Primary Shoulder Hemiarthroplasty: What Can Be Learned From 359 Cases That Were Surgically Revised?

Three- or four-part proximal humeral fractures in middle-aged and active elderly group of patients: a narrative review of treatment options

Background and Objective

Proximal humerus fractures (PHFs) occur in all age groups but more in elderly population with variety of treatment options. The choice of treatment of PHFs is rather controversial in the middle-aged and active elderly population. This review article highlights the current literature on the efficacy of treatment options for PHFs in middle-aged and active elderly patients which could help surgeons in decision making in clinical practice.

Methods

PubMed and Scopus databases from January 1953 to February 2024 were searched and screened for studies, including systematic reviews, on the treatment of PHFs in middle-aged and elderly that served for narrative review of rationale behind such design.

Key Content and Findings

Patients with minimally displaced fractures should be treated nonoperatively. Internal fixation with intramedullary nailing is a viable option in cases of two-part surgical neck fractures, those with diaphyseal involvement and no significant displacement of the tuberosities, or pathologic fractures. Those elderly patients with displaced three- or four-part PHFs fractures with intact rotator cuff muscles should be treated with locking plate fixation if anatomical reduction of fracture fragments including tuberosity is possible, as the results after union despite avascular necrosis are favorable. Moreover, patients with failed fixation treated with salvage reverse shoulder arthroplasty (RSA) have similar outcomes to RSA for acute PHFs. Hemiarthroplasty should be reserved for select group of young active patients with unconstructable fracture, intact rotator cuff, and good tuberosity bone stock. RSA should be offered as first option for elderly patients with poor bone stock, rotator cuff insufficiency, fracture dislocations, head-split fractures, and severely displaced 3- and 4-part PHFs.

Conclusions

The treatment of choice in middle-aged and active elderly patients with three- or four-part PHFs depends on several factors such as fracture pattern, bone quality, possibility of anatomical reduction, status of rotator cuff, and patient expectations. The success of treatment is based on patient selection while setting correct patient expectations.

Pyrocarbon Hemi-Shoulder Arthroplasty Provides Satisfactory Outcomes Following Prior Open Latarjet

Purpose

To assess the clinical and radiographic outcomes, at a minimum follow-up of 4 years, following HSA using pyrocarbon in patients that had prior open Latarjet.

Methods

The authors retrieved the records of 61 consecutive patients that underwent HSA with a pyrocarbon humeral head at 2 centers between December 2013 and October 2019. Eight patients (9 shoulders) had undergone previous Latarjet procedures without other surgical antecedents. Patients underwent radiological assessment, and clinical assessment including Constant score, Subjective Shoulder Value (SSV), and pain on VAS. Finally, range of motion was assessed, including active forward elevation and external rotation.

Results

The initial cohort of 9 shoulders, comprised 1 woman and 7 men (1 bilateral), aged 52.5 ± 5.2 at their index HSA, which was performed 27.7 ± 9.3 years following their prior Latarjet procedure. One shoulder required conversion to reverse shoulder arthroplasty, 3 years after HSA. The remaining 8 shoulders were assessed at 6.1 ± 1.6 years (range, 4-8) after the index HSA. Glenoid erosion only progressed in 1 shoulder from mild to moderate. The Constant score was 79.6 ± 12.7, pain on VAS was 1.0 ± 2.1, and SSV was 80.0 ± 25.6. The active forward elevation improved from 96°±41° to 151°±29°, and external rotation from 11°±17° to 32°±8°.

Conclusion

Patients that underwent HSA using pyrocarbon heads following prior Latarjet had satisfactory clinical scores, and glenoid erosion only progressed in 1 patient. Furthermore, only 1 patient required conversion to RSA. The clinical relevance is that HSA using pyrocarbon heads is a safe treatment and grants satisfactory clinical outcomes in patients with prior Latarjet.

Level of Evidence

Level III, retrospective comparative study.

