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Carofino BC. Letter to the Editor regarding Kleim et al: "pyrocarbon hemiprostheses show little glenoid erosion and good clinical function at 5.5 years of follow-up". J Shoulder Elbow Surg 2024; 33:e459-e460. [PMID: 38692403 DOI: 10.1016/j.jse.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/05/2024] [Indexed: 05/03/2024]
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Kleim BD, Brunner UH. Response to Carofino editor regarding: "pyrocarbon hemiprostheses show little glenoid erosion and good clinical function at 5.5 years of follow-up". J Shoulder Elbow Surg 2024; 33:e461-e463. [PMID: 38692405 DOI: 10.1016/j.jse.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 03/05/2024] [Indexed: 05/03/2024]
Affiliation(s)
- Benjamin D Kleim
- Department of Sports Orthopaedics, Technical University of Munich, Munich, Germany; Department for Trauma and Orthopaedic Surgery, Agatharied Hospital, Hausham, Germany.
| | - Ulrich H Brunner
- Department for Trauma and Orthopaedic Surgery, Agatharied Hospital, Hausham, Germany
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Papadopoulos DV, Nikolaou VS, Masouros P, Babis GC, Imbriglia JE. The impact of glenoid parameters and implant overstuffing on functional outcomes of shoulder hemiarthroplasty in patients with glenohumeral joint arthritis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3531-3538. [PMID: 37212913 DOI: 10.1007/s00590-023-03584-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 05/10/2023] [Indexed: 05/23/2023]
Abstract
PURPOSE The outcomes of shoulder hemiarthroplasty are highly dependent on the baseline glenoid morphology and the rotator cuff integrity. The objective of this study was to assess whether certain glenoid parameters and implant overstuffing are associated with worse clinical outcomes following shoulder hemiarthroplasty. METHODS We retrospectively reviewed 25 patients who underwent shoulder hemiarthroplasty for shoulder arthritis, with a mean follow-up of 5.3 years. The baseline glenoid morphology, the glenoid wear rate, the proximal humeral head migration and implant overstuffing were evaluated radiologically in all patients. The radiological parameters were correlated with the functional outcomes. RESULTS The Constant-Murley score, the ASES score, and the OSS score were significantly better for patients with a concentric baseline glenoid compared to those with an eccentric glenoid. The Constant-Murley score and the ASES score were also improved in patients without implant overstuffing compared to patients with implant overstuffing (p < 0.05). However, glenoid wear was not associated with worse functional outcomes (p = 0.23 for Constant-Murley score, p = 0.15 for ASES score and p = 0.27 for OSS score). Last, a worse Constant-Murley score was strongly correlated with proximal humeral head migration (p < 0.001), while worse ASES and OSS scores were moderately correlated with proximal humeral head migration (p < 0.001). CONCLUSION Our findings indicate that the results of hemiarthroplasty can be improved through careful selection of patients upon the baseline glenoid type morphology and proper implant sizing to avoid implant overstuffing. Moreover, glenoid wear is not associated with worse clinical outcomes, therefore shoulder hemiarthroplasty should be reconsidered as an alternative in younger patients with shoulder arthritis.
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Affiliation(s)
| | - Vasileios S Nikolaou
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, 3-5 Konstantopoulou Str, 14233, Athens, Greece
| | | | - George C Babis
- 2nd Academic Department of Orthopaedics, School of Medicine, Konstandopoulio General Hospital, National & Kapodistrian University of Athens, 3-5 Konstantopoulou Str, 14233, Athens, Greece
| | - Joseph E Imbriglia
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
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Kawamata J, Suenaga N, Oizumi N, Yoshioka C, Miyoshi N, Goya I. Glenoid wear and its impact on clinical results after humeral head replacement using a single prosthesis in cuff tear arthropathy with more than 8 years of follow-up. J Shoulder Elbow Surg 2022; 31:2586-2594. [PMID: 35716899 DOI: 10.1016/j.jse.2022.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 04/24/2022] [Accepted: 05/09/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Glenoid wear (GW) is a long-term complication after humeral head replacement (HHR) and is one of the major reasons for revision surgery. This study aimed to evaluate GW at >8 years of follow-up after HHR in patients with cuff tear arthropathy (CTA) by use of a modified classification of GW, to examine the relationship between GW and clinical outcomes, and to identify risk factors for GW progression. METHODS This retrospective case-series study included 34 shoulders that were monitored for >8 years after HHR in patients with CTA (13 men and 21 women; mean age at surgery, 70.9 years [range, 55-82 years]). Patients were monitored for a mean of 10.3 years (range, 8.1-13.2 years). GW was classified using plain radiographs as follows: grade 0, no remarkable postoperative changes; grade 1, postoperative glenohumeral joint space narrower than preoperative glenohumeral joint space; grade 2, contact between glenoid and humeral head prosthesis; and grade 3, glenoid erosion. Grade 3 cases were further classified into the following subtypes: grade 3A, partial erosion of anterior glenoid; grade 3B, partial erosion of superior glenoid; and grade 3C, concentric erosion of glenoid. Clinical outcomes including range of motion (active flexion and active external rotation) and postoperative pain (Constant score) were compared between grade 0-2 shoulders and grade 3 shoulders, as well as between the grade 3 subtypes. Age, sex, preoperative range of motion, preoperative pain, and number of ruptured tendons were analyzed as possible risk factors for progression to grade 3. RESULTS The final GW grade was grade 0 in 3 shoulders, grade 1 in 10, grade 2 in 6, and grade 3 in 15 (grade 3A in 2, grade 3B in 6, and grade 3C in 7). The grade 3 group had lower pain scores (10.7 ± 6.2 vs. 14.2 ± 1.9, P = .044) and limited active flexion (108.2° ± 42.3° vs. 140.6° ± 26.7°, P = .041) compared with the grade 0-2 group. Subtype comparison showed that the grade 3B group had lower pain scores (7.0 ± 6.7 vs. 15.0 ± 0.0, P = .007) and limited active flexion (80.0° ± 26.2° vs. 140.8° ± 27.5°, P = .010) compared with the grade 3C group. Limited preoperative active external rotation was an individual risk factor for grade 3 GW (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P = .009). CONCLUSIONS In the long term (>8 years) after HHR with tendon transfer in patients with CTA, patients with the development of grade 3C GW ultimately achieve pain relief even without revision surgery whereas grade 3B GW is associated with persistent pain and might require revision surgery.
