Bipolar shoulder arthroplasty for rotator cuff arthropathy

Between July 1991 and February 1995, 33 patients underwent bipolar shoulder arthroplasty for painful rotator cuff arthropathy of the shoulder. Twenty-two of these patients have been followed for an average of 28 months (range 24 to 48 months) and comprised the study group. All patients had massive, irreparable rotator cuff tears and presented with preserved passive motion, good deltoid function, and obliterated glenohumeral joint surfaces. Function and comfort were dramatically improved in all patients, with an average increase in active forward elevation of 29° and a gain in active external rotation of 39°. There was one complication requiring reoperation at 4 years. Utilizing the UCLA and Swanson scoring systems, all patients were rated fair or better.     

Outcomes for reverse total shoulder arthroplasty after failed open reduction internal fixation versus primary reverse total shoulder arthroplasty for proximal humerus fractures

BackgroundThe purpose of this study is to determine the clinical and radiographic outcomes of reverse total shoulder arthroplasty (RTSA) after failed open reduction internal fixation (ORIF) for proximal humerus fracture (PHF) and compare them to outcomes of primary RTSA for PHF.MethodsWe performed a retrospective comparative study of patients who underwent RTSA between 2008 and 2015 at our institution by one of two fellowship-trained shoulder and elbow surgeons for an acute PHF or for continued pain or functional limitations following ORIF of a PHF. We compared the American Shoulder and Elbow Surgeons (ASES) scores, Simple Shoulder Test (SST) scores, range-of-motion, and radiographic measurements between cohorts.ResultsIn total, there were 20 patients treated with RTSA after failed ORIF and 30 patients treated acutely with RTSA for PHF. The average ASES score was significantly greater for primary RTSA (82.0 ± 13.5) than for delayed RTSA (64.0 ± 27.2, P = 0.016). The average SST score for primary RTSA (69.4%±19.1%) was significantly higher than the average for delayed RTSA (49.1%±8.9%, P = 0.020). Forward elevation achieved postoperatively was significantly greater for patients treated with primary RTSA versus those with delayed RTSA (130±31° vs 107±31°, P = 0.035). No difference was detected between groups in postoperative external rotation (P = 0.152) or internal rotation (P = 0.872). Radiographically, the tuberosities healed in an anatomic position in 70% of the primary cases versus the prior ORIF group in which the tuberosities were in an anatomic position in all cases (P = 0.007).ConclusionsIn an elderly population, primary RTSA for PHF resulted in better clinical outcomes compared to RTSA following failed ORIF in this retrospective cohort study.Level of EvidenceLevel III; Retrospective Comparative Study     

反球型人工肩关节置换术治疗合并肩袖损伤的老年粉碎性肱骨近端骨折

目的:探讨采用反球型人工肩关节置换术治疗老年粉碎肱骨近端骨折的临床疗效。方法:自2017年1月至2017年12月治疗12例老年粉碎性肱骨近端骨折或骨折-脱位患者,根据术前MRI检查以及术中直视下检查确认肩袖损伤诊断,采用反球型人工肩关节假体置换手术治疗。其中男7例,女5例;年龄65～86岁;左侧受累5例,右侧受累7例。观察患者肩关节活动度及术后并发症情况,采用VAS评分评价疼痛缓解程度,并采用UCLA评分评价肩关节功能恢复情况。结果:12例患者术后获得随访,时间8～18个月。末次随访时患者肩关节活动度:前屈上举90°～150°,外旋为5°～30°,内旋平均为L_3水平(S_1水平～L_1水平)。VAS疼痛评分为0～6分,UCLA评分为18～32分,其中良5例,差7例。所有患者术后均无感染、假体松动、肩峰应力骨折、神经血管损伤等并发症发生。结论:合并肩袖损伤的老年粉碎肱骨近端骨折采用反球型人工肩关节置换术治疗,术后早期肩关节活动范围恢复良好,疼痛较轻,患者满意度高。     

Outcomes of reverse total shoulder arthroplasty are similar in rotator cuff-intact and rotator cuff-deficient shoulders

