Preoperative factors associated with improvements in shoulder function after humeral hemiarthroplasty

Glenoid wear and its impact on clinical results after humeral head replacement using a single prosthesis in cuff tear arthropathy with more than 8 years of follow-up

BACKGROUND

Glenoid wear (GW) is a long-term complication after humeral head replacement (HHR) and is one of the major reasons for revision surgery. This study aimed to evaluate GW at >8 years of follow-up after HHR in patients with cuff tear arthropathy (CTA) by use of a modified classification of GW, to examine the relationship between GW and clinical outcomes, and to identify risk factors for GW progression.

METHODS

This retrospective case-series study included 34 shoulders that were monitored for >8 years after HHR in patients with CTA (13 men and 21 women; mean age at surgery, 70.9 years [range, 55-82 years]). Patients were monitored for a mean of 10.3 years (range, 8.1-13.2 years). GW was classified using plain radiographs as follows: grade 0, no remarkable postoperative changes; grade 1, postoperative glenohumeral joint space narrower than preoperative glenohumeral joint space; grade 2, contact between glenoid and humeral head prosthesis; and grade 3, glenoid erosion. Grade 3 cases were further classified into the following subtypes: grade 3A, partial erosion of anterior glenoid; grade 3B, partial erosion of superior glenoid; and grade 3C, concentric erosion of glenoid. Clinical outcomes including range of motion (active flexion and active external rotation) and postoperative pain (Constant score) were compared between grade 0-2 shoulders and grade 3 shoulders, as well as between the grade 3 subtypes. Age, sex, preoperative range of motion, preoperative pain, and number of ruptured tendons were analyzed as possible risk factors for progression to grade 3.

RESULTS

The final GW grade was grade 0 in 3 shoulders, grade 1 in 10, grade 2 in 6, and grade 3 in 15 (grade 3A in 2, grade 3B in 6, and grade 3C in 7). The grade 3 group had lower pain scores (10.7 ± 6.2 vs. 14.2 ± 1.9, P = .044) and limited active flexion (108.2° ± 42.3° vs. 140.6° ± 26.7°, P = .041) compared with the grade 0-2 group. Subtype comparison showed that the grade 3B group had lower pain scores (7.0 ± 6.7 vs. 15.0 ± 0.0, P = .007) and limited active flexion (80.0° ± 26.2° vs. 140.8° ± 27.5°, P = .010) compared with the grade 3C group. Limited preoperative active external rotation was an individual risk factor for grade 3 GW (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P = .009).

CONCLUSIONS

In the long term (>8 years) after HHR with tendon transfer in patients with CTA, patients with the development of grade 3C GW ultimately achieve pain relief even without revision surgery whereas grade 3B GW is associated with persistent pain and might require revision surgery.

Risk factors for eccentric glenoid wear after humeral head replacement for cuff tear arthropathy

Background

In our previous report, glenoid wear (GW) after humeral head replacement for cuff tear arthropathy was classified with modified Goya’s classification (grade 0-3), and, among 3 subtypes of grade 3 (glenoid bone erosion), grade 3B (superior eccentric erosion) showed significantly more pain and limited active flexion postoperatively compared to grade 3C (concentric erosion). The purpose of this study was to detect individual risk factors for the progression to grade 3B GW.

Methods

Seventy-nine shoulders in 70 patients who were followed up for a mean of 8.2 years (range, 5.0-13.2 years), including 29 men and 41 women, with a mean age at the surgery of 71.1 years (range, 54-87 years), were reviewed. Atrophy and fatty degeneration of torn cuff muscle, preoperative humeral head displacement (superior translation ratio [STR], anterior translation ratio, and other several parameters) on preoperative magnetic resonance imaging, and other individual factors were analyzed as possible risk factors.

Results

GW at the final follow-up was grade 0: 5 shoulders, grade 1: 17, grade 2: 20, and grade 3: 37 (3A: 4, 3B: 22, and 3C: 11). Preoperative higher STR was defined as a risk factor for grade 3 GW (odds ratio, 35.5; 95% confidence interval, 1.8-693.0; P = .018). Comparison among the three subtypes of grade 3 showed that patients with grade 3B GW had larger STR than 3C (41.4 ± 14.2% vs. 23.5 ± 13.3 % P = .006).

Conclusion

Patients with preoperative high STR are considered to have a risk for grade 3B GW, which possibly relates to poor clinical outcome and future revision.

The Recovery Curve of Anatomic Total Shoulder Arthroplasty for Primary Glenohumeral Osteoarthritis: Mid-term Results at a Minimum of 5 Years

Background

Excellent results have been reported for anatomic total shoulder arthroplasty (TSA) for the treatment of primary glenohumeral osteoarthritis (GHOA). We aim to assess the recovery curve and longitudinal effects of time, age, sex, and glenoid morphology on patient-reported outcomes (PROs) after primary anatomic TSA for primary GHOA.

Methods

Patients who underwent primary anatomic TSA over 5 years ago were included: Short-Form 12 Physical Component Summary, American Shoulder and Elbow Surgeons scores, Quick Disabilities of the Arm Shoulder and Hand Score, Single Assessment Numeric Evaluation, and patient satisfaction were assessed. Linear mixed-effects models were used to model progression in PROs longitudinally. Unadjusted models and models controlling for sex and age were constructed.

Results

Eighty-one patients (91 shoulders) were included. Significant improvements from the preoperative period to 1 year postoperatively in the median American Shoulder and Elbow Surgeons (48 to 93; P < .001), Quick Disabilities of the Arm Shoulder and Hand Score (42 to 11; P < .001), Single Assessment Numeric Evaluation (50 to 91; P < .001), and Short-Form 12 Physical Component Summary (35 to 53; P = .004) scores were noted. No significant decrease was observed for any of the outcome scores. Median satisfaction at the final follow-up was 10 out of 10. At 1, 2, 3, 4, 5, 6, and 7 years postoperatively, 77%, 64%, 79%, 57%, 86%, 56%, and 78% of patients, respectively, reported sports participation equal to or slightly below preinjury level. There was no association between the glenoid morphology and functional outcomes.

Conclusion

Patients undergoing anatomic TSA for primary GHOA showed excellent improvement in PROs and satisfaction in the first year, and these results were maintained postoperatively for a minimum of 5 years. Age- and sex-adjusted models or glenoid morphology did not substantially alter any trends in PROs postoperatively.

