Reverse shoulder arthroplasty with a cementless short metaphyseal humeral prosthesis without a stem: survivorship,early to mid-term clinical and radiological outcomes in a prospective study from an independent centre

Introduction

The use of reverse total shoulder arthroplasty has increased for the management of cuff-deficient glenohumeral joint arthritis and fractures. With bone preservation being a major target in reverse shoulder arthroplasty, metaphyseal humeral components without a stem were developed. The aim of this study is to present the survivorship, functional and radiological outcomes of a novel short metaphyseal prosthesis without a diaphyseal stem from an independent centre.

Methods

Clinical function and radiological features of patients undergoing stemless reverse shoulder arthroplasty were prospectively recorded. Patients’ demographics, indications for surgery, complications, functional and radiological assessment at the final follow-up as well as survivorship with the end point of revision for any reason were recorded.

Results

Between 2009 and 2016, 36 patients received 37 reverse shoulder arthroplasties with the stemless Verso prosthesis. Mean age of the patients was 76.9 years. The most common indication for surgery was cuff tear arthropathy. Mean follow-up was 3 years (range 1–7 years). Oxford shoulder score improved from an average of 11 pre-operatively (range 2–19) to 44 post-operatively (range 29–48) (p < 0.0001). There was one case of a deep post-operative infection that needed washout, liner exchange with retention of the prosthesis. Radiographic analysis showed no lucencies, or stress shielding around the humeral or glenoid components. Constant score at the final follow-up was on average 63 (range 35–86). Activities of daily living with requirement for internal and external rotation score (ADLEIR) was on average 12 pre-operatively (range 0–27) and 31 post-operatively (range 18–36) (p < 0.0001). There was 100% survivorship of the prosthesis in this early to mid-term study.

Conclusion

This early to mid-term prospective study demonstrates excellent survivorship and radiological results of the Verso reverse shoulder replacement. It needs a simple reproducible technique, and the results have been replicated at an independent centre. This study underlines its survivorship in the early to mid-term and confirms lower incidence of complications such as instability, notching, loosening and the need for revision surgery. Most importantly, it conserves the humeral bone stock for revision arthroplasties in the future. Our results are similar to those of the currently published literature.

     

Stemless and stemmed total shoulder arthroplasty: a comparison of short-term clinical and radiographic outcomes

BackgroundStemless total shoulder arthroplasty could provide benefits over stemmed arthroplasty which has represented the gold standard for decades. Proposed benefits of stemless arthroplasty include better reproduction of anatomy and reduction in stress shielding; however, this does not appear to be confirmed by any study. The hypothesis was there would be no clinical differences between the stemless and the short-stem prosthesis, but the stemless prosthesis would better reproduce coronal radiographic anatomy and have less radiographic evidence of stress shielding.Materials and MethodsA prospectively collected data of patients undergoing primary, anatomic total shoulder arthroplasty for osteoarthritis were retrospectively reviewed. Patient-determined outcomes including the Western Ontario Osteoarthritis Index, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation, Simple Shoulder Test, and Shoulder Activity Level were recorded preoperatively, at 1 year, and at 2 years. Preoperative and 1-year postoperative range of motion was recorded. Radiographic parameters to assess restoration of proximal humeral anatomy included humeral head height, humeral neck angle, humeral centering on the glenoid, and postoperative restoration of the anatomic center of rotation. Final postoperative radiographs were assessed for evidence of stress shielding.ResultsForty-eight patients had a stemmed humeral prosthesis, and 109 patients had a stemless prosthesis. Patient-determined outcomes were available from 2 years postoperatively in 99.4%. Both groups had significant improvements in all patient-reported outcomes and range-of-motion metrics, but there were no differences between the stemless and stemmed groups in these outcomes. The prosthetic humeral head of the stemmed components was more likely to extend further superior to the humeral osseous margin than that of the stemless group (2.0 ± 2.4 vs. 0.8 ± 1.4 mm; P = .0004). The stemless group had a smaller postoperative deviation from the anatomic center of rotation than the stemmed group (2.5 ± 1.9 vs. 3.2 ± 2.1 mm; P = .04). The humeral neck angle was comparable between the stemmed group and the stemless group (133 ± 7° vs. 131 ± 8°; P = .06). There was similar mean deviation of humeral head centering on the glenoid prosthesis between the stemmed and stemless groups (1.9 ± 1.8 vs. 1.6 ± 1.7 mm; P = .20). There was evidence of stress shielding in 10 patients (21%) with a stemmed prosthesis and in no patients with a stemless prosthesis at 1-year follow-up (P < .0001).ConclusionsThere were no differences in patient-determined outcomes between the groups at 2-year follow-up. Restoration of proximal humeral anatomy was either better or equivalent with the stemless prosthesis compared to the stemmed one. Radiographic evidence of stress shielding was found in the stemmed prosthesis but not in the stemless prosthesis at 1-year follow-up.     

