Non-operative management of humeral periprosthetic fracture after stemless shoulder arthroplasty.

PURPOSE: Periprosthetic fractures around a stemless implant often involve lesser and greater tuberosities with a well-fixed implant in the metaphysis. This exposes the surgeon to unique questions and challenges as no surgical option (open reduction and internal fixation or revision to a stem) appears satisfactory to address them. Purpose of this study was to evaluate the clinical outcomes after non-operative management of periprosthetic fractures after stemless shoulder arthroplasty. METHODS: A retrospective multicenter study was conducted to identify all patients who had sustained non-operative management of a periprosthetic fracture after a stemless shoulder. Exclusion criteria were as follows: (1) intraoperative fractures and (2) implant loosening. Primary outcomes included mean Constant score and mean active range of motion. Secondary outcomes were VAS, radiological analysis, and complications. RESULTS: Nine patients were included. One was excluded due to the loss of follow-up at three months. Mean age was 79 years. At the last follow-up, no significant difference was observed between the Constant score, VAS, or the range of motion before fracture and at the last follow-up. Fracture healing did not result in any change in angulation in the frontal plane in seven cases and was responsible for a varus malunion in two cases of anatomic arthroplasty. No change in lateralization or distalization was reported. No cases of implant loosening after fracture have been observed. CONCLUSIONS: Conservative management seems to be appropriate in cases of minimally displaced fractures without implant loosening.

Heterotopic ossification of the shoulder after arthroscopic rotator cuff repair: A case report.

INTRODUCTION AND IMPORTANCE: Heterotopic ossification (HO) often arises in response to trauma, prior surgical procedures, neurological injuries, or burns. However, its presentation as a complication of shoulder arthroscopy is uncommon and can sometimes lead to functional impairment. In our study, we report a case of HO complicating rotator cuff repair, along with details of the surgical treatment and subsequent progression. CASE PRESENTATION: We report the case of a 45-year-old man with no medical history, who had undergone a rotator cuff arthroscopic repair of his left shoulder. Despite initial improvements, he developed intense pain and stiffness of the operated shoulder. X-rays revealed an extensive HO. Surgical revision and excision of the ossification, followed by high-dose indomethacin in combination with proton pump inhibitors and specialized physiotherapy, resulted in remarkable improvement in shoulder function. CLINICAL DISCUSSION: Studies investigating HO in shoulder arthroplasty have unveiled a diverse range of formation rates, spanning from 15 % to 62 %. Nonetheless, it's noteworthy that the prevalence of HO around the shoulder remains less common in comparison to other anatomical sites, especially in the context of arthroscopic surgical procedures. The exact mechanism and pathophysiology that leads to HO formation remains unknown. It is believed to stem from a combination of multiple factors and is associated with various contributors. Arthroscopic intervention, coupled with high-dose Indomethacin, offers an effective approach for managing HO. CONCLUSION: While HO remains an uncommon complication after shoulder arthroscopy, it is crucial for clinicians to consider it in patients experiencing post-surgery stiffness and pain.

Stemless shoulder arthroplasty.

The concept of stemless shoulder arthroplasty was born in 2005. It is now a valid option in the context of either anatomical or reverse shoulder replacement. Several questions have come up over our 15 years of using this system: How was the stemless shoulder arthroplasty concept born? It was motivated by a desire to have epiphyso-metaphyseal fixation using a corolla-shaped impacted anchor design. What are the features of commercially available stemless shoulder arthroplasty implants? The stemless anatomical implants now available have either a cage or central peg that is impacted or a system that is screwed into the epiphysometaphyseal bone. Several companies have introduced stemless reverse implants, some of which have an onlay configuration. How do the results of stemless implants compare to those of traditional stemmed implants? At a mean follow-up of 10 years, the outcomes of stemless TSA can be superimposed with those of traditional stemmed TSA. What are the advantages of stemless shoulder implants? The advantages are their simple implantation, ability to adapt to patient morphology and any malunions, various orientation angles, no stress-shielding, reduced risk of infection and bleeding and less complex revision surgery (if needed). What are the limitations or drawbacks of using stemless implants? The two main limitations are insufficient metaphyseal bone stock and poor bone quality, especially for reverse configurations. What does the future hold for stemless shoulder arthroplasty? Like with traditional stemmed implants, the longevity of stemless shoulder arthroplasty depends on its tribology, which can still be improved. In the future, a stemless implant will need to be convertible like stemmed humeral implants, and if possible, provide an inlay reverse configuration.

