Is there still a place for anatomic hemiarthroplasty in patients with high functional demands in primary, nonreconstructable proximal humeral fractures? A clinical and radiographic assessment.

BACKGROUND: Vitality-threatening proximal humerus fractures often provide an indication for prosthetic treatment. We investigated the issue of how anatomic hemiprostheses perform in younger, functionally challenging patients with the use of a specific fracture stem and systematic tuberosity management in medium-term follow-up. METHODS: Thirteen skeletally mature patients with a mean age of 64 ± 9 years and a minimum follow-up of 1 year after primary open-stem hemiarthroplasty for 3- and 4-part proximal humeral fractures were included. All patients were followed up regarding their clinical course. Radiologic follow-up included fracture classification, healing of tuberosities, proximal migration of the humeral head, evidence of stem loosening, and glenoid erosion. Functional follow-up included range of motion, pain, objective and subjective performance scores, complications, and return to sports rates. We statistically compared treatment success based on the Constant score between the cohort with proximal migration and the cohort with regular acromiohumeral distance by means of the Mann-Whitney U test. RESULTS: After an average follow-up period of 4.8 years, satisfactory results were obtained. The absolute Constant-Murley score was 73.2 ± 12.4 points. The disabilities of the arm, shoulder, and hand score was 13.2 ± 13.0 points. Patients reported their mean subjective shoulder value as 86.6% ± 8.5%. Pain was reported as 1.1 ± 1.3 points on a visual analog scale. Flexion, abduction, and external rotation values were 138 ± 31°, 134 ± 34°, and 32 ± 17°, respectively. 84.6% of the referred tuberosities healed successfully. Proximal migration was observed in 38.5% of cases and was associated with worse Constant score results (P = .065). No patient showed signs of loosening. Mild glenoid erosion was apparent in 4 patients (30.8%). All patients who were interviewed and participated in sports before surgery were able to return to their primary sport after surgery and continued to do so during the final follow-up. CONCLUSIONS: With narrow indications, use of a specific fracture stem and adequate tuberosity management, successful radiographic and functional results are presented after a mean follow-up of 4.8 years after hemiarthroplasty for primary nonreconstructable humeral head fractures. Accordingly, open-stem hemiarthroplasty appears to remain a possible alternative to reverse shoulder arthroplasty in younger, functionally challenging patients with primary 3- or 4-part proximal humeral fractures.

Complications and revisions in anatomic and reverse short stem shoulder arthroplasty.

INTRODUCTION: One current trend in the field of shoulder arthroplasty is a design shift to shorter and metaphyseal fixed humeral stem components. The aim of this investigation is to analyze complications resulting in revision surgery after anatomic (ASA) and reverse (RSA) short stem arthroplasty. We hypothesize that complications are influenced by the type of prosthesis and indication for arthroplasty. MATERIALS AND METHODS: A total of 279 short stem shoulder prostheses were implanted by the same surgeon (162 ASA; 117 RSA), and 223 of these prostheses were implanted as primary procedures; in 54 cases, arthroplasty was performed secondary to prior open surgery. Main indications were osteoarthritis (OA) (n = 134), cuff tear arthropathy (CTA) (n = 74) and posttraumatic deformities (PTr) (n = 59). Patients were evaluated at 6 weeks (follow-up 1; FU1), 2 years (FU2) and the time span of the last follow-up defined as FU3 with a minimum FU of 2 years. Complications were categorized into early complications (within FU1), intermediate complications (within FU2) and late complications (> 2 years; FU3). RESULTS: In total, 268 prostheses (96.1%) were available for FU1; 267 prostheses (95.7%) were available for FU2 and 218 prostheses (77.8%) were available for FU3. The average time for FU3 was 53.0 months (range 24-95). A complication leading to revision occurred in 21 prostheses (7.8%), 6 (3.7%) in the ASA group and 15 (12.7%) in the RSA group (p < 0.005). The most frequent cause for revision was infection (n = 9; 42.9%). After primary implantation, 3 complications (2.2%) occurred in the ASA and 10 complications (11.0%) in the RSA group (p < 0.005). The complication rate was 2.2% in patients with OA, 13.5% in CTA and 11.9% in PTr. CONCLUSIONS: Primary reverse shoulder arthroplasty had a significantly higher rate of complications and revisions than primary and secondary anatomic shoulder arthroplasty, respectively. Therefore, indications for reverse shoulder arthroplasty should be critically questioned in each individual case.

