Arthroscopic glenoid removal for aseptic loosening in total shoulder arthroplasty

BackgroundGlenoid loosening is the most common long-term complication of total shoulder arthroplasty (TSA) and frequently necessitates revision. Though arthroscopic glenoid removal is an accepted treatment option for glenoid loosening, there is a paucity of outcomes literature available. The purpose of this study was to report the long-term clinical and radiographic outcomes of arthroscopic glenoid removal for failed or loosened glenoid component in TSA. We hypothesized that arthroscopic glenoid removal would produce acceptable clinical and patient-reported outcomes while limiting the need for further revisions.MethodsThis was a retrospective analysis of 11 consecutive patients undergoing 12 arthroscopic glenoid removals for symptomatic glenoid loosening by a single orthopedic surgeon between March 2005 and March 2018. Indication for arthroscopic glenoid removal included symptomatic glenoid loosening with radiographic evidence of a 1-2 mm radiolucent line around the glenoid. Shoulder range of motion, functionality (American Shoulder and Elbow Surgeons, Simple Shoulder Test), and pain (visual analog scale [VAS]) were evaluated. Radiographs were assessed for glenohumeral subluxation, humeral superior migration, and glenohumeral offset following glenoid removal.ResultsThe mean follow-up period since arthroscopic glenoid removal was 55 months (range, 20-172 months). Glenoid component removal significantly reduced forward elevation, with a mean decrease from 147 ± 13° preoperatively to 127 ± 29° postoperatively (P= .031). However, there was no significant change in external rotation (44 ± 9° vs. 43 ± 19°; P= .941) or internal rotation (L4 vs. L4; P= .768). Importantly, glenoid removal significantly decreased VAS pain scores from 7 ± 3 preoperatively to 5 ± 3 postoperatively (P= .037). Additionally, improvement in ASES approached statistical significance, increasing from 33 ± 25 preoperatively to 53 ± 28 postoperatively (P= .055). With regard to radiographic outcomes, there was no evidence of glenohumeral subluxation and humeral superior migration developed in 1 patient. However, there was significant medialization of the greater tuberosity relative to the acromion, with a mean lateral offset of 6 ± 7 mm preoperatively and −2 ± 4 mm postoperatively (P= .002). Two patients required conversion to reverse TSA for persistent pain. There were no complications.DiscussionThese findings suggest that arthroscopic glenoid removal for symptomatic glenoid loosening is a viable option to improve pain while limiting the need for additional reoperations and decreasing the risks associated with revision arthroplasty. However, continual follow-up to monitor medialization is recommended.Level of EvidenceLevel IV; Case Series; Treatment Study     

Comparison of mid-term outcomes of total shoulder arthroplasty for B2 and A glenoids treated with trabecular metal glenoid components

BackgroundTreatment of B2 glenoids in total shoulder arthroplasty (TSA) has been associated with worse clinical outcomes and increased rates of glenoid loosening. The purpose of this study was to describe and compare the mid-term outcomes of TSA using a trabecular metal-backed glenoid in patients with B2 and A glenoids.MethodsPatients who underwent anatomic TSA with a trabecular metal-backed glenoid component (second generation trabecular metal glenoid) for primary osteoarthritis and had minimum 5-year follow-up were reviewed. All patients underwent eccentric glenoid reaming to treat biconcavity, if present. Preoperative imaging was reviewed and patients were divided into 2 groups: Type A and Type B2. Mid-term outcome measures including patient-rated outcome scores (Patient Reported Outcome Measurement Information System and American Shoulder and Elbow Surgeons [ASES]) and shoulder range of motion were determined. ASES score was compared between groups. Radiographs were graded for radiolucent lines and posterior humeral head migration and evaluated for glenoid loosening.ResultsTwenty-two patients had Type A glenoids and 22 patients had B2 glenoids. Sixteen patients in the A group and 18 patients in the B2 group had full radiographic and physical exam follow-up. Both groups had similar follow-up (6.7 ± 1.1 years A, 6.6 ± 0.9 years B2, P = .88). Groups were similar in terms of age at surgery, gender distribution, body mass index, severity of medical comorbidities, and hand dominance distribution. The B2 patients had a mean preoperative glenoid retroversion of 17.5° ± 6.7° and posterior subluxation of 8.5% ± 5.3%. No patients in either group had evidence of glenoid loosening at follow-up. No patients required revision surgery. Nine of 16 in the A group had evidence of mild radiolucent lines (8 grade 1, 1 grade 2). Eight of 18 patients in the B2 group had mild radiolucencies (all grade 1). Two of 16 Type A and 6 of 18 B2 patients had evidence of posterior humeral migration, but all cases were graded as mild. Both groups had similar follow-up mean ASES scores (95.5 A, 89.0 B2, P = .25).ConclusionAt minimum 5-year follow-up, patients who underwent TSA with a trabecular metal-backed glenoid component demonstrated excellent clinical and patient-reported outcomes regardless of preoperative glenoid morphology (A or B2). No patients in either group had evidence of glenoid loosening or required revision surgery. These favorable mid-term outcomes of trabecular metal-backed glenoids in B2 deformities need to be followed longitudinally to determine long-term durability.Level of EvidenceLevel III; Retrospective Comparative Study     

