Reverse Shoulder Arthroplasty for the Treatment of Rotator Cuff Deficiency: A Concise Follow-up, at a Minimum of 10 Years, of Previous Reports.

We previously evaluated 94 patients (96 shoulders) who underwent reverse shoulder arthroplasty using a central compressive screw with 5.0-mm peripheral locking screws for baseplate fixation and a center of rotation lateral to the glenoid as treatment for end-stage rotator cuff deficiency. The purpose of this study was to report updated results at a minimum follow-up of 10 years. Forty patients (42 shoulders) were available for clinical follow-up. In the patients available for study, implant survivorship, with the end point being revision for any reason, was 90.7%. Since our 5-year report, 2 patients underwent revision surgery; 1 patient sustained a periprosthetic fracture 7 years postoperatively and 1 patient had a dislocation because of chronic shoulder instability at 8 years postoperatively. At a minimum follow-up of 10 years, the patients continued to maintain their improved outcome scores and range of motion, which were comparable with earlier follow-up evaluations. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Partial rotator cuff repair and biceps tenotomy for the treatment of patients with massive cuff tears and retained overhead elevation: midterm outcomes with a minimum 5 years of follow-up.

BACKGROUND: A subset of patients with massive irreparable rotator cuff tears present with retained overhead elevation and pain as their primary complaint. Our aim was to evaluate the outcomes of partial arthroscopic rotator cuff repair with biceps tenotomy and to report the failure rate of this procedure for patients with >5 years of follow-up. METHODS: Thirty-four patients underwent partial rotator cuff repair and biceps tenotomy for treatment of a massive rotator cuff tear. Patients had preoperative active forward elevation >120° and no radiographic evidence of glenohumeral arthritis. Patients were followed up clinically and radiographically, and 28 patients had a minimum of 5 years of follow-up. Failure was defined as an American Shoulder and Elbow Surgeons score of <70, loss of active elevation >90°, or revision to reverse shoulder arthroplasty during the study period. RESULTS: Patients demonstrated improvements in average preoperative to postoperative American Shoulder and Elbow Surgeons scores (46.6 to 79.3 [P < .001]) and Simple Shoulder Test scores (5.7 to 9.1 [P < .001]) along with decrease in visual analog scale for pain scores (6.9 to 1.9 [P < .001]). No significant change in forward elevation (168° to 154° [P = .07]), external rotation (38° to 39° [P = 1.0]), or internal rotation (84% to 80% [P = 1.0]) was identified; 36% of patients had progression of the Hamada stage. The failure rate was 29%; 75% of patients were satisfied with their index procedure. CONCLUSION: Partial rotator cuff repair and biceps tenotomy for patients with massive irreparable rotator cuff tears with retained overhead elevation and pain as the primary complaint produced reasonable outcomes at midterm follow-up of at least 5 years.

Evaluation of Factors Affecting Acute Postoperative Pain Levels After Arthroscopic Rotator Cuff Repair.

PURPOSE: To evaluate multiple preoperative and operative factors that may be predictive of and correlate with acute postoperative pain levels after arthroscopic rotator cuff repair. METHODS: One hundred eighty-one patients underwent arthroscopic rotator cuff surgery along with subacromial decompression and met the inclusion criteria for this study. Postoperative visual analog scale (VAS) scores were obtained on postoperative days 1, 7, and 90. Multivariate linear regression analysis was used to correlate postoperative VAS scores with multiple independent factors, including preoperative subjective pain tolerance, preoperative VAS score, preoperative narcotic use, sex, smoking status, number of suture anchors used, tear size, single- or double-row repair, and patient age. RESULTS: Preoperative subjective pain tolerance, notably those patients rating themselves as having an extremely high pain tolerance, was the most significant predictor of high VAS pain scores on both postoperative day 1 (P = .0001) and postoperative day 7 (P < .0001). Preoperative narcotic use was also significantly predictive (P = .010) of high pain scores on postoperative day 1 and day 7 (P = .019), along with nonsmokers (P = .008) and younger patients (P = .006) being predictive on day 7. There were no patient factors that were predictive of VAS scores 3 months postoperatively (P = .567). CONCLUSIONS: Preoperative subjective pain tolerance, notably those patients rating themselves as having an extremely high pain tolerance, was the strongest factor predicting high acute pain levels after arthroscopic rotator cuff surgery. Preoperative narcotic use, smokers, and younger patients were also predictive of higher pain levels during the first postoperative week. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Comparison of hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures in elderly patients.

