Pyrocarbon humeral heads for hemishoulder arthroplasty grant satisfactory clinical scores with minimal glenoid erosion at 5-9 years of follow-up.

BACKGROUND: Hemishoulder arthroplasty (HSA) is a more conservative alternative to total shoulder arthroplasty for young and active patients with minimal glenoid erosion or deformity. Pyrocarbon humeral heads were introduced as an alternative to metallic humeral heads, which were associated with glenoid erosion in 28%-43%. The purpose of this study was to evaluate the progression of glenoid erosion and clinical scores of HSA using pyrocarbon humeral heads from short- (2-4 years) to midterm (5-9 years). METHODS: We retrieved the records of 45 consecutive patients who underwent HSA with pyrocarbon humeral heads from 2013 to 2017. Patients were evaluated radiographically and clinically at a first follow-up (2-4 years) and a second follow-up (5-9 years). Preoperative glenoid morphology was assessed using computed tomography scans, and glenoid erosion was assessed using plain radiographs according to Sperling et al. The Constant score (CS), American Shoulder and Elbow Surgeons (ASES) score, and Subjective Shoulder Value (SSV) score were assessed by an independent observer. RESULTS: From the initial cohort of 45 patients, 2 underwent revision surgery (4.4%) due to persistent pain (without signs of rotator cuff pathology or glenoid erosion) and 6 were lost to follow-up (13%), leaving 37 for outcome assessment (82%). At the first follow-up of 2.2 ± 0.4 years, all clinical scores improved substantially (CS from 29.3 ± 13.5 to 76.7 ± 14.4, ASES from 23.7 ± 15.6 to 87.0 ± 16.0, and SSV from 25.3 ± 12.2 to 84.1 ± 15.2), and at the second follow-up of 6.2 ± 1.2 years, good clinical scores were maintained (CS from 76.7 ± 14.4 to 80.8 ± 16.0, ASES from 87.0 ± 16.0 to 92.3 ± 15.0, and SSV from 84.1 ± 15.2 to 82.8 ± 18.3). At the second follow-up, glenoid erosion was moderate in 9 (24%) and severe in 3 (8.1%). When comparing with immediate postoperative radiographs, 10 shoulders exhibited progression of glenoid erosion by 1 grade (n = 9) or 2 grades (n = 1). CONCLUSION: Pyrocarbon humeral heads for HSA grant satisfactory clinical scores with minimal glenoid erosion.

Reverse shoulder arthroplasty for primary glenohumeral osteoarthritis: significantly different characteristics and outcomes in shoulders with intact vs. torn rotator cuff.

PURPOSE: To compare outcomes of reverse shoulder arthroplasty (RSA) for primary osteoarthritis (OA) with and without rotator cuff (RC) tears to those with secondary OA due to RC tears. METHODS: We reviewed records of all patients who received RSA for primary OA or secondary OA. All patients had preoperative radiographs, computed tomographic arthrography (CTA), and/or magnetic resonance imaging (MRI) scans of their shoulders to assess their etiology, glenoid morphology, and fatty infiltration. Pre- and postoperative (at minimum follow-up of 2 years) Constant scores and range of motion were compared between patients who had RSA for primary OA with and without RC tears to those with secondary OA due to RC tears. RESULTS: Of the initial cohort of 605 shoulders (583 patients), 153 were lost to follow-up (25.3%), 25 required revision with implant removal (4.1%), and 13 died of causes unrelated to the surgery (2.1%), and left a final cohort of 414 patients. Of the final cohort, 97 had primary OA with intact RC, 62 had primary OA with RC tears, and 255 had secondary OA. Postoperative Constant scores were significantly higher for primary OA with intact RC (73.8 ± 14.3), compared with both primary OA with RC tears (66.1 ± 14.6, P < .001) and secondary OA (64.1 ± 14.8, P < .001). There were no differences in pre- or postoperative scores between primary OA with RC tears and secondary OA. CONCLUSION: At 2 or more years following RSA, Constant scores were significantly higher for primary OA with intact RC, compared to either primary OA with RC tears or secondary OA, whereas there were no differences in pre- or postoperative scores of shoulders that had primary OA with RC tears vs. secondary OA. The authors recommend distinguishing primary OA with intact RC from primary OA with RC tears, as the two have considerably different characteristics and prognosis following RSA.

Revision rotator cuff repair: can a Sugaya III tendon considered to be healed or not.