Hemiarthroplasty in Proximal Humerus Fractures: Does Modular Metaphyseal Stem Design Lead to Better Results? An Analysis of 24 Cases

Introduction

Anatomic hemiarthroplasty (aHA) is a treatment option for non-reconstructable constructable multifragment proximal humeral fractures that preserves range of motion. Our study aims to evaluate the radiographic and clinical outcomes of patients who received a modular aHA with anatomical sizing of the tubercle-bearing metaphyseal components.

Materials and Methods

The medical records of thirty-nine consecutive patients were reviewed. Patients were treated at a single institution with aHA as first-line treatment following a non-reconstructable constructable proximal humeral fracture. Tubercle resorption and cranialization of the aHA were analyzed using radiographic controls. Patient clinical function was assessed using the Constant Murley Score (CS).

Results

Twenty-four patients (62%) were available for clinical follow-up, with a mean CS of 54 points after a mean 56-month follow-up period. There was no significant difference in functional outcome on average between patients with healed tubercles (CS = 57) and resorbed tubercles (CS = 51). Radiographic follow-up was available in 33 patients (85%), demonstrating healed tubercles in 33% of the patients. Patients with resorbed tubercles had significant smaller acromio-humeral distances (AHD) than patients with healed tubercles (p = 0.043). A positive correlation was observed between greater AHD and increased constant scores (p = 0.022).

Conclusions

The final patient outcome measures demonstrated a positive correlation with a greater acromio-humeral distance and tubercle healing rates. However, the modular stem design with sizing of the metaphyseal components did not result in superior outcomes when compared with the literature.

Convertible-platform shoulder arthroplasty

Background

Shoulder arthroplasty has become an increasingly common procedure used to treat degenerative, inflammatory, and traumatic conditions of the glenohumeral joint. With a significant increase in primary anatomic and reverse total shoulder arthroplasty, revision procedures have likewise increased. Updates in shoulder arthroplasty have allowed for the convertibility of implants, which allows for the retention of both glenoid and humeral components during revision surgery. This review aims to highlight the epidemiology, indications, and outcomes of convertible-platform total shoulder arthroplasty procedures.

Methods

A review of the current literature surrounding convertible-platform shoulder arthroplasty was completed to highlight the advantages and disadvantages of commercially available instrumentation and implant systems as well as their outcomes.

Discussion

Leading causes of shoulder arthroplasty revision surgery include glenoid failure, implant instability, and rotator cuff dysfunction. Variations in implant design between inlay and onlay humeral components and metal-backed glenoid components are important considerations at the time of revision surgery. Advantages of convertible-platform systems include increased efficiency and decreased complications during revision procedures as well as shorter recovery, lower cost, and better functional outcomes. Limitations of convertible systems include poorly positioned components during the index procedure, excessive soft-tissue tensioning, and problems associated with metal-backed glenoid implants. Changes in arm length have also been documented. These findings indicate the benefit of additional research and design to improve the effectiveness and utility of convertible-platform shoulder arthroplasty systems.

Functional Outcomes and a Review of Management Options for Revision Shoulder Arthroplasty

Introduction

Increase in the number of primary shoulder arthroplasty has led to an increase in the number of revisions which presents many complex challenges and often has inferior outcomes.

Materials and Methods

Data was collected retrospectively, and patients were classified using Dines classification. Comprehensive case reviews were done to identify preoperative and intra-operative challenges. The primary outcome measure was Oxford shoulder score (OSS). The secondary measures were range of motion (ROM) and patient satisfaction (very satisfied, satisfied, not satisfied or worse).

Results

A total of 32 patients were identified with a mean age of 67.64 years and the most common cause of revision was a combination of bone and soft tissue failure (39.3%). All patients (n=8) with hemiarthroplasty had rotator cuff deficiency while patients with resurfacing had both rotator cuff failure and bony erosion. Four patients needed a proximal humeral osteotomy and six patients needed allograft reconstruction of the glenoid for bone loss. Twenty-one shoulders were revised to reverse total shoulder arthroplasty (TSA), 2 to anatomical TSA and 5 were left with cement spacer in situ. Mean duration of follow-up was 41.6 months. Mean OSS at the last follow-up was 26.88 with statistically significant improvement in ROM. There was no statistical difference in clinical outcomes (p>0.05) based on the type of primary prosthesis or cause of revision. A total of 70% patients were pain free. Patients with infection had inferior outcomes with a mean OSS of 17.

