Subacromial Balloon Spacer for Irreparable Rotator Cuff Tear Treatment Shows Improved Pain and Strength at 5-Year Follow-Up.

PURPOSE: To report on minimum 5-year outcomes following subacromial balloon spacer implantation (SBSI), in terms of survivorship, pain reduction, functional outcomes, complications, and reoperations. METHODS: Data were prospectively collected and retrospectively analyzed for consecutive patients undergoing SBSI between April 1, 2012, and June 30, 2016. Patients completed preoperative and postoperative follow-up for minimum 5 years on the following patient-reported outcomes (PROs): Constant-Murley Score (CMS), visual analog scale for pain (VAS), strength, and patient satisfaction. Reoperations and complications were recorded. Minimal detectable change (MDC) was calculated and the proportion of patients achieving MDC for CMS and VAS were calculated. RESULTS: During the study period, SBSI was performed in 36 patients. Three patients were deceased within 5 years. Of the remaining 33 patients, follow-up was available on 29 patients (80.6%). Mean age at the time of operation was 72.7 ± 4.5 years, and 69% of the patients were males. Mean follow-up time was 72.5 months. Significant improvements from preoperative to last follow-up were demonstrated in CMS (36.08 vs. 63.88; P < .001), VAS (6.72 vs. 1.68; P < .001), and strength (3.8 vs 5.87 kg; P < .001). These improvements were demonstrated at 3 weeks, 6 months, 12 months, 24 months, and 60 months. Mean patient satisfaction at last follow-up was 8.72. The MDC for both CMS and VAS was achieved by 75.9% (22/29) of patients. Four patients underwent conversion to a reverse total shoulder arthroplasty (RTSA). Complications included one patient with balloon dislocation and one patient with a secondary infection due to urinary tract infection. CONCLUSIONS: Pain reduction and functional improvements are sustained at minimum 5 years after SBSI in patients with irreparable rotator cuff tears. The 5-year conversion rate to an RTSA was 13.79%. LEVEL OF EVIDENCE: Level IV, retrospective case-series.

The "purse string" technique for anterior glenohumeral instability: long-term results 7-13-year follow-up.

PURPOSE: The "Purse-String Technique" (PST) is an arthroscopic horizontal mattress suture technique for recurrent anterior shoulder instability that uses a single double-loaded suture anchor at the 4-o' clock position, achieving a Bankart labral repair and an infero-superior capsular shift. In this study, we describe the long-term results of the PST. METHODS: The study included 69 individuals (70 shoulders), with a mean age of 30 years, who had recurrent post-traumatic anteroinferior instability. A purse-string suture anchor at the 4-o'clock position was used to address the Bankart lesion and capsular laxity, recreating the anterior glenoid bumper. All patients were assessed via telephone interview at a mean of 116 months after surgery (7-13-year follow-up). RESULTS: Postoperatively, the mean Constant score was 94, mean Rowe score was 93 and mean Walch-Duplay score was 89. 89% of patients resumed their preinjury sport activities, with 61% of patients achieving preinjury levels and most professional athletes returning to full activity. Seven patients had recurrent dislocation postoperatively (10% failure rate). Of these patients, three had revision arthroscopic stabilization, one patient had revision arthroscopic stabilization with remplissage, two had a Latarjet procedure, whereas one patient decided to seek no further treatment. CONCLUSION: The long-term results of PST are promising, with a low failure rate, high patient satisfaction and a high rate of return to sport. LEVEL OF EVIDENCE: Level IV; Case series; Treatment study.

Acute versus delayed reverse total shoulder arthroplasty for proximal humeral fractures: a consecutive cohort study.

