A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus.

PURPOSE: Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS. METHODS: The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience. RESULTS: Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS. CONCLUSIONS: A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale. LEVEL OF EVIDENCE: Level I.

Complications and Intraoperative Fractures in Reverse Shoulder Arthroplasty: A Systematic Review.

INTRODUCTION: The reverse shoulder arthroplasty is nowadays a treatment option for a variety of shoulder problems. As its incidence rose, also the number of complications increased, including intraoperative fractures. SIGNIFICANCE: We performed a systematic review and critical analysis of the current literature following the PRISMA guidelines. Our purpose was to: 1) determine incidence, causes, and characteristics of intraoperative fractures; 2) evaluate their current treatment options, possible related complications, reoperation rates, and the patients' outcome; and 3) determine the overall incidence of each complication related to reverse shoulder arthroplasty. The articles were selected from PubMed medical database in April 2020 using a comprehensive search strategy. Rayyan software was used to support the selection process of the records. A descriptive and critical analysis of the results was performed. RESULTS: The study group included a total of 13,513 reverse shoulder arthroplasty procedures. The total number of complications was 1647 (rate 12.1%). The most common complication was dislocation (340 cases, rate 2.5%). Forty-six studies reported a total of 188 intraoperative fractures among the complications (rate 1.4%). The intraoperative fracture rate was 2.9% and 13.6% in primary and revision settings, respectively. There were 136 humeral fractures, 60% of them occurred in revision RSAs, during the removal of the previous implant, and involved the shaft in the majority of cases (39%). Glenoid fractures were 51 and occurred mostly during the reaming of the glenoid. We observed 7 further related complications (rate of 4%) and 3 reoperations (rate of 1.5%). The outcome was satisfactory in the majority of cases. CONCLUSIONS: A comprehensive review on intraoperative fractures in reverse shoulder arthroplasties is presented. Results suggest favorable outcomes for all treatment methods, with a modest further complication rate. This investigation may aid in the treatment decision-making for these complications.

Long-term results of the Latarjet procedure for anterior instability of the shoulder.

BACKGROUND: The Latarjet procedure is effective in managing anterior glenohumeral instability in the short term, but there is concern for postoperative arthritis. The purpose of this study was to evaluate the long-term functional outcome after the Latarjet procedure and to assess the prevalence of and risk factors for glenohumeral arthritis after this procedure. MATERIALS AND METHODS: A retrospective review was conducted of 68 Latarjet procedures at a mean of 20 years postoperatively. The mean age at surgery was 29.4 years. Functional outcome was determined by the Rowe score, subjective shoulder value, and recurrence of instability. Preoperative arthritis and postoperative radiographs were reviewed to evaluate the development or progression of arthritis. RESULTS: The mean Rowe score increased from 37.9 preoperatively to 89.6 at final follow-up (P < .001). The mean subjective shoulder value was 90.9% at final follow-up. The postoperative rate of recurrence was 5.9%. Of the 60 shoulders without arthritis preoperatively, 12 (20%) had developed arthritis at final follow-up. Among the 8 shoulders with preoperative arthritis (all stage 1), 4 (50%) demonstrated progression of arthritis at final follow-up. Overall, postoperative arthritis was stage 1 in 14.7%, stage 2 in 5.9%, and stage 3 in 8.8% of cases; no stage 4 arthritis was observed. Risk factors for postoperative arthritis were older age, high-demand sports activity, and lateral overhang of coracoid bone graft. CONCLUSION: The Latarjet procedure provides excellent long-term outcomes in the treatment of recurrent anterior glenohumeral instability. Twenty years after the Latarjet procedure, arthritis may develop or progress in 23.5% of cases, but the majority of arthritis is mild.

Revision surgery of reverse shoulder arthroplasty.

BACKGROUND: There is limited knowledge regarding revision of reverse shoulder arthroplasty (RSA). This study assesses reasons for failure in RSA and evaluates the outcomes of revision RSA. MATERIALS AND METHODS: Between 1997 and 2009, 37 patients with RSA had revision surgery. Clinical and radiologic examinations performed preoperatively and at 3 months, at 6 months, and then annually postoperatively were analyzed retrospectively. Patients were reviewed with a minimum 2-year follow-up. RESULTS: The most common causes for RSA revision were prosthetic instability (48%); humeral loosening, derotation, or fracture (21%); and infection (19%). Only 2 patients (3%) had to be reoperated on for glenoid loosening. More than 1 re-intervention was performed in 11 patients (30%) because of recurrence of the same complication or appearance of a new complication. Underestimation of humeral shortening and excessive medialization were common causes of recurrent prosthetic instability. Proximal humeral bone loss was found to be a cause for humeral loosening or derotation. Previous surgery was found as a potential cause of low-grade infection. At a mean follow-up of 34 months, 32 patients (86%) had retained the RSA whereas 2 patients (6%) had undergone conversion to humeral hemiarthroplasty and 3 (8%) to a resection arthroplasty. The mean Constant score in patients who retained the RSA increased from 19 points before revision to 47 points at last follow-up (P < .001). CONCLUSIONS: Even if revision may lead to several procedures in the same patient, preservation or replacement of the RSA is largely possible, allowing for a functional shoulder. Full-length scaled radiographs of both humeri are recommended to properly assess humeral shortening and excessive medialization before revision.