BACKGROUND: Treatment of complex three and four-part proximal humeral fractures with hemiarthroplasty in elderly patients has yielded mixed clinical results. Reverse shoulder arthroplasty has emerged as a treatment option for comminuted proximal humeral fractures for these patients. The purpose of the study was to perform a prospective evaluation of patient outcomes comparing hemiarthroplasty and reverse shoulder arthroplasty for the treatment of comminuted proximal humeral fractures in elderly patients. METHODS: Fifty-three consecutive elderly patients (average age, 74.4 years) underwent an arthroplasty for a complex proximal humeral fracture. Indications for arthroplasty were four-part fractures, three-part fractures with severe comminution of the greater tuberosity, and fractures that involved an articular split of the humeral head. Twenty-six patients underwent hemiarthroplasty (the HA group), followed by twenty-seven patients who underwent reverse shoulder arthroplasty (the RSA group). A total of forty-seven patients (twenty-three in the HA group and twenty-four in the RSA group) were available for follow-up at a minimum of two years. RESULTS: Final average outcome scores were lower in the HA group than in the RSA group (American Shoulder and Elbow Surgeons [ASES] score of 62 versus 77 [p = 0.0001] and Simple Shoulder Test [SST] of 5.8 versus 7.4 [p = 0.0062]), and patient-reported satisfaction was lower in the HA group than in the RSA group (61% versus 91%; p = 0.038). Radiographic healing of the tuberosities occurred in 61% of the patients in the HA group compared with 83% of the patients in the RSA group (p = 0.17). Forward elevation of the arm was higher in the RSA group (139°) than in the HA group (100°) (p = 0.0002), but no significant differences were observed for shoulder external rotation or internal rotation. Complication rates in both groups were similar. Three patients (13%) in the HA group elected revision to reverse shoulder arthroplasty because of failed tuberosity healing and resultant shoulder pseudoparesis. CONCLUSIONS: In this series, reverse shoulder arthroplasty resulted in better clinical outcomes and a similar complication rate compared with hemiarthroplasty for the treatment of comminuted proximal humeral fractures in the elderly.

Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency: a concise follow-up, at a minimum of five years, of a previous report.

UNLABELLED: We previously evaluated ninety-four patients (ninety-six shoulders) who underwent reverse shoulder arthroplasty with use of a central compressive screw along with 5.0-mm peripheral locking screws for baseplate fixation and a center of rotation lateral to the glenoid. The purpose of this study was to report updated results at a minimum follow-up of five years. Since the last report, an additional two patients underwent revision surgery: one for recurrent instability and one for resorption of a proximal humeral allograft. The patients continue to have improved outcome scores and range of motion. Survivorship with the end point being revision for any reason was 73.5 months, with 94% survival at sixty months. Radiographic follow-up showed that two (3%) of seventy-six patients included in the survivorship analysis had asymptomatic humeral loosening, seven (9%) had scapular notching, and no patient had glenoid baseplate loosening or baseplate failure. The patients have maintained their improved function with durable clinical and radiographic results at a minimum of five years. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Prospective evaluation of postoperative compliance and outcomes after rotator cuff repair in patients with and without workers' compensation claims.

BACKGROUND: This study prospectively evaluated compliance and outcomes after rotator cuff repair in patients with and without Workers' Compensation claims. MATERIALS AND METHODS: From December 2007 to January 2010, 42 consecutive patients with Workers' Compensation claims (Work Comp group), and 50 consecutive patients without a Workers' Compensation claim (non-Work Comp group) underwent arthroscopic rotator cuff repair and were enrolled in this study. Compliance with a postoperative protocol of shoulder immobilization and physical therapy was documented. Patients were monitored clinically for a minimum of 12 months. RESULTS: Noncompliance with protocol was documented in 22 of 42 patients (52%) in the Work Comp group compared with 2 of 50 (4%) in the non-Work Comp group (P < .001). The Work Comp group had less improvement in preoperative to postoperative outcome scores for the American Shoulder and Elbow Surgeons (ASES) score (40.4 to 60.1), Simple Shoulder Test (SST) score (3.9 to 6.0) and visual analog scale (VAS) for pain (7.0 to 3.5) compared with the non-Work Comp group (ASES, 41.7 to 89.2; SST, 4.3 to 10.7; VAS, 6.2 to 0.35; P < .0001). The compliant Work Comp patients had more favorable results in final outcome scores (ASES, 73.1; SST, 7.9; VAS, 1.5) than noncompliant Work Comp patients (ASES, 48.4; SST, 4.3; VAS, 5.3; P < .0001). CONCLUSIONS: Patients with Workers' Compensation claims demonstrated a high rate of postoperative noncompliance (52%) compared with patients without Workers' Compensation claims (4%) after rotator cuff repair. Those Workers' Compensation patients who had no evidence of noncompliance had significant improvements and more favorable outcomes than the noncompliant Workers' Compensation patients.