Substantial clinical benefit, responsiveness, and sensitivity to change of three common outcome measures following shoulder arthroplasty

Objectives:

It is important for clinicians involved in the care of patients with advanced glenohumeral osteoarthritis to determine clinically significant change when using outcome measures. There is little information on the amount of substantial clinical benefit in shoulder outcomes after shoulder arthroplasty. The purpose of this study was twofold: (1) to quantify substantial clinical benefit for the American Shoulder and Elbow Surgery score, the Constant Murley Score, and the Western Ontario Osteoarthritis of the Shoulder index and (2) to provide estimates of responsiveness and sensitivity to change for these measures following shoulder arthroplasty.

Methods:

The study involved a secondary analysis of previously collected data. The substantial clinical benefit and responsiveness of the measures were calculated based on external anchors related to change in pain, range of motion, and ability to carry out activities of daily living. The areas under curve and standardized response mean represented responsiveness and sensitivity to change.

Results:

The data of 159 and 131 patients with complete follow-up at 6 months and 2 years were reviewed. The amount of substantial clinical benefit was dependent on the outcome measure and the external anchor and increased for all measures from 6 months to 2 years. Responsiveness was high (areas under curve > 0.80) at 6 months and further improved at 2 years (areas under curve > 0.88). The standardized response mean values of both time points were over 2.00, indicating high effect sizes. The standardized response means of the Constant Murley Score were statistically significantly higher than the standardized response means of the American Shoulder and Elbow Surgery and Western Ontario Osteoarthritis of the Shoulder.

Conclusion:

Amount of substantial clinical improvement in pain, range of motion, and activities of daily living following shoulder arthroplasty depends on the type of outcome measure used. All three measures, the American Shoulder and Elbow Surgery, absolute and relative Constant Murley Score, and Western Ontario Osteoarthritis of the Shoulder, demonstrated good to excellent accuracy and optimal standardized response means.

Level of evidence:

Level III, Retrospective Cohort study

Clinical effectiveness and safety of the extended humeral head arthroplasty for selected patients with rotator cuff tear arthropathy

BACKGROUND

Cuff tear arthropathy is commonly managed with a reverse total shoulder arthroplasty (RTSA). A humeral hemiarthroplasty with an extended humeral head may provide a less invasive alternative for selected patients with cuff tear arthropathy if the shoulder has preserved active elevation. Because evidence regarding this procedure is limited, we investigated its safety and efficacy in treating selected patients with cuff tear arthropathy.

METHODS

We analyzed the preoperative characteristics, surgical findings, and clinical outcomes for patients selected for extended head hemiarthroplasty.

RESULTS

For 42 patients with 2-year follow-up, there were no complications or revisions. The Simple Shoulder Test score improved from a median of 3.0 to 8.0 (P < .001). The median percentage of maximal possible improvement was 50% (P < .001). The percentage of patients able to perform each of the functions of the Simple Shoulder Test was significantly improved; for example, the ability to sleep comfortably increased from 19% to 71%, and the ability to place a coin on the shelf at shoulder level increased from 38% to 86% (P < .001).

CONCLUSIONS

There are circumstances in which RTSA is clearly the preferred procedure for cuff tear arthropathy, including pseudoparalysis, anterosuperior escape, and glenohumeral instability; however, in shoulders with preserved active motion and stability of the humeral head provided by an intact coracoacromial arch, the extended head humeral arthroplasty can enable selected patients to realize improved comfort and function without the potential risks of RTSA. Extended humeral head hemiarthroplasty can provide a safe and effective alternative for the management of selected patients with rotator cuff tear arthropathy and preserved active motion.

Thirty-day Complications and Readmission Rates in Elderly Patients After Shoulder Arthroplasty

Introduction

Shoulder arthroplasty procedures are increasingly being performed in older patients despite an increased perioperative risk. The purpose of this study is to determine the complications and 30-day readmission rates in the elderly population after shoulder arthroplasty and hemiarthroplasty.

Methods

Total shoulder arthroplasty, reverse total shoulder arthroplasty, and hemiarthroplasty cases were collected from the National Surgical Quality Improvement Program database from 2006 to 2015. The 30-day complication and readmission rates, surgical time, discharge destination, and total hospital length of stay were calculated, comparing patients by age (elderly: ≥80 years; older: 65 to 79 years; younger: <65 years). Multivariable logistic regression analysis was performed to identify variables associated with any complication within 30 days of surgery.

Results

Of 11,450 patients, 1,956 (17.1%) underwent shoulder hemiarthroplasty and 9,494 (82.9%) underwent total shoulder arthroplasty. By age group, 1,708 (14.9%) were ≥80, 6,073 (53.0%) were 65 to 79, and 3,669 (32.0%) were <65. The overall 30-day postoperative complication rate was significantly higher in elderly patients (15.3% versus 8.2% versus 6.8%; P < 0.001), length of stay (2.6 versus 2.1 versus 1.8 days; P < 0.001), and unplanned readmissions (5.5% versus 2.6% versus 2.3%; P < 0.001). The strongest independent variables significantly associated with any complication included revision arthroplasty indication (odds ratio [OR], 4.34; P < 0.001), fracture indication (OR, 4.14; P < 0.001), and history of cardiac disease (OR, 2.33; P < 0.001), followed by elderly age (OR, 2.01; P < 0.001).

Conclusions

The 15.3% complication rate (major, 4.8%; minor, 10.7%), 2.6 days of average length of stay, and 5.5% unplanned readmission among elderly patients (>80) are significantly higher than younger patients. Although surgical indications and comorbidities are higher-quality predictors of complications, elderly patients should be appropriately counseled and medically optimized according to the perioperative risk profile before surgery.