BackgroundControversy exists regarding the biomechanical and clinical effects of reverse total shoulder arthroplasty (RTSA) in shoulders with an intact versus a torn rotator cuff (RC). We compared clinical and radiographic outcomes at a minimum of 2 years after RTSA for cuff-intact or cuff-deficient conditions.MethodsRetrospective review identified 182 patients with at least 2 years of follow-up: 32 with an intact rotator cuff but advanced glenoid bone loss and 150 with a torn rotator cuff. Revision arthroplasties and those for osteonecrosis or trauma were excluded, and a matched cohort was created to compare 32 cuff-intact to 32 cuff-deficient shoulders. Assessments included preoperative and postoperative visual analog pain scores (VAS), American Shoulder and Elbow Surgeons (ASES) scores, narcotic use, strength, range of motion (ROM), complications, and revisions. Radiographs were analyzed for signs of loosening or mechanical failure.ResultsMean age for all patients was 71.7 (61-82) years, and the mean follow-up was 2.7 (2.0-5.5) years. Preoperatively, the groups were similar in almost every functional preoperative category, with no differences in gender, laterality, age, preoperative narcotic use, body mass index, or other co-morbidities. Postoperatively, no significant differences were found regarding VAS pain, ASES, ROM, strength, complication rate, revision rate, narcotic use, implant loosening, or mechanical failure; both groups showed significant improvements in all categories measured.ConclusionsRTSA provides reliably good functional and radiographic outcomes with low complication rates in indicated patients, regardless of the preoperative status of the rotator cuff.Level of evidenceLevel III; Retrospective Comparative Study     

Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients

Proximal humerus fractures are the third most common fracture in elderly patients. Hemiarthroplasty has been the treatment of choice in patients with bone quality and fracture patterns not amenable to open reduction and internal fixation. Reverse total shoulder arthroplasty is a newer option that appears to be less dependent on tuberosity healing than hemiarthroplasty. The authors hypothesized that reverse total shoulder arthroplasty provides improved functional outcomes compared with hemiarthroplasty for fractures in elderly patients.A retrospective review was performed of all patients treated with arthroplasty for acute proximal humerus fractures in an orthopedic practice using a Current Procedural Terminology code search, patient charts, and radiographs. Validated outcome scores were used to assess satisfaction, function, and general well-being. Twenty-three patients were treated for acute proximal humerus fractures (11 reverse total shoulder arthroplasties and 12 hemiarthroplasties). Three patients were lost to follow-up, and 6 patients were deceased. Mean follow-up was 3.6 years (range, 1.3-8 years). Reverse total shoulder arthroplasty outperformed hemiarthroplasty with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score.Reverse total shoulder arthroplasty is a reliable option for acute, proximal humerus fractures that are not amenable to closed treatment or reconstruction in elderly patients. Improved functional outcomes when compared with hemiarthroplasty must be balanced against the increased cost and limited life expectancy of patients with this injury.     

Hemi- versus bipolar shoulder arthroplasty for chronic rotator cuff arthropathy

Both bipolar and hemiarthroplasty have been used to treat rotator cuff arthropathy (RCA) of the shoulder in patients with low functional demands. In this study, 41 patients treated with either a bipolar or hemiarthroplasty were selected retrospectively to detect possible differences in the functional outcome and to evaluate radiological properties of the implants. Patients were examined before and 30 +/- 6 months after surgery. There were no differences in the Constant scores between the groups treated with hemiarthroplasty and bipolar arthroplasty, 58.9 +/- 13.1 points and 55.8 +/- 13.5 points, respectively (P = 0.457). We found a significant increase in abduction postoperatively in both groups (P = 0.041 bipolar, P = 0.000 hemiarthroplasty) but without statistical significance between the hemiarthroplasty and bipolar arthroplasty groups (P = 0.124, F = 2.6). This result is related in the bipolar group due to movement between the shell and inner head (P = 0.042) and in the hemiarthroplasty group due to movement between the humeral head component and the glenoid (P = 0.000). In conclusion, we found that both hemiarthroplasty and bipolar arthroplasty are effective treatment options for carefully selected patients with RCA and low functional demands, with no differences between the groups.     

