The initial treatment of complex proximal humerus fracture affects the outcome of revision with reverse shoulder arthroplasty.

PURPOSE: The purpose of the study is to report the results of reverse shoulder arthroplasty (RSA) after three types of initial treatment performed for complex proximal humeral fracture (PHF): conservative, reduction and internal fixation (RIF), or hemiarthroplasty. METHODS: This is a retrospective study of 63 patients separated into three groups with a minimum follow-up of two years. Group I included 25 patients with an initial conservative fracture treatment, group II included 25 patients treated by RIF, and group III included 13 patients initially treated by hemiarthroplasty. Patients were assessed using the absolute Constant-Murley score, functional parameters, complications rate, and radiological follow-up. RESULTS: One patient died and five were lost to follow-up. All functional outcomes improved significantly post-operatively for the three groups (p < 0.005). The mean Constant-Murley score increased from 13.7 to 54.1 (group I); 16.6 to 48.5 (group II); and 22.6 to 48.2 (group III) (p < 0.001). The gain of Constant-Murley and SST scores was better for group I (p = 0.049 and 0.028, respectively), while post-operative pain was better in group III (p = 0.033). The complication rate was 38% in group III, 30% in group II, and 14.3% in group I. CONCLUSIONS: Reverse shoulder arthroplasty represents a good surgical option in complex proximal humeral fracture sequelae. Whatever the initial treatment, function and motion of the shoulder are improved. The final result is better if the initial treatment was conservative. The group initially treated with hemiarthroplasty had the most complications.

Convertible Glenoid Components Facilitate Revisions to Reverse Shoulder Arthroplasty Easier: Retrospective Review of 13 Cases.

Removal of a cemented glenoid component often leads to massive glenoid bone loss, which makes it difficult to implant a new glenoid baseplate. The purpose of this study was to demonstrate the feasibility of revisions with a completely convertible system and to report clinical and radiographic results of a retrospective review of 13 cases. Between 2003 and 2011, 104 primary total shoulder arthroplasties (TSAs) were performed with an uncemented glenoid component in our group. Of these patients, 13 (average age, 64 years) were revised to reverse shoulder arthroplasty (RSA) using a modular convertible platform system and were included in this study. Average follow-up after revision was 22 months. Outcome measures included pain, range of motion, Constant-Murley scores, Simple Shoulder Tests, and subjective shoulder values. Active flexion increased significantly from a mean of 93° (range, 30°-120°) to 138° (range, 95°-170°) (P = 0.021), and active external rotation increased significantly from 8° (range, -20°-15°) to 25° (range, -10°-60°). Mean pain scores significantly improved from 4.2 to 13.3 points. The mean Constant Scores improved from 21 (range, 18-32) to 63 (range, 43-90). Subjectively, 12 patients rated their shoulder as better or much better than preoperatively. This retrospective study shows that a complete convertible system facilitates conversion of TSAs to RSAs with excellent pain relief and a significant improvement in shoulder function.

The main cause of instability after unconstrained shoulder prosthesis is soft tissue deficiency.

BACKGROUND: Instability is one of the major causes of failures in unconstrained anatomic total shoulder arthroplasty (TSA). This study reviewed the instabilities that may occur in an anatomic shoulder platform system to identify its potential predictors. We hypothesized that soft tissue deficiency was the main cause of instability and that the best treatment option would be conversion to a reverse shoulder arthroplasty (RSA). MATERIALS AND METHODS: Between 2003 and 2013, we reviewed 27 patients who experienced postoperative instability, and the overall incidence was 5.07%. There were 8 hemiarthroplasties (HAs), 14 TSAs with metal-backed glenoid components, and 5 TSAs with cemented glenoid components. RESULTS: We reported 10 isolated subscapularis tears, 6 massive rotator cuff tears, 8 component malpositions, 2 component dissociations or loosening, and 1 humeral shortening. These dislocations occurred early, within the first 6 months postoperatively, in 20 patients and later in 7. Specific procedures were performed in 8 patients, 17 were converted successfully to a RSA, and no surgery was done in 2 patients. At the last follow-up (mean, 36.96 months) Constant scores, Subjective Shoulder Value, and Simple Shoulder Test scores improved significantly to 49.9, 56.4%, and 6.9 of 12, respectively (P < .05). None of the 25 patients who were revised were categorized as failures. Patients who underwent conversion had a better outcome than those who had other specific procedures (P = .001). CONCLUSION: The major cause of instability in our series was soft tissue deficiency. Most of the patients required conversion, and the platform system we used made conversions easier.