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Affiliation(s)
- Jun Kawamata
- Department of Orthopaedic Surgery, Kaisei Hospital, Obihiro, Japan.
| | - Naoki Suenaga
- Upper Extremity Center of Joint Replacement and Endoscopic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Naomi Oizumi
- Upper Extremity Center of Joint Replacement and Endoscopic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Chika Yoshioka
- Upper Extremity Center of Joint Replacement and Endoscopic Surgery, Hokushin Orthopaedic Hospital, Sapporo, Japan
| | - Naoki Miyoshi
- Department of Orthopaedic Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Isoya Goya
- Department of Orthopaedic Surgery, Nanbu Tokusyukai Hospital, Japan
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Risk factors for eccentric glenoid wear after humeral head replacement for cuff tear arthropathy. JSES Int 2022; 6:889-895. [PMID: 36353441 PMCID: PMC9637801 DOI: 10.1016/j.jseint.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background In our previous report, glenoid wear (GW) after humeral head replacement for cuff tear arthropathy was classified with modified Goya’s classification (grade 0-3), and, among 3 subtypes of grade 3 (glenoid bone erosion), grade 3B (superior eccentric erosion) showed significantly more pain and limited active flexion postoperatively compared to grade 3C (concentric erosion). The purpose of this study was to detect individual risk factors for the progression to grade 3B GW. Methods Seventy-nine shoulders in 70 patients who were followed up for a mean of 8.2 years (range, 5.0-13.2 years), including 29 men and 41 women, with a mean age at the surgery of 71.1 years (range, 54-87 years), were reviewed. Atrophy and fatty degeneration of torn cuff muscle, preoperative humeral head displacement (superior translation ratio [STR], anterior translation ratio, and other several parameters) on preoperative magnetic resonance imaging, and other individual factors were analyzed as possible risk factors. Results GW at the final follow-up was grade 0: 5 shoulders, grade 1: 17, grade 2: 20, and grade 3: 37 (3A: 4, 3B: 22, and 3C: 11). Preoperative higher STR was defined as a risk factor for grade 3 GW (odds ratio, 35.5; 95% confidence interval, 1.8-693.0; P = .018). Comparison among the three subtypes of grade 3 showed that patients with grade 3B GW had larger STR than 3C (41.4 ± 14.2% vs. 23.5 ± 13.3 % P = .006). Conclusion Patients with preoperative high STR are considered to have a risk for grade 3B GW, which possibly relates to poor clinical outcome and future revision.
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Levins J, Passarelli E, Adkins J, Molino J, Henry H, Paxton ES, Green A. Early outcome of humeral head replacement with glenoid reaming arthroplasty (Ream and Run) for treatment of advanced glenohumeral osteoarthritis. J Shoulder Elbow Surg 2022; 31:1846-1858. [PMID: 35276348 DOI: 10.1016/j.jse.2022.01.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/23/2022] [Accepted: 01/29/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Long-term outcomes of anatomic total shoulder arthroplasty (aTSA) can be compromised by glenoid loosening and failure. The purpose of this study was to evaluate the short- and midterm outcomes of humeral head replacement with glenoid reaming arthroplasty (Ream and Run) for the treatment of advanced glenohumeral osteoarthritis, and to identify associations between preoperative factors and outcomes. METHODS Forty-nine shoulders (mean age 60 ± 7 years) with minimum 2-year follow-up (mean 4.6 ± 1.7) were evaluated. Forty-three (87.8%) were male. Thirteen (26.5%) had previous nonarthroplasty shoulder surgery. There were 19 (38.8%) Walch type A and 30 (61.2%) type B glenoids. Pre- and postoperative shoulder motion, patient-reported outcomes (PROMs), and health-related quality of life (HRQoL) were assessed. Pre- and postoperative plain radiographs were evaluated. Mixed effects models were used to investigate factors associated with outcomes. RESULTS Active forward elevation and active external rotation improved from 111.7° ± 23.8° to 139.2° ± 21.1° and 13.3° ± 20.7° to 38.7° ± 14.7°, respectively (P < .001). The mean American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), Simple Shoulder Test (SST), and visual analog scale (VAS) shoulder pain scores at the most recent follow-up were 86.6 ± 19.9, 10.1 ± 14.1, 10.5 ± 2.2, and 1.5 ± 2.3, respectively. The mean changes of PROMs were significant and exceeded the minimal clinically important difference for aTSA. The percentage maximal possible improvement for ASES, DASH, and SST were greater than 75%. Male sex (P < .008) and not having prior shoulder surgery (P < .04) were significantly associated with better absolute and greater change in PROMs. Age, preoperative shoulder motion, and Walch glenoid classification were not associated with PROMs. Five (10.2%, 95% confidence interval [CI] 1.8%-18.6%) patients underwent revision for pain. Three additional patients were dissatisfied at final follow-up without undergoing revision, resulting in 16.7% (95% CI 6.1%-27.2%) of patients being dissatisfied with their outcome after their initial RnR. Mean Short Form-6 Dimensions scores improved from 0.66 ± 0.12 to 0.77 ± 0.13 and mean EuroQol-5 Dimensions scores improved from 0.68 ± 0.20 to 0.85 ± 0.17 (P < .001). Improvement in HRQoL was significantly associated with nondominant arm treatment, increased age, and greater preoperative SST score. Annual medialization of the humeral head center of rotation was 0.56 ± 1.6 mm/yr. No radiographic measure was associated with long-term PROMs. CONCLUSION Ream and Run can provide significant and clinically important improvement in PROMs and HRQoL for a high percentage of patients at short- and midterm follow-up. This procedure is an appropriate alternative to aTSA in select patients.
