Distal biceps section and reinsertion for chronic distal biceps tendinopathy.

BACKGROUND: Surgical reinsertion of the distal biceps tendon for acute and chronic tears is a widely accepted procedure, but little is known about surgical treatment of distal biceps tendinopathy. METHODS: Twenty patients underwent a surgical procedure for distal biceps tendinopathy after failure of conservative treatment. The surgery was performed through a single incision. The biceps tendon was detached, debrided and reinserted using a ToggleLoc (Zimmer Biomet) device. Clinical and radiologic evaluation was performed after a minimum follow-up of 1 year. Quick-Dash score, Liverpool Elbow Score, Mayo Elbow Performance Index, Broberg and Morrey Score and Short HSS Scoring System were used, and isokinetic testing was performed. RESULTS: The outcome of these five clinical elbow scores showed no clinically relevant differences between the affected and non-affected side. Isokinetic testing of peak torque in flexion and supination showed equal strength between both sides. These results indicate good functional outcome and recovery of flexion and supination, compared to the non-operated side and the normal population. CONCLUSION: This study demonstrates that distal biceps tendon debridement and reinsertion is a safe and valid option for patients with distal biceps tendinopathy after failure of conservative treatment. LEVEL OF EVIDENCE: Level 3 retrospective cohort study.

Revision of reversed shoulder arthroplasty: Is a reoperation possible?

INTRODUCTION: As the number of reversed shoulder arthroplasty (RSA) procedures increases, the revision rate will also increase. In case of severe bone insufficiency, instability or infection of the primary RSA, revision to another RSA is preferable but not always possible. Hemiarthroplasty (HA), spacers and resection arthroplasty (RA) have been described in this indication. MATERIALS AND METHODS: Between 2004 and 2016, 20 shoulders in 19 patients were treated at Ghent University Hospital for failed revision of RSA. Nine received a megahead prosthesis, a spacer was implanted in 6, and 5 underwent RA. RESULTS: Indications for implantation of a megahead prosthesis were loosening RSA (n = 5), infection (n = 4), dislocation (n = 1) and nerve irritation (n = 1). Improvement of range of motion was observed. Anterosuperior migration of the prosthesis was noted in 2 patients. Another 2 patients were ultimately revised to RSA. Seven permanent spacers were implanted for infection, of which 2 remain in place till today. The other 5 were revised to RSA. Of the 5 patients treated with RA, 3 were revised further on to RSA, resulting in pain relief and regain of function. DISCUSSION: Our study shows that a megahead prosthesis has better functional results than RA, but is inferior to RSA. Due to increasing surgical experience and improving technique, 9 patients could ultimately be reconverted to another RSA. A review of current literature is presented. In HA and RA, the functional results are poor, and pain relief is uncertain. Results of spacers are variable and can be satisfactory. Arthrodesis is a last resort. CONCLUSION: In our case series study, a hemiarthroplasty can be performed in case of failure of RSA. However, the results are inferior to another RSA.

A Critical Review on Prosthetic Features Available for Reversed Total Shoulder Arthroplasty.

Reversed total shoulder arthroplasty is a popular treatment in rotator cuff arthropathy and in displaced proximal humeral fractures in elderly. In 2016, 29 models of commercially available designs express this popularity. This study describes all the different design parameters available on the market. Prosthetic differences are found for the baseplate, glenosphere, polyethylene, and humeral component and these differences need to be weighed out carefully for each patient knowing that a gain in one mechanical parameter can balance the loss of another. Patient specific implants may help in the future.

What do standard radiography and clinical examination tell about the shoulder with cuff tear arthropathy?

BACKGROUND: This study evaluates the preoperative conventional anteroposterior radiography and clinical testing in non-operated patients with cuff tear arthropathy. It analyses the radiological findings in relation to the status of the rotator cuff and clinical status as also the clinical testing in relation to the rotator cuff quality. The aim of the study is to define the usefulness of radiography and clinical examination in cuff tear arthropathy. METHODS: This study analyses the preoperative radiological (AP-view, (Artro-)CT-scan or MRI-scan) and clinical characteristics (Constant-Murley-score plus active and passive mobility testing) and the peroperative findings in a cohort of 307 patients. These patients were part of a multicenter, retrospective, consecutive study of the French Orthopaedic Society (SOFCOT-2006). All patients had no surgical antecedents and were all treated with prosthetic shoulder surgery for a painful irreparable cuff tear arthropathy (reverse-(84%) or hemi-(8%) or double cup-bipolar prosthesis (8%)). RESULTS: A positive significancy could be found for the relationship between clinical testing and the rotator cuff quality; between acromiohumeral distance and posterior rotator cuff quality; between femoralization and posterior rotator cuff quality. CONCLUSION: A conventional antero-posterior radiograph can not provide any predictive information on the clinical status of the patient. The subscapular muscle can be well tested by the press belly test and the teres minor muscle can be well tested by the hornblower' sign and by the exorotation lag signs. The upward migration index and the presence of femoralization are good indicators for the evaluation of the posterior rotator cuff. An inferior coracoid tip positioning suggests rotator cuff disease.

Prosthetic overhang is the most effective way to prevent scapular conflict in a reverse total shoulder prosthesis.

