Humeral surface replacement for osteoarthritis.

BACKGROUND AND PURPOSE: Humeral resurfacing has shown promising results for osteoarthritis, but revisions for glenoid erosion have been reported frequently. We investigated the hypothesis that preoperative glenoid wear and postoperative progress of glenoid erosion would influence the clinical outcome. METHODS: We reviewed 61 resurfacing hemiarthroplasties (55 patients) for primary osteoarthritis. 6 patients were lost to follow-up and 5 had undergone revision arthroplasty. This left 50 shoulders in 44 patients (mean age 66 years) that were followed for mean 30 (12-44) months. Complications, revisions, and the age- and sex-related Constant score were assessed. Radiographs were evaluated for loosening and glenoid erosion according to Walch. RESULTS: Of the 50 shoulders that were functionally assessed, the average age- and sex-related Constant score was 73%. In patients with preoperative type-B2 glenoids, at 49% it was lower than in type-A1 glenoids (81%, p = 0.03) and in type-B1 glenoids (84%, p = 0.02). The average age- and sex-related Constant score for patients with type-A2 glenoids (60%) was lower than for type-A1 and -B1 glenoids and higher than for type-B2 glenoids, but the differences were not statistically significant. In the total population of 61 shoulders, the radiographs showed postoperative glenoid erosion in 38 cases and no humeral prosthetic loosening. Revision arthroplasty was performed in 11 cases after 28 (7-69) months. The implant size had no statistically significant influence on the functional outcome. The size was considered to be adequate in 28 of the 50 functionally assessed shoulders. In 21 cases, the implant size was too large and in 1 case it was too small. INTERPRETATION: We found frequent postoperative glenoid erosion and a high rate of revision arthroplasty after humeral resurfacing for primary osteoarthritis. Oversizing of the implants was common, but it had no statistically significant influence on the functional outcome. Inferior results were found in the presence of increased eccentric preoperative glenoid wear. Total shoulder arthroplasty should be considered in these patients.

Short and midterm results of reverse shoulder arthroplasty according to the preoperative etiology.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has shown promising results for cuff tear arthropathy but the indication has been extended to fracture sequelae and revision shoulder arthroplasty with different preconditions. Further, the clinical relevance of inferior scapular notching for different etiologies is uncertain. Our hypothesis was that preoperative etiology as well as the occurrence of scapular notching would significantly influence the clinical outcome. METHODS: We reviewed 76 reverse shoulder arthroplasties for cuff tear arthropathy (45 patients), fracture sequelae (10 patients) and revision arthroplasty (21 patients) retrospectively. The follow-up consisted of 71 patients and the mean follow-up period was 23 months (±14 months). All patients were evaluated postoperatively using the Constant score adjusted for age and gender and the simple shoulder test. A radiological investigation was performed preoperatively and at the time of the final follow-up including the evaluation of scapular notching according to Sirveaux. For further evaluation of scapular notching, patients were separated into three groups according to the inferior glenosphere overlap: negative or no inferior overlap -6-0 mm), mild overlap (1-4 mm) and pronounced overlap (5-9 mm). RESULTS: After a mean follow-up of 23 months the average age- and gender-adjusted Constant score (CS) was 77.8 % (±26 %). According to the etiology, patients with cuff tear arthropathy (CTA) showed a higher CS of 83 % compared with patients with fracture sequelae (CS 73 %) and compared with patients who had undergone RSA as a revision for failed shoulder arthroplasty (CS 69 %). The difference was significant comparing the cuff tear arthropathy patients with the revision surgery patients (p = 0.035). Within the group of fracture sequelae, patients with type three sequelae according to the Boileau classification (surgical neck nonunion) had a significantly worse outcome compared with the type four fracture sequelae patients (severe tuberosity dislocation) (CS 57 vs. 87 %, p = 0.01). The overall complication rate was 27 % with 8 % infections and 9 % dislocations. Revision surgery was necessary in 11.5 % with removal or replacement of the implants in 8 %. Inferior scapular notching was detected in 43 % of the patients. These patients had an inferior CS (70 ± 18 %) compared with patients without scapular notching (84 ± 25 %, p = 0.015). The incidence of scapular notching was significantly reduced with an increasing inferior overlap of the glenosphere. CONCLUSIONS: In conclusion, we found the preoperative etiology to influence the clinical results after RSA with superior results given for cuff tear arthropathy and inferior results for revision arthroplasty and fracture sequelae type three. Further, we found a correlation between scapular notching and the clinical outcome. The inferior scapular notching was significantly reduced by an increased inferior glenosphere overlap. LEVEL OF EVIDENCE: Level IV, case series, treatment study.

