Range of Movement and Patient-Reported Outcomes in Shoulder Arthroplasty in the Elderly: A Comparison of Anatomical Versus Reverse Shoulder Replacements.

Introduction Shoulder arthroplasty is in increasing demand in the elderly given the rising prevalence of glenohumeral osteoarthritis (OA) across the population. There is a dearth of evidence in the current literature comparing anatomical total shoulder arthroplasty and reverse total shoulder arthroplasty (RTSA) in the elderly population. This study compares patient-reported outcome measures and range of movement (ROM) between anatomical and reverse total shoulder replacements in matched patient cohorts over the age of 70 years. Materials and methods This retrospective cohort study compares range of movement and patient-reported outcomes between anatomical total shoulder arthroplasty and reverse total shoulder arthroplasty in matched cohorts over the age of 70 years at a single institution between 2011 and 2015. Overall, 75 patients were recruited, including 44 patients with anatomical total shoulder arthroplasty and 31 patients with reverse total shoulder arthroplasty. Cohorts were matched according to age, preoperative Oxford Shoulder Score (OSS), and preoperative range of movement. The minimum clinical follow-up was one year. Results At one year, range of movement metrics in flexion, abduction, and external rotation all demonstrated greater improvements in the anatomical total shoulder arthroplasty cohort in comparison to the reverse total shoulder arthroplasty cohort (p<0.0001). No statistical difference in Oxford Shoulder Score was evident between cohorts. Conclusion Anatomical total shoulder arthroplasty demonstrates a significant improvement in range of movement in comparison to reverse total shoulder arthroplasty in matched elderly patient cohorts. However, there was no statistical difference in functional assessment scores between reverse shoulder replacement and anatomical shoulder replacement.

Bursal Acromial Reconstruction (BAR) Using an Acellular Dermal Allograft for Massive, Irreparable Posterosuperior Rotator Cuff Tears: A Dynamic Biomechanical Investigation.

PURPOSE: To investigate the effect of bursal acromial reconstruction (BAR) using an acellular dermal allograft on glenohumeral joint kinematics including maximum abduction angle, glenohumeral superior translation, cumulative deltoid force, and subacromial contact pressure. METHODS: In this dynamic biomechanical cadaveric shoulder study, 8 fresh-frozen cadaveric shoulders (age 53.4 ± 14.2 years, mean ± standard deviation) were tested using a dynamic shoulder testing system. Maximum abduction angle (MAA), glenohumeral superior translation (ghST), maximum cumulative deltoid force (cDF), and subacromial peak contact pressure (sCP) were compared across 3 conditions: (1) intact shoulder; (2) massive retracted irreparable posterosuperior rotator cuff tear (psRCT) according to Patte III; and (3) BAR. Additionally, humeral head containment was measured using contact pressure. RESULTS: Compared with the simulated psRCT, BAR significantly increased mean MAA and significantly decreased ghST (P < .001, respectively) and cDF (P = .017) Additionally, BAR was found to significantly decrease sCP compared with psRCT (P = .024). CONCLUSION: In a dynamic biomechanical cadaveric shoulder simulator, resurfacing the undersurface of the acromion using the BAR technique leads to significantly improved ghST, MAA, cDF, and sCP compared with the irreparable rotator cuff tear. CLINICAL RELEVANCE: With the BAR technique, native humeral containment may be restored, which can potentially delay progressive subacromial and glenoidal abrasive wear and improve overall shoulder function. As such, the proposed BAR technique can be considered as a technically feasible and potentially cost- and timesaving procedure, as no bone anchors are needed, glenoidal or humeral side graft ruptures can be avoided, and postoperative rehabilitation can be started immediately. However, future clinical studies are needed.

Bursal Acromial Reconstruction (BAR) Using an Acellular Dermal Allograft as a Surgical Solution for the Treatment of Massive Irreparable Rotator Cuff Tears.

Massive, irreparable rotator cuff tears in patients without severe signs of osteoarthritis remains a major challenge for orthopaedic surgeons. These can be a source of significant pain and functional loss occurring most commonly in a relatively frail, elderly patient population. A plethora of surgical techniques covering minimally invasive, arthroscopic techniques and open, salvage procedures have been described for this challenging patient cohort. Continuous evolvement of arthroscopic techniques has led to all-arthroscopic superior capsular reconstruction techniques using allografts, thereby reducing donor side morbidity along with decreased soft tissue dissection. However, conventional superior capsular reconstruction is noted to be a technically complex, time-consuming, and high-cost surgery, which may put this technique beyond the confidence of many shoulder surgeons. The subacromial balloon spacer has emerged as a potential solution in these patients, providing interposition between the humeral head and acromion. However, the subacromial balloon biodegrades rapidly and its effect is only temporary. Thus this technique article presents using an acellular human dermal allograft to reconstruct the bursal layer, which is normally interposed between the humeral head and the acromion. The proposed technique provides a permanent interposition graft preventing humeral acromial contact, which does not undergo rapid biodegradation. The surgical technique is technically feasible, both minimizing surgical time and therefore operative risk to the patient.

