Bilateral anatomic total shoulder arthroplasty versus reverse shoulder arthroplasty

The results of anatomic total shoulder arthroplasty and reverse shoulder arthroplasty have previously been reported separately. Although the indications differ, scenarios exist in which a patient may have a total shoulder arthroplasty on 1 shoulder and a reverse shoulder arthroplasty on the contralateral shoulder.Between 1992 and 2009, twelve patients underwent bilateral sequential primary shoulder arthroplasty with a total shoulder arthroplasty on 1 side and reverse shoulder arthroplasty on the contralateral side. Constant score, American Shoulder and Elbow Surgeons (ASES) score, subjective shoulder value, and patient satisfaction were obtained a minimum 1 year postoperatively. Mean postoperative Constant score was 77 after total shoulder arthroplasty and 73 after reverse shoulder arthroplasty (P<.2488). Mean postoperative active forward flexion was similar after total shoulder arthroplasty compared with reverse shoulder arthroplasty (P=.8910). Greater external rotation at the side (43° vs 12°; P<.0001) and internal rotation (T8 vs L1; P<.0001) were observed after total shoulder arthroplasty. Mean ASES score was 89.6 after total shoulder arthroplasty compared with 82.4 after reverse shoulder arthroplasty (P=.0125). Patient satisfaction was 92% for both prostheses, and mean subjective shoulder value was similar (85.4% vs 82.5%; P=.6333).Bilateral shoulder arthroplasty performed with a total shoulder arthroplasty and reverse shoulder arthroplasty on opposite shoulders can provide good functional outcome and high patient satisfaction. Although range of motion is better following total shoulder arthroplasty, no difference was observed in final Constant score or subjective patient assessment.     

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.     

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。     

Reverse shoulder arthroplasty for deltoid-deficient shoulder following latissimus dorsi flap transfer. Case report

IntroductionThe usual indication for reverse shoulder arthroplasty is glenohumeral arthritis with inadequate rotator cuff and intact deltoid muscle. We report here a case of reverse shoulder arthroplasty using a lattisimus dorsi flap in a patient with deltoid-deficient shoulder following a gunshot injury.Presentation of the caseThe patient was an otherwise healthy 51-year-old male with a history of gunshot injury of the left shoulder 2006. Upon presentation in 2011, the patient had a loss of most of his shoulder bony and muscular structures. Due to deltoid muscle deficiency, the patient underwent Lattisimus Dorsi muscle flap followed by reverse shoulder arthroplasty in order to establish an upper limb function.Upon discharge, 11 days after the surgery, the patient was able to achieve 150° flexion and 90° abduction while in the supine position and 45° in each direction, while sitting. He was able to perform internal rotation (behind back) up to the level of the L1 vertebra, assisted active abduction of 90°, and external rotation of 20°. Power tests showed power of grade 4/5 for both shoulder flexion and extension and grade 2+/5 for both abduction and adduction.At the last follow up one year after the operation, The patient still had passive pain-free full range of motion, but no progress in active range of motion beyond that upon discharge.ConclusionReverse shoulder arthroplasty after Latissmus dori flap in patient with deltoid deficient shoulders can be a successful and reproducible approach to treat such conditions.     

Anatomic versus reverse shoulder arthroplasty for post-traumatic sequelae of operatively and nonoperatively treated proximal humerus fractures