Neuropathic Pain after Shoulder Arthroplasty: Prevalence, Impact on Physical and Mental Function, and Demographic Determinants

Purpose: The objectives of this survey study were to provide an estimate of the prevalence of neuropathic pain (NP) and to explore the cross-sectional and longitudinal group differences postoperatively. Method: A cohort of consecutive patients who had undergone total shoulder arthroplasty (TSA), reverse shoulder arthroplasty (RSA), or humeral head replacement (HHR) were surveyed within an average of 3.8 years after surgery. Questionnaires completed at the time of the survey were the Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) pain scale, the visual analogue scale (VAS) for pain, the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, the Patient Health Questionnaire-9 (PHQ-9), and a satisfaction questionnaire. Results: Of the 141 candidates who were invited to participate in the study, 115 patients participated (85 TSA, 21 HHR, and 9 RSA), for an 82% response rate. Five patients (4%) met the criteria for NP, of whom one had a loosening of the prosthesis and required further surgery. Having NP was associated with greater pain (VAS; p=0.001), greater depression (PHQ-9; p=0.001), more disability (WOOS; p=0.030), and less satisfaction with the surgery (p=0.014). There was no relationship between the presence of NP and patients' age, sex, preoperative pain, range of motion results, or WOOS scores (p>0.05). Conclusions: Persistent pain of neuropathic origin is not common after shoulder arthroplasty, but it is a significant contributor to poor mental and physical well-being and thus warrants further research.

Primary Shoulder Hemiarthroplasty: What Can Be Learned From 359 Cases That Were Surgically Revised?

BACKGROUND

Primary shoulder hemiarthroplasty is used to address a range of glenohumeral disorders, including fracture, arthritis, avascular necrosis, and capsulorrhaphy arthropathy; some patients with hemiarthroplasties undergo revision surgery for persistent pain or residual shoulder dysfunction. The literature does not clarify the features of the hemiarthroplasties having repeat surgery in a way that can guide surgeons' efforts to minimize the need for revision. To help address this gap, we analyzed the characteristics of patients from our region for whom we performed surgical revision of a prior humeral hemiarthroplasty QUESTIONS/PURPOSES: (1) What are the common characteristics of shoulder hemiarthroplasties having a revision? (2) What are the common characteristics of the subset of revised shoulder hemiarthroplasties that were performed for fracture? (3) What are characteristics of the subset of all revised hemiarthroplasties that were associated with glenoid bone erosion?

METHODS

Data for 983 patients for whom we performed a surgical revision of any type of shoulder arthroplasty between January 1991 and January 2017 were identified in our longitudinally maintained institutional arthroplasty revision database. In each case, revision had been elected by shared patient and surgeon decision-making after consideration of the disorder, degree of compromised comfort and function, treatment alternatives, and the risks of surgery. Of these 983 patients, 359 (37%) had a revision of a prior primary hemiarthroplasty; these patients were the subjects of this investigation. In this group of patients, we investigated the patient demographics, shoulder characteristics, prerevision radiographic findings, and findings at revision surgery. No patients were excluded. The patients having revision of primary hemiarthroplasties had severe loss of self-assessed shoulder comfort and function, with Simple Shoulder Test (SST) scores averaging 2.2 ± 2.2 of the maximum score of 12. The majority of these patients (81%) were women. The medical records of these 359 patients were abstracted to determine the diagnosis for the index primary hemiarthroplasty, clinical characteristics before surgery, and findings at surgical revision. One hundred twelve of the arthroplasties had been performed for fracture-related diagnoses; a subgroup analysis was performed on these patients. Two hundred seventy-three of the 359 patients (76%) had plain radiographs performed within 3 months before revision surgery that were adequate for assessing the radiographic characteristics of the glenoid, humerus, humeral component, and glenohumeral relationships; a subgroup analysis was performed on these patients. The degree of glenoid erosion was measured by a single observer in accordance with established criteria: Grade 1 is no erosion, Grade 2 is erosion limited to subchondral bone, Grade 3 is moderate erosion with medialization, and Grade 4 is medialization beyond the coracoid base. Some patients were included in both of these subgroups.

RESULTS

Common characteristics of the revised hemiarthroplasties included female sex (81%), rotator cuff (89 of 359; 25%) or subscapularis (81 of 359; 23%) failure, problems related to prior fracture (154 of 359; 43%), glenoid erosion 125 of 359; 35%), and component malposition (89 of 359; 25%). Hemiarthroplasties performed for fracture-related problems often were associated with tuberosity malunion or nonunion (58 of 79; 73%) and decentering of the humeral component on the glenoid surface (45 of 71; 63%). Major erosion of the bony glenoid (Grade 3 or 4) was more common in decentered hemiarthroplasties (42 of 102; 41%) than for centered hemiarthroplasties (36 of 146; 25%) (Fisher's exact p = 0.008) and more common for hemiarthroplasties positioned in valgus (28 of 50; 56%) than for those positioned in neutral or varus (40 of 188; 21%) (Fishers' exact p < 0.0001).

CONCLUSIONS

These findings suggest that some revisions of primary hemiarthroplasties may be avoided by surgical techniques directed at centering the prosthetic humeral articular surface on the glenoid concavity using proper humeral component positioning and soft tissue balance, by avoiding valgus positioning of the humeral component, and by managing glenoid disorders with a primary glenohumeral arthroplasty rather than a hemiarthroplasty alone. When durable security of the subscapularis, rotator cuff, and tuberosities is in question, the surgeon may consider a reverse total shoulder arthroplasty.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Rotator cuff surgery in patients with rheumatoid arthritis: clinical outcome comparable to age, sex and tear size matched non-rheumatoid patients

Aims This study aimed to compare the clinical outcomes of rotator cuff repair in patients with rheumatoid arthritis with those of patients who have no known history of the disease. We hypothesised that the functional outcomes are comparable between patients and without rheumatoid arthritis and may be affected by the level of disease activity, as assessed from C-reactive protein (CRP) level and history of systemic steroid intake. Patients and methods We conducted a retrospective review of the institutional surgical database from May 1995 to April 2012. Twenty-nine patients with rheumatoid arthritis who had rotator cuff repair were enrolled as the study group. Age, sex, and tear size matched patients with no disease who were selected as the control group. The mean duration of follow-up was 46 months (range 24-92 months). Clinical outcomes were assessed with the American Shoulder and Elbow Surgeons (ASES) questionnaire, Constant score and visual analogue scale (VAS). All data were recorded preoperatively and at regular postoperative follow-up visits. CRP was measured preoperatively as the disease activity marker for rheumatoid arthritis. Medication history was thoroughly reviewed in the study group. Results In patients with rheumatoid arthritis, all shoulder functional scores improved after surgery (ASES 56.1-78.1, Constant 50.8-70.5 and VAS 5.2-2.5; P < 0.001). The functional outcome of surgery in patients with rheumatoid arthritis was comparable to that of the control group (difference with control: ASES 78.1 vs. 85.5, P = 0.093; Constant 70.5 vs. 75.9, P = 0.366; VAS 2.5 vs. 1.8, P = 0.108). Patients with rheumatoid arthritis who had an elevated CRP level (> 1 mg/dl) showed inferior clinical outcomes than those with normal CRP levels. Patients with a history of systemic steroid intake showed inferior functional outcomes than those who had not taken steroids. Conclusions Surgical intervention for rotator cuff tear in patients with rheumatoid arthritis improved the shoulder functional outcome comparable to that in matched patients without rheumatoid arthritis. Elevated preoperative CRP level and history of systemic steroid intake portend inferior functional outcome in patients with rheumatoid arthritis.