Arthroscopic Superior Capsular Reconstruction for Management of Massive Irreparable Rotator Cuff Tears: A Simple Alternative Technique.

The use of acellular dermal allograft in arthroscopic superior capsular reconstruction is a promising treatment option for massive irreparable rotator cuff tears. However, indications are limited to a subset of patients, so it is not routinely performed. Therefore, the surgery is technically demanding, although it has evolved in recent years. The authors present a simple alternative technique that addresses common pitfalls. [Orthopedics. 2021;44(3):e458-e462.].

Arthroscopic Superior Capsular Reconstruction of the Shoulder Using Dermal Allograft.

Irreparable massive cuff tears in young patients pose a difficult problem for shoulder surgeons. Arthroscopic superior capsular reconstruction has shown promise in recent years in the treatment of this challenging patient population. The majority of the literature is limited to surgical techniques. The authors present the 2-year clinical outcomes of 25 patients undergoing arthroscopic superior capsular reconstruction with dermal allograft from a single center. The Oxford Shoulder Score and range of motion were assessed preoperatively and then at 3 to 6 months, 1 year, and 2 years following surgery. Patient satisfaction was recorded at final follow-up. Magnetic resonance imaging was performed at 3 months postoperatively to assess graft integrity. All patients were available at 1-year follow-up, and 23 were available at 2 years. The mean Oxford Shoulder Score improved by a minimum of 10 points at all time points compared with preoperatively. The mean forward flexion and abduction improved by 20° and external rotation by 7°. Revision to reverse shoulder arthroplasty was seen in 3 patients (12%). Graft failure was seen in 4 patients (16%). Overall, 20 patients had successful outcomes at 1 year (80%) and 18 patients had successful outcomes at 2 years (72%). Superior capsular reconstruction offers a safe and effective short-term bridging option for young patients with irreparable supraspinatus tears in the absence of glenohumeral arthritis. However, long-term outcome studies are required to evaluate the true clinical effectiveness and failure rates. [Orthopedics. 2020;43(4):215-220.].

Total Humeral Endoprosthesis Replacement to Salvage Periprosthetic Fractures in Rheumatoid Arthritis.

The authors report their experience in the management of a 53-year-old woman with rheumatoid arthritis who presented with bilateral asynchronous traumatic periprosthetic fractures of the humerus after bilateral elbow replacements. One side was treated with a long-stem revision and internal fixation with bone graft, while the other side was treated with a long-stem distal humeral replacement. She sustained pathological periprosthetic fractures on top of the long-stemmed implants. Total humeral endoprosthesis replacements were performed bilaterally as salvage procedures to provide a stable platform for her elbow and hand function. At manuscript submission, the patient was 24 months and 36 months postoperatively on the left and right sides, respectively. Her Oxford Shoulder Scores were 21 (left side) and 24 (right side). There is little information about the management of periprosthetic fractures of the humerus after long-stem revisions with severe bone loss. To the best of the authors' knowledge, this is the first case report describing the use of bilateral total humeral endoprosthesis replacements in the management of complex unstable periprosthetic fractures. This is a valuable treatment option for patients with poor bone quality, bone loss, and loose components. [Orthopedics. 2017; 40(2):e363-e366.].

A New "Trapdoor technique" for Fixation of Displaced Greater Tuberosity Fractures of the Shoulder.

Isolated greater tuberosity fractures of the proximal humerus are frequently displaced posteriorly and superiorly by the pull of the rotator cuff. This displacement can lead to a decline in function if left untreated. Traditionally these fractures have been treated surgically using screw fixation. On occasions this metalwork can remain prominent and potentially cause impingement. We present a new surgical "trapdoor" technique for fixation of isolated greater tuberosity fractures which can avoid these problems and be utilised either open or arthroscopically. Following reduction of the isolated greater tuberosity fragment, two double loaded metal screw in anchors are placed through stab incisions in the rotator cuff at the bone-tendon interface and secured into the humeral head. A suture from each of the anchors is tied together to secure the tuberosity fragment proximally and a suture-less anchor is inserted distal to the fracture site forming an inverted triangle. The remaining sutures are placed through the suture-less anchor and tensioned independently. As the sutures are tied and snugged tight, the distal aspect of the fracture reduces, thus closing the "trapdoor." This is a newly described versatile technique that can be used regardless of the size and comminution of the tuberosity fragment and can be performed either open or arthroscopically. It avoids the problems of metalwork prominence and irritation and the use of the suture-less anchor allows independent tensioning of the sutures to ensure adequate fracture reduction.

A Reproducible Technique for Arthroscopic Acromioclavicular Joint Excision.

