Two-year minimum survivorship and radiographic analysis of a pressfit short humeral stem for total shoulder arthroplasty.

Background: Newer generation humeral stem designs in total shoulder arthroplasty (TSA) are trending towards shorter lengths and uncemented fixation. The goal of this study is to report a 2-yr minimum clinical and radiographic outcomes of an uncemented short-stem press-fit humeral stem in anatomic total shoulder arthroplasty (ATSA) and reverse total shoulder arthroplasty (RTSA). Methods: A retrospective multicenter database review was performed of all patients who received an uncemented short-length press-fit humeral stem (Equinoxe Preserve humeral stem, Exactech, Inc., Gainesville, FL, USA) in ATSA and RTSA with a minimum two-year follow-up. The primary outcome was the prevalence of humeral stems at risk of radiographic loosening. Secondary outcomes included evaluation of functional outcome scores and prevalence of revision TSA for humeral stem loosening. Two blinded observers performed radiographic analyses, which included humeral stem alignment, canal filling ratio, radiolucent lines, stress shielding (calcar and greater tuberosity), and changes in component position (subsidence and stem shift). At risk stems were defined by the presence of one or more of the following: humeral stem with shifting or subsidence, scalloping of the humeral cortex, or radiolucent lines measuring 2 mm or greater in 3 or more zones. Results: 287 patients (97 ATSA and 190 RTSA) were included in this study. The mean follow-up was 35.9 (±6.1) months. There were significant improvements for all functional outcome scores (P < .05), range of motion (P < .05), and visual analogue pain scale pain (P < .05). The prevalence of humeral stem at risk of radiographic loosening was 1% in the ATSA group (1/97) and 18.4% in the RTSA group (35/190). Calcar resorption was seen in 34% of ATSA and 19% of RTSA, with severe resorption in 12.4% of ATSA and only 3.2% of RTSA. Greater tuberosity resorption was present in 3.1% of ATSA and 7.9% of RTSA. The mean canal filling ratio was 50.2% (standard deviation 11.2%). Using logistic regression, a significant positive correlation between canal filling ratio and stress shielding (P < .01) was seen for both calcar and tuberosity stress shielding. The revision surgery rate was 0% in ATSA compared to 1.6% in RTSA. Conclusion: This retrospective study demonstrates a low revision rate and low prevalence of humeral stems at risk of radiographic loosening at two years with a press-fit short-stem humeral design in ATSA. Physiologic subsidence of humeral stems can account for higher prevalence of humeral stems at radiographic risk of loosening in RTSA compared to ATSA.

Prognostic value of the Walch classification for patients before and after shoulder arthroplasty performed for osteoarthritis with an intact rotator cuff.

BACKGROUND: The Walch classification is commonly used by surgeons when determining the treatment of osteoarthritis (OA). However, its utility in prognosticating patient clinical state before and after TSA remains unproven. We assessed the prognostic value of the modified Walch glenoid classification on preoperative clinical state and postoperative clinical and radiographic outcomes in total shoulder arthroplasty (TSA). METHODS: A prospectively collected, multicenter database for a single-platform TSA system was queried for patients with rotator cuff-intact OA and minimum 2 year follow-up after anatomic (aTSA) and reverse TSA (rTSA). Differences in patient-reported outcome scores (Simple Shoulder Test, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, Shoulder Pain and Disability Index, visual analog scale for pain, Shoulder Function score), combined patient-reported and clinical-input scores (Constant, University of California-Los Angeles shoulder score, Shoulder Arthroplasty Smart Score), active range of motion values (forward elevation [FE], abduction, external rotation [ER], internal rotation [IR], and radiographic outcomes (humeral and glenoid radiolucency line rates, scapula notching rate) were stratified and compared by glenoid deformity type per the Walch classification for aTSA and rTSA cohorts. Comparisons were performed to assess the ability of the Walch classification to predict the preoperative, postoperative, and improved state after TSA. RESULTS: 1008 TSAs were analyzed including 576 aTSA and 432 rTSA. Comparison of outcomes between Walch glenoid types resulted in 15 pairwise comparisons of 12 clinical outcome metrics, yielding 180 total Walch glenoid pairwise comparisons for each clinical state (preoperative, postoperative, improvement). Of the 180 possible pairwise Walch glenoid type and metric comparisons studied for aTSA and rTSA cohorts, <6% and <2% significantly differed in aTSA and rTSA cohorts, respectively. Significant differences based on Walch type were seen after adjustment for multiple pairwise comparisons in the aTSA cohort for FE and ER preoperatively, the Constant score postoperatively, and for abduction, FE, ER, Constant score, and SAS score for pre- to postoperative improvement. In the rTSA cohort, significant differences were only seen in abduction and Constant score both postoperatively and for pre- to postoperative improvement. There were no statistically significant differences in humeral lucency rate, glenoid lucency rate (aTSA), scapular notching rate (rTSA), complication rates, or revision rates between Walch glenoid types after TSA. CONCLUSION: Although useful for describing degenerative changes to the glenohumeral joint, we demonstrate a weak association between preoperative glenoid morphology according to the Walch classification and clinical state when evaluating patients undergoing TSA for rotator cuff-intact OA. Alternative glenoid classification systems or predictive models should be considered to provide more precise prognoses for patients undergoing TSA for rotator cuff-intact OA.