Pyrocarbon hemiarthroplasty of the shoulder: indications and pitfalls

AimsThe outcomes with metal head hemiarthroplasties (HA) are contrasted, especially in young, active patients. An innovative Pyrocarbon interface was introduced in 2014 in order to decrease potential glenoid wear. The aim of this study is to evaluate survival and short-term results of HA with a pyrocarbon head.MethodsWe conducted a retrospective single-centre study: 30 consecutive patients underwent HA with pyrocarbon humeral head and were assessed with a minimum follow-up of 2 years. The mean age at surgery was 54 ± 13 years; 38% of patients (n = 13) had undergone surgery at least once on the affected shoulder. Depending on the aetiology, 4 groups were analyzed: group 1 (osteonecrosis, n = 12), group 2 (primary gleno humeral osteoarthritis, n = 10), group 3 (fracture sequelae, n = 4) and group 4 (revision, n = 4).ResultsA significant improvement in clinical results was documented at mean follow-up of 38 months: mean Constant score (preop 35 ± 15 vs. postop 67 ± 19 points; <0.0001) and mean SSV (Subjective Shoulder Value; preop 35 ± 20 vs. postop 79 ± 16; <0.0001). Four patients (13%) required revision surgery with an average follow-up of 35 ± 12 months: two patients for infection (one in group 1 and the other in group 3), one patient for humeral false path (group 3) and one patient for rotator cuff tear (group 1). No revision was performed in groups 2 and 4. Glenoid wear did not increase significantly, regardless of the indication. In the subgroup analysis, the best gain was found in group 2: Constant score (+33 points; P< .001) and SSV (+50%; P< .001). The best results were obtained in group 4: Constant score 75 points and SSV score 87%.ConclusionHemiPYC provided satisfactory clinical outcomes without glenoid wear at short-term follow-up. Disappointing results were recorded in the case of severe fracture sequelae. Mid and long-term studies should be carried out to confirm these results.Level of evidenceLevel IV, retrospective case series.     

Hemiarthroplasty and total shoulder arthroplasty for avascular necrosis of the humeral head

The purpose of this study was to review the outcome of patients with osteonecrosis of the humeral head, based on etiology and treatment with either hemiarthroplasty or total shoulder arthroplasty (TSA). Sixty-four shoulders, with an average age of 57 years, were evaluated at a mean of 4.8 years. Outcomes included L'Insalata and American Shoulder and Elbow Surgeons (ASES) scores, as well as range of motion (ROM). The overall ASES score was 67, average flexion was 127 degrees, and external rotation was 49 degrees. Outcomes did not differ based on etiology, but ROM was decreased with post-traumatic osteonecrosis. There was no difference in outcome or ROM between hemiarthroplasty and TSA. The complication rate was significantly higher with TSA (22%) than with hemiarthroplasty (8%). Achieving ROM in patients with post-traumatic osteonecrosis remains difficult. TSA was associated with a higher complication rate and decreased mobility and should be reserved for patients with stage V osteonecrosis.     

