Proximal humeral bone loss in stemless shoulder arthroplasty: potential factors influencing bone loss and a new classification system.

INTRODUCTION: Proximal humeral bone loss in total shoulder arthroplasty (TSA) is more frequent than in hemiarthroplasty. Factors such as age, gender, inclination angle, and radiolucent lines may also contribute. Additionally, current bone loss grading systems are often not sensitive enough to detect slight bone changes, especially at the medial calcar where bone loss is commonly observed. This study uses a new, more detailed bone loss grading system to evaluate factors that could influence bone loss at the proximal humerus. MATERIALS AND METHODS: In this single-center prospective study, patients underwent hemiarthroplasty or TSA with an anatomic stemless prosthesis. Bone loss was measured at the proximal humerus using the new grading system. The effect of treatment type, age, gender, radiolucent lines, and inclination angle on bone loss was evaluated. The Constant-Murley score of patients was assessed and complications recorded. RESULTS: Ninety-one shoulders were available for the final follow-up examination at a median of 85.0 months (range 82.6-121.1 months). Bone loss was found at the proximal humerus in approximately one-third of shoulders, and significantly more shoulders had bone loss in TSA than in hemiarthroplasty (P = 0.03). However, this difference was no longer significant after stratifying by gender and age (P > 0.05). Bone loss significantly correlated with gender (P = 0.03) but not with treatment type, radiolucent lines, and the postoperative inclination angle (P > 0.05). Most Constant-Murley score components did not differ significantly between shoulders with and without bone loss (P > 0.05). Lastly, six complications and four revisions were reported. CONCLUSIONS: Results showed gender had the greatest influence on bone loss after stemless shoulder arthroplasty. Furthermore, both patients with or without bone loss can expect similar clinical outcomes with the stemless prosthesis used in this study. Lastly, the new grading system is simple and straightforward to use.

Conversion of Hemiarthroplasty to Reverse Shoulder Arthroplasty with Humeral Stem Retention.

The purpose of this study is to evaluate the mid-term clinical results of an ongoing case series on conversion reverse shoulder arthroplasty (RSA) with a modular prosthesis system. We included 17 elderly patients revised for failed hemiarthroplasty after proximal humeral fracture, of which 13 were converted using a modular reverse shoulder prosthesis. Four could not be converted due to overstuffing. For the conversion RSA, we determined the Constant score, American Shoulder and Elbow Surgeons Shoulder Score, visual analogue scale for pain and satisfaction, and range of motion preoperatively, at one year, and at the last follow-up. All measured clinical outcomes improved significantly at both follow-up time points (p < 0.05). The mean duration of surgery was 118.4 min (range: 80.0 to 140.0 min). We observed complications in three patients; these included one late infection and two aseptic stem loosenings. Modular shoulder arthroplasty is a suitable procedure for conversion RSA in elderly patients. All measured postoperative clinical outcomes improved significantly, the complication rate was acceptable, and no prosthesis-related complications occurred. Conversion RSA, although not feasible in every case, is a viable treatment option in the elderly, which can provide successful mid-term results.

Reverse total shoulder arthroplasty in massive rotator cuff tears: does the Hamada classification predict clinical outcomes?