Radial head replacement for acute complex elbow instability: a long-term comparative cohort study of 2 implant designs.

BACKGROUND: Radial head fractures not amenable to reconstruction should be treated by radial head replacement (RHR) when there is associated elbow or forearm instability. There are multiple RHR designs with different philosophies, but 2 of the most commonly used implants include the anatomic press-fit radial head system and the loose-fit metallic spacer. There is little information available specifically comparing the long-term clinical and radiographic outcomes of these 2 systems. The objective of this study was to compare the long-term clinical and radiologic outcomes of 2 RHR designs in the context of complex acute elbow instability. MATERIALS AND METHODS: Ninety-five patients with an average age of 54 years (range, 21-87 years) underwent an acute RHR (46 press-fit Acumed anatomic and 49 loose-fit Evolve metallic spacer) and were prospectively followed for an average of 61 months (range, 24-157 months). There were 34 terrible triads; 36 isolated RH fractures with medial, lateral, or longitudinal instability; and 25 RH fractures associated with a proximal ulnar fracture. Clinical outcome and disability were evaluated with the Mayo Elbow Performance Score (MEPS), the Oxford Elbow Score, and the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Pain and satisfaction were assessed using a visual analog scale. Radiographic analysis included presence of loosening, bone loss, and overstuffing related to the RHR. RESULTS: Eight patients with an anatomic RHR (2 with overstuffing, 3 for stiffness, and 3 with loose implants) and 1 patient with a spacer (with stiffness) required implant removal. There were no significant differences between spacer RHR and anatomic RHR in arc of motion (120° vs. 113°, P = .14), pain relief (1 vs. 1.7, P = .135), MEPS (94 vs. 88; P = .07), Oxford Elbow Score (42.3 vs. 42.2, P = .4), or DASH score (12.2 vs. 14.4, P = .5). However, patients with a spacer RHR were significantly more satisfied (9 vs. 7.7; P = .004) than those with an anatomic implant. Radiographically, 19 anatomic implants had significant proximal bone loss and 10 showed complete lucent lines around the stem. Lucent lines were common around the spacer RHR. These radiographic changes were not always related to worse clinical outcomes. CONCLUSION: Both the anatomic and spacer RHR designs can provide good clinical long-term outcomes. However, patients with a spacer showed a higher degree of satisfaction and those with an anatomic press-fit RHR had a higher revision rate, with radiographic changes that warrant continued follow-up.

Drain use can be avoided in reverse shoulder arthroplasty.

