Shoulder arthroplasty for proximal humeral malunions: long-term results

Shoulder Arthroplasty After Previous Nonarthroplasty Surgery: A Systematic Review and Meta-Analysis of Clinical Outcomes and Complications

BACKGROUND

Many patients who undergo shoulder arthroplasty (SA) have had at least 1 nonarthroplasty shoulder surgery before the surgery. There is conflicting evidence regarding the effects of previous shoulder surgery on the outcome of SA. A systematic review was conducted to compare functional outcomes and complications between SA patients with and without prior non-SA surgery on the ipsilateral shoulder.

METHODS

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE/PubMed, Embase, Scopus, and Web of Science comprehensively from inception to January 2023. Based on 9,279 records reviewed, 26 comparative studies were included in the meta-analysis consisting of 5,431 shoulders with prior nonarthroplasty procedures (cases) and 55,144 shoulders without previous surgery (controls). Variables such as functional scores, complications, and range of motion were compared between cases and controls using Review Manager Software. In addition, subgroup analysis was conducted based on prior surgery type (rotator cuff repair [RCR], open reduction and internal fixation [ORIF], soft tissue repairs, and not specified) and type of SA (hemiarthroplasty, anatomical total shoulder arthroplasty, and reverse total shoulder arthroplasty [RTSA]). The results were presented as odds ratios (ORs) or standardized mean differences (SMDs).

RESULTS

Except for a higher rate of periprosthetic joint infection (PJI) in patients who had undergone previous arthroscopic surgery (OR, 2.58; 95% confidence interval [CI], 1.66-4.01; p < 0.01), a higher rate of complications was only observed in patients with previous ORIF. These complications included aseptic loosening (OR, 3.43; 95% CI, 2.14-5.50; p < 0.01), shoulder dislocation (OR, 2.25; 95% CI, 1.05-4.84; p = 0.04), overall complication (OR, 3.95; 95% CI, 2.38-6.55; p < 0.01), and revision (OR, 2.52; 95% CI, 1.28-4.97; p = 0.01). Patients with a history of previous surgery demonstrated inferior functional outcomes in comparison with the control group, including American Shoulder and Elbow Surgeons (SMD, -0.39; 95% CI, -0.51 to -0.27; p < 0.01; I2 = 36%), Constant-Murley score (SMD, -0.34; 95% CI, -0.44 to -0.24; p < 0.01; I2 = 0%), abduction (SMD, -0.26; 95% CI, -0.45 to -0.08; p = 0.01; I2 = 54%), and flexion (SMD, -0.33; 95% CI, -0.46 to -0.21; p < 0.01; I2 = 40%). Subgroup analysis by previous type of surgery was not possible regarding functional outcomes.

CONCLUSION

Patients who have had prior fracture surgery are at a higher risk of complications, reoperations, and revisions after SA than controls. The normal shoulder anatomy may be disrupted by prior surgery, which makes arthroplasty technically challenging, particularly when it comes to soft tissue balance. On the other hand, RCR before SA did not negatively affect clinical outcomes after RTSA and did not have a higher rate of overall complications (except PJI).

LEVEL OF EVIDENCE

Level III (Treatment Studies). See Instructions for Authors for a complete description of levels of evidence.

Proximal humerus fracture sequelae: are corrective osteotomies still a taboo? The role of three-dimensional preoperative planning and patient-specific surgical guides for proximal humerus corrective osteotomy in combination with reverse shoulder arthroplasty

Background

Symptomatic proximal humeral fracture sequelae (PHFS) represent a surgical challenge due to the altered bone and soft tissue morphology. The purpose of this study was to report the outcome of Multiplanar Corrective Humeral Osteotomies (MCHOs) in combination with reverse total shoulder arthroplasty (rTSA) performed following a three-dimensional (3D) preoperative planning and using a 3D-printed patient-specific surgical instrumentation (PSI) in type 1C, 1D, and 4 PHFS.

Methods

In this prospective monocentric study, we enrolled patients affected by symptomatic PHFS type 1C, 1D, or 4 of Boileau's classification, treated between 2018 and 2019 with rTSA associated to MCHO and followed-up at 12 and 24 mo. The preoperative and postoperative Constant Score (CS), visual analog scale, and Disabilities of the Arm, Shoulder and Hand (DASH) score were recorded. All patients underwent a preoperative computed tomography, then a dedicated software was used to run a segmentation algorithm on computed tomography images. Metaphyseal bone cuts were virtually performed before surgery in all patients, and a 3D-printed PSI was used to reproduce the planned osteotomies in vivo.

Results

Twenty patients completed a 2-y follow-up. The mean (± standard deviation) CS, visual analog scale, and DASH values improve from 24.3 (± 8.8), 6.5 (± 1.3), 60.7 (± 9.6) preoperatively, to 67.7 (± 11.4), 1.6 (± 0.8), 24.1 (± 13.1) points after surgery, respectively. The minimally clinical important difference for CS and DASH score was achieved in 95% of patients. No major complication was observed. One patient showed an unexplained worsening of clinical scores between the 12 and the 24-mo follow-up, while in one patient bone resorption of the greater tuberosity was observed on radiographs at 2 y, with no clinical impact.

Conclusion

The combination of preoperative 3D planning and intraoperative use of 3D-printed PSI to perform MCHO as concurrent procedure in the context of rTSA in the treatment of Boileau type 1C, 1D, and 4 PHFS may lead to a satisfactory clinical outcome at 2 y of follow-up.

Use of 3D Planning and Patient-specific Guides for Proximal Humerus Corrective Osteotomy Associated With Shoulder Prosthesis Implantation in Proximal Humeral Varus Malunion

Humeral stem prosthesis implantation in case of proximal humerus varus malunion (type 1D fracture sequelae) is often complicated by greater tuberosity fracture and by posterosuperior rotator cuff iatrogenic damage. Moreover, the varus malunited humeral head could lead to scapular impingement and reduce the range of motion. To address this problem, we introduced a new surgical procedure consisting in a proximal humerus osteotomy, planned with three-dimensional (3D) preoperative virtual surgery, and performed with patient-specific surgical guides, to correct humerus deformity before the implantation of the prosthetic humeral stem. A 3D evaluation of the deformity, based on the comparison to the healthy contralateral side or to anatomical standard values, is firstly performed. The metaphyseal osteotomy is then planned and virtually performed. To faithfully reproduce the planned correction, 3D printed surgical guides are prepared. Before the surgery, it is advisable to perform a simulation of the planned osteotomies to verify their real feasibility and to find any critical issues. Preliminary outcomes of this surgical technique are encouraging, but formal studies are warranted to validate its clinical utility and longevity of results.