BACKGROUND: Sugaya et al described a classification system to assess postoperative rotator cuff tendon healing. Although Sugaya I and II tendons can be considered as healed and Sugaya type IV and V can be considered as retorn, the exact status of Sugaya III tendons remains unclear. The objective of this study was to evaluate the impact of Sugaya III tendons on postoperative functional scores in a population of patients undergoing revision rotator cuff repair. METHODS: We retrospectively studied the records of all patients who underwent revision rotator cuff repair in one of 12 different institutions between July 2001 and December 2020. A total of 203 shoulders were included (59% males, mean age: 51 ± 8 years old, mean follow-up 11.5 years [range: 2-28.8 yr]). Fifty-four patients (61% males, mean age 52 ± 6 years old, mean follow-up 14.1 years [range: 10.4-28.8 yr]) had a follow-up ≥10 years (mean 14.1 years [range: 10.4-28.8 yr]) and were included in a long-term follow-up subgroup analysis. Structural integrity of the repaired tendon was evaluated on magnetic resonance imaging at last follow-up. Functional scores, acromiohumeral index (AHI), and progression of fatty infiltration and of osteoarthritis were compared according to Sugaya type. RESULTS: Mean Constant score and mean strength were significantly higher in Sugaya I and II tendons than in Sugaya III (P = .021 and .003) and Sugaya IV and V tendons (P = .07 and .038), but did not differ between Sugaya III and Sugaya IV and V tendons. Mean Subjective Shoulder Value, pain, AHI were significantly higher and fatty infiltration and progression in the Hamada classification were significantly lower in Sugaya I and II tendons and in Sugaya III than in Sugaya IV and V tendons (P < .05), but did not differ between Sugaya I and II and Sugaya III tendons. Similar characteristics could also be observed in the long-term follow-up subgroup. CONCLUSION: Sugaya III tendons after revision rotator cuff repair do not allow restoration of strength thereby impacting the Constant score. However, there seems to be a protective effect of Sugaya III tendons with regard to pain, progression of proximal migration of the humeral head, osteoarthritis, and fatty infiltration, which seems to last at long-term follow-up.

Clinical Results and CT Analysis of ISA Stemless at a Minimum Follow-up of 2 Years.

INTRODUCTION: The utilization of stemless anatomic total shoulder arthroplasty is on the rise. Epiphyseal fixation leads to radiological bone remodeling, which has been reported to exceed 40% in certain studies series. The aim of this study was to present the clinical and radiological outcomes of a stemless implant with asymmetric central epiphyseal fixation at an average follow-up of 31 months. MATERIALS: This retrospective multicenter study examined prospective data of patients undergoing total anatomic arthroplasty with ISA Stemless implant and followed up at least 2 years. Clinical assessment included preoperative and final follow-up measurements of active range of motion (ROM), Constant score, and Subjective Shoulder Value (SSV). Anatomical epiphyseal reconstruction and bone remodeling at the 2-year follow-up were assessed by standardized Computed Tomography Scanner (CT scan). Statistical analysis employed unpaired Student's t-test or chi-squared test depending on the variable type, conducted using EasyMedStat software (version 3.22; www.easymedstat.com). RESULTS: Fifty patients (mean age 68 years, 62% females) were enrolled, with an average follow-up of 31 months (24-44). Primary osteoarthritis (68%) with type A glenoid (78%) was the prevailing indication. The mean Constant score and SSV improved significantly from 38 ± 11 to 76 ± 11 (p<0.001) and from 31% ± 16 to 88% ± 15 (p<0.001) respectively at the last follow-up. Forward elevation, external rotation and internal rotation ROM increased by 39° ± 42, 28° ± 21 and 3,2 ± 2,5 points respectively, surpassing the Minimally Clinically Important Difference (MCID) after total shoulder arthroplasty. No revisions were necessary. CT scans identified 30% osteolysis in the posterior-medial calcar region, devoid of clinical repercussions. No risk factors were associated with bone osteolysis. CONCLUSION: At an average follow-up of 31 months, ISA Stemless implant provided favorable clinical results. CT analysis revealed osteolysis-like remodeling in the posterior-medial zone of the calcar (30%), without decline in clinical outcomes and revisions. Long-term follow-up studies are mandated to evaluate whether osteolysis is associated with negative consequences.

Arthroscopic posterior capsulolabral repair grants adequate outcomes in shoulders with posterior instability without glenoid cartilage lesions.