Conclusion

Management of patients with failed shoulder arthroplasty is often challenging but has good clinical outcome except in infections.

Long-term outcomes of hemiarthroplasty using a smaller head combined with rotator cuff reconstruction in patients with cuff-tear arthropathy

Background

Hemiarthroplasty (HHR) using a smaller head with rotator cuff reconstruction is a treatment option for cuff-tear arthropathy, offering advantages like facilitating rotator cuff-tear closure, increasing the lever arm of deltoid, and restoring function in irreparable cuff tears. This study aimed to evaluate the long-term outcomes of this procedure.

Methods

A retrospective analysis was conducted for 91 shoulders undergoing HHR using a smaller head with rotator cuff reconstruction between May 2005 and September 2012. Surgery involved reducing the size of humeral head and performing rotator cuff reconstruction based on the site of the deficient rotator cuff. The study analyzed University of California, Los Angeles shoulder scores, Japanese Orthopaedics Association shoulder scores, range of motion, and postoperative radiographs.

Results

Twenty-eight patients, divided into an elderly group (14 women, 2 men, mean age 74.5 ± 3.8 years) and a younger group (6 women, 6 men, mean age 63.5 ± 3.1 years) were followed up for a mean of 133.2 ± 14.1 months. No complications were reported. The clinical scores and range of motion significantly improved postoperatively and remained over 10 years. Radiographs revealed high incidence of glenoid wear (82.1%), bone resorption (43%) and cranial humeral head migration (54%), with no prosthesis loosening.

Conclusion

We believe that HHR using a smaller head with rotator cuff reconstruction is a surgical technique that can maintain stable long-term outcomes in both elderly and younger individuals with cuff-tear arthropathy.

Novel Use of a Fibular Strut Allograft with Fibular Head in an Elderly Patient with Proximal Humeral Fracture and Severe Metaphyseal Comminution: An Alternative to Shoulder Arthroplasty

Treatment of a comminuted proximal humerus fracture (PHF) in elderly patients with severe osteoporosis is challenging, often leading to arthroplasty (such as hemiarthroplasty or reverse shoulder arthroplasty) as the treatment of choice. However, arthroplasty does not always guarantee favorable outcomes. In contrast, the use of intramedullary fibular strut allografts provides additional reduction stability during locking plate fixation; however, to our knowledge, there is limited literature on the use of fibular strut allografts, including the fibular head. Here we aim to report the advantages of using a fibular strut containing the fibular head in severe osteoporotic PHFs. We present the case of an 88-year-old female patient with severe osteoporosis diagnosed with a left PHF accompanied by severe metaphyseal comminution following a fall from a chair. Rather than shoulder arthroplasty, we performed osteosynthesis using a fibular strut allograft containing the fibular head. At the one-year follow-up after surgery, we observed excellent bony union and a favorable functional outcome without major complications, such as reduction loss. The novel use of a fibular strut allograft containing the fibular head could be promising for PHFs with severe metaphyseal comminution, potentially avoiding the need for arthroplasty.

Pyrocarbon hemiarthroplasty and the shoulder: biomechanical and clinical results of an emerging treatment option

While shoulder hemiarthroplasty is still used to treat young patients with shoulder pathology, the use of this procedure has substantially declined in recent years due to its significant complication profile. Glenoid wear with arthrosis is one of the major postoperative complications following shoulder hemiarthroplasty, and efforts to prevent this complication led many scientists to explore alternative weight-bearing surfaces on arthroplasty implants to decrease joint wear and improve patient outcomes. Pyrolytic carbon, or pyrocarbon, is a material that has better biocompatibility, survivorship, strength, and wear resistance compared to the materials used in traditional shoulder hemiarthroplasty. Pyrocarbon implants have been used in orthopedics for over 50 years; recently, their utility in shoulder hemiarthroplasty has garnered much interest. The purpose behind the use of pyrocarbon in shoulder hemiarthroplasty is to decrease the risk of progressive glenoid wear, especially in young active patients in whom joint preservation is important. Promising survivorship and outcomes have been demonstrated by recent studies, including limited glenoid wear following pyrocarbon hemiarthroplasty. Nevertheless, these clinical studies have been limited to relatively small case series with limited long-term follow-up. Accordingly, additional research and comparative studies need to be conducted in order to properly assess the therapeutic efficacy and value of pyrocarbon hemiarthroplasty.