Shoulder hemiarthroplasty for the treatment of three and four part fractures of the proximal humerus using Comprehensive? Fracture stem

We looked at the functional outcome of 32 consecutive patients with proximal humeral fractures that required hemiarthroplasty. Functional status was assessed using University of California Los Angeles (UCLA) shoulder end result assessment, simple shoulder test (SST) and American Shoulder and Elbow Society (ASES) shoulder index. Mean age of the patients was 72.2 years and the mean follow-up was 25.3 months. The mean score on UCLA shoulder end result assessment was 24.8, the mean SST score was 7.4 and the mean ASES shoulder index was 67.2. Mean active forward elevation was 85.1°. Patient satisfaction was around 81%. Radiologically, no dislocation, loosening or greater tuberosity pull off was seen. Superior migration of the humeral head was seen in 11 patients (34%). There was no significant difference seen in functional outcome among different genders, age and those who had radiological superior migration of the prosthesis. However, there was a significant statistical difference seen in the functional outcome between patients who had a deficient or a good quality cuff showing that quality of the rotator cuff is an important predicator of functional outcome.     

Preoperative differences in glenoid deformity,patient-determined outcomes,and range of motion as per disease type in shoulders undergoing total shoulder arthroplasty

BackgroundDiseases commonly treated with shoulder arthroplasty include the following: osteoarthritis, rotator cuff tear arthropathy (RCTA), and irreparable rotator cuff tears (IRCTs). Currently, there are few data available that identify if preoperative differences exist between these disorders in (1) computed tomography findings, (2) patient-determined outcome scores, and (3) range of motion. Understanding these disease-specific differences may allow for the development of disease-specific strategies in total shoulder arthroplasty to attempt to improve patient outcomes and implant longevity.MethodsA database of shoulders undergoing anatomic and reverse total shoulder arthroplasty was reviewed. The cohort was divided into three groups as per the disease treated with total shoulder arthroplasty: osteoarthritis, RCTA, and IRCT. The outcomes included preoperative range of motion, 3-dimensional computed tomography determination of glenoid morphology, and patient-determined outcomes including the Western Ontario Osteoarthritis Scale, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and the Single Assessment Numeric Evaluation. Differences between the groups were examined with analysis of variance with post hoc Tukey’s HSD test. The level of significance was P = .05.ResultsTwo hundred seventy-nine shoulders met inclusion and exclusion criteria. One hundred fifty-four shoulders had osteoarthritis, 94 shoulders had RCTA, and 21 shoulders had an IRCT. Patients with osteoarthritis had significantly greater mean glenoid retroversion (12.9°) than patients with an IRCT (7°; P = .03) and RCTA (8.6°; P = .004). Patients with osteoarthritis had significantly less mean superior glenoid inclination (5.9°) than patients with an IRCT (10.2°; P = .03) and RCTA (9.5°; P = .001). Patients with osteoarthritis had greater mean posterior humeral subluxation (68.9%) than patients with an IRCT (58.3%; P = .002) and RCTA (60.2%; P = .001).There was no difference in preoperative Western Ontario Osteoarthritis Scale (P = .86), American Shoulder and Elbow Surgeons score (P = .81), Simple Shoulder Test (P = .13), and Single Assessment Numeric Evaluation (P = .57). Patients with osteoarthritis had greater mean flexion (101°) than the IRCT (86°; P = .17) and RCTA groups (84°; P = .001). Patients with osteoarthritis had greater mean external rotation in the abducted position (54°) than the RCTA group (38°; P = .001) but similar to the IRCT group (48°; P = .68). The osteoarthritis group had inferior mean internal rotation in the abducted position (0.2°) compared with the RCTA (20.6°; P = .001). There were no differences in extension (P = .08), external rotation (P = .58), and abduction (P = .15).ConclusionShoulders with osteoarthritis have greater glenoid retroversion and posterior humeral subluxation, whereas shoulders with RCTA or IRCT have greater superior glenoid inclination. Patient-determined outcome scores do not differ between these diseases. Shoulders with osteoarthritis have greater baseline (1) flexion and (2) abducted external rotation but inferior abducted internal rotation.     