BACKGROUND: Drains have demonstrated no clear benefits and some potentially harmful effects in hip and knee replacements. There is little evidence about the effects of its use in shoulder arthroplasty. We hypothesized that drain use would increase postoperative blood loss without reducing wound complications. METHODS: We included 103 reverse shoulder arthroplasties (RSA), 71 were operated for degenerative pathology, 32 due to a fracture. All complications were recorded. Hemoglobin (Hb) and hematocrit (Htc.) level were collected and compared to postoperative data. Length of hospitalization and volume output were also noted. RESULTS: 45 patients received a closed-suction drain. Patients with coagulopathy had significant higher bleeding and were excluded (p = 0.03). Patients operated for a fracture were older (80.1y.o vs 72.1 p < 0.01) and had higher blood drop (∆Hb p = 0.01; ∆Htc p = 0.03). There were neither differences between drain and control group in ∆Hb or ∆Htc in the degenerative RSA group (1.84+/-0.89 vs 1.68+/-0.84, p = 0.36; 5.78+/-2.89 vs 5.53+/-2.87 p = 0.50) nor in the fracture RSA group (2.65+/-0.94 vs 2.65+/-1.01, p = 0.90; 7.91+/-2.99 vs. 7.09+/-4.21, p = 0.56). There were neither differences in complications (degenerative p = 0.33; fracture p = 0.21). Drain use was related to a longer hospital stay in elective surgery (2.6 vs 1.8 days; p < 0.01). DISCUSSION: The rate of complication is similar between patients with and without drain use. Drain use after shoulder arthroplasty does not affect postoperative bleeding but increases the length of hospital stay. Drains seems to be an unnecessary intervention after RSA that may increase associated costs and can be safely abandoned. LEVEL OF EVIDENCE: Level III retrospective comparative study.

Limiting spread of COVID-19 in an orthopaedic department-a perspective from Spain.

Besides national and international recommendations, orthopaedic departments face significant changes in daily activity and serious issues to maintain their standards in musculoskeletal care during the pandemic Covid-19 crisis that we are facing. This report retrospectively addresses measures that were progressively put in place to modify in a week time the activity of a busy orthopaedic department in a large tertiary university hospital in face of the pandemic. Surgical priorities and surgical outcomes are key aspects to consider. The experience may offer some insight to areas where the spread of the disease may be slower or delayed. Abrupt stop of scheduled surgery and clinics is useful to adapt an orthopaedic department to the overall hospital resource reorganization. Orthopaedic surgeons need to be aware of the risks to patients and personnel in view of underdiagnosed cases, which make pre-operative Covid-19 evaluation mandatory for all surgical cases.

Neurologic complications after surgical management of complex elbow trauma requiring radial head replacement.

BACKGROUND: Radial head arthroplasty (RHA) has become a successful procedure for addressing acute unreconstructible radial head fractures that compromise elbow stability in complex elbow trauma. The purpose of this study was to investigate the incidence of and risk factors for the development of neurologic complications after surgical treatment of complex elbow fractures that require an RHA. METHODS: Sixty-two patients with an unreconstructible radial head fracture and complex elbow instability treated with RHA were included. There were 33 men and 29 women, with a mean age of 54 years (range, 22-87 years). The average follow-up period was 5.2 years (range, 3-16 years). All patients were neurologically intact before surgery. The arthroplasty was implanted through a Kocher approach in 55 cases, whereas a Kaplan approach was used in 7. An uncemented smooth stem arthroplasty (Evolve) was used in 27 patients, and an anatomic ingrowth system (Anatomic Radial Head), in 35. At the time of surgery, 23 patients underwent fixation of a coronoid fracture and 15 underwent plating of the proximal ulna. All patients were clinically examined immediately after surgery and during follow-up to detect any degree of neurologic deficit. Radial and ulnar nerve injuries were classified according to the Hirachi and McGowan classifications, respectively. Functional outcomes were evaluated with the Mayo Elbow Performance Score. RESULTS: A complete posterior interosseous nerve palsy occurred postoperatively in 2 patients. Hand function had completely recovered in both at 2 months after surgery without sequelae. Nine patients complained of ulnar nerve symptoms (immediately after surgery in 6 and as delayed ulnar neuropathy in 3). Most patients with ulnar nerve deficits had undergone additional surgical procedures to address ulnar fractures. Among patients with ulnar neuropathies, only 3 complained of mild sensory symptoms at the latest follow-up. No significant differences in range of motion and Mayo Elbow Performance Score were found between patients with and without neurologic complications. Associated olecranon or coronoid fixation and a prolonged tourniquet time were identified as risk factors for neurologic complications. CONCLUSION: This study shows that the incidence of neurologic complications associated with the surgical treatment of complex elbow fractures requiring implantation of a radial head prosthesis may be underestimated in the literature. Inappropriate retraction in the anterior aspect of the radial neck, a prolonged ischemia time, and concomitant coronoid or olecranon fracture fixation represent the main risk factors for the development of this complication. Although the great majority of patients have full recovery of their nerve function, they should be advised on the risk of this stressful complication.