Prospective randomized study of arthroscopic rotator cuff repair using an early versus delayed postoperative physical therapy protocol.

BACKGROUND: This study evaluated patient outcomes and rotator cuff healing after arthroscopic rotator cuff repair using a postoperative physical therapy protocol with early passive motion compared with a delayed protocol that limited early passive motion. MATERIALS AND METHODS: The study enrolled 68 patients (average age, 63.2 years) who met inclusion criteria. All patients had a full-thickness crescent-shaped tear of the supraspinatus that was repaired using a transosseous equivalent suture-bridge technique along with subacromial decompression. In the early group, 33 patients were randomized to passive elevation and rotation that began at postoperative day 2. In the delayed group, 35 patients began the same protocol at 6 weeks. Patients were monitored clinically for a minimum of 12 months, and rotator cuff healing was assessed using ultrasound imaging. RESULTS: Both groups had similar improvements in preoperative to postoperative American Shoulder and Elbow Surgeons scores (early group: 43.9 to 91.9, P < .0001; delayed group: 41.0 to 92.8, P < .0001) and Simple Shoulder Test scores (early group: 5.5 to 11.1, P < .0001; delayed group: 5.1 to 11.1, P < .0001). There were no significant differences in patient satisfaction, rotator cuff healing, or range of motion between the early and delayed groups. CONCLUSIONS: Patients in the early group and delayed group both demonstrated very similar outcomes and range of motion at 1 year. There was a slightly higher rotator cuff healing rate in the delayed passive range of motion group compared with the early passive range of motion group (91% vs 85%).

The use of the reverse shoulder arthroplasty for treatment of failed total shoulder arthroplasty.

BACKGROUND: This study evaluated the outcomes of patients with failed total shoulder arthroplasty (TSA) who were treated with conversion to reverse shoulder arthroplasty (RSA). MATERIALS AND METHODS: We performed a retrospective case series of 24 consecutive patients with failed TSA who were treated with conversion to RSA. Twenty-two patients (16 women, 6 men) had a minimum 2-year clinical and radiographic follow-up. The average age at the time of revision was 68 years (range, 51-84 years). Indications for conversion to RSA included failure of TSA from glenohumeral instability in 19, mechanical failure of the humeral or glenoid component in 10, and infection in 2. RESULTS: The median total American Shoulder and Elbow Surgeons score improved from 38.5 preoperatively to 67.5 (P < .001). Visual analog scale pain scores decreased from 5 to 1.5 (P < .001), and function improved from 2 to 6.5 (P < .001). The median Simple Shoulder Test improved from 1 to 5 (P = .006). Forward flexion improved from 50° to 130° (P < .001), abduction from 45° to 100° (P < .001), and external rotation from 12.5° to 49.5° (P = .056). Internal rotation improved from a spinal level of S2 to L3 (P = .064). Fourteen patients rated their outcome as excellent, 3 as good, 3 as satisfactory, and 2 as unsatisfactory. The overall complication rate was 22.7% (5 of 22). CONCLUSION: RSA can be an effective treatment for failed TSA by decreasing pain and improving shoulder function. However, RSA in the revision setting is associated with a higher complication rate.

Proximal humeral malunion treated with reverse shoulder arthroplasty.