INTRODUCTION: Reverse total shoulder arthroplasty (RTSA) is a widely recognized treatment to reduce pain and improve shoulder function for patients in various disease stages of cuff tear arthropathy (CTA). However, it remains unclear whether outcomes after RTSA depend on the preoperative stage of CTA. Therefore, this study evaluated whether the Hamada classification influences midterm clinical outcomes after RTSA. MATERIALS AND METHODS: In this multicenter observational study, patients underwent inverted bearing RTSA for massive rotator cuff tears or CTA. Shoulders were grouped into those with (Hamada grades 4a, 4b, and 5) and those without (Hamada grades 1, 2, and 3) glenohumeral arthritis. Clinical outcomes, including range of motion, Constant score, American Shoulder and Elbow Surgeons score, and visual analog scale for pain and satisfaction, were determined preoperatively and at 24 and > 30 months. All complications were recorded, and survival free from any implant component revision was calculated. RESULTS: Overall, 202 patients (211 shoulders) were treated with RTSA at a mean age of 75.8 ± 6.6 years (range 41.9-91.6 years). Of these, 144 patients (151 shoulders) were available for a mean follow-up of 79.9 ± 24.7 months (range 30.2-132.3 months). No significant between-group differences were found for clinical outcomes at 24 and > 30 months (P > 0.05). Furthermore, the Hamada classification did not correlate with clinical outcomes at 24 (P = 0.98) and > 30 months (P = 0.29). Revision-free implant component survival was similar between groups (P = 0.17). Postoperative complications were found in 11 shoulders, of which 10 required revision. CONCLUSIONS: Inverted bearing RTSA was found to be an effective treatment with similarly good midterm clinical outcomes, similar revision rates, and high implant survival rates in every stage of massive rotator cuff tears. Overall, the preoperative Hamada classification did not influence clinical outcomes or complications after RTSA.

Inverted-bearing reverse total shoulder arthroplasty: scapular notching does not affect clinical outcomes and complications at up to 7 years of follow-up.

BACKGROUND: Scapular notching is a common complication of reverse total shoulder arthroplasty (RTSA). Inverted-bearing RTSA (IB-RTSA) systems, with polyethylene (PE) glenospheres and metal or ceramic humeral liners, reduce notching and PE wear compared with traditional Grammont prosthesis designs. However, whether notching after IB-RTSA influences clinical outcomes or complications remains unknown. Therefore, we evaluated the influence of notching on midterm clinical outcomes and complication rates after IB-RTSA. METHODS: In our prospective multicenter, observational study, patients underwent IB-RTSA, using a prosthesis system with a PE glenosphere and a metal humeral component. We assessed patients clinically for functional scores, active range of motion, and pain and radiographically for notching. RESULTS: Overall, 270 patients (284 shoulders) were treated with IB-RTSA. Of these, 229 shoulders were available for a mean follow-up of 86.7 months (range, 24.0-133.4 months). We observed notching in 35% of shoulders (28% grade 1; 3% grade 2; and 4% grade 3). IB-RTSA led to a distinct type of notching representing the mechanical indent of the humeral component into the scapular neck without PE-induced osteolysis. Patients with and without notching showed similar clinical outcomes (P ≥ .05), complication rates (P = .23), revision rates (P = .87), and survival of implant components after 10 years (P = .85). CONCLUSIONS: Midterm results confirmed our hypothesis that patients with notching had equally good clinical outcomes and low complication rates as patients without notching. Additionally, we found a distinct type of notching without signs of PE-induced osteolysis.

Treatment effects of reverse total shoulder arthroplasty - a simple method to measure outcomes at 6, 12, 24 and 60 months for each patient.

BACKGROUND: Although shoulder arthroplasty is less common than knee or hip arthroplasty, the number of procedures being performed is increasing rapidly. The treatment effect is a simple method to measure outcome of joint replacement. The method was applied to measure results of total hip/knee arthroplasty but not yet for shoulder arthroplasty. METHODS: Included were patients with unilateral cuff arthropathy (Hamada grades > = 2) treated with reversed total shoulder arthroplasty (RSA) in this prospective multicenter study. The patients were assessed with the ASES questionnaire. The treatment effects (TE) was calculated for each patient. TE = score reduction/baseline score. A positive TE means amelioration, TE = 0 unchanged, and a negative TE means worse. The primary aim was to calculate the TE's for RSA at 6, 12, 24, and 60 months postoperatively. The secondary aim was to analyze the influence of confounders (preoperative Hamada grade, age, gender, dominance, side of the affected shoulder, general co-morbidities measured using ASA grade). RESULTS: Two hundred three patients were included for this analysis of whom 183 patients had a complete 2 year follow up. Two years postoperatively the mean ASES score augmented significant from 20.5 to 78.7 (p < 0.001). The 2 year TE's ranged from 1 to 0.09. We had no patient with a negative TE. A higher Hamada grade was associated with better TE's (Hamada grade 4+ vs. 2, p-value 0.042). For age and dominant side there were weak associations where those aged 80+ and dominant side had better TE's. The patients with higher ASA grade had lower TE's (ASA grade 4+ vs. 1, p-value 0.013). The mean TE's were 0.77 at 6-months, 0.81 at 1 year, 0.76 at 2 years and 0.73 at 5 years. CONCLUSIONS: The outcome for reverse shoulder arthroplasty can be measured with the treatment effect method; the 2 years TE's vary from 1 to 0.09. The mean treatment effects change little in the first five postoperative years (from 0.73 to 0.81). The confounders for better TE's were: higher severity of cuff arthropathy (Hamada grade 3, 4 and 5), less co-morbidities (ASA Grade 1), higher age (80+) and dominant side. Gender did not influence the 2-year TE's. TRIAL REGISTRATION: Comité intercantonal d'éthique (Jura, Fribourg, Neuchâtel), number 01/2008, 24.09.2008.