The influence of mental health on outcomes following total shoulder arthroplasty

BackgroundAnxiety and depression symptoms have been associated with higher pain and lower functional scores in patients with glenohumeral osteoarthritis (GHOA). The influence of mental health on outcomes following total shoulder arthroplasty (TSA) for GHOA has not been fully investigated .MethodsThis observational cohort study included 143 shoulders in 135 subjects undergoing TSA for GHOA. Preoperative imaging was assessed for glenoid wear pattern. Patients completed preoperative and postoperative American Shoulder and Elbow Surgeons (ASES) score, Visual Analog Pain Scale (VAS), and PROMIS Upper Extremity (UE), Physical Function (PF), and Pain Interference (PI) scores. The Western Ontario Osteoarthritis Score (WOOS) was collected postoperatively. Mean postoperative pain and functional scores, improvement from preoperative scores, and surgical regret were compared between varying severity of anxiety or depression and pattern of glenoid wear.ResultsCompared to subjects without anxiety, those with moderate-to-severe anxiety reported worse postoperative ASES (p=0.019), WOOS (p<0.01) and PROMIS UE (p=0.02) and higher PROMIS PI scores (p<0.01). Compared to those without depression, those with moderate-to-severe depression reported worse postoperative ASES and WOOS and higher VAS and PROMIS Pain scores (p<0.01). Linear regression showed that anxiety and concentric glenoid wear were associated with worse postoperative PROMIS scores. There were no significant differences in pre-to-postoperative improvement in any outcome measures among those with and without anxiety or depression. Patients with moderate-to-severe depression were less likely to want to undergo the same procedure again (p=0.035).DiscussionPatients with anxiety and depression report similar improvements in pain and function following TSA similar to those without depression or anxiety. Despite the similar improvement, those with moderate-to-severe depression and anxiety symptoms reported persistently lower functional and higher pain scores. Though most patients are satisfied following TSA, those with moderate-to-severe depression may be more likely to regret undergoing surgery. Future studies should identify mental health symptoms preoperatively and evaluate the effect of preoperative intervention on postoperative outcomes following TSA.     

Self-assessed outcome at two to four years after shoulder hemiarthroplasty with concentric glenoid reaming

BACKGROUND: Active and young individuals with glenohumeral arthritis who are treated with total glenohumeral arthroplasty are at risk for loosening or wear of the prosthetic glenoid component. This study tests the hypothesis that patients with severe glenohumeral arthritis have improvement in self-assessed shoulder comfort and function at two to four years after treatment with the combination of humeral hemiarthroplasty and concentric glenoid reaming without tissue or prosthetic component interposition. METHODS: Thirty-seven consecutive patients (thirty-eight shoulders), with a mean age of fifty-seven years, who were managed by one surgeon were enrolled in this prospective study. The procedure consisted of an uncemented humeral hemiarthroplasty combined with reaming of the glenoid to a diameter 2 mm larger than that of the prosthetic humeral head. The duration of follow-up ranged from two to four years (average, 2.7 years) for thirty-five shoulders. Self-assessed comfort and function was documented with use of the Simple Shoulder Test, and radiographs were evaluated. RESULTS: Thirty-two shoulders demonstrated improved comfort and function according to patient self-assessment, one demonstrated no change, and two had worse function following the procedure. The total number of Simple Shoulder Test functions that could be performed increased from 4.7 (of a possible 12.0) before surgery to 9.4 at the time of the final follow-up. The patients demonstrated significant improvement in ten of the twelve individual functions of the Simple Shoulder Test (p < 0.022 to p < 0.00001). With the numbers studied, gender, diagnosis, age, glenoid wear, and preoperative glenoid erosion did not significantly affect final shoulder function or overall improvement. The range of motion was significantly improved for all individuals (p < 0.00001). Radiographically, twenty-two patients had a joint space between the glenoid bone and the humeral prosthesis at the time of final follow-up. These shoulders had significantly better function than those without a preserved joint space (p < 0.017). There were no surgical complications and no revisions to total shoulder arthroplasty. CONCLUSIONS: At a minimum follow-up of two years, a selected series of patients who had humeral hemiarthroplasty with concentric glenoid reaming for the treatment of glenohumeral arthritis showed significant improvement in self-assessed shoulder comfort and function. Further study, however, is needed before routine application of this procedure can be recommended. LEVEL OF EVIDENCE: Therapeutic Level IV.     