BACKGROUND: The purpose of this study was to determine the outcomes of patients with proximal humeral malunions treated with reverse shoulder arthroplasty (RSA). MATERIALS AND METHODS: Sixteen patients were treated with RSA for sequelae of a proximal humeral fracture with a malunion. Clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score, Simple Shoulder Test, visual analog scale [VAS] score for pain and function, range of motion, and patient satisfaction) and radiographs were evaluated at a minimum follow-up of 2 years. Wilcoxon signed-rank tests were used to analyze preoperative and postoperative data. RESULTS: All patients required alteration of humeral preparation with increased retroversion of greater than 30°. The total ASES score improved from 28 to 63 (P = .001), ASES pain score from 15 to 35 (P = .003), ASES functional score from 15 to 27 (P = .015), VAS pain score from 7 to 3 (P = .003), VAS function score from 0 to 5 (P = .001), and Simple Shoulder Test score from 1 to 4 (P = .0015). Forward flexion improved from 53° to 105° (P = .002), abduction from 48° to 105° (P = .002), external rotation from 5° to 30° (P = .015), and internal rotation from S1 to L3 (P = .005). There were no major complications reported. Postoperative radiographic evaluation showed 2 patients with evidence of notching and 1 patient with proximal humeral bone resorption. CONCLUSION: RSA is indicated for treating the most severe types of proximal humeral fracture sequelae. The results of RSA for proximal humeral malunions with altered surgical technique yield satisfactory outcomes in this difficult patient population.

Effects of tilt and glenosphere eccentricity on baseplate/bone interface forces in a computational model, validated by a mechanical model, of reverse shoulder arthroplasty.

HYPOTHESIS/BACKGROUND: Reverse shoulder arthroplasty is being used with greater frequency for patients with severe rotator cuff deficiency. There are several commercially available reverse shoulder devices, each with different glenosphere options. The purpose of this study was to determine: (1) forces at the baseplate-bone interface in glenospheres with centers of rotation located concentrically and eccentrically to the center of the baseplate; and (2) if baseplate-bone forces can be optimized by altering tilt of the baseplate. METHODS: A validated computer model was used to compare concentric glenospheres with neutral offset to eccentrically offset glenospheres (6 mm inferior or 6 mm lateral) in 3 baseplate tilts: 15° inferior, neutral, or 15° superior. A baseplate, simulated bone, screws, and humeral component were modeled, and forces underneath the baseplate were calculated as the arm was abducted through 90° of glenohumeral motion. RESULTS: For lateral and concentric glenospheres, inferior tilt provides the most even distribution of forces (mean difference in force between superior and inferior portions of baseplate: 11.3 N and 24.7 N, respectively) and superior tilt provides the most uneven distribution of forces (109.3 N and 78.7 N, respectively). For inferior eccentric glenospheres, inferior tilt provides the most uneven distribution of forces (58.7 N) and neutral tilt provides the most even distribution of forces (27.7 N). CONCLUSION: This is the first study to investigate force distribution under the baseplate in inferior eccentric glenospheres. Although inferior tilting of the baseplate is recommended for concentric and laterally offset glenospheres, this same recommendation may be detrimental to inferiorly offset glenospheres and warrants further investigation.

Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis.