Biomechanical comparison of open and arthroscopic Latarjet procedures.

PURPOSE: To biomechanically compare the effectiveness of the standard open and arthroscopic techniques of the Latarjet procedure to address a critical anterior glenoid defect in combination with a capsular insufficiency. METHODS: Translation testing of 12 human cadaveric shoulder specimens was performed in a robot-assisted setup under 3 different conditions: (1) intact/vented shoulder joint, (2) combined anterior glenoid bone and capsular defect, and (3) open and arthroscopic Latarjet procedures. Testing was performed for each condition in 2 test positions: 60° of glenohumeral abduction with neutral rotation (ABD position) and 60° of abduction and external rotation (ABER position). Each position was tested with a passive humerus load of 30 N in the anterior, inferior, and anteroinferior directions. Translational movement of the humeral head was evaluated with and without the application of a 10-N load to the conjoint tendon (CJT). RESULTS: In the ABD position, translations after the open Latarjet procedure significantly differed from the arthroscopic technique in the anterior and anteroinferior directions when testing was performed with loading of the CJTs (CJT loading). Without CJT loading, the open Latarjet technique showed significantly lower translations in the anterior, inferior (P = .004), and anteroinferior (P = .001) testing directions in the ABD position. In the ABER position, the arthroscopic procedure showed no significant difference compared with the standard open procedure. CONCLUSIONS: We found a superior stabilization effect of the open Latarjet technique in the ABD position. The difference is ascribed to the anterior capsular repair, which was performed within the open technique and omitted during the arthroscopic procedure. CLINICAL RELEVANCE: The reduction of translation in a pure abduction position of the arm is more effectively performed with a conventional open Latarjet technique that includes a capsular repair. In combined ABER position, there was no difference found between the open and arthroscopic Latarjet techniques.

Arthroscopic posterior shoulder stabilization with an iliac bone graft and capsular repair: a novel technique.

Several surgical approaches have been described for the treatment of recurrent posterior shoulder instability. Many authors have performed posterior bone block procedures with good results not only in the presence of glenoid bone loss or dysplasia but also in the case of capsular hyperlaxity and poor soft-tissue quality. Open techniques often require an extensive approach with the disadvantage of a poor cosmetic result and possible insufficiency of the deltoid muscle. Furthermore, the treatment of concomitant pathologies and the correct placement of the bone graft are difficult. Therefore we describe an all-arthroscopic posterior shoulder stabilization technique with an iliac bone graft and capsular repair that is intended to improve the pre-existing open procedure. The key steps of the operation are the precise placement and screw fixation of the bone block at the posterior glenoid under arthroscopic control and the subsequent posterior capsular refixation and plication using 2 suture anchors to create an extra-articular graft position.

Olfactory groove meningiomas: clinical outcome and recurrence rates after tumor removal through the frontolateral and bifrontal approach.

OBJECTIVE: Olfactory groove meningiomas account for 8 to 13% of all intracranial meningiomas. Surgical removal is often performed through the bifrontal, unilateral subfrontal (frontolateral), or pterional approach. We report on the clinical outcome and recurrence rate after surgical treatment of olfactory groove meningiomas in our neurosurgical department. METHODS: A retrospective study was conducted by analyzing the charts of the patients, including surgical records, discharge letters, histological records, follow-up records, and imaging studies. RESULTS: A total of 1800 meningiomas were operated on between 1978 and 2002 in our department. There were 82 patients with olfactory groove meningiomas, including 63 women and 19 men with a mean age of 57.8 years (age range, 33-91 yr). Most patients presented with mental disturbance. Tumors were operated through the bifrontal (n = 46), frontolateral (n = 34), and pterional (n = 2) approaches. Total tumor removal (Simpson Grade 1 or 2) was achieved in most cases (91.2% frontolateral, 93.5% bifrontal). Perioperative mortality was 4.9% (four out of 82 patients, all operated through the bifrontal approach). The overall recurrence rate was 4.9%, with four patients requiring surgery. The mean follow-up period was 63.4 months (range, 4-270 mo). CONCLUSION: Olfactory groove meningiomas were removed mainly through two different surgical approaches. Even in large tumors, high rates of total tumor resection could also be achieved with low recurrence rates using the simple and minimally invasive frontolateral approach. In recent years, we have preferred to use the frontolateral approach, which provides quick access to the tumor with less brain exposure while still enabling total tumor removal with a low morbidity rate and no mortality.