Adjustable stemmed shoulder hemiarthroplasty: Ten-year results of a prospective multicentre study.

BACKGROUND: Adjustable shoulder hemiarthroplasty (HA) allows the complex anatomy of the proximal humerus, including its centre of rotation, to be restored. However, whether better anatomical adaptation improves clinical outcomes and long-term survival remains unclear. Therefore long-term clinical and radiographic results of an eccentric adjustable hemiprosthesis were examined, focusing on the longevity and fixation of the humeral stem. HYPOTHESIS: Adjustable shoulder HA enhances long-term functional outcomes and reduces complications. MATERIALS AND METHODS: In this prospective multicentre study, 120 HAs were performed using a stemmed hemiprosthesis on 115 patients. The clinical and radiologic outcomes were measured at 3, 6, 12, and 24 months, and thereafter at 4, 7, and 10 years with a median follow-up period of 7.7 years (92.3 months, range 2.6-148.5 months). Revision-free survival rates were calculated up to 10 years postoperatively. RESULTS: The mean Constant-Murley score increased over the first 24 months from 26.2±9.0 to 61.0±17.3 points, then levelled off until the final follow-up. Patients with humeral head necrosis had the best clinical outcomes, while patients with fracture sequelae and rheumatoid arthritis had the worst. Although radiolucent lines were more frequent after cemented fixation, lines of>2mm only occurred after uncemented fixation. Finally, five cases required secondary glenoid implantation, and survival free from stem revision was 99.0% (95% confidence interval [CI], 92.8%-99.9%) at 4 years, 97.6 (95% CI, 90.6%-99.4%) at 7 years, and 92.2% (95% CI, 81.9%-96.8%) at 10 years. DISCUSSION: The study showed that adjustable shoulder HA is a safe and effective treatment option for various degenerative disorders of the shoulder joint. Functional scores first increased, then levelled off after 24 months. Moreover, revision-free survival compared well with previously reported values. Observed stable long-term results confirm that adjustable shoulder HA has beneficial clinical outcomes and a low complication rate.

Indication, Technique and Long-term Results after Shoulder Arthrodesis Performed with Plate Fixation.

