The evaluation, classification, and management of septic arthritis of the shoulder: the comprehensive shoulder sepsis system.

BACKGROUND: Septic arthritis of the shoulder is distinctly challenging to diagnose and treat. Guidelines for appropriate workup and management are limited and do not account for the variations in clinical presentation. The purpose of this study was to present a comprehensive and anatomically based classification system and treatment algorithm for septic arthritis of the native shoulder joint. METHODS: A multicenter, retrospective analysis of all patients treated surgically for septic arthritis of the native shoulder joint was performed at 2 tertiary care academic institutions. Preoperative magnetic resonance imaging and operative reports were used to classify patients as having 1 of 3 infection subtypes: type I, confined to the glenohumeral joint; type II, extra-articular extension; or type III, concomitant osteomyelitis. On the basis of these clinical groupings of patients, the comorbidities, types of surgical management, and outcomes were analyzed. RESULTS: Sixty-five shoulders in 64 patients met the inclusion criteria for the study. Of these infected shoulders, 9.2% had type I infections, 47.7% had type II, and 43.1% had type III. Age and the time between symptom onset and diagnosis were the only significant risk factors for the development of a more severe infection. Fifty-seven percent of shoulder aspirates revealed cell counts below the standard surgical cutoff of 50,000 cells/mL. On average, each patient required 2.2 surgical débridements to eradicate the infection. Infections recurred in 8 shoulders (12.3%). Body mass index was the only risk factor for recurrence of infection. Of the 64 patients, 1 (1.6%) died acutely of sepsis and multiorgan system failure. CONCLUSION: We propose a comprehensive system for the classification and management of spontaneous shoulder sepsis based on stage and anatomy. Preoperative magnetic resonance imaging can help determine the severity of disease and aid in surgical decision making. A systematic approach to septic arthritis of the shoulder as a unique entity from septic arthritis of other large peripheral joints may lead to more timely diagnosis and treatment and improve the overall prognosis.

What Factors are Associated With Clinically Important Improvement After Shoulder Hemiarthroplasty for Cuff Tear Arthropathy?

BACKGROUND: In selected patients with a desire to maintain activity levels greater than those recommended after reverse total shoulder arthroplasty, hemiarthroplasty remains an option for treatment of cuff tear arthropathy (CTA). However, given the relatively small case series that have been reported to date, little is known regarding which patients will show functional improvement after this surgery. QUESTIONS/PURPOSES: We asked: What factors are associated with achieving the minimum clinically important difference in the simple shoulder test (SST) after hemiarthroplasty for cuff tear arthropathy? PATIENTS AND METHODS: Between 1991 and 2007, two surgeons at one academic center performed 48 shoulder hemiarthroplasties for CTA. No patients were known to have died before data collection, and of those not known to have died, 42 (88%) were available for followup at a mean of 48 months (range, 24-132 months). During that time, the general indications for this approach were glenohumeral arthritis with superior decentering of the humeral head. The majority of the patients with CTA were treated nonoperatively with patient-directed physical therapy and other modalities. A total of 42 patients (42 shoulders; 24 males and 18 females) with CTA were treated with hemiarthroplasty and followed for a mean of 48 months (range, 24-132 months). This is a retrospective study that made use of a longitudinally maintained database, which included physical examination of ROM, the SST, VAS, and standardized radiographs. At latest followup, 33 of 42 patients achieved a clinically important percentage of maximum possible improvement (%MPI) in SST score, defined as an improvement of 30% of the total possible improvement on the 12-point scale (with higher scores representing better results). RESULTS: Intraoperative findings of a rotator cuff tear limited to the supraspinatus and infraspinatus (odds ratio [OR], ∞; 95% CI, 2.01 to ∞; p = 0.020) and limited preoperative external rotation (15° [range, -40° to 45°] vs 35° [range, 20°-45°], OR, 0.71; 95% CI, 0.38-0.90; p < 0.001) were associated with achieving the defined minimum functional improvement (30% of MPI) on multivariate analysis. Preoperative active elevation (p = 0.679) and use of a CTA-specific implant (p = 0.707) were not significantly associated with achievement of 30% of MPI. CONCLUSION: Patients with intact teres minor and subscapularis tendons and patients with lower preoperative external rotation had a better prognosis for achieving a clinically important percentage of MPI at short-term followup. Although some patients were followed for more than 10 years, the majority were followed for fewer than 5 years; future studies will need to determine whether these early functional results are maintained for longer periods. LEVEL OF EVIDENCE: Level III, therapeutic study.