BackgroundThis study aimed to determine whether there is a long-term difference in outcomes between anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (rTSA) performed for proximal humerus fracture (PHF) sequelae. Hypotheses were as follows: (1) patients undergoing aTSA would have improved functional outcomes but a greater incidence of adverse events (AEs) and reoperation than those undergoing rTSA and (2) patients undergoing shoulder arthroplasty after open reduction internal fixation (ORIF) would have worse outcomes with more AEs and reoperations than those undergoing shoulder arthroplasty for sequelae of nonoperatively managed PHF.MethodsA prospectively collected database was queried for patients with PHF sequelae undergoing aTSA or rTSA between 2007 and 2020 with minimum 2-year follow-up. Baseline demographics, perioperative data, postoperative AEs, functional outcomes, and range of motion (ROM) were compared between aTSA and rTSA groups. A secondary analysis was performed to compare patients treated with prior PHF ORIF vs. those treated nonoperatively.ResultsThere were 17 patients in the aTSA group and 83 patients in the rTSA group. Type I PHF sequelae predominated among patients who underwent aTSA (71% vs. 40%, P = .026). Incidence of total postoperative AEs was greater after aTSA than that after rTSA (12% vs. 5%, P = .277), with a significantly higher rate of glenoid aseptic loosening after aTSA (6% vs. 0%, P = .026). All AEs required reoperation except one in the rTSA group. The mean follow-up was 66 months for aTSA compared with 45 months for rTSA (P = .002). No differences in functional outcomes or ROM between aTSA and rTSA persisted beyond 3 months or at the final follow-up except external rotation, which favored aTSA for 3 years postoperatively. In the secondary analysis, there were 33 patients in the ORIF group and 67 in the non-ORIF group. One (3%) postoperative AE occurred in the ORIF group vs. five (7%) in the non-ORIF group (P = .385). At a mean follow-up of 4 years, there were no differences in functional outcome scores or ROM between ORIF and non-ORIF groups, except for patient-reported shoulder function (6.3 vs. 7.4, respectively, P = .037).ConclusionFor treatment of PHF sequelae, aTSA may result in a higher incidence of postoperative AEs and reoperation than rTSA, particularly due to glenoid aseptic loosening. No difference in functional outcome scores between aTSA and rTSA persists beyond 3 months or at the final follow-up. Although active external rotation is significantly improved after aTSA for the first 3 years postoperatively, no differences in ROM exist beyond 4 years at the final follow-up. Patients undergoing shoulder arthroplasty for PHF sequelae have comparable outcomes regardless of prior ORIF or nonoperative management.Level of evidenceLevel III; Retrospective Cohort Design; Treatment Study     

反肩置换在老年肱骨近端内固定失败翻修术中的疗效观察

目的：探讨反肩置换术在老年肱骨近端骨折内固定失败后翻修中的应用价值和效果。方法 ：回顾性分析2014年5月至2020年3月肱骨近端骨折内固定失败的患者8例,其中男3例,女5例;年龄65～75岁。8例均行反式肩关节置换术,病程8～16个月。记录并比较手术前和末次随访的关节活动度（range of motion,ROM）、加州大学（University of California at Los Angeles,UCLA）肩关节评分、肩关节视觉模拟评分（visual analogue scale,VAS）、焦虑自评量表（self-rating anxiety scale,SAS）评分、肩关节功能Constant-Murley评分,并分析手术并发症情况。结果：术后8例均获得随访,时间16～28个月。患肩关节活动度（前屈、外旋、外展、内旋）术后明显改善,术后VAS、SAS和UCLA评分也得到改善。肩关节功能Constant-Murley评分中末次随访疼痛、日常活动、活动范围、力量测试评分比术前均有明显提升,且总分比术前提高。1例发生肩胛盂切迹,影像学显示分级为1级,其余患者未发生相关特异性和非特...     

Assessment of intraoperative joint loads and mobility in reverse total shoulder arthroplasty through a humeral trial sensor

HypothesisThe use of intraoperative glenohumeral load sensors has the potential to facilitate an objective, quantitative assessment of the soft tissue tension during reverse total shoulder arthroplasty.Material and MethodsA reverse total shoulder arthroplasty was performed on eight fresh frozen cadaveric shoulders, creating three different tightness conditions for each shoulder by using various shim thicknesses attached to an instrumented, load-sensing humeral trial component. The glenohumeral loads were recorded during four dynamic maneuvers, consisting of maximum internal/external rotation at 0°, 45° and 90° abduction and forward elevation. The joint kinematics were synchronously recorded using an optical tracking system.ResultsFor normal tightness conditions, 98.3% of the observed loads were below 40 lbf. These loads varied through the range of motion with an increase in glenohumeral loads generally observed towards the limits of the range of motion. With increasing shoulder tightness, the range of motion of the joint was not significantly affected, though the average and maximum glenohumeral load significantly increased (p < 0.01 for all).ConclusionIn a cadaveric setting, higher glenohumeral loads were observed at higher tightness conditions, demonstrating the potential of a load-sensing humeral trial component to quantify intraoperative joint load with reverse total shoulder arthroplasty. The glenohumeral loads are increasing towards the limits of the range of motion, indicating the importance of performing dynamic assessment of stability at the extents of the range of motion during implant trialing.Level of EvidenceBasic Science Study     