INTRODUCTION: Posterior capsulolabral repair (posterior Bankart) is effective to restore shoulder stability and relieve pain, though a recent meta-analysis reported recurrent instability in 9.5% of patients, and that only 62.7% were able to resume sports. The purpose of this study was to assess the outcomes of arthroscopic posterior capsulolabral repair in a population of unselected patients, in terms of recurrence of instability, clinical scores, and return to sports. METHODS: The authors retrospectively studied a consecutive series of 22 patients that underwent posterior capsulolabral repair between 2009 and 2019. Patients were assessed before posterior capsulolabral repair and at a minimum follow-up of 24 months, in terms of subjective shoulder value (SSV), Western Ontario Shoulder Instability Index (WOSI), as well as level of sport. Following surgery, all complications, reoperations or episodes of instability were noted. RESULTS: The cohort comprised 21 men (95%) and 1 woman (5%), aged 38.8 ± 12.5 years (range 17-61) at index surgery. Of the 20 patients that performed sports, only 2 (10%) stopped sports after surgery, while 18 resumed their main sport (90%). At a follow-up of 65.4 ± 34.8 months (range 25-146), the SSV was 85.1 ± 14.7, pain on VAS was 1.9 ± 2.1, and the Constant-Murley score was 71.6 ± 17.9. Five patients had subjective instability without dislocation (23%). Nine patients (41%) had no pain (0 points), 6 patients (27%) had mild pain (1-2 points), 4 patients (18%) had moderate pain (3 points), while 3 patients (14%) had severe pain (5-8 points). CONCLUSION: Arthroscopic posterior capsulolabral repair prevented recurrent dislocation in patients with posterior shoulder instability at a minimum follow-up of 2 years, despite persistent pain in 32%, and subjective instability in 23%. These complications were mainly observed in patients with work-related accidents and glenoid cartilage lesions. LEVEL OF EVIDENCE: III, case series.

A new self-assessment tool following shoulder stabilization surgery, the auto-Walch and auto-Rowe questionnaires.

PURPOSE: Patient-reported outcome measures (PROMS) are increasingly used for patient evaluation, as well as for scientific research. Few are used for practical purposes in the clinical setting, and few are reliable enough to allow proper feedback to physicians. Two of the most commonly used assessment tools in shoulder instability are the Walch-Duplay and the Rowe scores. The aim of this study was to evaluate the validity of self-administered versions of the Walch-Duplay and Rowe scores following shoulder stabilization procedure. METHODS: Between the months of May and December 2021, all patients who were followed in one of six institutions for shoulder instability were included. Patients were required to anonymously fill a self-administered version of Walch-Duplay and Rowe score. The classic scores were measured by the surgeon. Correlations between self-assessment and physician-assessment were then recorded. RESULTS: A total of 106 patients were evaluated during the study period. Using the Spearman coefficient for correlation, a strong correlation (r > 0.5) was found between the results of the self-administered questionnaire and the surgeon-measured score. The difference between surgeon- and patient-administered questionnaires was non-significant. CONCLUSION: The self-administered version of the Walch-Duplay and Rowe questionnaires can reliably be used in the clinical setting for post-operative follow-up of patients undergoing shoulder stabilization procedures. LEVEL OF EVIDENCE: Level II.

Reverse shoulder arthroplasty renders better clinical scores at a minimum follow-up of two years for patients with no rotator cuff deficiency operated by the deltopectoral approach.

PURPOSE: The purpose of this multi-centre study was to report outcomes of a large cohort of reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years and to determine patient and surgical factors that influence postoperative outcomes. The hypothesis was that surgical indication, surgical approach, and implant design would affect clinical outcomes significantly. METHODS: The authors reviewed records of 743 RSAs in patients with primary osteoarthritis (OA) with or without rotator cuff (RC) tears, secondary OA due to RC tears, and irreparable massive rotator cuff tears (mRCT). The deltopectoral (DP) approach was used in 540 and the anterosuperior (AS) approach in 203. Pre- and postoperative Constant scores (CS) were recorded. Multivariable linear analyses were performed to determine if CS was associated with indications for surgery, surgical approach, or implant design. RESULTS: Of the 743 shoulders, 193 (25.7%) were lost to follow-up, 16 (2.1%) died, and 33 (4.4%) were revised, leaving 501 for analysis. At a mean follow-up of 3.2 ± 0.9 years, net improvement in CS was 29.2 ± 17.0. Multivariable analyses revealed that postoperative CS decreased with age and was worse in shoulders that had preoperative rotator cuff deficiency and in shoulders operated by the AS approach. Multivariable analyses also revealed worse net improvement in shoulders operated for secondary OA due to RC tears or for irreparable mRCT, as well as shoulders operated by the AS approach. CONCLUSION: This large multi-centre study confirms that, at two or more years following RSA, Constant scores are not associated with implant design, but rather with rotator cuff deficiency and surgical approach. Multivariable analysis revealed that postoperative CS was worse for shoulders with preoperative rotator cuff deficiency and for shoulders operated by the AS approach. Multivariable analysis also revealed that net improvement in CS was worse in shoulders treated for secondary OA due to RC tears and for shoulders with irreparable mRCT, as well as for shoulders operated by the AS approach.