Correlation between radiographic risk for glenoid component loosening and clinical scores in shoulder arthroplasty

Glenoid component loosening is the weak point in the failure of total shoulder arthroplasty (TSA). In this study we analyse the radiographic risk factors observed on 86 cemented polyethylene glenoid components and their relationship with clinical signs at a mean follow-up of 5.8 years. Clinical assessment included Simple Shoulder Test (SST) and Constant-Murley score. Radiograms were taken to detect periprosthetic radiolucency, tilt, medial displacement and polyethylene thinning. Pearson’s correlation coefficient and Spearman’s rank correlation coefficient were calculated for statistical analysis. In 61 patients (71%) lucent lines were less than 2 mm wide (grade 2) and in 6 cases (7%) they were ≥2 mm wide (grade 3 and 4). Thinning of the polyethylene was found in 11 cases (13%), glenoid tilt in 6 cases (7%) and medial migration of the component in 5 cases (6%). Complete glenoid prosthetic loosening was found in 3 cases (3.5%) associated with polyethylene wear and glenoid bone loss. The Constant-Murley score associated with radiolucency grade 3 and 4 was less than 45% (38.39 ± 8.9) (p < 0.05), while a score less than 56% (30.72 ± 8.7) was found in patients with glenoid tilt and medial migration (p < 0.01). The mean SST score was 4.8 ± 2.8 in case of glenoid tilt and migration of the component (p < 0.01). Removal of the glenoid component and conversion to hemiarthroplasty or reverse prostheses is suggested in painful glenoid loosening. An exhaustive analysis of radiograms is essential to detect early and late complications or risk factors of glenoid loosening.     

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.     

Shoulder arthroplasty for atraumatic avascular necrosis of the humeral head: nineteen shoulders followed up for a mean of seven years

Nineteen shoulder arthroplasties for the treatment of nontraumatic avascular necrosis of the humeral head were evaluated. The osteonecrosis was idiopathic in 6 shoulders, was a result of corticotherapy in 10, occurred after radiation in 2, and occurred after Gaucher's disease in 1. A total shoulder arthroplasty was performed in 5 cases and a hemiarthroplasty in 14. At 7 years' follow-up (range, 2 to 12 years), there were 7 excellent, 9 satisfactory, and 3 unsatisfactory results. The Constant score averaged 58 points, for an adjusted score of 78%. Radiolucent lines were present around 2 glenoid components, and 1 was radiographically loose. In 2 cases with humeral head replacement, there was painful glenoid wear. Shoulder arthroplasty for nontraumatic avascular necrosis yields satisfactory results with a pain-free shoulder in more than 80% of cases. However, limitation of motion often persists. Better results can be expected with shorter preoperative delay, when preoperative pain is moderate and range of motion preserved and when the etiology is not postradiation avascular necrosis, which in our series yielded the worst results.     

Shoulder hemiarthroplasty for steroid-associated osteonecrosis

Currently, there is little information on the outcome of humeral head replacement for steroid-associated osteonecrosis of the humeral head. The purpose of this study was to evaluate the outcome of patients who underwent humeral head replacement for steroid-associated osteonecrosis to determine the results, risk factors for an unsatisfactory outcome, and rates of revision surgery. Between 1980 and 2000, 32 shoulder hemiarthroplasties were performed for steroid-associated osteonecrosis. We included 31 hemiarthroplasties in 25 patients with a minimum 2-year follow-up (mean, 12.0 years) in the study. The mean age of the 23 female and 9 male patients was 49.4 years at the time of surgery (range, 25-86 years). Overall, mean pain scores decreased from 4.6 to 2.6 (P < .0001). However, moderate or severe pain was reported in 12 shoulders (38%) at the most recent follow-up, 2 of them requiring implant revision. The mean preoperative to postoperative active elevation increased from 92 degrees to 139 degrees (P < .0001), and external rotation increased from 36 degrees to 65 degrees (P < .0001). According to a modified Neer result rating system, there were 13 excellent results (42%), 4 satisfactory results (13%), and 14 unsatisfactory results (45%). Improvement in pain and function most often occurred after hemiarthroplasty as a treatment for steroid-associated osteonecrosis of the humeral head. However, there are a large number of unsatisfactory results related to glenoid cartilage wear over time.     