Factors affecting internal rotation after reverse shoulder arthroplasty

BackgroundThe limitation or loss of internal rotation (IR) after the surgery is a major problem in reverse shoulder arthroplasty (RSA). The particular factors associated with postoperative IR remain unclear. We aimed to analyze the predictors of IR after RSA.MethodsWe included primary RSA patients with the following implants and a minimum of 1-year follow-up: Wright Aequalis (n = 25), DJO Encore (n = 29), Biomet Comprehensive (n = 40), and Exactech Equinoxe (n = 29). Age, sex, dominant hand, primary diagnosis, implant type, preoperative critical shoulder angle, pre- and postoperative acromiohumeral distance, lateral offset of implant, glenosphere inclination, peg-glenoid rim distance (PGRD), glenosphere overhang, scapular notching, subscapularis (SSc) repair, pre- and postoperative ROM, and functional scores were assessed. IR was assessed using a 10-point scale based on the following anatomical levels: from the greater trochanter to the buttocks (2 points), from the sacrum to L4 (4 points), from L3 to L1 (6 points), from T12 to T8 (8 points), and from T7 to T1 (10 points). Univariable and multivariable analyses were performed to identify the factors affecting the IR after RSA.ResultsOne hundred twenty-three shoulders (123 patients) with a mean follow-up of 30.59 ± 19.55 (range, 12–83) months were evaluated. In the univariable analysis, preoperative diagnosis [odds ratio (OR) = 0.243, P = 0.001], implant type (P = 0.002), PGRD (OR = 1.187, P = 0.003), and preoperative IR (P < 0.001) were found to be factors associated with postoperative IR. Preoperative IR was the only factor associated with postoperative IR in the multivariable analysis (P < 0.001). Patients with preoperative IR scores of 10 or 8 points showed significantly better IR after RSA than those with preoperative IR scores of 2 or 4 points (10 points vs. 2 or 4 points; OR = 15.433, P = 0.002, 8 points vs. 2 or 4 points; OR = 6.078, P < 0.001).ConclusionPreoperative IR was the only independent factor for IR after RSA. Patients with excellent preoperative IR had better postoperative IR than those with poor preoperative IR. Preoperative diagnosis, implant type, SSc repair, implant lateralization, glenosphere inferior placement, and scapular notching were not identified as independent predictors of IR after RSA in our sample size.     

Effects of changes in whole-body alignment on ipsilateral knee pain after total hip arthroplasty

BackgroundTotal hip arthroplasty decreases hip pain and often reduces knee pain in patients with hip osteoarthritis. Whole-body alignment may be associated with knee pain, but to our knowledge this relationship has not been previously investigated. The purpose of this study was to investigate the effect of changes in whole-body alignment on ipsilateral knee pain in patients after total hip arthroplasty.MethodsIn total, 94 patients with unilateral hip osteoarthritis who underwent total hip arthroplasty were enrolled in this study. A visual analog scale (VAS) was used to investigate perioperative knee pain. An EOS 2D/3D X-ray system was used to quantify the whole-body alignment of the spine, pelvis, and lower extremities in the standing position. The relationship between perioperative changes in knee pain and whole-body alignment was investigated.ResultsAmong 61 patients who had preoperative ipsilateral knee pain, pain resolved in 30 (50%) and persisted in 31 (50%) after surgery. In these patients, average ipsilateral knee pain decreased significantly after surgery, from 41 mm to 14 mm on the VAS (P < 0.01). Preoperative knee pain was correlated with femorotibial rotation, and postoperative knee pain was correlated with K-L grade, preoperative knee pain visualized analog scale, and preoperative sagittal vertical axis. Multiple linear regression identified preoperative sagittal vertical axis as significantly associated with residual postoperative ipsilateral knee pain.ConclusionsIpsilateral knee pain decreased in half of patients after total hip arthroplasty. Patients with a considerable forward-bent posture may have residual ipsilateral knee pain after total hip arthroplasty.     