Arthroscopic acromioclavicular joint excision is a commonly performed but technically demanding procedure. Incomplete excision can leave residual symptoms. We present a simple, reproducible technique ensuring satisfactory excision of the joint.

Open reduction and fixation of displaced lateral clavicle fractures using the Minimally Invasive Acromioclavicular Joint Reconstruction (MINAR®) technique: a case series review.

BACKGROUND: Lateral end of clavicle fractures can be a challenge, with a 20% to 30% non-union rate if treated non-operatively. Several operative options exist, each having their own merits and some having potential disadvantages. The Minimally Invasive Acromioclavicular Joint Reconstruction (MINAR®) (Storz, Tutlingen, Germany) set uses an Orthocord (Depuy Synthes Mitek, Leeds, UK) suture and two Flip Tacks (Storz) via a transclavicular-coracoid approach to reconstruct the coracoclavicular ligaments. METHODS: Referrals were made to two senior surgeons at separate institutions regarding Robinson Type 3 fractures of the lateral end of the clavicle. All patients were treated with MINAR implant via a minimally invasive approach. Two-year follow-up was obtained using the Oxford Shoulder Score (OSS) and the Quick DASH (Disability of the Arm Shoulder and Hand) score. RESULTS: Sixteen cases of acute fractures of the lateral end of the clavicle were included in this series. At final follow-up, the mean OSS was 44.75 (range 35 to 48) and the median Quick DASH score was 2.3 (range 0 to 35.9). Fifteen patients achieved bony union (one asymptomatic non-union) and there were no complications or re-operations. CONCLUSIONS: The MINAR is reproducible and safe when treating lateral end of clavicle fractures. We consider that, over the short- to mid-term, it achieves results equivalent to those for other implants.

Arthroscopic suprascapular neurotomy for the painful irreparable rotator cuff tear.

BACKGROUND: Massive irreparable rotator cuff tears are becoming increasingly difficult to manage. METHODS: Patients were considered for treatment if they had a painful shoulder in the presence of a compensated cuff tear. All patients had radiological evidence of a massive irreparable cuff tear and underwent suprascapular neurotomy, arthroscopically. RESULTS: There were 15 males and 25 females with a mean age of 74 years (range 59 years to 88 years). The mean pre-operative Oxford Shoulder Score (OSS) in all patients was 17.7, with a mean pre-operative visual analogue score (VAS) of 8.0. The mean post-operative OSS was 30.8 [27.42-34.18 = confidence interval (CI) 95%] with a mean VAS of 3.6 (2.64-4.56 CI 95%) at the 3-month (short-term) period (n = 32). The medium-term (1-year) OSS and VAS had improved to 33.6 (32.27-34.93 = CI 95%) and 3.7 (0-8.39 CI 95%) respectively (n = 26). The difference pre- and postoperatively at 12 months was statistically significant (p < 0.001). Patients who underwent biceps tenotomy at the time of surgery had a less significant improvement in their VAS and OSS. CONCLUSIONS: Suprascapular neurotomy can afford medium-term benefit in over two-thirds of the patients who would otherwise have undergone reverse polarity shoulder replacements. We consider that this is a reproducible technique.

A simple method for identifying the acromioclavicular joint during arthroscopic procedures.

Arthroscopic acromioclavicular joint excision is performed via an anterior portal and is technically demanding. We present a simple method for identifying the acromioclavicular joint during arthroscopic procedures.

Which way around does this go? A simple method for ensuring the correct glenosphere offset.

The correct glenosphere offset in a reverse total shoulder replacement ensures prosthetic stability, longevity and avoids scapula notching. We present a simple technique for ensuring the correct glenosphere offset when the prosthesis is implanted.

Utilisation of shoulder arthroplasty in the UK.

AIMS: To estimate the per capita utilisation of shoulder prostheses in the UK and to compare UK figures to those from the US. METHODS: A postal and telephone survey was undertaken of all hospitals in the UK carrying out orthopaedic operations. The relative usage of total shoulder replacement and hemi-arthroplasty for both elective and trauma indications were analysed and UK figures compared to those from the US. RESULTS: There were 281 replies from 314 questionnaires, a response rate of 90%. The per capita rate of shoulder replacement is approximately one-tenth for total replacement and one-fifth for hemiarthroplasty compared to the US, suggesting that there is an unmet demand in the UK. In the US, the proportion of total replacements to hemi-arthroplasties for elective indications is approximately equal whereas in the UK there are twice as many hemi-arthroplasties, which raises the question as to whether hemi-arthroplasties are being used when a total replacement might be preferable. The numbers of shoulder arthroplasties implanted by individual surgeons and units is, except for a few large centres, small. Consequently, it is much more difficult for the surgeon to evaluate the various prosthetic designs and surgical techniques. CONCLUSION: There is a need for a national register to increase the knowledge about such designs and techniques and to analyse risk factors.