Cuff tear arthropathy shoulder hemiarthroplasty: a radiographic outcome study

OBJECTIVE

Cuff tear arthropathy (CTA) head prosthesis has recently become an alternative to standard shoulder hemiarthroplasty in patients with severe cuff disease by offering an increased surface area and decreased impingement. The purpose of this study is to evaluate the radiographic outcomes of CTA prosthesis and to correlate them with clinical outcomes.

MATERIALS AND METHODS

In this retrospective study of CTA hemiarthroplasties over an 11-year period, two radiologists reviewed pre-/postoperative radiographs and clinical data. Radiographic complications were correlated with subsequent surgery using Cox regression models. Rates of surgical revision and radiographic complications over time were estimated using Kaplan-Meier curves.

RESULTS

Ninety-seven CTA hemiarthroplasties were identified in 92 patients (5 bilateral) with a mean patient age of 68.7 years. Mean radiographic follow-up was 12 months with a mean of 3.3 radiographs per prosthesis. Twenty-six arthroplasties (26.8%) experienced at least one radiographic complication, including acromion remodeling (19.5%), anterior-posterior subluxation (5.2%), periprosthetic fracture (4.1%), glenoid remodeling (3.1%), hardware loosening (2.1%), superior subluxation (2.1%), and subsidence (1.0%). Eight cases underwent revision surgery (8.2%). The occurrence of a postoperative radiographic complication was associated with increased risk of surgical revision (hazard ratio 11.5, 95% CI: 2.4-55.7, p = 0.002); 73.5% of radiographic complications occurred by 3 months after the initial surgery (complication rate of 23.3%) based on Kaplan-Meier curve analysis.

CONCLUSION

Radiographic complications after CTA head hemiarthroplasty are common with most occurring by 3 months after surgery and are highly associated with surgical revision.

Use of cuff tear arthroplasty head prosthesis for rotator cuff arthropathy treatment in elderly patients with comorbidities

Objective

To evaluate the clinical and functional behavior of patients undergoing cuff tear arthroplasty at different stages of the disease.

Methods

Cuff tear arthroplasty hemiarthroplasties were performed in 34 patients with rotator cuff arthropathy and associated comorbidities, classified according to Seebauer. The mean age was 76.3 years, and the sample comprised 23 females (67.6%) and 11 males (32.4%). The mean follow-up period was 21.7 months, and evaluations were performed using the Visual Analog Scale for pain and the Constant scale.

Results

There were no statistically significant differences in the mean reduction in the Visual Analog Scale or in the Constant scale increase between the female and male groups. The variation between the pre- and postoperative Visual Analog Scale and Constant scale evaluations was significant. There was also no statistically significant difference between the Seebauer classification groups regarding the mean Visual Analog Scale reduction, or the mean Constant scale increase.

Conclusion

Cuff tear arthroplasty shoulder hemiarthroplasty is a good option for rotator cuff arthropathy in patients with comorbidities.

Risk factors for glenoid erosion in patients with shoulder hemiarthroplasty: an analysis of 118 cases

BACKGROUND

Glenoid erosion is one of the main concerns in shoulder hemiarthroplasty. The goal of this study was to quantify glenoid erosion and to identify risk factors in patients with humeral hemiarthroplasty.

METHODS

There were 118 shoulders in 113 patients available for a standardized retrospective review. Erosion was graded as follows: grade 1, none; grade 2, mild (erosion into subchondral bone); grade 3, moderate (medialization of subchondral bone with hemispheric deformation); or grade 4, severe. The findings were then analyzed for confounding factors using a multivariate analysis.

RESULTS

Mean follow-up was 31 months (range, 5-86 months). Negative predisposing factors for erosion were glenoid cysts (odds ratio, 5.4; P < .001, approximately 3 times more frequent in women), fatty infiltration of the rotator cuff musculature (R, 0.43; P < .001), and rheumatoid arthritis (odds ratio, 3.6; P = .049). A valgus position of the prosthetic head relative to the glenoid (angle >50°) appeared to lead to local destruction of the cartilage. The degree of erosion did not correlate with age and glenoid or humeral head size. Only 1 patient (of 30) with a fracture-type prosthesis developed progressive glenoid erosion.

CONCLUSION

In this series, favorable conditions for resistance to erosion after hemiarthroplasty were lack of glenoid cysts, intact glenoid cartilage, intact rotator cuff musculature, and a fracture situation. Age, the version of the glenoid, and the size of the prosthetic head showed no importance. The use of hemiarthroplasty seems to be associated with glenoid destruction in female patients with impending osteoarthritis, with rheumatoid arthritis, and if the head is implanted in a valgus position.

Predictors of medium-term clinical outcomes after total shoulder arthroplasty

PURPOSE

The study aims to measure the relationship of potential clinical and radiographic predictors and medium-term clinical outcomes after total shoulder arthroplasty in primary osteoarthritis.

MATERIALS AND METHODS

In a prospective follow-up study, preoperatively collected clinical and radiographic variables were recorded in 103 patients with an average age of 66 years (range 37-83 years) to measure their influence on the clinical outcome by use of the Constant score. The average length of follow-up was 6 years (range 3-12 years). Radiographs and a computed tomography (CT) of the shoulders were obtained preoperatively for evaluating the acromiohumeral distance, the lateral glenohumeral offset and the morphology of the glenoid, which was classified according to the method by Walch (type-A1 to type-C glenoids).

RESULTS

The mean Constant score improved from its preoperative value of 25 points (range 6-54 points) to 65 points (range 10-86 points) postoperatively (p < 0.001). The mean age- and sex-normalized Constant score was similarly improved from 34 points (range 8-78 points) preoperatively to 90 points (range 14-130 points) at the time of follow-up (p < 0.001). The Walch classification of glenoid wear had a significant negative effect (r = -0.32, p < 0.001). The other predictors showed no significant influence on the Constant score (p > 0.05).