Impact of spine alignment on the rotator cuff in long-term wheelchair users.

BACKGROUND: We investigated the impact of poor seated posture on the prevalence of rotator cuff tears (RCTs) among wheelchair-dependent individuals with long-standing paraplegia. METHODS: The study included 319 patients. Lateral radiographs of the spine were collected from a database and analyzed to assess the global spinopelvic alignment (SPA). Magnetic resonance images of both shoulders were obtained to detect the presence of cuff tears. Patients were divided into 2 groups: Group RCT-I included all patients with cuff tears (right, left, or bilateral), whereas group RCT-II consisted exclusively of patients with bilateral cuff tears. We used the classification systems developed by Kendall et al and Roussouly et al to assess the sagittal spine alignment and SPA, respectively. Univariate and multivariate analyses were performed. To fit both models (groups RCT-I and RCT-II) to the data, the 4 spine curves according to Roussouly et al were subdivided into 2 groups: Group SPA-I included both type 1 and type 2, whereas group SPA-II included both type 3 and type 4. RESULTS: Magnetic resonance images showed a cuff tear in 192 patients (60.19%) (group RCT-I). Among those, 37 patients (11.60%) had tears in both shoulders (group RCT-II). In group RCT-I, 70.31% of the patients had a kyphotic-lordotic posture. The kyphotic-lordotic posture, a longer duration, and a more rostral neurologic level of injury were highly associated with cuff tear prevalence. In group RCT-II, the multivariate analysis showed that only the duration of spinal cord injury was significantly associated with RCTs. CONCLUSION: Thoracic hyperkyphosis was associated with a markedly high rate of RCTs. The data from this study may provide support for developing preventive strategies.

Total shoulder arthroplasty: risk factors for intraoperative and postoperative complications in patients with primary arthritis.

BACKGROUND: This study evaluated and identified risk factors for the development of intraoperative and postoperative surgical complications in total shoulder arthroplasty in patients with primary osteoarthritis. METHODS: We evaluated patient-specific factors, including age, sex, body mass index, prior nonarthroplasty surgery, smoking, alcohol consumption, and the American Society of Anesthesiologists (ASA) Physical Status Classification System in 275 patients (76 men, 199 women) with an average age of 68 years (range, 51-85 years). We categorized the number and severity of all complications and correlated these results with the patient-specific factors RESULTS: Twenty-seven complications (9.8%) in 275 shoulder arthroplasties were recorded. We identified 22 patients (8%) with category I complications and 5 (2.8%) with category II complications. Patients with an ASA score of 3 showed an increased likelihood of having a surgical complication compared with the control group with ASA scores of 1 and 2 (odds ratio, 4.28; 95% confidence interval, 1.79-10.20; P < .01). Smokers were more prone to surgical complications than nonsmokers (odds ratio, 5.08; 95% confidence interval, 1.96-13.11; P = .02). CONCLUSION: Surgical complication rates after anatomic total shoulder arthroplasty in patients with primary osteoarthritis correlate with the patient's overall health status and nicotine consumption. This may be useful for predicting the likelihood of surgical complications and may thus prove important for clinicians to better assess and explain possible risks before surgery.

Reverse arthroplasty for patients with chronic locked dislocation of the shoulder (type 2 fracture sequela).

BACKGROUND: The aim of this multicenter study was to analyze the clinical and radiographic outcome and to report on the types of complications in patients with chronic locked shoulder dislocation treated with reverse shoulder arthroplasty. METHODS: Twenty-two patients with a mean age of 71 years were included. The mean duration of follow-up was 3.5 years. Preoperatively, computed tomography or magnetic resonance imaging scans were performed and analyzed for bone defects and the status of the rotator cuff. Radiographs in 2 planes were obtained before arthroplasty and at final follow-up (mean, 3.5 years; range, 2-9 years). The Constant-Murley score was documented, together with active shoulder flexion, external rotation, and internal rotation. RESULTS: There was a significant increase in mean Constant-Murley score from 13.6 points preoperatively to 47.4 points postoperatively (P < .001). Mean shoulder flexion was 37.7° before arthroplasty and 103° thereafter (P < .001). External rotation increased from -0.5° to 14.7° (P < .003). There were 7 complications (32%), leading to revision surgery in 6 cases (27%). The most common reason for revision surgery was failure of the glenoid component due to bone defects on the glenoid side. Eight patients rated their subjective result as very good, 5 as good, 5 as satisfactory, and 4 as unsatisfactory. CONCLUSION: Reverse shoulder arthroplasty may be a viable treatment option for chronic locked shoulder dislocations with concomitant rotator cuff lesions and an intact glenoid. However, improvement in function is only fair and in this series, there was a high percentage of complications requiring re-operation.