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Affiliation(s)
- James Levins
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Emily Passarelli
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jacob Adkins
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Janine Molino
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - E Scott Paxton
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Andrew Green
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Providence, RI, USA.
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Matsen FA, Carofino BC, Green A, Hasan SS, Hsu JE, Lazarus MD, McElvany MD, Moskal MJ, Parsons IM, Saltzman MD, Warme WJ. Shoulder Hemiarthroplasty with Nonprosthetic Glenoid Arthroplasty: The Ream-and-Run Procedure. JBJS Rev 2021; 9:01874474-202108000-00010. [PMID: 34432729 DOI: 10.2106/jbjs.rvw.20.00243] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Glenoid component wear and loosening are the principal failure modes of anatomic total shoulder arthroplasty (aTSA). » The ream-and-run (RnR) procedure is an alternative glenohumeral arthroplasty for patients who wish to avoid the risks and limitations of a prosthetic glenoid component. » During the RnR procedure, the arthritic glenoid is conservatively reamed to a single concavity, while the prosthetic humeral component and soft tissues are balanced to provide both mobility and stability of the joint. » The success of the RnR procedure depends on careful patient selection, preoperative education and engagement, optimal surgical technique, targeted rehabilitation, and close postoperative communication between the surgeon and the patient. » While the RnR procedure allows high levels of shoulder function in most patients, the recovery can be longer and more arduous than with aTSA. » Patients who have undergone an RnR procedure occasionally require a second closed or open procedure to address refractory shoulder stiffness, infection, or persistent glenoid-sided pain. These second procedures are more common after the RnR than with aTSA.
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Affiliation(s)
- Frederick A Matsen
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | | | - Andrew Green
- Department of Orthopaedic Surgery, Warren Alpert Medical School of Brown University, East Providence, Rhode Island
| | - Samer S Hasan
- Mercy Health-Cincinnati SportsMedicine and Orthopaedic Center, Cincinnati, Ohio
| | - Jason E Hsu
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Mark D Lazarus
- Department of Orthopaedics, The Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - Matthew D McElvany
- Department of Orthopaedics, The Permanente Medical Group, Santa Rosa, California
| | | | - I Moby Parsons
- The Knee, Hip and Shoulder Center, Portsmouth, New Hampshire
| | - Matthew D Saltzman
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Winston J Warme
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
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Garcia GH, Gowd AK, Liu JN, Malaret MR, Cabarcas BC, Romeo AA. Return to Sport Following Hemiarthroplasty With Concentric Reaming Versus Total Shoulder Arthroplasty: A Matched Pair Analysis. Orthopedics 2019; 42:276-284. [PMID: 31269217 DOI: 10.3928/01477447-20190627-05] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 06/03/2019] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to establish functional outcomes regarding return to sport activity for patients receiving anatomical total shoulder arthroplasty (aTSA) vs the ream and run procedure (hemi RR). Patients who underwent hemi RR and who underwent aTSA with a polyethylene glenoid component for end-stage glenohumeral arthritis were retrospectively identified from 2000 to 2014. Patients were matched regarding age, body mass index, sex, and hand dominance. Patients were surveyed to determine their level of sport and satisfaction after surgery. At a mean follow-up of 69.1±24.8 months, a total of 26 hemi RR and 30 aTSA patients met inclusion/exclusion criteria. Mean±SD age at the time of surgery was 53.0±8.5 years. There was no statistical difference between the two cohorts regarding patients who reported no postoperative problems (69.2% vs 76.7%, P=.529), reoperation (11.5% vs 6.7%, P=.522), return to overall sport (94.4% vs 86.4%, P=.395), return to high-demand upper-extremity sport (92.3% vs 81.3%, P=.390), and return to same or better level of intensity sport (83.3% vs 72.7%, P=.424). Patients returned to sport at a mean of 7.5±5.7 months and 6.2±3.6 months in the hemi RR and aTSA cohorts, respectively (P=.485). Radiographic measurements of medialization (mean, -2.4±5.0 vs -2.2±5.7; P=.913) and postoperative decentering (mean, 3.6%±2.6% vs 4.3%±3.3%; P=.795) were equivalent for the two cohorts. Hemi RR was found to have high and equivalent rates of sporting outcomes, clinical outcomes, and radiographic outcomes compared with aTSA. As appropriately indicated patients are counseled for surgery, realistic expectations regarding sports should be discussed. [Orthopedics. 2019; 42(5):276-284.].
