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Pasqualini I, Menendez ME, Ardebol J, Denard PJ. Lesser Tuberosity Osteotomy for the Management of the Subscapularis During Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2023; 31:1120-1127. [PMID: 37506312 DOI: 10.5435/jaaos-d-22-01093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/23/2023] [Indexed: 07/30/2023] Open
Abstract
Subscapularis integrity is critical after anatomic total shoulder arthroplasty, with failure leading to potential instability, loss of function, and revision surgery. The three well-described subscapularis mobilization techniques during total shoulder arthroplasty include tenotomy, peel, and lesser tuberosity osteotomy (LTO). While several comparative studies exist, the optimal approach remains controversial. LTO has been associated with the highest healing rates, but techniques and repair constructs are highly variable. The purpose of this article was to provide an overview of LTO with attention on radiographic assessment, repair options, and clinical outcomes.
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Dillon MT, Beleckas CM, Navarro RA. Techniques for Managing the Subscapularis and Addressing Failures of the Tendon in Anatomic Total Shoulder Arthroplasty. Orthopedics 2023; 46:e264-e272. [PMID: 37216563 DOI: 10.3928/01477447-20230517-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Anatomic total shoulder arthroplasty (aTSA) is an accepted treatment for a variety of degenerative conditions of the glenohumeral joint. The manner in which the subscapularis tendon is handled during the approach in aTSA is not universally agreed on. Failure of the repair after aTSA has been shown to be associated with poorer outcomes in some cases. There is no consensus on how to treat failures, as all techniques described in the literature demonstrate shortcomings. The purpose of this review is to evaluate the methods of handling the tendon in aTSA and to review options for treating failure following surgery. [Orthopedics. 2023;46(5):e264-e272.].
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McBride AP, Ross M, Duke P, Hoy G, Page R, Dyer C, Taylor F. Shoulder joint arthroplasty in young patients: Analysis of 8742 patients from the Australian Orthopaedic Association National Joint Replacement Registry. Shoulder Elbow 2023; 15:41-52. [PMID: 37692877 PMCID: PMC10492526 DOI: 10.1177/17585732211058717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 10/17/2021] [Accepted: 10/18/2021] [Indexed: 09/12/2023]
Abstract
Background Shoulder replacement is a reliable treatment for the relief of pain and improvement of function in patients with glenohumeral arthritis, rotator cuff arthropathy, osteonecrosis and fracture. Limited data is available comparing revision rates for the different types of shoulder replacement when used in younger patients. This study aims to compare the survivorship of hemi resurfacing, stemmed hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty in younger patients using data from a large national arthroplasty registry. Methods Data from the Australian Orthopaedic Association National Joint Replacement Registry was obtained for the period 16 April 2004-31 December 2018. The study population included all shoulder arthroplasty patients aged <65 years. These were stratified into two groups: <55 years and 55-64 years. A total of 8742 primary shoulder arthroplasty procedures were analysed (1936 procedures in the <55 years and 6806 in the 55-64 years age group). Results In the <55 years age group, there was no difference in revision rate for total shoulder arthroplasty versus reverse total shoulder arthroplasty at any time point. Reverse total shoulder arthroplasty had a lower revision rate after six months when compared to hemi resurfacing (HRA) (p = 0.031). Also, reverse total shoulder arthroplasty had a higher early rate of revision in the first 12 months compared to hemiarthroplasty (p = 0.018). However, from 2 years reverse total shoulder arthroplasty had a lower revision rate overall (p = 0.029).In the 55-64 years patient age group, reverse total shoulder arthroplasty had a lower earlier revision rate. This was statistically significant compared to hemi resurfacing (HRA) (p = 0.028), hemiarthroplasty (p = 0.049) and total shoulder arthroplasty (p < 0.001). Conclusion This study demonstrated that for patients aged <55 years there was no significant difference in the rate of revision when total shoulder arthroplasty and reverse total shoulder arthroplasty were compared. reverse total shoulder arthroplasty had a lower rate of revision when compared to hemi resurfacing and hemiarthroplasty after 2 years. reverse total shoulder arthroplasty had the lowest comparative revision rate in patients aged 55-64 years overall.
