The magnitude and durability of functional improvement after total shoulder arthroplasty for degenerative joint disease.

So that patients with degenerative glenohumeral joint disease who wish to consider total shoulder arthroplasty will be better informed, we sought to document the magnitude and durability of the improvement in shoulder function after this procedure. The function of 124 shoulders with primary degenerative joint disease was documented by patient self-assessment with the Simple Shoulder Test before and sequentially after total shoulder arthroplasty performed with a standardized technique. Patients reported that they could perform 3.8 +/- 0.3 (SEM) of the 12 Simple Shoulder Test functions before surgery. The total number of performable functions was consistent at different follow-up intervals: 8.0 +/- 0.4 at 6 months, 9.5 +/- 0.4 at 1 year, 10.0 +/- 0.3 at 2 years, 9.2 +/- 0.4 at 3 years, 9.6 +/- 0.4 at 4 years, and 10.0 +/- 0.4 at 5 years. We conclude that total shoulder arthroplasty can provide substantial and durable improvement in shoulder function.

Simple home program for frozen shoulder to improve patients' assessment of shoulder function and health status.

BACKGROUND: The purpose of this investigation was to test the hypothesis that a simple home program can improve the self-assessed shoulder function and health status of a group of patients with frozen shoulders. METHODS: A case series using a one-group pretest, posttest design analyzing 41 patients from a single orthopedic practice who had a frozen shoulder were included in this study. The patients completed the Simple Shoulder Test (SST) and the Medical Outcomes Study Short-Form Health Survey (SF-36) questionnaire at the time of initial consultation, had treatment consisting of education regarding frozen shoulder and home stretching instructions, and were asked to complete the same questionnaires mailed every 6 months. Initial results were compared with previously published control values to establish level of impairment, and follow-up results were compared with the initial results to determine the extent of improvement. RESULTS: Patients initially had serious deficits in the 12 shoulder functions inventoried by the SST and were also compromised in their general health status as reflected by the SF-36 scores. At follow-up, 4 of 10 SST functions were improved (P < 0.001). The SF-36 health status scores of physical function, comfort, and physical role function were also improved (P < 0.001). CONCLUSION: These data suggest that this home program for frozen shoulder can lead to improved self-assessed shoulder function and health status in patients similar to those in the study population.

Prosthetic replacement of the shoulder for the treatment of defects in the rotator cuff and the surface of the glenohumeral joint.

We operatively treated, between 1978 and 1987, twenty-one shoulders in nineteen patients, fifty-four to eighty-four years old, who had disabling pain attributable to a massive tear of the rotator cuff, accompanied by loss of the surface of the glenohumeral joint. These patients were not candidates for total shoulder replacement because of the massive deficiency in the cuff and the fixed upward displacement of the humeral head. A prerequisite for hemiarthroplasty was a functionally intact coracoacromial arch to provide superior secondary stability for the prosthesis. One important aspect of the operative technique was the selection of a sufficiently small prosthesis so that excessive tightness of the posterior aspect of the capsule could be avoided. Eighteen shoulders in sixteen patients were available for follow-up, which ranged from twenty-five to 122 months. Pain decreased from marked or disabling in fourteen shoulders preoperatively to none or slight in ten and to pain only after unusual activity in four. Active forward elevation improved from an average of 66 degrees preoperatively to an average of 109 degrees postoperatively. One patient, who had had an excellent result, fell and sustained an acromial fracture, so the functional result changed to poor. Three patients had persistent, substantial pain in the shoulder that led to a revision. Neither infection nor prosthetic loosening developed in any shoulder.

Residual motion and function after glenohumeral or scapulothoracic arthrodesis.