Arthroscopic Latarjet procedure and suture-button fixation: can we predict nonunion early?

BACKGROUND: The arthroscopic Latarjet procedure is a technically challenging technique that provides well-known results. The first series reported fixation with screws. An alternative fixation technique has been proposed, using a button, to improve the reproducibility and to decrease the complications due to screws. The first reports using this fixation technique have yielded comparable rates of fusion. The objective of this study was to assess the fusion rate and bone modifications with this type of fixation. METHODS: Two hundred sixteen patients were included in this prospective study. An arthroscopic Latarjet procedure, fixed with 1 button according to the Smith & Nephew technique, was performed by a single surgeon for the treatment of anterior instability. The radiographic protocol consisted of computed tomography scans at 3, 12, and 24 weeks postoperatively. We measured the coronal and sagittal positions of the bone block, distance between the bone block and the glenoid, diameter of the glenoid tunnel, fusion rate, and time to fusion. RESULTS: The position was deemed flush in 92.6% of cases in the coronal plane and under the equator in 87.5% of cases in the sagittal plane. At last follow-up, we observed 9 cases of nonunion (4%), as well as 18 cases of delayed fusion. The fusion rate was 92% at 3 months and 96% at 6 months. For bone blocks that ultimately healed, the diameter of the glenoid tunnel was <2 mm in 62% of cases at 3 weeks and <1 mm in 90% of cases at 3 months. Conversely, the diameter of this tunnel significantly increased and was >3 mm in all cases of delayed union or nonunion. CONCLUSION: The described technique achieved a reliable position of the bone block and a very good fusion rate with a new type of fixation. The time to obtain fusion can be lengthy, occurring between the third and sixth months. The diameter of the glenoid tunnel was the best predictive factor for fusion. Widening of the glenoid tunnel diameter >3 mm during the first 3 weeks was the most predictive factor for delayed union or nonunion of the bone block. This finding is probably explained by a sliding effect of the sutures through this tunnel, comparable to the bungee effect in anterior cruciate ligament repair in the knee.

Osteoarthritis of the shoulder in under-50 year-olds: A multicenter retrospective study of 273 shoulders by the French Society for Shoulder and Elbow (SOFEC).

INTRODUCTION: Osteoarthritis (OA) of the shoulder in under-50 year-olds is rare, and treatment is delicate. Shoulder replacement incurs frequent long-term risk of progression and a high revision rate, making it unsuited to young active patients. The aim of the present study was to determine the epidemiology of shoulder OA in under-50 year-olds and to assess the clinical results of the various treatment options. HYPOTHESIS: The main study hypothesis was that well-conducted non-operative treatment can allow shoulder replacement to be postponed. The secondary hypothesis was that anatomic total shoulder arthroplasty (TSA) is the treatment of choice when other options fail. MATERIALS AND METHODS: A multicenter retrospective study included primary (POA) and post-instability osteoarthritis (PIOA) in patients aged≤50years at symptom onset. Exclusion criteria comprised post-traumatic OA, rheumatoid arthritis and necrosis. Two hundred and sixty-six patients for 273 shoulders were included from 13 shoulder surgery centers: 2 types of non-operative treatment (28 by platelet-rich plasma [PRP] and 88 by viscosupplementation), 73 arthroscopies, and 150 implantations (62 humeral hemiarthroplasties [HA], comprising 10 hemi-metal, 24 hemi-pyrocarbon and 28 hemi-resurfacing; 77 anatomic total prostheses, and 11 reverse prostheses). Minimum follow-up was 12 months for non-operative treatment and 24 months for arthroplasty (some patients having both). Endpoints comprised Constant score, Subjective Shoulder Value (SSV) and number of complications/revision procedures. RESULTS: Mean age at treatment was 43 years (range, 23-65 years), with 75% male predominance. Symptom onset was earlier in PIOA than in POA: 36 vs. 39 years (range, 20-50 years). PRP and viscosupplementation postponed implantation by a mean 3.5 years in 86% of cases, as did arthroscopy in 56%. ER1 restriction was the most negative factor. At 74 months' follow-up for HA and 95 months for TSA, mean Constant score was significantly lower for HA (56 vs. 67; p=0.004), with higher rates of complications (31% vs. 11%) and implant exchange (13% vs. 9%). DISCUSSION/CONCLUSION: PRP, viscosupplementation and arthroscopy allow implantation to be postponed until the shoulder becomes stiff and painful. In case of failure, TSA is the most effective solution in the medium-term. LEVEL OF EVIDENCE: IV a; therapeutic study - investigating the results of treatment.