Factors that affect external rotation following reverse shoulder arthroplasty: a retrospective multi-centre study on 501 shoulders.

INTRODUCTION: The purpose of this multi-centre study was to assess external rotation in a large cohort following reverse shoulder arthroplasty (RSA) at a minimum follow-up of 2 years, and identify factors that influence postoperative and/or net-improvement of external rotation. METHODS: The authors retrospectively reviewed records of 743 RSAs performed between January 2015 and August 2017 by 16 surgeons that participated in a large national society symposium; 193 (25.7%) were lost to follow-up, 16 (2.1%) died, and 33 (4.4%) were revised with implant exchange, which left 501 available for assessment at 2.0-5.5 years. Pre- and post-operative active forward elevation, active external rotation (ER1), active internal rotation (IR1) and constant score (CS) were collected. Regression analyses were performed to determine associations of patient demographics, surgical and implant parameters, rotator cuff muscles status and radiographic angles with ER1. RESULTS: Multivariable analyses revealed postoperative ER1 decreased with age (ß, - 0.35), increased with lateralisation shoulder angle (LSA) (ß, 0.26), and was better in shoulders operated by the antero-superior (AS) approach (ß, 11.41), but worse in shoulders with absent/atrophic teres minor muscles (ß, - 10.06). Net-improvement of ER1 increased with LSA (ß, 0.39), was better with inlay stems (ß, 8.33) and BIO RSA (ß, 6.22), but worse in shoulders operated for primary OA with rotator cuff (RC) tears (ß, - 16.26), for secondary OA due to RC tears (ß, - 16.06), or for mRCT (ß, - 18.96). CONCLUSIONS: This large multi-centre study revealed that, at a minimum of 2 years following RSA, ER1 improved by 16.1°. Postoperative ER1 was better in shoulders which had normal or hypertrophic teres minor muscles, were operated by the AS approach, or with greater LSA. Net-improvement of ER1 was better in shoulders with inlay stems, with BIO RSA, or with greater LSA, but worse in shoulders with rotator cuff deficiency. LEVEL OF EVIDENCE: IV.

Partial and complete repairs of massive rotator cuff tears maintain similar long-term improvements in clinical scores.

PURPOSE: The authors have previously published early outcomes of arthroscopic repairs of 86 massive rotator cuff tears (mRCTs) and aimed to determine whether their clinical scores are maintained or deteriorate after 5 more years. METHODS: Of the initial series of 86 shoulders, 2 had deceased, 16 lost to follow-up and 4 reoperated, leaving 64 for assessment. The repairs were complete in 44 and partial in 20, and 17 shoulders had pseudoparalysis. Preoperative assessment included absolute Constant score, shoulder strength, tear pattern, tendon retraction, and fatty infiltration. Patients were evaluated at 8.1 ± 0.6 years (range 7.1-9.3) using absolute and age-/sex-adjusted Constant score, subjective shoulder value (SSV), and simple shoulder test (SST). RESULTS: Absolute Constant score was 80.0 ± 11.7 at first follow-up (at 2-5 years) but diminished to 76.7 ± 10.2 at second follow-up (at 7-10 years) (p < 0.001). Adjusted Constant score was 99.7 ± 15.9 at first follow-up and remained 98.8 ± 15.9 at second follow-up (ns). Comparing other outcomes revealed a decrease in strength over time (p < 0.001) but no change in pain, SSV or SST. Partially-repaired shoulders had lower strength at both follow-ups (p < 0.05). Pseudoparalytic shoulders had lower absolute and adjusted Constant score at second follow-up (p < 0.05), but their net improvements in absolute Constant score were higher (p = 0.014). CONCLUSIONS: Both partial and complete arthroscopic repairs grant satisfactory long-term outcomes for patients with mRCTs, regardless of their tear pattern, fatty infiltration and presence of pseudoparalysis. Absolute Constant score decreased over time for both repair types, but adjusted Constant score remained stable, suggesting that decline is due to aging rather than tissue degeneration. The clinical relevance of this study is that arthroscopic repair should be considered for mRCTs, even if not completely repairable, rather than more invasive and/or risky treatments, such as reverse shoulder arthroplasty. LEVEL OF EVIDENCE: IV.

Prevalence of metal hypersensitivity in patients with shoulder pathologies.