BACKGROUND: The purpose of the present study was to evaluate the indications for, and outcomes of, reverse shoulder arthroplasty in patients with massive rotator cuff tears but without glenohumeral arthritis. METHODS: From December 1998 to December 2006, sixty-nine patients (seventy-two shoulders) were managed with reverse shoulder arthroplasty for the treatment of irreparable rotator cuff dysfunction without glenohumeral arthritis. The indications for reverse shoulder arthroplasty were persistent shoulder pain and dysfunction despite a minimum of six months of nonoperative treatment, the presence of at least a two-tendon tear, and Hamada stage-1, 2, or 3 changes in a patient for whom a non-arthroplasty option did not exist. Fifty-eight patients (sixty shoulders) had a minimum of two years of follow-up. Thirty-four shoulders had had no previous surgery (Group A), and twenty-six shoulders had had at least one previous surgical procedure (Group B). Postoperatively, patients were prospectively followed both clinically and radiographically. Survival analysis was performed, with the end points being removal or revision of the implant, radiographic loosening, and declining American Shoulder and Elbow Surgeons score. RESULTS: Common characteristics of patients managed with reverse shoulder arthroplasty in this study were pain and (1) <90° of arm elevation at the shoulder without anterosuperior escape (n = 40; 66.6%); (2) <90° of elevation with anterosuperior escape (n = 16; 26.7%); or (3) irreparable rotator cuff tear and pain with >90° of elevation (n = 4; 6.7%). The average duration of follow-up was fifty-two months (range, twenty-four to 101 months). All measured outcomes improved postoperatively. For all patients, the average American Shoulder and Elbow Surgeons score improved from 33.3 to 75.4 (p < 0.0001), the average Simple Shoulder Test score improved from 1.6 to 6.5 (p < 0.0001), the average visual analog score for pain improved from 6.3 to 1.9 (p < 0.0001), the average visual analog score for function improved from 3.2 to 7.1 (p < 0.0001), the average forward flexion improved from 53° to 134° (p < 0.0001), the average abduction improved from 49° to 125° (p < 0.0001), the average internal rotation improved from S1 to L2 (p < 0.0001), and the average external rotation improved from 27° to 51° (p = 0.001). There were a total of twelve complications in eleven patients (prevalence, 20%). The survivorship at a mean of fifty-two months (range, twenty-four to 101 months) was 90.7% for all patients, 91.8% for Group A, and 87% for Group B. CONCLUSIONS: When non-arthroplasty options either have failed or have a low likelihood of success, reverse shoulder arthroplasty provides reliable pain relief and return of shoulder function in patients with massive rotator cuff tears without arthritis at the time of short to intermediate-term follow-up.

Effects of acquired glenoid bone defects on surgical technique and clinical outcomes in reverse shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty is the accepted method of treatment for selected shoulder disorders. The purpose of this study was to compare primary reverse shoulder arthroplasty surgical techniques as well as clinical and radiographic outcomes in patients with acquired glenoid bone defects and in those with normal glenoid morphology. METHODS: Preoperative three-dimensional computed tomography scans were performed on 216 shoulders in 211 patients undergoing primary reverse shoulder arthroplasty between 2004 and 2007. The glenoids were classified as normal or abnormal on the basis of preoperative radiographs and three-dimensional reconstructions of the scapula. One hundred and forty-three shoulders had been followed for two years. There were eighty-seven normal and fifty-six abnormal glenoids. The surgical techniques that were compared included bone-grafting and glenosphere selection. The clinical outcomes for the two groups were compared with respect to the American Shoulder and Elbow Surgeons score. RESULTS: Surgical technique differed between the groups. All fifty-six glenoids with acquired bone defects had center screw placement along an alternative (scapular spine) centerline. A bone graft was used in twenty-two shoulders with acquired glenoid bone defects compared with none of those with normal glenoid morphology (p = 0.016). Shoulders with glenoid defects were treated with larger glenospheres (36 or 40 mm) more often than those with normal glenoids (p < 0.001). No significant difference was detected between the groups with regard to the preoperative or postoperative American Shoulder and Elbow Surgeons scores. Radiographs did not demonstrate failure or resorption of a glenoid bone graft when present. All outcomes improved significantly postoperatively. There were five complications, and one patient was unsatisfied with the result. CONCLUSIONS: Glenoid bone defects, when managed with an alteration of surgical technique, including bone-grafting when indicated, are not a contraindication to reverse total shoulder arthroplasty.

Reverse shoulder arthroplasty in patients with rheumatoid arthritis.

BACKGROUND: The purpose of this study was to describe the pathoanatomy of patients diagnosed with rheumatoid arthritis and rotator cuff deficiency and report their outcomes following reverse shoulder arthroplasty. METHODS: Twenty-one shoulders were evaluated prospectively. Nine had no prior surgery, 9 had a failed rotator cuff repair, and 3 had a failed arthroplasty. Patients were followed for a minimum of 2 years (average, 36 months). All patients had preoperative radiographs and 19 shoulders had an MRI or CT available for evaluation of muscular and bony deficiency. Radiographs at most recent follow-up were evaluated for loosening and scapular notching. RESULTS: All outcome measures improved significantly: ASES scores improved from 28 preoperatively to 82 postoperatively (P < .0001); SST scores improved from 1 to 7 (P < .0001); VAS pain scores improved from 7 to 1 (P < .0001); VAS function scores improved from 3 to 6 (P=.0058); elevation improved from 52° to 126° (P < .0001); abduction improved from 55° to 116° (P=.0002); external rotation improved from 19° to 33° (P=.02); and internal rotation improved from S1 to L4 (P=.02). Twelve patients rated their outcome as excellent, 6 as good, 2 as satisfactory, and 1 as unsatisfactory. Severe glenoid erosion was seen in 10 of the shoulders and 5 of the defects required structural grafting. Three patients (14%) sustained a complication that required reoperation: 2 for infection and 1 for periprosthetic fracture. CONCLUSIONS: In patients with rheumatoid arthritis and rotator cuff deficiency, reverse shoulder arthroplasty can provide improvement in function and decreased pain.