Total shoulder arthroplasty with an all-polyethylene pegged bone-ingrowth glenoid component: a clinical and radiographic outcome study.

BACKGROUND: Loosening of the glenoid component continues to be the foremost cause of medium and long-term failure of shoulder replacements. The purpose of this study was to evaluate the clinical and radiographic results of a minimally cemented all-polyethylene pegged glenoid component designed for biologic fixation. METHODS: Forty-four shoulders in forty-one patients with a mean age of sixty-six years underwent total shoulder arthroplasty with a pegged bone-ingrowth glenoid component. Outcome data included the American Shoulder and Elbow Surgeons questionnaire, the Simple Shoulder Test, and visual analog scales. A detailed radiographic analysis was performed by two board-certified musculoskeletal radiologists who were blinded to clinical and patient-reported outcomes. The radiographs were evaluated with regard to the presence of radiolucent lines at the bone-cement interface, implant seating, and the radiodensity between the flanges of the central peg. RESULTS: The mean duration of clinical follow-up was four years and the mean duration of radiographic follow-up was three years. Twenty shoulders had perfect seating and radiolucency grades, thirty had increased radiodensity between the flanges of the central peg, and three demonstrated osteolysis. Radiodensity about the uncemented central peg at the time of the latest follow-up was positively associated with perfect seating and radiolucency grades on the initial postoperative radiographs (p = 0.03, Fisher exact test). The Simple Shoulder Test score, the American Shoulder and Elbow Surgeons score, and all visual analog scale scores had improved significantly (p < 0.01) at the time of the latest follow-up. CONCLUSIONS: Total shoulder arthroplasty with a minimally cemented, all-polyethylene, pegged glenoid implant can yield stable and durable fixation at short to medium-term follow-up (mean, four years).

Treatment of traumatic posterior sternoclavicular dislocations.

BACKGROUND: Traumatic posterior sternoclavicular joint injuries are rare, but complications are common and include brachial plexus and vascular injury, esophageal rupture, and death. MATERIALS AND METHODS: The records of 21 patients treated at our institution for a posterior sternoclavicular injury were reviewed. All patients underwent a trial of closed reduction, which was effective in 8 patients (group I). The remaining 13 patients were treated with open reduction and sternoclavicular joint reconstruction (group II). RESULTS: Closed reduction was more likely to be successful (P < .05) in dislocations treated within 10 days of injury. Patients were evaluated by use of the University of California, Los Angeles rating scale. Overall, 18 of 21 patients were graded as good or excellent. Patients treated with either open or closed reduction as their definitive management compared favorably in terms of ratings for pain, strength, and motion. CONCLUSION: Our experience suggests that closed reduction compares favorably with open reduction. Of patients treated, 38% required only closed reduction as their definitive treatment. In this series early closed reduction was successful and obviated the risks of surgery. Patients who in whom closed reduction failed obtained good results with operative treatment aimed at reconstruction of the costoclavicular ligaments.

Results of treatment of luxatio erecta (inferior shoulder dislocation).

HYPOTHESIS: Traumatic inferior shoulder dislocation (luxatio erecta) injuries are rare, comprising less than 0.5% of all shoulder dislocations. Few cases have been reported, and the outcome of treatment has been ill defined. MATERIALS AND METHODS: Between 1968 and 2000, 18 patients (20 shoulders) with luxatio erecta were evaluated at our institution. Two patients (2 shoulders) were lost to follow-up, leaving 16 patients (18 shoulders) for long-term follow-up (average, 9 years). Associated injuries included peripheral nerve injury, humeral fracture, acromial fracture, and rotator cuff tear. All patients were initially managed with closed reduction, which was successful in 9 shoulders. The remaining 9 shoulders required operative treatment. RESULTS: Patients were evaluated with respected to pain, function, range of motion, strength, and patient satisfaction, according to the University of California at Los Angeles Rating Scale. Overall, 13 of the 16 patients were graded as good or excellent. Patients treated with closed reduction or operative treatment compared favorably in terms of improvements in ratings for pain, strength, motion, and the ability to perform work and sports. DISCUSSION: Our experience suggests that treatment of luxatio erecta is largely successful, with good or excellent results obtained in 83% of the shoulders. Half of the patients evaluated, required only closed reduction as their definitive treatment. Operative treatment is typically indicated for associated displaced humeral head fractures or patients with recurrent instability. Recurrent instability appears to be more likely in patients with a previous history of dislocation. Associated neurologic or vascular injury did not affect the final outcome.

