Arthroplasty of the shoulder

[Cementless humeral surface replacement arthroplasty in patients less than 55 years of age]

BACKGROUND

Cementless humeral surface replacement arthroplasty is a viable treatment option for degenerative diseases of the shoulder joint. The aim of this prospective study was to analyse the results of this treatment option in patients younger than 55 years of age with different pathologies of the shoulder.

PATIENTS AND METHODS

Twenty-three patients (26 implants) treated with cementless humeral surface replacement arthroplasty were included in this study. Mean follow-up was 2.5 years (1-6 years). Ten patients had posttraumatic osteoarthritis, seven had primary osteoarthritis, and six had osteonecrosis. Patients were evaluated using the Constant score, shoulder motion, and subjective satisfaction.

RESULTS

The mean Constant score increased significantly from 33 points preoperatively (8-69 points) to 61 points postoperatively (25-83 points; p<0.0001), adjusted to age and gender from 38% (8-86%) to 70% (28-114%; p<0.0001). Significant improvement for the whole cohort was found regarding patients' pain, activity, mobility, shoulder flexion and abduction, and internal and external rotation (p<0.001). In one case, reoperation was necessary due to a superficial wound infection, and in another case, implant revision to a total shoulder replacement was performed because of glenoid erosion.

CONCLUSION

Cementless humeral surface replacement arthroplasty is a viable bone-preserving treatment option for young and active patients. Later conversion to total shoulder replacement is possible. Good clinical results, a low complication rate, and high patient satisfaction were found in the short and mid term. Long-term investigations are necessary to confirm these observations.

Radiographic and histopathologic analysis of osteolysis after total shoulder arthroplasty

HYPOTHESIS

This study analyzed clinical, radiographic, and histologic data from failed total shoulder arthroplasties (TSAs) to determine factors associated with osteolysis.

MATERIALS AND METHODS

From 1985 to 2005, 52 patients (mean age, 61.6 years) underwent revision TSA at a single institution at a mean of 4.3 years after their index surgery. Patients were retrospectively assigned to 2 cohorts based on the presence (n = 10) or absence (n = 42) of osteolysis around their implants on the last prerevision surgery radiographs. Clinical information, associated histopathology from tissues obtained at revision surgery, and polyethylene wear data from the retrieved glenoid components were compared between groups.

RESULTS

In the osteolysis group, 20% had screw fixation compared with 2.5% without osteolysis (P = .039). The radiolucency score was significantly higher in the osteolysis group: 12.7 +/- 2.0 vs 8.7 +/- 3.7 (P = .003). Wear analysis of the osteolysis group demonstrated significant increases in third-body particles compared with those implants without osteolysis (P = .004). Histology available from retrieved implants demonstrated particulate debris in 62% of patients with osteolytic lesions vs 67% without osteolytic lesions (P > .05).

DISCUSSION

Significant differences were found in patients with osteolytic lesions compared with patients undergoing TSA revision surgery without such lesions, specifically with regard to glenoids that used adjuvant screw fixation, the presence of increased radiolucent lines, and an abundance of third-body wear. No significant differences were found in particulate wear debris despite the prevailing notion that osteolysis is associated with particulate debris from implant wear.

CONCLUSION

Screw fixation and third-body wear were associated with osteolysis after TSA.

Indications for reverse total shoulder arthroplasty in rotator cuff disease

BACKGROUND

Reverse total shoulder arthroplasty (RTSA) was introduced to treat rotator cuff tear arthropathy but is now used to treat a variety of problems. Although its use has expanded substantially since the FDA's approval in 2004, the appropriateness in patients with rotator cuff disease is unclear.

QUESTIONS/PURPOSES

We review the use of RTSA in patients with rotator cuff disease to (1) describe classification of rotator cuff tear reparability and the concept of a balanced shoulder; (2) explore the theory behind RTSA design relative to rotator cuff arthropathy; (3) discuss the indications and contraindications for RTSA; and (4) review published outcomes of RTSA for rotator cuff arthropathy.

METHODS

We performed a selective review of the literature on the use of RTSA in the treatment of rotator cuff disease.

RESULTS

Modern RTSA designs restore deltoid tension and a functional fulcrum to the rotator cuff deficient shoulder, which allows recovery of active shoulder elevation and effectively restores function in short- and medium-term followup studies.