Is a formal physical therapy program necessary after total shoulder arthroplasty for osteoarthritis?

HYPOTHESIS: A retrospective analysis was conducted of 2 consecutive groups of patients undergoing total shoulder arthroplasty (TSA) for primary osteoarthritis. One group was treated with formal physical therapy (PT), and one group was treated with home-based, physician-guided PT. We hypothesized that patients with a formal postoperative PT protocol would have significantly better postoperative clinical outcomes than patients with no formal PT. METHODS: Group A (43 patients) had a standard PT program. Group B (38 patients) had a home-based, physician-guided PT program. Clinical outcomes (preoperatively, 3, 6, and 12 months and most recent follow-up) were analyzed. A minimum sample size of 31 patients gives power to detect a 10-point American Shoulder and Elbow Surgeons (ASES) score (alpha=0.05, beta=0.80). RESULTS: ASES and Simple Shoulder Test (SST) scores significantly improved in both groups at all follow-up periods. Forward flexion and abduction were significantly improved in group B at all time points, whereas an initial improvement in forward flexion and abduction in group A was lost at final follow-up. There were no significant differences in final ASES or SST scores between groups at final follow-up. However, forward flexion, abduction, and the Short Form-36 physical component summary in group B were significantly better than group A at final follow-up. No significant improvements in internal rotation or SF-36 mental component summary were seen within or between the groups at final follow-up. Overall, there was no difference in patient satisfaction, with 88% satisfaction in group A and 95% satisfaction in group B (chi(2)=0.471, P=.4924). CONCLUSIONS: A home-based, physician-guided therapy program may provide adequate rehabilitation after TSA, allowing for a reduction in cost for the overall procedure.

Glenoid morphology in reverse shoulder arthroplasty: classification and surgical implications.

BACKGROUND: A great challenge in reverse shoulder arthroplasty is the wide variation in glenoid morphology that adds uncertainties in glenoid component placement. The purpose of this study was to classify glenoid morphology and examining its effect on possible glenoid component fixation. MATERIALS AND METHODS: The morphology of 216 glenoids was classified into normal and abnormal with subgroups defined by erosion sites. Six anatomic and 2 surgical parameters were compared among the classified groups. Plain radiographs or 2-dimensional (2D) computed tomography (CT) scans showed 62.5% of glenoids were normal and 37.5% were abnormal, with further subclassification of abnormal in posterior (17.6%), superior (9.3%), global (6.5%), and anterior (4.2%) erosions using 3D CT models. RESULTS: The standard centerline became significantly shorter in abnormal (19.6 +/- 9.1 mm) than in normal (28.6 +/- 4.1 mm, P < .0001) glenoids. Alternatively, the spine centerline provided longer bony distance in abnormal glenoids (34.9 +/- 17.0 mm). Abnormal glenoid morphology also reduced peripheral screw placement area by 42% and limited it to the anterior and inferior quadrants. DISCUSSION: Glenoid morphology of the rotator cuff deficient shoulder can be reliably classified using this classification system consisting of normal and abnormal, which included 4 subgroups of posterior, superior, global, and anterior erosions. CONCLUSIONS: Abnormal glenoid morphology was shown to have a significant effect on anatomical and surgical factors which can necessitate adjustments in surgical technique for reverse shoulder arthroplasty. LEVEL OF EVIDENCE: Basic Science Study.

Pyrolytic carbon endoprosthetic replacement for osteonecrosis and femoral fracture of the hip: a pilot study.