Aseptic glenoid loosening or failure in total shoulder arthroplasty: revision with glenoid reimplantation.

HYPOTHESIS AND BACKGROUND: Reimplantation of a new glenoid component for symptomatic glenoid failure after total shoulder arthroplasty (TSA) is a well-established surgical strategy. In case of aseptic glenoid loosening or failure, revision of TSA by reimplantation of a cemented glenoid implant would be a reliable therapeutic option. MATERIALS AND METHODS: This retrospective multicenter study included 42 TSAs with symptomatic failed glenoids revised by reimplantation of an all-polyethylene (PE), cemented glenoid component. All patients were reviewed clinically and radiologically, with a mean follow-up of 74 months. RESULTS: The failed initial glenoid component was metal backed in 32 cases and PE cemented in 10. The main cause of glenoid failure was component loosening in 19 cases (46%) and PE wear or dissociation in 23 (54%). Associated complications were very frequent, including rotator cuff tears, subscapularis insufficiency, and prosthesis instability. At last follow-up, 7 patients (17%) had already been re-revised because of symptomatic recurrent glenoid loosening. The overall rate of recurrent glenoid loosening (re-revision plus radiologic loosening) was 67%. Soft-tissue problems and prosthetic instability were significantly associated with recurrent loosening. Of the 10 associated bone grafts performed during the revision procedure, all were partially or totally lysed. At follow-up, the mean Constant score was 57 points (gain of 16 points) and the mean active anterior elevation was 125° (gain of 19°). CONCLUSION: This study suggests that revision of a TSA with reimplantation of an all-PE cemented glenoid component does not solve the problem of glenoid loosening. Soft-tissue failure and prosthetic instability are underestimated preoperatively and may explain, in part, the high rate of recurrent glenoid loosening.

Influence of arm lengthening in reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty (RSA) can improve anterior active elevation (AAE) by lengthening of the deltoid and hence increasing its lever arm. However, evaluations of functional outcomes of RSA have shown variable improvements in the range of motion. The aim of our study was to correlate humeral and arm lengthening to postoperative AAE. METHODS: We reviewed 183 RSAs with a minimum follow-up of 1 year. Lengthening of the humerus and the arm was evaluated in relation to the contralateral side. RESULTS: We observed mean humeral lengthening of 0.2 ± 1.4 cm (range, -4.7 to +5.2 cm) and mean arm lengthening of 1.6 ± 1.9 cm (range, -5.1 to +5.4 cm). Postoperative AAE was 140° ± 27° (range, 30° to 180°). We found no significant correlation between lengthening or shortening of the humerus and AAE (P = .169). Shortening of the arm led to a mean AAE value of 122°; lengthening of 0 and 1 cm, mean AAE of 140°; lengthening of greater than 1 cm to 2.5 cm, mean AAE of 144°; and lengthening of greater than 2.5 cm, mean AAE of 147°. When we compared patients with lengthening of the arm and those with shortening, the postoperative AAE was significantly greater after arm lengthening, 145° versus 122°, with a mean difference of 23° (95% confidence interval, 13° to 33°) (P < .001). CONCLUSION: This study shows that shortening of the arm reduced AAE. With respect to arm lengthening, a lengthening threshold was not found. An objective assessment of deltoid lengthening is possible preoperatively, intraoperatively, and postoperatively, and this measure seems to correlate with the functional outcome.

Glenoid loosening and failure in anatomical total shoulder arthroplasty: is revision with a reverse shoulder arthroplasty a reliable option?