CONCLUSIONS

In short-term followup the RTSA relieves symptoms and restores function for patients with cuff tear arthropathy and irreparable rotator cuff tears with pseudoparalysis (preserved deltoid contraction but loss of active elevation). Severely impaired deltoid function, an isolated supraspinatus tear, and the presence of full active shoulder elevation with a massive rotator cuff tear and arthritis are contraindications to RTSA.

CLINICAL RELEVANCE

For properly selected patients who have symptomatic and disabling rotator cuff deficiency, RTSA can result in life-changing improvements in pain, motion, function, and patient satisfaction.

LEVEL OF EVIDENCE

Level V therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Functional outcome of shoulder hemiarthroplasty for fractures: A multicentre analysis

In this multicentre study, data on 102 shoulder hemiarthroplasties for the treatment of fractures were analysed retrospectively with regard to tuberosity healing and functional outcome.

METHODS

Clinical outcome was assessed using the constant score (CS) and the American Shoulder and Elbow Score (ASES). The mean follow-up time was 28.1 months. The proportion of patients presenting tuberosity healing was 35.3% (36 out of 102).

RESULTS

Anatomical tuberosity healing has a significant effect on CS, especially for lateral elevation (p=0.0076), forward elevation (p=0.0002), power (p=0.0023) and the ASES (p=0.017). However, the pain value of the CS was not influenced by tuberosity healing (p=0.34). In patients with anatomically healed tuberosities, the CS averaged 53.0 points, whereas in the group of patients with non-anatomical tuberosity healing, the score averaged 40.1 points (p=0.0004). There was an 11-fold increase in tuberosity nonunion in females compared with males (p=0.0045). Further, nonunion was seen to be associated with advanced age of >70 years (p=0.037) and the presence of osteoporosis (p=0.034).

CONCLUSION

In this study, we found that anatomical tuberosity healing around the prosthesis improved functional outcome and range of motion.

The reverse shoulder prosthesis in the treatment of fractures of the proximal humerus in the elderly

We have previously described the short-term outcome of the use of reverse shoulder arthroplasty in the treatment of acute complex proximal humeral fractures in the elderly. We now report the clinical and radiological outcome of 36 fractures at a mean of 6.6 years (1 to 16). Previously, at a mean follow-up of 6 years (1 to 12) the mean Constant score was 58.5; this was reduced to 53 points with the further follow-up. A total of 23 patients (63%) had radiological evidence of loosening of the glenoid component. Nevertheless, only one patient had aseptic loosening of the baseplate at 12 years' follow-up. The reduction in the mean Constant score with longer follow-up and the further development of scapular notching is worrying. New developments in design, bearing surfaces and surgical technique, and further follow-up, will determine whether reverse shoulder arthroplasty has a place in the management of complex proximal humeral fractures in the elderly.

Management of the infected shoulder prosthesis: a retrospective analysis and review of the literature

Experience with infected shoulder arthroplasty is limited. Treatment options are either one- or two-stage reimplantation, débridement with retention of the prosthesis, resection arthroplasty or arthrodesis. We retrospectively analysed ten patients with an infected shoulder prosthesis and evaluated the diagnostic and therapeutic management as well as the clinical outcome, assessed by the Constant score, Neer's criteria and the mean abduction ability. We identified an infecting organism before surgery in nine patients. Four patients were treated by two-stage exchange reimplantation, five by resection arthroplasty and one underwent serial débridement combined with vacuum-irrigation therapy. Infection was eradicated in all patients of this series. The mean Constant score in resected patients was 32.7, in patients treated by stage exchange 40.1 (no difference) and we measured 90 points in the patient with retention of the implant. In patients treated by resection arthroplasty, merely the mean abduction yielded a better result (63 vs 31°) than in patients treated by two-stage exchange-with the pain level being identical in both groups. Treatment of infected shoulder implants in patients who often have to deal with concomitant diseases remains unsatisfactory. Two-stage exchange procedures yielded only slightly better functional results than resection arthroplasty, which should be considered in cases of elderly or chronically ill patients because it offers good pain relief. Serial débridement combined with irrigation therapy is a new method which offers good clinical results, however with an unknown risk of persisting infection. The authors recommend isolating the infecting organism prior to surgery to allow the administration of organism-specific antibiotics as early as possible during surgery in order to efficiently eradicate the infection.

Reliability of the glenoid plane

HYPOTHESIS

The purpose of this study was to investigate the 3-dimensional (3-D) orientation of the glenoid and scapular planes. Different definitions of the glenoid plane were used and different planes measured, and we hypothesed that the 3-D plane with the least variation would be best to define the most reliable glenoid plane.