Mid-term results with an anatomic stemless shoulder prosthesis in patients with primary osteoarthritis

ObjectiveThe introduction of a stemless prosthesis in shoulder arthroplasty represents a novel design whereby the proximal humerus is restored anatomically, while leaving the diaphysis of the humerus untouched. The aim of this study was to present the mid-term results of total evolutive shoulder system (TESS; Biomet^®), a stemless shoulder prosthesis.MethodsThe study included 38 consecutive patients (18 men and 20 women; mean age: 66 years; range: 55-81 years) treated with shoulder arthroplasty between 2009 and 2011 with TESS for primary glenohumeral arthritis. Total shoulder arthroplasty (TSA) was performed in 28 cases (74%), hemi-shoulder arthroplasty (HSA) in 10 (26%). Constant score, active range of motion, patient satisfaction rate, and radiological assessment were analyzed. Mean time of follow-up was 37 months.ResultsConstant score improved from 21.8 points (28.6 adjusted for age) preoperatively to 74.1 points (86.6 adjusted for age) postoperatively. Active range of motion increased significantly from the pre- to postoperative status. Eighty-nine percent were very satisfied or satisfied with shoulder replacement surgery. One cemented glenoid was revised due to aseptic loosening. None of the components were found to be loose at the final follow-up. No signs of stress shielding were seen.ConclusionsThis study shows promising results of this implant concept in the short- to mid-term. These results are comparable with the results achieved with long-established arthroplasty designs.Level of EvidenceLevel IV, Therapeutic Study.     

Clinical and radiological outcomes using the LIMA SMR stemless implant—A 2-year follow-up in 49 patients

BackgroundSince the introduction of stemless anatomic total shoulder arthroplasty (TSA), many studies have been published on this specific group of TSA implants. The following study aimed to evaluate clinical and radiological short- to mid-term outcomes of the LIMA SMR stemless anatomical implant.MethodsWe prospectively evaluated the outcome of 53 TSAs in 52 patients, with a mean age of 58.45 years (range 47-78 years) at the time of implantation with a minimum follow-up of 2 years (range 24-47 months). All patients were physically and radiologically examined; the results were documented by the Constant-Murley Score and the Simple Shoulder Value.ResultsSignificant improvements from preoperative to latest follow-up were documented in Constant-Murley Score (29.0-75.84 pts; P < .001), active range of motion (abduction 84.7°-133.2°, flexion 95.3°-146.4°, and external rotation 12.7°-32.4°). The mean Simple Shoulder Value was 82.15% at the last follow-up. There was no complete loosening of the humeral component, but a lowering of bone mineral density (radiolucencies, RLL) was observed in anteroposterior or axially views—radiographs at the humeral component in 10.2% of the cases, most of them on the anteroposterior view at the calcar region. There was no statistical difference in the outcome of the patients with RLL compared with the ones without radiolucencies. Major complications or revisions did not occur.ConclusionThis study provides comparable improvement in functional, radiographic, and subjective mid-term results with other stemless anatomic implants.     

Stemless shoulder prosthesis for treatment of proximal humeral malunion does not require tuberosity osteotomy

Purpose

When the proximal humeral anatomy is altered because of malunion, shoulder arthroplasty is a challenge for the orthopaedic surgeon, and tuberosity osteotomy should be avoided whenever possible. The purpose of this study was to investigate the clinical and radiological outcomes of anatomic stemless shoulder arthroplasty in cases of malunion. We hypothesized that a stemless prosthesis can be implanted without performing tuberosity osteotomy.

Methods

We conducted a continuous, single surgeon, retrospective case series study with a minimum follow-up of two years (mean of 44 months, range 24–80). The Constant-Murley score, active range of motion and X-rays were evaluated in 27 patients (mean age of 60 years, range 37–83) with proximal humeral malunion who were treated with a stemless anatomic shoulder prosthesis.

Results

In all patients, the prosthesis was implanted without the need for tuberosity osteotomy. The Constant score improved from 27 to 62 (p?≤?0.001), active anterior elevation from 81° to 129° (p?≤?0.001), and external rotation from 5° to 40° (p?≤?0.001). There was no evidence of radiological loosening.