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Affiliation(s)
| | - Mark Ross
- Brisbane Hand and Upper limb Research Institute, Brisbane, Australia
| | - Phil Duke
- Brisbane Hand and Upper limb Research Institute, Brisbane, Australia
| | - Greg Hoy
- Melbourne Orthopaedic Group, Windsor, Australia
| | - Richard Page
- University Hospital and St John of God Hospital Geelong, Barwon Centre of Orthopaedic Research and Education, Deakin University; Australian Orthopaedic Association National Joint Replacement Registry, Queensland, Australia
| | - Chelsea Dyer
- South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia
| | - Fraser Taylor
- Gold Coast University Hospital, Southport, Australia
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Griffin JW, Werner BC, Lederman E, Gobezie R, Mazzocca AD, Romeo AA, Denard PJ. Lesser Tuberosity Osteotomy Does Not Appear to Compromise Fixation or Function Compared With Peel in Short-Stem Anatomic Shoulder Arthroplasty. Orthopedics 2022; 45:151-155. [PMID: 35112962 DOI: 10.3928/01477447-20220128-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Several methods are available for subscapularis management in total shoulder arthroplasty (TSA). The goal of this study was to compare radiographic and clinical outcomes of short-stem TSA stratified by subscapularis management technique. A multicenter trial was completed evaluating primary short-stem TSA performed with a subscapularis peel (n=80) or lesser tuberosity osteotomy (LTO) (n=59). The primary outcome measure was subscapularis function, as measured by internal rotation and strength at 1 year postoperatively. Secondary outcomes included patient-reported outcomes, radiographic changes, and implant loosening. Patients in the peel group obtained better active internal rotation by spinal level (P=.004). No difference was seen between groups for internal rotation with 90° shoulder abduction (P=.862) or belly press (P=.903). Statistically significant improvements in functional outcomes were seen without clinical differences. Radiographic changes showed no difference in stem shift, subsidence, or at-risk loosening rate. Anterior subluxation of the humerus was observed among 2% of the LTO group vs 17% of the peel group (P=.006). At short-term follow-up, those in the peel group appear to have a better final spinal level of internal rotation, whereas those in the LTO group have a significantly lower rate of anterior humeral subluxation. Both LTO and subscapularis peel appear safe for short-stem TSA, with no radiographic evidence of loosening. [Orthopedics. 2022;45(3):151-155.].
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Werner BC, Griffin JW, Thompson T, Lendhey M, Higgins LD, Denard PJ. Biomechanical evaluation of 2 techniques of repair after subscapularis peel for stemless shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:2240-2246. [PMID: 33675968 DOI: 10.1016/j.jse.2021.01.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 01/19/2021] [Accepted: 01/31/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Stemless anatomic total shoulder arthroplasty (TSA) has been gaining significant popularity but poses unique challenges for subscapularis repair. Tenotomy with side-to-side repair has been the most frequently reported technique for subscapularis repair with stemless TSA but has the poorest biomechanical properties, and clinical failures have been reported. There is limited biomechanical evidence evaluating other subscapularis repair techniques for stemless TSA. Therefore, the goal of this study was to investigate 2 additional techniques using a subscapularis peel for subscapularis repair with a stemless TSA. METHODS We used 18 male cadaveric specimens to investigate the native subscapularis (n = 6) and 2 subscapularis repair techniques (n = 12) after stemless anatomic TSA (Eclipse). A subscapularis peel with double-row, knotless anchor-based repair (n = 6) was compared with a subscapularis peel with a "backpack" repair (n = 6). The specimens then underwent biomechanical testing, including cyclic displacement and load-to-failure testing. The mode of failure was also recorded. RESULTS The native tendon had the highest ultimate load to failure (mean, 1017.1 N). Load to failure was similar between the 2 study groups: 397.9 N for the peel and backpack repair and 593.7 N for the knotless anchor-based repair (P > .05 for all comparisons). Moreover, no significant differences in cyclic displacement or construct stiffness were found between the groups (P > .05 for all comparisons). CONCLUSIONS A double-row, knotless anchor-based repair of a subscapularis peel for stemless anatomic shoulder arthroplasty has similar biomechanical properties to a backpack repair technique; however, both techniques fail to reproduce the native biomechanical properties at time zero.