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Smith MJ, Loftis CM, Skelley NW. Eccentric Reaming for B2 Glenoids: History, Preoperative Planning, Surgical Technique, and Outcome. J Shoulder Elb Arthroplast 2019; 3:10.1177_2471549219870348. [PMID: 34514277 PMCID: PMC8282167 DOI: 10.1177/2471549219870348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/17/2019] [Accepted: 07/26/2019] [Indexed: 11/16/2022] Open
Abstract
Background The biconcave (B2) glenoid is characterized by preservation of the anterior
portion of the native glenoid with asymmetric wear of the posterior glenoid.
Surgical options for glenoid correction have evolved. The goal of shoulder
arthroplasty is to place the implants in such a manner to return the humeral
head to a centered position and restore the joint line to a neutral
position. There is no current consensus on method of treatment and
correction. Methods The current and historical literature on total shoulder arthroplasty was used
to examine technique viability. Results Asymmetric remaining can be used to address up to 15° of version correction
without compromise of cortical bone. It is important to have the proper
presurgical planning, to understand the limitations of correction, and to
have other options available to treat the biconcave glenoid.
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Affiliation(s)
- Matthew J Smith
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | | | - Nathan W Skelley
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
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Survivorship of Hemiarthroplasty With Concentric Glenoid Reaming for Glenohumeral Arthritis in Young, Active Patients With a Biconcave Glenoid. J Am Acad Orthop Surg 2017; 25:715-723. [PMID: 28953086 DOI: 10.5435/jaaos-d-16-00019] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Hemiarthroplasty with concentric glenoid reaming (known as "ream and run") may be an option for treating glenohumeral arthritis in younger patients with a biconcave glenoid. The goal of this study was to evaluate early results of this technique. METHODS Two senior, fellowship-trained shoulder surgeons (G.R.W. and M.D.L.) performed a retrospective review of 23 patients (24 shoulders) with a biconcave glenoid and end-stage degenerative glenohumeral arthritis treated with hemiarthroplasty with concentric glenoid reaming. The mean patient age at the time of surgery was 50 years. We evaluated the Penn Shoulder Score (PSS), Single Assessment Numeric Evaluation (SANE) score, and Simple Shoulder Test (SST) score or the time to revision surgery. RESULTS Twenty-four humeral hemiarthroplasties with concentric glenoid reaming were performed in 23 patients. Twenty patients (21 shoulders) reached the end point of 2-year follow-up or revision surgery. Six shoulders (25%) required revision surgery at an average of 2.7 years (range, 0.7 to 7.2 years), and three were lost to follow-up. The remaining 14 patients (15 shoulders) were followed up for an average of 3.7 years (range, 2.3 to 4.9 years). At 2-year follow-up, these 15 shoulders did not require revision surgery and had an average SANE score, PSS, and SST score of 74.5%, 82.9, and 10.4, respectively. Increasing age correlated positively with the SANE score (r = 0.62; P = 0.015), PSS (r = 0.52; P = 0.047), and SST score (r = 0.63; P = 0.012). Early postoperative forward elevation correlated weakly with the PSS (r = 0.24; P = 0.395), and early postoperative external rotation correlated moderately with the PSS (r = 0.53; P = 0.044). Final external rotation correlated moderately with the PSS (r = 0.69; P = 0.005). DISCUSSION Modest results were achieved with a hemiarthroplasty and concentric glenoid reaming in young patients with end-stage glenohumeral arthritis and a biconcave glenoid. Younger age and stiffness were associated with worse outcomes. Given the high revision rate and the percentage of patients who had unsatisfactory results, this procedure should be performed only after careful patient selection. Patients who are willing and able to undergo aggressive physical therapy focused on achieving early range of motion are more likely to have a satisfactory outcome after humeral hemiarthroplasty with concentric glenoid reaming.