Rationalizing routine postoperative blood testing following elective shoulder arthroplasty

BackgroundImprovements in perioperative care have decreased complication rates following arthroplasty surgery and enabled outpatient surgery. Although studies have suggested selective routine postoperative blood tests for lower limb arthroplasty, there is currently a paucity of research into its utility for shoulder arthroplasty. Our aim was to define an algorithm based on Charlson Comorbidity Index (CCI) value as part of a predictive algorithm to identify low-risk patients undergoing elective anatomic and reverse shoulder arthroplasty that can safely do without routine postoperative blood tests.MethodsElectronic medical records were retrospectively reviewed for patients who underwent elective primary shoulder arthroplasty at our institution, both anatomic and reverse, between January 2009 and October 2020. Inclusion criteria included patients who underwent reverse or anatomic shoulder arthroplasty for glenohumeral joint osteoarthritis or rotator cuff arthropathy and had documented preoperative and postoperative blood tests including full blood count and serum electrolytes. Exclusion criteria included patients who had revision and trauma indications for surgery because of the increased complication rates associated with these indications. Variables recorded included age, gender, body mass index, indication for surgery, comorbidities, American Society of Anesthesiologists score, CCI score, preoperative blood test values from preadmission assessment, postoperative day one blood test values, and interventions required based on blood results.ResultsA total of 140 patients were included in the study. Eighteen patients (12.85%) required intervention based on postoperative blood tests, the most common indications being anemia and hyponatremia. Patients that required intervention had higher CCI (P = .001) and lower preoperative hemoglobin (P = .014). With the application of cutoff values of hemoglobin of ≥106 g/L, and CCI score of less than 4, only one patient in our study required intervention.ConclusionRoutine postoperative blood test following primary elective shoulder arthroplasty is not required in low-risk patients, defined as those with a CCI score of <4 and a preoperative hemoglobin of >106 g/L.     

Reverse shoulder arthroplasty for proximal humeral fractures: better clinical midterm outcome after primary reverse arthroplasty versus secondary reverse arthroplasty after failed ORIF in the elderly

BackgroundJoint replacement surgery as a treatment for complex proximal humeral fractures is an established option, especially in the elderly. In light of the increased attention to reverse total shoulder arthroplasty (rTSA), this study has analyzed the outcomes of patients with primary reverse arthroplasty and after secondary reverse arthroplasty for failed osteosynthesis.MethodsWe retrospectively reviewed 57 patients with an average age of 76 years (min. 55; max. 94; SD 7) from 2010 and 2015 who underwent primary rTSA (30) and secondary rTSA after the failure of plate osteosynthesis (27) after proximal humeral fractures. The functional outcome of the operated shoulder was evaluated by clinical scores (Constant-Score, ASES, DASH and Oxford), range of motion (RoM), pain and activity level.ResultsPrimary rTSA had a significantly better functional outcome, mean-follow-up 37.3 months, measured by Constant-Score (57.13 vs 45.78 points; p= .015) compared to secondary RTSA, mean follow-up 42.1 months. A significantly better active abduction (P= .002), forward flexion (P = .003) and internal rotation (P = .037) was observed in the primary rTSA group, especially in the follow-up > 35 months.ConclusionReverse shoulder arthroplasty is an effective treatment for proximal humeral fractures as primary or revision surgery. The reliable clinical outcome especially in the follow-up to 40 months after primary reverse arthroplasty may suggest to prefer rTSA for complex humeral fractures in the elderly.Level of evidenceLevel III; Retrospective comparative study     

Clinical outcomes of shoulder arthroplasty for post-instability arthropathy after open anterior bone block stabilization

