Limited reliability of grading scapular notching according to Nerot-Sirveaux on anteroposterior radiographs

Reverse rhino sign as a radiological sign of low-grade infected reverse shoulder arthroplasty

INTRODUCTION

Low-grade infections following shoulder surgery are difficult to diagnose. Recently, curved-shaped bony spurs, further mentioned "reverse rhino signs" because of its shape, growing inferior on the glenoid were noticed on X-rays of patients with a reverse shoulder arthroplasty (RSA) and a Cutibacterium acnes (C. acnes) infection. This study aimed to determine the sensitivity and specificity of the reverse rhino sign as a radiological marker for detecting low-grade shoulder infections in RSA.

MATERIALS AND METHODS

A diagnostic study was performed including patients who underwent revision surgery of an RSA with perioperative cultures taken. Blinded radiographic evaluation was performed by two orthopedic surgeons for presence of rhino signs, humeral osteophytes, and notching. Efficacy measures of the reverse rhino sign for detecting low-grade infections were determined. Furthermore, results were stratified for notching and gender.

RESULTS

Thirty-two revised RSA patients had a low-grade infection and 36 had no infection. Seventeen (53%) patients with infection had a reverse rhino sign present, compared to 6 (17%) in the non-infection group. Sensitivity, specificity, positive and negative predictive value of the reverse rhino sign were, respectively, 53%, 83%, 74%, and 67%. These measures changed to 68%, 77%, 72%, and 74% for patients without notching and to 47%, 100%, 100%, and 8% for males.

CONCLUSION

In the absence of a reverse rhino sign in RSA patients, a low-grade shoulder infection is unlikely. Hence, the reverse rhino sign can be used to rule in a low-grade shoulder infection, especially in males and in the absence of notching. Low-grade infections should be considered in patients with unexplained persistent shoulder complaints after RSA placement, especially when a rhino sign is present. For these patients, we advise to perform mini-open biopsy for cultures.

LEVEL OF EVIDENCE

Diagnostic level IV.

Lateralized vs. classic Grammont-style reverse shoulder arthroplasty for cuff deficiency Hamada stage 1-3: does the design make a difference?

BACKGROUND

Reverse shoulder arthroplasty (RSA) with a lateralized design is thought to improve outcomes. Our aim was to compare RSA with the classic Grammont prosthesis against a prosthesis with 135° inclination and a lateralized glenosphere for cuff-deficient shoulders.

METHODS

Patients with irreparable massive posterosuperior rotator cuff tear Hamada grade 1-3 underwent RSA and were documented prospectively up to 24 months postsurgery. Comparative RSA groups were "lateralized" (L), with 135° humeral inclination and 36+4-mm lateralized glenosphere (n = 44), and "Grammont" (G), with 155° humeral inclination and 36+2-mm eccentric glenosphere (n = 23). Range of motion including the Apley scratch test, abduction strength, Constant-Murley score (CS), and Shoulder Pain and Disability Index (SPADI) were assessed. Anteroposterior and axial radiographs were evaluated at 24 months, and additional measurements of scapular neck and glenoid anatomy, baseplate and glenosphere position, center of rotation, humeral offset, and lateralization and distalization shoulder angles were made. Linear regression and mixed models adjusted for sex differences and preoperative values were applied.

RESULTS

Overall CS and SPADI outcomes were not significantly different between groups (P ≥ .654). For group L, external rotation remained stable up to the 2-year follow-up and was higher than for group G (P = .012 ); a greater proportion of group L patients could reach the lumbar vertebra 3 (L3) (70% vs. 48% in group G) (P = .26). Group G had a higher inferior glenosphere overhang (P = .020) and center of rotation (COR) medialization (P < .001), whereas group L had higher humeral offset (P < .001) and lateralization shoulder angle (P < .001) with a trend toward higher baseplate positioning (P = .045). The rate of scapular notching was 2.9 times higher for group G than group L (P = .001).

CONCLUSION

RSA with 135° humeral inclination and a lateralized glenosphere shows similar outcome scores as the classic Grammont design but enables better preservation of external rotation and reduces the rate of scapular notching compared with the classic Grammont design in Hamada 1-3 patients with irreparable posterosuperior tears.

Minimum five-year outcomes of reverse total shoulder arthroplasty using a trabecular metal glenoid base plate

AIMS

Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes.