Surgical treatment of the humeral head osteochondral defects in chronic shoulder dislocation: Literature review

Background. The shoulder joint is the one most amenable to dislocation. Dislocation of the humeral head is complicated by combined injuries of the shoulder joint, and if the patient does not seek treatment on the first day after the dislocation, irreversible changes in bone and soft tissue structures are formed.The aim of this review was to analyze modern methods of diagnosis and treatment of patients with defects in the articular surfaces of the scapula and humerus head with chronic shoulder dislocations.Material and methods. To search for literature data, we used the electronic databases MEDLINE, PudMed, eLIBRARY with a selection of sources published from 2000 to 2020. The analysis was carried out on works devoted to the diagnosis, surgical treatment and complications of traumatic shoulder dislocations.Results. When analyzing the literature on the surgical treatment of shoulder dislocations, we did not find clear criteria for planning the extent of surgery. The obtained results of surgical treatment testify to well-studied technologies for treating osteochondral defects of the humeral head up to 25 % of its total area. In the presence of a defect of 50 % of humeral head area or more, satisfactory results are shown when carrying out arthroplasty of the joint using a reverse endoprosthesis. However, the treatment of defects ranging in size from 25 to 50 % is still an unexplored problem. There are single techniques using allografts, mainly in English-speaking countries and, to a lesser extent, on the territory of the Russian Federation. Thus, the search for an algorithm for choosing a surgical treatment based on multi-layer spiral computed tomography and/or magnetic resonance imaging data, and the development of a new method of surgical treatment taking into account the obtained data are priority areas in modern traumatology and orthopedics.

SECEC Grammont Award 2017: the prejudicial effect of greater tuberosity osteotomy or excision in reverse shoulder arthroplasty for fracture sequelae

HYPOTHESIS

The aim was to evaluate risk factors for complications, revision, and mid- to long-term outcomes after reverse shoulder arthroplasty (RSA) implanted for proximal humeral fracture sequelae (PHFS).

METHODS

The radiographs of 98 patients (mean age, 68 years) who underwent RSA for the treatment of PHFS were reviewed at a minimum 5-year follow-up. PHFS were divided into 4 types according to the Boileau classification: type 1 (46 cases), type 2 (6 cases), type 3 (12 cases), and type 4 (34 cases). The tuberosities underwent osteotomy in 28 cases and excision in 12 (all type 3 or 4 PHFS). The mean follow-up period was 8.4 years (range, 5-14 years).

RESULTS

The functional results and rate of RSA survival without revision (85% vs. 100% at 10 years, P = .007) were significantly lower for types 3 and 4 vs. types 1 and 2. Overall, our findings showed that RSA for PHFS is not the panacea that surgeons once believed: At a mean follow-up of 8.5 years (range, 5-14 years), 59% of the patients in our series had fair or poor results. Patients who underwent tuberosity osteotomy or excision had lower functional results (adjusted Constant score, 69% vs. 88%; P < .001), more postoperative complications (32% vs. 9%, P = .003), and a higher revision rate (15% vs. 2%, P = .017). Patients who underwent tuberosity osteotomy or excision at the time of RSA were at risk of postoperative prosthetic instability and humeral stem loosening. The absence of the greater tuberosity at last radiographic follow-up was predictive of higher rates of complications and revisions, as well as a poorer final outcome. Previous fracture fixation was associated with a higher rate of complete tuberosity resorption (56% vs. 33%, P = .026) and with higher rates of postoperative complications (27% vs. 13%, P = .099) and reinterventions (17% vs. 2%, P = .018).

CONCLUSION

The functional results and rates of complications and revision depend on the type of fracture sequelae and tuberosity management. Patients with more severe (type 3 and 4) fracture sequelae who undergo tuberosity osteotomy or excision are at risk of having a poorer functional result and higher rates of complications and revision with lower survival. Previous fracture fixation is also a prejudicial factor.

Treatment of nonunions of the humeral shaft with nonvascularized fibular strut allograft: postoperative outcomes and review of a surgical technique

Hypothesis

Persistent humeral shaft nonunions result in continued pain and disability of the affected arm and are difficult to treat even with several surgical procedures and locked plating. A fibular allograft provides bony purchase for fixation as well as rotational stability and bridging of nonunion defects.

Methods

We conducted a retrospective review of a single surgeon's clinical practice between July 1995 and January 2011. The inclusion criteria were patients aged ≥ 18 years who underwent revision surgery for a humeral shaft nonunion by open reduction and revision internal fixation with a supplementary fibular strut allograft.

Results

Thirteen patients who met the inclusion criteria were evaluated with physical examinations, validated functional outcome measures, and radiographs to assess union rates. The mean follow-up period was 7.5 years (range, 0.5-15.6 years); there were 11 women (85%) and 2 men (15%). Of the patients, 3 (23%) had proximal-third nonunions, 7 (54%) had middle-third nonunions, and 3 (23%) had distal-third nonunions. After revision surgery with fibular allograft, 10 of 13 patients went on to achieve healing, giving a union rate of 76.9%. The mean postoperative Disabilities of the Arm, Shoulder and Hand score was 38.1 points (standard deviation [SD], 27.6 points). The mean Constant score was 55.2 points (SD, 24.0 points), representing a 62% return of function compared with the contralateral side. The mean postoperative American Shoulder and Elbow Surgeons score was 65.4 points (SD, 28.5 points), and the average visual analog scale pain score (out of 10) was 2.1 (SD, 3.3) at final follow-up.

Conclusion

Fibular allograft is an effective and straightforward option for treating humeral midshaft and distal-shaft nonunions; however, treatment of proximal-third nonunions remains challenging.

Reverse Shoulder Arthroplasty with <i>Latissimus Dorsi</i> Transfer for Humerus Fractures Sequelae

Relevance. Fractures of the proximal humerus occupy the 3rd place in the structure of fractures in the elderly. Failure to treat these injuries leads to irreversible changes in the shoulder. The main treatment for the latter is arthroplasty. The surgical treatment of this category of patients is still a difficult task. The purpose of this study was to compare the effectiveness of standard reverse arthroplasty with reverse arthroplasty in combination with the reconstruction of the external rotators of the shoulder or transposition of the latissimus dorsi. Materials and Methods. The retrospective evaluation of treatment results of 96 patients with consequences of shoulder injuries was conducted. Of these, 51 patients underwent standard reverse arthroplasty (group I), and 45 patients (group II) underwent arthroplasty with reconstruction of the external rotators of the shoulder or transposition of the latissimus dorsi. The female patients accounted for 68.8%. The duration of the injury varied from 8 months to 2.5 years, the follow-up — from 1 to 7 years (Me = 3.5). The results were assessed with VAS, ASES, UCLA scales. Results. The positive outcomes were observed in most patients. Complications: dislocations of the endoprosthesis occurred in 16.7%, infectious complications — in 5.2%, shoulder component instability — in 2.1%, fracture of the humeral diaphysis — in 3.1%, neurovascular bundle injury — in 2.1% of cases. In the patients of group I, dislocations occurred significantly more often than in the patients of group II. To reduce the risk of complications, a rational tactic has been developed for treating patients with consequences of shoulder injuries. If electroneuromyography values from the deltoid muscle were less than 40% of the contralateral side, or if mineral bone density T-score was less than 2.5 SD, arthroplasty was not performed. During arthroplasty, it is necessary to perform the direct suturing of the of the infraspinatus and teres minor tendons to the humerus. If it is impossible, the latissimus dorsi transfer is indicated. Conclusion. Reverse arthroplasty in the treatment of the humerus fractures sequelae is an effective technique. To reduce the risk of complications, it is necessary to provide the additional stability of the endoprosthesis by reconstruction of the external rotators or latissimus dorsi transfer. It is advisable to refrain from arthroplasty in cases of severe deltoid hypotrophy and severe osteoporosis.

