The Basic Shoulder Arthroplasty: Simple Shoulder Replacement for the Generalist.

Shoulder arthroplasty was first introduced through the developments of Dr. Charles Neer and over the past decade has seen several advancements. Improved recognition and training have heightened the awareness of arthroplasty as a treatment alternative both for surgeons and patients. The addition of reverse shoulder arthroplasty has been the driving force behind the explosive growth of arthroplasty and is now performed more often than anatomic shoulder arthroplasty. Although revision shoulder arthroplasty is primarily of interest to the subspecialist, it is a skill sought by the general orthopaedic surgeon. It is important for the orthopaedic surgeon to be knowledgeable about the planning, necessary skills, and management of basic shoulder arthroplasty.

One and two-year clinical outcomes for a polyethylene glenoid with a fluted peg: one thousand two hundred seventy individual patients from eleven centers.

PURPOSE: Clinical shoulder science lacks a benchmark against which the early clinical value of new glenoid components can be compared; such a benchmark may be derived from a multicenter study of patients receiving an established, internationally used design of glenoid component. METHODS: We obtained data from 11 centers on 1270 patients having total shoulder arthroplasty using an all-polyethylene component with a fluted central peg. We analyzed individual patient outcomes at 1 and 2 years after surgery. We compared the improvement for each patient to the minimal clinically important difference (MCID) and calculated each patient's improvement as a percent of maximal possible improvement (MPI). RESULTS: The preoperative scores improved from SST 3 ± 2, ASES 37 ± 15, Constant score 36 ± 16, and Penn score 30 ± 19 to SST 10 ± 2, ASES 90 ± 12, Constant 76 ± 13, and Penn 80 ± 24 (p < 0.001 for each). A high percentage of patients improved by more than the MCID (SST 96%, ASES 98%, Constant 94%, Penn 93%) and obtained improvement of at least 30% of the MPI (SST 95%, ASES 98%, Constant 91%, Penn 87%). The clinical outcomes realized with this glenoid design were not worse for the 41% of shoulders with preoperative type B glenoids or for the 30% of shoulders with more than 15 degrees of glenoid retroversion. CONCLUSIONS: Individual patients from 11 international practices having total shoulder arthroplasty using a basic glenoid component design obtained highly significant clinical outcomes, providing a benchmark against which the early outcomes of new designs can be compared to determine whether they provide increased clinical value.

All Things Clavicle: From Acromioclavicular to Sternoclavicular and All Points in Between.

The clavicle is the most frequently injured bone in the human body. In most cases, fractures that occur in the midshaft of the clavicle can be managed nonsurgically. An increasing number of studies suggest that displaced midshaft clavicle fractures have improved outcomes after surgical management, and equivalent outcomes can be achieved with both plating and intramedullary techniques. Distal clavicle fractures are managed according to the disruption of the coracoclavicular ligaments. Fractures with disruption of the ligaments usually will require fixation, whereas fractures with intact ligaments may be treated with closed management. Multiple techniques of reconstruction appear to yield similar outcomes; however, hook-plating techniques result in the highest complication rates. The evaluation process for acromioclavicular joint injuries is moving from a static two-dimensional evaluation to a three-dimensional evaluation that involves an assessment for scapular dyskinesis. Surgical reconstruction is indicated for patients who exhibit scapular dyskinesis. Anterior sternoclavicular injuries can typically be managed nonsurgically, whereas posterior sternoclavicular dislocations always require urgent surgical management. Newer techniques of ligament reconstruction for sternoclavicular injuries yield improved biomechanical stability.

