At the time of follow-up 12 were two years from operation and 38 one year from operation. Active elevation was overall mean 160 degrees. Constant scores were 76 at 1 year, and 86 at 2 years, ASES 88 and 93, and satisfaction 96% and 98% respectively at one and 2 year follow up. There were no problems during insertion of the humeral prosthesis, or any radiolucent lines or movement of the prosthesis on later radiographs.

Conclusion:

The short stem prosthesis had no complications, and on follow up radiographs good bone fixation. These fairly short term clinical results were overall good.     

Proximal humerus fractures should be treated with a reverse shoulder replacement

Historically, fractures of the proximal humerus not amendable to closed treatment or internal fixation have been treated with hemiarthroplasty. Clinical outcomes following hemiarthroplasty have been variable and difficult to predict. Results are often correlated with increasing age, tuberosity healing, and tuberosity position. Reverse shoulder arthroplasty has demonstrated effectiveness in elderly patients with rotator cuff arthropathy and has been increasingly employed for complex fractures in older patients. Several small trials have compared the reverse arthroplasty and hemiarthroplasty for acute fractures, and reverse shoulder arthroplasty has demonstrated more reproducible results in elderly patients.     

Reverse total shoulder arthroplasty for irreparable rotator cuff tears without arthritis: A systematic review

IntroductionIndications for reverse total shoulder arthroplasty (RTSA) have expanded over recent years. Whilst cuff tear arthropathy is an accepted indication, the results of its use in those without arthritis is not clear. The aim of this article is to review the literature on RTSA for massive rotator cuff tears without associated arthritis.MethodsA systematic review search was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to find all studies with clinical outcomes on RTSA performed for massive irreparable rotator cuff tears (MIRCT) without arthritis.ResultsOf the 160 studies produced by the search, a detailed analysis found 11 articles to be included in this review. There was variability in the implant style used and the outcome measures utilised, but all studies found improvement in the outcome following RTSA. Many studies advised judicious use following high complication rates, and caution was advised in those patients with pre-operatively preserved active forward elevation.ConclusionThe available evidence suggests that RTSA is a reliable option in older patients with persistent pain and lack of function following MIRCT even without arthritis. However, as outcomes are not significantly worse following failed rotator cuff repair, joint preserving options in the younger age group should be carefully considered in light of the relatively high complication rate associated with RTSA.Level of evidenceIV.     

Reverse shoulder arthroplasty for massive cuff tears in patients <65 years: An age-old dilemma

Reverse shoulder arthroplasty has proven an effective pain-alleviating treatment option for rotator cuff tear arthropathy and has gained popularity since its reintroduction to the U.S. After several initial iterations and failures in the 1970s, the prosthesis was removed from the market due to high complication rates before being retooled and approved in 2004. Upon reintroduction, the FDA-recommended indication age was 70 years. We review the history and common complications of reverse arthroplasty before discussing its use in addressing massive cuff tears in younger patients. While only based on early follow-up, this third-generation implant gives cause for guarded optimism.