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.

Evaluating the Use of PROMs in Paediatric Orthopaedic Registries

Patient-reported outcome measures (PROMs) provide structured information on the patient's health experience and facilitate shared clinical decision-making. Registries that collect PROMs generate essential information about the clinical course and efficacy of interventions. Whilst PROMs are increasingly being used in adult orthopaedic registries, their use in paediatric orthopaedic registries is not well known. The purpose of this systematic review was to identify the frequency and scope of registries that collect PROMs in paediatric orthopaedic patient groups. In July 2023, six databases were systematically searched to identify studies that collected PROMs using a registry amongst patients aged under 18 years with orthopaedic diagnoses. Of 3190 identified articles, 128 unique registries were identified. Three were exclusively paediatric, 27 were majority paediatric, and the remainder included a minority of paediatric patients. One hundred and twenty-eight registries collected 72 different PROMs, and 58% of these PROMs were not validated for a paediatric population. The largest group of orthopaedic registries collected PROMs on knee ligament injuries (21%). There are few reported dedicated orthopaedic registries collecting PROMs in paediatric populations. The majority of PROMs collected amongst paediatric populations by orthopaedic registries are not validated for patients under the age of 18 years. The use of non-validated PROMs by registries greatly impedes their utility and impact. Dedicated orthopaedic registries collecting paediatric-validated PROMs are needed to increase health knowledge, improve decision-making between patients and healthcare providers, and optimise orthopaedic management.

Incidence of complications related to shoulder arthroplasties identified on computed tomography

PURPOSE

Determine incidence of shoulder arthroplasty complications identified on computed tomography (CT).

MATERIALS AND METHODS

Retrospective institutional database review of patients with shoulder arthroplasties who underwent CT between 01/2006-11/2021 at a tertiary academic referral center with subspecialized orthopedic shoulder surgeons. CT reports were reviewed for arthroplasty type and complication. Data were stratified and summarized. Associations between complications and arthroplasty types were determined with Chi-squared goodness of fit test.

RESULTS

Eight hundred twelve CTs in 797 unique patients were included (438 (53.9%) females and 374 (46.1%) males; mean age 67 ± 11 years). There were 403 total shoulder arthroplasties (TSA), 317 reverse total shoulder arthroplasties (rTSA), and 92 hemiarthroplasties (HA). Complications were present in 527/812 (64.9%) and incidences were: loosening/aseptic osteolysis 36.9%, periprosthetic failure 21.6%, periprosthetic fracture 12.3%, periprosthetic dislocation 6.8%, joint/pseudocapsule effusion 5.9%, prosthetic failure 4.8%, infection 3.8%, and periprosthetic collection 2.1%. Complications per arthroplasty were: 305/403 (75.7%) TSAs, 176/317 (55.5%) rTSAs, and 46/92 (50%) HAs (p < 0.001). Periprosthetic fracture (20.8%), prosthetic dislocation (9.8%), and prosthetic failure (7.9%) were highest in rTSAs (p < 0.001, p < 0.013, p < 0.001, respectively). Loosening/aseptic osteolysis most frequent in TSAs (54.1%) (p < 0.001). Periprosthetic failure most frequent in HA (32.6%) (p < 0.001). Significant associations were identified with joint/pseudocapsule effusion and loosening/aseptic osteolysis (p = 0.04) and prosthetic dislocation (p < .001).