Morphometry of the radiocapitellar joint: is humeral condyle diameter a reliable predictor of the size of the radial head prosthesis?

BACKGROUND AND HYPOTHESIS: Radial head arthroplasty (RHA) is a reliable procedure to manage complex injuries of the elbow, but complications due to inadequate sizing have been observed. Radiocapitellar morphometry has been studied widely, but RHA preoperative planning is not yet well defined. We hypothesized that specific morphologic parameters of the radiocapitellar joint measured with simple clinical software for radiographic analysis could be useful tools for clinical practice to predict RHA size preoperatively. METHODS: Radiologic radiocapitellar joint dimensions (humeral condyle diameter [HCDi], radial head diameter [RHDi], and radial head height) were analyzed on true anteroposterior and lateral radiographs, using commercial picture archiving and communication system software, in 43 patients with non-osseous pathology of the elbow and 24 patients with RHA. Interobserver concordance was studied, and a regression model to relate different parameters was developed. RESULTS: Interobserver concordance was greater than 0.8 for HCDi and RHDi on the lateral view and RHDi on the anteroposterior view for the general population. The parameter with the best correlation with the radial head arthroplasty diameter (RHADi) size was HCDi on the lateral view. A regression model was calculated and defined as follows: RHADi = 6.99 + 0.733 × HCDi on lateral view. This model allows prediction of RHADi in 67% of cases. CONCLUSION: Radiologic radiocapitellar parameters show good interobserver reliability. RHADi can be calculated preoperatively from HCDi on the lateral view in 67% of cases.

Management of Elbow Trauma: Anatomy and Exposures.

The elbow is a complex joint from the anatomic and biomechanical point of view. A thorough understanding of elbow anatomy greatly aids the surgeon in dealing with elbow trauma. The close vicinity of neurovascular structures should always be kept in mind when selecting a surgical approach. Any approach to the elbow needs to be safe and versatile. Knowledge of the attachment and orientation of elbow ligaments reduces the risk of inadvertent intraoperative injury and/or postoperative instability. Surgeons dealing with elbow trauma should have a good working understanding of elbow anatomy and the available approaches to effectively and efficiently conduct the surgical procedure to maximize outcomes and minimize complications.

Application of adipose tissue-derived stem cells in a rat rotator cuff repair model.

INTRODUCTION: Healing tissue of the rotator cuff does not regenerate the native enthesis; fibrovascular scar tissue is formed instead and this has less favourable biomechanical properties. The purpose of this study was to determine if the application of adipose tissue-derived stem cells (ASCs) could improve biomechanical and histological properties of the repair. MATERIAL AND METHODS: Fifty Sprague-Dawley rats underwent detachment and repair of the supraspinatus tendon, 32 for the biomechanical study and 18 for the histological examination. Animals were randomised in two groups to receive either a collagen carrier alone (untreated group) or the carrier plus 2×10(6) ASCs (ASCs group). A control group (suture only) was also included for the histological examination. The animals were sacrificed at 2 and 4 weeks for the biomechanical study and at 24 hours, and 1 and 4 weeks for the histological study. Maximum load failure energy, elastic energy, mechanical deformation, stiffness and absorbed energy were measured. Immunofluorescence testing was conducted to show the presence of ASCs in the repair area. RESULTS: There were no differences between the untreated group and the ASCs group in any of the biomechanical variables at the 2- and 4-week time points. The mechanical deformation before failure was higher for the ASCs group compared with the untreated group at 2 weeks and 4 weeks (p=0.09), as was the absorbed energy (p=0.06). Differences in maximum load to failure between 2 and 4 weeks were significant for the untreated group (p=0.04) but not for the ASCs group (p=0.17). Histological examination showed less acute inflammation with diminished presence of oedema and neutrophils in the ASCs group. There were no differences in the orientation of collagen fibres between groups at either time point. In the ASCs group, collagen was present only at the last time point. CONCLUSION: The application of ASCs in a rat rotator cuff repair model did not improve the biomechanical properties of the tendon-to-bone healing. However, the ASCs group showed less inflammation, which may lead to a more elastic repair and less scarred healing.

Platelet-rich fibrin in arthroscopic repair of massive rotator cuff tears: a prospective randomized pilot clinical trial.