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Somerson JS, Neradilek MB, Service BC, Hsu JE, Russ SM, Matsen FA. Clinical and Radiographic Outcomes of the Ream-and-Run Procedure for Primary Glenohumeral Arthritis. J Bone Joint Surg Am 2017; 99:1291-1304. [PMID: 28763415 DOI: 10.2106/jbjs.16.01201] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The ream-and-run procedure can provide improvement in shoulder function and comfort for selected patients with primary glenohumeral arthritis who wish to avoid a prosthetic glenoid component. The purpose of this study was to evaluate factors associated with medialization of the humeral head after this procedure as well as the relationship of medialization to the clinical outcome. METHODS We collected patient, shoulder, and procedure characteristics along with Simple Shoulder Test (SST) scores before surgery and at the time of follow-up. Medialization was determined by comparing the position of the humeral head prosthesis in relation to the scapula on postoperative baseline radiographs made within 6 weeks after surgery with that on comparable follow-up radiographs made ≥18 months after surgery. RESULTS Two-year clinical outcomes were available for 101 patients (95% were male). Comparable radiographs at postoperative baseline and follow-up evaluations were available for 50 shoulders. For all patients, the mean SST score (and standard deviation) increased from 4.9 ± 2.8 preoperatively to 10.3 ± 2.4 at the latest follow-up (p < 0.001). Significant clinical improvement was observed for glenoid types A2 and B2. Shoulders with a type-A2 glenoid morphology, with larger preoperative scapular body-glenoid angles, and with lower preoperative SST scores, were associated with the greatest clinical improvement. Clinical outcome was not significantly associated with the amount of medialization. CONCLUSIONS The ream-and-run procedure can be an effective treatment for advanced primary glenohumeral osteoarthritis in active patients. Further study will be necessary to determine whether medialization affects the clinical outcome with follow-up of >2 years. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeremy S Somerson
- 1The University of Texas Medical Branch, Galveston, Texas 2The Mountain-Whisper-Light Statistics, Seattle, Washington 3Orthopaedic Surgery and Sports Medicine, Orlando Health, Orlando, Florida 4Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
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12
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Hasan SS. Revisiting the Socket: Commentary on an article by Jeremy S. Somerson, MD, et al.: "Clinical and Radiographic Outcomes of the Ream-and-Run Procedure for Primary Glenohumeral Arthritis". J Bone Joint Surg Am 2017; 99:e85. [PMID: 28763423 DOI: 10.2106/jbjs.17.00496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Samer S Hasan
- Mercy Health/Cincinnati Sports Medicine and Orthopaedic Center, Cincinnati, Ohio
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13
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Herschel R, Wieser K, Morrey ME, Ramos CH, Gerber C, Meyer DC. Risk factors for glenoid erosion in patients with shoulder hemiarthroplasty: an analysis of 118 cases. J Shoulder Elbow Surg 2017; 26:246-252. [PMID: 27545049 DOI: 10.1016/j.jse.2016.06.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 05/29/2016] [Accepted: 06/07/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Glenoid erosion is one of the main concerns in shoulder hemiarthroplasty. The goal of this study was to quantify glenoid erosion and to identify risk factors in patients with humeral hemiarthroplasty. METHODS There were 118 shoulders in 113 patients available for a standardized retrospective review. Erosion was graded as follows: grade 1, none; grade 2, mild (erosion into subchondral bone); grade 3, moderate (medialization of subchondral bone with hemispheric deformation); or grade 4, severe. The findings were then analyzed for confounding factors using a multivariate analysis. RESULTS Mean follow-up was 31 months (range, 5-86 months). Negative predisposing factors for erosion were glenoid cysts (odds ratio, 5.4; P < .001, approximately 3 times more frequent in women), fatty infiltration of the rotator cuff musculature (R, 0.43; P < .001), and rheumatoid arthritis (odds ratio, 3.6; P = .049). A valgus position of the prosthetic head relative to the glenoid (angle >50°) appeared to lead to local destruction of the cartilage. The degree of erosion did not correlate with age and glenoid or humeral head size. Only 1 patient (of 30) with a fracture-type prosthesis developed progressive glenoid erosion. CONCLUSION In this series, favorable conditions for resistance to erosion after hemiarthroplasty were lack of glenoid cysts, intact glenoid cartilage, intact rotator cuff musculature, and a fracture situation. Age, the version of the glenoid, and the size of the prosthetic head showed no importance. The use of hemiarthroplasty seems to be associated with glenoid destruction in female patients with impending osteoarthritis, with rheumatoid arthritis, and if the head is implanted in a valgus position.
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Affiliation(s)
- Ramin Herschel
- Orthopaedic Department of the Balgrist University Hospital, University of Zürich, Zürich, Switzerland.
| | - Karl Wieser
- Orthopaedic Department of the Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Mark E Morrey
- Orthopaedic Department of the Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Carlos H Ramos
- Orthopaedic Department of the Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Christian Gerber
- Orthopaedic Department of the Balgrist University Hospital, University of Zürich, Zürich, Switzerland
| | - Dominik C Meyer
- Orthopaedic Department of the Balgrist University Hospital, University of Zürich, Zürich, Switzerland
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Kircher J. [Shoulder endoprosthesis in the elderly : Hemiarthroplasty or total shoulder arthroplasty? Anatomic or reverse?]. DER ORTHOPADE 2016; 46:40-47. [PMID: 27921129 DOI: 10.1007/s00132-016-3365-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Implantation of reverse shoulder endoprostheses is becoming more popular for elderly patients besides the well-established standard anatomic endoprostheses. The reasons for this are the increased life expectancy, age-dependent degeneration of the rotator cuff leading to cuff tear arthropathy, posttraumatic disability after failed osteosynthesis and primary reverse fracture arthroplasty. Stemless implants are more frequently used for primary osteoarthritis with the bone quality being the limiting factor. Modern implant systems allow the stepwise extension from bone preserving primary implants to modular and convertible revision implants that allow a partial exchange of components. Revision surgery, especially that of reverse arthroplasty, has limited potential for secondary treatment options and therefore implantation and revision should be performed in specialized treatment facilities.