METHODS

We studied 150 CT scans from nonpathological shoulders from patients between 18 and 80. The scapular plane and 5 different glenoid planes were determined: inferior, anterior, posterior, superior, and neutral. All plane versions and inclination angles were measured. Because all examinations were done in a standardized position to the coronal, sagittal, and transverse planes of the body, the scapular plane could be defined versus the coronal, sagittal, and transverse planes of the body.

RESULTS

The version (mean, 3.76) of the inferior glenoid plane showed a significantly lower standard deviation than the version of the anterior (P < .001), posterior (P=.001), and superior (P=.001) glenoid plane (ANOVA). For inclination all planes have a similar variance. The scapular plane was different between gender (P=.022) and correlated with age.

CONCLUSION

This study showed that the retroversion of the inferior glenoid is reasonably constant. The osseous anthropometry of the inferior glenoid can offer a reproducible point of reference to be used in prosthetic surgery of the shoulder.

Mid-term survivorship analysis of a shoulder replacement with a keeled glenoid and a modern cementing technique

We have investigated the mid-term outcome of total shoulder replacement using a keeled cemented glenoid component and a modern cementing technique with regard to the causes of failure and loosening of the components. Between 1997 and 2003 we performed 96 total shoulder replacements on 88 patients, 24 men and 64 women with a mean age of 69.7 years (31 to 82). The minimum follow-up was five years and at the time of review 87 shoulders (77 patients) were examined at a mean follow-up of 89.1 months (60 to 127). Cumulative survival curves were generated with re-operations (accomplished and planned), survivorship of the proshesis, loosening of the glenoid (defined as tilt > 5 degrees or subsidence > 5 mm), the presence of radiolucent lines and a Constant score of < 30 as the endpoints. There were two re-operations not involving revision of the implants and the survival rate of the prosthesis was 100.0% for the follow-up period, with an absolute Constant score of > 30 as the endpoint the survival rate was 98%. Radiological glenoid loosening was 9% after five years, and 33% after nine years. There was an incidence of 8% of radiolucent lines in more than three of six zones in the immediate post-operative period, of 37.0% after the first year which increased to 87.0% after nine years. There was no correlation between the score of Boileau and the total Constant score at the latest follow-up, but there was correlation between glenoid loosening and pain (p = 0.001). We found that total shoulder replacement had an excellent mid-term survivorship and clinical outcome. The surgical and cementing techniques were related to the decrease in radiolucent lines around the glenoid compared with earlier studies. One concern, however, was the fact that radiolucent lines increased over time and there was a rate of glenoid loosening of 9% after five years and 33% after nine years. This suggests that the design of the glenoid component, and the implantation and cementing techniques may need further improvement.

Surgical interventions for the rheumatoid shoulder

BACKGROUND

Involvment of the shoulder joint in patients with rheumatoid arthritis (RA) leads to severe destruction of the glenohumeral joint. When conservative treatment does not result in sufficient improvement, surgical procedures may be considered as the only beneficial treatment option.

OBJECTIVES

To assess beneficial and harmful effects of all forms of surgical treatment in the management of the shoulder in people with rheumatoid arthritis.

SEARCH STRATEGY

Articles were identified by searches in The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SCISEARCH and reference lists of relevant articles (January 1995 to May 2008).

SELECTION CRITERIA

Randomised Controlled Trials, and Controlled Clinical Trials reporting on effects of shoulder surgery. In addition case-series were included for the assessment of complications.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data.

MAIN RESULTS

One RCT, one CCT and 21 case-series were included. The RCT compared cemented versus uncemented humeral stem fixation in arthroplasty and found no significant differences between the two groups after two years (low quality evidence). The CCT compared rotator cuff repair with augmented subscapularis transposition versus subscapularis transposition alone and reported significant differences in favour of the augmented subscapularis transposition after 2 years in function, mean difference (MD) 4.00 on a 0 to 30 scale (95% CI 1.11 to 6.89) and pain, MD 4.00 on a 0 to 20 scale (95% CI 0.84 to 7.16) (low quality evidence). Based on 11 case series (mean follow up 4.5 to 12 years) complications were reported in 11% (95% CI: 9.9% to 12.1%) of the total shoulder arthroplasties, while 10 case-series (mean follow-up 2.7 to 11.3 years) reported complications in 9.9% (95% CI: 8.4% to 11.4%) of the hemiarthroplasties (very low quality evidence).

AUTHORS' CONCLUSIONS

The effects of surgical treatment in the management of the shoulder in people with rheumatoid arthritis are largely unknown due to the paucity of randomised controlled trials.