The objective of this study was to prospectively evaluate the feasibility of a large- scale project on the influence of local application of Platelet Rich Fibrin (PRF) on the functional outcome and integrity of the arthroscopically repaired tendons in patients with massive tears of the rotator cuff. A prospective, randomized pilot clinical trial was performed on 28 patients (22 females, 6 males) with an average age of 65 years (range: 53 to 77) undergoing complete arthroscopic repair of a massive rotator cuff tear. After the repair was completed, 6 ml PRF (Vivostat) was locally applied to the repair site in 14 patients; no similar action was done in the other 14 patients. All patients underwent a clinical examination and an arthro-MRI to evaluate the integrity of the repair, one year after the operation. They were followed clinically for a minimum of 2 years. Functional outcome was evaluated with the Constant and DASH scores. There were no reported complications in either group. None of the patients was lost to follow-up. Globally, the Constant score improved from 45 preoperatively (range: 25 to 65) to 64 at one year (range: 20 to 79) (p < 0.001), with no significant change at two years (mean 63, range: 20 to 77). The VAS for pain improved from 5.6/10 preoperatively to 1.7/10 at the most recent examination (p < 0.001). All but two patients were satisfied. With the numbers of patients available, we could not detect a significant difference in the preoperative (46 vs. 43; p = 037) or postoperative Constant score (61 vs. 68; p = 0.125) between the control group and the PRF group. On arthro-MRI, 19 of the 28 patients (68%) were found to have a large re-tear : 10/14 in the PRF group and 9/14 in the control group. Local application of autologous PRF to the repair site of massive rotator cuffs fully reconstructed arthroscopically failed to improve the clinical outcome and the healing rate, compared with a standard repair. However, a large-scale study would be necessary to confirm these results.

Long-term results of radial head resection following isolated radial head fractures in patients younger than forty years old.

BACKGROUND: In the past, radial head resection was the surgical treatment of choice for radial head fractures that could not be internally fixed. More recently, radial head implant arthroplasty has gained popularity for the treatment of isolated radial head fractures. The purpose of the present study was to review the long-term results of radial head resection after radial head fractures not associated with elbow instability in patients younger than forty years of age. METHODS: Twenty-six patients younger than forty years of age who had sustained an isolated fracture of the radial head (including six patients who had sustained a Mason type-II fracture and twenty who had sustained a Mason type-III fracture) that had been treated with primary radial head resection were reviewed retrospectively at a minimum of fifteen years (mean, twenty-five years). Outcomes were evaluated according to the Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder and Hand score. Radiographic assessment of osteoarthritic changes and the carrying angle was also performed. RESULTS: Twenty-one patients (81%) had no elbow pain, three had mild pain, and two had moderate pain. The mean arc of motion was from 9 degrees to 139 degrees of flexion. All but one patient had a functional arc of motion. The mean pronation was 84 degrees, and the mean supination was 85 degrees. Nineteen elbows had normal strength in comparison with the unaffected side. The mean Mayo Elbow Performance Score was 95 points; the score was classified as good or excellent for twenty-four elbows (92%) and as fair for two. The mean Disabilities of the Arm, Shoulder and Hand score was 6 points. Three patients complained of wrist pain, which was mild in two patients and moderate in one. In four patients, some degree of elbow instability could be detected on physical examination. The mean carrying angle of the involved elbow was significantly greater than that of the uninjured elbow (21 degrees compared with 10 degrees). Radiographic changes of arthritis were considered mild in seventeen elbows and moderate in nine. We could not detect significant differences in functional outcome on the basis of the degree of radiographic change. CONCLUSIONS: Radial head resection in young patients with isolated fractures without instability yields long-term satisfactory results in >90% of cases. Osteoarthritic changes are uniformly present but typically are not associated with functional impairment.

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

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

Shoulder arthroplasty for locked posterior dislocation of the shoulder.