BACKGROUND: The treatment of displaced proximal humeral fractures (PHFs) remains controversial. Open reduction-internal fixation (ORIF) can be challenging, especially in elderly patients with poor bone quality, whereas hemiarthroplasty has had unpredictable outcomes. Conservative treatment may result in severe fracture sequelae with poor outcomes, requiring late reverse total shoulder arthroplasty (RTSA) in many cases. The past few years have seen a shift toward the use of RTSA for the treatment of PHFs. The aim of this study was to compare the outcomes of RTSA between patients with acute fractures and patients who underwent delayed RTSA for fracture sequelae. Our hypothesis was that the outcomes of RTSA for acute PHFs would be better than those of delayed RTSA for fracture sequelae. METHODS: We followed up 36 patients with a mean age of 79.1 years who underwent primary RTSA for acute PHFs and 56 patients with a mean age of 72.1 years who underwent RTSA in delayed fashion for fracture sequelae, including failed ORIF. The minimum follow-up period was 24 months. The mean follow-up period was 39.3 months in the acute RTSA group and 56.6 months in the delayed RTSA group. Demographic data, radiographs, and surgery data were prospectively collected and analyzed. At final follow-up, range of motion and radiographic analysis findings, as well as the Subjective Shoulder Value (SSV) and Constant score (CS), were recorded. RESULTS: The clinical results favored the group undergoing acute RTSA for acute PHFs, with a mean SSV of 8.3 of 10 and adjusted CS of 88.9% compared with a mean SSV of 8.0 of 10 and adjusted CS of 77.6% in the group undergoing late RTSA for fracture sequelae-but without statistically significant differences between the groups. Although the acute RTSA group showed slightly better range-of-motion values, no statistically significant differences were found between the groups. No intraoperative complications occurred. The time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group. CONCLUSION: Although there were no statistically significant differences in outcomes between early RTSA for acute PHFs and late RTSA for fracture sequelae, the time from injury to the regaining of good pain-free function was significantly shorter in the acute RTSA group. Therefore, we advocate early RTSA for acute PHFs in elderly patients to provide a quicker recovery and an early return to good predictable outcomes with a much shorter period of pain and discomfort. In cases of failed conservative treatment, malunion, or failed ORIF, salvage RTSA has the potential to provide a good outcome.

Accelerated rehabilitation following reverse total shoulder arthroplasty.

BACKGROUND: Postoperative rehabilitation is considered essential and indeed routine practice following rTSA. However, the optimal approach to postoperative rehabilitation is unknown, based on protocols for anatomic TSA, and published literature is sparse, as is the quantity and quality of research evidence. The aim of this study is to outline the accelerated rehabilitation protocol (with immediate activity and no immobilization at all) following reverse total shoulder arthroplasty (rTSA) and assess its safety and effectiveness compared to the more conservative rehabilitation protocols of immobilization in a sling for 6 weeks and for 3 weeks. MATERIALS AND METHODS: Between July 2005 and October 2017, a total of 357 consecutive rTSA in 320 patients underwent a primary rTSA and were included in the study. Patients were divided into 3 groups depending on rehabilitation protocol (6 and 3 weeks' postoperative immobilization, respectively, for groups 1 and 2, and no immobilization for group 3). Patients were assessed preoperatively and reviewed at 3 weeks, 3, 6, and 12 months, and yearly thereafter postoperatively. Constant score (CS), Subjective Shoulder Value (SSV), patient satisfaction, and pain scores were used at each appointment and patients assessed both clinically and radiographically. RESULTS: Mean age at surgery was 76 years (range 40-93). At 1-year follow-up, the CS improved from 16.6 (adjusted 23.9) to 63.2 (adjusted 91.5) in group 1 (n = 114), from 21.5 (adjusted 30.7) to 67.7 (adjusted 98.4) in group 2 (n = 125), and from 22.6 (adjusted 31.3) to 66.6 (adjusted 94.9) in group 3 (n = 118). Pain score improved from 3.1/15 preoperatively to 12.5/15 postoperatively in group 1, from 3.5/15 to 13/15 in group 2, and from 3.7/15 to 12.5/15 in group 3. SSV improved to 8.5/10, 8.6/10, and 8.1/10 for groups 1, 2, and 3, respectively. Mean range of motion (ROM) improved to 142° elevation and 131° abduction in group 1, 153° elevation and 144° abduction in group 2, and 149° elevation and 146° abduction in group 3. No statistically significance differences were observed in CS, SSV, patient satisfaction, pain, and ROM between the 3 groups. Less postoperative complications were observed in group 3 (No immobilization). CONCLUSION: Accelerated rehabilitation regime post rTSA without immobilization is safe and lead to reliable good clinical results and quick return to function. This study confirms noninferiority of the accelerated rehabilitation regime with fewer postoperative complications related to falls. Accelerated rehabilitation regime post rTSA have further psychological and emotional advantage to the patient, with earlier return to normal function and regaining independence. We recommend the accelerated rehabilitation regime without immobilization following rTSA.

Software simulations of changing offsets and thus soft tissue tension when revising anatomic to reverse total shoulder arthroplasty in convertible platform systems.