BACKGROUND: To date, medical history and dedicated questionnaires are the fastest and easiest way to assess risks of joint metal hypersensitivity. No published studies determined the overall prevalence of hypersensitivity to metals in patients with shoulder pathologies. The purpose of this study was therefore to estimate the prevalence of metal hypersensitivity reported by patients with shoulder pathologies, and to identify patients at risk of joint metal hypersensitivity based on a dedicated questionnaire. METHODS: The authors prospectively asked all adult patients consulting for shoulder pathologies between September 2018 and February 2019 at 10 centers to fill in a form. The main outcome was "reported hypersensitivity to metals," comprising belt buckles, coins, earrings, fancy jewelry, keys, leather, metallic buttons, piercings, spectacles, watch bracelets, or zips. RESULTS: A total of 3217 patients agreed to fill in the survey, aged 55 ± 16 (range, 18-101) with equal proportions of men (51%) and women (49%), and a majority of patients consulting for cuff pathology (55%). A total of 891 (28%) patients had professions considered at risk for metal hypersensitivity. The most frequently reported metal hypersensitivities were fancy jewelry (15%), earrings (13%), and watch bracelets (9%). A total of 629 (20%) patients, of which the vast majority were women, reported hypersensitivity to 1 or more metals. CONCLUSIONS: This survey of 3217 patients identified 20% who reported metal hypersensitivities, though only 2.2% had done patch tests. Matching profiles of those with positive patch tests to those with no patch tests revealed that 9.4% of the total cohort had similar sex and self-reported metal hypersensitivities. Factors associated with a positive patch test were female sex, self-reported cutaneous allergy, and self-reported metal hypersensitivity. The clinical applicability of these estimates remains uncertain as there is insufficient evidence that allergy to metal implants can be predicted by questionnaires or patch tests.

Clinical and radiographic outcomes of the open Latarjet procedure in skeletally immature patients.

INTRODUCTION: Recurrent anterior glenohumeral instability has been studied in the young population and limited evidence is available for adolescent patients. Our study is a retrospective review of patients aged <17 years who underwent open Latarjet procedure. METHODS: Forty-five patients were available for review. Clinical outcomes were assessed by range of movements, stability, Walch-Duplay score (WDS), Rowe score (RS), Constant-Murley score (CMS), Subjective Shoulder Value (SSV), and return to sport. Radiographs were reviewed for osteoarthritis and complications. RESULTS: The median age of patients was 15.7 years (13-17), and 56% had hyperlaxity. The median follow-up time was 6.6 years (3-26). The median postoperative movements showed recovered elevation (175°), external rotation (60°), and internal rotation (T9 level). Seventy-five percent of patients returned to the same level of sport, and 98% were satisfied. Clinical outcomes showed WDS, RS, and CMS scores of 85, 95, and 84 points, respectively, and an SSV of 95%. Twenty percent of patients described mild postoperative pain, and 1 had persistent stiffness. Other complications included 24% subjective apprehension, 4% redislocation, 4% wound problems, and 2% infection. Nine percent of cases had postoperative arthritis. The overall reoperation rate was 11%: 1 open washout for infection and 4 arthroscopic screw removal due to persistent pain. We found that hyperlaxity, female sex, and large or deep Hill-Sachs lesions were frequently associated with persistent apprehension at the last follow-up. CONCLUSIONS: The open Latarjet procedure provides a low rate of recurrent instability with acceptable complication rates in the long term for skeletally immature patients. It is an effective, safe treatment option without any significant glenoid growth disturbance.

Immediate self-rehabilitation after open Latarjet procedures enables recovery of preoperative shoulder mobility at 3 months.

PURPOSE: To evaluate short-term clinical outcomes of shoulders treated for anterior instability by open Latarjet procedures (OLP) followed by immediate self-rehabilitation. The hypothesis was that patients would recover preoperative function at 3 months with no adverse events related to self-rehabilitation. METHODS: The authors retrieved clinical and radiographic records of 307 consecutive shoulders treated by the same surgeon for anterior instability by OLP with immediate self-rehabilitation. Four shoulders did not meet eligibility criteria and 38 were lost to follow-up, leaving a study cohort of 265 shoulders. Patients performed self-rehabilitation exercises at home from the first postoperative day. Follow-ups at 1 and 3 months evaluated recurrence of instability, postoperative complications, pain, active forward elevation (AFE), passive forward elevation (PFE), external rotation (ER) and internal rotation (IR). RESULTS: The difference between mobility before surgery and at 3 months was 0° for AFE, 0° for PFE, 10° for ER, and 0 spine segments for IR. Thirteen shoulders (5%) which had not followed the self-rehabilitation protocol during the first month had significantly more pain and less improvements in mobility (p < 0.05). Multivariable analyses revealed that patients who adhered to self-rehabilitation in the first month had greater improvements of AFE, PFE, and IR (p < 0.05). CONCLUSIONS: Immediate self-rehabilitation after open Latarjet procedures enabled recovery of preoperative shoulder mobility at 3 months. Patients who did not adhere to immediate self-rehabilitation had more pain and less improvement in mobility. Furthermore, immediate self-rehabilitation was found to be independently associated with better recovery and did not cause any adverse events. LEVEL OF EVIDENCE: Level IV.

