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Adam MF, Lädermann A, Denard PJ, Lacerda F, Collin P. Preoperative diagnosis and rotator cuff status impact functional internal rotation following reverse shoulder arthroplasty. J Shoulder Elbow Surg 2024:S1058-2746(24)00021-1. [PMID: 38218405 DOI: 10.1016/j.jse.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/13/2023] [Accepted: 11/19/2023] [Indexed: 01/15/2024]
Abstract
PURPOSE This study aimed to evaluate whether functional internal rotation (fIR) following reverse shoulder arthroplasty (RSA) differs based on diagnosis of either: primary osteoarthritis (OA) with intact rotator cuff, massive irreparable rotator cuff tear (MICT) or cuff tear arthropathy (CTA). METHODS A retrospective review was carried out on RSAs performed by a single surgeon with the same implant over a 5-year period. Minimum 2-year follow-up was available in 235 patients; 139 (59.1%) were female, and the mean patient age was 72 ± 8 years. Additional clinical evaluation included the Subjective Shoulder Value and Constant score. Postoperative internal rotation was categorized as type I: hand to the buttock or hip; type II: hand to the lower lumbar region; or type III: smooth motion to at least the upper lumbar region. Type I was considered "nonfunctional" internal rotation, and type II and III were fIR. RESULTS Preoperatively, internal rotation was classified as type I in 60 patients (25.5%), type II in 114 (48.5%), and type III in 62 (26%). Postoperatively, internal rotation was classified as type I in 70 patients (30%), type II in 86 (36%), and type III in 79 (34%). Compared with preoperative status, fIR improved significantly in OA patients (P < .001), with 49 (52.6%) classified as type II or III postoperatively. In CTA patients, there was no significant change (P = .352). In patients with MICTs, there was a significant loss in fIR postoperatively (P = .003), with 25 patients (30.8%) deteriorating to type I after having either type II or III preoperatively, and only 5 patients (6.1%) improving to either type II or III. CONCLUSIONS Patients who undergo RSA for primary OA have a better chance of postoperative fIR improvement. A decrease in fIR is common after RSA for MICTs.
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Affiliation(s)
- Mahmoud Faisal Adam
- CHP Saint-Gregoire, Saint-Grégoire, France; Faculty of Medicine, Luxor University, New Tiba City, Egypt.
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, Hôpital de La Tour, Meyrin, Switzerland; Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | | | - Felipe Lacerda
- CHP Saint-Gregoire, Saint-Grégoire, France; Orthopedic Center of Barra, Rio de Janeiro, Brazil; Clinica Meta, Rio de Janeiro, Brazil
| | - Philippe Collin
- CHP Saint-Gregoire, Saint-Grégoire, France; Clinique Victor Hugo, Paris, France; American Hospital of Paris, Neuilly-sur-Seine, France
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Pasqualini I, Menendez ME, Ardebol J, Denard PJ. Lesser Tuberosity Osteotomy for the Management of the Subscapularis During Total Shoulder Arthroplasty. J Am Acad Orthop Surg 2023; 31:1120-1127. [PMID: 37506312 DOI: 10.5435/jaaos-d-22-01093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/23/2023] [Indexed: 07/30/2023] Open
Abstract
Subscapularis integrity is critical after anatomic total shoulder arthroplasty, with failure leading to potential instability, loss of function, and revision surgery. The three well-described subscapularis mobilization techniques during total shoulder arthroplasty include tenotomy, peel, and lesser tuberosity osteotomy (LTO). While several comparative studies exist, the optimal approach remains controversial. LTO has been associated with the highest healing rates, but techniques and repair constructs are highly variable. The purpose of this article was to provide an overview of LTO with attention on radiographic assessment, repair options, and clinical outcomes.