UNLABELLED: Hemiarthroplasty in young patients has the potential for eliminating bearing wear, but has the disadvantage of cartilage wear. Low-temperature isotropic (LTI) pyrolytic carbon reportedly reduces cartilage wear in canine hemiarthroplasties. We therefore initiated a study in humans when it was released for human use. However, we observed failures in some patients. We therefore document and report the high failure rate observed in a subset of patients treated with an LTI pyrolytic carbon femoral head for osteonecrosis. We conducted a prospective pilot study of 17 patients treated with a titanium stem and an LTI pyrolytic carbon femoral head bearing surface for unipolar hemiarthroplasty for either femoral neck fracture (10 patients) or osteonecrosis (seven patients). One of 10 patients in the fracture group underwent conversion to THA as a result of arthritic progression compared with six of seven patients with osteonecrosis who underwent conversion to THA as a result of acetabular wear and severe groin pain. In this small series, patients with osteonecrosis had a higher rate of revision compared with the patients treated for femoral neck fracture. LEVEL OF EVIDENCE: Level III, therapeutic study.

Revision reverse shoulder arthroplasty for glenoid baseplate failure after primary reverse shoulder arthroplasty.

BACKGROUND: The aim of this study is to document a single surgeon's experience performing revision reverse shoulder arthroplasty after baseplate failure. METHODS: Revision reverse shoulder arthroplasty (RSA) for mechanical failure of the glenoid baseplate after RSA was performed in 14 patients. Clinical and radiographic data were collected preoperatively, prior to baseplate failure, after baseplate failure, and at latest follow-up after revision (average, 33 months). RESULTS: When comparing the pre-operative values to post-revision, ASES, forward elevation, and abduction were significantly improved. There was no significant difference in any of the outcome measures when comparing the prefailure data to the post-revision data. The post-revision prosthesis-scapular neck angle (PSNA) showed a significant increase in inferior tilt of the baseplate when compared to pre-failure PSNA (P < .001). Two patients (14%) required a second revision RSA for glenoid baseplate failure (1) and dislocation (1); 1 additional patient developed a postoperative hematoma which resolved without surgery. CONCLUSION: Revision RSA for the treatment of glenoid baseplate mechanical failure can restore pain relief and function to the levels gained after the index RSA.

Revision arthroplasty with use of a reverse shoulder prosthesis-allograft composite.

BACKGROUND: Patients with disabling pain and loss of shoulder function with associated proximal humeral bone loss following shoulder arthroplasty have limited reliable treatment options. Our objective was to report the results, obtained as part of a prospective outcomes study, of the use of a reverse shoulder prosthesis-allograft composite in these patients. METHODS: Between 2002 and 2005, 353 patients treated with a reverse shoulder prosthesis were enrolled in a prospective cohort study. Twenty-five patients received, in addition, a proximal humeral allograft for the management of severe proximal humeral bone loss, and they comprise the study group. The average bone loss measured 53.6 mm (range, 34.5 to 150.3 mm). Patients were followed clinically with use of the American Shoulder and Elbow Surgeons (ASES) score, the Simple Shoulder Test (SST), and a scale with which the patients rated their satisfaction, and they were followed radiographically to detect mechanical failure, loosening, notching, and graft healing. All patients were followed for a minimum of two years (average, 30.2 months). RESULTS: The total average ASES score improved from 31.7 points preoperatively to 69.4 points at the time of follow-up (p < 0.0001), and the average SST score improved from 1.4 to 4.5 points (p < 0.0001). Nineteen patients (76%) reported a subjective good or excellent result, five reported a satisfactory result, and one reported that the result was unsatisfactory. The range of motion improved in forward flexion (from 32.7 degrees to 82.4 degrees ; p < 0.0001), abduction (from 40.4 degrees to 81.4 degrees ; p < 0.0001), and internal rotation. Radiographic evaluation at the time of final follow-up showed incorporation of the allograft in the metaphyseal region in 84% (twenty-one) of the twenty-five patients and incorporation of the allograft in the diaphyseal region in 76% (nineteen) of the patients. Four patients had complications. CONCLUSIONS: Use of a reverse shoulder prosthesis-proximal humeral allograft composite for the treatment of shoulder dysfunction following arthroplasty associated with substantial proximal humeral bone loss has shown promising early results. The allograft may restore proximal humeral bone stock, thereby helping to maintain the height of the prosthesis bone construct and thus deltoid tension. Additional, long-term studies are needed to evaluate the longevity of this construct.