AIM: Arthrodesis of the shoulder joint is a radical event, so it is difficult to explain its significance to patients. It has been the last resort in hopeless cases. Knowledge of long-term results and evaluation of advantages and disadvantages seems to be helpful in this regard. METHODS: Eleven patients with mean age of 45 (31 - 58) years were operated between 2000 and 2013. All patients could be included in the investigation (FU mean 8.5 [3 - 16] years; 8 male and 3 female; right 9, left 2). Patients had the following indications: persistent instability 5 (2 with epilepsy), rotator cuff rupture 2 (1× after combined latissimus dorsi and teres major transfer), brachial plexus injury/defect 2, locked dislocation 1 and posttraumatic arthropathy 1. Fixation with DC plate (pre-bent to 110°) was used in all cases; with special focus on placing at least one screw in the scapular neck. The targeted arthrodesis position was abduction 30°, forward flexion 30°, and internal rotation 30°. RESULTS: Active abduction improved from 12 to 63°, forward flexion from 21 to 79° and internal rotation from 10 to 47° (mean values). In the resting position with hanging arm aside, mean abduction was 3° and forward flexion 8°. Nine of 11 patients had considerable relief of pain, from 8.3 to 2.4 points VAS. Five patients rated the outcome as excellent, 3 as good and 1 as satisfactory. Nine patients would repeat the procedure. In summary, an Oxford Shoulder Score of 31.6 points was achieved, and SSV of 58%. Bony fusion was achieved in all cases, 3 - 4 months p. o. in mean. There were no important neurological or angiological complications. CONCLUSIONS: Plate arthrodesis in the technique used achieves high fusion and a low complication rate. Relief of pain and functional improvement are astonishing. Analysis of our results indicates that correction of the positions mentioned above is necessary: i. o. arthrodesis position for abduction 25° (by means of pre-bending plate of 105°), forward flexion 20° and internal rotation 30° are suggested.

Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears.

BACKGROUND: Irreparable posterosuperior rotator cuff tears are treated in several ways. Transfer of the latissimus dorsi is an alternative with acceptable mid-term results, but long-term results have rarely been published. METHODS: The cases of 108 consecutive patients with 115 shoulders treated with latissimus dorsi transfer between 2000 and 2005 were reviewed clinically and radiographically. Ninety-three shoulders in eighty-six patients were included in the follow-up analysis. The mean duration of follow-up was 9.3 years (range, 6.6 to 11.7 years), and the mean age at the operation was fifty-six years (range, forty to seventy-two years). Outcome measures included the Constant-Murley score (Constant score), American Shoulder and Elbow Surgeons (ASES) index, and visual analog scale (VAS) for pain. The progress of cuff tear arthropathy was determined with radiographic evaluation according to the system described by Hamada et al. RESULTS: The mean relative Constant score improved from 44% preoperatively to 71% at the time of follow-up (p < 0.0001, effect size = 0.6), excluding the clinical failures. Similarly, the mean ASES index improved from 30 to 70 (p < 0.0001, effect size = 0.7), and the mean VAS score decreased from 7.8 to 2.4 (p < 0.0001, effect size = 0.8). A pain-free outcome was reported in only eighteen shoulders (19%). Active shoulder movement improved significantly (p < 0.05). The mean Hamada radiographic grade of cuff tear arthropathy increased from 1.7 (range, 0 to 2) preoperatively to 2.2 (range, 1 to 5) (p < 0.0001, effect size = 0.2). The rate of clinical failure of latissimus dorsi transfer was 10%, and the rate of shoulder prosthetic replacement after latissimus dorsi transfer was 4%. CONCLUSIONS: Pain relief and improvement of shoulder function were maintained a mean of 9.3 years after latissimus dorsi transfer for irreparable posterosuperior cuff defects. The younger the patient, the better the outcome.

Reversed shoulder arthroplasty with inversed bearing materials: 2-year clinical and radiographic results in 101 patients.

INTRODUCTION: This study documents 2-year clinical and radiographic results following reversed total shoulder arthroplasty using a novel prosthesis with inverted bearing materials (polyethylene glenoid; metal humeral component). This design was intended to avoid massive PE abrasion on the humeral side. Therefore, we predicted a lack of subsequent osteolysis-induced exacerbation of scapular notching, and because of other design features and modified operating technique a reduced notching rate. MATERIALS AND METHODS: An ongoing, prospective, international, multicenter study of patients implanted with a novel prosthesis at six European centers. The current analysis presents 2-year follow-up data (patients operated between December 2007 and July 2009). Clinical evaluation tools comprised the Constant-Murley score (CS), the American Shoulder and Elbow Surgeon score, range of motion, and a visual analog scale to assess pain and satisfaction. Radiographs were evaluated for notching and radiolucent lines. Any complications were recorded. RESULTS: In total, 113 prostheses (113 patients) with a mean follow-up of 27.6 (±3.6) months were analyzed. CS increased from 22.5 (±13.7) to 65.3 (±14.9) points (p = 0.06). Inferior scapular notching (only grade 1 and 2) was identified in 20.5 % of patients, with no signs of PE-induced osteolysis. 4.4 % of patients experienced an implant-related complication. CONCLUSIONS: Inversion of the materials led to another type of notching with no signs of PE-induced osteolysis and no increase in the risk of short-term complications. Clinical results were comparable with other prostheses. Mid- to long-term results are required before any firm conclusions on clinical outcome and survival can be drawn.