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3
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Wellington IJ, Hewitt CR, Hawthorne BC, Mancini MR, Dorsey CG, Quintana JO, Talamo M, Obopilwe E, Cote MP, Mazzocca AD, Sethi PM. Biomechanical Evaluation of the Efficacy of Suture Tape Augmentation for Subscapularis Peel Repair. Orthop J Sports Med 2023; 11:23259671231162361. [PMID: 37056453 PMCID: PMC10087657 DOI: 10.1177/23259671231162361] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/19/2023] [Indexed: 04/15/2023] Open
Abstract
Background Failure of a subscapularis repair construct after anatomic total shoulder arthroplasty can result in difficulty with internal rotation and an increased likelihood of dislocation. Although suture tape has been demonstrated to be an efficacious augment for tendonous repairs elsewhere in the body, it has not been investigated as a method for augmenting subscapularis peel repairs. Purpose To determine the biomechanical efficacy of suture tape augmentation for the repair of a subscapularis peel. Study Design Controlled laboratory study. Methods Twelve human cadaveric shoulders underwent a subscapularis peel. Specimens were randomly split into 2 groups: 6 specimens underwent repair using a transosseous bone tunnel technique with 3 high-strength sutures placed with a Mason-Allen configuration (control group), and 6 specimens underwent the control repair using augmentation with 2 suture tapes placed in an inverted mattress fashion and secured to the proximal humerus using a suture anchor (augmentation group). Shoulders underwent biomechanical testing to compare repair displacement with cyclic loading, load at ultimate failure, and construct stiffness. Results There were no significant between-group differences in displacement after cyclic loading at the superior (P = .87), middle (P = .47), or inferior (P = .77) portions of the subscapularis tendon. Load to failure was significantly greater in the augmentation group (585.1 ± 97.4 N) than in the control group (358.5 ± 81.8 N) (P = .001). Stiffness was also greater in the augmentation group (71.8 ± 13.7 N/mm) when compared with the control group (48.7 ± 5.7 N/mm) (P = .003). Conclusion Subscapularis peel repair with augmentation via 2 inverted mattress suture tapes secured with an anchor in the proximal humerus conferred significantly greater load at ultimate failure and construct stiffness when compared with a traditional repair using 3 Mason-Allen sutures. There was no difference in repair displacement with cyclic loading between the repair groups. Clinical Relevance Suture tape augmentation of subscapularis peel repairs after shoulder arthroplasty provides an effective segment to the strength of the repair.
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Affiliation(s)
- Ian J. Wellington
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
- Ian J. Wellington, MD,
Department of Orthopaedic Surgery, University of Connecticut School of Medicine,
120 Dowling Way, Farmington, CT 06032, USA (
)
| | - Cory R. Hewitt
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Benjamin C. Hawthorne
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Michael R. Mancini
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Caitlin G. Dorsey
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Julio O. Quintana
- Orthopaedic & Neurosurgery
Specialists, ONS Foundation, Greenwich, Connecticut, USA
| | - Michael Talamo
- Orthopaedic & Neurosurgery
Specialists, ONS Foundation, Greenwich, Connecticut, USA
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Mark P. Cote
- Department of Orthopaedic Surgery,
University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Augustus D. Mazzocca
- Massachusetts General Brigham Sports
Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul M. Sethi
- Orthopaedic & Neurosurgery
Specialists, ONS Foundation, Greenwich, Connecticut, USA
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4
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Hawthorne BC, Shuman ME, Wellington IJ, Mancini MR, Hewitt CR, Dorsey CG, Quintana JO, Talamo M, Obopilwe E, Cote MP, Mazzocca AD, Sethi PM. Biomechanical evaluation of subscapularis peel repairs augmented with the long head of the biceps tendon for anatomic total shoulder arthroplasty. J Shoulder Elbow Surg 2023; 32:326-332. [PMID: 36108881 DOI: 10.1016/j.jse.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/28/2022] [Accepted: 07/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Subscapularis failure is a troublesome complication following anatomic total shoulder arthroplasty (aTSA). Commonly discarded during aTSA, the long head of the biceps tendon (LHBT) may offer an efficient and cheap autograft for the augmentation of the subscapularis repair during aTSA. The purpose of this study was to biomechanically compare a standard subscapularis peel repair to 2 methods of subscapularis peel repair augmented with LHBT. METHODS 18 human cadaveric shoulders (61 ± 9 years of age) were used in this study. Shoulders were randomly assigned to biomechanically compare subscapularis peel repair with (1) traditional single-row repair, (2) single row with horizontal LHBT augmentation, or (3) single row with V-shaped LHBT augmentation. Shoulders underwent biomechanical testing on a servohydraulic testing system to compare cyclic displacement, load to failure, and stiffness. RESULTS There were no significant differences in the cyclic displacement between the 3 techniques in the superior, middle, or inferior portion of the subscapularis repair (P > .05). The horizontal (436.7 ± 113.3 N; P = .011) and V-shape (563.3 ± 101.0 N; P < .001) repair demonstrated significantly greater load to failure compared with traditional repair (344.4 ± 82.4 N). The V-shape repair had significantly greater load to failure compared to the horizontal repair (P < .001). The horizontal (61.6 ± 8.4 N/mm; P < .001) and the V-shape (62.8 ± 6.1; P < .001) repairs demonstrated significantly greater stiffness compared to the traditional repair (47.6 ± 6.2 N). There was no significant difference in the stiffness of the horizontal and V-shape repairs (P = .770). CONCLUSIONS Subscapularis peel repair augmentation with LHBT autograft following aTSA confers greater time zero load to failure and stiffness when compared to a standard subscapularis peel repair.