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Affiliation(s)
- Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA.
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Goetti P, Denard PJ, Collin P, Ibrahim M, Mazzolari A, Lädermann A. Biomechanics of anatomic and reverse shoulder arthroplasty. EFORT Open Rev 2021; 6:918-931. [PMID: 34760291 PMCID: PMC8559568 DOI: 10.1302/2058-5241.6.210014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The biomechanics of the shoulder relies on careful balancing between stability and mobility. A thorough understanding of normal and degenerative shoulder anatomy is necessary, as the goal of anatomic total shoulder arthroplasty is to reproduce premorbid shoulder kinematics.With reported joint reaction forces up to 2.4 times bodyweight, failure to restore anatomy and therefore provide a stable fulcrum will result in early implant failure secondary to glenoid loosening.The high variability of proximal humeral anatomy can be addressed with modular stems or stemless humeral components. The development of three-dimensional planning has led to a better understanding of the complex nature of glenoid bone deformity in eccentric osteoarthritis.The treatment of cuff tear arthropathy patients was revolutionized by the arrival of Grammont's reverse shoulder arthroplasty. The initial design medialized the centre of rotation and distalized the humerus, allowing up to a 42% increase in the deltoid moment arm.More modern reverse designs have maintained the element of restored stability but sought a more anatomic postoperative position to minimize complications and maximize rotational range of motion. Cite this article: EFORT Open Rev 2021;6:918-931. DOI: 10.1302/2058-5241.6.210014.
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Affiliation(s)
- Patrick Goetti
- Division of Orthopaedics and Trauma Surgery, Centre Hospitalier |Universitaire Vaudois, Lausanne, Switzerland
| | - Patrick J. Denard
- Denard Department of Orthopaedic & Rehabilitation, Oregon Health & Science University, Portland, Oregon, United States
| | - Philippe Collin
- Collin Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), Saint- Grégoire, France
| | - Mohamed Ibrahim
- Mohamed Ibrahim, Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Adrien Mazzolari
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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Entezari V, Henry T, Zmistowski B, Sheth M, Nicholson T, Namdari S. Clinically significant subscapularis failure after anatomic shoulder arthroplasty: is it worth repairing? J Shoulder Elbow Surg 2020; 29:1831-1835. [PMID: 32249145 DOI: 10.1016/j.jse.2020.01.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/12/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Symptomatic subscapularis (SC) failure after anatomic total shoulder arthroplasty (TSA) is difficult to treat. The purpose of this study was to determine the outcomes of reoperation for SC failure. METHODS All patients undergoing reoperation for SC failure after TSA were identified from a single-institution database. Patients underwent either revision SC repair or revision to reverse shoulder arthroplasty. At a minimum of 1 year after reoperation, complications, reoperations, and functional outcomes were collected. RESULTS Patients who initially underwent SC repair were significantly younger than patients who underwent revision to reverse shoulder arthroplasty (mean age, 59.3 years vs. 70.3 years; P = .004), had a better comorbidity profile (mean Charlson Comorbidity Index, 2.2 vs. 3.6; P = .04), and had a more acute presentation (mean time between injury and surgery, 9.1 weeks vs. 28.5 weeks; P = .03). Patients who underwent SC repair also had a significantly higher reoperation rate (52.9% vs. 0.0%, P = .01). At final follow-up, functional outcomes scores and patient satisfaction rates were not significantly different between treatment groups. DISCUSSION Decision making on how to treat patients with SC failure following TSA remains challenging and should be individualized to the patient's age, level of activity, comorbidities, timing and mechanism of SC failure, and functional expectations.
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Affiliation(s)
- Vahid Entezari
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tyler Henry
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Mihir Sheth
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Thema Nicholson
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA.