Does lateralisation of the centre of rotation in reverse shoulder arthroplasty avoid scapular notching? Clinical and radiological review of one hundred and forty cases with forty five months of follow-up.

PURPOSE: Our purpose was to evaluate the influence of metallic lateralisation of the centre of rotation (COR) in reverse shoulder arthroplasty (RSA) on the incidence of scapular notching and its eventual clinical and radiological consequences. METHODS: We analysed 140 RSAs with a lateralised design (Arrow, FH Orthopedics, Mulhouse, France) implanted for massive rotator cuff tear with/without arthritis. Mean follow-up was 45 months (range 24-120, standard deviation 20). Patients were evaluated clinically using the Constant and Murley (Clin Orthop Relat Res 214:160-164, 1987) score and active range of motion (ROM) and radiologically using standard anteroposterior and axillary view. Scapular notching was assessed according to Sirveaux classification Simovitch et al. (J Bone Joint Surg Am, 89:588-600, 2007), and patients were separated into two groups (scapular notch/no scapular notch) and compared. RESULTS: Forty-one notches (29 %) were found: 20 grade 1, 18 grade 2, and three grade 3. The latter three patients had a follow-up of 44, 70 and 84 months, respectively, and the scapular notch did not evolve in the final two years. Better pre-operative function was significantly associated with scapular notching (p < 0,05 for flexion and abduction), but no final clinical differences in ROM and Constant score were found between groups. A body mass index (BMI) <30 increased the risk of scapular notching, which was observed in 43 % of patients with a BMI < 30 and 30 % of patients with a BMI > 30 p = 0,048). Pre-operative narrowing of the subacromial space increased the risk of scapular notching, but age or gender showed no influence. However, there was a significantly greater number of scapular notches in patients operated on the dominant side (p = 0,04). No significant difference in lateral offset was found between groups (p = 0,99). Glenoid implantation in an excessively high position (p = 0,033) and absence of inferior tilt (p = 0,0029) were significantly associated with scapular notching. CONCLUSIONS: In this series, metallic lateralisation of the COR in RSA did not impair clinical results, with patients achieving good flexion recovery ROM increase in rotations. Metallic lateralisation of the COR in RSA leads to a lower incidence of scapular notching (29 %) compared with previously reported results using other arthroplastic systems with a more medialised COR. However, although scapular notching was not totally eliminated, those that were found did not evolve over time. Several factors increased the incidence of scapular notching: BMI <30, better preoperative ROM, an excessively high glenoid implant and absence of inferior tilt.

A convertible shoulder system: is it useful in total shoulder arthroplasty revisions?

PURPOSE: The frequency of total shoulder arthroplasty (TSA) implantation is constantly increasing. This leads to revisions because of stem or glenoid component loosening, infection, instability or glenoid subsidence. Significant rotator cuff lesions and/or bone loss necessitate reverse shoulder arthroplasty (RSA) with bone reconstruction, which is a demanding procedure. Our hypothesis is that a platform system (versatile humeral stem with metal back glenoid component) makes revision surgery less demanding and less time consuming, and helps reduce the risks of complication. The purpose of this study is to analyse our revision experience with such a system to support our hypothesis. METHODS: We present 29 revision cases of a convertible platform shoulder system: five hemi arthroplasties (HA), eight TSA with cemented glenoid (TSACG) and 16 TSA with metal backed glenoid component (TSAMB). Three TSACG were switched to TSAMB, and 26 other arthroplasties were switched to RSA. The pre-operative Constant score was 27 (range, 0-38). Our revision incidence was 5.4 % (29 revisions out of 537 shoulder arthroplasties over five years). RESULTS: At revision, Constant score was 60 (range, 42-85). The humeral stem (versatile with TSA and RSA) was kept in three out of four cases. Most of the time it was changed because of too high a position, making it impossible to reduce the RSA. Nevertheless, 12 PTAMB were switched in 12 RSA without any metal backed revisions. CONCLUSION: A platform shoulder system allows much easier revisions.

Comparison of functional gains after arthroscopic rotator cuff repair in patients over 70 years of age versus patients under 50 years of age: a prospective multicenter study.