Acute versus delayed reverse total shoulder arthroplasty for proximal humerus fractures in the elderly: Mid-term outcomes

BackgroundTreatment of proximal humerus fractures (PHFs) via reverse total shoulder arthroplasty (RTSA) has shown early promise when compared to historical treatment modalities. Ideal surgical timing remains unclear. The purpose of this study was to compare the outcomes of early versus delayed RTSA for PHF. We hypothesized that acute RTSA would display superior outcomes compared to those receiving delayed surgical intervention.MethodsThis multicenter study retrospectively analyzed 142 patients who underwent RTSA for fracture. Patients treated within 4 weeks of injury were placed in the acute group (n = 102), and patients treated longer than 4 weeks after injury were placed in the chronic group (n = 38). A comprehensive panel of patient reported outcome measures, VAS pain scores, range of motion, and patient satisfaction were evaluated.ResultsThe acute group had significantly better final follow-up SPADI scores (20.8 ± 23.9 vs. 30.7 ± 31.7) (p<0.05). No further differences were detected in other postoperative range of motion measurements, subjective outcomes, or VAS scores.ConclusionsOur results suggest that patients treated acutely display similar mid-term outcomes to those who receive delayed treatment. With this in mind, surgeons may first give consideration to a period of nonoperative treatment.Level of evidenceLevel II.     

复杂肱骨近端骨折人工肱骨头置换术中肩袖重建的长期疗效观察

目的探讨Neer 3、4部分肱骨近端骨折人工肱骨头置换术中肩袖重建的远期临床效果。方法回顾性分析自2001-01—2012-12采用人工肱骨头置换术治疗的25例Neer 3、4部分肱骨近端骨折。术前测量健侧大结节最低点至肱骨头最高点的距离,术中尽量解剖复位肱骨大、小结节,合理控制假体高度及后倾角度,尽可能修复重建损伤肩袖,术后分阶段康复锻炼。结果本组22例获得有效随访,随访时间平均120(49~190)个月。末次随访时ASES评分为80~92(86.28±3.36)分,肩关节内旋至T10水平,患肢主动前屈上举125°~135°,外旋36°~42°。1例合并臂丛神经损伤者术后肩关节功能恢复满意。结论对于骨折端无法良好复位、肱骨头缺血性坏死可能性大的复杂肱骨近端骨折,人工肱骨头置换同时进行精细的肩袖重建可以获得无痛和良好运动范围的肩关节。     

反式全肩关节置换治疗盂肱关节骨关节炎伴巨大肩袖撕裂

目的探讨反式全肩关节置换术治疗盂肱关节骨关节炎合并巨大肩袖撕裂的近期临床疗效。 方法回顾性分析2016年1月至2018年12月在南部战区总医院接受初次反式全肩关节置换术治疗的15例盂肱关节骨关节炎合并巨大肩袖撕裂患者,均有肩关节持续性疼痛、功能障碍,且三角肌无损伤具有功能;排除有臂丛或腋神经损伤以及有肩关节手术史的患者。评估其术前、术后1年的肩关节主动活动度,使用美国肩肘外科协会(ASES)肩关节评分、加州大学洛杉矶分校(UCLA)最终结果评分评价肩关节功能,分析X线及CT并发症出现情况。采用配对t检验对术前及术后的活动度和评分差异进行性分析。 结果15例患者均顺利完成手术并获得随访,随访时间17个月(范围12～36个月)。反式全肩关节置换术后1年肩关节主动前屈(124±11)°较术前(58±18)°提高(t＝14.316,P<0.01),外展(120±12)°较术前(58±20)°提高(t＝9.959,P<0.01),内旋较术前改善,外旋(26±8)°较术前(25±9)°无明显变化(t＝1.598,P>0.05),术后1年ASES评分(78±7)显著高于术前(33±8)(t＝16.487,P<0.01);术后1年UCLA评分(31±4)显著高于术前(15±3)(t＝12.826,P<0.01)。 结论RTSA能够有效治疗盂肱关节骨关节炎合并巨大肩袖撕裂,取得了良好的早期临床效果,但术后肩关节外旋无明显改善,术前需评价小圆肌情况以确定相关治疗方案。     

Treatment of fracture sequelae of the proximal humerus: comparison of hemiarthroplasty and reverse total shoulder arthroplasty

Introduction

Fracture sequelae (FS) of the proximal humerus is a challenging scenario in shoulder surgery. Despite they have been traditionally treated with hemiarthroplasty (HA), the use of reverse shoulder arthroplasty (RSA) has been recently introduced. However, there are no studies comparing the results of HA and RSA in FS. The purpose of this study was to compare the functional and quality of life-related outcomes, and complications in the treatment of proximal humeral FS between HA and RSA.