Clinical and radiological follow-up of the Aequalis third-generation cemented total shoulder replacement

There are no long-term published results on the survival of a third-generation cemented total shoulder replacement. We describe a clinical and radiological study of the Aequalis total shoulder replacement for a minimum of ten years. Between September 1996 and May 1998, 39 consecutive patients underwent a primary cemented total shoulder replacement using this prosthesis. Data were collected prospectively on all patients each year, for a minimum of ten years, or until death or failure of the prosthesis. At a follow-up of at least ten years, 12 patients had died with the prosthesis intact and two had emigrated, leaving 25 available for clinical review. Of these, 13 had rheumatoid arthritis and 12 osteoarthritis. One refused radiological review leaving 24 with fresh radiographs.

Survivorship at ten years was 100% for the humeral component and 92% for the glenoid component. The incidence of lucent lines was low. No humeral component was thought to be at risk and only two glenoid components. The osteoarthritic group gained a mean 65° in forward flexion and their Constant score improved by a mean 41.4 points (13 to 55). The rheumatoid group gained a mean of 24° in flexion and their Constant score improved by 29.4 points. This difference may have been due to failure of the rotator cuff in 75% of the patients with rheumatoid arthritis.

Thus a third-generation total shoulder replacement gives an excellent result in patients with osteoarthritis and an intact rotator cuff. Patients with rheumatoid arthritis have a 75% risk of failure of the rotator cuff at ten years.

Early management of complex proximal humeral fractures using the Aequalis fracture prosthesis

We reviewed the outcome of 28 patients who had been treated using the Aequalis fracture prosthesis for an acute fracture of the proximal humerus at a mean follow-up of 39.3 months (24 to 63). The mean age of the patients at the time of the fracture was 66.3 years (38 to 80). The mean Constant score was 68.2 (37 to 84) for the operated shoulder, which represented 89.5% of the mean score for the uninjured side (p < 0.001). The quality of the reconstruction as shown on the immediate post-operative radiographs was categorised into three types, anatomical, acceptable, and unacceptable, depending on the position of the tuberosities relative to the prosthetic head and the humeral shaft. Anatomical reconstruction was associated with a higher mean Constant score as well as higher mean values of anterior forward elevation, abduction and external rotation than the other types, but the differences were not statistically significant (p > 0.231).

A total of 18 patients had active anterior elevation ≥150°. Their mean active abduction and external rotation were 163.6° and 31.3°, respectively. In seven of the 28 patients, the mean active anterior elevation, abduction and external rotation were 130.7°, 129.2° and 22.8°, respectively. In all, 12 patients were very satisfied with the results, 12 were satisfied, two were dissatisfied and two were disappointed; 26 reported no or only mild pain while only two had moderate pain. In five patients proximal migration of the humeral head was shown on the anteroposterior radiographs of the shoulder. No evidence of loosening was found in any prosthesis.

Total shoulder replacement in rheumatoid disease

We describe the longer term clinical and radiological findings in a prospectively followed series of 49 rheumatoid patients (58 shoulders) who had undergone Neer II total shoulder replacement. The early and intermediate results have been published previously.

At a mean follow-up of 19.8 years (16.5 to 23.8) 14 shoulders survived. Proximal migration of the humeral component was associated with progressive loosening of the glenoid and humeral components, but was independent of the state of the rotator cuff at the time of operation. Despite these changes the range of movement was preserved. Most patients had little or no pain in the shoulder, could sleep undisturbed and could attend to personal hygiene and grooming.

Delta III reverse shoulder arthroplasty: radiological outcome for acute complex fractures of the proximal humerus in elderly patients

PURPOSE OF THE STUDY

Acute complex proximal humerus fractures in the elderly population, treated by internal fixation or hemiarthroplasty, give well reported radiological results. We investigated the radiological outcome of the reverse arthroplasty concept in this indication.

MATERIAL AND METHODS

From 1993 to 2007, 41 Delta III prostheses were implanted following 32 three-part and four-part displaced fractures, and in nine fracture/dislocations; three fractured patients were males and 38 females; mean age at fracture time was 75 years. The results were evaluated on AP and Lamy lateral shoulder views.