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.

Functional results of hemi- and total shoulder arthroplasty according to diagnosis and patient age at surgery.

Background and purpose - There is a lack of information on any associations between the functional outcome and age and diagnosis in patients who have undergone shoulder arthroplasty. We therefore evaluated the functional outcome in "young" and "old" patients treated with either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) with diverse diagnoses. Patients and methods - The functional results of 496 primary shoulder arthroplasties were analyzed using the Constant score (age- and sex-adjusted) and subjective satisfaction. Patients ≤55 years of age at surgery were defined as "young. Diagnoses were primary osteoarthritis (n = 339), posttraumatic osteoarthritis (n = 78), cuff tear arthropathy (n = 36), avascular necrosis (n = 30), and rheumatoid arthritis (n = 13). Mean length of follow-up was 4 (2-14) years. Results - 70% of the TSA patients were very satisfied with the postoperative result, as compared to 39% after HA. The Constant score and patient satisfaction were similar in the "young" and "old" groups. Pain relief was better in the "old" group. The mean improvement in the Constant score after cuff tear arthropathy (22 points) was inferior to that for primary osteoarthritis (36 points), avascular necrosis (34 points), and rheumatoid arthritis (37 points). Inferior mean Constant scores were also seen for posttraumatic osteoarthritis (29 points) compared to primary osteoarthritis (36 points). 63% of patients with primary osteoarthritis were very satisfied, as compared to only 36% of the patients with posttraumatic osteoarthritis. Interpretation - Shoulder arthroplasty is successful in the medium term for different glenohumeral diseases, irrespective of patient age at surgery. However, the appropriate treatment method for cuff tear and posttraumatic conditions of the shoulder remains to be found, particularly in young patients.

Radiologic bone adaptations on a cementless short-stem shoulder prosthesis.

BACKGROUND: This study evaluated the timing and location of radiologic bone adaptations related to shoulder arthroplasty using a single type of cementless short-stem shoulder prosthesis. METHODS: Uncemented short-stem shoulder arthroplasties were evaluated in 52 patients at a mean age of 71.6 years (range, 58.1-86.6) with a minimum clinical and radiologic follow-up of 2 years (mean, 32 months; range, 23-52 months). All radiographs were analyzed for inclination of the stem, filling ratio of metaphysis and diaphysis, bone remodeling around the stem, radiolucent lines around the glenoid, and subsidence of the humeral stem. Finally, the radiographic and clinical findings were compared between patients with low and high bone adaptations. RESULTS: At final follow-up, no loosening, subsidence, or osteolysis was seen. High bone adaptations were present in 27 patients (51.9%). Cortical thinning and osteopenia in the medial cortex (82.7%) and spot welds in the lateral cortex (78.6%) were the most frequently occurring bone adaptations. Patients with high bone adaptations had significantly higher metaphyseal (0.60 ± 0.05 vs. 0.56 ± 0.06; P = .024) and diaphyseal filling ratio (0.66 ± 0.04 vs. 0.61 ± 0.06; P = .019) at 2-year follow-up than patients with low bone adaptations. Clinical outcome was not influenced by the radiographic changes. CONCLUSION: The clinical and radiologic results of the short-stem shoulder arthroplasty are comparable to those with the third and fourth generations of standard stem arthroplasty. Higher filling ratios in the metaphysis and the diaphysis were significantly associated with the occurrence of high bone adaptations.

Do overhead sports increase risk for rotator cuff tears in wheelchair users?