Olfactory groove meningiomas: clinical outcome and recurrence rates after tumor removal through the frontolateral and bifrontal approach.

OBJECTIVE: Olfactory groove meningiomas account for 8 to 13% of all intracranial meningiomas. Surgical removal is often performed through the bifrontal, unilateral subfrontal (frontolateral), or pterional approach. We report on the clinical outcome and recurrence rate after surgical treatment of olfactory groove meningiomas in our neurosurgical department. METHODS: A retrospective study was conducted by analyzing the charts of the patients, including surgical records, discharge letters, histological records, follow-up records, and imaging studies. RESULTS: A total of 1800 meningiomas were operated on between 1978 and 2002 in our department. There were 82 patients with olfactory groove meningiomas, including 63 women and 19 men with a mean age of 57.8 years (age range, 33-91 yr). Most patients presented with mental disturbance. Tumors were operated through the bifrontal (n = 46), frontolateral (n = 34), and pterional (n = 2) approaches. Total tumor removal (Simpson Grade 1 or 2) was achieved in most cases (91.2% frontolateral, 93.5% bifrontal). Perioperative mortality was 4.9% (four out of 82 patients, all operated through the bifrontal approach). The overall recurrence rate was 4.9%, with four patients requiring surgery. The mean follow-up period was 63.4 months (range, 4-270 mo). CONCLUSION: Olfactory groove meningiomas were removed mainly through two different surgical approaches. Even in large tumors, high rates of total tumor resection could also be achieved with low recurrence rates using the simple and minimally invasive frontolateral approach. In recent years, we have preferred to use the frontolateral approach, which provides quick access to the tumor with less brain exposure while still enabling total tumor removal with a low morbidity rate and no mortality.

Tuberculum sellae meningiomas: clinical outcome considering different surgical approaches.

OBJECTIVE: Tuberculum sellae meningiomas present a special challenge because of their proximity to arteries of the anterior circulation, anterior visual pathways, and the hypothalamus. The authors report on the clinical outcome after surgical treatment of tuberculum sellae meningiomas in our neurosurgical department. METHODS: A retrospective study was conducted analyzing the charts of the patients, including surgical records, discharge letters, histological records, follow-up records, and imaging studies. Patients with associated neurofibromatosis Type 2 were excluded from the study. RESULTS: One thousand eight hundred meningiomas were operated on between 1978 and 2002. Seventy-two of these patients had tuberculum sellae meningiomas; four had undergone previous surgical procedures in outside hospitals. Fifty-five patients were women; 17 were men. Their mean age was 54.3 years (range, 30-86 yr). All patients had visual disturbances at presentation. Tumors were operated through the bifrontal approach (n = 21, from 1978 through 1995), the pterional/frontotemporal approach (n = 21, from 1982 through 2002), and the frontolateral approach (n = 30, from 1984 through 2002). Total tumor removal was achieved in most patients (Simpson 1 + 2, 91.7%). The perioperative mortality rate was 2.8% (two out of 72 patients). Immediate postoperative improvement of visual disturbance was observed in 65% of patients. Visual improvement was dependent on the duration of preoperative visual symptoms, but not on preoperative visual acuity or tumor size. The visual improvement rate was significantly better in patients who underwent frontolateral tumor resection (77.8%) compared with those who underwent bifrontal craniotomy (46.2%). The overall recurrence rate was 2.8% (two out of 72 patients). The mean follow-up time for all patients was 4 to 238 months (mean, 45.3 mo [3.8 yr]). CONCLUSION: From 1978 through 2002, tuberculum sellae meningiomas were removed microsurgically using three different surgical approaches. Considering the operative morbidity and mortality, the frontolateral and pterional approach provided remarkable improvement compared with the bifrontal approach. These approaches allowed quick access to the tumor and were minimally invasive with less brain exposure, but still engendered high rates of total tumor removal. By comparison, the frontolateral approach provided the best results concerning visual outcome while representing the least invasive surgical approach.