RESULTS

Since nine of these patients were deceased and two had moved, 30 cases were available at review, with a mean follow-up of 6.5 years (range, 1-14). The radiographs showed two thick radiolucent lines on the glenoid component with one aseptic loosening of the base plate at 12 years. Based on the Nérot classification, 17 cases of inferior scapular notching were, in total, observed. The mean time to onset was 2 years for the seven grade 1 notches (41%), 4 years for the five grade 2 notches (30%), 5 years for the three grade 3 notches (17%) and 6 years for the two grade 4 notches (12%). Fourteen inferior spurs (stable after emergence) were reported with a mean time to onset of 2.5 years (range, 1-6 years). One joint ossification occurred at 6 months and was stable at the 6-year follow-up review. The humeral component results comprised four cases of medial (5, 6, 7 and 10 years) proximal bone loss and two cases of bone-cement interface deterioration (medial radiolucent lines at two-third of the stem height at the 5-year follow-up). In these six cases, a notch was present above this area. In addition, one case of humeral septic loosening is reported at 2-year follow-up.

CONCLUSION

For acute proximal humeral complex fractures in the elderly population, when refixation of the tuberosities on a classical orthopaedic devices appears compromised, the use of a Delta III reverse prosthesis is an attractive alternative; however, with a mean follow-up of 6.5 years, this prosthesis demonstrates unsatisfactory images in 70% of the cases. These flaws were noted on the glenoid component in 70% of the cases, appeared before 7 years in 86% and were progressive in 50% of the cases. However, only one revision was required for an aseptic loosening of the base plate at 12 years. New developments in designs and bearing surfaces and larger numbers analysis of long-term results will probably be needed to encourage extensive utilization of the reverse concept in this fracture indication.

LEVEL OF EVIDENCE

Level IV. Therapeutic retrospective study.

The effect of the offset humeral head on the micromovement of pegged glenoid components

In a prospective study between 2000 and 2005, 22 patients with primary osteoarthritis of the shoulder had a total shoulder arthroplasty with a standard five-pegged glenoid component, 12 with non-offset humeral head and ten with offset humeral head components. Over a period of 24 months the relative movement of the glenoid component with respect to the scapula was measured using radiostereometric analysis.

Nine glenoids needed reaming for erosion. There was a significant increase in rotation about all three axes with time (p < 0.001), the largest occurring about the longitudinal axis (anteversion-retroversion), with mean values of 3.8° and 1.9° for the non-offset and offset humeral head eroded subgroups, respectively. There was also a significant difference in rotation about the anteversion-retroversion axis (p = 0.01) and the varus-valgus (p < 0.001) z-axis between the two groups. The offset humeral head group reached a plateau at early follow-up with rotation about the z-axis, whereas the mean of the non-offset humeral head group at 24 months was three times greater than that of the offset group accounting for the highly significant difference between them.

Simulation of surgical glenoid resurfacing using three-dimensional computed tomography of the arthritic glenohumeral joint: the amount of glenoid retroversion that can be corrected

HYPOTHESIS

The magnitude of glenoid retroversion that can be surgically corrected in total shoulder arthroplasty and still enable implantation of a glenoid component has not been established. We hypothesized that increased retroversion will require smaller glenoid components for successful implantation when the glenoid is surgically corrected and that correction beyond 20 degrees of retroversion is not feasible without peg penetration.

METHODS

Using 3-dimensional models created from computed tomography of 19 patients with advanced shoulder osteoarthritis, we simulated glenoid resurfacing on varying degrees of retroverted, osteoarthritic glenoids using an in-line 3-peg glenoid component and asymmetric reaming to correct version.

RESULTS

Glenoids with preoperative retroversion of less than 12 degrees could always be implanted with 46-mm and 52-mm glenoid components at neutral version without vault violation. Conversely, glenoids with greater than 18 degrees of preoperative retroversion could not be implanted at neutral version due to vault violation from the pegs. The average preoperative glenoid retroversion of patients in which a 46-mm glenoid was implanted at neutral version was 8.9 degrees +/- 6.4 degrees compared with 19.0 degrees +/- 7.1 degrees for those that could not be implanted at neutral (P = .005).

DISCUSSION

Computer-aided surgical simulation shows that glenoid retroversion is a critical factor in determining successful glenoid implantation. Smaller sized glenoid components allow for greater version correction and less residual postsimulation retroversion when an in-line pegged component is used.