Two-year follow-up of revision total hip arthroplasty using a ceramic revision head with a retained well-fixed femoral component: a case series.

INTRODUCTION: It is known that a well-fixed stem can be left in situ when only the acetabular component and femoral head have to be changed. However, in a revision case, the use of a ceramic head on an existing taper is not recommended. Slight damages of the taper may increase the risk of a ceramic fracture. Until now in a revision case a primary ceramic-on-ceramic or ceramic-on-polyethylene pairing was changed to a metal-on-polyethylene pairing or the well-fixed stem was removed as well. During the past several years, a ceramic head with a metallic sleeve has been introduced as an option for revisions with a stem left in situ. We report short-term results of a ceramic revision head in this clinical setting. METHODS: Eight patients with a ceramic revision head were clinically and radiologically followed up two years after revision surgery. Their Harris Hip Score and visual analogue scale scores for pain and satisfaction were recorded, and their radiographs were checked for osteolysis and heterotopic ossifications. RESULTS: The mean Harris Hip Score increased from 46.5 points before surgery to 88.3 points 2 years after surgery. The mean visual analogue scale score for pain improved from 6.7 to 1.1, and the mean visual analogue scale for satisfaction rose from 5.1 to 8.3. The radiological results did not show osteolysis in any of the patients. Grade I heterotopic ossification according to the Brooker classification system was seen in one patient. CONCLUSIONS: The early clinical and radiological results in this case series are in agreement with previously published studies. Ceramic revision heads with a metallic sleeve are a promising approach in the revision of a ceramic head with a well-fixed stem which can be left in situ. This solution avoids an unnecessary exchange of a well-fixed stem and thereby shortens the surgical time of the revision and may reduce the peri-operative complications.

Glenoid morphology affects the incidence of radiolucent lines around cemented pegged polyethylene glenoid components.

PURPOSE: Radiolucent lines (RLL) are frequent findings around cemented all-polyethylene glenoid implants. The present study evaluates the frequency, extend and the clinical impact of RLL around a cemented two-pegged glenoid implant with special focus on the influence of preoperative glenoid morphology. Our hypothesis was that glenoid morphology does not affect clinical outcome and RLL in the investigated setting. METHODS: Between 2003 and 2008, a total of 113 cases of total shoulder arthroplasties (Affinis, Mathys Ltd Bettlach, Switzerland) were performed in three surgical centres using a pegged cemented polyethylene glenoid component. A total of 90 cases could be evaluated clinically and radiographically. Clinical outcome was analysed using the constant score (CS) and range of motion assessment. Radiographic evaluation was performed in true anterior-posterior and axial views with special focus on loosening and RLL. Further, preoperative glenoid morphology was documented and its correlation to radiolucent lines and clinical outcomes was evaluated. RESULTS: At a mean of 58.8 (range 31.2-92.5)-month follow-up the CS improved from 21.5 points preoperatively to 62.3 points postoperatively. Radiolucent lines were found in 76.6 % of cases. If present, RLL were located at the backside of the implant (74.4 %) in the majority of the cases not around the pegs (10 %). There was no significant correlation between RLL and clinical outcome or follow-up time. The amount and extend of RLL were correlated to glenoid morphology with significantly higher values for glenoid types B2 and C according to Walch in comparison to glenoid types A1, A2 and B1. CONCLUSIONS: RLL did not affect clinical outcome and did not correlate with the follow-up time. Patients with glenoid morphology types B2 and C showed significantly worse radiographic results. LEVEL OF EVIDENCE: Level IV case series study.