The purpose of this study was to characterize humerothoracic motion and function after glenohumeral or scapulothoracic arthrodesis and to compare those results with those from normal shoulders. We evaluated 12 shoulders in 11 patients at an average of 71 months after glenohumeral arthrodesis and seven shoulders in six patients at an average of 32 months after scapulothoracic arthrodesis. The residual motion of the unfused articulation was measured with a spatial position sensor. Various activities of daily living and standard clinical range-of-motion tests were performed. Nearly all humerothoracic motions were significantly decreased in patients after either type of shoulder arthrodesis. Patients with a glenohumeral fusion maintained their scapulothoracic motion at levels comparable with that of normal subjects. Residual glenohumeral extension and external rotation after scapulothoracic fusion were significantly decreased; internal rotation remained unchanged compared with motion in subjects with normal shoulders. Glenohumeral fusion decreased the patients' ability to perform personal care activities requiring extremes of internal rotation or elevation. Although glenohumeral arthrodesis limited total humerothoracic motion considerably, the majority of patients were improved functionally and were relatively free from pain. Most personal care activities were performed successfully by all patients with scapulothoracic fusion.

Humeroscapular positions in a shoulder range-of-motion-examination.

Positions of the arm are traditionally described in relation to the thorax. Yet shoulder pathology most often lies in and about the glenohumeral joint, which then becomes the focus of treatment. Little is known about the relative motion between the humerus and the scapula primarily because there is no clinically accepted method for assessing and describing these positions. This paper proposes a clinical method for describing and measuring humeroscapular positions based on an anatomic definition of the plane of the scapula. Humeroscapular positions achieved by 75 normal subiects during a conventional (humerothoracic) shoulder range-of-motion examination are presented. Identification of the plane of the scapula is based on four palpable anatomic landmarks: (7) the inferior pole of the scapula, (2) the medial border of the scapula at the level of the scapular spine, (3) the posterolateral corner of the acromion, and (4) the tip of the coracoid. The plane of the scapula is defined by the line connecting the first two of these points and a point midway between the last two. Humeroscapular positions are specified by the plane of elevation and the angle of elevation in relation to this mobile scapular plane. Measurement of these positions was done with a goniometer facilitated by a "scapula-locating device" designed for this study. Maximal humerothoracic elevation of the arm was achieved with the humerus lust behind the scapular plane at 90° of humeroscapular elevation. Cross-body adduction positioned the humerus in a plane 51° anterior to the plane of the scapula, with most of the cross-body motion occurring between the scapula and thorax. External rotation at 90° of elevation in the coronal plane of the body (the apprehension position) positioned the humerus in a plane 17° posterior to the scapular plane. Humerothoracic extension and reaching up the back took place at very low angles of humeroscapular elevation.

Surgical management of complex irreparable rotator cuff deficiency.

The authors surgically treated 23 shoulders in 23 patients with disabling pain associated with irreparable tears of the musculotendinous cuff. In a total of 12 shoulders with preserved passive motion, normal deltoid function, loss of glenohumeral joint surfaces, and sculpturing of the coracoacromial arch, a standard or oversized Neer II humeral prosthesis without glenoid replacement was selected. A total of 11 shoulders that failed to meet these prerequisites or demanded heavy use after operation underwent arthrodesis. Twenty-two patients (12 from the hemiarthroplasty group and 10 from the arthrodesis group) were available for evaluation at an average follow-up period of 37.5 months. Comfort level and overall function were improved in both groups. Active forward elevation improved an average of 44 degrees in the hemiarthroplasty group and an average of 15 degrees in the arthrodesis group. The success of hemiarthroplasty and the problems of glenoid loosening in the presence of cuff deficiency with upward head displacement have led to the conclusion that humeral hemiarthroplasty is the preferred method for managing complex irreparable tears of the rotator cuff in which the articular surface is destroyed, yet the deltoid muscle is functional. Shoulder arthrodesis is reserved for those patients who have both irreparable tears of the rotator cuff and irreparable deficiencies of the deltoid muscle, or the younger patient with demands for substantial strength at low angles of flexion.

Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff.