Complications rates, reoperation rates, and the learning curve in reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has ushered a new era in shoulder surgery. However, the results of RSA also described the complication rates associated with the procedure as inordinate and a learning curve associated with the incidence of complications. METHODS: The records of 112 patients who underwent 114 RSA procedures by the senior author (G.I.G.) were reviewed for complications related to a RSA. Of these, 93 RSA procedures were the primary treatment for the shoulder, and 21 were revisions. RESULTS: The total complication rate for the entire group was 7%. Complications included 3 periprosthetic fractures, 3 hematomas, 1 acromion fracture, and 1 deep infection. The complication rate was 19% in the revision RSA group and 4.3% in the primary RSA group (P ≤ .02). Complication rates in the initial RSA patients in this series did not differ from the final procedures in this series (P = .96). The total reoperation rate was 5.3%, and was 19% in the revision RSA group vs 2.2% in the primary RSA group (P ≤ .02). CONCLUSION: Complications and reoperations associated with a RSA, although significant, occurred at much lower rate than in previous reports. This series demonstrates a significant difference in complication rates and reoperation rates between primary and revision RSA. Revision RSA complications and reoperations were far more common than in primary RSA procedures. No evidence of a learning curve related to surgical experience was demonstrated in this series.

Management of traumatic sternoclavicular joint injuries.

Traumatic sternoclavicular joint injuries account for <3% of all traumatic joint injuries. Proper recognition and treatment are vital because these injuries may be life threatening. Injuries are classified according to patient age, severity, and, in the setting of dislocation, the direction of the medial clavicle. Anterior injuries are far more common than posterior injuries. Posterior dislocation may be associated with complications such as dyspnea, dysphagia, cyanosis, and swelling of the ipsilateral extremity as well as paresthesia associated with compression of the trachea, esophagus, or great vessels. These life-threatening complications may present at the time of injury but can develop later, as well. Radiography has been largely supplanted by CT for evaluation of this injury, although an oblique view developed by Wirth and Rockwood is useful in evaluating isolated sternoclavicular injury. MRI is useful in differentiating physeal injury from sternoclavicular dislocation in patients aged<23 years.

Results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems.

BACKGROUND: Hemiarthroplasty continues to be a common surgical treatment for glenohumeral arthritis. Unfortunately, some patients will develop painful glenoid arthrosis necessitating revision to total shoulder arthroplasty. Previously reported results of revision have demonstrated variability in results and difficulty. The purpose of this study was to determine the difficulty and results of revision from hemiarthroplasty to total shoulder arthroplasty utilizing modular component systems. MATERIALS AND METHODS: Between 1995 and 2007, the authors identified 15 patients who underwent revision from hemiarthroplasty (HA) to total shoulder arthroplasty (TSA). Patients were assessed with the use of a UCLA score and a visual analogue scale at the time of the latest follow-up (mean, 40 months; range, 24-70 months). Radiographs were assessed for the presence of glenoid loosening, subluxation, and shift in component position. RESULTS: Revision HA to TSA was significantly associated with pain relief (P < .01) as well as improvement in forward elevation from a mean of 91° to 141°. According to the UCLA scoring, the result was excellent in 9 shoulders, good in 5, and fair in 1. No instances of humeral or glenoid loosening were identified at the most recent examination. Only 2 stem revisions were necessary in this series of modular shoulder arthroplasties. CONCLUSION: The data from this study suggest that revision of painful HA for glenoid arthrosis to TSA is a reliable procedure with good improvements in pain, range of motion, and function. With modular components, the complexity of the procedure is minimized. Poor results and the need for stem revision are infrequent occurrences.

Treatment of traumatic posterior sternoclavicular dislocations.

BACKGROUND: Traumatic posterior sternoclavicular joint injuries are rare, but complications are common and include brachial plexus and vascular injury, esophageal rupture, and death. MATERIALS AND METHODS: The records of 21 patients treated at our institution for a posterior sternoclavicular injury were reviewed. All patients underwent a trial of closed reduction, which was effective in 8 patients (group I). The remaining 13 patients were treated with open reduction and sternoclavicular joint reconstruction (group II). RESULTS: Closed reduction was more likely to be successful (P < .05) in dislocations treated within 10 days of injury. Patients were evaluated by use of the University of California, Los Angeles rating scale. Overall, 18 of 21 patients were graded as good or excellent. Patients treated with either open or closed reduction as their definitive management compared favorably in terms of ratings for pain, strength, and motion. CONCLUSION: Our experience suggests that closed reduction compares favorably with open reduction. Of patients treated, 38% required only closed reduction as their definitive treatment. In this series early closed reduction was successful and obviated the risks of surgery. Patients who in whom closed reduction failed obtained good results with operative treatment aimed at reconstruction of the costoclavicular ligaments.