Functional improvement is sustained following anatomical and reverse shoulder arthroplasty for fracture sequelae: a registry-based analysis

INTRODUCTION

Shoulder arthroplasty for proximal humerus fracture sequelae is known to provide significant patient improvement, yet this outcome varies with time, prosthesis type, and fracture sequelae. We outline the expected course of postoperative shoulder pain and function in patients with anatomical (ASA) or reverse (RSA) shoulder arthroplasty following different fracture sequelae.

MATERIALS AND METHODS

Of 111 consecutive patients from our local shoulder arthroplasty registry, 32 underwent ASA for Boileau type 1 sequelae and 77 RSA patients were identified with Boileau types I, III, and IV. By 5 year post-surgery, there were 72 patients available. All patients underwent standardised ASA or RSA procedures with anatomical (Promos Standard; Lima SMR™; Arthrex Eclipse™; Univers™ II) or reverse prostheses (Promos Reverse^®; Lima SMR™ Reverse; Univers Revers™; Aequalis^® Reversed). Range of motion, Constant-Murley, Disability of the Arm, Shoulder and Hand (DASH), and Shoulder Pain and Disability Index (SPADI) scores were compared at 6, 12, 24, and 60 months postoperatively. We used generalised linear mixed models or random-effects ordered logistic regression to investigate postoperative changes of outcome parameters from baseline to follow-up time points for each group as well as for group comparisons.

RESULTS

Range of motion and clinical scores improved until 24 months postoperatively and did not deteriorate thereafter, except for internal rotation of Boileau type III and IV patients and external rotation of RSA patients with type I and IV sequelae. At all follow-ups, ASA patients with Boileau type I sequelae had significantly better internal and external rotation versus patients with RSA and/or other Boileau types (p < 0.001), while Constant, DASH, and SPADI scores were not significantly different between groups.

CONCLUSION

In humeral fracture sequelae, ASA and RSA lead to sustained clinical improvements. Surgeons may primarily consider implantation of ASA in type I sequelae.

A higher reoperation rate following arthroplasty for failed fixation versus primary arthroplasty for the treatment of proximal humeral fractures

Aims

To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) versus secondary arthroplasty for failed open reduction and internal fixation (ORIF).

Patients and Methods

We identified patients aged 50 years and over, who sustained a PHF between 2004 and 2015, from linkable datasets. We used intervention codes to identify patients treated with initial ORIF or arthroplasty, and those treated with ORIF who returned for revision arthroplasty within two years. We used multilevel logistic regression to compare reoperations between groups.

Results

We identified 1624 patients who underwent initial arthroplasty for PHF, and 98 patients who underwent secondary arthroplasty following failed ORIF. In total, 72 patients (4.4%) in the primary arthroplasty group had a reoperation within two years following arthroplasty, compared with 19 patients (19.4%) in the revision arthroplasty group. This difference was significantly different (p < 0.001) after covariable adjustment.

Conclusion

The number of reoperations following arthroplasty for failed ORIF of PHF is significantly higher compared with primary arthroplasty. This suggests that primary arthroplasty may be a better choice for patients whose prognostic factors suggest a high reoperation rate following ORIF. Prospective clinical studies are required to confirm these findings. Cite this article: Bone Joint J 2019;101-B:1272–1279

Management of the Failed Arthroplasty for Proximal Humerus Fracture

A variety of reasons exist for failure of arthroplasty performed for management of proximal humerus fracture. Revision surgery for these failures is complex and has a high likelihood of inferior outcomes compared with primary arthroplasty. Successful management requires consideration of various modes of failure including tuberosity malunion or resorption, rotator cuff deficiency, glenoid arthritis, bone loss, component loosening, stiffness, or infection. Although revision to a reverse shoulder arthroplasty is an appealing option to address instability, rotator cuff dysfunction, and glenoid arthritis, there are concerns with higher complication rates and inferior results compared with primary reverse replacement. Any treatment plan should appropriately address the cause for failure to optimize outcomes.

Application of three-dimensional prototyping in planning the treatment of proximal humerus bone deformities

Objective

To describe the use of three-dimensional prototyping or rapid prototyping in acrylic resin to create synthetic three-dimensional models in order to promote the understanding of bone deformities of the shoulder.

Methods

Five patients were analyzed between ages of 11 and 73 years old, treated between 2008 and 2013 with glenohumeral deformities that required a more thorough review of the anatomical alterations, for whom three-dimensional prototyping was performed.

Results

Patient 1 was treated conservatively and is awaiting humeral head arthroplasty if symptoms get worse. Patient 2 underwent a valgus proximal humerus osteotomy secured with pediatric locked hip plate according to a prior assessment with prototyping. Patient 3 underwent a disinsertion of the rotator cuff, tubercleplasty and posterior reinsertion of the rotator cuff. Patient 4 underwent an arthroscopic step-off resection, 360-degree capsulotomy, and tenolysis of the subscapularis. Patient 5 underwent a reverse shoulder arthroplasty with an L-shaped bone graft on the posterior glenoid.

Conclusions

Rapid prototyping in acrylic resin allows a better preoperative planning in treatment of bone deformities in the shoulder, minimizing the risk of intraoperative complications in an attempt to improve the results.

Anatomical and biomechanical framework for shoulder arthroplasty rehabilitation

This article provides an anatomical and biomechanical framework for the postoperative management and progression of treatment for shoulder arthroplasty. The clinical relevance of normal shoulder anatomy, biomechanics, and pathomechanics related to this surgery is emphasized to provide the reader with an understanding of the rationale for treatment. We review the rehabilitation implications of surgical indications and technique for both traditional total shoulder arthroplasty and reverse total shoulder arthroplasty procedures with an emphasis on biomechanical considerations. Relevant factors that affect rehabilitation outcomes are discussed along with supporting evidence from the literature. Principles to guide and progress treatment are highlighted with a discussion on return to sports with the ultimate objective of providing a comprehensive approach for successful rehabilitation.

Outcomes of Reverse Total Shoulder Arthroplasty for Proximal Humeral Fractures: Primary Arthroplasty Versus Secondary Arthroplasty After Failed Proximal Humeral Locking Plate Fixation

OBJECTIVE

To compare the outcomes of reverse shoulder arthroplasty (RSA) between patients with failed proximal humeral locking plate (PHLP) fixation and those with acute fractures.

DESIGN

Matched case-control study.

SETTING

University hospital, Level I trauma center.

PATIENTS

Thirty consecutive patients with fracture sequelae because of failed PHLP fixation (mean age 73) were age and sex matched to 30 patients with acute fracture (mean age 75).

INTERVENTION

All patients underwent RSA.

MAIN OUTCOME MEASUREMENTS

Constant, University of California Los Angeles (UCLA) and Disability of the Arm, Shoulder and Hand (DASH) scores. Radiological assessments were also performed.