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     

Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study

Shoulder arthroplasty outcomes have been reported in many case series. Typically, these series have followed either a single prosthesis used to treat a variety of arthritic disorders of the shoulder or experience in a single institution. In contrast, this report of a prospective study summarizes the experience of several surgeons with a single prosthetic design for treatment of primary osteoarthritis of the shoulder. A prospective, multicenter clinical outcome study evaluated 176 shoulders in 160 patients with primary osteoarthritis. This study evaluated a single prosthetic design (Global Shoulder) used by 19 contributing surgeons. Enrollment included 133 total shoulder replacements and 43 humeral head replacements (hemiarthroplasty) in 98 men and 62 women. Neither age nor sex affected whether hemiarthroplasty or total shoulder arthroplasty was performed. Patients with full-thickness cuff tears preferentially had hemiarthroplasty. The decision to perform total shoulder arthroplasty or hemiarthroplasty was based on the surgeon's preference. There were significant improvements (P <.001) in all evaluated and self-assessed outcome parameters from the preoperative baseline for both total shoulder arthroplasty and hemiarthroplasty. The results confirm that prosthetic arthroplasty leads to dramatic improvement in pain, function, and patient satisfaction. Intraoperative complications occurred in 5.4% of cases, and postoperative complications occurred in 7.8%. The most common intraoperative complications were intraoperative fractures, occurring in 9 cases. The most common postoperative complications were glenoid component loosening and humeral head subluxation. Almost all cases of humeral head instability were associated with rotator cuff tears or glenoid component loosening (or both). Seven shoulders underwent 9 additional surgeries during the 5-year study period. Thirteen shoulders in 11 patients were lost as a result of death unrelated to the procedure; 2 shoulders in 1 patient were lost within 3 days/3 months after the bilateral replacements as a result of death from pulmonary embolism. Nine percent of the shoulders (16/176) had full-thickness rotator cuff tears. Eight of the 16 shoulders with full-thickness supraspinatus cuff tears had hemiarthroplasty. All of these tears were isolated to the supraspinatus tendon, and all were repairable. There were no differences in postoperative pain, function, American Shoulder and Elbow Surgeons scores, or range of motion. There were no differences between total shoulder arthroplasty and hemiarthroplasty in those patients with a reparable rotator cuff tear. Total shoulder arthroplasty and hemiarthroplasty for treatment of primary osteoarthritis result in good or excellent pain relief, improvement in function, and patient satisfaction in 95% of cases. Avoiding intraoperative humeral shaft fractures through use of an uncemented, canal-filling prosthetic stem requires careful attention to reaming and component sizing. Postoperative humeral head subluxation is often associated with other factors including rotator cuff tears or glenoid component loosening.     

Does non-spherical humeral head with inlay glenoid re-center the glenohumeral joint?

BackgroundTreatment of glenohumeral osteoarthritis (OA) with Walch type B glenoid poses a challenge for orthopedic surgeons. Although various techniques have been described, it is still a major concern in terms of management and long-term results. We hypothesized that total shoulder arthroplasty (TSA) using a combination of non-spherical humeral head resurfacing (HHR) and inlay glenoid replacement would re-center the glenohumeral joint in patients with Walch type B glenoid without surgical correction of glenoid version.MethodsWe retrospectively screened patients who underwent TSA using a combination of non-spherical HHR and inlay glenoid replacement for primary glenohumeral OA with posteriorly subluxated humeral head (HH) (Walch Type B1, B2 and B3) between 2015 and 2019. Ratios of preoperative and postoperative HH subluxation were compared using Walch index and the point of contact ratio method. Two orthopedic surgeons performed radiographic measurements blinded to each other. Means of 2 independent measurements were included in the final analysis for each shoulder. We also screened for postoperative complications, dislocation events and radiographic loosening.ResultsInitial cohort included 49 patients. A total of 29 shoulders in 28 patients were eligible for screening. The numbers of shoulders with Walch type B1, B2, and B3 glenoids were 3, 22, and 4, respectively. Mean preoperative and postoperative Walch indices were 56.57 ± 6.08% and 49.47 ± 4.78%, respectively. The mean preoperative and postoperative point of contact ratios were 62.97 ± 8.45% and 50.08 ± 3.87%, respectively. The difference between preoperative and postoperative subluxation ratios was significant for both methods (P < .01). Inter-rater reliability was found to be good-excellent. The overall complication rate at a mean follow-up period of 37.79 months was 10.34% (3/29). One patient experienced deep vein thrombosis (DVT) (3.22%) on postoperative day 8. Two patients experienced infection (6.45%), one of which required a revision TSA (3.22%) at 19 months after surgery. No patient experienced shoulder dislocation and no loosening was detected on postoperative radiographs.ConclusionWhen coupled with an inlay glenoid component in patients with eccentric glenoid wear and posterior subluxation, glenohumeral re-centering was consistently observed in this challenging patient population without the use of joint correction or augmentation procedures. It will be important to follow the clinical outcomes over the long-term to determine whether these observations translate to better clinical results than other techniques currently employed to deal with eccentric erosion and posterior subluxation of the arthritic glenohumeral joint although recent published mid-term results suggest results equal to or better than previously reported results in literature with different reconstructive techniquesLevel of evidenceLevel IV; Retrospective cohort     