METHODS

All consecutive elective RTSAs performed at a single centre between November 2008 and October 2014 were reviewed. Patients who had primary TM-RTSA for rotator cuff arthropathy and osteoarthritis with deficient cuff were included. A total of 190 shoulders in 168 patients (41 male, 127 female) were identified for inclusion at a mean of 7.27 years (SD 1.4) from surgery. The primary outcome was survival of the implant with all-cause revision and aseptic glenoid loosening as endpoints. Secondary outcomes were clinical, radiological, and patient-related outcomes with a five-year minimum follow-up.

RESULTS

The implant was revised in ten shoulders (5.2%) with a median time to revision of 21.2 months (interquartile range (IQR) 9.9 to 41.8). The Kaplan-Meier survivorship estimate at seven years was 95.9% (95% confidence interval (CI) 91.7 to 98; 35 RTSAs at risk) for aseptic mechanical failure of the glenoid and 94.8% (95% CI 77.5 to 96.3; 35 RTSAs at risk) for all-cause revision. Minimum five-year clinical and radiological outcomes were available for 103 and 98 RTSAs respectively with a median follow-up time of six years (IQR 5.2 to 7.0). Median postoperative Oxford Shoulder Score was 38 (IQR 31 to 45); median Constant and Murley score was 60 (IQR 47.5 to 70); median forward flexion 115° (IQR 100° to 125°); median abduction 95° (IQR 80° to 120°); and external rotation 25° (IQR 15° to 40°) Scapular notching was seen in 62 RTSAs (63.2%).

CONCLUSION

We present the largest and longest-term series of TM-backed glenoid implants demonstrating 94.8% all-cause survivorship at seven years. Specifically pertaining to glenoid loosening, survival of the implant increased to 95.9%. In addition, we report satisfactory minimum five-year clinical and radiological outcomes. Cite this article: Bone Joint J 2021;103-B(8):1333-1338.

The Schulthess local Shoulder Arthroplasty Registry (SAR): cohort profile

PURPOSE

Clinical registries are essential for evaluation of surgical outcomes. The Schulthess Shoulder Arthroplasty Registry (SAR) was established in 2006 to evaluate safety, function, quality-of-life and patient satisfaction in patients undergoing shoulder arthroplasty.

PARTICIPANTS

Adult patients undergoing anatomic or reverse shoulder joint replacement at the Schulthess Klinik, a high-volume, leading orthopaedic surgery centre in Zürich, Switzerland.

FINDINGS TO DATE

Between March 2006 and December 2019, the registry covered 98% of eligible operations. Overall, 2332 patients were enrolled with a total of 2796 operations and 11 147 person-years of follow-up. Mean age at baseline was 71 (range: 20-95), 65% were women. Most common indication was rotator cuff tears with osteoarthritis (42%) and the mean preoperative Constant Score was 31 (±15). The most frequent arthroplasty type was reverse, increasing from 61% in 2006-2010 to 86% in 2015-2019. Functional recovery peaked at 12-month postoperatively and did not show a clinically relevant deterioration during the first ten follow-up years. Since its establishment, the registry was used to address multiple pertinent clinical and methodological questions. Primary focus was on comparing different implant configurations (eg, glenosphere diameter) and surgical techniques (eg, latissimus dorsi transfer) to maximise functional recovery. Additionally, the cohort contributed to the determination of the clinical relevance and validity of radiological monitoring of cortical bone resorption and scapular notching. Finally, SAR data helped to demonstrate that returning to sports was among key patient expectations after reverse shoulder arthroplasty.

FUTURE PLANS

As first patients are approaching the 15 years follow-up landmark, the registry will continue providing essential data on long-term functional outcomes, implant stability, revision rates and aetiologies as well as patient satisfaction and quality-of-life. In addition to research and quality-control, the cohort data will be brought back to the patients by bolstering real-time clinical decision support.

Clinical implications of scapular notching at 2 and 5-year follow-up after reverse total shoulder arthroplasty

Objective

Scapular notching is a unique radiographic sequela of reverse total shoulder arthroplasty (rTSA) with unclear long-term clinical consequences.

Methods

Our retrospective review of a single surgeon, single implant, primary rTSA database investigates the incidence of scapular notching at 2 and 5-year follow-up. Various patient outcome scores were also obtained.

Results

Of 158 primary rTSAs performed, 82 (52%) patients completed 2-year and subsequent 5-year follow-up. The incidence of scapular notching at 2 and 5-years was 11.9% and 19.5%, respectively.

Conclusion

Scapular notching negatively affects validated post-operative outcome scores, active range of motion and total complications, and furthermore increases with time.