CONCLUSION

In this single tertiary academic referral center cohort, the incidence of shoulder arthroplasty complication identified on CT was 64.9% and the most commonly occurring complication was loosening/aseptic osteolysis (36.9%). TSA had the highest incidence of complication (75.7%).

Use of LARS for soft tissue function reconstruction during tumor-type hemi-shoulder replacement achieves a good prognosis: a retrospective cohort study

BACKGROUND

Shoulder soft tissue function reconstruction during tumor-type hemishoulder replacement is an important step to restore shoulder function. This study evaluates the functional prognosis and postoperative complications of ligament advanced reinforcement system (LARS)-assisted soft tissue functional reconstruction in tumor-type hemi-shoulder replacement.

MATERIALS AND METHODS

Twenty-two patients with an average age of 37.5 ± 17.8 years diagnosed with benign invasive tumors, primary malignant bone tumors, or bone metastases were enrolled in this study. The patient's medical records (history and surgical details), histological sections, imaging files, oncological prognosis, functional prognosis, and postoperative complications were collected. The upper limb function and shoulder joint function were evaluated using the Musculoskeletal Tumor Society (MSTS) system and American Shoulder and Elbow Surgeons (ASES) scoring criteria, respectively.

RESULTS

Twenty-two patients comprising 12 males and 10 females were enrolled. Overall, 9 patients had preoperative pathological fractures. The mean lesion length was 8.6 ± 3.0 cm. The local recurrence was observed in 3 cases, including 2 cases of osteosarcoma and 1 case of MGCT. A further 4 cases had pulmonary metastasis, including 2 cases with local tumor recurrence. The average postoperative MSTS score was 25.8 ± 1.7, and the score of postoperative ASES was 85.7 ± 6.0, both of which showed satisfactory functional recovery. Two cases experienced postoperative complications requiring surgical intervention, including one periprosthetic fracture and one giant cell granuloma. Prosthesis dislocation occurred in 1 case. None of the cases of periprosthetic infection or postoperative complications resulted in implant failure.

CONCLUSIONS

LARS-assisted soft tissue function reconstruction in benign and malignant proximal humerus tumors after a tumor-type hemi-shoulder replacement is an effective technical improvement, which can effectively repair the integrity of the joint capsule to restore joint stability, provide a medium for soft tissue attachment to rebuild the muscular dynamic system, and eliminate residual dead space around the prosthesis, effectively improving limb function and reduce postoperative infection complications.

Accuracy of free-hand humeral head resection planned on 3D-CT models in shoulder arthroplasty: an in vitro analysis

INTRODUCTION

Three-dimensional planning of humeral head osteotomy in shoulder arthroplasty (SA) is understudied. This study evaluated whether a standard osteotomy technique along the anterosuperior anatomic neck (ASOT) could be surgically reproduced as pre-operatively planned on 3D-CT models.

MATERIAL AND METHODS

Pre-operative planning in 12 cadaver shoulders was performed on a 3D-CT model of the humerus to calculate the planned osteotomy plane (planned OP). The osteotomy was then performed using a free-hand technique, and a post-operative CT scan was obtained for analysis (performed OP). Planes were compared with regards to inclination, retroversion, and resected humeral head thickness so the accuracy could be quantified.

RESULTS

The absolute errors between the performed and planned OP were 2° (0-10°), 5° (0-14°), and 4 mm (1-7 mm) for inclination, retroversion, and resected head thickness, respectively. Deviation < 10° for inclination and retroversion and < 5 mm for resected humeral head thickness between planned and performed OP was achieved in 92%, 83%, 58% of cases, respectively. No differences were found for inclination (p = 0.289), whereas retroversion and resected head thickness were smaller than planned (p ≤ 0.027).

CONCLUSIONS

Pre-operative planning of the ASOT using a 3D-CT model is accurate within a threshold of 10° when using a free-hand technique in 92% of cases for inclination. Retroversion and resected head thickness differed from the pre-operative plan, thereby limiting the unrestricted use of humeral head osteotomy planning from 3D-CT models in SA. These findings are a reference for further studies to develop and quantify the accuracy of pre-operative planning software including cutting guides for SA using 3D-CT models.