Charles Neer: on the giant of the shoulder.

In the world of orthopedics, certain giants have become known as associated with a single subspecialty or for work on a single joint. Among these are John Charnley, for his work on total hip arthroplasty, and Amory Codman, for his work on the shoulder. But in the second half of the 20th century, the true giant of shoulder surgery was Charles Neer. His contributions to our subspecialty may not have been surpassed by any orthopedic surgeon for any subspecialty. This article explores his life and his contributions to shoulder surgery from those who knew him best.

Treatment of fractures adjacent to humeral prostheses.

Fifteen patients with fractures adjacent to a humeral prosthesis were treated between 1986 and 2002. There were 10 females and 5 males. The average age was 58 years. The fractures were classified as to location relative to the prosthesis. Type I fractures (N = 3) occurred proximal to the tip of the prosthesis. Type II fractures (N = 7) occurred in which the fracture line extended from the proximal portion of the humeral shaft to beyond the distal tip of the prosthesis. Type III (N = 5) fractures occurred entirely distal to the tip of the prosthesis. Two type I and 3 type II fractures were managed with a fracture orthosis. The remainder of the fractures were treated surgically with a combination of cerclage wires and long stem prosthesis. All fractures progressed to union at an average of 11 weeks. Average forward elevation for the group was 124 degrees . No patient required a shoulder spica or bone grafting to obtain union. Treatment resulted in fracture union, prosthesis stability, and a paucity of complications.

Treatment of glenohumeral arthritis with a hemiarthroplasty. Surgical technique.

BACKGROUND: Glenohumeral hemiarthroplasty is well established as a method to treat glenohumeral arthritis. This study was designed to report longer-term results and to provide a decision model to assist surgeons in achieving successful outcomes. Our selection strategy for hemiarthroplasty included shoulders with (1) a concentric glenoid with eburnated bone, (2) a nonconcentric glenoid that could be converted to a smooth concentric surface, and (3) a humeral head centered within the glenoid after soft-tissue balancing. METHODS: Fifty-seven consecutive patients (sixty-four shoulders) who had osteoarthritis of the glenohumeral joint, without advanced disease in the glenoid, were treated with hemiarthroplasty. In each instance, a modular prosthesis was implanted. Clinical assessment was performed preoperatively and at one-year intervals postoperatively for at least five years with use of patient self-assessment instruments, including the American Shoulder and Elbow Surgeons questionnaire, the Simple Shoulder Test, and a visual analog pain scale. A detailed radiographic analysis was performed to determine the presence of glenohumeral subluxation, periprosthetic radiolucency, and glenoid bone loss. RESULTS: Forty-three patients (fifty shoulders) were followed for a minimum of five years (mean, 7.5 years). Of the remaining fourteen patients (fourteen shoulders), ten were lost to follow-up, three had died, and one was excluded. For the Simple Shoulder Test, and for every visual analog scale measure, the results at the final follow-up evaluation were significantly better than the preoperative results (p < 0.0001 for each). The mean Simple Shoulder Test score at the time of the final follow-up was 9.4 positive responses compared with 9.7 positive responses at the two-year evaluation (p = 0.32), and the mean visual analog scale score for pain was 18.6 points compared with 14.9 points at two years (p = 0.45). Radiographic analysis showed the majority of stems had either no lucency or lucencies only near the tip of the stem. Glenoid bone loss and subluxation improved postoperatively, and the results were maintained at the final follow-up evaluation. CONCLUSIONS: Shoulder hemiarthroplasty provides sustained good-to-excellent pain relief and functional improvement at five to ten years postoperatively in carefully selected patients with osteoarthritis.

Replicating proximal humeral articular geometry with a third-generation implant: a radiographic study in cadaveric shoulders.