BACKGROUND AND PURPOSE: Despite good clinical results with the reverse total shoulder arthroplasty, inferior scapular notching remains a concern. We evaluated 6 different solutions to overcome the problem of scapular notching. METHODS: An average and a "worst case scenario" shape in A-P view in a 2-D computer model of a scapula was created, using data from 200 "normal" scapulae, so that the position of the glenoid and humeral component could be changed as well as design features such as depth of the polyethylene insert, the size of glenosphere, the position of the center of rotation, and downward glenoid inclination. The model calculated the maximum adduction (notch angle) in the scapular plane when the cup of the humeral component was in conflict with the scapula. RESULTS: A change in humeral neck shaft inclination from 155° to 145° gave a 10° gain in notch angle. A change in cup depth from 8 mm to 5 mm gave a gain of 12°. With no inferior prosthetic overhang, a lateralization of the center of rotation from 0 mm to 5 mm gained 16°. With an inferior overhang of only 1 mm, no effect of lateralizing the center of rotation was noted. Downward glenoid inclination of 0º to 10º gained 10°. A change in glenosphere radius from 18 mm to 21 mm gained 31° due to the inferior overhang created by the increase in glenosphere. A prosthetic overhang to the bone from 0 mm to 5 mm gained 39°. INTERPRETATION: Of all 6 solutions tested, the prosthetic overhang created the biggest gain in notch angle and this should be considered when designing the reverse arthroplasty and defining optimal surgical technique.

Consequences of scapular anatomy for reversed total shoulder arthroplasty.

The reverse total shoulder prosthesis provides successful functional outcome in many patients with rotator cuff tear arthropathy. However, scapular notching, a direct consequence of mechanical impingement between the humeral prosthesis and the glenoid, remains a major concern. We presumed a better knowledge of the anatomy of the scapula would enable design or placement modifications to minimize this phenomenon. After establishing a uniform spatial reference system using easy locatable surgical reference points and planes, we analyzed 200 dry bony scapulae and defined the glenoid and infraglenoid anatomy relative to the reference system. The bony rim of the two inferior quadrants of the glenoid forms a semicircle the center of which can be used perioperatively as an easy locatable bony reference point. The infraglenoid tubercle varies in width and length, and can interfere with the humeral part of the reverse prosthesis, creating scapular notching. To avoid notching, we suggest using a convex base plate with a smaller radius than currently used, placing it as low as possible with a 42-mm glenosphere eccentrically assembled to create a posterior offset. If prosthetic overhang cannot be obtained, we suggest removing part of the infraglenoid tubercle.

Glenosphere disengagement: a potentially serious default in reverse shoulder surgery.

UNLABELLED: Implant failure is a serious complication in reverse shoulder arthroplasty. We determined the incidence of glenosphere disengagement in a cohort of 479 reverse shoulder prostheses (468 Delta III [DePuy International Ltd, Leeds, UK], 11 Aequalis [Tornier, Grenoble, France]). We also determined whether disengagement adversely affected clinical outcomes. The minimum followup was 12 months (mean, 28.6 months; range, 12-72 months). Disengagement of the glenosphere occurred in 16 of 479 shoulders (3.2%). In 13 patients, the disengagement was partial (clear step-off between the baseplate and the glenosphere) and was not associated with a poor functional outcome with this short-term followup. In three patients, the disengagement led to a fracture of the central screw, leading to a complete disengagement of the glenosphere from the baseplate, necessitating revision in two; the third refused revision. Partial disengagement was seen in five of 11 Aequalis prostheses (45.4%) and eight of 468 Delta III prostheses (1.7%). The three total disengagements with central screw breakage all occurred in Delta III prostheses. We believe differences in the type of locking screws may explain the differences observed between the two types of reverse prostheses. LEVEL OF EVIDENCE: Level III, retrospective study. See the Guidelines for Authors for a complete description of levels of evidence.

Echocardiographically estimated left ventricular end-diastolic and right ventricular systolic pressure in normotensive healthy individuals.

AIM: To study the effect of aging on and the relationship between echocardiographically estimated left ventricular (LV) filling pressure and estimated right ventricular (RV) systolic pressure among healthy normotensive individuals. METHODS: We analyzed 249 healthy individuals (aged 18-82 years, 52% men) with normal echocardiographic findings and reliably measurable tricuspid regurgitation gradients. Subjects with blood pressure >140/90 mmHg and/or LV hypertrophy were excluded. LV & RV dimensions and LV mass were measured with M-mode echocardiography. Atrial (A) volumes were determined with the area-length method. Diastolic function was assessed with transmitral Doppler and mitral annulus tissue Doppler. The ratio of transmitral early peak velocity to early diastolic mitral annulus velocity (E/E') was used as estimation of LV filling pressure. The transtricuspid Doppler gradient was used to estimate RV end-systolic pressure. RESULTS: Even in normotensive individuals aging was accompanied by an increase in LV mass and LA dimensions and an increase in relaxation abnormalities. E/E' increased with every decade: from 7.8 for age 18-35 years to 10.9 for age > or =75 years (p<0.0001) as did the transtricuspid gradient: from 18.3 mmHg for age 18-35 years to 25.8 mmHg for age > or =75 years (p<0.0001). Linear regression showed that estimated RV systolic pressure was independently predicted by age, LA volume, LV systolic function and E/E'. CONCLUSION: Among normotensive healthy individuals both E/E' and tricuspid regurgitation gradients increase significantly with aging. Moreover the E/E' ratio was independently predicting the tricuspid regurgitation gradient. These findings support the need for further studies defining age specific normal values.