LEVEL OF EVIDENCE

Basic science article.

Do preoperative factors and implant design features influence humeral stem extraction efforts?

BACKGROUND

Variations in humeral component designs in hemiarthroplasty and anatomic total shoulder arthroplasty cases can impact the degree of difficulty during a revision surgery that necessitates the removal of the humeral stem. However, no metric exists to define stem extraction effort nor to identify associated factors that contribute to extraction difficulty. The purpose of this study is to describe a method to quantify stem extraction difficulty and to define features that will impact the effort during stem removal.

METHODS

This was a retrospective review of 58 patients undergoing revision of hemiarthroplasty or anatomic total shoulder arthroplasty requiring stem extraction. Each included patient had existing preoperative radiographic examination, an intraoperative video of the stem removal process, and explants available for analysis by 3 surgeons. The following factors were assessed for the impact on extraction difficulty: (1) preoperative features such as cement use, fill of proximal humerus, and stem design features; (2) intraoperative data on extraction time and bone removal; and (3) postoperative findings related to extraction artifacts (EAs). A scoring system was established to distinguish easy (Easy group) and difficult (Difficult group) stem removal cases and further used to identify the features that may affect intraoperative difficulty of stem removal.

RESULTS

The Difficult group accounted for 26% (15/58) of the study population with an 18-minute average stem extraction time, average EA count of 69, and 35 mm of bone removed. The Easy group accounted for 74% (43/58) of patients, with a 4-minute average extraction time, average EA count of 23, and 10 mm of bone removed. Logistic regression model was able to correctly classify 82% of the cases, explaining 26.7% of the variance in humeral stem removal with cement and proximal coating variables. The likelihood of cemented stem removal being difficult is 5 times greater compared to an uncemented stem, and having proximal coating doubles the likelihood of a difficult stem removal compared to cases with no coating.

CONCLUSIONS

Quantifying stem extraction difficulty is possible with intraoperative video as well as explant analysis. Preoperative features of the fixation type and specific features of stem design such as proximal coating will impact difficulty of stem extraction.

Prosthesis Designs and Tuberosity Fixation Techniques in Reverse Total Shoulder Arthroplasty: Influence on Tuberosity Healing in Proximal Humerus Fractures

Reverse total shoulder arthroplasty (RTSA) is increasingly used for the treatment of complex proximal humerus fractures and fracture sequelae. In 2021, half a dozen models of fracture stems are commercially available, reflecting its growing utility for fracture management. Prosthesis designs, bone grafting and tuberosity fixation techniques have evolved to allow better and more reliable fixation of tuberosities and bony ingrowth. Patients with anatomical tuberosity healing not only have an increased range of active anterior elevation and external rotation, but also experience fewer complications and longer prosthesis survival. This review provides an overview of recent evidence on basic and fracture-specific RTSA design features as well as tuberosity fixation techniques that can influence tuberosity healing.

Shoulder Hemiarthroplasty with Nonprosthetic Glenoid Arthroplasty: The Ream-and-Run Procedure

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Glenoid component wear and loosening are the principal failure modes of anatomic total shoulder arthroplasty (aTSA).

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The ream-and-run (RnR) procedure is an alternative glenohumeral arthroplasty for patients who wish to avoid the risks and limitations of a prosthetic glenoid component.

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During the RnR procedure, the arthritic glenoid is conservatively reamed to a single concavity, while the prosthetic humeral component and soft tissues are balanced to provide both mobility and stability of the joint.

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The success of the RnR procedure depends on careful patient selection, preoperative education and engagement, optimal surgical technique, targeted rehabilitation, and close postoperative communication between the surgeon and the patient.

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While the RnR procedure allows high levels of shoulder function in most patients, the recovery can be longer and more arduous than with aTSA.

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Patients who have undergone an RnR procedure occasionally require a second closed or open procedure to address refractory shoulder stiffness, infection, or persistent glenoid-sided pain. These second procedures are more common after the RnR than with aTSA.