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Affiliation(s)
- Benjamin C Hawthorne
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA.
| | - Matthew E Shuman
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Ian J Wellington
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Michael R Mancini
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Cory R Hewitt
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Caitlin G Dorsey
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Julio O Quintana
- Orthopaedic & Neurosurgery Specialists, ONS Foundation, Greenwich, CT, USA
| | - Michael Talamo
- Orthopaedic & Neurosurgery Specialists, ONS Foundation, Greenwich, CT, USA
| | - Elifho Obopilwe
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Mark P Cote
- Department of Orthopaedic Surgery, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Augustus D Mazzocca
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul M Sethi
- Orthopaedic & Neurosurgery Specialists, ONS Foundation, Greenwich, CT, USA
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Lesser Tuberosity Osteotomy Healing in Stemmed and Stemless Anatomic Shoulder Arthroplasty Is Higher with a Tensionable Construct and Affected by Body Mass Index and Tobacco Use. J Clin Med 2023; 12:jcm12030834. [PMID: 36769482 PMCID: PMC9918114 DOI: 10.3390/jcm12030834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/16/2023] [Accepted: 01/19/2023] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND This study compared the healing rates of lesser tuberosity osteotomy (LTO) for anatomic total shoulder arthroplasty (TSA), repaired with either standard knot tying or a tensionable construct. Second, we evaluated LTO healing in stemmed and stemless prostheses and identified the patient characteristics associated with healing. METHODS An analysis of consecutive primary TSAs approached with an LTO performed by a single surgeon between 2016 and 2020 was conducted. In the first two years of the study period, the LTOs were repaired with four #2 polyblend sutures passed through drill tunnels and around a short press-fit stem, followed by manual knot tying. Subsequently, a tensionable construct with suture tapes (TCB) was universally adopted. The radiographic appearance of the LTO was evaluated at a minimum of six months postoperatively. RESULTS A total of 340 patients met the study criteria, including 168 with manual knot tying, 84 TCB repairs with a stemmed implant, and 88 TCB repairs with a stemless implant. There was no difference in the baseline demographics between the groups. The LTO healing rate of the manual knot tying group (85%) was lower than that of the stemmed (95%) and stemless (98%) TCB groups (p < 0.001). When directly comparing the LTO healing between the stemmed and stemless TCB groups, the differences were not significant (p = 0.44). Across all constructs, the body mass index (BMI) was higher in the displaced nonunion group (p = 0.04), with a failure rate of 9.4% for a BMI between 30 and 40, 12.5% for a BMI between 40 and 50, and 28.6% for a BMI > 50. The rate of tobacco use was higher in the displaced nonunion group (p = 0.037). CONCLUSION A tensionable construct improves LTO healing compared to manual knot tying, irrespective of the implant type. In addition to the surgical technique, the patient factors that influence tuberosity healing include a greater BMI and tobacco use. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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6
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Denard PJ, Ardebol J, Pasqualini I, Horinek JL, Dines J, Tokish JM. Compressed autograft biceps tendon augmentation of subscapularis repair following shoulder arthroplasty. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:535-538. [PMID: 37588457 PMCID: PMC10426527 DOI: 10.1016/j.xrrt.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Subscapularis integrity is correlated with function following shoulder arthroplasty. Failure of healing, particularly following anatomic total shoulder arthroplasty, is associated with poor outcomes and the need for revision. Graft augmentation has been used to increase healing following rotator cuff repair but has not been commonly advocated for augmenting the subscapularis following shoulder arthroplasty. The long head biceps tendon is typically tenodesed and discarded during shoulder arthroplasty. Rather than discarding the tendon, the tendon may be compressed and applied to the subscapularis as a biologic scaffold to potentially improve subscapularis healing following shoulder arthroplasty.