CONCLUSION

A higher Walch classification is a negative predictor for the postoperative clinical function. The proven significant negative effect  on outcomes in total shoulder arthroplasty emphasizes the importance of the preoperative evaluation of humeral head subluxation and glenoid erosion, which are associated with less favorable postoperative results. The measured internal patient variables gave no negative predictions on the medium-term clinical outcomes in the study population.

A prospective multi-site registry study of a specific protocol of autologous bone marrow concentrate for the treatment of shoulder rotator cuff tears and osteoarthritis

INTRODUCTION

Shoulder pain is a common musculoskeletal complaint in the general population. Bone marrow concentrate (BMC) injections offer promising potential as a minimally invasive approach for treatment of shoulder pain in degenerative disease. In this study, we investigated the clinical outcomes of the BMC injections for treatment of shoulder pain and disability due to osteoarthritis (OA) and rotator cuff tears in a treatment registry population.

METHODS

A total of 115 shoulders in 102 patients were treated with autologous BMC injections for symptomatic OA at the glenohumeral joint and/or rotator cuff tears. Data were collected for factors potentially influencing outcome, including age, sex, body mass index, and the type of condition treated (ie, OA or rotator cuff tear). Clinical outcomes were assessed serially over time using the disabilities of the arm, shoulder and hand score (DASH), the numeric pain scale (NPS), and a subjective improvement rating scale. Baseline scores were compared to the most recent outcome scores at the time of the analysis and adjusted for demographic differences. We reported comparisons of pre- and post-treatment scores, the differences between osteoarthritis and rotator cuff groups, and the predictive effects on the clinical outcomes.

RESULTS

At the most current follow-up assessment after treatment, the average DASH score decreased (improved) from 36.1 to 17.1 (P<0.001) and the average numeric pain scale value decreased (improved) from 4.3 to 2.4 (P<0.001). These changes were associated with an average subjective improvement of 48.8%. No differences were observed between outcomes among the shoulders treated for OA versus rotator cuff tears, nor did age, sex, or body mass index influence pain or functional outcomes. There were no significant treatment-related adverse events reported.

DISCUSSION

We observed preliminarily encouraging results following BMC injections for shoulder OA and rotator cuff tears. These results serve as basis for the design of an adequately powered randomized controlled trial.

Anatomic shoulder arthroplasty: an update on indications, technique, results and complication rates

A shoulder replacement is indicated in patients affected by glenohumeral arthropathy with severely reduced range of motion, persistent pain, especially at night, and loss of strength. There is much discussion in the scientific community about the prosthetic options for these cases: hemiarthroplasty, anatomic total shoulder arthroplasty, and reverse total shoulder arthroplasty. We analyzed the indications for, results of, and complications associated with this kind of surgery, focusing on anatomic arthroplasty and on the concept of modularity.

The use of shoulder hemiarthroplasty and humeral head resurfacing: a review of current concepts

Since Neer's early work in the 1950s shoulder arthroplasty has evolved as a treatment option for various glenohumeral joint disorders. Both hemiarthroplasty and total shoulder prostheses have associated problems. This has led to further work with regards to potential resurfacing, with the aim of accurately restoring native proximal humeral anatomy while preserving bone stock for later procedures if required. Hemiarthroplasty remains a valuable treatment option in the low demand patient or in the trauma setting. Additional work is required to further define the role of humeral resurfacing, with the potential for it to become the gold standard for younger patients with isolated humeral head arthritis.

Stemless shoulder prosthesis versus conventional anatomic shoulder prosthesis in patients with osteoarthritis: a comparison of the functional outcome after a minimum of two years follow-up

Background

The stemless shoulder prosthesis is a new concept in shoulder arthroplasty. To date, only a few studies have investigated the results of this prosthesis. The aim of this study was to investigate the clinical and radiological midterm results of this implant in comparison with a standard anatomic stemmed shoulder prosthesis.

Materials and methods

The Constant score, the DASH score, the active range of motion (abduction, anteversion, external rotation), and the radiological results were examined in 82 patients with primary osteoarthritis of the shoulder treated with either the Total Evolutive Shoulder System^® (Biomed, France) stemless shoulder prosthesis or the Affinis^® (Mathys, Switzerland) stemmed shoulder prosthesis to detect possible differences in the functional outcome and to evaluate radiological properties of the implants. Patients were examined before and 32 ± 4 months after surgery.

Results

There was no significant difference in the Constant scores of the groups treated with the stemless shoulder prosthesis (65.0 ± 11.0 points) and the stemmed shoulder prosthesis (73.2 ± 11.3 points; P = 0.162). The estimated blood loss (P = 0.026) and the mean operative time (P = 0.002) were significantly lower in the group with the stemless shoulder prosthesis.

Conclusions

The use of the stemless shoulder prosthesis yielded good results which, in a mid-term follow-up, were comparable with those provided by a standard anatomic shoulder prosthesis. Further investigations are needed regarding the long-term performance of this prosthesis.

The prognosis for improvement in comfort and function after the ream-and-run arthroplasty for glenohumeral arthritis: an analysis of 176 consecutive cases

BACKGROUND

Knowledge of the factors affecting the prognosis for improvement in function and comfort with time after shoulder arthroplasty is important to clinical decision-making. This study sought to identify some of these factors in 176 consecutive patients undergoing the ream-and-run procedure.

METHODS

The time course for improvement in patient function and comfort was determined for the entire group as well as for subsets by sex, age, diagnosis, preoperative function, and surgery date. Patients having repeat surgery were analyzed in detail.

RESULTS

Shoulder comfort and function increased progressively after the ream-and-run procedure, reaching a steady state by approximately twenty months. The shoulders in 124 patients with at least two years of follow-up were improved by a minimal clinically important difference. The shoulders in sixteen patients with at least two years of follow-up were not improved by the minimal clinically important difference. Twenty-two patients had repeat procedures, but only seven had revision to a total shoulder arthroplasty. Fourteen patients did not have either a known revision arthroplasty or two years of follow-up. The best prognosis was for male patients over the age of sixty years, with primary osteoarthritis, no prior surgical procedures, a preoperative score on the simple shoulder test of ≥5 points, and surgery after 2004. Repeat surgical procedures were more common in patients who had a greater number of surgical procedures before the ream-and-run surgery.