BACKGROUND: Revision shoulder arthroplasty may involve the need to remove a well-fixed humeral stem. To avoid this, convertible platform systems have been introduced. The biomechanics of reverse total shoulder arthroplasty (rTSA) differs from anatomic shoulder arthroplasty (aTSA). The different humeral osteotomy and soft tissue tension may jeopardize the optimal results of the converted rTSA. The aim was to evaluate the radiographic parameters of soft tissue distraction when converting an aTSA to rTSA in a platform system and assess the capability of conversion without "over-stuffing" the shoulder in the "best-case scenario". METHODS: Radiographic analysis of soft tissue distraction parameters: difference in acromio-humeral distance, difference in lateral humeral offset and difference in latero-inferior displacement were evaluated in aTSA and in the converted rTSA in six different implants. Image analysing software was used on 10 non-deformed osteoarthritic shoulder X-rays to simulate conversion. RESULTS: The greatest increase in arm length was found for Tornier Ascend Flex (26.8 ± 3.6 mm) while the smallest increase was observed with Lima SMR (19.3 ± 4 mm). The humerus remained most lateralized with the Zimmer Anatomical/Inverse ( - 1.4 ± 2.9 mm) while Lima SMR ( - 15.8 ± 2.7 mm) was more medialized. The greatest increase in latero-inferior distance was found in the onlay systems. A group analysis of onlay rTSA showed an increase of 46% in arm length (p < 0.0001), 83% larger humeral offset (p < 0.0001) and 144% increase in latero-inferior distraction (p < 0.0001) when compared to inlay rTSA. CONCLUSION: The conversion of aTSA to rTSA using a convertible platform system may lead to significant increase in radiographic parameters corresponding to soft tissue tension. This may alter the biomechanics, restrict the convertibility or jeopardize the optimal clinical outcome of rTSA even in the best-case scenario.

Shoulder proprioception following reverse total shoulder arthroplasty.

Joint replacement affects the proprioception, as shown in knees, elbows, and shoulder studies. AIM: The aim was to evaluate shoulder joint position sense (JPS) following reverse total shoulder arthroplasty (rTSA) for patients with cuff arthropathy. METHODS: Twenty-nine patients that underwent unilateral rTSA (19 females, 10 males) and 31 healthy volunteers evaluated for JPS of shoulder using a dedicated high accuracy electronic goniometer. Error of active reproduction of joint position (EARJP) was assessed at the following reference positions: 30°, 60°, 90°, and 120° for forward flexion and abduction and 15°, 30°, and 45° for internal and external rotation in rTSA, contralateral non-operated, and control shoulders. RESULTS: Results of EPRJP for rTSA, contralateral, and control (respectively) are as follows:Forward flexion: 30° = (8.0 ± 5.7, 9.8 ± 6.1, and 4.9 ± 3.0), 60° = (5.0 ± 2.8, 5.9 ± 2.7, and 5.1 ± 3.2), 90° = (3.1 ± 1.6, 5.5 ± 2.6, and 3.2 ± 1.4), and 120° = (3.4 ± 2.1, 5.6 ± 4.0, and 3.5 ± 1.7)Abduction: 30° = (5.2 ± 2.5, 9.1 ± 6.1, and 4.6 ± 2.3), 60° = (5.2 ± 3.6, 6.6 ± 4.1, and 5.3 ± 3.1), 90° = (3.8 ± 2.0; 7.4 ± 5.5, and 4.1 ± 1.9), and 120° = (5.3 ± 2.9, 7.7 ± 5.3, and 4.2 ± 1.9)Internal rotation: 15° = (4.3 ± 3.1, 6.2 ± 4.4, and 2.8 ± 1.2), 30° = (3.2 ± 1.9, 4.5 ± 2.3, and 3.3 ± 1.4), and 45° = (3.5 ± 2.0, 4.1 ± 1.8, and 2.8 ± 1.0)External rotation: 15° = (3.0 ± 1.7, 4.2 ± 2.2, and 3.6 ± 1.4) and 30° = (3.1 ± 1.5, 3.8 ± 2.6, and 3.4 ± 1.6)The results showed significantly better JPS (lower EPRJP) in shoulders following rTSA and normal control shoulders comparing with the patient's contralateral shoulder. The explanation can be that rTSA improves joint kinematics and stability, which allows better muscular performance and proprioception feedback. CONCLUSION: Shoulders following rTSA show JPS superior to non-operated contralateral shoulders and comparable with healthy population shoulders. It seems that rTSA restores shoulder proprioception.

The anatomical properties of the indirect head of the rectus femoris tendon: a cadaveric study with clinical significance for labral reconstruction surgery.