BackgroundPost-instability glenohumeral arthropathy can occur after nonanatomic instability repairs. With advanced secondary arthritis, subsequent shoulder arthroplasty may be complicated by altered surgical anatomy, poor range of motion, subscapularis deficiency, unique glenoid wear patterns, and/or aberrant neurovascular anatomy. The purpose of this study was to evaluate the clinical outcomes of patients undergoing shoulder arthroplasty after previous open nonanatomic anterior shoulder stabilization, particularly glenoid bone block procedures.MethodsBetween 2008 and 2014, all patients with shoulder arthroplasty for symptomatic post-instability glenohumeral arthropathy after prior open stabilizations were identified from surgical case logs of two senior shoulder surgeons. Demographic variables were extracted from electronic medical records, operative reports, and preoperative and postoperative radiographs, and a minimum 24-month follow-up with completion of patient-reported questionnaires was required. Postoperative active forward elevation and active external rotation were recorded. The primary outcome measures were the visual analog scale for pain, American Shoulder and Elbow Surgeons Shoulder score, and the Simple Shoulder Test. Perioperative complications and rates of secondary reoperation were extracted.ResultsA total of 12 patients were identified with an average age of 63 ± 12 years (range, 46-83), including 7 males and 5 females, and index surgery included open Bristow (n = 7), open Latarjet (n = 2), iliac crest bone graft (n = 1), and Putti-Platt procedure (n = 2). Seven patients underwent anatomic TSA, 4 reverse TSA, and 1 hemiarthroplasty. At an average of 44 ± 21 months follow-up, average active forward elevation and active external rotation improved from 100 ± 36 preoperatively to 132 ± 41 (P = .12) postoperatively and 19 ± 15 to 49 ± 11 (P < .01), respectively. The average visual analog scale decreased from 5 ± 3 to 1 ± 2 (P < .01) and mean American Shoulder and Elbow Surgeons improved from 44 ± 23 to 79 ± 17 (P < .01); and the average Simple Shoulder Test improved from 4 ± 2 to 9 ± 3 (P < .01). No perioperative complications or secondary reoperations were required, and only one patient experienced subsequent instability due to subsequent shoulder trauma.ConclusionDespite the surgical complexity and unique challenges associated with post-instability arthropathy, shoulder arthroplasty after prior open anterior bone block procedure or nonanatomic reconstruction is a safe procedure with low risk of perioperative complication, subsequent shoulder instability, or secondary revision surgery. All patients experienced significant improvements in pain, range of motion, and self-reported function at short- to mid-term follow-up.     

The incidence of humeral bone resorption in uncemented reverse shoulder arthroplasty and the impact on functional outcomes

BackgroundFull-thickness bone resorption around the humeral stem in shoulder arthroplasty is an increasingly recognized phenomenon, but the impact on outcomes remains unclear. This study aims to investigate prevalence of bone resorption in patients with the Zimmer-Biomet Comprehensive reverse shoulder arthroplasty and the impact on the functional outcomes.MethodsA retrospective analysis was carried out on 65 consecutive patients with primary reverse total shoulder arthroplasty using the Comprehensive Shoulder System from 2014 to 2020, with a minimum of 12-month follow-up. The prevalence of humeral bone resorption was graded from 0 to 4, and risk factors for these changes and their impact on functional outcomes were further investigated.ResultsThe majority of patients (75%) were female with an average age of 75 years (53-93), with an overall average follow-up of 26 months (12-60). Bone resorption occurred in 53 patients (82%), and full-thickness bone resorption occurred in only 8 patients (12%). Metaphyseal bone (zones 1 and 7) is mostly at the risk of high-grade resorption. There was no difference in the final Oxford Shoulder Score between patients who had differential resorption grades from 0 to 4 (P = .5742). None of the risk factors from the previous literature including age, sex, indication for surgery, rotator cuff tear and repair, and intramedullary occupation ratio of the implant showed any impact on the rate of resorption.ConclusionFull-thickness humeral bone resorption occurred in approximately 12% of patients when using the Comprehensive reverse shoulder arthroplasty, but it has no impact on the functional outcomes or revision rate in the short-to-medium term.     

Mid-term outcomes of reverse shoulder arthroplasty using the alternate scapular line baseplate orientation for glenoid bone loss

BackgroundGlenoid-sided bone loss poses a challenge when performing reverse shoulder arthroplasty. Placing the baseplate in an anteverted position along the alternate scapular line is an option when dealing with glenoid erosion or cavitary defects. Although this allows for stable initial baseplate fixation, questions remain about the effects of placing the baseplate in a more anteverted position relative to the standard glenoid center line. The purpose of this study was to evaluate the mid-term outcomes of patients treated with reverse shoulder arthroplasty using an alternate scapular line baseplate orientation in the setting of glenoid bone loss.Materials and methodsFrom September 2007 to March 2014, 71 patients underwent reverse shoulder arthroplasty using the alternate scapular line baseplate orientation and had a minimum of 5 years of follow up. Patients with no prior surgery, prior nonarthroplasty surgery, and prior arthroplasty surgery were included in this analysis. Patients were followed clinically (American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, range of motion analysis, patient satisfaction) as well as radiographically, with data recorded at the 2-year point and their last recorded follow-up after a minimum of 60 months.ResultsAt the final follow-up point (average 78 months) patients had maintained their improvement in American Shoulder and Elbow Surgeons score (75 [P<.0001]), Simple Shoulder Test score (7.8 [P < .0001]), forward elevation (1300 [P < .0001]), external rotation (310 [P < .0001]) with no change in internal rotation (62% with full IR [P = 1.0]). No significant deterioration in outcome scores or motion was noted between the 2-year and final follow-up time point. At final follow-up, 92% remained satisfied with their outcome. There was a 7% complication rate (3 acromial fractures, 1 hematoma, 1 dislocation), with 1 patient requiring revision surgery secondary to instability.ConclusionUtilizing the alternate scapular line baseplate orientation in cases with glenoid bone loss resulted in clinical improvements with no deterioration in outcome scores, range of motion or patient satisfaction at a minimum of 5 years of follow-up. Anteverting the baseplate in this position allowed for stable glenoid-sided fixation with no mechanical failures of the baseplate and did not appear to compromise the patient's functional outcomes. In patients with significant glenoid bone loss, where adequate bone stock along the standard glenoid line may be in question, use of the alternate scapular line for baseplate orientation is an effective option yielding sustained clinical improvements and a low rate of complications.Level of evidenceLevel IV; Case Series; Treatment Study     