RESULTS

The mean postoperative follow-up was 3.2 (range, 2-5) years. All functional scores significantly improved from preoperative to postoperative (P = 0.001) in the sequelae group. Pain was relieved in all but one patient, and all but 2 patients were satisfied with their RSA. However, the functional outcomes at the last follow-up were significantly worse in the sequelae group compared with acute group in terms of adjusted Constant (P = 0.013), UCLA (P = 0.020) and DASH (P = 0.048) scores, strength (P = 0.01), anterior forward (P = 0.021), and abduction (P = 0.007). Six patients (20%) in the sequelae group had complications including 2 intraoperative (diaphyseal false passages), 2 early dislocations, 1 acromial fracture, and 1 aseptic loosening of glenoid component. Four of these patients were revised resulting all in a successful outcome at the last follow-up. In the acute group there was one intraoperative humeral fracture with no impact on the final outcome.

CONCLUSIONS

Patients with failed PHLP fixation for fracture who were revised to RSA secondarily obtained marginally lower functional scores and higher complication rates compared with patients treated with primary RSA for fracture. However, patients who treated with secondary RSA had significant functional improvement and pain relief compared with their preoperative status, and most complications were manageable without a significant effect on final outcome.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis

BACKGROUND

Intraoperative anesthetic typically consists of either general anesthesia (GA) or isolated regional anesthesia (RA).

METHODS

A retrospective propensity-matched cohort analysis on patients undergoing TSA was performed to determine differences between GA and RA in regard to patient population, complications, LOS and hospital readmission.

RESULTS

4158 patients underwent TSA with GA or isolated RA. Propensity-matching resulted in 912 patients in each cohort. RA had lower overall in-hospital complications and greater homebound discharge disposition with lower 90-day readmission rates than GA.

CONCLUSION

After TSA, isolated RA was associated with lower in-hospital complications, readmission rates and odds of hospital readmission than GA.

The medium- and long-term outcome of total shoulder arthroplasty for primary glenohumeral osteoarthritis in middle-aged patients

Aims

Promising medium-term results from total shoulder arthroplasty (TSA) have been reported for the treatment of primary osteoarthritis in young and middle-aged patients. The aim of this study was to evaluate the long-term functional and radiological outcome of TSA in the middle-aged patient.

Patients and Methods

The data of all patients from the previous medium-term study were available. At a mean follow-up of 13 years (8 to 17), we reviewed 21 patients (12 men, nine women, 21 shoulders) with a mean age of 55 years (37 to 60). The Constant-Murley score (CS) with its subgroups and subjective satisfaction were measured. Radiological signs of implant loosening were analysed.

Results

Two shoulders (two patients) were revised and in two shoulders of two different patients, revision surgery was recommended. The mean CS increased from 23.3 (10 to 45) pre-operatively to 56.5 (26 to 81; p < 0.0001), but with a decrease in CS from 62.8 (38 to 93) to 56.5 (26 to 81) between medium- and long-term follow-up (p = 0.01). Without revision surgery, 18 patients (95%) rated their result as good or very good. The mean radiolucent line score for the glenoid components increased from 1.8 (0 to 6) to 8.2 (2 to 18) between medium- and long-term follow-up (p < 0.001).

Conclusion

TSA in young and middle-aged patients leads to improvement in clinical function and a relatively high satisfaction rate. However, clinical or radiological glenoid loosening worsens in the long term. Further studies are needed to optimise the treatment options in this patient population. Cite this article: Bone Joint J 2017;99-B:939–43.

Intermediate-term outcome of hemiarthroplasty for comminuted proximal humerus fractures

BACKGROUND

The purpose of this study was to evaluate the outcome of hemiarthroplasty for comminuted proximal humerus fractures and to verify the risk factors for functional and radiologic outcomes.

MATERIALS AND METHODS

We treated 29 comminuted proximal humerus fractures by hemiarthroplasty with a low-profile prosthesis and a bone block graft, with an average follow-up period of 53.9 (24-119) months. The patients' mean age at surgery was 71.7 (52-85) years. We evaluated visual analog scale (VAS) scores for pain and satisfaction, active range of motion, modified University of California-Los Angeles (UCLA) score, and shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score. Radiographs were checked for stem position, loosening, and tuberosity union. The statistical evaluation was conducted to compare 2 demographics.

RESULTS

The mean VAS score was 2.1 (0-5) for pain and 8.0 (4-10) for satisfaction. Mean active forward flexion was 125° (90°-170°); external rotation, 42° (25°-70°); and internal rotation, at T11 (T7-L2). The mean modified UCLA score was 20 (12-30), and the mean QuickDASH score was 25 (12-38). All stems were stable without any loosening. All tuberosities were united except 2 tuberosity absorptions.

DISCUSSION

Patients older than 70 years and patients with chronic debilitating disease, >5-mm displacement of the prosthetic head from the glenoid, and a critical shoulder angle of >38° showed significantly poorer clinical outcome.

CONCLUSION

Low-profile hemiarthroplasty with bone block graft had unique advantages for tuberosity union. During surgery, good prosthetic positioning with respect to the anatomic axis of the glenoid and critical shoulder angle (>38°) were essential. However, age (>70 years) and systemic comorbidity showed poor clinical outcome. These factors should be considered in standardizing the clinical results.

Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly

BACKGROUND

Anatomic reduction and stable internal fixation of complex proximal humeral fractures in the elderly is challenging. Secondary displacement, screw perforation, and humeral head necrosis are common complications. The outcome of hemiarthroplasty is unpredictable and strongly dependent on the uncertain healing of the greater tuberosity. This multicenter study retrospectively analyzes the midterm results of primary reverse total shoulder arthroplasty for the treatment of acute, complex fractures of the humerus in an elderly population.

METHODS

Fifty-two shoulders in 51 patients with a mean age of 77 years treated with reverse total shoulder arthroplasty for an acute, complex fracture of the proximal humerus were clinically and radiographically analyzed after a mean follow-up period of 35 months (range, 12-90 months).

RESULTS

There were no intraoperative complications. Revision surgery was performed in 4 shoulders. At final follow-up, the absolute and relative Constant scores averaged 62 points (range, 21-83 points) and 86% (range, 30%-100%), respectively, with a mean Subjective Shoulder Value of 83% (range, 30%-100%). Of the patients, 92% rated the treatment outcome as excellent or good. Patients with a resected or secondarily displaced greater tuberosity had an inferior clinical outcome to those with a healed greater tuberosity.

CONCLUSION

The midterm clinical results are predictably good, with low complication rates and a rapid postoperative recovery of painfree everyday function. If secondary displacement of the greater tuberosity occurs, revision surgery may warrant consideration in view of potential improvement of ultimate outcome.

[Posttraumatic arthrosis of the glenohumeral joint. From partial resurfacing to reverse shoulder arthroplasty]

BACKGROUND

Arthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results.

OBJECTIVE

Discussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration.

METHODS

Selective literature review and description of personal experience.

RESULTS

The geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article.

CONCLUSION

Each case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.

Treatment of fracture sequelae of the proximal humerus: comparison of hemiarthroplasty and reverse total shoulder arthroplasty

INTRODUCTION

Fracture sequelae (FS) of the proximal humerus is a challenging scenario in shoulder surgery. Despite they have been traditionally treated with hemiarthroplasty (HA), the use of reverse shoulder arthroplasty (RSA) has been recently introduced. However, there are no studies comparing the results of HA and RSA in FS. The purpose of this study was to compare the functional and quality of life-related outcomes, and complications in the treatment of proximal humeral FS between HA and RSA.