CONCLUSIONS

This study is unique in that it characterizes the factors affecting the time course for improvement in shoulder comfort and function after a ream-and-run procedure. Improvement occurs after this procedure for at least 1.5 years. This procedure appears to be best suited for an older male patient with reasonable preoperative shoulder function without prior shoulder surgery.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for authors for a complete description of levels of evidence.

The glenoid in total shoulder arthroplasty

Management of glenohumeral arthrosis with a total shoulder prosthesis is becoming increasingly common. However, failure of the glenoid component remains one of the most common causes for failure. Our understanding of this problem has evolved greatly since the first implants were placed in the 1970's. However glenoid failure remains a challenging problem to address and manage. This article reviews the current knowledge regarding the glenoid in total shoulder arthroplasty touching on anatomy, component design, implant fixation, causes of implant failure, management of glenoid failure and alternatives to glenoid replacement.

Management of glenohumeral arthritis in the young adult

The majority of cases of glenohumeral arthritis in older adults are primary osteoarthritis and treatment algorithms are well defined, with shoulder arthroplasty providing reliable pain relief and functional improvement of satisfactorily duration. In younger adults, however, diagnoses are more complex and arthroplasty outcomes are less durable. Arthroscopy may be useful both as a diagnostic tool for characterizing lesions and as a therapeutic tool for debridement. Arthroscopic debridement is most likely to benefit patients with mild glenohumeral arthritis, small lesions, and involvement of only one side of the glenohumeral joint. Reconstruction of the humeral joint surface may consist of cartilage repair or reconstruction, resurfacing arthroplasty, or arthroplasty with a stemmed component. Patients treated with hemiarthroplasty avoid glenoid implant loosening, but the procedure provides less predictable pain relief than does total shoulder arthroplasty and may lead to increased postoperative glenoid erosion.

Surgical interventions for the rheumatoid shoulder

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Comparison of patients undergoing primary shoulder arthroplasty before and after the age of fifty

BACKGROUND

The reported outcomes of shoulder arthroplasty in patients under the age of fifty years are worse than those in patients over fifty. While there are several possible explanations for this finding, we explored the possibility that patients who had a primary shoulder arthroplasty when they were under fifty years of age differed from those who had the procedure when they were over fifty with respect to their pre-arthroplasty self-assessed comfort and function, sex distribution, and specific type of arthritis.

METHODS

The study group consisted of patients with glenohumeral arthritis who were treated with a primary shoulder arthroplasty by the same surgeon between 1990 and 2008. For each decade of age, the sex distribution, the pre-arthroplasty self-assessed shoulder comfort and function, and the prevalence of twelve different diagnoses were documented. We reviewed the series for three potential causes of worse outcomes in patients under fifty years of age as compared with those over fifty years of age: (1) a higher percentage of women, (2) a lower score for pre-arthroplasty self-assessed comfort and function, and (3) more complex pathological conditions.

RESULTS

Patients under the age of fifty years were not more likely than those over fifty to be female or to have a lower pre-arthroplasty self-assessed comfort and function score, but they did have more complex pathological conditions, such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic arthritis. Only 21% of the younger patients had primary degenerative joint disease, whereas 66% of the older patients had that diagnosis. This difference was significant (p < 0.000000001).

CONCLUSIONS

Surgeons performing shoulder arthroplasty in individuals under the age of fifty should be prepared to encounter pathological conditions such as capsulorrhaphy arthropathy, rheumatoid arthritis, and posttraumatic arthritis rather than primary osteoarthritis, which is more common in individuals older than fifty. The pathoanatomy in these younger patients may complicate the surgery, the rehabilitation, and the outcome of the shoulder arthroplasty.

Osteonecrosis of the humeral head

Osteonecrosis of the humeral head is considerably less common than osteonecrosis of the hip. However, as in the hip, the interaction between a genetic predisposition and certain risk factors may lead to increased intraosseous pressure, loss of circulation, and eventual bone death. The most common risk factor remains corticosteroid use, which accounts for most reported cases. Radiographic staging and measurement of lesion size are predictive of disease progression and can be used to determine appropriate intervention. Recent studies have reported the use of various treatment modalities such as pharmacologics, core decompression with small-diameter drilling, arthroscopic-assisted core decompression, and bone grafting. Prospective, randomized studies are needed to determine the efficacy of these joint-preserving procedures. Newer resurfacing techniques have a role in treating articular surface loss. Hemiarthroplasty and total shoulder arthroplasty are recommended for patients with end-stage disease.

Chronic locked posterior shoulder dislocation with severe head involvement

Arthroplasty is the treatment of choice for severely damaged humeral heads in chronic locked posterior dislocation of the shoulder. We retrospectively reviewed the results of 12 shoulder arthroplasties (11 patients) between 1999 and 2005. Mean follow-up was 37.4 +/- 16.8 months. Mean postoperative Constant score (CS) was 59.4 +/- 21.6 (normative age and gender-related CS 67.1 +/- 24). There was a significant improvement in range of motion for flexion, abduction and external rotation. There was negative correlation (Pearson's coefficient) between the related CS and number of previous operations, pain and duration of symptoms. One patient underwent revision surgery 36 months postoperatively with polyethylene insert exchange. There were two patients with mild and one with severe migration of the humeral head. Shoulder arthroplasty resulted in good midterm results for this patient group with benefits for range of motion, pain and patient satisfaction.

Shoulder hemiarthroplasty for steroid-associated osteonecrosis

Currently, there is little information on the outcome of humeral head replacement for steroid-associated osteonecrosis of the humeral head. The purpose of this study was to evaluate the outcome of patients who underwent humeral head replacement for steroid-associated osteonecrosis to determine the results, risk factors for an unsatisfactory outcome, and rates of revision surgery. Between 1980 and 2000, 32 shoulder hemiarthroplasties were performed for steroid-associated osteonecrosis. We included 31 hemiarthroplasties in 25 patients with a minimum 2-year follow-up (mean, 12.0 years) in the study. The mean age of the 23 female and 9 male patients was 49.4 years at the time of surgery (range, 25-86 years). Overall, mean pain scores decreased from 4.6 to 2.6 (P < .0001). However, moderate or severe pain was reported in 12 shoulders (38%) at the most recent follow-up, 2 of them requiring implant revision. The mean preoperative to postoperative active elevation increased from 92 degrees to 139 degrees (P < .0001), and external rotation increased from 36 degrees to 65 degrees (P < .0001). According to a modified Neer result rating system, there were 13 excellent results (42%), 4 satisfactory results (13%), and 14 unsatisfactory results (45%). Improvement in pain and function most often occurred after hemiarthroplasty as a treatment for steroid-associated osteonecrosis of the humeral head. However, there are a large number of unsatisfactory results related to glenoid cartilage wear over time.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Inter-rater reliability of an arthritic glenoid morphology classification system

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

Hemiarthroplasty for the rotator cuff-deficient shoulder

BACKGROUND

Hemiarthroplasty is a common treatment for cuff tear arthropathy and glenohumeral arthritis associated with a massive tear of the rotator cuff; however, to our knowledge, long-term outcomes and preoperative factors affecting results have not been reported.