BACKGROUND: Acetabular labral tear is a common pathology. In some clinical situations, primary labral repair may not be possible and labral reconstruction is indicated. PURPOSE AND CLINICAL RELEVANCE: Describe the anatomy of the indirect head of the rectus femoris (IHRF) tendon with clinical application in arthroscopic labral reconstruction surgery. METHODS: Twenty-six cadaver hips were dissected. Thirteen measurements, each with clinical relevance to arthroscopic labral reconstruction using an IHRF tendon graft were taken on each hip. All measurements were taken in triplicate. Mean values, standard deviations and intra-observer reliability were calculated. RESULTS: The mean footprint of the direct head of the rectus femoris tendon was 10.6 mm × 19.6 mm. The width and thickness at the confluence of both heads were 10.9 mm and 6.9 mm, respectively. The mean total length of the footprint and "free portion" of the IHRF was 55.3 mm, the mean cranial to caudal footprint measured at the 12 o'clock, 1 o'clock, and 2 o'clock positions were 22.3 mm. The mean length of the Indirect Head footprint alone was 38.1 mm. The mean length of IHRF tendon suitable for grafting was 46.1 mm and the mean number of clock face sectors covered by this graft was 3.3 clock face sectors. Intra-observer reliability was ≥ 0.90 for all recorded measurements. The origin of the IHRF on the acetabulum fans out posteriorly, becoming thinner and wider as the origin travels posteriorly. The tendon footprint is firmly attached on the lateral wall of the ilium and becomes a free tendon overlying the acetabular bone as it travels anteriorly and distally towards its muscular attachment. CONCLUSION: The IHRF tendon is in an ideal location for harvesting and contains the appropriate thickness, length and triangular architecture to serve as a safe and local graft source for acetabular labral reconstruction surgery.

Do elderly patients gain as much benefit from arthroscopic rotator cuff repair as their younger peers?

BACKGROUND: This study was conducted to ascertain whether patients aged older than 75 years achieve outcomes after arthroscopic rotator cuff repair comparable to younger patients. METHODS: Arthroscopic cuff repair was performed in 60 shoulders of 59 patients aged older than 75 years. A control group of 60 younger patients, matched for sex, tear size, and American Society of Anesthesiology Functional Classification grade were included. Surgery occurred from 2006 to 2016. Prospective outcomes were the Constant score (CS), Subjective Shoulder Value, pain, satisfaction, and operative complications. Mean follow-up was 29 months. RESULTS: The elderly group was a mean age of 78 years compared with 59 years for controls. Tear sizes were 25 massive, 20 large, 12 medium, and 3 small. The CS improved by 25.1 points in elderly patients compared with 23.7 points for controls (P = .742). Pain improved by 7.5 of 15 in elderly patients vs. 6.2 of 15 in controls (P = .055). Fifty-five of 59 older patients were satisfied compared with 52 of 60 controls (P = .378). The overall complication rate did not differ between the groups (P = .509). Both groups had 1 infection and 1 stiffness. An acromioclavicular joint cyst developed in 1 younger patient, and a traumatic retear occurred in 1 patient. Subsequent reverse total shoulder arthroplasty was performed in 4 elderly patients at a mean of 28 months after cuff repair. Massive tears had higher risk for subsequent reverse total shoulder arthroplasty (P = .026). CONCLUSION: Elderly patients benefit as much from arthroscopic rotator cuff repair as their younger counterparts. Similar improvements in CS, Subjective Shoulder Value, pain, and satisfaction occurred for both elderly and control patients. Arthroscopic repair was safe and effective in both groups. Even elderly patients with massive tears showed clinically significant improvements. Arthroscopic rotator cuff repair should be considered as a valuable treatment irrespective of age.

Acetabular cup orientation and postoperative leg length discrepancy in patients undergoing elective total hip arthroplasty via a direct anterior and anterolateral approaches.

BACKGROUND: Total hip arthroplasty (THA) is considered a successful surgical procedure. It can be performed by several surgical approaches. Although the posterior and anterolateral approaches are the most common, there has been increased interest in the direct anterior approach. The goal of the present study is to compare postoperative leg length discrepancy and acetabular cup orientation among patients who underwent total hip arthroplasty through a direct anterior (DAA) and anterolateral (ALA) approaches. METHODS: The study included 172 patients undergoing an elective THA by a single surgeon at our institution within the study period. Ninety-eight arthroplasties were performed through the ALA and 74 arthroplasties through the DAA. Preoperative planning was performed for all patients. Assessment of the two groups included the following postoperative parameters: abduction angle, cup anteversion angle and leg length discrepancy (LLD). Additional analysis was done to evaluate component positioning by comparing deviation from the Lewinnek zone of safety in both approaches. RESULTS: For the DAA the absolute LLD was 11 mm, ranging from -6 mm to 5 mm. For the ALA, the absolute LLD was 36 mm, ranging from -22 mm to 14 mm. None of the DAA patients had an absolute LLD greater than 6 mm. Comparatively, 7.4% of the ALA group exceeded 6 mm of LLD in addition to 2.1% with LLD greater than 10 mm. 15% of the ALA group resided out of the Lewinnek abduction zone compared to 3% of the DAA group (P = 0.016). 17% of the ALA group were out of the Lewinnek anteversion zone as opposed to 8% of the DAA group (P = 0.094). CONCLUSION: Our study demonstrates good component positioning outcomes and LLD values in patients following THA through the DAA compared to the ALA.