Conclusions

Use of a stemless anatomic shoulder prosthesis avoids the need for tuberosity osteotomy and certain surgical difficulties, even in cases of severe tuberosity malunion, and leads to good functional outcomes in the short term.

     

Stemless shoulder prosthesis versus conventional anatomic shoulder prosthesis in patients with osteoarthritis

Background

The stemless shoulder prosthesis is a new concept in shoulder arthroplasty. To date, only a few studies have investigated the results of this prosthesis. The aim of this study was to investigate the clinical and radiological midterm results of this implant in comparison with a standard anatomic stemmed shoulder prosthesis.

Materials and methods

The Constant score, the DASH score, the active range of motion (abduction, anteversion, external rotation), and the radiological results were examined in 82 patients with primary osteoarthritis of the shoulder treated with either the Total Evolutive Shoulder System^® (Biomed, France) stemless shoulder prosthesis or the Affinis^® (Mathys, Switzerland) stemmed shoulder prosthesis to detect possible differences in the functional outcome and to evaluate radiological properties of the implants. Patients were examined before and 32 ± 4 months after surgery.

Results

There was no significant difference in the Constant scores of the groups treated with the stemless shoulder prosthesis (65.0 ± 11.0 points) and the stemmed shoulder prosthesis (73.2 ± 11.3 points; P = 0.162). The estimated blood loss (P = 0.026) and the mean operative time (P = 0.002) were significantly lower in the group with the stemless shoulder prosthesis.

Conclusions

The use of the stemless shoulder prosthesis yielded good results which, in a mid-term follow-up, were comparable with those provided by a standard anatomic shoulder prosthesis. Further investigations are needed regarding the long-term performance of this prosthesis.     

The clinical outcomes and tuberosity healing after reverse total shoulder arthroplasty for acute proximal humeral fracture using the turned stem tension band technique

BackgroundRecent studies have reported the clinical effectiveness of tuberosity healing after reverse total shoulder arthroplasty in patients with proximal humeral fractures with respect to joint stability, long-term survival, and postoperative range of motion. However, it is challenging to achieve robust fixation of the fragile bone fragments in elderly patients. This study aimed to report on the radiographic and clinical outcomes of patients who underwent reverse total shoulder arthroplasty for acute proximal humeral fractures using a Turned stem Tension Band technique–a simple suture configuration that can apply a compressive force on both tuberosities at the same time.MethodsEighteen patients who underwent reverse total shoulder arthroplasty for complex proximal humeral fractures (age 80.4 ± 4.7 years, range 70–87 years), using our Turned stem Tension Band technique, were included in this study and evaluated postoperatively for range of motion, American Shoulder and Elbow Surgeons score, Numerical Rating Scale, and tuberosity healing, with minimum 2-years follow-up (mean 34.5 months, range 24–60 months).ResultsAt the final follow-up, mean range of motion results were active flexion, 119 ± 34°; active abduction, 116 ± 35°; active external rotation, 27 ± 12°; and active internal rotation, L3. Six of 11 (55%) patients with 4-part dislocated fractures had neurological disorders from the time of injury; of these, three patients obtained shoulder elevation under 90° at the final follow-up. The mean American Shoulder and Elbow Surgeons score was 77.3 ± 10.7, and the mean Numerical Rating Scale was 1.2 ± 0.9. Fifteen of 18 (83%) patients were satisfied with the results. The tuberosity healing rate was 100% (18 of 18).ConclusionsThe Turned stem Tension Band technique in reverse total shoulder arthroplasty for proximal humeral fractures provides a robust fixation, regardless of the fracture pattern, which results in a high tuberosity healing rate.     

Short to mid-term results of stemless reverse shoulder arthroplasty in a selected patient population compared to a matched control group with stem

Purpose

Little scientific evidence on the clinical and radiological outcome after stemless reverse shoulder arthroplasty (RSA) exists. The hypothesis of this study was that stemless RSA has an inferior outcome compared to RSA with stem.

Methods

All cases of cuff-arthropathy fullfilling strict selection criteria (selection rate 18.4 %) were treated with stemless RSA between 2009 and 2013. Twenty nine of 37 cases (78.4 %) were clinically and radiologically examined by an independent observer. Twenty four of the 29 cases could be matched with 24 patients that underwent conventional stemmed RSA at a different institution based on the following criteria: indication (cuff-arthropathy), age (within 5 years), gender, and time of follow-up (within 2 years). Clincial and radiological outcomes of both groups were compared.