Clinical and radiographic outcomes of open Latarjet procedure in patients aged 40 years or older.

BACKGROUND: The Latarjet procedure is often used to treat shoulder instability in younger patients. Little is reported on the outcomes of this procedure in older (≥40 years) populations. The purpose of this study was to evaluate the clinical and radiographic outcomes of patients aged 40 years or older with recurrent anterior shoulder instability who underwent open Latarjet stabilization. METHODS: A total of 168 patients aged 40 years or older were treated surgically for recurrent anterior shoulder instability with an open Latarjet procedure between 1988 and 2014. Bankart lesions or anteroinferior glenoid fractures were confirmed preoperatively with a computed tomography arthrogram. Outcomes were assessed with preoperative and postoperative physical examinations, clinical outcome scoring, and radiographic examinations. RESULTS: Ninety-nine patients with complete data were available with a mean follow-up period of 13 years (range, 3-23 years). At the time of final follow-up, 94% of patients did not have recurrence of instability. Of the patients, 90% were satisfied or very satisfied with their outcomes and 54% returned to their preinjury level of activity. The overall complication rate was 21% (the most common complications being subjective apprehension [9%] and recurrent instability [6%]), with 9% of patients requiring reoperation. A full-thickness rotator cuff requiring repair was identified in 22% of patients. CONCLUSIONS: The Latarjet procedure is an effective treatment option for older patients (aged ≥ 40 years) with recurrent anterior shoulder instability in the setting of an anteroinferior capsulolabral and/or bony injury.

Postoperative radiographic findings of an uncemented convertible short stem for anatomic and reverse shoulder arthroplasty.

BACKGROUND: Several short-stemmed press-fit humeral components have been developed in recent years for anatomic total shoulder arthroplasty (TSA) as well as reverse shoulder arthroplasty (RSA). Varying radiographic outcomes have been reported, with some studies reporting concerning rates of aseptic loosening. This study analyzed the radiographic findings of a press-fit convertible short-stemmed humeral component in both TSA and RSA. METHODS: There were 150 anatomic TSAs (group 1) and 77 RSAs (group 2) analyzed radiographically at a minimum follow-up of 2 years postoperatively. Plain radiographs were reviewed for stem loosening, alignment, signs of stress shielding, and the filling ratio. RESULTS: At final follow-up, 49% of group 1 and 65% of group 2 had no evidence for radiographic changes. In those with radiographic changes, low bone adaptions were found in 83% and high adaptions in 17% in both groups. Larger stem sizes with higher filling ratios were associated with high radiographic adaptions in both groups (P = .02). The overall filling ratios were higher in group 2 (P = .002). Cortical contact of the stem led to higher bone adaptions (P = .014). CONCLUSIONS: The short humeral component analyzed in this study showed encouraging survival rates without aseptic loosening. Radiographic changes are associated with a higher filling ratio and cortical contact of the stem. Surgeons should aim to achieve fixation with the minimal required canal filling to minimize radiographic changes with the uncemented humeral component used in this study.

Clinical and anatomic results of rotator cuff repair at 10 years depend on tear type.