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7
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Werner BC, McClish SJ, Mealey NC, Wijdicks C, Thompson T, Higgins LD. A biomechanical comparison of subscapularis tenotomy repair techniques for stemless shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:711-717. [PMID: 34775037 DOI: 10.1016/j.jse.2021.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/06/2021] [Accepted: 10/11/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND One of the leading challenges for surgeons shifting to stemless anatomic total shoulder arthroplasty (TSA) is subscapularis repair. In the available literature reporting outcomes after stemless TSA, subscapularis tenotomy with side-to-side repair is the most common technique despite some concerns regarding this technique in the biomechanical and clinical literature. Accordingly, this study investigated subscapularis tenotomy repair with stemless TSA with 2 primary objectives: (1) to evaluate the subscapularis tendon dimensions with reference to subscapularis tenotomy to determine the amount of tendon remaining for side-to-side repair after shoulder arthroplasty and (2) to biomechanically compare 2 methods of subscapularis tenotomy repair after stemless TSA-side-to-side repair and anchor-based repair. METHODS We used 12 male shoulder specimens for this study. To address our first objective, measurements were made to calculate the dimensions of the subscapularis tendon at the superior, middle, and inferior levels to determine the amount of tendon remaining after tenotomy. These specimens were then divided into 2 groups (n = 6 in each group) to biomechanically compare subscapularis tenotomy repair with (1) traditional side-to-side repair and (2) anchor-based repair. The shoulders then underwent biomechanical testing with primary outcomes including load to failure and cyclic displacement. RESULTS The mean subscapularis tendon width measured from the medial insertion at the lesser tuberosity to the muscle-tendon junction varied depending on the level: 19.5 mm superiorly (95% confidence interval [CI], 16.2-22.8 mm); 18.3 mm at the midportion (95% CI, 13.6-23.0 mm); and 13.1 mm inferiorly (95% CI, 9.1-17.1 mm). With a tenotomy made 1 cm medial to the lesser tuberosity insertion, a mean of 3.1 mm of tendon remained medially at the inferior subscapularis, with one-third of specimens having no tendon left medially at this level. On comparison of tenotomy repair techniques, the anchor-based technique had a 57% higher ultimate load to failure compared with the side-to-side repair (448 N vs. 249 N, P < .001). There were no significant differences in cyclic displacement (6.1 mm vs. 7.1 mm, P = .751) and construct stiffness (38.1 N/mm vs. 42.9 N/mm, P = .461) between techniques. CONCLUSIONS With traditional techniques for subscapularis tenotomy for anatomic TSA, there is very little tendon remaining inferiorly for side-to-side repair. When subscapularis tenotomy is performed for stemless TSA, a double-row anchor-based repair has a better time-zero ultimate load to failure compared with side-to-side repair.
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Affiliation(s)
- Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA.
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8
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Relationship between postoperative integrity of subscapularis tendon and functional outcome in reverse shoulder arthroplasty. J Shoulder Elbow Surg 2022; 31:63-71. [PMID: 34216783 DOI: 10.1016/j.jse.2021.05.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 05/17/2021] [Accepted: 05/23/2021] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS AND BACKGROUND The role of the subscapularis in reverse shoulder arthroplasty (RSA) remains controversial. Studies have shown that subscapularis repair has no significant influence on the functional outcomes of patients. However, few studies have assessed the postoperative integrity of the subscapularis tendon after RSA. The aims of this study were to investigate the postoperative healing of the subscapularis after RSA via ultrasound and to evaluate the relationship between tendon integrity and functional outcomes. We hypothesized that subjects with a healed subscapularis after RSA would have higher Constant scores and better internal rotation (IR) than those without a healed subscapularis. METHODS This was a retrospective review of all patients who underwent primary RSA with subscapularis tenotomy repair performed by a single surgeon with a minimum 2-year follow-up period. The inclusion criteria were (1) primary RSA and (2) complete intraoperative repair of the subscapularis tenotomy if the tendon was amenable to repair. The total Constant score and active and passive range of motion were measured preoperatively and at every postoperative visit. IR was further subcategorized into 3 functional types (type I, buttock or sacrum; type II, lumbar region; and type III, T12 or higher). The integrity of the subscapularis on ultrasound at 2 years was reported using the Sugaya classification. The correlation between subscapularis integrity and functional outcomes including functional IR was evaluated. RESULTS A total of 86 patients (mean age, 73 ± 7.4 years; age range, 50-89 years) were evaluated. The mean postoperative Constant score for all patients significantly improved from 38 points to 72 points (P < .001) at last follow-up (mean, 3.3 years). There was significant improvement in all Constant score functional subscales and in terms of range of motion. The rate of sonographic healing of the subscapularis was 52.6%. There was no difference in Constant scores between "intact" and "failed" tendon repairs; however, intact tendons demonstrated significantly better IR with no difference in external rotation (P < .01). CONCLUSION The healing rate of the subscapularis following RSA was only 52.6%. IR function in patients with an intact subscapularis at 2 years after RSA was significantly better than in patients with failed or absent tendon repairs. Primary repair of reparable subscapularis tendons during RSA should be strongly considered.