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Affiliation(s)
- J Kircher
- Schulter- und Ellenbogenchirurgie, Klinik Fleetinsel Hamburg, Admiralitätstr. 3-4, 20459, Hamburg, Deutschland.
- Orthopädische Klinik, Universitätsklinikum, Medizinische Fakultät, Heinrich-Heine-Universität Düsseldorf, Moorenstr. 5, 40255, Düsseldorf, Deutschland.
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de Beer J, Bhatia DN. Arthroplasty of the shoulder joint. INTERNATIONAL JOURNAL OF SHOULDER SURGERY 2016; 10:57-8. [PMID: 27186056 PMCID: PMC4857531 DOI: 10.4103/0973-6042.180716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Joe de Beer
- Cape Shoulder Institute, Cape Town, South Africa
| | - Deepak N Bhatia
- Department of Orthopaedic Surgery, Seth GS Medical College, King Edward VII Memorial Hospital, Mumbai, Maharashtra, India
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Abstract
The number of shoulder arthroplasty procedures has increased dramatically in recent years, with the primary indication being osteoarthritis (OA). Thus, morphology and subchondral bone changes associated with OA may be important factors to consider when choosing a replacement component. For surgical treatment, many implant options exist and survivability is often dependent on patient age, activity level, and progression of OA. In the placement of these replacement components, patient-specific guides now exist to improve component positioning, with the goal to improve long-term survivability by ensuring that intra-operative placement meets component design.
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Affiliation(s)
- Nikolas K Knowles
- The University of Western Ontario, London, ON, Canada.
- Roth McFarlane Hand and Upper Limb Centre, Surgical Mechatronics Laboratory, St. Joseph's Health Care, London, ON, Canada.
- Collaborative Training Program in Musculoskeletal Health Research and Bone and Joint Institute, The University of Western Ontario, London, ON, Canada.
| | - Louis M Ferreira
- The University of Western Ontario, London, ON, Canada.
- Roth McFarlane Hand and Upper Limb Centre, Surgical Mechatronics Laboratory, St. Joseph's Health Care, London, ON, Canada.
- Collaborative Training Program in Musculoskeletal Health Research and Bone and Joint Institute, The University of Western Ontario, London, ON, Canada.
| | - George S Athwal
- The University of Western Ontario, London, ON, Canada.
- Roth McFarlane Hand and Upper Limb Centre, Surgical Mechatronics Laboratory, St. Joseph's Health Care, London, ON, Canada.
- Collaborative Training Program in Musculoskeletal Health Research and Bone and Joint Institute, The University of Western Ontario, London, ON, Canada.
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17
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Matsen FA, Warme WJ, Jackins SE. Can the ream and run procedure improve glenohumeral relationships and function for shoulders with the arthritic triad? Clin Orthop Relat Res 2015; 473:2088-96. [PMID: 25488406 PMCID: PMC4419005 DOI: 10.1007/s11999-014-4095-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 12/02/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The arthritic triad of glenoid biconcavity, glenoid retroversion, and posterior displacement of the humeral head on the glenoid is associated with an increased risk of failure of total shoulder joint replacement. Although a number of glenohumeral arthroplasty techniques are being used to manage this complex pathology, problems with glenoid component failure remain. In that the ream and run procedure manages arthritic pathoanatomy without a glenoid component, we sought evidence that this procedure can be effective in improving the centering of the humeral head contact on the glenoid and in improving the comfort and function of shoulders with the arthritic triad without the risk of glenoid component failure. QUESTIONS/PURPOSES We asked, for shoulders with the arthritic triad, whether the ream and run procedure could improve glenohumeral relationships as measured on standardized axillary radiographs and patient-reported shoulder comfort and function as recorded by the Simple Shoulder Test. METHODS Between January 1, 2006 and December 14, 2011, we performed 531 primary anatomic glenohumeral arthroplasties for arthritis, of which 221 (42%) were ream and run procedures. Of these, 30 shoulders in 30 patients had the ream and run procedure for the arthritic triad and had two years of clinical and radiographic follow-up. These 30 shoulders formed the basis for this case series. The average age of the patients was 56 ± 8 years; all but one were male. Two of the 30 patients requested revision to total shoulder arthroplasty within the first year after their ream and run procedure because of their dissatisfaction with their rehabilitation progress. For the 28 shoulders not having had a revision, we determined on the standardized axillary views before and after surgery the glenoid type, glenoid version (90° minus the angle between the plane of the glenoid face and the plane of the body of the scapula), and location of the humeral contact point with respect to the anteroposterio dimension of the glenoid (the ratio of the distance from the anterior glenoid lip to the contact point divided by the distance between the anterior and posterior glenoid lips). We also recorded the patient's self-assessed shoulder comfort and function before and after surgery using the 12 questions of the Simple Shoulder Test. RESULTS For the 28 unrevised shoulders the mean followup was 3.0 years (range, 2-9.2 years). In these patients, the ream and run procedure resulted in improved centering of the humeral head on the face of the glenoid (preoperative: 75% ± 7% posterior; postoperative: 59% ± 10% posterior; mean difference 16% [95% CI, 13%-19%]; p < 0.001), notably this improved centering was achieved without a significant change in the glenoid version. Patient-reported function was improved (preoperative Simple Shoulder Test: 5 ± 3, postoperative Simple Shoulder Test: 10 ± 4, mean difference 5 [95% CI, 4-6], p < 0.001). CONCLUSIONS For shoulders with the arthritic triad, the ream and run procedure can provide improvement in humeral centering on the glenoid and in patient-reported shoulder comfort and function without the risk of glenoid component failure. In that ream and run is a new procedure, substantial additional clinical research with long-term follow-up is needed to define specifically the shoulder characteristics, the patient characteristics and the technical details that are most likely to lead to durable improvements in the comfort and function of shoulders with the challenging pathology known as the arthritic triad. LEVEL OF EVIDENCE Level IV, therapeutic study.