Results

After mean follow-up of 35 months (range 24–75) no significant difference regarding constant score, ASES, subjective shoulder value, pain score, patient satisfaction, strength, and range of motion was detected. One case of traumatic dislocation was observed in the stemless RSA group. Scapular notching grade 1 was detected in two cases of the stemless group while in the stemmed group five cases with grade 1 and four cases with grade 2 notching were observed. Average post-operative humeral component inclination (neck-shaft angle) in the stemless RSA group (134.4°) was significantly steeper than in the stemmed RSA group (155°) (p?<?0.001). No loosening of the humeral component was observed in both groups.

Conclusion

At short to mid-term follow-up, stemless RSA does not feature inferior clinical or radiological outcomes in a strictly selected patient population.

     

Implantation accuracy of custom-made glenoid implants for treating severe glenoid bone deficiencies with reverse shoulder arthroplasty

BackgroundCustom-made three dimensional–printed glenoid implants for reverse shoulder arthroplasty are a modern treatment option for severe glenoid bone deficiencies. The potential advantages of not only achieving primary stability but also being able to realize the preoperative plan in terms of implantation accuracy at the same time have not yet been sufficiently investigated. The purpose of this study was to quantify the implantation precision of custom-made glenoid implants.MethodsTwelve consecutive patients with severe glenoid bone defects were treated between May 2019 and August 2020 using a custom-made glenoid implant (ProMade) (LimaCorporate, San Daniele, Italy) with reverse shoulder arthroplasty at a single hospital. All patients were eligible for inclusion and could be enrolled in this institutional review board–approved study. The immediate postoperative computer tomography–evaluated position of the glenoid implant was compared with the preoperative computer-based plan, on which the manufacturing process was based. As a result of this comparison, deviation measurements in six degrees of freedom (inclination, version, mediolateral offset, anteroposterior offset, superoinferior offset, and roll rotation) emerged.ResultsThe absolute average (mean value ± standard deviation) implantation deviation related to the plan was 1.6° ± 5.4° for version, 1.9° ± 4.1° for inclination, 0.3 mm ± 3.3 mm for mediolateral offset, 0.1 mm ± 1.9 mm for anteroposterior offset, 0.0 mm ± 2.4 mm for superoinferior offset, and 1.0° ± 6.3° for roll rotation. The augment volume averaged 9.0 cm³ ± 2.6 cm³. All custom-made glenoid implants were implanted with a subjectively sufficient primary stability.ConclusionThis study gives an indication that custom-made three dimensional–printed glenoid implants can be implanted with statistically high accuracy. To evaluate the clinical benefit and radiographic stability, a longer follow-up investigation is needed.     

Isokinetic Evaluation of Shoulder Strength and Endurance after Reverse Shoulder Arthroplasty: A Comparative Study

ObjectiveThe present study aimed to compare the isometric strength and endurance of shoulder abduction and internal and external rotation between operated shoulders and nonoperated, contralateral shoulders of patients who underwent reverse shoulder replacement due to unilateral rotator cuff tear arthropathy.Patients and methodsWith a diagnosis of cuff tear arthropathy, 41 consecutive patients (mean age of 70.8 years; age range, 57 to 84; 36 females, 5 males) who underwent unilateral reverse shoulder arthroplasty were reviewed based on functional and radiological data. In all cases, cuff tear arthropathy was unilateral and contralateral shoulder was asymptomatic, with normal shoulder function. The average length of follow-up was 34 months (range of 12–67).To assess patients' functional level, the Constant score and the Disabilities of the Arm, Shoulder, and Hand (the Quick-DASH) outcome measure were used preoperatively and at the final examination.The primary outcomes of the present study were measurement of isokinetic strength and endurance of shoulder abduction and internal and external rotation using an isokinetic evaluator.ResultsPatients exhibited marked improvement in functional level as reflected by a significant increase in the mean Constant score from 38 preoperatively to 65 at the final follow-up (p = 0.03). The functional improvement was supported by a decrease in the mean Quick-DASH from 64 preoperatively to 26 at the final follow-up (p = 0.018).In the comparison of the isokinetic strength and endurance of shoulder abduction, no statistical difference was observed between operated shoulders and contralateral shoulders (p > 0.05). However; the strength and endurance of internal and external rotation were lower in operated shoulders than in contralateral shoulders (p < 0.05). Similarly, there was no statistically significant difference in comparisons of the durability of abduction (p > 0.05); however, the durability of internal and external rotation were significantly lower in operated shoulders (p < 0.05).ConclusionIn terms of durability and strength of abduction, similar results with the unaffected shoulder may be accomplished; nonetheless, the surgeon should be aware that durability and strength of rotation would be weak.Level of evidenceLevel III, Therapeutic Study.     