INTRODUCTION: Our purpose was to evaluate if, in case of aseptic glenoid loosening and failure in anatomical total shoulder arthroplasty (TSA), revision by a reverse shoulder arthroplasty (RSA) is a reliable therapeutic option. METHODS: Retrospective multicenter cohort study of 37 consecutive anatomical TSA revised by RSA for aseptic glenoid loosening or failure. The decision to implant a RSA was related to the presence of associated complications: rotator cuff tears (n = 24), subscapularis insufficiency (n = 29), prosthetic instability (n = 13), and glenoid bone deficiency (n = 37). The patients were reviewed clinically and radiographically at a mean follow-up of 47 months (range, 24-104). RESULTS: Eighty-six percent of the patients were satisfied or very satisfied. The average Constant score increased from 24 to 55 pts (P < .0001) and active anterior elevation from 68° to 121° (P < .0001). Twenty-two of the 29 (76%) associated bone grafts were incorporated in the glenoid. Eight patients (21%) needed a subsequent reoperation because of recurrent or new complications: glenoid loosening (n = 3), prosthetic anterior instability (n = 3), and humeral subsidence (n = 2); the reverse prosthesis had to be converted to a hemiarthroplasty in 1 patient and removed in another. CONCLUSION: Revision with a RSA is a reliable therapeutic option which provides the double benefit of glenoid bone stock reconstruction by fixing the bone graft with the help of the baseplate and screws and of solving the problem of soft tissue insufficiency and prosthetic instability. However, surgeons should be aware that the rate of postoperative complications and subsequent reoperations is high, and that the surgical technique is demanding.

A ten-year radiologic comparison of two-all polyethylene glenoid component designs: a prospective trial.

BACKGROUND: Aseptic glenoid component loosening remains a common problem in total shoulder arthroplasty (TSA). This study presents long-term prospective follow-up of 2 cemented all-polyethylene glenoid components with different backside design geometry and the effect on the presence and progression of radiolucent lines (RLLs). MATERIALS AND METHODS: Fifty-six TSAs were performed for primary osteoarthritis. Two surgeons used an identical technique to implant 32 flat-back and 24 convex-back glenoids. In particular, the glenoid components were cemented after a minimal reaming and bone compaction. Standardized postoperative radiologic and clinical follow-up was at 2 and 10 years. Three independent observers evaluated the x-ray images for RLLs around the base plate and keel. The results were analyzed for progression and influencing factors. RESULTS: At 10 years, progression of RLL was seen in both components, but there was no difference between the 2 glenoid designs (P = .16). Younger patient age (P = .03), hand dominance (P = .017), and presence of early RLLs (P = .018) were significant factors for progression of RLLs. Constant scores deteriorated with progression of RLLs (P = .006). The glenoid revision rate at 10 years was 5%. CONCLUSION: At 10 years there was no difference in the presence or progression of RRLs between a flat-back and a convex-back glenoid all-polyethylene design. Young age, hand dominance, and poor implantation technique influence glenoid RLLs and affect the clinical result of TSA.

The teres minor muscle in rotator cuff tendon tears.

OBJECTIVES: Although the teres minor has received little attention in the literature compared to the other musculotendinous units of the rotator cuff, it is an important component of shoulder function. Our purpose was to study the appearance of the teres minor muscle on CT and MRI images in various patterns of rotator cuff tears. MATERIALS AND METHODS: We analyzed the appearance of the teres minor according to the Walch classification (normal, hypertrophic, atrophic, or absent) in 1,332 CT and in 240 MRI images of rotator cuff tears and we correlated it with the type of rotator cuff tears, time period between initial onset of symptoms and diagnostic imaging, age of the patient at the time of imaging, and degree of fatty infiltration of other rotator cuff muscles. RESULTS: The teres minor was classified as normal in 90.8% of cases, hypertrophic in 5.8%, atrophic in 3.2%, and absent in 0.2%. Significant variability existed in the appearance of the teres minor muscle among different patterns of rotator cuff tears in the CT (P < 0.0001) and MRI groups (P < 0.0001). The teres minor appeared most frequently hypertrophic in anterior tears and atrophic in posterior-superior tears. CONCLUSIONS: The teres minor was normal in most rotator cuff tears. A morphologic classification system allowed the appearance of the teres minor to be defined in isolated and multiple rotator cuff tears in CT and MRI images.

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.

Natural history of infraspinatus fatty infiltration in rotator cuff tears.

BACKGROUND/HYPOTHESIS: Muscular fatty infiltration (FI) represents an important prognostic factor in rotator cuff repair. The goal of this study was to analyze the natural history of infraspinatus FI in rotator cuff tears to determine the timing of the appearance and the speed of progression of this phenomenon. METHOD: The preoperative MRI or CT-arthrograms of 1688 patients operated for rotator cuff tears were reviewed. The degree of infraspinatus FI was correlated with the type of tendon tear, patient sex, dominant hand, presence of traumatic injury, delay between the onset of symptoms and imaging studies, and age of the patients at imaging. Infraspinatus FI was graded on axial images according to Goutallier classification and described as minimal (stage 0 or 1), medium (stage 2), and severe (stages 3 and 4). Statistical regression was used to determine the most significant factors. RESULTS: Infraspinatus FI increased significantly in presence of an infraspinatus tendon tear and when multiple tendons were torn (P < .0005), with increasing delay between the onset of symptoms and imaging studies (P < .0005) and increasing patient age (P < .0005). Medium FI appeared on average 2 and a half years after the onset of symptoms, and severe FI appeared at an average of 4 years after symptom onset. CONCLUSION: Larger tendon tears, longer delays after tendon rupture and older patient age are associated with more severe and frequent FI. Stage 2 FI appears at an average of 2 and a half years after the onset of symptoms, and surgical repair should be done within this time frame if possible.