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Dekker TJ, Steele JR, Vinson EV, Garrigues GE. Current peri-operative imaging concepts surrounding shoulder arthroplasty. Skeletal Radiol 2019; 48:1485-1497. [PMID: 30798396 DOI: 10.1007/s00256-019-03183-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 01/21/2019] [Accepted: 02/06/2019] [Indexed: 02/02/2023]
Abstract
Glenohumeral osteoarthritis is a prevalent degenerative disease that can lead to excruciating pain and debility. End-stage osteoarthritis can be treated by both conservative and surgical interventions. Along with a comprehensive history and physical exam, pre-operative imaging with plain radiographs, computerized tomography, and magnetic resonance imaging plays an essential role in the decision-making process guiding whether the patient undergoes a shoulder hemiarthroplasty, anatomic total shoulder arthroplasty, or a reverse total shoulder arthroplasty. The most important pre-operative imaging factors are the integrity of the rotator cuff and presence of significant glenoid erosion. Imaging is also critical postoperatively, as signs of prosthetic loosening, rotator cuff failure (especially involving the subscapularis), periprosthetic fracture, and stress fractures are important entities to recognize. This article will review pertinent imaging findings related to the pre- and post-operative management of patients with glenohumeral osteoarthritis.
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Affiliation(s)
- Travis J Dekker
- Department of Orthopaedics, Duke University Hospital, 2301 Erwin Road, Durham, NC, 27710, USA.
| | - J R Steele
- Department of Orthopaedics, Duke University Hospital, 2301 Erwin Road, Durham, NC, 27710, USA
| | - E V Vinson
- Department of Radiology, Duke University Hospital, 2301 Erwin Road, Durham, NC, 27710, USA
| | - G E Garrigues
- Department of Orthopaedics, Duke University Hospital, 2301 Erwin Road, Durham, NC, 27710, USA
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Levy JC, DeVito P, Berglund D, Vakharia R, Moor M, Malarkey A, Polansky S. Lesser tuberosity osteotomy in total shoulder arthroplasty: impact of radiographic healing on outcomes. J Shoulder Elbow Surg 2019; 28:1082-1090. [PMID: 30723032 DOI: 10.1016/j.jse.2018.11.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 10/29/2018] [Accepted: 11/09/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lesser tuberosity osteotomy (LTO) has gained popularity in anatomic total shoulder arthroplasty (TSA); however, healing rates have not been universally high. This study examined differences in outcomes based on variations in LTO healing. METHODS A retrospective review identified primary TSA patients with 2-year minimum follow-up treated with a LTO. Postoperative radiographs classified LTO healing as "bony union," "nondisplaced nonunion," "displaced nonunion," and "not seen," creating 4 cohorts. Comparisons were made among patient-reported outcome measures (PROMs), motion, and radiographic evidence of component loosening. RESULTS The study cohort consisted of 189 patients who met inclusion criteria, with an average age of 69.5 years (range, 32-89 years) and follow-up of 50 months (range, 24-95 months). There were 143 patients with union, 16 with nondisplaced nonunion, 14 with displaced nonunion, and 16 not seen. There were no differences in preoperative comparisons. All cohorts demonstrated significant improvements in PROMs and ranges of motion; however, the displaced nonunion cohort had no improvement in Single Assessment Numeric Evaluation (0.114) or internal rotation (P = .279). Patients with displaced nonunion had lower postoperative functional scores (Simple Shoulder Test and American Shoulder and Elbow Surgeons scores; P < .01), and higher pain scores (visual analog scale for pain; P < .01). However, 85.7% of patients reported they would have the same procedure again. Simple Shoulder Test (2.5) and American Shoulder and Elbow Surgeons score (37.5) improvements exceeded minimal clinically important difference thresholds for TSA. A higher rate of glenoid gross loosening was present in the displaced nonunion cohort (3 patients [21.4%]; P < .01). There were no cases of loose humeral stems. CONCLUSION Patients with a displaced nonunion LTO site have lower functional scores and higher pain scores but still achieve substantial clinical improvement and high satisfaction rates.