Survival and radiographic analysis of a glenoid component with a cementless fluted central peg.

BACKGROUND: Aseptic loosening of glenoid components is a common problem associated with total shoulder arthroplasty and one cause for failure. A new cementless fluted glenoid component was developed and has shown excellent bony ingrowth in a canine model. HYPOTHESIS: Clinical utilization of this cementless fluted pegged glenoid component in total shoulder arthroplasty would lower rates of radiolucent lines and aseptic loosening. MATERIALS AND METHODS: Between January 2005 and December 2007, 83 primary shoulder arthroplasties with a minimum of 2 years' follow-up were performed with the uncemented fluted pegged glenoid component. Radiographs and records were reviewed to determine stability and survival of the glenoid component. RESULTS: All cementless fluted pegged glenoid components had survived at the most recent clinical follow-up. Radiographs showed no evidence of component loosening or radiolucent lines. Evidence of fingerlike projections of bone between the flanges of the implant was found in 24 cases (29%). CONCLUSIONS: A cementless fluted pegged glenoid component showed excellent initial clinical survival and integration. Further studies regarding continued durability of this component appear warranted.

Results of treatment of luxatio erecta (inferior shoulder dislocation).

HYPOTHESIS: Traumatic inferior shoulder dislocation (luxatio erecta) injuries are rare, comprising less than 0.5% of all shoulder dislocations. Few cases have been reported, and the outcome of treatment has been ill defined. MATERIALS AND METHODS: Between 1968 and 2000, 18 patients (20 shoulders) with luxatio erecta were evaluated at our institution. Two patients (2 shoulders) were lost to follow-up, leaving 16 patients (18 shoulders) for long-term follow-up (average, 9 years). Associated injuries included peripheral nerve injury, humeral fracture, acromial fracture, and rotator cuff tear. All patients were initially managed with closed reduction, which was successful in 9 shoulders. The remaining 9 shoulders required operative treatment. RESULTS: Patients were evaluated with respected to pain, function, range of motion, strength, and patient satisfaction, according to the University of California at Los Angeles Rating Scale. Overall, 13 of the 16 patients were graded as good or excellent. Patients treated with closed reduction or operative treatment compared favorably in terms of improvements in ratings for pain, strength, motion, and the ability to perform work and sports. DISCUSSION: Our experience suggests that treatment of luxatio erecta is largely successful, with good or excellent results obtained in 83% of the shoulders. Half of the patients evaluated, required only closed reduction as their definitive treatment. Operative treatment is typically indicated for associated displaced humeral head fractures or patients with recurrent instability. Recurrent instability appears to be more likely in patients with a previous history of dislocation. Associated neurologic or vascular injury did not affect the final outcome.

Treatment of fractures adjacent to humeral prostheses.

Fifteen patients with fractures adjacent to a humeral prosthesis were treated between 1986 and 2002. There were 10 females and 5 males. The average age was 58 years. The fractures were classified as to location relative to the prosthesis. Type I fractures (N = 3) occurred proximal to the tip of the prosthesis. Type II fractures (N = 7) occurred in which the fracture line extended from the proximal portion of the humeral shaft to beyond the distal tip of the prosthesis. Type III (N = 5) fractures occurred entirely distal to the tip of the prosthesis. Two type I and 3 type II fractures were managed with a fracture orthosis. The remainder of the fractures were treated surgically with a combination of cerclage wires and long stem prosthesis. All fractures progressed to union at an average of 11 weeks. Average forward elevation for the group was 124 degrees . No patient required a shoulder spica or bone grafting to obtain union. Treatment resulted in fracture union, prosthesis stability, and a paucity of complications.