Short-stem uncemented anatomical shoulder replacement for osteoarthritis in patients older than 70 years: is it appropriate?

BACKGROUND: Despite a new trend to systematically use reverse shoulder arthroplasty (RSA) in elderly population regardless of the indication, total anatomical shoulder arthroplasty can get good functional results in this population. The purpose of this study was to evaluate clinical and radiological outcomes of uncemented short-stem anatomic total shoulder arthroplasty (TSA) for primary glenohumeral osteoarthritis in patients older than 70 years and to compare these results to a matched population with an uncemented short-stem RSA. METHODS: In this retrospective monocentric study, clinical outcomes were based on constant score (Cst), subjective shoulder value (SSV) score, and range of motion. The aim of radiographic analysis was to identify glenoid component loosening and humeral bone remodeling around the uncemented short stem. RESULTS: At an average follow-up of 44 ± 12.5 months, 32 uncemented short-stem TSA in 31 patients with a minimum of 2 years of follow-up were included and were compared to 32 uncemented RSA. Fifty three percent of the patients had "a forgotten prosthesis". ROM was significantly improved in all cases. Cst reached 73 ± 9 pts and SSV 90 ± 10.8% (P < .001). In 8 patients with repairable supraspinatus tendon tears, clinical outcomes were not statistically different from patients with an intact rotator cuff: Cst (77 ± 6.2 points vs 72 ± 9.6 points, P = .3) and SSV (88 ± 11.5% vs. 91 ± 10.5%; P = .59). The type of glenoid wear (A vs B) did not influence the constant score: 73 ± 9 points versus 74 ± 11 points respectively; P = .81. Despite a complication rate of 6% (n = 2), no prosthesis revision was performed. At last follow-up, range of motion was better in the TSA group compared to the RSA group for internal (7.8 ± 1.3 vs 6.25 ± 2; P = .001) and external (47 ± 14 vs 24 ± 21; P < .001) rotations. The postoperative SSV score was also better in the TSA group (91.3 ± 10% vs 82.2 ± 13%; P = .002). CONCLUSIONS: At medium-term, uncemented short-stem anatomic TSA in patients older than 70 years provided satisfactory clinical results. Patients have forgotten their prosthesis in over 50% of cases. This prosthetic design is still indicated in this patient population in case of primary osteoarthritis with a functional rotator cuff with an almost normal rotator cuff muscle trophicity.

Surgical treatment of peri-acetabular metastatic disease: Retrospective, multicentre study of 91 THA cases.

INTRODUCTION: The occurrence of peri-acetabular metastasis (PAM) is a turning point in the progression of cancer because the disabling pain prevents the patient from walking or makes it difficult. Recent progress in controlling cancers that spread to the bone and controlling local bone destruction justify this national study. Since the data in France is incomplete or based on small studies, we analysed a multicentre retrospective cohort of patients with PAM who underwent total hip arthroplasty (THA) to evaluate 1) the clinical and radiological outcomes and 2) the factors impacting patient survival. HYPOTHESIS: The clinical outcomes, complication rate and survivorship are comparable to that of recent published studies. METHODS: Ninety-one patients (27 men, 64 women) with a mean age of 62.7±10.5 years (extremes 38 and 88) with PAM secondary to breast cancer [42 patients (46%)] or lung cancer [20 patients (22%)] underwent THA. The metastasis was the first sign of cancer in 33 cases (36%). Concurrent visceral metastases were present in 30 patients (33%), multiple peripheral bone metastasis in 48 patients (53%) and synchronous spine metastasis in 39 patients (43%). The most common construct was a cemented stem with metal reinforcement cage and cemented dual mobility cup [71 times (78%), while 85/91 had a dual mobility cup (93%)]. RESULTS: Elimination or reduction of pain was reported in 81 patients (91%). Overall walking ability was deemed normal or acceptable in 74 patients (83%). Six patients died (7%) before the end of the 3rd month. There were seven general complications (8%) including five thromboembolic events. There were 22 complications related to the surgical procedure in 20 patients (22%) that required surgical revision, including 10 surgical site infections (11%) and 3 dislocations (3%) (one concerning a dual mobility cup and 2 after single mobility cup). The median survivorship all causes combined was 19.5 months; it was 23.7 months for patients with breast cancer and 8.9 months for those with lung cancer. CONCLUSION: Despite different endpoints being used, the clinical outcomes in our study are like those in other published studies, as were the incidence of surgery-related complications and the survivorship. The recommended surgical technique is the implantation of an acetabular reinforcement cage, curettage with cement filling of osteolytic areas, dual mobility cup and cemented stem followed by radiation therapy. The role of THA versus interventional radiology procedures must still be determined. LEVEL OF EVIDENCE: IV, retrospective study without control group.

Functional results and survival after surgery for peripheral skeletal metastasis: A 434-case multicenter retrospective series.

INTRODUCTION: Peripheral skeletal metastasis (PSM) has a negative impact on quality of life. New treatments for the primary tumor or the osteolysis hold out hope of improved survival. The few published French series were small, and we therefore undertook a multicenter retrospective analysis of PSM surgery between 2005 and December 2016, with the aim of assessing: 1) rate and type of complications, 2) functional results, and 3) overall survival and corresponding risk factors. HYPOTHESIS: The French data for clinical results, survival and complications are in agreement with the international literature. MATERIALS AND METHOD: The series comprised 391 patients with 434 metastatic locations. There was female predominance: 247 women (63%). Two sites were treated in 46 patients (12%), and three in 5. The main etiologies were breast cancer (151/391: 39%), lung cancer (103/391: 26%) and kidney cancer (52/391: 13%). There was synchronous visceral metastasis in 166 patients (42.5%), other peripheral locations in 137 (35%) and spinal location in 142 (39%). One hundred (27%) had ASA score>3; 61 (16%) had WHO score>3. The reason for surgery was pathologic fracture (n=137: 35%). Locations were femoral (274: 70%), acetabular (58: 15%), humeral (40: 0%), tibial (12: 3%) or other (7: 2%). RESULTS: There were surgery site complications in 41 patients (9.4%), including 13 surgery site infections, and general complications in 47 patients (11%), including 11 cases of thromboembolism, 6 of blood loss, 9 pulmonary complications and 6 perioperative deaths. Overall survival, taking all etiologies and sites together, was 10 months (range, 5 days to 9 years; 95% CI, 8-13 months), and significantly better in females (14 versus 6 months; p=0.01), under-65 year-olds (p=0.001), and in preventive surgery versus fractured PSM (p=0.001). Median survival was 22 months (95% CI, 17-28 months) after breast cancer, 3 months (95% CI, 2-5 months) after lung cancer, and 17 months (95% CI, 8-58 months) after kidney cancer. Preoperatively, walking was impossible for 143 patients (38%), versus 23 (6.5%) postoperatively; 229 patients (63.5%) could walk normally or nearly normally after surgery, versus 110 (28%) before. After surgery, 3 patients (6%) were not using their operated upper limb, versus 27 (45%) before; 30 patients (54%) had normal upper limb use after surgery, versus 8 (5%) before. CONCLUSION: The study hypothesis was on the whole confirmed in terms of survival according to type of primary and whether surgery was indicated preventively or for fracture. LEVEL OF EVIDENCE: IV, retrospective study without control group.