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Affiliation(s)
- Jonathan C Levy
- Shoulder and Elbow Surgery, Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA.
| | - Paul DeVito
- Shoulder and Elbow Surgery, Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA
| | - Derek Berglund
- Department of General Surgery, Geisinger Medical Center, Danville, PA, USA
| | - Rushabh Vakharia
- Shoulder and Elbow Surgery, Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA
| | - Molly Moor
- Shoulder and Elbow Surgery, Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA
| | - Andy Malarkey
- Shoulder and Elbow Surgery, Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA
| | - Scott Polansky
- Department of Orthopedic Surgery, Broward Health Medical Center, Fort Lauderdale, FL, USA
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Levy JC, Berglund D, Vakharia R, Tahal DS, Mijc D, DeVito P, Motisi M. Midterm results of anatomic total shoulder arthroplasty with a third-generation implant. J Shoulder Elbow Surg 2019; 28:698-705. [PMID: 30472054 DOI: 10.1016/j.jse.2018.08.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 08/22/2018] [Accepted: 08/29/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Anatomic total shoulder arthroplasty (TSA) provides reliable, reproducible, and durable results; however, outcomes of many modern TSA systems are lacking. The present study reports early to midterm results of a third-generation TSA system using a traditional-length press-fit humeral stem and cemented glenoid. METHODS A retrospective review was conducted of TSA patients with minimum 2-year clinical follow-up. Patient-reported outcome measures, including Simple Shoulder Test, American Shoulder and Elbow Surgeons Total, visual analog scale for pain, 12-Item Short Form Health Survey, and Single Assessment Numeric Evaluation, as well as measured active motion (forward elevation, external and internal rotation), were recorded at preoperative and postoperative intervals. Preoperative midglenoid axial computed tomography scans were used to evaluate eccentric glenoid wear, humeral head subluxation, and glenoid version. Most recent postoperative radiographs were used to evaluate glenoid loosening, humeral loosening, lesser tuberosity union, and medial calcar resorption. Patient satisfaction at final follow-up was reported as excellent, good, satisfied, or unsatisfied. RESULTS There were 267 patients who met inclusion criteria, with a mean age of 70.9 years and mean clinical follow-up of 47 months. Average glenoid retroversion was 9.7°, and 27% had eccentric glenoid wear. At final follow-up, measured motion and nearly all patient-reported outcome measures showed significant improvements, with 75.6% of patients rating their satisfaction as excellent. No patient was considered "at risk" for humeral stem loosening. Glenoid radiolucencies were seen in 13.5% of shoulders (7 gross loosening). Five patients were revised to reverse TSA. CONCLUSION TSA using a third-generation traditional-length press-fit stem and cemented glenoid provides excellent early to midterm outcomes with low rates of loosening and high rates of excellent satisfaction.
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Affiliation(s)
- Jonathan C Levy
- Shoulder and Elbow Surgery, Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA.
| | - Derek Berglund
- Shoulder and Elbow Surgery, Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA
| | - Rushabh Vakharia
- Shoulder and Elbow Surgery, Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA
| | | | - Dragomir Mijc
- Shoulder and Elbow Surgery, Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA
| | - Paul DeVito
- Shoulder and Elbow Surgery, Holy Cross Orthopedic Research Institute, Fort Lauderdale, FL, USA
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Kwon YW, Zuckerman JD. Subscapularis-Sparing Total Shoulder Arthroplasty: A Prospective, Double-Blinded, Randomized Clinical Trial. Orthopedics 2019; 42:e61-e67. [PMID: 30427055 DOI: 10.3928/01477447-20181109-02] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/18/2018] [Indexed: 02/03/2023]
Abstract
Although total shoulder arthroplasty (TSA) is generally associated with good to excellent outcomes in most patients, the integrity and function of the subscapularis tendon (SSC) is of paramount importance because SSC rupture after TSA can lead to inferior outcomes. Therefore, the efficacy of a SSC-sparing TSA procedure was evaluated through a prospective, double-blinded, randomized study. Patients with end-stage osteoarthritis of the shoulder were randomized into 2 groups. Group 1 patients were treated with TSA in which the prosthesis was inserted entirely through the rotator interval without violating the SSC tendon (SPARING). Group 2 patients were treated with TSA using the SSC tenotomy approach (STANDARD). Both the patients and the evaluators remained blinded to the surgical approach throughout the study. Outcome data collected included the visual analog scale score for pain and the American Shoulder and Elbow Surgeons outcome score. Complete 2-year outcome data were collected from 32 SPARING and 38 STANDARD patients at a mean follow-up of 31.1 and 33.4 months, respectively. The American Shoulder and Elbow Surgeons and visual analog scale scores improved significantly for both groups. Differences between groups did not reach statistical significance. Complication profiles were similar for the 2 groups, with 3 patients in the SPARING group and 2 patients in the STANDARD group requiring revision surgery during the study. At short-term follow-up, the outcome of TSA using the SSC-sparing surgical approach was similar to the outcome of TSA using the standard approach. Studies with longer follow-up are required to document the potential benefits of this surgical technique. [Orthopedics. 2019; 42(1):e61-e67.].