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Affiliation(s)
- Frederick A Matsen
- Department of Orthopedics and Sports Medicine, University of Washington Medical Center, Box 356500, 1959 NE Pacific St., Seattle, WA, 98195, USA,
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18
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The ream and run: not for every patient, every surgeon or every problem. INTERNATIONAL ORTHOPAEDICS 2015; 39:255-61. [PMID: 25616729 DOI: 10.1007/s00264-014-2641-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Accepted: 12/12/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this paper is to provide some essential and basic information concerning the ream and run technique for shoulder arthroplasty. METHODS In a total shoulder arthroplasty, the humeral head prosthesis articulates with a polyethylene glenoid surface placed on the bone of the glenoid. Failure of the glenoid component is recognised as the principal cause of failure of total shoulder arthroplasty. By contrast, in the ream and run procedure, the humeral head prosthesis articulates directly with the glenoid, which has been conservatively reamed to provide a stabilising concavity and maximal glenohumeral contact area for load transfer. While no interpositional material is placed on the surface of the glenoid, animal studies have demonstrated that the reamed glenoid bone forms fibrocartilage, which is firmly fixed to the reamed bony surface. Glenohumeral motion is instituted on the day of surgery and continued daily after surgery to mold the regenerating glenoid fibrocartilage. When the healing process is complete - as indicated by a good and comfortable range of motion - exercises and activities are added progressively without concern for glenoid component failure. RESULTS The experience to date indicates that a technically well done ream and run procedure can restore high levels of comfort and function to carefully selected patients with osteoarthritis, capsulorrhaphy arthroplathy, and posttraumatic arthritis. CONCLUSIONS Patients considering the ream and run procedure should understand that this technique avoids the risks and limitations associated with a polyethylene glenoid component, but that it requires strong motivation to follow through on a rehabilitation course that may require many months. The outcome of this procedure depends on the body's regeneration of a new surface for the glenoid and requires rigorous adherence to a daily exercise program. This paper explains in detail the principal factors in patient selection and the key technical elements of the procedure. Clinical examples and outcomes are demonstrated.
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Addressing glenoid bone deficiency and asymmetric posterior erosion in shoulder arthroplasty. J Shoulder Elbow Surg 2013; 22:1298-308. [PMID: 23796384 DOI: 10.1016/j.jse.2013.04.014] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2012] [Revised: 03/29/2013] [Accepted: 04/17/2013] [Indexed: 02/01/2023]
Abstract
Glenoid bone deficiency and eccentric posterior wear are difficult problems faced by shoulder arthroplasty surgeons. Numerous options and techniques exist for addressing these issues. Hemiarthroplasty with concentric glenoid reaming may be a viable alternative in motivated patients in whom glenoid component failure is a concern. Total shoulder arthroplasty has been shown to provide durable pain relief and excellent function in patients, and numerous methods and techniques can assist in addressing bone loss and eccentric wear. However, the ideal amount of version correction in cases of severe retroversion has not yet been established. Asymmetric reaming is a commonly used technique to address glenoid version, but correction of severe retroversion may compromise bone stock and component fixation. Bone grafting is a technically demanding alternative for uncontained defects and has mixed clinical results. Specialized glenoid implants with posterior augmentation have been created to assist the surgeon in correcting glenoid version without compromising bone stock, but clinical data on these implants are still pending. Custom implants or instruments based on each patient's unique glenoid anatomy may hold promise. In elderly, sedentary patients in whom bone stock and soft-tissue balance are concerns, reverse total shoulder arthroplasty may be less technically demanding while still providing satisfactory pain relief and functional improvements.
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Matsen FA, Lippitt SB. Current Technique for the Ream-and-Run Arthroplasty for Glenohumeral Osteoarthritis. JBJS Essent Surg Tech 2012; 2:e20. [PMID: 31321140 PMCID: PMC6554086 DOI: 10.2106/jbjs.st.l.00009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION The ream and run is a technically demanding shoulder arthroplasty for the management of glenohumeral arthritis that avoids the risk of failure of the glenoid component that is associated with total shoulder arthroplasty. STEP 1 SURGICAL APPROACH After administration of prophylactic antibiotics and a thorough skin preparation, expose the glenohumeral joint through a long deltopectoral incision, incising the subscapularis tendon from its osseous insertion and the capsule from the anterior-inferior aspect of the humeral neck while carefully protecting all muscle groups and neurovascular structures. STEP 2 HUMERAL PREPARATION Gently expose the proximal part of the humerus, resect the humeral head at 45° to the orthopaedic axis while protecting the rotator cuff, and excise all humeral osteophytes. STEP 3 GLENOID PREPARATION After performing an extralabral capsular release, remove any residual cartilage, drill the glenoid centerline, and ream the glenoid to a single concavity. STEP 4 HUMERAL PROSTHESIS SELECTION Select a humeral prosthesis that fits the medullary canal and that provides the desired mobility and stability of the prosthesis. STEP 5 HUMERAL PROSTHESIS FIXATION Fix the humeral component using impaction autografting. STEP 6 SOFT-TISSUE BALANCING After the definitive humeral prosthesis is in place, ensure the desired balance of mobility and stability. If there is excessive posterior translation, consider a rotator interval plication. STEP 7 REHABILITATION Achieve and maintain at least 150° of flexion and good external rotation strength. RESULTS In our study, comfort and function increased progressively after the ream-and-run procedure, reaching a steady state by approximately twenty months. WHAT TO WATCH FOR IndicationsContraindicationsPitfalls & Challenges.