OBJECTIVE: To analyze whether frequent overhead-sports activity increases the risk for rotator cuff disease in patients with spinal cord injuries (SCIs) who are wheelchair dependent. DESIGN: Cross-sectional study, risk analysis. SETTING: Department of Orthopaedic Surgery, Trauma Surgery and Spinal Cord Injury. PARTICIPANTS: Patients (N=296) with SCI requiring the full-time use of a manual wheelchair were recruited for this study. The total population was divided into 2 groups (sports vs no sports), among them 103 patients playing overhead sports on a regular basis (at least 1-2 times/wk) and 193 patients involved in overhead sports less than once a week or in no sports activity at all. The mean age of the sports group was 49.1 years. The mean duration of wheelchair dependence was 26.5 years. The mean age of the no-sports group was 48 years. The mean duration of wheelchair dependence was 25.2 years. Each individual completed a questionnaire designed to identify overhead-sports activity on a regular basis and was asked about shoulder problems. Magnetic resonance imaging scans of both shoulders were performed in each patient and analyzed in a standardized fashion. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Possible differences in continuous data between patients with and without rotator cuff tear were evaluated. The relative risk of suffering from a rotator cuff tear between patients playing overhead sports and those not playing overhead sports was calculated. RESULTS: One hundred three patients played overhead sports regularly and 193 did not. There was no difference between groups regarding age, sex, level of SCI, and duration of wheelchair dependence. The body mass index was significantly lower in the sports group than in the no-sports group (P<.0001). A rotator cuff tear was present in 75.7% of the patients in the sports group and in 36.3% of the patients in the no-sports group (P<.0001). Rotator cuff tears were symptomatic in 92.6% of the patients. The estimated risk increase for the sports group to develop rotator cuff tears was twice as high as for the no-sports group (95% confidence interval, 1.7-2.6; P<.001). Similar results were found for the neurological level of lesion (T2-7/

How to discriminate between acute traumatic and chronic degenerative rotator cuff lesions: an analysis of specific criteria on radiography and magnetic resonance imaging.

BACKGROUND: Discrimination between acute traumatic and chronic degenerative rotator cuff lesions (RCLs) is an important aid to decision making in therapeutic management. To date, no clinical signs or radiologic findings that enable confident differentiation between these distinct etiologic entities have been identified. The purpose of this investigation was to perform a systematic analysis of known radiographic and magnetic resonance imaging (MRI) features of RCLs and of further, not yet accurately described parameters. The hypothesis was that there are specific radiologic features that allow reliable discrimination between traumatic and nontraumatic RCLs. METHODS: Fifty consecutive patients with RCLs confirmed by MRI were enrolled in this study. Group A was made up of 25 patients with a history of trauma within the previous 6 weeks and no pre-existing shoulder pain, whereas group B comprised 25 patients with shoulder pain for not more than 12 months and no history of relevant trauma. Radiographs and magnetic resonance images were analyzed in a standardized protocol. RESULTS: No radiographic features were found to differ significantly between the 2 groups. On MRI, edema in the injured muscle was more common in group A (37.5% vs 4%, P = .04). A characteristic feature in traumatic RCLs was a wavelike appearance (kinking) of the central tendon (64% vs 32%, P = .03). In group B, more muscular atrophy was found (29.2% vs 60%, P = .02). Thinning and retraction did not differ between the groups. CONCLUSION: MRI, but not radiography, can be used to help discriminate between traumatic and nontraumatic RCLs. Although no absolute distinguishing feature was found, edema, kinking, and muscular atrophy are positive criteria for differentiation.

Clinical and radiological results of a cementless short stem shoulder prosthesis at minimum follow-up of two years.

PURPOSE: Uncemented short stem shoulder arthroplasty combines the advantages of a bone-saving implantation with a straightforward revision option. Uncemented humeral long stems can be associated with stress shielding and loosening. Therefore, we analysed the clinical and radiological outcome of a short stem shoulder prosthesis with metaphyseal fixation. METHODS: This two-centre study included 82 total shoulder arthroplasties in 80 patients with short stem shoulder prosthesis and a cemented polyethylene glenoid performed between 2010 and 2012. Sixty-eight shoulders had primary osteoarthritis, eight shoulders had post traumatic sequelae and six had other diagnoses. Minimum follow-up was two years. Outcome data included the Constant Score (CS), Subjective Shoulder Value (SSV), Pain Scale (0-15) and range of motion. Radiographic evaluation was done in shoulders with primary osteoarthritis in a standard view. RESULTS: The mean clinical and radiological follow-up was 31.2 ± 7.2 months (20-52). CS improved from 36.7 ± 15.2 % to 90.4 ± 16.4% and SSV improved from 39.4 ± 15.5 points to 85.5 ± 13.2 points (p < 0.0001). Pain was rated as mild or none in 76 shoulders (92.7%) with a mean value of 13.2 ± 2.6. The mean active flexion was 157.0 ± 24.7°, abduction was 152.6 ± 29.1° and the active external rotation was 38.2 ± 14.8° at recent follow-up. Radiographic assessment was done in 44 shoulders. Six shoulders (13.6%) showed features of slight stress shielding at the medial cortex and no stem with subsidence was found. Three glenoids (6.8%) had minor radiolucent lines. CONCLUSIONS: Uncemented short stem shoulder arthroplasty with a cemented polyethylene glenoid can yield a stable fixation with a good clinical outcome at minimum follow-up of two years.