PURPOSE: To assess rotator cuff rupture characteristics and evaluate healing and the functional outcome after arthroscopic repair in patients older than 70 years versus patients younger than 50 years. METHODS: We conducted a multicenter, prospective, comparative study of 40 patients younger than 50 years (group A) and 40 patients older than 70 years (group B) treated with arthroscopic rotator cuff repair. Patients older than 70 years were operated on only if symptoms persisted after 6 months of conservative treatment, whereas patients younger than 50 years were operated on regardless of any persistent symptoms. Imaging consisted of preoperative magnetic resonance imaging and postoperative ultrasound. Preoperative and postoperative function was evaluated with Constant and modified Constant scores. Patient satisfaction was also assessed. The evaluations were performed at least 1 year postoperatively. RESULTS: No patient was lost to follow-up. The incidence of both supraspinatus and infraspinatus tears was greater in group B. Greater retraction in the frontal plane and greater fatty infiltration were observed in group B. The Constant score was significantly improved in both groups (51 ± 12.32 preoperatively v 77.18 ± 11.02 postoperatively in group A and 48.8 ± 10.97 preoperatively v 74.6 ± 12.02 postoperatively in group B, P < .05). The improvement was similar in both groups. The modified Constant score was also significantly improved in both groups (57.48 ± 18.23 preoperatively v 81.35 ± 19.75 postoperatively in group A and 63.09 ± 14.96 preoperatively v 95.62 ± 17.61 postoperatively in group B, P < .05). The improvement was greater for group B (P < .05). Partial rerupture of the rotator cuff occurred in 2 cases in group A and 5 cases in group B. Complete rerupture was observed in 2 patients in group B. In group A, 29 patients (72.5%) were very satisfied, 8 (20%) were satisfied, and 3 (7.5%) were less satisfied. In group B, 33 patients (82.5%) were very satisfied, 6 (15%) were satisfied, and only 1 (2.5%) was less satisfied. CONCLUSIONS: Rotator cuff tears are characterized by greater retraction in the frontal plane and greater fatty infiltration in patients older than 70 years compared with patients younger than 50 years. After arthroscopic repair, healing is greater for patients younger than 50 years. Functional gain is at least equal between the 2 groups. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Results of 30 reverse shoulder prostheses for revision of failed hemi- or total shoulder arthroplasty.

PURPOSE: Revision surgery for shoulder prosthesis remains a difficult task in shoulder surgery. The purpose of this retrospective study was to evaluate the clinical and radiological outcomes of a series of 30 reverse shoulder prostheses performed as revision of failed hemi- or total shoulder arthroplasty. The most relevant technical points in surgery are described, as are other surgical options; a rational strategy for the treatment of these patients is proposed. MATERIALS AND METHODS: Thirty patients (average age 69.5) were included. Mean follow-up was 36.4 months (range 24-100 months). There were 14 patients in group 1 (Delta III) and 16 in group 2 (Reverse Arrow). RESULTS: A total of 83% were satisfied (16 cases) or very satisfied (9 cases), and 17% were disappointed (5 patients). The mean Constant score increased from a mean of 25-52. The mean score for pain improved from 5 (range 0-15) to 13 (range 5-15) (p < 0.001). The mean score of strength improved from 1 (range 0-6) to 5 (range 0-10) (p < 0.001). The forward elevation changed from a mean of 55° (range 0-120) to 108° (range 40-160) (p < 0.001). There was no significant improvement of external rotation at 0° abduction (range 14°-18°) or internal rotation (range 5-4.63). There were 4 scapular notching. We could not find the influence of scapular notching on Constant Score. Complication rate was 26.6%. CONCLUSION: Reverse total shoulder arthroplasty prosthesis represents an available option in difficult cases of failed hemiarthroplasty or total shoulder arthroplasty when the rotator cuff is irreparable and the glenoid bone stock is sufficient. LEVEL OF EVIDENCE: Level 4.

How to deal with glenoid type B2 or C? How to prevent mistakes in implantation of glenoid component?

BACKGROUND: Although TSA has been shown to significantly yield better outcomes than hemiarthroplasty, glenoid prosthesis loosening remains the most common complication. Inadequate primary fixation enables the glenoid component to move. In primary glenohumeral osteoarthritis (GHOA), glenoid involvement and proper morphology vary considerably. Postero-inferior glenoid hypoplasia could be associated with some degree of osteoarthritis. According to Walch, 24 % of glenoids in GHOA are type B2 or C (excessive posterior retroversion), which increases the challenge for the glenoid component fixation. MATERIALS AND METHODS: A total of 30 cases of TSR with glenoid type B2 (20 cases) and type C (10 cases) were reviewed. Mean follow-up was 11.2 months. A metal-backed (MB) glenoid component was implanted, with a posterior bone graft reconstruction. Pre- and post-operative clinical evaluation was done using the Constant-Murley score and the SST from Matsen. RESULTS: There is no glenoid loosening, no joint narrowing and no radiolucent line. There was no bone graft osteolysis. With 4 patients revised (4 conversions from TSR to RSR for 3 instabilities and 1 secondary rotator cuff tear), on the overall 30 patients cohort, Constant score pain increased from 1.6 to 13.4, forward flexion from 92° to 146° and Constant score from 27 (36 %) to 70 (95 %). The statistical difference between pre- and post-operative values is greatly significant. CONCLUSION: Although MB prostheses have been noted to have a higher rate of loosening than full-cemented PE, this is not our experience, even in case of glenoid type B2 or C, where the technical challenge is demanding and most of the time a posterior bone graft is necessary.