Correlation between radiographic risk for glenoid component loosening and clinical scores in shoulder arthroplasty

Glenoid component loosening is the weak point in the failure of total shoulder arthroplasty (TSA). In this study we analyse the radiographic risk factors observed on 86 cemented polyethylene glenoid components and their relationship with clinical signs at a mean follow-up of 5.8 years. Clinical assessment included Simple Shoulder Test (SST) and Constant-Murley score. Radiograms were taken to detect periprosthetic radiolucency, tilt, medial displacement and polyethylene thinning. Pearson’s correlation coefficient and Spearman’s rank correlation coefficient were calculated for statistical analysis. In 61 patients (71%) lucent lines were less than 2 mm wide (grade 2) and in 6 cases (7%) they were ≥2 mm wide (grade 3 and 4). Thinning of the polyethylene was found in 11 cases (13%), glenoid tilt in 6 cases (7%) and medial migration of the component in 5 cases (6%). Complete glenoid prosthetic loosening was found in 3 cases (3.5%) associated with polyethylene wear and glenoid bone loss. The Constant-Murley score associated with radiolucency grade 3 and 4 was less than 45% (38.39 ± 8.9) (p < 0.05), while a score less than 56% (30.72 ± 8.7) was found in patients with glenoid tilt and medial migration (p < 0.01). The mean SST score was 4.8 ± 2.8 in case of glenoid tilt and migration of the component (p < 0.01). Removal of the glenoid component and conversion to hemiarthroplasty or reverse prostheses is suggested in painful glenoid loosening. An exhaustive analysis of radiograms is essential to detect early and late complications or risk factors of glenoid loosening.     

The results of tension band rotator cuff suture fixation of locked plating of displaced proximal humerus fractures

IntroductionThe purpose of this study was to assess 1-year outcomes of patients with displaced proximal humerus fractures who underwent treatment with locked plate fixation with rotator cuff suture augmentation.MethodsA total of 86 patients who had sustained 2, 3 and 4-part displaced proximal humerus fractures underwent locked plate fixation with multiple sutures placed in the cuff tendons. Clinical outcome variables included active forward elevation (AFE), active external rotation (AER), and Constant and American Shoulder and Elbow Surgeons (ASES) scores. Post-operative variables included the following complications: varus re-collapse, loss of fixation, osteonecrosis of the humeral head (AVN), screw cut out, hardware failure and infection.ResultsForty-one patients were available with minimum of 1-year follow-up. Mean AFE was 142 ± 17.0° and AER was 41 ± 13.0°. The overall complication rate was 14.6%, with osteonecrosis being the most common (12.2%). Of the 21 patients (51.2%) that initially had varus displacement, all but one maintained anatomic reduction and fixation. Mean ASES score was 78.2 ± 20.0 and average Constant score was 72.7 ± 17.6. Bivariate analyses demonstrated that pre-operative medial comminution (p = 0.297) or varus collapse (p = 0.95) were not associated with an increased likelihood of sustaining a complication.ConclusionsFollow-up of patients in this series demonstrated a low overall complication rate and excellent functional outcomes. We believe suture augmentation of the rotator cuff can counteract varus forces on proximal humerus fractures fixed with locked plates, and should be performed routinely in displaced 2, 3 and 4 part fractures.     