Results of cementless humeral head resurfacing with cemented glenoid components.

PURPOSE: The aim of this study was to analyse the short- and medium-term clinical and radiographic results of cementless humeral head resurfacing in combination with a cemented glenoid component. METHODS: Thirty-five patients with a mean age of 65 years (range 42-84) and a mean follow-up of three years (two to six) were followed up. The Constant score with its subgroups as well as shoulder motions and complications were recorded. Radiographs in two planes were analysed for loosening of the components. RESULTS: Mean Constant score improved from 29 points (6-63) to 70 points (41-89; p < 0.001). Mean shoulder flexion increased from 89° (20-170) to 158° (100-180) and mean external rotation from 10° (-10-30) to 39° (10-80). Satisfaction rate was 94 % at final follow-up. None of the components was found to be loose. There were three neurological complications, probably related to increased forces on the humeral head retractor during glenoid preparation. Two of them resolved completely; in one patient hyposensitivity remained. CONCLUSION: Cementless humeral surface replacement arthroplasty in combination with a cemented glenoid component leads to an overall satisfactory clinical outcome. However, the high rate of neurological complications found in this study, probably related to difficult glenoid exposure, led us to discontinue this implant configuration.

Reverse arthroplasty for osteoarthritis and rotator cuff deficiency after previous surgery for recurrent anterior shoulder instability.

PURPOSE: Osteoarthritis in combination with rotator cuff deficiency following previous shoulder stabilisation surgery and after failed surgical treatment for chronic anterior shoulder dislocation is a challenging condition. The aim of this study was to analyse the results of reverse shoulder arthroplasty in such patients. METHODS: Thirteen patients with a median follow-up of 3.5 (range two to eight) years and a median age of 70 (range 48-82) years were included. In all shoulders a tear of at least one rotator cuff tendon in combination with osteoarthritis was present at the time of arthroplasty. The Constant score, shoulder flexion and external and internal rotation with the elbow at the side were documented pre-operatively and at the final follow-up. Pre-operative, immediate post-operative and final follow-up radiographs were analysed. All complications and revisions were documented. RESULTS: Twelve patients were either satisfied or very satisfied with the procedure. The median Constant score increased from 26 points pre-operatively to 67 points at the final follow-up (p = 0.001). The median shoulder flexion increased significantly from 70° to 130° and internal rotation from two to four points (p = 0.002). External rotation did not change significantly (p = 0.55). Glenoid notching was present in five cases and was graded as mild in three cases and moderate in two. One complication occurred leading to revision surgery. CONCLUSIONS: Reverse arthroplasty leads to high satisfaction rates for patients with osteoarthritis and rotator cuff deficiency who had undergone previous shoulder stabilisation procedures. The improvements in clinical outcome as well as the radiographic results seem to be comparable with those of other studies reporting on the outcome of reverse shoulder arthroplasty for other conditions.

Treatment of severe cuff tear arthropathy with the humeral head resurfacing arthroplasty: two-year minimum follow-up.