Mid-term outcome of reverse shoulder prostheses in complex proximal humeral fractures.

The functional outcome of hemiarthroplasty in displaced proximal humeral 3- and 4-part fractures or fracture dislocations in elderly patients is frequently unpredictable and depends on the position of the prosthesis and tuberosity fixation. Reverse shoulder arthroplasty represents an alternative in elderly patients. The purpose of this study was to report the results of a retrospective series of 30 reverse shoulder prostheses in trauma indications. We also compared the results of a less medialized reverse shoulder prosthesis (Arrow) with those reported for the traditional (Delta III) reverse prosthesis. Twenty seven cases were available for analysis. The mean follow-up was 22.5 months. The mean absolute Constant score was 54.9, the score for pain was 13.5, for activities 14, for strength 4.59. The mean active anterior elevation was 112 degrees, abduction 97 degrees, external rotation with the arm at the side: 12.7 degrees, in abduction: 55 degrees. Radiographs revealed no loosening, no glenoid notching. Reverse shoulder prosthesis may be a good alternative for displaced three- and four-part proximal humeral fractures in selected patients. The functional results are more predictable than with hemiarthroplasty in elderly patients.

Do less medialized reverse shoulder prostheses increase motion and reduce notching?

BACKGROUND: Cuff tear arthropathy is the primary indication for total reverse shoulder arthroplasty. In patients with pseudoparalytic shoulders secondary to irreparable rotator cuff tear, reverse shoulder arthroplasty allows restoration of active anterior elevation and painless shoulder. High rates of glenoid notching have also been reported. We designed a new reverse shoulder arthroplasty with a center of rotation more lateral than the Delta prosthesis to address this problem. QUESTIONS/PURPOSES: Does reduced medialization of reverse shoulder arthroplasty improve shoulder motion, decrease glenoid notching, or increase the risk of glenoid loosening? PATIENTS AND METHODS: We retrospectively reviewed 76 patients with 76 less medialized reverse shoulder prostheses implanted for pseudoparalytic shoulder with rotator cuff deficiency between October 2003 and May 2006. Shoulder motion, Constant-Murley score, and plain radiographs were analyzed. Minimum followup was 24 months (mean, 44 months; range, 24-60 months). RESULTS: The absolute Constant-Murley score increased from 24 to 59, representing an increase of 35 points. The range of active anterior elevation increased by 61°, and the improvement in pain was 10 points. The gain in external rotation with elbow at the side was 15°, while external rotation with 90° abduction increased by 30°. Followup showed no glenoid notching and no glenoid loosening with these less medialized reverse prostheses. CONCLUSIONS: Less medialization of reverse shoulder arthroplasty improves external and medial rotation, thus facilitating the activities of daily living of older patients. The absence of glenoid notching and glenoid loosening hopefully reflects longer prosthesis survival, but longer followup is necessary to confirm these preliminary observations. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Reverse shoulder arthroplasty: does reduced medialisation improve radiological and clinical results?

The purpose of this retrospective study was to assess the effect of the reduced medialisation of the Arrow reverse shoulder prosthesis on short-term clinical and radiological results. The clinical and radiological results of 47 Delta III reverse prostheses and 49 Arrow reverse prostheses were retrospectively compared at a minimum of twelve months follow-up. There was a significant increase (p < 1.10(-4)) in range of motion from the preoperative range in the two groups except for internal rotation in the Delta III group (p = 0.1). Radiological analysis on anteroposterior view in neutral position showed greater lateralisation (p < 0.001) with the Arrow prosthesis. Scapular notching was noted in 32 patients with a Delta III prosthesis, and in no instance with an Arrow prosthesis. Complication rates were 14.9% for the Delta group and 10.2% for the Arrow group. The design features of the Arrow prosthesis--reduced medialisation of the center of rotation with lateralisation of the humerus--were found to be associated with slight improvement in range of motion and absence of scapular notching.

The reverse shoulder prosthesis--surgical technique.

In this article, the surgical technique of the reverse shoulder prosthesis is described in detail. Indications for the procedure, difficulties encountered during surgery, and potential postoperative complications and their solutions are discussed.