We evaluated the results of 105 operative repairs of tears of the rotator cuff of the shoulder in eighty-nine patients at an average of five years postoperatively. We correlated the functional result with the integrity of the cuff, as determined by ultrasonography. Eighty per cent of the repairs of a tear involving only the supraspinatus tendon were intact at the time of the most recent follow-up, while more than 50 per cent of the repairs of a tear involving more than the supraspinatus tendon had a recurrent defect. Older patients and patients in whom a larger tear had been repaired had a greater prevalence of recurrent defects. At the time of the most recent follow-up, most of the patients were more comfortable and were satisfied with the result of the repair, even when they had sonographic evidence of a recurrent defect. The shoulders in which the repaired cuff was intact at the time of follow-up had better function during activities of daily living and a better range of active flexion (129 +/- 20 degrees compared with 71 +/- 41 degrees) compared with the shoulders that had a large recurrent defect. Similar correlations were noted for the range of active external and internal rotation and for strength of flexion, abduction, and internal rotation. In the shoulders in which the cuff was not intact, the degree of functional loss was related to the size of the recurrent defect.(ABSTRACT TRUNCATED AT 250 WORDS)

Glenoid loosening in total shoulder arthroplasty. Association with rotator cuff deficiency.

Seven cases of total shoulder arthroplasty exhibiting major glenoid radiolucent lines or actual translation of the glenoid component were evaluated to identify factors associated with glenoid loosening. The average time from arthroplasty was 30 months (range, 14-44 months). Six of the patients had severe, incompletely reconstructable rotator cuff tears present at the time of surgery, and one patient developed a cuff tear within 1 year of surgery. The amount of superior migration of the humeral component was closely correlated with the degree of glenoid loosening. With superior displacement of the humeral component, superior tipping of the glenoid component was observed: a "rocking horse" glenoid. For comparison, a contemporary group of 16 consecutive total shoulder arthroplasty patients with intact rotator cuffs were reviewed. The control group had no glenoid loosening an average of 5 years after operation. Upward riding of the prosthetic humeral head in patients with rotator cuff deficiency may contribute to loosening of the glenoid component in total shoulder arthroplasty.

Total shoulder arthroplasty.

A prospective study was done of fifty total shoulder replacements in forty-four patients who were followed for an average of 3.5 years (range, 2.0 to 7.5 years). The preoperative diagnosis was osteoarthritis in thirty-three shoulders, rheumatoid arthritis in eleven, and a previous fracture of the humeral head in six shoulders. Nine of the shoulders had a tear of the rotator cuff. The Neer-II system of total shoulder replacement with a non-metal-backed component was used in all fifty shoulders. At follow-up, forty-four shoulders (88 per cent) had no significant pain. Of the six painful shoulders, four had loosening of the glenoid component and one had malposition of both components. Three of the six shoulders had no significant pain after revision. The average range of active forward elevation in all of the shoulders improved from 71 to 100 degrees, and both external and internal rotation improved as well. Five specific activities of daily living were evaluated, and the patients' ability to perform them improved from 14 to 78 per cent. Thirty-five shoulders (68 per cent) were rated by the patients as much better; thirteen shoulders (26 per cent), as better; and three (6 per cent), as no better. An incomplete lucent line was noted around five (10 per cent) of the cemented humeral stems and around thirty-seven (74 per cent) of the glenoid prostheses. Four arthroplasties (8 per cent) required revision: three for loosening of the glenoid component and one for malposition of both components.(ABSTRACT TRUNCATED AT 250 WORDS)

Pain complaint--exercise performance relationship in chronic pain.

Chronic pain patients typically display reduced activity level attributed to pain and implying a positive correlation between exercise or activity and pain complaints. This study correlated observed pain complaints with amount of prescribed exercise performed by chronic pain patients when exercising to tolerance. Patients were in evaluation of earliest stages of multi-modal treatment. Exercises were physician prescribed to assess use of involved body parts and to promote general activity level. Patients were instructed to do exercise repetitions until pain, weakness or fatigue caused them to stop. Patients decided when to stop. Observations of amount of exercise performed were correlated with observed visible or audible indications of pain or suffering (pain behaviors). Results indicate a consistent negative relationship, i.e., the more exercise performed, the fewer the pain behaviors. This finding is contrary to the frequently observed physician prescription with chronic pain to limit exercise when pain increases.