Indikationsspezifische mittelfristige Ergebnisse der anatomischen Kurzschaft-Schulterprothese

Background

The stemless shoulder prosthesis is a new concept in shoulder arthroplasty. To date, only few studies have investigated the results of this prosthesis. The aim of this study was to investigate the clinical and radiological midterm results of this implant with respect to different indications.

Materials and Methods

The Constant Murley score (CMS), the disabilities of the arm, shoulder, and hand (DASH) score, active range of motion (abduction, anteversion, external rotation) and radiological results were examined in 86?patients (31?male/55?female, age 65.4?±?8.7?years) with the TESS? stemless shoulder prosthesis. The average follow-up time was 31?±?4?months.

Results

The overall mean CMS improved significant (p?<?0.001) from 36.2?±?9.5?points preoperatively to 66.0?±?14.4?points after surgery and, as suspected, shows significant differences between the various patient groups (CMS after surgery: primary omarthrosis 73.3?±?11.4?points, posttraumatic omarthrosis 56.6?±?12.8?points, humeral head necrosis 62.7?±?9.8?points, rheumatoid arthritis 50.2?±?11.0?points, rotator cuff tear arthropathy 44.7?±?3.7?points). Regarding pain relief, there were no significant differences within the patient groups. In contrast, the functional results were significantly better in patient with primary omarthrosis and humerus head necrosis as compared to the other indications.

Conclusions

Depending on the indication, the use of stemless shoulder prostheses leads to good results that are comparable to those of conventional anatomic shoulder prostheses at mid-term follow-up.     

Opening wedge high tibial osteotomy for medial compartment knee osteoarthritis: Planning and improving outcomes: Case series and literature review

BackgroundOpening wedge high tibial osteotomy (OWHTO) is a safe surgical procedure to treat medial compartmental osteoarthritis caused by a varus deformity. Over-correction of this varus deformity can lead to lateral compartment over-loading. In our study, we planned our correction by using the mechanical axis deviation (MAD).PurposeThe purpose of this study is to evaluate the clinical and radiological results of OWHTO based on planning using the MAD measurements.Study DesignRetrospective Case Series.Methods14 patients with Kellgren- Lawrence classification (KL) grade 3 or above underwent OWHTO, with plans to have the mechanical axis pass through 5–15 mm lateral to the center of the tibial plateau. Pre-operative and post-operative radiographic measurements were made and compared using the student t-test. SF-36 scores were obtained for clinical performance.ResultsOur patients experienced MAD from 25.9 mm medial to the center of the tibial plateau pre-operatively to 12.7 mm lateral to the center of the plateau post-operatively. The mean change in MAD was 38.7 mm (p < 0.0001). The accuracy of our correction compared to the planned MAD was 98.3%. The mechanical axis angle shifted from 7.35° of varus to 3.5° of valgus (p < 0.0001). All patients had post-operative alignments of 1–6° of valgus, with 11 of out the 14 patients with alignments less than 5° of valgus, preventing over-loading of the lateral compartment.ConclusionUsing MAD measurements is an accurate planning method for OWHTO that corrects varus deformity without over-loading the lateral compartment, and leads to improved clinical outcomes.     

Computed tomography–based three-dimensional modeling of glenoid bone preservation with augmented baseplates

BackgroundReverse total shoulder arthroplasty (rTSA) is a treatment option for a variety of shoulder pathologies, including rotator cuff arthropathy, glenohumeral arthritis, and irreparable rotator cuff tears and fractures. There has been substantial improvement in rTSA implants and surgical techniques, such as augmented baseplates that preserve bone tissue. In this study, we used three-dimensional modeling to determine the extent of bone preservation with augmented baseplates in rTSA.MethodsComputed tomography scans from 50 consecutive patients before they underwent rTSA were used to create three-dimensional models of each glenoid. The virtual positions of reverse shoulder baseplate implants followed strict parameters for adequate fixation as determined through consensus among 4 fellowship-trained shoulder specialists. Parameters for adequate fixations included 100% backside contact, neutral scapular version, and 10° of inferior tilt. The 4 baseplate options trialed on each glenoid were a nonaugmented baseplate, a small 10° half-wedge augment, a medium 20° half-wedge augment, and a large 30° half-wedge augment. The extent of volumetric glenoid bone removal and lateralization of the baseplate was calculated for each scenario.ResultsPreoperative computed tomography imaging showed a mean of 10.7° of retroversion and a reverse shoulder arthroplasty angle of 21.3°. A medium augment (20° half wedge) was determined as optimal in 29 cases, and a large augment (30° half wedge) was considered optimal for the remaining 21 cases. The use of augmented baseplates was calculated to preserve 54% glenoid bone stock (1989 ± 650 mm³ bone removal vs. 4439 ± 1636 mm³ with nonaugmented baseplate; P < .001). The surgeon-selected augmented baseplate was on average 4.1 mm lateral in comparison to the nonaugmented baseplate.ConclusionsThe use of augmented baseplates reduces the volume of bone that needs to be removed in rTSA. Furthermore, augmented baseplates result in relative lateralization of the glenosphere, which has been theorized to improve soft tissue tension and limit impingement and scapular notching. Further exploration of the impact of augmented baseplates on clinical outcomes is needed.     

Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures

PurposeUnsatisfactory results of hemiarthroplasty in Neer's 3- and 4-part proximal humerus fractures in elderly, have led to the shift towards reverse shoulder arthroplasty (RSA). The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores.MethodsWe include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head. Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded. According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month, the patients were divided into 2 groups, as the group with successful tuberosity repair and the other with failed tuberosity repair. Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independent t-test for normally distributed parameters and Mann-Whitney test for the parameters, where data was not normally distributed.ResultsOf 41 patients, tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases. Lysis of the tuberosity occurred in 5 patients, tuberosity displacement in 2, and nonunion in 2. Mean age was 70.4 years (range 65 – 79 years) and mean follow-up was 58.7 months (range 18 – 93 months). There were no major complications. Group with successful tuberosity repair showed improvement in mean active range of movements, like anterior elevation (165.1° ± 4.9° vs. 144.6° ± 9.4°, p < 0.000), lateral elevation (158.9° ± 7.2° vs. 138.4° ± 9.6°, p < 0.000), external rotation (30.5° ± 6.9° vs. 35.0° ± 6.3°, p = 0.367), internal rotation (33.7° ± 7.5° vs. 32.6° ± 6.9°, p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1 vs. 55.5 ± 5.7, p < 0.000), American shoulder and elbow surgeons score (90.3 ± 2.4 vs. 69.0 ± 5.7, p < 0.000), disability of arm shoulder and hand score (22.1 ± 2.3 vs. 37.6 ± 2.6, p < 0.000).ConclusionSuccessful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion, strength and shoulder scores. Standardized repair technique and interposition of cancellous bone grafts, harvested from the humeral head can improve the rate of tuberosity healing.     

Computed tomography revealed the correlation between radiolucency and alignment of all-polyethylene pegged glenoid component more than 10 years after total shoulder arthroplasty in the Japanese population

BackgroundAnatomical total shoulder arthroplasty (TSA) provides successful long-term outcomes but complications can occur after 10 years that require revision. Computed tomography (CT) is a useful tool for assessing radiolucent lines around the glenoid component of TSA; however, the merits of long-term post-TSA follow up with CT are unclear. The purpose of this study was to evaluate the long-term outcomes after TSA of Japanese population and to identify factors related to radiolucency around the glenoid component using CT.MethodsA retrospective review was conducted of TSA patients who had completed at least 10 years of clinical follow up. Radiographs and CT images of the affected shoulder obtained at the last follow up were evaluated for radiolucent lines around the stem and each peg, superior inclination and retroversion of the glenoid component, subluxation index, and critical shoulder angle (CSA). Shoulder ROM, Constant–Murley score and UCLA score were compared between the preoperative and last follow up period.ResultsEighteen shoulders in 16 patients met the inclusion criteria. Mean patient age was 61 years, mean follow up period was 137 months, and mean Yian CT score was 19%. CT score was significantly highest in pegs located inferiorly (p < 0.05). Mean glenoid superior inclination was 12.6°, retroversion was ?0.3°, subluxation index was 46%, and CSA was 33.7°. Glenoid superior inclination was significantly lower (p = 0.007) in shoulders with possible loosening than in cases with no loosening (5.0° vs 15.6°). Mean Constant score and UCLA score improved significantly after TSA, from 25.8 to 10.7 points preoperatively to 70.1 and 28.9 points postoperatively, respectively. Mean shoulder flexion, internal rotation, and external rotation also showed improvement postoperatively.ConclusionTSA provides good long-term outcomes. Radiolucency was present most frequently around the inferior pegs of the glenoid component. Glenoid superior inclination may affect the formation of radiolucent lines around glenoid pegs.Level of evidenceLevel IV; Case Series; Treatment study.     