MATERIALS AND METHODS

A therapeutic prospective non-randomized comparative study was conducted. All consecutive patients with diagnosis of FS after non-operative treatment of proximal humeral fractures and no previous shoulder surgery were considered for this study. A total of 32 patients (24 females, 8 males) with a mean (SD) age at the time of surgery of 80.1 (4.9) years were finally included: 12 in the HA group, and 20 in the RSA group. FS were treated with shoulder arthroplasty by the implantation of either HA or RSA. Constant score (total and specific items), quality of life (assessed through SF-36), and complications requiring revision surgery were compared between groups.

RESULTS

All parameters of the Constant score significantly improved in the postoperative compared to preoperative period when considering the entire sample. The RSA group demonstrated a higher improvement in total Constant score (p = 0.06) and Constant activity level (p = 0.02) compared to the HA group. The HA demonstrated a higher number of complications compared to the RSA (p = 0.05). There were no differences in SF-36 scores between both groups.

CONCLUSIONS

The shoulder arthroplasty is an effective treatment for FS with significant improvement in pain and function. The RSA may be a better option than HA for FS given the trend towards better total Constant score and a significantly lower number of complications requiring revision surgery.

LEVEL OF EVIDENCE

Therapeutic level II evidence.

Anatomic shoulder arthroplasty for treatment of proximal humerus malunions

BACKGROUND

Malunion of proximal humeral fractures complicated by damage to the glenohumeral cartilage and injury to the joint capsule and rotator cuff can include treatment requiring anatomic shoulder arthroplasty. This study defines results and complications of this procedure and identifies factors associated with success or failure.

METHODS

From 1976 to 2007, 109 patients underwent shoulder arthroplasty for proximal humerus malunions. Ninety-five met the criteria for analysis with a mean follow-up period of 9.2 years. Fracture types according to the Neer classification were two part in 20, three part in 37, four part in 31, and head splitting in 2, with 16 fracture-dislocations. Hemiarthroplasty was performed in 45 patients, with 50 undergoing total arthroplasty.

RESULTS

Pain scores improved from 7.8 to 3.1 (P < .001). The mean active elevation and external rotation improved from 69° to 109° and from 8° and 39°, respectively (P = .001). Of 31 patients with available radiographs, 20 had healed tuberosity osteotomies. Sixteen complications required 10 reoperations, including 6 of 9 patients with severe postoperative instability. There were 57 excellent or satisfactory results by use of the Neer rating. No patient, injury pattern, previous treatment, surgical, or radiologic variation was significantly associated with an increased risk of an unsatisfactory result, except for severe postoperative instability. Kaplan-Meier survivorship for reoperation, in 109 shoulders, was 94.8% (95% confidence interval, 90.5%-99.4%) at 5 years and 90.1% (95% confidence interval, 83.6%-97.1%) at 10 and 15 years.

CONCLUSION

Anatomic shoulder arthroplasty improves pain and motion. Surgery is complex. Tuberosity osteotomies often heal. Postoperative instability is the most common complication leading to reoperation and is usually associated with rotator cuff and shoulder capsule injury.

Management of malunion of the proximal humerus: current concepts

Proximal humerus fractures remain one of the most common orthopaedic injuries, particularly in the elderly. Displaced fractures often require surgery, and management can be challenging because of comminution and poor bone quality. Despite advances in surgical technique and implant design, reoperation for malunion or nonunion of the tuberosity (arthroplasty) or screw penetration (open reduction and internal fixation) remains problematic. Recent studies have demonstrated acceptable results following nonsurgical management of displaced proximal humerus fractures in elderly, low-demand patients. In younger, more active patients, reduced function and pain that accompany select proximal humeral malunions are generally poorly tolerated. Surgical options for symptomatic, malunited tuberosities include osteotomy, tuberoplasty with rotator cuff repair and subacromial decompression, or decompression alone. Surgical neck malunion can be managed with corrective osteotomy and preservation of the native joint. Arthroplasty is reserved for complex malunions with joint incongruity. Surgical management of symptomatic proximal humeral malunion remains challenging, but good outcomes can be achieved with proper patient selection.

The effect of different humeral prosthesis fin designs on shoulder stability: a computational model

Humeral prostheses commonly use a fin structure as an attachment point for the supraspinatus muscle in total shoulder arthroplasty (TSA), but these fins may cause injury to the muscle during implantation, inadvertently influencing stability. In order to prevent supraspinatus injury, the effect of different humeral prostheses on shoulder joint stability needs to be investigated. A commercially available prosthesis and two modified humeral prostheses that substituted the fin structure for 2 (2H) or 3 holes (3H) were evaluated using computational models. Glenohumeral abduction was simulated and the superioinferior/anterioposterior stability of the shoulder joint after TSA was calculated. The results revealed that the 2H design had better superioinferior stability than the other prostheses, but was still less stable than the intact shoulder. There were no obvious differences in anterioposterior stability, but the motion patterns were clearly distinguishable from the intact shoulder model. In conclusion, the 2H design showed better superioinferior stability than the 3H design and the commercial product during glenohumeral joint abduction; the three prostheses show similar results in anterioposterior stability. However, the stability of each tested prosthesis was not comparable to the intact shoulder. Therefore, as a compromise, the 2H design should be considered for TSA because of its superior stability.

Uncommon indications for reverse total shoulder arthroplasty

Total shoulder arthroplasty and shoulder hemiarthroplasty have been the traditional method for treating a variety of shoulder conditions, including arthritis, cuff tear arthropathy, and some fracture types. However, these procedures did not provide consistently good results for patients with torn rotator cuffs. The development of the reverse prosthesis by Grammont in the late 20th century revolutionized the treatment of the rotator-cuff-deficient shoulder with arthritis. The main indication for the reverse prosthesis remains the patient with cuff tear arthropathy who has pain and loss of motion. Because the reverse total shoulder arthroplasty produced such good results in these patients, the indications for the reverse prosthesis have expanded to include other shoulder conditions that have previously been difficult to treat successfully and predictably. This review discusses and critically reviews these newer indications for the reverse total shoulder arthroplasty.

Malunion of the proximal humerus

Malunion of a proximal humerus fracture is difficult to manage once bone union has been achieved in a wrong position. Malunion may be encountered after conservative treatment or internal fixation of fractures, and also around a joint prosthesis. The malunion can involve the greater and lesser tuberosities, humeral head, bicipital groove, or the entire epiphysis. The nature of the malunion must be precisely characterized. Malunion can affect bone structures and the articular surface; any resulting displacements must be carefully measured. Clinical assessments will help to evaluate the functional repercussions and determine the need for correction. Radiographic imaging and CT scan guide the treatment plan. Arthroscopic surgery (acromioplasty or tuberoplasty) can be used to treat biceps tenosynovitis or impingement syndrome in cases where full correction of the malunion is not required. Corrective surgery of a metaphyseal malunion is used to realign the proximal humeral into the proper position. Tuberosity osteotomy is the main predictor for a poor outcome following secondary arthroplasty.