BACKGROUND: The aim of the study was to evaluate the outcome of a humeral head resurfacing arthroplasty implanted toward valgus for patients with cuff tear arthropathy (CTA). MATERIALS AND METHODS: We monitored 24 patients with CTA who underwent resurfacing arthroplasty. Patients were assessed with use of the Constant score and a subjective satisfaction score. The rotator cuff was evaluated preoperatively by magnetic resonance imaging. The Sirveaux classification of glenoid erosion in glenohumeral osteoarthritis with massive rupture of the cuff was used to grade the preoperative status of the glenoid. RESULTS: The mean absolute Constant score for the entire cohort improved from 21 points (range, 7-44 points) to 63 points (range, 23-89 points) at a mean of 38 months (range, 24-56 months). Patients with an intact or moderately atrophied teres minor muscle (n = 16) showed a significantly better Constant score (P = .011) and greater active external rotation (P = .034) than patients with severe atrophy. Neither the type of glenoid erosion according to Sirveaux nor the inclination angle of the implant has an effect on the clinical or functional outcome. CONCLUSIONS: For selected patients with CTA, resurfacing arthroplasty of the humeral head provides satisfactory medium-term outcomes. The teres minor muscle is necessary for maintaining or establishing external rotation. In patients with massive limitation of motion and total absence of the subscapularis tendon, the implantation of a humeral surface replacement should be seriously considered.

Etiology of rotator cuff tears in paraplegic patients: a case-control study.

BACKGROUND: The purpose of this study was to investigate the etiology and the demographic and functional characteristics of rotator cuff tears (RCTs) in 100 paraplegic patients as compared with 100 able-bodied volunteers. METHODS: The magnetic resonance imaging examination results of 200 shoulders in each group were analyzed. Clinical examination included the Constant score and a visual analog scale for pain intensity. RESULTS: The prevalence of RCTs was 63% in paraplegic patients versus 15% in able-bodied volunteers (P < .0001). All RCTs in the paraplegic group were associated with symptoms. Among the patients with RCTs, full-thickness tears were detected in 78% of cases in the paraplegic patient group versus 73% of cases in the volunteer group. The rate of partial-thickness tears was 22% in the paraplegic group versus 27% in the volunteer group. Paraplegic patients had a lower Constant score; Disabilities of the Arm, Shoulder and Hand score; and range of motion and a higher pain intensity than the volunteer cohort. The mean tear width in paraplegic patients was 14.4 mm (range, 8-28 mm) versus 9.9 mm (range, 8-14 mm) in the volunteers (P < .01). CONCLUSION: The etiology of RCTs in paraplegic patients seems to be based on wear-and-tear mechanisms rather than aging. These results are important for our understanding of shoulder pathology in long-term paraplegic patients and show the impact of this problem.

Proprioception 3 years after shoulder arthroplasty in 3D motion analysis: a prospective study.

BACKGROUND: This prospective study evaluated the development of proprioception over the course of 3 years after shoulder arthroplasty. METHODS: Twenty-one patients were enrolled who underwent total shoulder arthroplasty (n = 10) or hemiarthroplasty (HEMI) (n = 11) for shoulder osteoarthritis. All patients were examined 1 day before the operation, 6 months and 3 years after surgery in a motion analysis study with an active angle-reproduction (AAR) test. RESULTS: Overall proprioception measured by the AAR deteriorated significantly 3 years after surgery [from 6.6° (SD 3.1) to 10.3° (SD 5.7); p = 0.017] and was significantly worse than in the control group [10.3° (SD 5.7) vs. 7.8° (SD 2.3); p = 0.030). In the HEMI subgroup, 3 years after shoulder replacement, there is a significant deterioration of proprioception at 30° of external rotation [from 3.1° (SD 3.5) to 12.8° (SD 10.7); p = 0.031]. On average, in the TSA subgroup proprioception deteriorated from 7.1° (SD 3.1) to 8.6° (SD 1.4) and in the HEMI subgroup from 6.1° (SD 2.1) to 12.4° (SD 8.3). The comparison of postoperative impairment of proprioception between the TSA and HEMI subgroup showed significantly worse proprioception for the HEMI subgroup at 30° of external rotation [9.8° (SD 10.1) vs. 1.6° (SD 6.3) in the TSA group; p = 0.046]. CONCLUSION: In conclusion, proprioception that was measured by an AAR test remained unchanged or deteriorated 3 years after shoulder arthroplasty. The postoperative deterioration of proprioception was more distinctive in HEMI than in TSA group.

A cross-sectional study of demographic and morphologic features of rotator cuff disease in paraplegic patients.