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12
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Bloom ZJ, Lopez, BA CD, Maier SP, Shiu BB, Petkovic D, Levine WN, Jobin CM. Treatment Outcomes of Lesser Tuberosity Osteotomy Nonunion After Total Shoulder Arthroplasty. J Shoulder Elb Arthroplast 2018. [DOI: 10.1177/2471549218807777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction Lesser tuberosity osteotomy (LTO) during anatomic total shoulder arthroplasty has a 13% nonunion rate. Treatment for LTO nonunion is controversial and poorly described in the literature. The purpose of this study was to compare the surgical and nonsurgical treatment outcomes of LTO nonunion. Methods A retrospective case series of 9 consecutive patients with LTO nonunion after primary anatomic shoulder arthroplasty at 1 institution from 2010 to 2016 were studied. Outcomes measured were radiographic evaluation of LTO on axillary X-ray, clinical range of motion (ROM), subscapularis strength, and pain at the time of LTO nonunion diagnosis and after either conservative care or surgical repair of the LTO nonunion. Results LTO nonunion was treated surgically in 4 and conservatively in 5 patients with average follow-up of 30 and 22 months, respectively. There were no significant differences in age, sex, or smoking status between groups. Treatment decision was a shared model of surgeon and patient. Displaced LTO nonunion was treated surgically in 2 and conservatively in 3 patients. There were no differences in LTO union rate of 50% in the surgical versus 60% in the conservative group. Abdominal compression test was abnormal in 50% of surgical versus 40% of conservative groups. At follow-up, ROM was lower in the surgical group with 128° forward elevation (FE) and 33° external rotation (ER) compared to 148° FE and 62° ER. Only 1 patient with LTO nonunion required conversion to reverse replacement. Conclusion LTO nonunion after shoulder arthroplasty is rare. Surgical repair of LTO nonunion does not significantly improve clinical or radiographic outcomes compared to conservative care.
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Affiliation(s)
- Zachary J Bloom
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Cesar D Lopez, BA
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Stephen P Maier
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Brian B Shiu
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Djuro Petkovic
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - William N Levine
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Charles M Jobin
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
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13
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Bornes TD, Rollins MD, Lapner PLC, Bouliane MJ. Subscapularis Management in Total Shoulder Arthroplasty: Current Evidence Comparing Peel, Osteotomy, and Tenotomy. J Shoulder Elb Arthroplast 2018. [DOI: 10.1177/2471549218807772] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The optimal approach to management of the subscapularis in total shoulder arthroplasty (TSA) is controversial. Options include the subscapularis tenotomy, lesser tuberosity osteotomy (LTO), and peel. This review provides a summary of subscapularis anatomy and function, outcomes associated with subscapularis management options in TSA, and postoperative subscapularis deficiency. Based on the available literature, LTO appears to result in improved function and subscapularis integrity relative to tenotomy, while peel and LTO have generally led to equivalent outcomes. The highest level of evidence to date is derived from a randomized controlled trial that demonstrated that outcomes following peel and LTO were not significantly different. There is currently a paucity of high-quality evidence as most studies have consisted of small retrospective series with varying outcome measures. Furthermore, the optimal approach to establishing the diagnosis of subscapularis deficiency following TSA is unclear.