Recurrent rotator cuff tear: is ultrasound imaging reliable?

BACKGROUND AND HYPOTHESIS: The diagnostic workup of the painful shoulder after rotator cuff repair (RCR) can be quite challenging. The aim of this study was to assess the reliability of ultrasonography (US) for the detection of recurrent rotator cuff tears in patients with shoulder pain after RCR. We hypothesized that US for the diagnosis of recurrent rotator cuff tear after RCR would not prove to be reliable when compared with surgical arthroscopic confirmation (gold standard). METHODS: In this cohort study (diagnosis), we retrospectively analyzed the data of 39 patients with shoulder pain after arthroscopic RCR who had subsequently undergone US, followed by revision arthroscopy. The rotator cuff was evaluated first using US for the presence of retears. Thereafter, revision arthroscopy was performed, and the diagnosis was either established or disproved. The sensitivity and specificity of US were assessed in reference to revision arthroscopy (gold standard). RESULTS: A rotator cuff retear was indicated by US in 21 patients (54%) and by revision arthroscopy in 26 patients (67%). US showed a sensitivity of 80.8% and specificity of 100% in the diagnosis of rotator cuff retears. Omission of partial rotator cuff retears resulted in a spike in sensitivity to 94.7%, with 100% specificity remaining. CONCLUSION: US imaging is a highly sensitive and specific test for the detection of recurrent rotator cuff tears, as confirmed by revision arthroscopy, in patients with a painful shoulder after primary RCR.

Manipulation under anaesthetic for frozen shoulder using Codman's paradox: a safe and early return of function.

PURPOSE: Although previously frozen shoulder was thought to resolve by two to three years, recent studies demonstrated the symptoms can remain for much longer. Manipulation under anaesthetic (MUA) has been shown to be successful in relieving pain and restoring function. Yet, concerns have been raised regarding its safety and the risks of complications. We utilise Codman's paradox to manipulate the shoulder, avoiding rotational torque on the humerus. The aim of our study was to asses shoulder function in the early post MUA period. METHODS: Two hundred twelve consecutive patients (224 shoulders) (mean age 52.4 years) underwent MUA using Codman's paradox for frozen shoulder as sole procedure between 2005 and 2013. All were evaluated clinically, preoperatively and postoperatively, at three weeks and three months, for Constant score (CS), pain, range of motion (ROM), patient satisfaction and subjective shoulder value (SSV). RESULTS: At three weeks and three months, a significant improvement was found in CS from 30.7 to 66 and 70 respectively. Forward elevation improved from 91° to 154° and 160 °, abduction from 69° to 150° and 156 °, internal rotation from 12° to 62° and 66 °, and external rotation from 10° to 46° and 50 °. Pain score improved from 4.4/15 to 9.6/15 and 10.4/15, SSV improved from 1.5/10 to 6.5/10 and 6.7/10. (p<0.001). CONCLUSION: Use of Codman's paradox provides a safe and efficient way to perform MUA for frozen shoulder. It results in dramatic early improvement in ROM, functional outcomes and high satisfaction, as early as three weeks post-operatively.

Intraobserver and interobserver reliability of the Copeland-Levy classification for arthroscopic evaluation of subacromial impingement.

BACKGROUND: Defining a simple and reliable classification for acromial and bursal impingement lesions is necessary to standardize terminology, to improve communication, and to allow better evaluation of the proper treatment of impingement lesions and rotator cuff tears. The purpose of this study was to assess orthopedic surgeons' intraobserver and interobserver reliability of the Copeland-Levy classification. METHODS: Six fellowship-trained orthopedic surgeons reviewed shoulder arthroscopy videos of 69 consecutive patients who underwent shoulder arthroscopy for rotator cuff tear repair or subacromial decompression. The surgeons were asked to classify impingement lesions according to the Copeland-Levy classification. One month afterward, the surgeons were requested to repeat the evaluation of the same impingement lesions. Intraobserver reliability was calculated using Cohen's weighted κ. Interobserver reliability was calculated using Kendall's W. RESULTS: Overall intraobserver reliability for acromial and bursal lesions was κ = 0.86 (95% confidence interval, 0.82-0.9) and κ = 0.97 (95% confidence interval, 0.95-0.98), respectively. Interobserver reliability for acromial and bursal lesions was W = 0.87 and W = 0.92, respectively. CONCLUSION: Intraobserver and interobserver reliability of the Copeland-Levy classification among senior orthopedic surgeons is excellent. Hence, we suggest the Copeland-Levy classification be used to standardize terminology of the subacromial impingement lesion.