Impact of previous non-arthroplasty surgery on clinical outcomes after primary anatomic shoulder arthroplasty

BACKGROUND

The objectives of this study were to address the following questions regarding previous non-arthroplasty surgery prior to primary anatomic shoulder arthroplasty (either total shoulder arthroplasty [TSA] or ream-and-run arthroplasty): (1) To what degree is primary anatomic shoulder arthroplasty after prior non-arthroplasty surgery associated with inferior clinical outcomes and higher revision rates compared with arthroplasty without previous surgery? (2) Does type, approach, or timing of previous surgery affect outcomes after anatomic arthroplasty?

METHODS

A retrospective review of a primary shoulder arthroplasty database was performed and identified 640 patients undergoing anatomic shoulder arthroplasty (345 TSAs and 295 ream-and-run arthroplasties). Of these patients, 183 (29%) underwent previous non-arthroplasty surgery. Baseline and demographic information, 2-year postoperative outcome scores, and revision surgical procedures with associated culture results were collected.

RESULTS

In patients undergoing TSA, previous non-arthroplasty surgery was associated with a significantly lower 2-year Simple Shoulder Test (SST) score (P = .010), percentage maximum possible improvement (MPI) (P = .024), and Single Assessment Numeric Evaluation (SANE) score (P < .001) and a higher rate of reoperation (P < .001). In patients undergoing ream-and-run arthroplasty, previous non-arthroplasty surgery was associated with a nonsignificantly lower 2-year SST score, percentage MPI, and SANE score and higher reoperation rate. Prior fracture surgery carried a higher risk of reoperation than other types of surgery including rotator cuff repair and instability surgery. Among TSA and ream-and-run arthroplasty cases with prior non-arthroplasty surgery, prior open surgery and the time interval from most recent surgery were associated with nonsignificant differences in the 2-year SST score, percentage MPI, SANE score, and revision risk.

CONCLUSION

Previous surgery is associated with inferior clinical outcomes and higher revision rates in patients undergoing index TSA but not in those undergoing the ream-and-run procedure. Patients with previous fracture surgery carry the highest risk of reoperation.

Current concept of shoulder replacement arthroplasty

Since the development of the first anatomic shoulder replacement in 1950, the technology has undergone substantial evolution, making it a viable option to manage variable shoulder problems, including severe osteoarthritis, rheumatoid arthritis, and fracture of the proximal humerus. However, the design of conventional total shoulder arthroplasty prostheses does not account for concomitant musculotendinous pathologies, including larger rotator cuff tears, which are associated with fatty infiltration of the infraspinatus muscle and substantially compromise the outcome of total shoulder arthroplasty. For patients without a rotator cuff or with rotator cuff tear arthropathy, hemiarthroplasty was the conventional treatment. Unfortunately, for these indications, hemiarthroplasty may provide little improvement in range of motion or function. Recently, radical changes in prosthetic design were made that transformed poorly performing reverse ball-and-socket total shoulder prosthesis into a highly successful salvage implant for pseudoparalytic and severe rotator cuff–deficient shoulders. The annual number of reverse total shoulder arthroplasties is increasing dramatically, and the indications also have expanded to include several conditions. In this review, the current concept of variable shoulder arthroplasty is discussed for clinical physicians.

Does the etiology of a failed hemiarthroplasty affect outcomes when revised to a reverse shoulder arthroplasty?

BACKGROUND

The purposes of this study were to evaluate patient outcomes after revision of hemiarthroplasty to reverse shoulder arthroplasty (RSA) based on initial pathology, to determine the re-revision rate, and to identify characteristics that may predict subsequent re-revision.

METHODS

A total of 207 shoulder hemiarthroplasty, bipolar prosthesis, and humeral resurfacing cases revised to RSA between January 2004 and January 2017 were reviewed. Outcome measures included shoulder motion and American Shoulder and Elbow Surgeons and Simple Shoulder Test (SST) scores. Sixteen RSAs underwent re-revision. A case-control study with each revised RSA matched to 4 controls based on age, sex, and minimum 2-year follow-up was performed to evaluate for factors predicting re-revision.