METHODS

Thirty-four shoulders in thirty-one patients with cuff tear arthropathy or a massive rotator cuff tear with glenohumeral arthritis underwent hemiarthroplasty at an average age of seventy-two years. Outcomes in all patients were evaluated by direct physical examination and according to the limited goals criteria of Neer et al. at a mean of 3.7 years postoperatively. In twenty-five shoulders, long-term outcomes were measured with use of the American Shoulder and Elbow Surgeons (ASES) scoring system and follow-up data were obtained at a mean of ten years (range, four to sixteen years) postoperatively.

RESULTS

Twenty-six of thirty-four shoulders satisfied the limited goals criteria described by Neer et al. The mean active forward elevation improved from 78 degrees preoperatively to 111 degrees postoperatively (p < 0.001). The mean active external rotation improved from 15 degrees preoperatively to 38 degrees postoperatively (p < 0.0001). One patient with a history of four failed rotator cuff repairs had anterosuperior instability develop after surgery. The mean final total ASES score was 67 points (range, 35 to 100 points). Of the sixteen shoulders in patients who could actively elevate the arm to >or=90 degrees preoperatively, fourteen achieved satisfactory results according to the limited goals criteria of Neer et al. Patients who could actively elevate the arm to 90 degrees had significantly better function (mean ASES function score, 31 compared with 23 points; p = 0.05), pain relief (mean ASES pain score, 48 compared with 30 points; p = 0.002), and higher total ASES scores (mean, 80 compared with 54 points; p < 0.001) than the patients who were unable to actively elevate the arm to 90 degrees .

CONCLUSIONS

Hemiarthroplasty can provide good long-term results in rotator cuff-deficient patients with glenohumeral arthritis. Patients who have preoperative forward elevation of >or=90 degrees benefit the most. A low complication rate can be expected for this procedure.

Cementless humeral resurfacing arthroplasty in active patients less than fifty-five years of age

BACKGROUND

Cementless humeral resurfacing arthroplasty is a bone-conserving arthroplasty option for patients with glenohumeral arthritis. It has been successful in the older patient population. However, data regarding the results of arthroplasty in younger, more active patients are lacking. We report the two-year results of this procedure in active patients who were less than fifty-five years of age.

METHODS

We reviewed prospectively collected clinical data on a series of thirty-six patients under fifty-five years of age with end-stage glenohumeral arthrosis, but without osteonecrosis, who had undergone a cementless humeral resurfacing hemiarthroplasty performed by a single surgeon. All patients were followed for a minimum of two years. We assessed pain, function, and patient satisfaction and documented all complications. Radiographs were evaluated for implant loosening.

RESULTS

The thirty-six patients had a mean age of 42.3 years and were followed for a mean of 38.1 months. Scores measured with a visual analog pain scale, the Single Assessment Numeric Evaluation (SANE) scale, and the American Shoulder and Elbow Surgeons (ASES) scale all improved significantly from preoperatively to two years postoperatively (p < 0.001). Complications included one traumatic subscapularis rupture at six weeks, three cases of arthrofibrosis, and one deep hematoma. No obvious radiographic evidence of loosening was noted at the time of the latest follow-up. One shoulder was converted to a stemmed total shoulder arthroplasty at twenty-four months because of pain, but the implant was not loose at the revision. The remaining thirty-five patients were satisfied with the outcome at the time of the latest follow-up and had returned to their desired activity.

CONCLUSIONS

Cementless humeral resurfacing arthroplasty is a viable treatment option for younger, active patients. Early results indicate that the desired function and pain relief can be expected. Implant loosening and glenoid wear do not appear to be concerns in the short term despite the high activity levels of many patients. Long-term follow-up is needed to determine if these results persist.

Total shoulder replacement compared with humeral head replacement for the treatment of primary glenohumeral osteoarthritis: a systematic review

The optimal choice for the treatment of end-stage primary glenohumeral osteoarthritis remains controversial, with alternatives including total shoulder replacement (TSR) and humeral head replacement (HHR). The objective of this review was to analyze the effect of TSR compared with HHR on rates of pain relief, range of motion, patient satisfaction, and revision surgery in patients with primary glenohumeral osteoarthritis. We searched computerized databases for clinical studies published between 1966 and 2004 that reported on shoulder replacement for primary glenohumeral osteoarthritis. Pain data were converted to a 100-point score. Outcome assessment data were pooled when possible, and analyses via normal test statistics were performed. We identified 23 studies, with a total of 1952 patients and mean follow-up of 43.4 months (range, 30-116.4 months). The mean level of evidence was 3.73. Among the 23 studies, 7 different outcome instruments were used. Of the 23 studies, 14 (n = 1185) reported pain relief, 15 (n = 1080) reported range of motion, 12 (n = 969) reported patient satisfaction, and 14 (n = 1474) reported revision surgery. Compared with HHR, TSR provided significantly greater pain relief (P < .0001), forward elevation (P < .0001), gain in forward elevation (P < .0001), gain in external rotation (P = .0002), and patient satisfaction (P < .0001). Furthermore, only 6.5% of all TSRs required revision surgery, which was significantly lower than the percentage for all patients undergoing HHR (10.2%) (P < .025). Only 1.7% of all-polyethylene glenoid components required revision. On the basis of this review and analysis, in comparison with HHR, TSR for the treatment of primary glenohumeral osteoarthritis significantly improves pain relief, range of motion, and satisfaction and has a significantly lower rate of revision surgery. Inconsistent outcome reporting and poor study design may warrant standardization of outcome instruments and improved study design in the future.