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Affiliation(s)
- Troy D Bornes
- Division of Orthopaedic Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Meaghan D Rollins
- Division of Orthopaedic Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter LC Lapner
- Division of Orthopaedic Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Martin J Bouliane
- Division of Orthopaedic Surgery, University of Alberta, Edmonton, Alberta, Canada
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Lopez CD, Maier SP, Bloom ZJ, Shiu BB, Petkovic D, Jobin CM. Outcomes of lesser tuberosity osteotomy in revision anatomic shoulder arthroplasty. J Shoulder Elbow Surg 2018; 27:e219-e224. [PMID: 29396101 DOI: 10.1016/j.jse.2017.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 11/19/2017] [Accepted: 12/03/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lesser tuberosity osteotomy (LTO) is a common surgical approach during anatomic shoulder arthroplasty. Outcomes of LTO have been shown to be similar to subscapularis tenotomy and peel techniques, but little is known about the outcomes of LTO during revision arthroplasty. METHODS This retrospective case series included 10 consecutive patients who underwent LTO during revision shoulder arthroplasty at a single institution from 2012 to 2016. Patients underwent a preoperative computed tomography scan to evaluate the lesser tuberosity bone stock. Demographic information, radiographic evidence of LTO healing, outcomes of range of motion, subscapularis strength, and visual analog scale pain scores were analyzed. RESULTS Revision total shoulder arthroplasty with LTO was performed for glenoid arthritis after hemiarthroplasty in 10 patients. Average age at surgery was 59.8 years, and no humeral stems were revised. Eight of 10 patients had prior subscapularis tenotomy. Average follow-up after revision surgery was 9.2 months. LTO union was documented in 80% and nondisplaced nonunion in 20%. At follow-up, 50% reported mild pain. Subscapularis strength testing was graded normal in 80% and weak in 20%. Average visual analog scale pain improved from 9.4 prerevision to 4.8 postrevision (P < .05). On average, range of motion improved in active forward elevation from 123° to 141° and remained unchanged in active external rotation from 42° to 42°. CONCLUSION Patients undergoing LTO during revision anatomic shoulder arthroplasty demonstrate successful LTO bony healing, improvement in pain, and improved forward elevation. In select patients not requiring humeral stem revision, LTO is a safe and effective surgical approach to subscapularis management during revision anatomic shoulder arthroplasty.
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Affiliation(s)
- Cesar D Lopez
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Stephen P Maier
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Zachary J Bloom
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Brian B Shiu
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Djuro Petkovic
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Charles M Jobin
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA.
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Maier SP, Lopez CD, Bloom ZJ, Shiu BB, Petkovic D, Levine WN, Jobin CM. Lesser Tuberosity Osteotomy Outcomes After Anatomic Shoulder Arthroplasty in Patients With Atraumatic Avascular Necrosis. J Shoulder Elb Arthroplast 2018. [DOI: 10.1177/2471549218778446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Lesser tuberosity osteotomy (LTO) is an attractive option for subscapularis management during anatomic shoulder arthroplasty due to the biomechanical strength and reliable bone-to-bone healing. Patients with humeral head avascular necrosis (AVN) may have compromised bone healing, and the outcomes of LTO during AVN are unknown. Methods A retrospective consecutive case series of 6 patients with Cruess grade 4 or 5 humeral head AVN who underwent anatomic shoulder arthroplasty with LTO from 2010 to 2016 was performed. Postoperative radiographic evaluation for LTO healing at 6 months was analyzed, and clinical outcomes at latest follow-up, including range of motion (ROM), strength, and pain were studied.> Results Average age was 50.3 years. AVN was secondary to sickle cell in 1 patient, steroid use for systemic lupus erythematosus in 4, and chronic alcoholism in 1. By 6 months after arthroplasty, 100% had radiographically united and healed LTO. Patients averaged 140 ± 21° of active forward elevation and 42 ± 7° of active external rotation. Patients reported an improvement in visual analogue scale pain from 8.3 preoperatively to 3.8 postoperatively. All patients had a normal abdominal compression test. No patients required revision surgery. Conclusion The use of LTO during anatomic shoulder arthroplasty for AVN has an excellent bony healing rate with improvements in pain, ROM, and strength. The diseases that cause humeral head AVN do not negatively influence LTO healing outcomes during anatomic shoulder replacement. Level of Evidence IV Case Series