PURPOSE: Although good short-term and mid-term outcomes are reported for rotator cuff repair, few studies have investigated long-term outcome with clinical and MRI evaluation. The hypothesis was that 10 years following repair of rotator cuff tear, the clinical and anatomic results depend on the extension of the tear. METHODS: The records of all 965 patients who underwent repair of rotator cuff tears in 2003 were retrieved. The patients were reviewed in 2014 for evaluation at a minimum follow-up of 10 years. A total of 511 patients were evaluated clinically, of whom 397 were also evaluated using MRI. There were 289 isolated supraspinatus tears (SS), 94 tears with posterior extension (P), 92 with anterior extension (A) and 36 with anteroposterior (AP) extension. RESULTS: The Constant score had significantly improved from 53.8 ± 14.7 preoperatively to 77.7 ± 12.1 (P < 0.0001) at 10 years, with no significant difference between the four groups. The rate of retear (Sugaya IV, V) was lower in the SS group (19%) and higher in the P (32%) and AP groups (31%). At review, infraspinatus fatty degeneration was significantly greater (Fuchs > 2) in the P (P < 0.001) and AP (P < 0.001) groups and subscapularis fatty degeneration was significantly greater (Fuchs > 2) in the A (P < 0.001) and AP (P < 0.001) groups. The rate of osteoarthritis (Samilson > 2) was significantly higher at 11% (P = 0.001) in the A group. The failure rate was significantly lower (P = 0.044) in the SS group (25%) than the massive rotator cuff tear groups (A, P and AP groups) (35%). Complications occurred in 51 shoulders (10%) and repeat surgery was required in 62 shoulders (12%), with no difference between the four groups. CONCLUSIONS: The long follow-up period of this study, large series of patients and MRI evaluation of tendon repair allowed us to demonstrate that 10 years following rotator cuff tear repair, between 68 and 81% of tendons had healed. These findings are of value in predicting response to surgical treatment. Tears with posterior extension had a higher risk of retear. However, surgical repair appeared to give a good functional outcome whatever the type of tear, despite the overall rate of complications and repeat surgery. LEVEL OF EVIDENCE: IV.

Hidden degloving rotator cuff tears secondary to glenohumeral dislocation.

BACKGROUND: A rare form of rotator cuff tear (RCT) is observed secondary to glenohumeral dislocation, followed by immediate repositioning, as well as formation of scar tissue between tendons and tuberosities. Radiographic diagnosis of such "degloving" tears is problematic because they are obscured by scar tissue. We aimed to describe characteristics of degloving tears and report outcomes following their arthroscopic repair. METHODS: Among 67 patients who underwent arthroscopic repair of RCTs secondary to shoulder dislocation, we identified 8 patients (12%) (7 anterior dislocations and 1 posterior dislocation), aged 54.5 years (range, 38-61 years), with typical characteristics of degloving tears. Preoperative imaging revealed massive 2- or 3-tendon tears in all patients (6 with a ruptured or dislocated long head of the biceps), evaluated preoperatively and at greater than 2 years, using the absolute and age- and gender-adjusted Constant scores, Subjective Shoulder Value, and Simple Shoulder Test score. RESULTS: The absolute Constant score improved from 27 (range, 17-54) to 89 (range, 62-95). The age- and gender-adjusted Constant score improved from 31 (range, 24-57) to 97 (range, 83-100). The Simple Shoulder Test score improved from 2 (range, 0-4) to 12 (range, 9-12), while the Subjective Shoulder Value improved from 18 (range, 10-30) to 90 (range, 60-100). All patients were very satisfied (63%) or satisfied (37%). CONCLUSION: We have described a particular form of RCT secondary to glenohumeral dislocation, resulting in degloving of the rotator cuff, followed by repositioning of tendons. The formation of scar tissue can obscure tendon tears on ultrasound, in which case further imaging is recommended to ascertain the diagnosis and avoid therapeutic delays.

Short-term radiographic results of a cemented polyethylene keeled glenoid component with varying backside radiuses of curvature.

BACKGROUND: This study analyzed the radiographic results of a cemented all-polyethylene keeled glenoid component available in different sizes and multiple backside radiuses of curvature. METHODS: The study group consisted of 118 cases (114 patients). There were 63 women and 51 men. Mean age at the time of arthroplasty was 68 years (range, 51-85 years). True anterior-posterior radiographs obtained postoperatively and at the final follow-up were analyzed for implant seating and the occurrence of radiolucent lines. Glenoid morphology and fatty infiltration of the rotator cuff muscles were examined using computed tomography scans. Mean follow-up was 38 months (range, 24-70 months). RESULTS: The mean radiolucent line score after surgery was 0.54 points (range, 0-3 points), and 90% had no or only 1 radiolucent line. At the final follow-up, the mean score was 1.06 points (range, 0-3 points), and 74% had no or only 1 radiolucent line. The score increased significantly over time (P < .001). No component was at risk for loosening. No correlation was found between patient age, sex, hand dominance, glenoid morphology, or fatty infiltration of the rotator cuff muscles and the occurrence of radiolucent lines. CONCLUSION: In the short-term, the glenoid component analyzed in this study showed promising radiographic results, with a low number of radiolucent lines without failure. However, the mean radiolucent line score increased significantly over time, and long-term observations are necessary to confirm a possible advantage compared with older component designs.

Tenodesis renders better results than tenotomy in repairs of isolated supraspinatus tears with pathologic biceps.