BACKGROUND: This study analyzed the demographic and morphologic features of rotator cuff disease in paraplegic patients who presented with or without shoulder pain. METHODS: Clinical and magnetic resonance imaging examinations of both shoulders were performed in 317 paraplegic patients. Mean age was 49 (range, 19-76) years. The level of spinal cord injury was between T2 and T7 In 54% of patients and between T8 and L3 in 46%. Constant scores were measured for all shoulders. Pain was analyzed using a visual analog scale. RESULTS: Rotator cuff tears were not present in 51%, were unilateral in 20%, and were bilateral in 29%. Age was older and duration of spinal cord injury was significantly longer in patients with bilateral tears than in patients without or with unilateral tears (P < .001). In patients with unilateral tears, a full-thickness rupture of the supraspinatus tendon was found in 67%, whereas a partial-rupture was detected in 33%. Of the patients with bilateral tears, 75% presented with a full-thickness rupture and 25% with a partial rupture. The mean Constant score was 76 (range, 37-98) in patients without cuff tears, 69 (range, 16-94) for patients with unilateral tears, and 64 (16-96) for patients with bilateral tears (P < .001). CONCLUSIONS: Rotator cuff disease is common and correlates highly with age and duration of spinal cord injury, which underlines the theory of "wear and tear" in wheelchair-dependent patients.

Results of a convex-back cemented keeled glenoid component in primary osteoarthritis: multicenter study with a follow-up greater than 5 years.

PURPOSE: We assessed the clinical and radiologic results of a cemented all-polyethylene convex-back keeled glenoid component used with a third-generation prosthesis. METHODS: Between 1996 and 2003, in 4 European centers, 333 shoulder arthroplasties were performed for primary osteoarthritis by use of a cemented all-polyethylene convex-back keeled glenoid component. Kaplan-Meier survivorship analysis was performed, and clinical outcome was assessed with the Constant score, range of motion, and subjective evaluation. RESULTS: At a mean of 89.5 months' follow-up, the Constant score improved from 31.4 to 67.6 points (P < .0001). Active forward elevation improved from 94.9° to 146.6° (P < .0001) and external rotation from 9.0° to 35.3° (P < .0001). Of the patients, 93.5% were either satisfied or very satisfied. The rate of revision for glenoid loosening was 0.6%; however, the rate of radiologic glenoid loosening was 18.9%. Glenoid survival was 99.7% at 5 years and 98.3% at 10 years with endpoint defined as revision surgery for glenoid loosening and 99.7% at 5 years and 51.5% at 10 years with endpoint defined as radiologic loosening. CONCLUSIONS: We showed highly satisfactory clinical outcomes and extremely low rates of revision for glenoid loosening using a cemented convex-back keeled glenoid. There was a concerning rate of radiologic loosening, which only became apparent after 5 years, and this was associated with excessive glenoid reaming. Because radiologic changes are progressive and precede the need for revision, innovations in this field need to report radiologic and clinical results with follow-up of at least 5 to 10 years to prove any superiority.

Bone cement penetration pattern and primary stability testing in keeled and pegged glenoid components.

BACKGROUND: It has been proposed that bone mineral density has an influence on cement penetration in hip and knee arthroplasty. The hypotheses of this study were that: 1) there is a negative correlation between bone mineral density (BMD) and cement penetration in cemented glenoid components; and 2) that implant design has an influence on cement penetration into the glenoid bone. METHODS: BMD of 10 pairs of fresh frozen scapulas was measured. Micro-computed tomography (micro-CT) scans in 3 different sections were analyzed after implantation of keeled and pegged glenoid components using a 3(rd)-generation cementing technique with a vacuum mixing system. Cement penetration was analyzed and correlated with BMD. Pull-out strength testing was performed to analyze primary stability. RESULTS: The overall peak BMD was 0.6 [g/cm(2)] (range, 0.33-0.98). A strong negative correlation between BMD and mean cement penetration was found for the peg (R(2) = -.83; P < .003) and for the keel group (R(2) = -.81; P < .005). Mean cement penetration was 78.4 mm(2) (range, 60.6-94.2) in the keel and 113.9 mm(2) (range, 78.2-143.4) in the peg group (P < .0001). In all cases, the components were pulled out of the cement mantle, whereas the bone-cement interfaces remained intact. The mean pull-out strength was 1093N (764-1343N) for keeled and 884N (650-1264N) for pegged components (P < .05). CONCLUSION: A modern cementing technique, leading to a deep bonding between bone and cement, is crucial to prevent loosening of glenoid components. The findings of this study might help us to better understand the results of follow-up studies of cemented glenoid implants. Our results could be helpful for the choice of implants in patients with poor bone quality like osteoporosis or rheumatoid arthritis.