Revision of the humeral component for aseptic loosening in arthroplasty of the shoulder

Between 1976 and 2004, 38 revision arthroplasties (35 patients) were performed for aseptic loosening of the humeral component. The mean interval from primary arthroplasty to revision was 7.1 years (0.4 to 16.6). A total of 35 shoulders (32 patients) were available for review at a mean follow-up of seven years (2 to 19.3). Pre-operatively, 34 patients (97%) had moderate or severe pain; at final follow-up, 29 (83%) had no or only mild pain (p < 0.0001). The mean active abduction improved from 88 degrees to 107 degrees (p < 0.01); and the mean external rotation from 37 degrees to 46 degrees (p = 0.27). Excellent or satisfactory results were achieved in 25 patients (71%) according to the modified Neer rating system. Humeral components were cemented in 29, with ingrowth implants used in nine cases. There were 19 of standard length and 17 were longer (two were custom replacements and are not included). Bone grafting was required for defects in 11 humeri. Only two glenoid components were left unrevised. Intra-operative complications included cement extrusion in eight cases, fracture of the shaft of the humerus is two and of the tuberosity in four. There were four re-operations, one for recurrent humeral loosening, with 89% survival free of re-operations at ten years. Revision surgery for aseptic loosening of the humeral component provides reliable pain relief and modest improvement of movement, although there is a substantial risk of intra-operative complications. Revision to a total shoulder replacement gives better results than to a hemiarthroplasty.

Early management of proximal humeral fractures with hemiarthroplasty: a systematic review

We performed a comprehensive systematic review of the literature to examine the role of hemiarthroplasty in the early management of fractures of the proximal humerus. In all, 16 studies dealing with 810 hemiarthroplasties in 808 patients with a mean age of 67.7 years (22 to 91) and a mean follow-up of 3.7 years (0.66 to 14) met the inclusion criteria. Most of the fractures were four-part fractures or fracture-dislocations. Several types of prosthesis were used. Early passive movement on the day after surgery and active movement after union of the tuberosities at about six weeks was described in most cases. The mean active anterior elevation was to 105.7 degrees (10 degrees to 180 degrees) and the mean abduction to 92.4 degrees (15 degrees to 170 degrees). The incidence of superficial and deep infection was 1.55% and 0.64%, respectively. Complications related to the fixation and healing of the tuberosities were observed in 86 of 771 cases (11.15%). The estimated incidence of heterotopic ossification was 8.8% and that of proximal migration of the humeral head 6.8%. The mean Constant score was 56.63 (11 to 98). At the final follow-up, no pain or only mild pain was experienced by most patients, but marked limitation of function persisted.

The results of two-stage re-implantation for infected shoulder replacement

While frequently discussed as a standard treatment for the management of an infected shoulder replacement, there is little information on the outcome of two-stage re-implantation. We examined the outcome of 17 consecutive patients (19 shoulders) who were treated between 1995 and 2004 with a two-stage re-implantation for the treatment of a deep-infection after shoulder replacement. All 19 shoulders were followed for a minimum of two years or until the time of further revision surgery. The mean clinical follow-up was for 35 months (24 to 80). The mean radiological follow-up was 27 months (7 to 80). There were two excellent results, four satisfactory and 13 unsatisfactory. In 12 of the 19 shoulders (63%) infection was considered to be eradicated. The mean pain score improved from 4.2 (3 to 5 (out of 5)) to 1.8 (1 to 4). The mean elevation improved from 42 degrees (0 degrees to 140 degrees ) to 89 degrees (0 degrees to 165 degrees ), mean external rotation from 30 degrees (0 degrees to 90 degrees ) to 43 degrees (0 degrees to 90 degrees ), and mean internal rotation from the sacrum to L5. There were 14 complications. Our study suggests that two-stage re-implantation for an infected shoulder replacement is associated with a high rate of unsatisfactory results, marginal success at eradicating infection and a high complication rate.

Transfer of pectoralis major for the treatment of irreparable tears of subscapularis

Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis.

At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively.

Failure of the tendon transfer was highest in group II and was associated with pre-operative anterior subluxation of the humeral head. We conclude that in patients with irreparable rupture of subscapularis after shoulder replacement there is a high risk of failure of transfer of p?ctoralis major, particularly if there is pre-operative anterior subluxation of the humeral head.

Total shoulder replacement in young and middle-aged patients with glenohumeral osteoarthritis

Our aim in this prospective study was to evaluate the outcome of total shoulder replacement in the treatment of young and middle-aged active patients with primary glenohumeral osteoarthritis. We reviewed 21 patients (21 shoulders) with a mean age of 55 years (37 to 60). The mean follow-up was seven years (5 to 9). The same anatomical, third-generation, cemented implant had been used in all patients. All the patients were evaluated radiologically and clinically using the Constant and Murley score.