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Affiliation(s)
- Frederick A Matsen
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Box 356500, 1959 N.E. Pacific Street, Seattle, WA 98195. E-mail address:
| | - Steven B Lippitt
- Akron General Medical Center, 224 West Exchange, Suite 440, Akron, OH 44302-1718
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Gilmer BB, Comstock BA, Jette JL, Warme WJ, Jackins SE, Matsen FA. The prognosis for improvement in comfort and function after the ream-and-run arthroplasty for glenohumeral arthritis: an analysis of 176 consecutive cases. J Bone Joint Surg Am 2012; 94:e102. [PMID: 22810409 DOI: 10.2106/jbjs.k.00486] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Knowledge of the factors affecting the prognosis for improvement in function and comfort with time after shoulder arthroplasty is important to clinical decision-making. This study sought to identify some of these factors in 176 consecutive patients undergoing the ream-and-run procedure. METHODS The time course for improvement in patient function and comfort was determined for the entire group as well as for subsets by sex, age, diagnosis, preoperative function, and surgery date. Patients having repeat surgery were analyzed in detail. RESULTS Shoulder comfort and function increased progressively after the ream-and-run procedure, reaching a steady state by approximately twenty months. The shoulders in 124 patients with at least two years of follow-up were improved by a minimal clinically important difference. The shoulders in sixteen patients with at least two years of follow-up were not improved by the minimal clinically important difference. Twenty-two patients had repeat procedures, but only seven had revision to a total shoulder arthroplasty. Fourteen patients did not have either a known revision arthroplasty or two years of follow-up. The best prognosis was for male patients over the age of sixty years, with primary osteoarthritis, no prior surgical procedures, a preoperative score on the simple shoulder test of ≥5 points, and surgery after 2004. Repeat surgical procedures were more common in patients who had a greater number of surgical procedures before the ream-and-run surgery. CONCLUSIONS This study is unique in that it characterizes the factors affecting the time course for improvement in shoulder comfort and function after a ream-and-run procedure. Improvement occurs after this procedure for at least 1.5 years. This procedure appears to be best suited for an older male patient with reasonable preoperative shoulder function without prior shoulder surgery. LEVEL OF EVIDENCE Prognostic Level II. See Instructions for authors for a complete description of levels of evidence.
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Affiliation(s)
- Brian B Gilmer
- Department of Orthopaedics and Sports Medicine, University of Washington Medical Center, Box 356500, 1959 N.E. Pacific Street, Seattle, WA 98195, USA
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Mercer D, Saltzman MD, Neradilek MB, Gilmer BB, Warme WJ, Matsen FA. A reproducible and practical method for documenting the position of the humeral head center relative to the scapula on standardized plain radiographs. J Shoulder Elbow Surg 2011; 20:363-71. [PMID: 20951064 DOI: 10.1016/j.jse.2010.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 06/04/2010] [Accepted: 06/15/2010] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent articles in this journal showed the clinical importance of the position of the humeral head center in relation to the glenoid. However, the precision, reproducibility, and sensitivity of this and other methods of documenting the head center position have not been evaluated in detail. MATERIALS AND METHODS We used templates to fit a coordinate system to the scapular anatomy visible on standardized radiographs. Two observers then used these templates to measure the position of the head center relative to this coordinate system on 25 normal shoulder radiographs and on 25 radiographs of shoulders with cuff tear arthropathy (CTA). RESULTS Head center measurements had excellent precision. Normal shoulder radiographs showed a consistent head center position (0.7 ± 1.7 mm medial and 0.6 ± 1.3 mm inferior to the coordinate origin on the anteroposterior view and 0.1 ± 1.3 mm medial and 0.0 ± 1.3 mm anterior to the coordinate origin on the axillary view). The head center of CTA shoulder radiographs was 10.18 ± 5.16 mm above the coordinate origin on the anteroposterior view, significantly different from that for the normal shoulder radiographs (P < .001). DISCUSSION The relative position of the humeral head center to the scapula determines the resting length and the moment arms of the scapulohumeral muscles. Correlation of shoulder function with the head center position may provide insights into both shoulder pathomechanics and the optimization of shoulder arthroplasty. CONCLUSION This practical technique showed a high degree of precision and reproducibility for normal and CTA shoulder radiographs as well as a high level of discrimination between these two groups.
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Affiliation(s)
- Deana Mercer
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, WA, USA
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