Currently, there are no published series with mid- to long-term results on patients undergoing shoulder arthroplasty for locked posterior dislocation of the shoulder. We reviewed the results of patients who underwent shoulder arthroplasty for locked posterior dislocation of the shoulder to determine the results, the risk factors for an unsatisfactory outcome, and the rates of failure. Twelve shoulder arthroplasties were performed at our institution, between January 1, 1980, and December 31, 1997, in 12 patients who had a locked posterior dislocation of the shoulder. All 12 patients were followed up for a minimum of 5 years (mean, 9.0 years) or until the time of revision surgery. There was significant pain relief (P <.001) as well as improvement in external rotation from -13 degrees to 28 degrees (P =.001). On the basis of a modified Neer result rating system, there was 1 excellent, 6 satisfactory, and 5 unsatisfactory results. Three patients underwent revision surgery for posterior instability (two) and component loosening (one). Recurrent instability occurred in two patients in the early postoperative period. There were no cases of recurrent instability greater than 1 year from the time of surgery. The data from this study suggest that shoulder arthroplasty for locked posterior dislocation provides pain relief and improved motion. Among those with recurrent posterior instability, it usually appears in the early postoperative period.

Ulnohumeral arthroplasty for primary degenerative arthritis of the elbow: long-term outcome and complications.

BACKGROUND: Primary degenerative arthritis of the elbow is an uncommon disorder that recently has been more clearly recognized. The purpose of this study was to analyze the long-term results and complications of ulnohumeral arthroplasty as treatment of primary osteoarthritis of the elbow and to document any tendency for recurrence of the arthritis after the procedure. METHODS: The results of ulnohumeral arthroplasties performed at our institution, between 1986 and 1996, in forty-six elbows (forty-five patients) with primary osteoarthritis were reviewed at an average of eighty months (range, twenty-four to 164 months) after the operation. There were forty-four men and one woman with a mean age of forty-eight years. All patients complained of pain with terminal elbow extension. The pain was associated with locking in fourteen elbows and with ulnar nerve symptoms in twelve. The surgical procedure involved fenestration of the olecranon fossa and excision of olecranon and coronoid osteophytes in all patients, with removal of loose bodies in thirty-six elbows. A capsular release was performed in nineteen elbows, and an ulnar nerve transposition or neurolysis was done in eight. Preoperative and follow-up assessment included evaluation of elbow pain and range of motion with the Mayo Elbow Performance Score. RESULTS: The mean arc of flexion-extension improved from 79 degrees (range, 10 degrees to 135 degrees) preoperatively to 101 degrees (range, 45 degrees to 135 degrees) at the time of follow-up (p < 0.05). At the last follow-up examination, thirty-five elbows (76%) were not painful or were only mildly painful and eleven were moderately or severely painful. According to the Mayo Elbow Performance Score, the result was excellent for twenty-six elbows, good for eight, fair for four, and poor for eight. Thirteen of the forty-five patients reported some degree of ulnar nerve symptoms postoperatively, and six of them required another operation to decompress or translocate the nerve. Two other patients underwent additional surgery because of persistent symptoms. CONCLUSIONS: The data from this study show that ulnohumeral arthroplasty can yield satisfactory long-term pain relief and an increase in the range of motion. Patients with severe preoperative limitation of elbow extension of >60 degrees and flexion of <100 degrees and those who undergo manipulation under anesthesia in the early postoperative period to increase motion are at risk for the development of ulnar nerve dysfunction postoperatively. One should consider prophylactic ulnar nerve decompression or mobilization under these circumstances.

Shoulder arthroplasty for arthritis after instability surgery.