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.

     

Outcomes after anatomic total shoulder arthroplasty and reverse total shoulder arthroplasty in patients with long-term disability claims

BackgroundStudies have shown that patients with workers' compensation claims have worse clinical outcomes after various orthopedic procedures. This study aimed to determine the influence of disability status on 2-year clinical outcomes after reverse total shoulder arthroplasty (RTSA) and anatomic total shoulder arthroplasty (ATSA).MethodsReview of an institutional database identified patients on disability with a minimum of 2-year follow-up and compared them to a comorbidity-matched cohort of patients without disability claims. Assessments between patients included preoperative and postoperative Visual Analog Scale (VAS) pain scores, American Shoulder and Elbow Surgeons (ASES) scores, strength, range of motion (ROM), and postoperative complications.ResultsForty-eight shoulders (45 patients) were in the ATSA cohort (24 with disability, 24 without disability) and 46 shoulders (45 patients) in the RTSA cohort (23 with disability, 23 without disability). Patients in the ATSA cohort with disability claims had higher 3-month and 2-year VAS scores (4 vs. 1, P = .003; 4 vs. 1, P = .02, respectively), lower 2-year ASES scores (58 vs. 87, P = .015), and decreased forward elevation ROM and internal rotation ROM (150 vs. 170, P = .017; 60 vs. 62.5, P = .024, respectively) compared to the cohort without disability. Significant differences in baseline values also were noted between cohorts (lower preoperative ASES: 31.7 vs. 40.5, P = .033; higher VAS: 7 vs. 6, P = .03; decreased forward elevation ROM: 90 vs. 110, P = .02). Patients in the RTSA cohort with disability claims had higher 3-month and 2-year VAS (5 vs. 1, P = .02; 3 vs. 0.5, P = .04, respectively) scores than those without claims. The baseline values for the disability cohort with RTSA demonstrated lower ASES (22.1 vs. 43.6, P = .005) and higher VAS (8 vs. 4, P = .004) scores. No significant differences were noted in improvement for the ATSA or RTSA cohorts in any parameter. The ATSA with disability cohort had a higher complication rate (45% vs. 16.6%, P = .0299). No differences were noted in complication rates in the RTSA group.ConclusionPatients who have reported disability status demonstrated worse outcomes after ATSA and RTSA compared to patients without disability claims. However, there was no significant difference in the amount of change in outcomes between groups, indicating that patients on disability can still realize significant improvements after shoulder arthroplasty.     

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.     