Evaluating flexibility and predicting curve correction using fulcrum-bending radiographs in Lenke type 2 adolescent idiopathic scoliosis

BackgroundFulcrum-bending (FB) correction is considered to provide the best estimation of main thoracic (MT) curve flexibility and postoperative correction in surgical treatment for adolescent idiopathic scoliosis (AIS). However, few studies evaluated the usefulness of FB radiographs for proximal thoracic (PT) curve. We aimed to perform flexibility assessments using both active side-bending (SB) and FB radiographs and evaluate surgical outcomes after posterior spinal fusion (PSF) for Lenke type 2 AIS.MethodsThis study included 38 consecutive patients with Lenke type 2 AIS who underwent PSF using a pedicle screw construct with a minimum 2-year follow-up. Radiographic parameters, including correction rate, SB and FB flexibility, and FB correction index (FBCI: [correction rate/FB flexibility] × 100), were evaluated preoperatively, immediately after surgery, and at the 2-year follow-up. The clinical outcomes were preoperatively evaluated using the Scoliosis Research Outcomes Instrument-22 and at the follow-up.ResultsAll scoliosis curves significantly improved and shoulder balance shifted toward left shoulder elevation (all comparisons, p < 0.0001). There were significant differences between the SB and FB corrections in the PT and MT curves (p < 0.0001). The magnitudes of the discrepancies between the SB and FB corrections in the PT and MT curves were 11.2° ± 5.2° and 11.6° ± 7.2°, respectively. FB correction did not differ from postoperative Cobb angles correction immediately after surgery or at the 2-year follow-up; the mean FBCIs in the PT and MT curves were 98.8% and 105.5%, respectively. The self-image domain SRS-22 scores had significantly increased at the 2-year follow-up (p < 0.0001).ConclusionsThere were significant differences between the SB and FB corrections, and FB correction tended to approximate the postoperative curve correction (FBCI = 100%) for PT and MT curves in patients with Lenke type 2 AIS. FB flexibility is more reliable than SB flexibility in evaluating actual curve flexibility even for the PT curve.     

Glenoid neck length in a healthy population and its association with scapular notching

BackgroundScapular notching is a radiographic finding associated with the use of a reverse shoulder prosthesis. The morphological characteristics of the glenoid neck have been scarcely explored as a relevant factor in relation to scapular notching. The objective of this study is to measure the length of the glenoid neck in a three-dimensional CT reconstruction of a healthy population and to simulate the scapular notching free range of motion for the “long neck” and for the “short neck” groups.MethodsCT scans of 214 shoulders were reviewed, excluding incomplete, poor quality, or altered studies. 100 CT scans were finally processed. The mean age was 51.7 years (SD 19.4; range, 15–84 years), with 49 female and 51 male patients. For each of the scapulae, four morphometric measurements were obtained: anterior glenoid neck (AGN), middle glenoid neck (MGN), posterior glenoid neck (PGN) and alternative posterior glenoid neck (aPGN). Using 3D software, we simulated a reverse shoulder prosthesis, and the scapular notching free range of motion was registered. Differences between measurements were evaluated with an unpaired t-test using StataIC16®. P-values < 0.05 were considered significant. The intraobserver and interobserver correlation was evaluated with the intraclass correlation coefficient.ResultsThe AGN measured 7.43 ± 2.52 mm (range, 1.72–13.3 mm); MGN measured 8.05 mm ± 1.93 (range, 2.92–13.2 mm); PGN measured 7.26 ± 2.6 mm (range, 2–13.4 mm); and aPGN measured 8.97 ± 2.3 mm (range, 4.08–15.4 mm). The scapular notching free range of motion for the “long neck” group was 74.98° ± 7.35 (range, 55–83°) and for the “short neck” group, it was 62.93° ± 6.84 (range, 45–70°) (p = 0.0004).ConclusionsMeasurement of posterior glenoid neck length exhibits excellent reliability and reproducibility, as well as being associated to the scapular notching free range of motion.Study designBasic, retrospective, CT images research.     