BACKGROUND: We are not aware of any large published studies regarding the intermediate to long-term results of shoulder arthroplasty performed for the treatment of osteoarthritis after instability surgery. Therefore, we reviewed the results of this procedure, the risk factors for an unsatisfactory outcome, and the rates of failure in our patients. METHODS: Between January 1, 1978, and December 31, 1997, thirty-three patients (thirty-three shoulders) with glenohumeral arthritis after instability surgery were treated with a shoulder arthroplasty at our institution. Two patients were excluded from the study: one died less than two years postoperatively, and one had not been managed by the senior surgeon. The remaining thirty-one patients, including twenty-one patients who had had a total shoulder arthroplasty and ten who had had a hemiarthroplasty, were followed for a minimum of two years (mean, seven years) or until the time of revision surgery. The mean age at the time of the shoulder arthroplasty was forty-six years. RESULTS: Shoulder arthroplasty was associated with significant pain relief (p < 0.001) as well as significant improvement in external rotation (from 4 degrees to 43 degrees; p < 0.001) and active abduction (from 94 degrees to 141 degrees; p < 0.001). There was not a significant difference between the hemiarthroplasty group and the total shoulder arthroplasty group with regard to postoperative external rotation, active abduction, or pain. According to a modification of the rating system of Neer et al., there were four excellent, two satisfactory, and four unsatisfactory results in the hemiarthroplasty group and three excellent, five satisfactory, and thirteen unsatisfactory results in the total shoulder arthroplasty group. Three patients in the hemiarthroplasty group and eight patients in the total shoulder arthroplasty group underwent revision surgery. The estimated survival of the components (and 95% confidence interval) was 97% (91% to 100%) at two years, 86% (74% to 99%) at five years, and 61% (42% to 86%) at ten years. CONCLUSIONS: The data from the present study suggest that shoulder arthroplasty for the treatment of osteoarthritis of the glenohumeral joint following instability surgery in this relatively young group of patients provides pain relief and improved motion but is associated with high rates of revision surgery and unsatisfactory results due to component failure, instability, and pain due to glenoid arthritis.

Shoulder arthroplasty for proximal humeral nonunions.

Between 1980 and 1997, 27 patients underwent shoulder arthroplasty because of pain or functional impairment due to a proximal humeral nonunion. Twenty-five of the 27 shoulders with a mean 6-year follow-up period (range, 2-15 years) were included in the study. There were 19 women and 6 men, with a mean age of 65 years. The most frequent original fracture types were 2-part surgical neck (64%) and 3-part greater tuberosity fractures (28%). Twenty-one shoulders underwent hemiarthroplasty, and 4 underwent total shoulder arthroplasty. Shoulder arthroplasty resulted in significant pain relief, with mean pain scores decreasing from 4.6 to 1.8 points (P <.05). Mean active elevation improved from 41 degrees preoperatively to 88 degrees postoperatively (P <.05), and mean external rotation from 22 degrees to 38 degrees (P =.045). In 11 shoulders the greater tuberosity resorbed or was nonunited. Two of the 25 shoulders required another operation after the arthroplasty: one for periprosthetic humeral fracture and one for instability. Twenty shoulders were much better or better, and 5 were the same or worse. On the basis of a modified Neer result rating system, there was 1 excellent result, 11 satisfactory results, and 13 unsatisfactory results. Patients who have significant functional impairment from a nonunion of the humeral surgical neck with failed internal fixation, severe osteoporosis, cavitation of the humeral head, or secondary osteoarthritis may benefit from shoulder arthroplasty. Although function is not completely restored, pain relief and high levels of subjective satisfaction can be achieved.

Shoulder arthroplasty for proximal humeral malunions: long-term results.

Between 1976 and 1997, 50 shoulders with proximal humeral malunions in 50 patients were treated with hemiarthroplasty or total shoulder arthroplasty and followed up for a mean of 9 years (range, 2-21 years) or until the time of revision surgery. Of these, 13 had a 4-part malunion, 24 had a 3-part greater tuberosity malunion, 6 had a 2-part greater tuberosity malunion, and 7 had a 2-part head segment malunion. Articular incongruity resulted from an articular surface step-off in 5 shoulders, from osteonecrosis in 19, and from secondary degenerative arthritis in 26. Shoulder arthroplasty resulted in significant pain relief (P <.005). At most recent follow-up, shoulder pain was more intense in patients who had initial operative treatment of their fracture, in those with osteonecrosis, and in those who had arthroplasty less than 2 years after their fracture. Active elevation improved from 65 degrees to 102 degrees on average, and external rotation improved from 12 degrees to 35 degrees on average. There was significantly less postoperative motion in those who had initial operative treatment of their fracture or who underwent tuberosity osteotomy. Of the 24 shoulders undergoing tuberosity osteotomy, 14 healed in good position, 4 had a nonunion develop, 3 had some degree of malunion develop, and in 3 the tuberosity resorbed. On the basis of the Neer result rating, 12 shoulders had an excellent result, 13a satisfactory result, and 25 an unsatisfactory result. Unsatisfactory results occurred in 8 who underwent reoperation with component revision or removal and because of lack of postoperative motion in 14, moderate pain in 2, and patient dissatisfaction in 1. All shoulders with tuberosity nonunion or resorption had an unsatisfactory result.