The influence of over-reaming on stem stability in reverse shoulder arthroplasty

BackgroundContemporary cementless reverse total shoulder arthroplasty (RSA) systems utilize a range of interference conditions based on the geometric relationships between the system instrumentation and the prosthesis design. The impact of prosthesis/bone interference, however, on the primary stability of the stemmed humeral component has not been characterized. The aim of this study was to evaluate the effect of over-reaming, standard reaming, and use of an upsized stem on stem stability in press fit reverse shoulder arthroplasty.MethodsThree-dimensional humeral models were generated from CT data of 59 non-arthritic shoulders. Each model was prepared following the intended surgical technique, including resection of the humeral head and reaming of the humeral canal, assuming 1 mm spacing in reamer diameters. The appropriate humeral stem (2 mm increments in distal stem diameter) was then placed to represent instances of over-reaming (increased distal clearance between stem and reamed bone), standard reaming, and use of an upsized stem. Finite element analysis was performed to predict the primary stability of the humeral stem subjected to expected loads in RSA.ResultsOver-reaming was associated with both increased stem subsidence as well as stem-bone micromotion, as compared to standard bone preparation (P < 001). No significant differences in stem translation or stem-bone micromotion were found between standard bone preparation and use of an upsized stem. Over-reaming was associated with approximately 50% increased rotation of the stem following functional loading, as compared to stems placed using standard preparation or upsized stems.ConclusionOver-reaming of the humeral canal in cementless reverse shoulder arthroplasty results in increased micromotion and decreased primary stability of the humeral stem when subjected to loading representative of daily activities. Use of an upsized stem can recover the primary stability expected for standard reaming.Level of EvidenceBiomechanical Study     

Differences in cervical sagittal alignment between the standing and sitting positions

BackgroundSagittal spinal alignment has mainly analyzed in the standing position. According to previous studies, there are significant differences in lumbopelvic alignment between the standing and sitting positions and cervical alignment is affected by lumbopelvic alignment. In this study, therefore, we hypothesized that cervical sagittal alignments are different between the standing and sitting positions.MethodsA total of 108 patients with spinal degenerative diseases underwent whole spine radiography. Cervical lordosis (CL), C2-7 SVA, T1S, C7–S1 SVA, TK, LL, SS, PT, and PI were measured in the standing and sitting positions. Patients were classified into 3 groups according to the changes in CL (ΔCL, CL in the sitting position − CL in the standing position); ΔCL < −3° (Decreased group: DG; 28.7%), −3° ≤ ΔCL ≤ 3° (Unchanged group: UG; 41.7%), and ΔCL > 3° (Increased group: IG; 29.6%).ResultsThe parameters of the UG in the standing position were closer to the ideal alignment (SRS-Schwab classification). In the DG, CL, T1S, and C7–S1 SVA in the standing position were significantly higher than in the UG. In the IG, PI-LL in the standing position was significantly higher than in the UG. In the sitting position, pelvis was rotated posteriorly (decrease in SS and increase in PT) and lumbar lordosis was flattened (decrease in LL) in all groups, and C2-7 SVA was significantly higher in the DG than in the UG.ConclusionsCL was different between the standing and sitting positions in 58.3% of individuals. However, patients with good spinal sagittal alignment appeared to not undergo any changes in cervical alignment. Our results suggest the possibility that patients who had a positive imbalance and large PI-LL mismatch in the standing position had decreased CL and increased CL, respectively, when in the sitting position.     

Characteristics affecting cervical sagittal alignment in patients with chronic low back pain

BackgroundSagittal spino-pelvic malalignment in patients with chronic low back pain (CLBP) have been reported in the past, which may also affect cervical spine lesions. The purpose of this study is to investigate the cervical alignment in patients with CLBP.MethodOf the patients who visited an orthopedic specialist due to low back pain lasting more than three months, 121 cases (average 71.5-years-old, 46 male and 75 female) with whole standing spinal screening radiographs were reviewed (CLBP group). Cervical parameters included cervical lordosis (CL), C2–C7 sagittal vertical axis (C2-7 SVA), and the T1 slope minus CL (T1S-CL). Cervical spine deformity was defined as C2-7 SVA >4 cm, CL <0°, or T1S-CL ≧20°. We compared the cervical alignment of these patients with 121 age and gender matched volunteers (control group).ResultsThe prevalence of cervical spine deformity was significantly higher in the CLBP group than in the control group (20.7% vs. 10.7%, P = 0.034). The mean CL was smaller in the CLBP group than in the control group (16.1° vs. 21.4°, P = 0.002). The mean C2-7 SVA was 17.6 mm vs. 18.7 mm in the CLBP group and in the control group, respectively (P = 0.817). The mean T1S-CL was larger in the CLBP group than in the control group (9.1° vs. 3.5°, P < 0.001). Multivariate analysis showed that people with CLBP were more likely to have cervical deformities than people without CLBP (odds ratio 2.16, 95% confidence interval 1.006 to 4.637).ConclusionsThis study results suggest that people with CLBP present with worse cervical sagittal alignment and higher prevalence of cervical spine deformities than age and gender matched volunteers with no CLBP. This means CLBP impacts cervical spine lesions negatively.Level of evidenceⅣ