Prosthetic shoulder arthroplasty must replicate humeral geometry or risk compromising success. The purpose of our study was to evaluate humeral head replacement with respect to replicating proximal humeral anatomy. Using scanning technology and AutoCAD, this study was conducted in 2 parts. First, geometric parameters were measured on 35 cadaveric humeri and were used to design a new shoulder arthroplasty system. Second, humeral head replacement was performed on 18 of these humeri by use of the new shoulder arthroplasty system, and selected preoperative and postoperative measurements were compared. Preoperative to postoperative differences were minimal and exhibited improvement compared with earlier designs. In this study, humeral head replacement with a third-generation system reproduced the original anatomy of 18 cadaveric humeri more accurately than previously reported. This finding is important because accurate anatomic reconstruction in shoulders is essential for minimizing subacromial contact and optimizing range of motion.

Compaction bone-grafting in prosthetic shoulder arthroplasty.

BACKGROUND: Compaction bone-grafting has been suggested as a means of improving the stability of the humeral component in shoulder arthroplasty, but the clinical and radiographic results of the procedure have not been reported in the literature, to our knowledge. To address this deficit, we report on a series of shoulder arthroplasties performed with compaction bone-grafting to secure humeral component fixation. These prostheses were implanted in shoulders demonstrating a suboptimal interference fit of the humeral component. METHODS: Fifty-eight shoulders in fifty-three patients were treated with prosthetic shoulder arthroplasty that included compaction bone-grafting. Clinical assessments were performed at regular intervals with use of visual analog scales for pain, shoulder comfort and function, and overall quality of life, and with use of patient self-assessments including the American Shoulder and Elbow Surgeons Score and the validated Simple Shoulder Test. A detailed radiographic analysis was performed by three raters to determine whether radiolucent lines were present immediately postoperatively and at a later follow-up interval. The humeral tilt angle was determined by measuring the angle between the humeral axis and the component. Subsidence was also evaluated. The mean of the raters' measurements was used in the analysis. RESULTS: The mean duration of follow-up was sixty-nine months (range, twenty-six to 148 months). No loose stems were observed, and no humeral component was revised. At the time of follow-up, there was significant improvement in the Simple Shoulder Test scores and all visual analog scores (p < 0.0001 in each instance). Thirty-four stems had no radiolucent line at the time of follow-up, and the mean maximum thickness of the lucent lines was 0.21 mm in the entire group of fifty-eight shoulders. Most lucent lines occurred near the distal stem tip. The mean tilt of the valgus and varus humeral components was 2.2 degrees and 2.6 degrees , respectively, on the immediate postoperative radiographs. No humeral component shifted from varus to valgus or vice versa. The duration of follow-up was not correlated with the maximum thickness of the humeral component lucency, and the presence or absence of a prosthetic glenoid was also unrelated to the maximum thickness of the lucency. CONCLUSIONS: Compaction bone-grafting in shoulder arthroplasty can yield stable and durable fixation of the humeral component, as seen clinically and radiographically, without use of cement. Our findings provide evidence that compaction bone-grafting in shoulder arthroplasty is an option to ensure intermediate-term fixation (at a mean of five years) of humeral components that have a suboptimal fit.

Shoulder arthroplasty in cases with avascular necrosis of the humeral head.

Avascular necrosis (AVN) is a relatively uncommon cause of glenohumeral arthritis. Previous retrospective reviews of shoulder arthroplasty for AVN have shown very good results in small numbers of patients. This study prospectively evaluated a consecutive series of 21 shoulders in 19 patients treated with the same modular prosthesis at a single institution. Of the shoulders, 8 developed AVN after a proximal humeral fracture, 1 was associated with a massive rotator cuff tear, 10 developed after corticosteroid therapy, and 2 were idiopathic. The patients, 14 women and 5 men, with a mean age of 54 years, were followed up for a mean of 4.7 years (range, 2 to 8 years). Hemiarthroplasty was performed in 15 shoulders, whereas 6 required total shoulder arthroplasty. Assessment included visual analog scales, the Simple Shoulder Test, and the American Shoulder and Elbow Surgeons Shoulder Score Index (SSI). Physical examination was performed, and radiographs were obtained. The visual analog scale scores for pain and function improved significantly after surgery (P < .01). The mean SSI score rose from 36 to 81 (where 0 indicates the worst outcome and 100 indicates the best outcome). The mean number of positive responses on the Simple Shoulder Test increased from 3 to 10. Mean active elevation increased from 88 degrees to 123 degrees . External rotation improved from 7 degrees to 34 degrees , and internal rotation improved from L4 to T12. No difference in outcome was noted based on age or sex. Patients with steroid-related or idiopathic AVN had greater pain and functional impairment preoperatively (mean SSI score, 26) than those with prior fracture or rotator cuff tear (mean SSI score, 49) (P < .01). Postoperatively, however, these groups fared equally well (mean SSI score, 78 vs 82). Shoulder arthroplasty for AVN produces good pain relief and function, although a concurrent series with osteoarthritis yielded better results. Forward elevation did not approach normal as had been previously reported.