Variability of medial and posterior offset in patients with fourth-generation stemmed shoulder arthroplasty.

PURPOSE: Most anthropometric data on the proximal humerus has been obtained from deceased healthy individuals with no deformities. Endoprostheses are implanted for primary and secondary osteoarthritis, rheumatoid arthritis,humeral-head necrosis, fracture sequelae and other humeral-head deformities. This indicates that pathologicoanatomical variability may be greater than previously assumed. We therefore investigated a group of patients with typical shoulder replacement diagnoses, including posttraumatic and rheumatic deformities. MATERIAL AND METHODS: One hundred and twenty-two patients with a double eccentrically adjustable shaft endoprosthesis served as a specific dimension gauge to determine in vivo the individual humeral-head rotation centres from the position of the adjustable prosthesis taper and the eccentric head. RESULTS: All prosthesis heads were positioned eccentrically.The entire adjustment range of the prosthesis of 12 mm medial/lateral and 6 mm dorsal/ventral was required. Mean values for effective offset were 5.84 mm mediolaterally[standard deviation (SD) 1.95, minimum +2, maximum +11]and 1.71 mm anteroposteriorly (SD 1.71, minimum −3,maximum 3 mm), averaging 5.16 mm (SD 1.76, minimum +2,maximum + 10). The posterior offset averaged 1.85 mm(SD 1.85, minimum −1, maximum + 6 mm). CONCLUSIONS: In summary, variability of the combined medial and dorsal offset of the humeral-head rotational centre determined in patients with typical underlying diagnoses in shoulder replacement was not greater than that recorded in the literature for healthy deceased patients.The range of deviation is substantial and shows the need for an adjustable prosthetic system.

Wear-induced loss of mass in reversed total shoulder arthroplasty with conventional and inverted bearing materials.

The notching phenomenon is one of the major concerns with reversed total shoulder arthroplasty. Repetitive contact between the humeral implant and the scapula (mechanical notching) produces progressive abrasion of the implant if the moving part is made of polyethylene. Its debris may then lead to active osteolysis (biological notching). Inversion of bearing materials, i.e. Glenosphere made of polyethylene and humeral Inlay made of metal, aims at the reduction of this phenomenon. However, the question arises if the tribological behavior would then be different. On an experimental setup, the gravimetric wear of both material configurations was measured after loading and moving over 500,000 cycles. The abrasion of the polyethylene Inlay due to mechanical notching was calculated by means of 3D CAD models with different notching stages. The loss of mass due to gravimetric wear was compared to the loss of mass caused by mechanical notching. After 500,000 cycles the measured amount of wear of the polyethylene components was between 8 and 10 mg for both tribological pairings. The calculated loss of mass of the polyethylene Inlay caused by mechanical notching ranged from 73 to 3881 mg. The results of this study indicate that the gravimetric polyethylene wear in the estimated life-time is very low and not significantly different between both material configurations. However, the polyethylene abrasion due to mechanical notching in the configuration with polyethylene Inlay is by far more important than any gravimetric wear. These results support the continued use of inverted bearings in reversed total shoulder arthroplasty.

Replication of the rotational center of the humeral head with second-generation stemmed prostheses.

OBJECTIVES: Reconstruction of the anatomy of the proximal humerus is an indispensible prerequisite to achieve good clinical results and long-term prosthesis stability. Modern, adjustable prostheses have greater flexibility of inclination, retrotorsion, as well as medial and dorsal offset, in comparison to older prostheses. Such improvements are expected to allow for more accurate reconstruction of the anatomical condition, such as targeted reconstruction of the primary and the secondary rotational centers. METHODS: The reconstruction of the humeral rotational center was assessed in 48 second-generation prostheses. All reconstructions were compared by radiographic parameters with the preoperative state and the operated opposite side. RESULTS: The positions of the new rotational centers after arthroplasty were not close to those of pre-operative and healthy opposite side's radiographs. No characteristic change in the position of the humeral head, or of its rotational center was detected. CONCLUSION: Second-generation prostheses can only provide a limited reconstruction of the original anatomy in shoulder hemiarthroplasty. In contrast, the modern third- and fourth-generation modular prostheses with variable inclination are more potent in replicating the original shoulder anatomy with its primary and secondary rotational centers.