RESULTS

The mean time from initial hemiarthroplasty to RSA was 3.6 years (range, 0.1-20 years). There were 114 patients with a minimum of 2 years' follow-up (mean, 57 months; range, 24-144 months). The most common initial diagnoses for hemiarthroplasty were fracture (n = 72), cuff tear arthropathy (CTA) (n = 22), and osteoarthritis (OA) (n = 20). Overall mean scores and range-of-motion values were as follows: American Shoulder and Elbow Surgeons score, 59 (95% confidence interval [CI], 54-64); SST score, 4 (95% CI, 4-5); forward flexion, 106° (95% CI, 96°-116°); and abduction, 95° (95% CI, 85°-105°). Compared with fracture cases, CTA cases had better forward flexion (P = .01) and abduction (P = .006) and OA cases had better SST scores (P = .02) and abduction (P = .04). The re-revision rate was 7.7% at a mean of 31 months (range, 0-116 months), with the most common diagnosis being fracture (10 of 16 cases). Humeral loosening (8 of 16 cases) was the most common failure mechanism, and larger glenosphere sizes were more likely to be revised.

CONCLUSION

Functional outcome scores of hemiarthroplasty cases revised to RSA were better for patients with OA than for patients with CTA or fracture. Cases of hemiarthroplasty for fracture had decreased motion after revision to RSA compared with CTA and OA. Humeral loosening was the most common failure mechanism.

Reverse Shoulder Arthroplasty for Proximal Humerus Fracture

PURPOSE OF REVIEW

The purpose of this review is to examine trends, outcomes, and principles in treatment of proximal humerus fractures in the elderly with a critical focus on reverse shoulder arthroplasty as a developing treatment option.

RECENT FINDINGS

Recent literature shows an increase in reverse shoulder arthroplasty and a decrease in hemiarthroplasty performed for proximal humerus fractures. More predictable outcomes and lower revision rates are seen in older individuals treated primarily or secondarily with reverse shoulder arthroplasty compared to those treated with hemiarthroplasty. We report current and historical treatments, outcomes, and principles in reverse shoulder arthroplasty for treatment of complex, displaced proximal humerus fractures in older individuals (≥ 65 years old).

Role of Ultrasound in the Detection of Rotator-Cuff Syndrome: An Observational Study

Background

Physical tests are usually preferred to assess rotator-cuff syndrome but are insufficient to predict the morphology and size of the rotator-cuff. The objective of the study was to rate the ultrasound findings for patients with sudden shoulder pain and to determine potential predictors of the same.

Material/Methods

A total of 112 patients with sudden shoulder pain with rotator-cuff syndrome, suspected by orthopedic doctors, were subjected to ultrasonography. Real-time ultrasonography was done for the acromioclavicular joint, biceps, infraspinatus, posterior labrum, subscapularis, supraspinatus, teres minor tendon, and the sub-acromial-subdeltoid bursa. Each tendon was assessed via scanning planes in orientation as per longer and shorter axis, and from their myotendinous junction shoulder to bony insertions. Linear and logistic regression analysis were performed to predict the associations of medical history with rotator-cuff injury.

Results

Ultrasonography identified that 82% of the enrolled patients had at least one particular cause of the rotator-cuff disorder. Among the rotator-cuff disorders, calcific tendonitis (54%) was observed more frequently followed by tendinopathy (32%), subacromial-subdeltoid bursitis (22%), and partial thickness tear (21%). Also, 46 patients (41%) had multiple findings. Older age (older than 40 years) was a strong predicting factor of rotator-cuff disorder (r²=0.36, P=0.0004).

Conclusions

Ultrasonography is a vital diagnostic procedure used by orthopedic surgeons for diagnosis of the rotator-cuff disorder(s) in patients with sudden shoulder pain.

Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: management of periprosthetic shoulder infection

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. A multidisciplinary team of international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology was assembled to form the International Consensus Group. The following consensus proceedings from the International Consensus Meeting involve 30 questions pertaining to the management of periprosthetic shoulder infection.