Late prosthetic shoulder hemiarthroplasty after failed management of complex proximal humeral fractures

Background. The purpose of this study was to report our experience with shoulder hemiarthroplasty in the context of old trauma. Methods. 33 patients with failed treatment for a complex proximal humeral fracture underwent prosthetic hemiarthroplasty. There were 15 men and 18 women with a mean age of 58.1 years. The average period from initial treatment was 14.9 months. Sequelae included 11 malunions, 4 nonunions, 15 cases with avascular necrosis (AVN) and 3 neglected posterior locked dislocations. Follow up investigation included radiological assessment and clinical evaluation using the Constant score and a visual analogue pain scale. Results. After a mean follow up of 82.5 months the median Constant score was 75.7 points, improved by 60% in comparison to preoperative values. Greater tuberosity displacement, large cuff tears and severe malunion were the factors most affected outcome. No cases of stem loosening or severe migration were noted. 60% of the patients were able to do activities up to shoulder level compared with 24% before reconstruction. Conclusions. Late shoulder hemiarthroplasty is technically difficult and the results are inferior to those reported for acute humeral head replacement, nonetheless remains a satisfactory reconstructive option when primary treatment fails.

Prognostic factors and limitations of anatomic shoulder arthroplasty for the treatment of posttraumatic cephalic collapse or necrosis (type-1 proximal humeral fracture sequelae)

BACKGROUND

The aim of this study was to evaluate the prognostic factors and limitations of anatomic unconstrained shoulder arthroplasty, performed without tuberosity osteotomy, for the treatment of secondary glenohumeral arthritis following posttraumatic cephalic collapse or necrosis of the humeral head, defined as type-1 fracture sequelae.

METHODS

Fifty-five patients with type-1 fracture sequelae treated with anatomic shoulder arthroplasty were included in this retrospective single-center cohort study. All anatomic humeral prostheses were implanted without performing a greater tuberosity osteotomy. Glenoid resurfacing was performed in forty-four patients (80%). Clinical and radiographic analysis was performed at a mean of fifty-two months (range, twenty-four to 180 months) postoperatively.

RESULTS

Four reoperations (7%) were performed, including two revisions in patients who required glenoid resurfacing because of glenoid erosion after hemiarthroplasty. At the time of the latest follow-up, 93% of patients were satisfied or very satisfied, and the mean Subjective Shoulder Value (SSV) was 81%. There were significant improvements in the mean Constant score (from 32 to 69 points), active anterior elevation (from 88° to 141°), external rotation (from 6° to 34°), and internal rotation (from the buttock to L3). Significantly poorer results were associated with proximal humeral deformity in varus and with fatty infiltration of the rotator cuff muscles. Patients with proximal humeral deformity, specifically varus or valgus malunion of the greater tuberosity, had a mean Constant score that was 10 points lower and active elevation that was almost 20° less than patients with no such deformity. The poorest results were observed in patients with varus malunion.

CONCLUSIONS

Our study confirmed that the outcomes of anatomic shoulder arthroplasty for the treatment of type-1 fracture sequelae are good and predictable when deformation of the proximal humerus is acceptable(i.e., when no greater tuberosity osteotomy is necessary). The results were negatively affected by proximal humeral varus deformity and by fatty infiltration of the rotator cuff on imaging studies. In such cases, reverse shoulder arthroplasty may be more appropriate, especially in elderly patients.

Proximal humeral malunion treated with reverse shoulder arthroplasty

BACKGROUND

The purpose of this study was to determine the outcomes of patients with proximal humeral malunions treated with reverse shoulder arthroplasty (RSA).

MATERIALS AND METHODS

Sixteen patients were treated with RSA for sequelae of a proximal humeral fracture with a malunion. Clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score, Simple Shoulder Test, visual analog scale [VAS] score for pain and function, range of motion, and patient satisfaction) and radiographs were evaluated at a minimum follow-up of 2 years. Wilcoxon signed-rank tests were used to analyze preoperative and postoperative data.

RESULTS

All patients required alteration of humeral preparation with increased retroversion of greater than 30°. The total ASES score improved from 28 to 63 (P = .001), ASES pain score from 15 to 35 (P = .003), ASES functional score from 15 to 27 (P = .015), VAS pain score from 7 to 3 (P = .003), VAS function score from 0 to 5 (P = .001), and Simple Shoulder Test score from 1 to 4 (P = .0015). Forward flexion improved from 53° to 105° (P = .002), abduction from 48° to 105° (P = .002), external rotation from 5° to 30° (P = .015), and internal rotation from S1 to L3 (P = .005). There were no major complications reported. Postoperative radiographic evaluation showed 2 patients with evidence of notching and 1 patient with proximal humeral bone resorption.

CONCLUSION

RSA is indicated for treating the most severe types of proximal humeral fracture sequelae. The results of RSA for proximal humeral malunions with altered surgical technique yield satisfactory outcomes in this difficult patient population.

The use of the Lima reverse shoulder arthroplasty for the treatment of fracture sequelae of the proximal humerus

BACKGROUND

Experience treating proximal humerus fracture sequelae with reverse total shoulder arthroplasty is limited. We report our results.

PATIENTS

Forty-four patients with sequelae of a proximal humeral fracture were treated with a reverse total shoulder prosthesis. There were 26 women and 18 men, with a mean age of 77 years (range, 74-84 years). The mean follow-up after reverse arthroplasty was 48 months (range, 40-84 months).

RESULTS

The mean Constant score increased from 28 preoperatively to 58 postoperatively (p < 0.0001). The average anterior elevation increased from 40° to 100° (p < 0.0001), abduction from 41° to 95° (p < 0.0001), external rotation from 15° to 35° (p < 0.0001) and internal rotation from 25° to 60° (p < 0.0001). The average subjective shoulder score increased from 13% preoperatively to 56% postoperatively (p < 0.0001). All but six patients would undergo the same procedure again if faced with the same problem. Twenty-four patients were very satisfied, 14 satisfied and 6 unhappy with the operation. Six prosthetic dislocations occurred (13.6%). Two of them were successfully treated by adding an extension to the humeral neck component to increase the offset and tension. In the other four dislocations this procedure failed, and the prosthesis was revised and converted to a hemiarthroplasty. There was one case of glenoid component loosening that was converted to a hemiarthroplasty.

CONCLUSIONS

The reverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae. However, the dislocation rate is high.

Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus

INTRODUCTION

Angular stable osteosynthesis has become the gold standard in the operative treatment of proximal humeral fractures. The aim of this article is to determine the indications for osteosynthesis versus primary arthroplasty based on clinical and radiological parameters.

METHODS

A total of 368 surgically treated proximal humeral fractures were reviewed. Preoperative X-rays were used to evaluate the displacement and vascularity of the humeral head (according to the Hertel criteria) and the AO (Arbeitsgemeinschaft für Osteosynthesefragen) fracture type. Postoperative X-rays were analysed to assess the quality of the reduction, the reconstruction of the medial hinge and the displacement of the tuberosities. Follow-up X-rays were used to evaluate healing progress, the occurrence of avascular necrosis, loss of reduction and implant related failures. The American Shoulder and Elbow Surgeons score (ASES score) was used to evaluate the functional outcome. Correlations between a set of variables, type of treatment and eventual outcome were verified in both univariate and multivariate settings, with the significance rate set at p<0.05.