Stemless shoulder prosthesis for treatment of proximal humeral malunion does not require tuberosity osteotomy.

PURPOSE: When the proximal humeral anatomy is altered because of malunion, shoulder arthroplasty is a challenge for the orthopaedic surgeon, and tuberosity osteotomy should be avoided whenever possible. The purpose of this study was to investigate the clinical and radiological outcomes of anatomic stemless shoulder arthroplasty in cases of malunion. We hypothesized that a stemless prosthesis can be implanted without performing tuberosity osteotomy. METHODS: We conducted a continuous, single surgeon, retrospective case series study with a minimum follow-up of two years (mean of 44 months, range 24-80). The Constant-Murley score, active range of motion and X-rays were evaluated in 27 patients (mean age of 60 years, range 37-83) with proximal humeral malunion who were treated with a stemless anatomic shoulder prosthesis. RESULTS: In all patients, the prosthesis was implanted without the need for tuberosity osteotomy. The Constant score improved from 27 to 62 (p ≤ 0.001), active anterior elevation from 81° to 129° (p ≤ 0.001), and external rotation from 5° to 40° (p ≤ 0.001). There was no evidence of radiological loosening. CONCLUSIONS: Use of a stemless anatomic shoulder prosthesis avoids the need for tuberosity osteotomy and certain surgical difficulties, even in cases of severe tuberosity malunion, and leads to good functional outcomes in the short term.

The TESS reverse shoulder arthroplasty without a stem in the treatment of cuff-deficient shoulder conditions: clinical and radiographic results.

BACKGROUND: Reverse total shoulder arthroplasty (RSA) is a recent concept that enables good functional outcomes in cases of massive rotator cuff tear and cuff tear arthropathy. Design parameters influence the functional results and complications. The purpose of this study is to present the results of a novel RSA, the Total Evolutive Shoulder System (TESS; Biomet, Warsaw, IN, USA), based on a reverse corolla without a stem. METHODS: We enrolled 101 patients with 105 RSAs in a prospective study, with a minimum follow-up period of 24 months. The analysis concerned 91 RSAs in 87 patients (61 men and 26 women), with a mean age of 73 years, at a mean follow-up of 41 months (range, 24-69 months). RESULTS: Ninety-six percent of patients rated their satisfaction as good or excellent. Mean flexion was 143° (range, 90°-170°), and mean external rotation was 39° (range, 20°-70°). The Constant score improved from 40 points preoperatively to 68 points at last follow-up (P < .001). The mean American Shoulder and Elbow Surgeons score was 24 points. The mean neck-shaft angle was 154° (range, 142°-165°). Inferior scapular notching occurred in 17 cases (19%). The notching rate was higher when the glenometaphyseal angle increased (P < .001), when the inferior tilt decreased (P = .003), and when the neck-shaft angle increased. There was no evidence of component loosening. CONCLUSION: TESS RSA provided encouraging midterm results with favorable outcomes and a low rate of complications. The stemless TESS with a reverse corolla is a reliable, less invasive system.