Bilateral reverse total shoulder arthroplasty-functional outcome and activities of daily living.

BACKGROUND: Reverse total shoulder arthroplasty (rTSA) has gained popularity in recent years, providing good shoulder elevation, yet less predictable rotations. Good rotations are crucial for performance of activities of daily living (ADLs), including personal hygiene. Concerns remain regarding bilateral rTSA over lack of rotations bilaterally and resultant difficulties with ADLs. This study examined the outcome of patients with bilateral rTSA in restoration of function and ADLs. METHODS: Data were prospectively collected for 19 patients (15 women, 4 men; 38 shoulders), with a mean age of 74.5 years, who underwent staged bilateral rTSA between 2007 and 2013. Mean follow-up was 48.4 months (range, 24-75 months). Patients were evaluated clinically using the Constant score, patient's satisfaction, Subjective Shoulder Value, and the Activities of Daily Living External and Internal Rotations (ADLEIR) score. Video clips were also recorded for documentation at all visits. RESULTS: Mean duration between staged operations was 18.2 months (range, 3-46 months). The Constant score improved from 18.7 to 65.1 points (age- and sex-adjusted, 100.2). Elevation improved from 57.5° to 143°, internal rotation (IR) from 9° to 81° (30 shoulders could reach above the sacroiliac joint), and external rotation (ER) from 20° to 32° (35 shoulders had >20° ER in adduction, 31 shoulders had full ER in elevation). The Subjective Shoulder Value improved from 2.1 of 10 to 9.2 of 10. Mean ADLEIR score was 33 of 36 (P < .001 for all). Most patients resumed their leisure and sport activities (gardening, golf, swimming, bowling). CONCLUSION: Bilateral rTSA results in marked and predictable improvement in all movements, pain relief, and functional outcomes, with high patient satisfaction and high ADLEIR score. All patients were able to perform perineal hygiene after their rTSA. Most patients had no limitation in ADLs and their leisure activities.

Radiographic templating of total hip arthroplasty for femoral neck fractures.

PURPOSE: The purpose of this study was to evaluate the use of pre-operative digital templating to minimize complications including limb length discrepancy (LLD), intraoperative fractures and early dislocations in patients with intracapsular femoral neck fractures. METHODS: We retrospectively compared 23 patients undergoing total hip arthroplasty (THA) for intracapsular femoral fractures with pre-operative digital templating and 48 patients without templating. RESULTS: The mean post-operative LLD was significantly lower in patients who had pre-operative templating than in the control group (6.7 vs. 11.5 mm, p = 0.023). Only three patients (13 %) with templating had LLD greater than 1.5 cm, compared to the 15 patients (31 %) without templating (p = 0.17). In eight cases the final femoral stem size matched the templated size, while 19 patients were within two size increments. Complications included one dislocation and one intra-operative fracture in the control group. CONCLUSION: The present study demonstrated that careful pre-operative planning may reduce LLD in patients undergoing THA due to intracapsular hip fractures.

Reverse shoulder arthroplasty with a cementless short metaphyseal humeral implant without a stem: clinical and radiologic outcomes in prospective 2- to 7-year follow-up study.

BACKGROUND: Reverse shoulder prostheses are increasingly used in recent years for treatment of glenohumeral arthropathy with deficient rotator cuff. Bone preservation is becoming a major goal in shoulder replacement surgery. Metaphyseal humeral components without a stem were developed to minimize bone resection and preserve bone. This study evaluated the clinical and radiologic outcomes at 2 to 7 years using a novel short metaphyseal reverse total shoulder arthroplasty (rTSA) prosthesis without a diaphyseal stem. METHODS: Between 2005 and 2010, 102 consecutive patients underwent rTSA with this implant, and 98 (20 men, 78 women) were available for follow-up. Mean age was 74.4 years (range, 38-93 years). Indications were cuff tear arthropathy, 65; fracture sequelae, 12; rheumatoid arthritis, 13; failed rotator cuff repair, 3; cuff deficiency with loosening of anatomic prosthesis, 3; and acute trauma, 2; with 17 of these as revisions. RESULTS: Patients' satisfaction (Subjective Shoulder Value) improved from 8 of 100 to 85 of 100. The Constant score improved from 14 to 59 (age- and sex-adjusted, 86; P < .0001). Range of motion improved from 47° to 129° in elevation, 10° to 51° in external rotation, and 21° to 65° in internal rotation. Radiographic analysis showed no lucencies, subsidence, or stress shielding around the humeral or glenoid components. Glenoid notching was found in 21 patients (18 grade 1-2; 3 grade 3). CONCLUSIONS: The short metaphyseal rTSA design without a diaphyseal stem shows encouraging short- to midterm results, with excellent pain relief and shoulder function, restoration of good active range of motion, and high patient satisfaction scores. The design of this implant seems to result in improved rotational movements, low incidence of glenoid notching, and no implant loosening, subsidence, or stress shielding.