BACKGROUND: Many authors recommend systematic biceps tenotomy or tenodesis when repairing rotator cuff tears, regardless of whether the biceps is normal or pathologic. The purpose of this study was to determine whether 10-year outcomes of repairs of isolated supraspinatus tears are influenced by adjuvant biceps tenodesis or tenotomy. METHODS: Patients who underwent repair of isolated supraspinatus tears were recalled for evaluation at a minimum follow-up of 10 years. A total of 249 patients (51% men) aged 56.7 ± 6.3 years were evaluated clinically (Constant score), of whom 182 were also evaluated using magnetic resonance imaging (Sugaya classification). The biceps was intraoperatively found to be pathologic in 52% of shoulders, of which 39% had a tenotomy and 54% had a tenodesis; it was found to be normal in 48% of shoulders, of which 88% were left intact. RESULTS: There were no significant differences in Constant scores for patients who had normal biceps without adjuvant procedures (77.1 ± 11.7) compared with patients who had pathologic biceps with either tenodesis (79.8 ± 11.5, P = .104) or tenotomy (75.3 ± 10.7, P = .420). However, for patients who had pathologic biceps, Constant scores were significantly better for those with tenodesis compared with those with tenotomy (P = .025). Multivariable regression revealed Constant scores to be significantly lower for women, as well as patients with fatty infiltration of stages 1 and 2, but significantly higher for patients who underwent tenodesis. CONCLUSION: Adjuvant biceps procedures are not required when repairing isolated supraspinatus tears, unless biceps pathology is observed intraoperatively, for which tenodesis grants better function and strength than tenotomy.

Increased scapular spine fractures after reverse shoulder arthroplasty with a humeral onlay short stem: an analysis of 485 consecutive cases.

BACKGROUND: Scapular stress fractures after reverse shoulder arthroplasty (RSA) are a potentially serious complication with modern lateralized and onlay implants. The aim of this study was to report the scapular spine stress fracture rate after RSA with an onlay, 145° humeral stem, analyzing potential fracture risk factors and clinical outcomes in a large cohort of patients. METHODS: A consecutive series of 485 RSAs were implanted with the Aequalis Ascend Flex stem. Data collection included preoperative and postoperative clinical and radiographic assessment findings (rotator cuff Goutallier grade; Hamada, Walch, and Favard classifications; range of motion; Constant score) and perioperative data. Patients with a scapular spine fracture following RSA were matched with nonfracture control patients, and preoperative variables were tested to determine whether they were predictive of a scapular spine fracture. RESULTS: A scapular spine fracture following RSA occurred in 21 patients (4.3%), with a mean time to diagnosis of 8.6 months (range, 1-34 months). No preoperative factor was found to be a significant predictor of scapular spine fracture. Both groups showed significant improvements in active mobility measurements and Constant scores from preoperatively to final follow-up (P < .001). The control group scored significantly better than the scapular spine fracture group regarding the Constant score and forward flexion. CONCLUSION: Scapular spine fractures have shown an increased prevalence after onlay-design RSA. This series was not able to link any clear risk factors. Functional results are limited, regardless of the fracture management.

Should massive rotator cuff tears be reconstructed even when only partially repairable?

PURPOSE: (1) To evaluate midterm functional outcomes of arthroscopic repair of massive rotator cuff tears and (2) to determine the prognostic factors that could influence outcome. The hypothesis was that both partial and complete repairs would result in equivalent improvement of clinical score. METHODS: From a prospective series of 525 rotator cuff repairs, we analysed records of the 73 patients who were treated for massive tears. The median follow-up was 41 months (range 29-55), and functional outcome was evaluated using the Constant score, shoulder strength, and subjective shoulder value. RESULTS: The median CS improved from 34 points to 81 points (p < 0.001). The scores were better for both types of two-tendon tears, posterosuperior (83, n = 33) and anterosuperior (85, n = 13) (n.s.), than for three-tendon tears (74, n = 27) (p < 0.001). The scores were also better when fatty infiltration was of stage I (84, n = 28) than of stage II (78, n = 34) (p < 0.001) or stage III (74, n = 11) (p = 0.04). The scores were only slightly higher for completely reparable tears (81.5, n = 50) than for partially reparable tears (79, n = 23) (n.s.). Ultrasonic examination revealed incomplete healing, in 10 of the 50 completely repaired tears, and in 11 of the 23 partially repaired tears. CONCLUSIONS: The results of the present study compare favourably with those in recent literature and confirm the hypothesis that both partial and complete repairs of massive rotator cuff tears produce equivalent improvements of Constant scores. The clinical relevance of these observations is that even if repairs of two-tendon tears result in superior functional outcomes, repairs of three-tendon tears produce equivalent 'relative' improvement that grants sufficient patient satisfaction and autonomy. LEVEL OF EVIDENCE: Comparative case series, Level IV.