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.     

High prevalence of early stress shielding in stemless shoulder arthroplasty

IntroductionThe rates of early stress shielding in stemless total shoulder arthroplasty (TSA) in current literature are very low and inconsistent with our observations. We hypothesized that the incidence of early stress shielding in stemless TSA would be higher than previously reported.MethodsAll stemless TSA in a prospective database using a single humeral implant comprised the study cohort of 104 patients, of which 76.0% (79 patients) had a minimum one year radiographic and clinical follow-up. Radiographs were reviewed for humeral stress shielding, humeral radiolucent lines, and humeral or glenoid loosening/migration. Stress shielding and radiolucent lines were classified by location. Demographics and clinical outcomes, including American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) pain score, were compared between patient cohorts with and without stress shielding.ResultsAt one year, 41.8% of patients had humeral stress shielding. Medial calcar osteolysis was seen in 32.9% of all patients and 78.8% of the stress shielding cohort. There were no cases of radiolucent lines or humeral or glenoid loosening/migration. There was no significant difference in age between cohorts (P = .308), but there were significantly more females (P = .034) and lower body mass index in the stress shielding cohort (P = .004). There were no significant differences in preoperative ASES (P = .246) or VAS scores (P = .402) or postoperative ASES (P = .324) or VAS scores (P = .323).ConclusionStress shielding in stemless TSA is more prevalent than previously published, largely due to infrequently reported medial calcar osteolysis. Stress shielding is more common in women and patients with lower body mass index. At early follow-up there were no significantly worse outcomes in the stress shielding cohort, but longer-term follow-up is needed to fully understand the impact of stress shielding on function and stability.     

Clinical and Radiologic Outcomes of Small Glenoid Baseplate in Reverse Total Shoulder Arthroplasty: A Prospective Multicenter Study

BackgroundThe purpose of this study was to evaluate the clinical and radiologic outcomes of reverse total shoulder arthroplasty (RTSA) using a small glenoid baseplate in patients with a small glenoid and to analyze the contributing factors to scapular notching.MethodsA total of 71 RTSAs performed using a 25-mm baseplate were evaluated at a mean of 37.0 ± 3.3 months. Shoulder function was evaluated using American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) for pain, Single Assessment Numeric Evaluation (SANE) for satisfaction, and active range of motion. Scapular neck angle (SNA), prosthesis-scapular neck angle (PSNA), peg glenoid rim distance (PGRD), and sphere bone overhang distance (SBOD) were measured to assess the effects on scapular notching.ResultsShoulder function (ASES: 39.4 ± 13.8 preoperative vs. 76.2 ± 9.5 at last follow-up, p < 0.001), VAS for pain (6.1 ± 1.8 vs. 1.7 ± 1.4, p < 0.001), SANE for satisfaction (7.0 ± 11.8 vs. 83.4 ± 15.3, p < 0.001), and active forward flexion (115.6° ± 40.1° vs. 141.6° ± 17.2°, p < 0.001) were significantly improved. The mean diameter of the inferior glenoid circle was 26.0 ± 3.0 mm and the mean glenoid vault depth was 24.0 ± 4.5 mm. Scapular notching was found in 13 patients (18.3%) and acromial fracture in 2 patients (2.8%). There were no significant differences in preoperative SNA and PSNA at postoperative 3 years between patients with and without scapular notching (101.6° ± 10.5° and 110.8° ± 14.9° vs. 97.3° ± 13.3° and 104.9° ± 12.4°; p = 0.274 and p = 0.142, respectively). PGRD and SBOD were significantly different between patients with scapular notching and without scapular notching (24.8 ± 1.6 mm and 2.6 ± 0.5 mm vs. 21.9 ± 1.9 mm and 5.8 ± 1.9 mm; p < 0.001 and p < 0.001, respectively).ConclusionsRTSA using a 25-mm baseplate in a Korean population who had relatively small glenoids demonstrated low complication rates and significantly improved clinical outcomes. Scapular notching can be prevented by proper positioning of the baseplate and glenosphere overhang using size-matched glenoid baseplates.