Revision shoulder arthroplasty: does the stem really matter?

BACKGROUND: The management of a failed shoulder arthroplasty represents a complex and difficult problem for the treating surgeon, with potential difficulties and complications that are related to the need to remove a well-fixed stem. The aim of this study is to compare the intraoperative complications, postoperative complications, and outcome of revisions from stemmed arthroplasties (STAs) with those from surface replacement arthroplasties (SRAs). METHODS: From 2005 to 2012, 40 consecutive revision shoulder arthroplasties were performed at our institute: 17 from STAs and 23 from SRAs. Perioperative events, operation time, blood loss, intraoperative fractures, and use of structural allograft were recorded. Clinical and radiologic outcomes were analyzed. RESULTS: Operation time, need for humeral osteotomy, need for structural allograft, and number of intraoperative fractures were significantly higher in the STA group. Blood loss, drop in hemoglobin level, need for blood transfusion, and hospitalization time were also higher in the STA group, but these differences were not statistically significant. Reoperation was performed in 3 patients in the SRA group. A significant clinical improvement was observed in both groups. The Constant score was higher in the SRA group. CONCLUSION: Revision of STAs is a more demanding procedure. The postoperative complication rate was slightly higher in the SRA group. The group with revision of SRAs showed slightly better clinical and radiographic results, but there was no statistically significant difference between the groups.

Capsular closure does not affect development of heterotopic ossification after hip arthroscopy.

PURPOSE: The purpose of this study was to evaluate the role of capsular closure after hip arthroscopy in reduction of the incidence of heterotopic ossification (HO). METHODS: One hundred (50 study group, 50 control group) consecutive hip arthroscopy procedures with radiographic follow-up of more than 9 weeks were included in the study. The study group consisted of 50 patients in whom capsular closure with 2 No. 1 polydioxanone (PDS) sutures was performed, and a control group consisted of 50 patients in whom the capsule remained open after capsulotomy. HO was assessed by radiographs using the Brooker classification. Statistical analysis of the data was carried out with the χ-square or Fisher exact test and Student t test, when appropriate, at a significance level of .05. RESULTS: Thirty-six (36%) patients had radiographic evidence of postoperative HO (14 patients in the capsular closure group). No significant difference was found regarding sex, side of operation, age, or HO rate between the study and the control groups (P = .778, P = .123, P = .744, and P = .144, respectively). Furthermore, no significant difference was found in the rate of HO with potential clinical significance (Brooker classification > I) between the control and study groups (P = .764). CONCLUSIONS: Capsular closure did not seem to alter the rate of HO when compared with a control group of patients in whom the capsulotomy was not repaired. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Surface replacement arthroplasty for glenohumeral arthropathy in patients aged younger than fifty years: results after a minimum ten-year follow-up.

BACKGROUND: The role of cementless surface replacement arthroplasty (CSRA) in young individuals is currently unclear. The aim of this study was to evaluate CSRA long-term results for glenohumeral arthritis in young patients. METHODS: Between 1990 and 2003, 54 CSRAs were performed on 49 patients (25 men, 24 women) aged younger than 50 years. Mean age was 38.9 years (range, 22-50 years). Three patients (4 shoulders) died over time and 8 were lost to follow-up, leaving 38 patients (42 shoulders) with a mean follow-up of 14.5 years (range, 10-25 years). There were 17 total shoulder replacements with metal back glenoid, and 37 underwent humeral head resurfacing with microfracture of the glenoid. RESULTS: The indications were avascular necrosis, 16; rheumatoid arthritis, 20; instability arthropathy, 7; primary osteoarthritis, 5; fracture sequelae, 3; postinfection arthritis, 2; and psoriatic arthritis, 1. The mean relative Constant score increased from 11.5% to 71.8% (P < .0001), and the mean patient satisfaction at final follow-up was 8.7 of 10. The mean relative Constant score for the humeral head resurfacing with microfracture of the glenoid improved to 77.7% compared with 58.1% for total resurfacing arthroplasty. Two required early arthrodesis due to instability and deep infection. Seven were revised to stemmed prosthesis: 1 for traumatic fracture and 1 for glenoid erosion 16 years after the index procedure. Five shoulders in 4 patients (4 rheumatoid arthritis, 1 avascular necrosis) were revised at 8 to 14 years after surgery for cuff failure and loosening. Three were revised to stemless reverse total shoulder arthroplasty due to rotator cuff failure at 23, 16, and 13 years after surgery. CONCLUSIONS: CSRA provides good long-term symptomatic and functional results in the treatment of glenohumeral arthropathy in patients aged younger than 50 years in 81.6% of the patients. This improvement is maintained over more than 10 years after surgery, with high patient satisfaction (8.7 of 10). However, 10 shoulders (of 54) (18.5%) underwent revision arthroplasty. Resurfacing offers a valuable tool in treating young patients with glenohumeral arthritis, providing reasonably good long-term results in 81.6% of the patients, while allowing preservation of bone stock if the need for revision arises. All the revision arthroplasty options are preserved, including less invasive procedures.