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Affiliation(s)
- Stephen P Maier
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Cesar D Lopez
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Zachary J Bloom
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Brian B Shiu
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Djuro Petkovic
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - William N Levine
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
| | - Charles M Jobin
- Department of Orthopedic Surgery, Columbia University Medical Center, New York, New York
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Sanchez-Sotelo J. Subscapularis Tenotomy in Anatomic Total Shoulder Arthroplasty. J Shoulder Elb Arthroplast 2017. [DOI: 10.1177/2471549217743605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Gregory TM, Boukebous B, Gregory J, Pierrart J, Masemjean E. Short, Medium and Long Term Complications After Total Anatomical Shoulder Arthroplasty. Open Orthop J 2017; 11:1133-1141. [PMID: 29152008 PMCID: PMC5676001 DOI: 10.2174/1874325001711011133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/14/2017] [Accepted: 05/14/2017] [Indexed: 12/20/2022] Open
Abstract
Total shoulder arthroplasty (TSA) is an effective approach for the treatment of a variety of clinical conditions affecting the shoulder, including osteoarthritis, inflammatory arthritis and osteonecrosis, and the number of TSA implanted has grown exponentially over the past decade. This review gives an update of the major complications, mainly infections, instability and loosening, encountered after TSA, based on a corpus of recent publications and a dynamic approach: The review focuses on the causes of glenoid loosening, which account for 80% of the complication, and underlines the importance of glenoid positioning in the recovery of early shouder function and in the long term survival rate of TSA.
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Affiliation(s)
- T M Gregory
- Upper Limb and orthopaedic surgery department, Avicenne Teaching Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 13, Paris, France.,Department of Mechanical Engineering, Imperial College, London, UK
| | - B Boukebous
- Upper Limb and orthopaedic surgery department, Avicenne Teaching Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 13, Paris, France
| | - J Gregory
- Upper Limb Surgery Unit, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris, University Paris Descartes, Paris, France
| | - J Pierrart
- Upper Limb and orthopaedic surgery department, Avicenne Teaching Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 13, Paris, France
| | - E Masemjean
- Upper Limb and orthopaedic surgery department, Avicenne Teaching Hospital, Assistance Publique-Hôpitaux de Paris, University Paris 13, Paris, France
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Lift-off Test Results After Lesser Tuberosity Osteotomy Versus Subscapularis Peel in Primary Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2017; 25:304-313. [PMID: 28234638 DOI: 10.5435/jaaos-d-16-00138] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The ideal method for management of the subscapularis tendon during anatomic total shoulder arthroplasty (TSA) remains controversial. METHODS In a retrospective cohort study, primary anatomic TSA procedures performed with either a subscapularis peel or a lesser tuberosity osteotomy from 2002 to 2010 were reviewed at a minimum 1-year follow-up. The primary outcome measure was the performance of a normal lift-off test postoperatively. Multivariate logistic regression analysis was performed to determine if other covariates besides surgical technique correlated with an abnormal lift-off test result. RESULTS Ninety TSA procedures were evaluated. Forty-six procedures were performed with subscapularis peel, and 44 were performed with lesser tuberosity osteotomy. Mean follow-up was 4 years. In the subscapularis peel group, 32 of 46 shoulders (69.6%) had a normal lift-off test, compared with 40 of 44 shoulders (90.9%) in the lesser tuberosity osteotomy group (P = 0.01). The results of multivariate logistic regression suggested that lesser tuberosity osteotomy was associated with a normal postoperative lift-off test 4.5 times more often than was subscapularis peel. CONCLUSIONS Our study suggests that the use of lesser tuberosity osteotomy as the surgical approach for anatomic TSA is a reliable option that provides the patient with a better chance of maintaining subscapularis function postoperatively than the subscapularis peel does. LEVEL OF EVIDENCE Level III retrospective cohort study.
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Affiliation(s)
- Kamal I Bohsali
- 1Jacksonville Orthopaedic Institute, Jacksonville Beach, Florida 2Section of Orthopaedic Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada 3Department of Orthopaedics, University of Texas HSC-San Antonio, San Antonio, Texas
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