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Okafor C, Anastasio AT, Christian RA, Klifto CS, Lassiter T, Anakwenze O. Subscapularis management in stemmed and stemless total shoulder arthroplasty: a surgeon decision-making analysis study. JSES REVIEWS, REPORTS, AND TECHNIQUES 2021; 1:353-356. [PMID: 37588702 PMCID: PMC10426477 DOI: 10.1016/j.xrrt.2021.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Stemless total shoulder arthroplasty (TSA) continues to grow in popularity as an evolution of stemmed humeral implants. Proposed advantages include bone preservation and ease of potential revision. However, absence of a stem may necessitate a change in subscapularis takedown approach. Specifically, there is theoretical concern about violation of supportive bone with lesser tuberosity osteotomy when using a stemless device. Therefore, the goal of this study was to identify if surgeons change their subscapularis takedown preference when performing stemless vs. stemmed TSA. Methods and materials Data from a consecutive series of patients who underwent stemmed and stemless TSA at an academic institution were collected. The subscapularis management technique was documented. Subscapularis takedown techniques were divided into 2 groups: soft-tissue approach (subscapularis tenotomy or peel) and bony approach (lesser tuberosity osteotomy). Historical preference for each surgeon was determined by evaluating techniques employed using stemmed TSA. A Cramers V analysis was run to determine the strength of association between this historical preference and subscapularis management technique used for stemless TSA. Results One hundred and fifty-four patients were included in this analysis. There were 72 and 82 stemmed and stemless arthroplasty cases performed, respectively. Of the 154 patients, 50.6% were women. The average age of patients was 64.2 years. Four surgeons were included in this study. In all, there were 79 and 75 bony and soft-tissue subscapularis techniques, respectively. The historical preference for 3 of the surgeons was a subscapularis bony approach, and the historical preference for one of the surgeons was a soft-tissue approach. A Cramer's V analysis was used to measure the relative strength of association between patient factors, historical subscapularis management preference, and subscapularis takedown approach in stemless TSA. Our analysis yielded a value of 0.65 (P < .01), indicating a redundant association between subscapularis management approach used between stemmed and stemless implant per surgeon. Conclusion In determining subscapularis tendon management strategy, in surgeons who performed stemmed TSA before stemless TSA, the subscapularis takedown approach used for stemless TSA is strongly associated with surgeon's historical preference for stemmed TSA. Future research will be needed to determine the clinical ramifications of this finding.