Natural history of fatty infiltration and atrophy of the supraspinatus muscle in rotator cuff tears.

BACKGROUND: In some patients nonoperative treatment of a rotator cuff tear is sufficient, while in others it is only the first stage of treatment prior to surgery. Fatty infiltration progresses throughout the nonoperative treatment although it is not known at what point fatty infiltration contributes to poor functional outcomes, absence of healing, or increased rerupture rates. QUESTIONS/PURPOSES: We therefore identified factors related to the appearance of supraspinatus muscle fatty infiltration, determined the speed of appearance and progression of this phenomenon, and correlated fatty infiltration with muscular atrophy. METHODS: We retrospectively reviewed 1688 patients with rotator cuff tears and recorded the following: number of tendons torn, etiology of the tear, time between onset of shoulder symptoms and diagnosis of rotator cuff tear. Fatty infiltration of the supraspinatus was graded using either CT or MRI classification. Muscular atrophy was measured indirectly using the tangent sign. RESULTS: Moderate supraspinatus fatty infiltration appeared an average of 3 years after onset of symptoms and severe fatty infiltration at an average of 5 years after the onset of symptoms. A positive tangent sign appeared at an average of 4.5 years after the onset of symptoms. CONCLUSIONS: Our results suggest that rotator cuff repair should be performed before the appearance of fatty infiltration (Stage 2) and atrophy (positive tangent sign)-especially when the tear involves multiple tendons. LEVEL OF EVIDENCE: Level IV, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Objective evaluation of lengthening in reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty requires a re-tensioning of the deltoid to obtain active elevation and implant stability. Currently, there is no objective and reliable technique described for the preoperative planning of reverse shoulder prosthesis or the postoperative evaluation of deltoid tension and arm lengthening. The purpose of this investigation was to outline a standardized technique for measuring deltoid length and to preoperatively plan a reverse shoulder arthroplasty, and to determine whether complications are related to inadequate deltoid lengthening. METHODS: Fifty-eight patients were included in this radiographic review. Variations in humeral length, overall arm length, and the height of the subacromial space were evaluated before and after reverse shoulder arthroplasty. RESULTS: The average postoperative lengthening of the humerus was 2 +/- 7 mm (range, -9-16, P = .243) and the arm was lengthened 23 +/- 12 mm (range, 1-47, P <.001). Measured preoperative and postoperative differences of the subacromial space were statistically significant when comparing the operated and contralateral arm (P < .0001). Lengthening was not correlated to sex (P = .242), acromial fractures, or neurological complications (P = .83). However, in cases of postoperative instability, both humeral and overall arm lengthening were statistically lower (P < .0001). CONCLUSION: A technique to preoperatively plan adequate deltoid tensioning using radiographs of the contralateral arm is described. This technique is critical in challenging cases and postoperatively in cases of complication to assess the deltoid length. Subjective intraoperative criteria to evaluate deltoid tension should be replaced by objective measures to prevent insufficient or excessive deltoid tension. LEVEL OF EVIDENCE: Level 3.

Fatty infiltration of the supraspinatus: a reliability study.

BACKGROUND: The Goutallier classification of rotator cuff fatty infiltration is an accepted standard, yet no recommendations exist for which computed tomography plane is best to identify fatty infiltration of the supraspinatus. Our purpose was to determine the most reliable plane to evaluate supraspinatus fatty infiltration, assess reliability of the tangent sign, and to correlate fatty infiltration and muscle atrophy. METHODS: Fatty infiltration in 87 computed tomography scans was reviewed by 3 shoulder surgeons using the 5-tiered Goutallier classification and a separate 3-grade scale. The supraspinatus muscle was evaluated in the axial, coronal, and sagittal plane. The tangent sign was used to assess muscle atrophy. RESULTS: The axial plane produced the highest agreement for both the 5-tiered and 3-tiered systems. An objective radiographic marker was described to reliably determine grade 3 fatty infiltration. The tangent sign produced excellent agreement for the presence of muscle atrophy. A significant relationship between the tangent sign and fatty infiltration was discovered (P < .0001); grades 3 and 4 fatty infiltration correlated statistically with supraspinatus atrophy. CONCLUSION: The tangent sign is acceptable for determining the presence of muscle atrophy and clinical decision making. A positive tangent sign is an indicator of advanced fatty infiltration. The axial computed tomography plane should be used when evaluating fatty infiltration. LEVEL OF EVIDENCE: Level 3; Diagnostic study.