Prospective study of double-eccentric hemi shoulder arthroplasty in different aetiologies: midterm results.

This prospective study aimed to analyse the effect of a newly developed double-eccentric adjustable stemmed prosthesis on reconstruction of the osseous anatomy, range of motion, strength and pain relief. A total of 91 consecutive hemiprostheses were evaluated preoperatively and three, six, 12, 24 and 48 months postoperatively (mean±SD 46.2 ± 10.9 months) by the American Shoulder and Elbow Surgeons (ASES) and Constant scores as well as radiological assessment. Clinical evaluations showed an increase in Constant score from 21.9 to 64.8 points and in ASES score from 24.9 to 77.9 points after two years. The results depend mainly on the underlying pathology. The best results were observed for primary osteoarthritis and avascular necrosis of the humeral head. All heads were eccentrically positioned. Specific stem-related complications were not observed. Because of the eccentric positioning of all heads it is reasonable to use adjustable shaft prostheses. The clinical results are comparable to data in the literature. Additional study provided a better or comparable clinical outcome and a low revision rate, when compared with other modern adjustable implants in the literature.

Differences in reconstruction of the anatomy with modern adjustable compared to second-generation shoulder prosthesis.

Reconstruction of the anatomy of the proximal humerus is a prerequisite to achieving good long-term clinical results after shoulder arthroplasty. Modern, adjustable prostheses have greater flexibility of inclination, retroversion, and medial and dorsal offset in comparison with older prostheses. Such improvements should allow for better reconstruction of the centre of rotation compared to older prostheses. Reconstruction of the humeral head centre was assessed in 106 modern adjustable (Affinis) and 47 second-generation prostheses. All reconstructions were compared both to the preoperative state and the unoperated shoulder. To describe the pre- and postoperative states, the geometry and position of the humeral head in relation to the glenoid were analysed on patient radiographs. Applying the defined parameters, modern adjustable prostheses showed better reconstruction than second generation prostheses. Parameter values measured in reconstructions using fourth generation prostheses were comparable to those of the unoperated shoulder, but differed significantly from the preoperative state. Second generation prostheses, in contrast, only show non-specific differences in parameter values. This suggests that an approximate reconstruction of normal anatomy can be achieved using a modern fourth generation prosthesis. Reconstruction of the complex anatomy of the proximal humerus is significantly better with modern adjustable prostheses compared to second generation prostheses. Improved clinical outcome can therefore be predicted in a functional and intact rotator cuff. The advantage of using modern prostheses systems over older models is clearly demonstrated in this study.

Reversed shoulder arthroplasty in cuff tear arthritis, fracture sequelae, and revision arthroplasty.

BACKGROUND AND PURPOSE: Reversed shoulder arthroplasty may be used for severe arthropathy where conventional prostheses cannot restore the function sufficiently. We analyzed the medium-term results and potential complications of the reversed prostheses, and also the influence of etiology on the result. METHODS; 52 women and 7 men, average age 70 (60-82) years, were followed for mean 4 (2-7) years. The indications were cuff tear arthropathy (CTA) (23), fracture sequelae (20), and revision of a failed conventional arthroplasty (16). RESULTS: The average Constant score improved from 18 (2-55) points to 59 (17-96) points. It rose from 26 to 74 points in patients with CTA, from 12 to 48 in those with fracture sequelae, and from 10 to 54 points in revision arthroplasty. We also found an overall improvement in active forward flexion from 47 degrees to 105 degrees , and in active abduction from 46 degrees to 93 degrees . Scapular notching was seen in 51 shoulders. Radiolucent lines below the base-plate were present in 2 cases. There were no instances of loosening. Revisions were necessary in 15 patients: 5 with infections (all had had prior surgery), 5 with hematoma, 3 with dislocations, and 2 with disconnections of the shaft components. INTERPRETATION: Reversed prosthetic replacement is a suitable method for restoring function and attaining pain relief in severe arthropathies. The results in revision arthroplasty are less predictable, with complications and revision rates higher than those in CTA patients. The reversed prosthesis should therefore only be used when conventional methods have failed.