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Affiliation(s)
| | - Albert T. Anastasio
- Duke University School of Medicine, Department of Orthopedic Surgery, Durham, NC, USA
| | - Robert A. Christian
- Duke University School of Medicine, Department of Orthopedic Surgery, Durham, NC, USA
| | - Christopher S. Klifto
- Duke University School of Medicine, Department of Orthopedic Surgery, Durham, NC, USA
| | - Tally Lassiter
- Duke University School of Medicine, Department of Orthopedic Surgery, Durham, NC, USA
| | - Oke Anakwenze
- Duke University School of Medicine, Department of Orthopedic Surgery, Durham, NC, USA
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10
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Werner BC, Griffin JW, Thompson T, Lendhey M, Higgins LD, Denard PJ. Biomechanical evaluation of 2 techniques of repair after subscapularis peel for stemless shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:2240-2246. [PMID: 33675968 DOI: 10.1016/j.jse.2021.01.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 01/19/2021] [Accepted: 01/31/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Stemless anatomic total shoulder arthroplasty (TSA) has been gaining significant popularity but poses unique challenges for subscapularis repair. Tenotomy with side-to-side repair has been the most frequently reported technique for subscapularis repair with stemless TSA but has the poorest biomechanical properties, and clinical failures have been reported. There is limited biomechanical evidence evaluating other subscapularis repair techniques for stemless TSA. Therefore, the goal of this study was to investigate 2 additional techniques using a subscapularis peel for subscapularis repair with a stemless TSA. METHODS We used 18 male cadaveric specimens to investigate the native subscapularis (n = 6) and 2 subscapularis repair techniques (n = 12) after stemless anatomic TSA (Eclipse). A subscapularis peel with double-row, knotless anchor-based repair (n = 6) was compared with a subscapularis peel with a "backpack" repair (n = 6). The specimens then underwent biomechanical testing, including cyclic displacement and load-to-failure testing. The mode of failure was also recorded. RESULTS The native tendon had the highest ultimate load to failure (mean, 1017.1 N). Load to failure was similar between the 2 study groups: 397.9 N for the peel and backpack repair and 593.7 N for the knotless anchor-based repair (P > .05 for all comparisons). Moreover, no significant differences in cyclic displacement or construct stiffness were found between the groups (P > .05 for all comparisons). CONCLUSIONS A double-row, knotless anchor-based repair of a subscapularis peel for stemless anatomic shoulder arthroplasty has similar biomechanical properties to a backpack repair technique; however, both techniques fail to reproduce the native biomechanical properties at time zero.
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Affiliation(s)
- Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, USA.
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11
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Goetti P, Denard PJ, Collin P, Ibrahim M, Mazzolari A, Lädermann A. Biomechanics of anatomic and reverse shoulder arthroplasty. EFORT Open Rev 2021; 6:918-931. [PMID: 34760291 PMCID: PMC8559568 DOI: 10.1302/2058-5241.6.210014] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The biomechanics of the shoulder relies on careful balancing between stability and mobility. A thorough understanding of normal and degenerative shoulder anatomy is necessary, as the goal of anatomic total shoulder arthroplasty is to reproduce premorbid shoulder kinematics.With reported joint reaction forces up to 2.4 times bodyweight, failure to restore anatomy and therefore provide a stable fulcrum will result in early implant failure secondary to glenoid loosening.The high variability of proximal humeral anatomy can be addressed with modular stems or stemless humeral components. The development of three-dimensional planning has led to a better understanding of the complex nature of glenoid bone deformity in eccentric osteoarthritis.The treatment of cuff tear arthropathy patients was revolutionized by the arrival of Grammont's reverse shoulder arthroplasty. The initial design medialized the centre of rotation and distalized the humerus, allowing up to a 42% increase in the deltoid moment arm.More modern reverse designs have maintained the element of restored stability but sought a more anatomic postoperative position to minimize complications and maximize rotational range of motion. Cite this article: EFORT Open Rev 2021;6:918-931. DOI: 10.1302/2058-5241.6.210014.