Good clinical and radiologic outcomes with the SMR Stemless anatomic TSA after a minimum of 2 years’ followup

BackgroundThis study evaluated the clinical and radiologic mid-term outcomes of anatomic total shoulder arthroplasty for osteoarthritis using a new stemless system.MethodsBetween July 2015 and May 2018, 49 shoulders in 47 patients received an anatomic total shoulder arthroplasty for osteoarthritis with the SMR Stemless shoulder system. Forty patients could be included. A review was conducted at a minimum follow-up of 24 months. There were 18 male and 22 female patients. The average age at the time of surgery was 67 years. Clinical evaluation was conducted using the Oxford Shoulder Score (OSS), American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), scoring patient satisfaction, and range of motion. Standardized radiographs were assessed for radiolucency, loosening, superior migration of the humeral head, and reduced bone density.ResultsThe mean clinical follow-up was 35 months (range, 24-54 months). The mean OSS was 46 points (range, 35-48) and the mean ASES score was 89 points (range, 52-100) at final follow-up. The rate of either “satisfied” or “very satisfied” patients was 97%. No radiolucency around the humeral implant or loosening was found. Radiolucent lines of 2 mm or less around the glenoid were detected in 3 shoulders. The overall complication rate was 7.5% and the rate of revision was 5%.ConclusionsPatients treated with the SMR Stemless Shoulder System for shoulder osteoarthritis achieved good clinical and radiologic results comparable with the midterm results of other stemless designs. The convertible design of the SMR Stemless simplifies future revision to reverse total shoulder arthroplasty.Level of evidenceLevel IV; Case Series; Treatment Study.     

The influence of deltoid tensioning on functional outcomes following reverse shoulder arthroplasty

BackgroundWe aimed to investigate the relationship between functional outcomes and radiological and clinical measurements (based on deltoid moment arm length measurements) of reverse total shoulder arthroplasty (RTSA) performed in patients for irreparable rotator cuff tears.MethodsThirty-eight patients who underwent RTSA after irreparable rotator cuff tears between 2016 and 2019 were included in the study. Patients with primary osteoarthritis, rheumatoid arthritis, or post-traumatic RTSA were excluded from the study. The patients were evaluated functionally using the range of motion, Quick DASH, and Constant Scores (CS). Deltoid lengthening was measured both clinically by the difference in upper extremity length (dUEL) and radiologically by the acromiohumeral distance (AHD) and deltoid lever length (DLL). AHD was measured with true anteroposterior radiographs and ultrasound guidance.ResultsThe mean age of the patients was 66.39 ± 7.92 (range, 49–83) years. Of 38 patients, 31 (81.57%) were female and 7 (18.43%) were male. The mean follow-up durations were 26.43 ± 17.05 (range, 12–58) months. The mean active anterior elevation (AAE), abduction (AAB), and external rotation (AER) increased from 57.32°, 41.25°, and 22.32° preoperatively to 149°, 110°, and 34° at the last follow-up, respectively. Preoperatively, the mean QuickDASH score was 58.04, and at the last follow-up, it was 38.19. The mean Constant Score rose from 24.75 preoperatively to 60.64 at the last follow-up. The AHD, DLL, and dUEL mean values were 2.346, 1.89, and 1.746 cm, respectively. There was a significant relation between the DLL and the AAE (P < .01).ConclusionOptimizing deltoid tension plays an essential role in regaining function, and this study demonstrates that lengthening the deltoid increases the patient’s ability to elevate anteriorly, likely by recreating the force-length relationship of the deltoid muscle.     

Treatment of massive irreparable rotator cuff tears using dermal allograft bridging reconstruction

AimsVarious options are available for treating massive irreparable rotator cuff tears, but all have their own limitations and no gold standard currently exists. Our aim was to report on outcomes of bridging repair with a dermal allograft for symptomatic massive irreparable rotator cuff tears where primary or partial repair was not possible.Patients and methodsWe prospectively reviewed 22 patients who underwent an open interposition bridging repair with an allograft (GraftJacket) sutured medially to the residual rotator cuff stump and laterally to the footprint with suture anchors. Mean age at time of surgery was 59 years (range 53–66 years). The Oxford Shoulder Score, pain visual analogue scale and range of motion were compared pre-operatively and at mean follow up of 2.8 years. All patients had a postoperative MRI scan.ResultsThere was a significant improvement in mean Oxford Shoulder Score from a pre-operative score of 14.2–34.3 points (p < 0.01) at final follow up. Pain VAS score improved from 6.6 points to 2.8 points (p < 0.05). Significant improvements in range of motion were also seen. Postoperative MRI scans showed a retear in 8 patients (36%), but the retear size was smaller and an improvement in outcomes maintained at final follow up.ConclusionOpen dermal allograft bridging repair for massive irreparable rotator cuff tears can lead to satisfactory outcomes and delay the need for a reverse shoulder arthroplasty.