The complex characteristics of 282 unsatisfactory shoulder arthroplasties

The purpose of our study is to augment the knowledge of patient dissatisfaction after a shoulder arthroplasty. A total of 353 shoulders were prospectively enrolled into the Shoulder Arthroplasty Failure Experience (SAFE) project. Of these, 282 patients had complete data for the final analysis, including demographic information, medical history, physical examination, standard radiographs, and the Simple Shoulder Test (SST) scores. These data were analyzed to determine the frequency of 17 possible characteristics of an unsatisfactory arthroplasty. Pain was the most common reason for patients to seek an evaluation (241 of 282 shoulders). Shoulder function was substantially reduced at presentation, with patients only able to perform an average of 2.6 of 12 SST functions. Overall, technical factors such as component malpositioning and glenohumeral malalignment were the most common characteristics identified among all the shoulders. Loosening of glenoid components was noted in 85 of the 136 total shoulder arthroplasties, and glenoid erosion was found in 51 of 80 hemiarthroplasties performed for degenerative conditions. Patients with an unsatisfactory outcome after shoulder arthroplasty present with poor shoulder function and pain. Component malposition, glenohumeral malalignment, and glenoid failure are all prevalent features among patients with an unsatisfactory outcome.

Shoulder arthroplasty: the socket perspective

Although much attention has been directed to the development of the humeral components used in shoulder arthroplasty, the major unsolved challenge lies on the glenoid side of the articulation. This challenge arises from difficulties resisting eccentric loading and providing adequate implant-bone fixation. Current glenoid component designs use polyethylene and polymethyl methacrylate and are prone to loosening, plastic deformation, particulate debris, and third-body wear. Metal-backed components present further challenges, and results have generally been disappointing. There is interest in biologic resurfacing procedures, including the interposition of fascia, capsule, or meniscal allograft and nonprosthetic glenoid arthroplasty, or what has become known as the "ream-and-run" procedure. Despite encouraging results, important questions remain unanswered about these procedures. However, each may warrant further exploration with a goal of providing an effective and durable approach to glenoid arthritis that avoids the risks associated with polymethyl methacrylate and polyethylene.

Management of shoulder hemiarthroplasty in a patient with rheumatoid arthritis

STUDY DESIGN

Case report.

BACKGROUND

Rehabilitation after shoulder hemiarthroplasty for rotator cuff tear arthropathy (RCTA) represents a significant challenge to physical therapists. Limited goals have been defined for this patient population and include no pain or slight pain at rest, moderate pain with vigorous activity, shoulder external rotation active range of motion (AROM) greater than 20 degrees, and shoulder abduction AROM greater than 90 degrees.

CASE DESCRIPTION

The patient was a 60-year-old female elementary school teacher with functional class III adult-onset rheumatoid arthritis, who came to physical therapy 2 weeks after undergoing a hemiarthroplasty for RCTA of the right shoulder. Physical therapy included 33 treatment sessions involving 4 to 11 exercises each session. All sessions were performed under the direct supervision of a physical therapist utilizing specially designed equipment. Physical therapy emphasized early active assisted elevation range of motion (ROM), graded progressive exercise, and functional training. All exercises were performed in a pain-free ROM or a ROM that did not increase shoulder pain.

OUTCOMES

Following physical therapy, subjective pain scale at rest was 0/10 and during vigorous activity 1/10 to 2/10. Shoulder AROM was normal and shoulder rotation and elevation strength was good. There was a significant improvement in shoulder proprioception and the patient demonstrated a negative belly press test for subscapularis muscle integrity. Additionally, the patient's score on the self-report section of the American Shoulder and Elbow Surgeons Assessment Form increased from 0% at the initial examination to 70% at discharge.

DISCUSSION

Despite limited expectations, this patient achieved normal shoulder ROM and near normal shoulder strength after 14 weeks of physical therapy. Overall, an early, aggressive, progressively graded exercise program appears to be a safe and effective form of treatment after shoulder hemiarthroplasty for RCTA.

The results of arthroplasty in osteoarthritis of the shoulder

We have undertaken a prospective clinical and radiological analysis of 124 shoulder arthroplasties (113 patients) carried out for osteoarthritis. The clinical results showed improvement in the absolute Constant score and the American Shoulder and Elbow Surgeons score of 22 and 43, respectively. Both were statistically significant (p < 0.001). There was no significant difference in the scores after hemiarthroplasty and total arthroplasty in those patients with an intact rotator cuff. When revision was used as the end-point for survival at ten years, survival of 86%, or 90% if glenoid components made of Hylamer sterilised in air were omitted, was obtained in primary osteoarthritis. The most common cause for revision in the hemiarthroplasty group was glenoid pain at a mean of 1.5 years; in the total arthroplasty group it was loosening of the glenoid at a mean of 4.5 years. Analysis of pre-operative factors showed that the risk of gross loosening of the glenoid increased threefold when there was evidence of erosion of the glenoid at operation. Shoulder arthroplasty should not be delayed once symptomatic osteoarthritis has been established and should be undertaken before failure of the cuff or erosion of the glenoid are present.

Advancements in the surgical and alternative treatment of arthritis

PURPOSE OF REVIEW

Surgical and nonsurgical treatment of arthritis is a rapidly developing and evolving field. It is vital for clinicians to keep up on the latest advances. This review focuses on clinical trials or large prospective studies over the past year that evaluated orthopedic surgical techniques for the treatment of arthritis and new nonsurgical therapies that may prevent the need for surgical intervention. Increasing attention has also been focused on the relation between surgeon or hospital case load and the quality of outcomes after surgery.

RECENT FINDINGS

No fewer than 10 studies have been published over the past year evaluating the use of hyaluronic acid (a visco-supplement) or corticosteroid injections as alternative treatments to knee arthroscopy for osteoarthritis of the knee. Joint replacement research has explored minimally invasive and computer-guided or robot-guided joint replacement surgery, the best operative choice for advanced shoulder arthritis (hemiarthroplasty compared with total shoulder replacement), the role of patellar resurfacing during total joint replacement, and the use of bisphosphonates for retention of bone density after joint replacement.

SUMMARY

The increasing attention on high-quality surgical trials should continue to improve surgical options based on sound research for patients with arthritis. Future research should continue to improve the available high-quality research for treatment choices.