Treatment of glenohumeral arthritis with a hemiarthroplasty: a minimum five-year follow-up outcome study.

BACKGROUND: Glenohumeral hemiarthroplasty is well established as a method to treat glenohumeral arthritis. This study was designed to report longer-term results and to provide a decision model to assist surgeons in achieving successful outcomes. Our selection strategy for hemiarthroplasty included shoulders with (1) a concentric glenoid with eburnated bone, (2) a nonconcentric glenoid that could be converted to a smooth concentric surface, and (3) a humeral head centered within the glenoid after soft-tissue balancing. METHODS: Fifty-seven consecutive patients (sixty-four shoulders) who had osteoarthritis of the glenohumeral joint, without advanced disease in the glenoid, were treated with hemiarthroplasty. In each instance, a modular prosthesis was implanted. Clinical assessment was performed preoperatively and at one-year intervals postoperatively for at least five years with use of patient self-assessment instruments, including the American Shoulder and Elbow Surgeons questionnaire, the Simple Shoulder Test, and a visual analog pain scale. A detailed radiographic analysis was performed to determine the presence of glenohumeral subluxation, periprosthetic radiolucency, and glenoid bone loss. RESULTS: Forty-three patients (fifty shoulders) were followed for a minimum of five years (mean, 7.5 years). Of the remaining fourteen patients (fourteen shoulders), ten were lost to follow-up, three had died, and one was excluded. For the Simple Shoulder Test, and for every visual analog scale measure, the results at the final follow-up evaluation were significantly better than the preoperative results (p < 0.0001 for each). The mean Simple Shoulder Test score at the time of the final follow-up was 9.4 positive responses compared with 9.7 positive responses at the two-year evaluation (p = 0.32), and the mean visual analog scale score for pain was 18.6 points compared with 14.9 points at two years (p = 0.45). Radiographic analysis showed the majority of stems had either no lucency or lucencies only near the tip of the stem. Glenoid bone loss and subluxation improved postoperatively, and the results were maintained at the final follow-up evaluation. CONCLUSIONS: Shoulder hemiarthroplasty provides sustained good-to-excellent pain relief and functional improvement at five to ten years postoperatively in carefully selected patients with osteoarthritis.

A prospective functional outcome study of shoulder arthroplasty for osteoarthritis with an intact rotator cuff.

Prospective pain relief and functional outcome data were obtained on 65 shoulder arthroplasties in 55 patients. Thirty-seven total shoulder arthroplasties (TSAs) and twenty-eight hemiarthroplasties were followed up for a mean of 4.3 years (range, 2-8 years). The mean age was 63 years. Pain scores on a visual analog scale improved from a preoperative mean of 64 to 12 postoperatively. TSA and hemiarthroplasty postoperative scores did not differ significantly, but TSA patients started with a worse preoperative score and improved more. Five other visual analog scale scores improved, including function and quality of life. There were similar relationships between TSAs and hemiarthroplasties in each instance (poorer preoperative scores and more improvement). The American Shoulder and Elbow Surgeons Shoulder Score Index improved from 39 to 88 with surgery. The hemiarthroplasty group improved from a mean of 42 to 84, and the TSA group improved from 37 to 91. Although the numerical differences were small, the superiority of TSAs with regard to final score and rate of improvement was statistically significant. Patients with the poorest preoperative scores improved the most, regardless of prosthesis type. Mean active forward elevation improved from 100 degrees to 147 degrees, external rotation improved from a mean of 7 degrees to 39 degrees, and internal rotation improved by a mean of 3 spinal segments. These measures did not differ between TSA and hemiarthroplasty patients. One implant failure was treated with revision from TSA to hemiarthroplasty. Radiographic parameters characterizing component position and offset were measured, but none was found to predict outcome. The results suggest a modest superiority of TSA over hemiarthroplasty in the medium term. Because both TSA and hemiarthroplasty provide considerable and nearly comparable improvement, the long-term risks of glenoid wear and loosening need to be clearly defined before a definitive conclusion can be reached regarding the differential indications for these two procedures.