No patients required revision. In one a tear of the supraspinatus tendon occurred. Overall, 20 patients (95%) were either very satisfied (n = 18) or satisfied (n = 2) with the outcome. Significant differences (p < 0.0001) were found for all categories of the Constant and Murley score pre- and post-operatively. The mean Constant and Murley score increased from 24.1 points (10 to 45) to 64.5 points (39 to 93), and the relative score from 30.4% (11% to 50%) to 83% (54% to 116%). No clinical or radiological signs of loosening of the implant were seen.

For young and middle-aged patients with osteoarthritis, third-generation total shoulder replacement is a viable method of treatment with a low rate of complications and excellent results in the mid-term.

Development of a predictive model for estimating the probability of treatment success one year after total shoulder replacement - cohort study

OBJECTIVE

To Estimate the probability of treatment success 1 year after a total shoulder arthroplasty by developing a model based on preoperative clinical factors.

METHOD

Between June 2003 and December 2006, 140 patients undergoing shoulder operations were assessed for age, gender, current rheumatoid arthritis, Short Form (SF) 36 physical and mental sum scores, previous shoulder operations, the Disabilities of Arm, Shoulder and Hand (DASH) symptom and function scores, the Shoulder Pain and Disability Index (SPADI), and insurance status. One year after the operation a Constant score of 80 or more out of 100 indicated successful treatment. Patient variables were analyzed with a logistic regression model augmented in a stepwise manner and bootstrapped 100 times. Variables selected at least 33 times were incorporated into a final model and the Area under the Receiver Operating Characteristics Curve (aROC) was calculated.

RESULTS

There were 47/140 (33.6%) successful treatments. The probability of success was reduced in patients with previous shoulder operations (Odds Ratio [O.R.] 0.17, 95% Confidence Interval (95%CI) 0.04-0.85; P=0.03) and older than 75 years (O.R. 0.21, 95%CI 0.05-0.77; P=0.02). The probability of success increased in patients with a higher SF 36 mental sum score (O.R. 1.03, 95%CI 0.96-1.09, P=0.42) and a higher DASH function score (O.R. 1.05, 95%CI 1.02-1.07, P=0.001). The aROC was 0.79 (0.70-0.88) indicating that the model has a high predictive capacity.

CONCLUSION

Once validated this model based on four preoperative clinical factors offers a prediction of whether a patient will respond to treatment 1 year after total shoulder arthroplasty.

Inter-rater reliability of an arthritic glenoid morphology classification system

To our knowledge, no independent analysis of the inter-rater agreement of the widely used Walch classification for osteoarthritic glenoid morphology has been performed. The computed tomography scans of 24 shoulders with primary osteoarthritis were used by 4 experienced shoulder surgeons to classify the glenoids independently according to Walch et al. The weighted kappa statistic was calculated to determine the inter-rater and intrarater agreement among observers. The overall inter-rater agreement for the Walch classification was fair (kappa = 0.37) when classified into the 5 types (A1, A2, B1, B2, and C). Agreement for the various subclassifications was as follows: A1, kappa = 0.22; A2, kappa = 0.33; B1, kappa = 0.17; B2, kappa = 0.32; and C, kappa = 0.86. When the classification system was simplified to just the 3 major types (A, B, and C), overall agreement was moderate (kappa = 0.44). Agreement for each type was moderate for A (kappa = 0.59) and B (kappa = 0.59) and almost perfect for C (kappa = 0.89). Overall intrarater agreement was fair (kappa = 0.37). We conclude that only fair agreement was found among experienced shoulder surgeons when classifying arthritic shoulders using the classification system of Walch et al. A glenoid classification scheme that relies more upon glenoid morphology and less upon humeral head position may demonstrate greater observer agreement and, therefore, may offer greater value.