A patient-derived Constant-Murley score is comparable to a clinician-derived score.

BACKGROUND: Although there are many advantages to patient-based assessment for musculoskeletal conditions, one common problem is that many of these assessments are perceived to be subjective. To overcome this limitation for patient-based shoulder evaluation, we developed a modified Constant-Murley score that allows patients to complete subjective and objective sections of the score. QUESTIONS/PURPOSES: The purpose of our study was to assess the reliability of the new patient-based Constant-Murley score questionnaire by comparing composite scores and subscores obtained with those obtained using the standard physician-based Constant-Murley questionnaire in the same group of patients. METHODS: Between August and October 2000, all patients having shoulder surgery in our institute were invited to participate in this study; 58 of 61 (95%) opted to do so and completed the patient-based questionnaire at preoperative and postoperative assessments. The clinician-based Constant-Murley score was performed by a clinician who was blinded to the corresponding patient-based questionnaire. Patients underwent various procedures ranging from manipulation under anesthesia and arthroscopic procedures to reverse shoulder arthroplasty. RESULTS: The mean patient-based and the clinician-based Constant-Murley scores were 47 (SD = 19.5; range, 4-90; N = 108) and 48 (SD = 19.9; range, 4-90; N = 108) points respectively. The mean difference was -1.3 (SD = 3; range, -11 to 8; N = 108) points. The new patient-based Constant-Murley score questionnaire reproduced the patient-based method and had substantial to almost perfect agreement with it for the composite score and various subgroups. CONCLUSIONS: These results suggest that a patient-based questionnaire can be used interchangeably with or in place of a clinician-based Constant-Murley score. These results apply to subjective and objective items of the Constant-Murley score.

Clinical and functional outcome after acetabular labral repair in patients aged older than 50 years.

PURPOSE: To assess the clinical and functional outcome of labral repair in patients aged older than 50 years. METHODS: We performed a prospective analysis of 20 patients aged older than 50 years who had undergone arthroscopic repair of a torn acetabular labrum (6 men and 14 women; mean age, 58 years). The indication for surgery was groin pain due to various causes with or without associated mechanical symptoms that did not respond to nonoperative treatment for more than 6 months. Intraoperatively, all patients were diagnosed with labral pathology. The mean duration of symptoms was 3.1 years (range, 0.5 to 15 years). The mean follow-up period was 22 months (range, 12 to 35 months). The outcome was prospectively measured with the modified Harris Hip Score (MHHS) and Hip Outcome Score (HOS). RESULTS: The indication for surgery was femoroacetabular impingement (FAI) with cam deformity and a labral tear in 4 patients, FAI with pincer deformity and a labral tear in 1 patient, FAI with both deformities in 1 patient, a gluteus medius tear in 2 patients, and an isolated labral tear in 12 patients. Acetabular chondral lesions were present in 11 patients (55%). The mean preoperative and postoperative MHHS was 62.5 and 87.2, respectively (P < .001); the mean preoperative and postoperative HOS was 42.7 and 86.3, respectively (P < .001); and the mean preoperative and postoperative level of function during usual activities of daily living according to the HOS was 46.0% and 73.7%, respectively (P < .001). No significant difference was identified in MHHS and HOS between gender groups. CONCLUSIONS: Arthroscopic management of FAI and labral repair in patients aged older than 50 years without significant arthritis (Tönnis grade 1 or better) are associated with significant improvement in outcome. Because of the potential importance of the labrum for long-term hip joint integrity, we advocate repair of the labrum in patients aged older than 50 years when possible. LEVEL OF EVIDENCE: Level IV, therapeutic case series.