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Affiliation(s)
- Patrick Goetti
- Division of Orthopaedics and Trauma Surgery, Centre Hospitalier |Universitaire Vaudois, Lausanne, Switzerland
| | - Patrick J. Denard
- Denard Department of Orthopaedic & Rehabilitation, Oregon Health & Science University, Portland, Oregon, United States
| | - Philippe Collin
- Collin Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), Saint- Grégoire, France
| | - Mohamed Ibrahim
- Mohamed Ibrahim, Department of Orthopaedics and Trauma Surgery, Faculty of Medicine, Fayoum University, Fayoum, Egypt
| | - Adrien Mazzolari
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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Tross AK, Lädermann A, Wittmann T, Schnetzke M, Nolte PC, Collin P, Raiss P. Subsidence of Uncemented Short Stems in Reverse Shoulder Arthroplasty-A Multicenter Study. J Clin Med 2020; 9:jcm9103362. [PMID: 33092155 PMCID: PMC7590048 DOI: 10.3390/jcm9103362] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/22/2020] [Accepted: 10/06/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The radiological phenomenon of subsidence following the implantation of uncemented short-stem reverse prostheses (USSP) has not yet been described. The purpose of this study was to describe the rate and potential risk factors for subsidence. We hypothesized that subsidence may be a frequent finding and that a subsidence of >5 mm (mm) is associated with an inferior clinical outcome. METHODS A total of 139 patients with an average age of 73 ± 9 years were included. The clinical and radiological outcome was evaluated at a minimum follow-up (FU) of 12 months. RESULTS No humeral component loosening was present at a mean FU of 18 (range, 12-51) months. Mean Constant Score (CS) and Subjective Shoulder Value (SSV) improved significantly from 34.3 ± 18.0 points and 37.0 ± 19.5% preoperatively to 72.2 ± 13.4 points and 80.3 ± 16.5% at final FU (p < 0.001). The average subsidence of the USSP was 1.4 ± 3.7 mm. Subsidence of >5 mm was present in 15 patients (11%). No association between a subsidence >5 mm and CS or SSV was found (p = 0.456, p = 0.527). However, a subsidence of >5 mm resulted in lower strength at final FU (p = 0.022). Complications occurred in six cases (4.2%), and the revision rate was 3.5% (five cases). CONCLUSIONS Although subsidence of USSP is a frequent radiographic finding it is not associated with loosening of the component or a decrease in the clinical outcome at short term FU. LEVEL OF EVIDENCE Level 4, retrospective study.
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Affiliation(s)
- Anna-K. Tross
- Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118 Heidelberg, Germany;
| | - Alexandre Lädermann
- Division of Orthopaedics and Trauma Surgery, La Tour Hospital Meyrin, Avenue Jacob-Daniel Maillard 31217 Meyrin, Switzerland;
- Faculty of Medicine, University of Geneva, Rue Michel Servet 1, 1211 Geneva, Switzerland
- Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205 Geneva, Switzerland
| | - Thomas Wittmann
- OCM (Orthopädische Chirurgie München), Steinerstrasse 6, 81369 Munich, Germany;
| | - Marc Schnetzke
- German Joint Centre, ATOS Clinic Heidelberg Bismarckstraße 9, 69115 Heidelberg, Germany;
- BG Trauma Center Ludwigshafen at the University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen on the Rhine, Germany;
| | - Philip-C. Nolte
- BG Trauma Center Ludwigshafen at the University of Heidelberg, Clinic for Trauma and Orthopaedic Surgery, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen on the Rhine, Germany;
| | - Philippe Collin
- Centre Hospitalier Privé Saint-Grégoire (Vivalto Santé), 6 Boulevard de la Boutière, 35768 Saint-Grégoire, France;
| | - Patric Raiss
- OCM (Orthopädische Chirurgie München), Steinerstrasse 6, 81369 Munich, Germany;
- Correspondence:
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Abstract
Background Humeral stem length in anatomic total shoulder arthroplasty (TSA) continues to decrease in an attempt to preserve bone. Outcomes following short-stem TSA are not well documented. The purpose was to systematically review and report the outcomes and revisions following short-stem humeral implants for TSA. Methods A systematic review was registered with PROSPERO and performed with PRISMA guidelines using 3 publicly available free databases. Therapeutic clinical outcome investigations reporting TSA outcomes of short-stem implants with levels of evidence I-IV were eligible for inclusion. All study, subject, and surgical technique demographics were analyzed and described. Results Thirteen studies were included (average follow-up: 33 months, range 24-84 months; 8 studies [62%] were multicenter and 6 [46%] were from Europe). All studies were published in the last 8 years, and almost all (12/13, 92%) reported results of uncemented components. Most of the studies (9/13, 70%) reported results from the Aequalis Ascend or Ascend Flex Stem (Tornier). Improvements were seen in all measured range of motion planes and patient-reported outcome scores. Complications were infrequent, with a 2% humeral loosening rate, a 3% overall revision rate, and a 1% rate of revision for aseptic humeral loosening. Radiographic results showed a 13% rate of radiolucent lines, a 16% rate of condensation lines, and a 22% rate of calcar osteolysis. Conclusion Short-stem TSA humeral implants provide excellent results, with low revision rates in the short term. Long-term follow-up will be necessary to understand the clinical impact of radiographic calcar osteolysis.
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