RESULTS

In total, 307 shoulders were evaluated. Mean follow-up was 4.3 years and showed a 15.3% failure rate, a 23.8% re-operation rate and a mean ASES score of 75.3. Better results were noted in patients who were younger at the time of surgery. More displaced fractures, AO type C fractures, varus fracture configuration and reduced head vascularity all led to a worse outcome. Anatomical reduction correlated with better results. Articular fractures had better results when treated with a plate.

CONCLUSION

Surgical treatment of proximal humeral fractures remains difficult, with a failure rate of 15.3% and a re-operation rate of 23.8% at 4.3 years. A significantly displaced varus articular fracture in the older patient results in the worst outcome.

Total shoulder arthroplasty

Shoulder arthroplasty has been the subject of marked advances over the last few years. Modern implants provide a wide range of options, including resurfacing of the humeral head, anatomic hemiarthroplasty, total shoulder arthroplasty, reverse shoulder arthroplasty and trauma-specific implants for fractures and nonunions. Most humeral components achieve successful long-term fixation without bone cement. Cemented all-polyethylene glenoid components remain the standard for anatomic total shoulder arthroplasty. The results of shoulder arthroplasty vary depending on the underlying diagnosis, the condition of the soft-tissues, and the type of reconstruction. Total shoulder arthroplasty seems to provide the best outcome for patients with osteoarthritis and inflammatory arthropathy. The outcome of hemiarthroplasty for proximal humerus fractures is somewhat unpredictable, though it seems to have improved with the use of fracture-specific designs, more attention to tuberosity repair, and the selective use of reverse arthroplasty, as well as a shift in indications towards internal fixation. Reverse shoulder arthroplasty has become extremely popular for patients with cuff-tear arthropathy, and its indications have been expanded to the field of revision surgery. Overall, shoulder arthroplasty is a very successful procedure with predictable pain relief and substantial improvements in motion and function.

Results of a new stemless shoulder prosthesis: radiologic proof of maintained fixation and stability after a minimum of three years' follow-up

HYPOTHESIS

In total shoulder arthroplasty, the humeral component, particularly the stem, can be involved in some of the complications and technical difficulties increase in posttraumatic arthritis with proximal humeral malunion. To decrease the intraoperative complications related to the stem, the TESS (Biomet Inc, Warsaw, IN) humeral implant, was designed in 2004 hypothesis that we can obtain a good fixation with a stemless prosthesis. This investigation reports the preliminary results of this prosthesis with more than 3 years of follow-up.

METHODS

Between March 2004 and June 2005, 70 patients underwent 72 shoulder replacements with the TESS humeral prosthesis. Sixty-three patients were reviewed with a follow-up of more than 36 months (average, 45.2 months; range, 36-51 months). The mean preoperative Constant score was 29.6.

RESULTS

Gain in active mobility was 49 degrees for forward flexion and 20 degrees for external rotation. The postoperative Constant score was 75. Radiographic analysis showed no radiolucencies or implant migration. Functional results are comparable with previous reports on prosthetic glenohumeral replacement.

DISCUSSION

Our clinical results are similar to this with classical prosthesis. The humeral head removal facilitates the glenoid exposure and implantation. After the initial cases any specific complication was seen.

CONCLUSIONS

Owing to the automatic central positioning of the implant, an anatomic reconstruction was achieved. In malunions, no tuberosity osteotomy was required. At 3 years of follow-up, there is radiologic evidence of maintained implant stability. These encouraging preliminary results confirm our belief that a stemless prosthesis can be used to obtain an anatomic reconstruction of the proximal humerus. A longer-term follow-up study is needed to validate these results.

Hemiarthroplasty for proximal humerus fractures in patients with Parkinson's disease

BACKGROUND

Parkinson's disease is a relatively common problem in geriatric patients with an annual incidence rate of 20.5 per 100,000. These patients are at increased risk for falls and resultant fractures. Several reports suggest total shoulder arthroplasty in patients with fractures has a relatively high rate of complications. Whether hemiarthroplasty reduces the rate of complications or improves pain or function is not known.

QUESTIONS/PURPOSES

We therefore determined the ROM, pain, complications, and rate of failure of hemiarthroplasty for management of proximal humerus fractures in patients with Parkinson's disease.

PATIENTS AND METHODS

We retrospectively reviewed all eight hemiarthroplasties in patients with Parkinson's disease for fracture of the proximal humerus between 1978 and 2005. Seven patients (seven shoulders) had a minimum of 2 years followup (mean, 9.9 years; range, 2-16 years).

RESULTS

Postoperatively, the mean active abduction was 97 degrees , mean external rotation was 38 degrees , and internal rotation was a mean of being able to reach the level of the sacrum. The mean postoperative pain score was 2.5 points (on a scale of 1-5). There was a greater tuberosity nonunion in one patient and a superior malunion of the greater tuberosity in three patients. No patient had revision surgery.

CONCLUSIONS

The benefit of hemiarthroplasty for proximal humerus fractures in patients with Parkinson's disease was marginal with three shoulders in seven patients having moderate to severe persistent pain and limited function postoperatively.

LEVEL OF EVIDENCE

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

Survivorship of the humeral component in shoulder arthroplasty

BACKGROUND

Loosening of the humeral component is rarely a cause for revision. This study was conducted to determine long-term survivorship of humeral components and investigate the risk factors associated with humeral component removal or revision.

MATERIALS AND METHODS

From 1984 to 2004, 1423 patients underwent 1584 primary Neer and Cofield shoulder arthroplasties. The Kaplan-Meier method was used to estimate implant survival. Cox proportional hazards regression was used to assess the effects of age, gender, etiology of the disease, surgery type (hemi vs total), fixation (cemented vs noncemented), and the humeral component design (Neer II, Cofield 1 or 2) with survival free of revision or removal of the humeral component.

RESULTS

There were 108 revisions and 17 removals of the humeral component. Estimates of survivorship free of revision or removal of the humeral component for any reason was 94.8% (95% confidence interval [CI], 93.6-96.0) at 5 years, 92.0% (95% CI, 90.4-93.6) at 10 years, 86.7% (95% CI, 84.2-89.4) at 15 years, and 82.8% (95% CI, 78.5-87.5) at 20 years. Younger age, male gender, replacement due to posttraumatic arthritis, an uncemented component, and use of a metal-backed glenoid component increased the likelihood of humeral component failure.

CONCLUSIONS

The need for revision of the humeral component is commonly related to glenoid or glenoid component issues. Patient and diagnostic factors play a role in implant survival; implant type and method of fixation are less important.

LEVEL OF EVIDENCE

Level 4; Case series, treatment study.

In vitro quantitative assessment of total and bipolar shoulder arthroplasties: a biomechanical study using human cadaver shoulders

BACKGROUND

Glenohumeral arthroplasty has produced results far inferior to those seen with hip and knee joint procedures. Therefore, the objective of this study was to evaluate the biomechanical parameters of the glenohumeral joint before and after total shoulder arthroplasty and bipolar hemiarthroplasty in 12 different positions simulating overhead activities.