Safety and utility of computer-aided shoulder arthroplasty

This study evaluated the safety and utility of a novel, image-free, shoulder navigation system in a cadaver and in an initial cohort of shoulder arthroplasty patients. Shoulder arthroplasty was performed on a cadaver and 27 patients using an image-free navigation system (NaviProtrade mark; Kinamed Navigation Systems LLC, Camarillo, CA). Optical trackers were attached to the proximal humerus and the coracoid process. Prior to and following humeral head resection, the anatomic neck axis (retroversion, inclination) and humeral head diameter were measured with the navigation system. Native glenoid surface orientation was registered, and a navigation tracker was attached to the glenoid reamer. The navigation system recorded change in inclination and version relative to the native glenoid during reaming. The cadaver results demonstrated that the trackers did not impede surgical performance and that system accuracy was 2.6 degrees +/- 2.5 degrees . In the clinical series, the navigation system reported the anatomic humeral neck measurements (retroversion 30.0 degrees +/- 16.0 degrees ; inclination 137.0 degrees +/- 11.7 degrees ), the humeral head diameters (major axis 46.2 mm +/- 4.8 mm; minor axis 43.2 mm +/- 3.8 mm), the humeral neck resection angles (retroversion 29.9 degrees +/- 15.1 degrees and inclination 135.6 degrees +/- 9.1 degrees ), and glenoid reaming orientation relative to the native glenoid (+3.0 degrees +/- 6.3 degrees of version; -6.7 degrees +/- 4.4 degrees of inclination). This initial clinical experience with computer-aided shoulder navigation demonstrates that the procedure is safe and can provide valuable intraoperative measurements. With an anatomic humeral implant system, the navigation system provides real-time feedback on the humeral resection as it relates to anatomic neck geometry. The system also provides real-time angulation of the glenoid reamer relative to preoperative glenoid deformity.

Die Bedeutung der Gleitpaarung beim jüngeren Endoprothesenpatienten

The success and long-term survival rates of modern joint arthroplasty leads to a high patient satisfaction and, together with its technical improvements, has broadened the indications to an increasingly younger population. Limitations to the established systems are the long-term survival rates, which are mainly influenced by wear of the articulating parts and the resulting problems. Beside "classic" long-stemmed cemented shafts articulating with metal against polyethylene, short-stemmed or cup designs with a hard-hard self pairing are increasingly used in total hip arthroplasty. This paper reflects the current state of the art in joint arthroplasty for younger patients with the focus on wear couples and discusses future perspectives. Special interest is focused on the advantages and disadvantages of ceramic bearings, problems with allergies to implant components and the design of endoprostheses with regard to avoidance of impingement.

Outcomes of shoulder arthroplasty in Olmsted County, Minnesota: a population-based study

Most studies on shoulder arthroplasty include a diverse group of patients presenting to a tertiary care center. Little information is available regarding outcomes in a community setting. We reviewed 98 residents (110 shoulders) of Olmsted County, Minnesota who had shoulder arthroplasties from 1976 to 2000. There were 65 total shoulder arthroplasties and 45 humeral head replacements. The most common indications were osteoarthritis for total shoulder arthroplasties (48/65) and acute fracture for hemiarthroplasties (27/45). The Neer ratings were excellent or satisfactory in 92% of total shoulder arthroplasties and 56% of hemiarthroplasties. The 10-year survival rate was 96%. The mean postoperative active forward elevation was greater in patients who had a total shoulder arthroplasty (132 degrees) compared with a hemiarthroplasty (113 degrees), as was external rotation (total shoulder arthroplasties = 58 degrees, humeral head replacements = 38 degrees). The outcomes for total shoulder arthroplasty and hemiarthroplasty compared favorably with outcomes reported in the literature. There was a high rate of satisfactory or excellent results after total shoulder arthroplasty for osteoarthritis. Hemiarthroplasty offered less satisfactory results, most likely related to the use of this procedure for trauma. This information will assist the community surgeon in counseling patients and weighing the risks and benefits of a shoulder arthroplasty.

Die Überbrückung von posttraumatischen Knochendefekten

Bony defects as a result of injury or disease can be caused by a variety of conditions such as acute injury, fall fractures in osteoporotic patients or tumours and congenital malformations of the musculoskeletal system which necessitate the resection of affected parts of the bone. This results in a multitude of defects concerning localisation and specificity as well as a number of conditions involving both hard and soft tissue structures and various situations of different patients. A reasonable classification of defects which is relevant for practical purposes includes four basic types: defects of the spine, metaphyseal defects as well as partial and complete diaphyseal defects of long bones. A variety of options exists for the treatment of these conditions. The aim of all efforts is to reinstall the integrity of affected structures long-lastingly and dependably and at the same time guarantee the normal function of joints involved. In addition to classical treatment strategies which involve the use of autogenous and allogenous corticocancellous bone grafts a great number of bone substitute materials can also be used. Further options lie in complex reconstructive methods such as the transport of whole segments or the transplantation of vascularised bone grafts. The field of new regenerative strategies including tissue engineering as well as stem cell and gene therapy holds great promise for the future. The aim of this review is to derive a ranking from the evaluation of biological and mechanical characteristics for the treatment of posttraumatic defects.