Materials and methods

A therapeutic prospective non-randomized comparative study was conducted. All consecutive patients with diagnosis of FS after non-operative treatment of proximal humeral fractures and no previous shoulder surgery were considered for this study. A total of 32 patients (24 females, 8 males) with a mean (SD) age at the time of surgery of 80.1 (4.9) years were finally included: 12 in the HA group, and 20 in the RSA group. FS were treated with shoulder arthroplasty by the implantation of either HA or RSA. Constant score (total and specific items), quality of life (assessed through SF-36), and complications requiring revision surgery were compared between groups.

Results

All parameters of the Constant score significantly improved in the postoperative compared to preoperative period when considering the entire sample. The RSA group demonstrated a higher improvement in total Constant score (p = 0.06) and Constant activity level (p = 0.02) compared to the HA group. The HA demonstrated a higher number of complications compared to the RSA (p = 0.05). There were no differences in SF-36 scores between both groups.

Conclusions

The shoulder arthroplasty is an effective treatment for FS with significant improvement in pain and function. The RSA may be a better option than HA for FS given the trend towards better total Constant score and a significantly lower number of complications requiring revision surgery.

Level of evidence

Therapeutic level II evidence.     

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。     

The metaphyseal bone defect predicts outcome in reverse shoulder arthroplasty for proximal humerus fracture sequelae

Reverse shoulder arthroplasty (RSA) represents an established procedure for treatment of fracture sequelae (FS) after proximal humerus fractures. The present work evaluates which factors are of influence for the clinical outcome. Fifty cases (mean age 69, range 44–89) have been evaluated postoperatively clinically [Constant Score (CS)] and radiographically (mean FU 34; range 24–93 months). The type of primary treatment, the amount of a metaphyseal bone defect, the preoperative status of the rotator cuff, the number of previous operative interventions and the type of FS according to Boileau were analysed whether they are of influence for clinical outcome. The mean CS increased significantly from 16.9 ± 6.7 preoperatively to 54.1 ± 15.7 points postoperatively. The CS of primary conservative treatment was significantly higher in comparison to primary operative treatment. Patients with a metaphyseal bone defect of more than 3 cm had significantly lower CS results. Degenerative changes of the teres minor muscle also had a significant negative influence on clinical results. Score results decreased with increasing number of previous operations. There were no significant difference in between patients classified as Boileau type I and II (category 1) compared to types III and IV (category 2). RSA significantly improved the clinical result. A metaphyseal bone defect and preoperative degeneration of the teres minor showed to be negative prognostic factors. Primary operative treatment and the number of previous operations also negatively influenced the clinical result.     

反置肩关节置换治疗肱骨近端骨折中影响术后肱骨大结节愈合的因素分析

目的分析探讨肱骨近端骨折反置肩关节置换术治疗中可能影响术后肱骨大结节愈合时间的影响因素。方法回顾分析2018年8月至2019年8月上海交通大学医学院附属瑞金医院骨科收治的14例患者;其中男4例,女10例,年龄67~95(80.0±8.1)岁;左侧8例,右侧6例。所有患者均因肱骨近端骨折行反置肩关节置换术。通过术前及术后影像学测量分析可能的影响因素。结果肱骨近端骨折反置肩关节置换治疗中,影响肱骨大结节骨折愈合时间的主要因素为大结节与近端皮质是否接触(P<0.01)、肱骨大结节骨块是否粉碎(P=0.01;P=0.04)以及肱骨大结节骨块前后向长度(P=0.02)。相比之下,肱骨近端骨折骨折是否合并不可修复肩袖损伤对反置肩关节置换术后肱骨大结节愈合时间无明显影响。结论采用反置肩关节置换治疗肱骨近端骨折,肱骨大结节与近端皮质不连续会导致肱骨大结节术后延迟愈合。粉碎的肱骨大结节尤其是前后向骨块较小的肱骨大结节可延长术后大结节愈合所需时间。