METHODS

Six matched pairs of cadaveric shoulders were used with a custom shoulder testing system to quantify the joint reactive force, contact areas, contact patterns and contact pressures in 12 different positions simulating overhead activities. The entire study was performed for the anatomic glenohumeral joint and following total shoulder arthroplasty on one side, and for the anatomic glenohumeral joint and following bipolar shoulder hemiarthroplasty on the contra-lateral side.

FINDINGS

There was a significant increase in posterior force following total shoulder arthroplasty in two positions of horizontal adduction (P<0.05). In positions of increased glenohumeral abduction and horizontal adduction, the contact pressures and patterns were greatly altered following both total shoulder arthroplasty and bipolar hemiarthroplasty procedures compared to the anatomic state.

INTERPRETATION

The alterations in joint reaction force, contact pressure and contact patterns following shoulder arthroplasty suggest a possible etiology for glenoid component edge loading in patients following total shoulder arthroplasty. This edge loading may lead to a rocking phenomenon of the glenoid component and subsequent loosening.

Shoulder arthroplasty: prosthetic options and indications

Glenohumeral arthropathy and failed shoulder arthroplasty can lead to debilitating pain, reduced motion and strength, and limited function. Primary osteoarthritis, posttraumatic osteoarthritis, rheumatoid arthritis, cuff tear arthropathy, and osteonecrosis are common in this patient population. Shoulder arthroplasty may fail because of problems with the prosthesis, such as wear, loosening, and dislocation of the components, or because of bone and soft-tissue problems, such as glenoid arthrosis and rotator cuff tear. The disparate pathogenesis of these processes presents unique challenges to the treating surgeon and requires diagnosis-specific treatment options, whether involving hemiarthroplasty, total shoulder arthroplasty, or reverse total shoulder arthroplasty. Until recently, prosthesis options were limited to a stemmed humeral component with or without a polyethylene glenoid component. The array of prosthetic options currently available allows individualized treatment.

Management of proximal humeral nonunions and malunions

Surgical treatment of proximal humeral nonunions and malunions are technically challenging. Osteosynthesis with bone grafting for the treatment of nonunions is indicated in young, active patients with adequate bone stock in the proximal fragment and preservation of the glenohumeral articular surfaces. Corrective osteotomy may be a reasonable option for proximal humeral malunions in young patients without evidence of degenerative joint disease. Arthroplasty for proximal humerus nonunions and malunions has a guarded outcome because of limitations in shoulder motion, but pain relief is more consistently improved upon.

Reverse shoulder arthroplasty for the treatment of rotator cuff deficiency

BACKGROUND

Early designs of reverse shoulder arthroplasty components for the treatment of glenohumeral arthritis associated with severe rotator cuff deficiency in some cases have been associated with mechanical failure. The purpose of this study was to perform a prospective outcomes study of reverse shoulder arthroplasty performed with use of 5.0-mm peripheral locking screws for baseplate fixation and a lateralized center of rotation for the treatment of a rotator cuff deficiency.

METHODS

From February 2004 to March 2005, 112 patients (114 shoulders) were treated with a reverse shoulder arthroplasty as part of a United States Food and Drug Administration Investigational Device Exemption study. Ninety-four patients (ninety-six shoulders) were available for a minimum follow-up of two years. Of the ninety-six shoulders, thirty-seven had a primary rotator cuff deficiency, thirty-three had a previous rotator cuff operation, twenty-three had a previous arthroplasty, and three had a proximal humeral nonunion. The patients were prospectively followed clinically (the American Shoulder and Elbow Surgeons [ASES] score, the Simple Shoulder Test [SST], and self-reported satisfaction) and radiographically (mechanical failure, loosening, and notching). Patients were videotaped while performing a standard active range-of-motion protocol before and after treatment. These videos were then analyzed in a blinded fashion by three independent observers using a digital goniometer.

RESULTS

At two years, the average total ASES scores had improved from 30 preoperatively to 77.6; the average ASES pain scores, from 15 to 41.6; and the average SST scores, from 1.8 to 6.8 (p < 0.0001 for all). Blinded analysis of range of motion showed that average abduction improved from 61 degrees preoperatively to 109.5 degrees (p < 0.0001); average flexion, from 63.5 degrees to 118 degrees (p < 0.0001); and average external rotation, from 13.4 degrees to 28.2 degrees (p < 0.0001). The patients rated the outcome as excellent in fifty-three shoulders (55%), good in twenty-six (27%), satisfactory in eleven (12%), and unsatisfactory in six (6%). There was no evidence of mechanical failure of the baseplate or scapular notching in any of the patients. Six of the ninety-four patients in this study had a complication.

CONCLUSIONS

Recent advances in reverse shoulder arthroplasty have allowed for improvement in patient outcomes while minimizing early mechanical failure and scapular notching and decreasing the overall complication rate at short-term follow-up.

Isolated tuberosity fractures of the proximal humeral: current concepts

Despite the relatively common occurrence of fractures of the proximal humeral amongst the elderly, the subgroup of isolated greater and lesser tuberosity fractures have remained less well understood. While the majority of two-part fractures result from a standing-height fall onto an outstretched hand, isolated tuberosity fractures are also commonly associated with glenohumeral dislocations or direct impact to the shoulder region. Inasmuch as isolated greater tuberosity fractures are considered uncommon, isolated lesser tuberosity fractures are generally considered exceedingly rare. Non-operative treatment including a specific rehabilitation protocol has been advocated for the majority of non-displaced and minimally displaced fractures, with generally good outcomes expected. The treatment for displaced fractures, however, has included both arthroscopically assisted fixation and open or percutaneous reduction and internal fixation (ORIF). The choice of fixation and approach depends not only on fracture type and characteristics, but also on a multitude of patient-related factors. With an expected increase in the level of physical activity across all age groups and overall longer lifespans, the incidence of isolated tuberosity fractures of the proximal humeral is expected to rise. Orthopaedic surgeons treating shoulder trauma should be aware of treatment options, as well as expected outcomes.

Shoulder hemiarthroplasty for acute fractures of the proximal humerus: a minimum five-year follow-up

Significant discrepancy in the functional outcome of hemiarthroplasty for proximal humerus fractures has been reported with short or mid-term follow-up. This study reports the long-term results and rate of complications of shoulder arthroplasty in the treatment of proximal humerus fractures. The review comprised 57 patients (44 women, 13 men) who underwent hemiarthroplasty between 1976 and 1996 as treatment of a proximal humerus fracture and who had a minimum 5-year follow-up (mean, 10.3 years). The mean patient age was 66 years at the time of surgery (range, 23-89 years). According to a modified Neer result rating system, results were satisfactory in 27 patients and unsatisfactory in 30. The mean active elevation was 100 degrees (range, 20 degrees -180 degrees ) and external rotation was 30 degrees (range, 0 degrees -90 degrees ). At the most recent follow-up, 9 patients (16%) had moderate or severe pain and 2 required implant revision or removal. The study data suggest that patients undergoing arthroplasty as treatment of an acute fracture of the proximal humerus may achieve satisfactory long-term pain relief; however, the result for overall shoulder motion is less predictable. In view of these results, current indications, surgical technique, and postoperative treatment may need to be revisited.