Anatomic and reverse shoulder prostheses in fracture sequelae of the humeral head.

OBJECTIVES: Arthroplasty for the proximal humerus problems secondary to fractures is troublesome, because of necrosis of the tubercles and the resulting insufficiency of the rotator cuff. The aim of this study was to investigate whether better results can be achieved with the differential use of anatomic and reverse shoulder prostheses, in comparison to the preoperative status. METHODS: Fifty-five patients with secondary fracture prostheses due to sequelae of fractures of the humeral head were followed. Anatomic prostheses were implanted in 36 cases (fracture sequelae types 1 and 2 according to Boileau), and reversed prostheses were implanted in 19 cases (fracture sequelae types 3 and 4). RESULTS: The mean scores of the patients improved from 19 to 68 points (anatomic prosthesis) for fracture sequelae types 1 and 2, and from 9 to 47.5 points (reverse prosthesis) for fracture sequelae types 3 and 4. CONCLUSION: The differential use of anatomic and reversed shoulder prostheses in secondary fracture treatment leads to an improvement in postoperative results. In fracture sequelae types 1 and 2, the anatomic prosthesis is a better choice. However, in fracture sequelae types 3 and 4 with severe deformities, the reversed prosthesis is clearly superior to the anatomic prosthesis.

Improved range of motion after medial-based T capsular shift for recurrent post-traumatic anterior shoulder dislocation.

Postoperative function and recurrence rates are reportedly similar following open and arthroscopic procedures for recurrent anterior instability of the shoulder. However, various studies have reported greater restriction of shoulder mobility with open stabilisation. Sixty-two patients with post-traumatic recurrent anterior instability of the shoulder underwent anatomic reconstruction of the capsular-labral complex using a medial-based T capsular shift. They were investigated preoperatively and 53 of them were reexamined at an average of 41.5 months after operation. Function and stability improved: the Rowe score increased from 33.2 to 80.6, the Constant score from 81.5 to 89.8 points. Pre- and post-operative mobility of the affected shoulder was reduced in all planes of movement compared to the contralateral side. Passive mobility did not deteriorate in any direction with surgery. Passive adduction, forward flexion and external rotation in 90 degrees abduction of the arm improved significantly and active mobility rose to the values of the contralateral side. The restriction of mobility noted postoperatively thus appears as a consequence of the underlying pathology rather than of the surgical procedure. The recurrence rate after primary stabilisation was 1.6%. Based on these findings, the medial-based T capsular shift remains an appropriate surgical option in the treatment of chronic post-traumatic anterior instability of the shoulder.

Latissimus dorsi transfer for irreparable rotator cuff tears: a longitudinal study.

Latissimus dorsi transfer is indicated for isolated posterior superior defects of the rotator cuff. Additional lesions limit the success of the outcome, but they are relatively frequent in revision surgery. We analyzed their influence on the postoperative function in 52 patients with an irreparable tear of the rotator cuff (35 primary operations, 17 revision surgeries). We observed a continuous improvement in the Constant score from 36 to 69 points, also in ROM, strength, relief of pain and of different subjective parameters for the entire group in consecutive examinations at 11.1, 35.7 and 50.2 months. We found increased osteoarthritis (from 1.0 to 1.5 mm), as well as a decrease in the acromiohumeral distance (from 5.6 to 4.7 mm). In contrast, we detected a slight decrease in the values in the revision group and in the presence of an additional subscapularis lesion.