Treatment of painful pseudoparesis due to irreparable rotator cuff dysfunction with the Delta III reverse-ball-and-socket total shoulder prosthesis

Biomechanical comparison of single versus double plate osteosynthesis in acromion type III fractures

Background

One of complications of the reverse shoulder arthroplasty is acromion fractures, and its therapy is controversial. The aim of the study was to investigate the double-plate osteosynthesis for these fractures.

Methods

An acromion type III fracture according to classification of Levy was simulated in 16 human shoulder cadavers, and the specimens were randomly divided into two groups. Single-plate osteosynthesis was performed in the first group (locking compression plate) and double-plate osteosynthesis (locking compression plate and one-third tubular locking plate) in the second group. Biomechanical testing included cycling load and load at failure on a material testing machine. During the test, the translation was measured using an optical tracking system.

Results

The load at failure for the single-plate osteosynthesis was 167 N and for the double-osteosynthesis 233.7 N (P = 0.328). The average translation was 11.1 mm for the single-plate osteosynthesis and 16.4 mm for the double-plate osteosynthesis (P = 0.753). The resulting stiffness resulted in 74.7 N/mm for the single-plate osteosynthesis and 327.9 N/mm for the double-plate osteosynthesis (P = 0.141).

Discussion

Results of the biomechanical study showed that double-plate osteosynthesis had biomechanical properties similar to those of single-plate osteosynthesis for an acromion type III fracture at time point zero. The missing advantages of double-plate osteosynthesis can be explained by the choice of plate configuration.

Is the Number of Citations Related to the Study Methodology in Shoulder Arthroplasty Literature? A Bibliometric and Statistical Analysis of Current Evidence

Background

We reviewed the shoulder arthroplasty (SA) literature to correlate citations, methodological characteristics and quality of most-cited articles in this field. We hypothesized that a greater number of citations would be found for high-quality clinical studies.

Methods

We searched the Web of Knowledge database for the 50 most-cited articles about SA and collected author name, publication year, country of origin, journal, article type, level of evidence (LoE), subject of paper, type of arthroplasty and metrics (number of citations and citation rate). Coleman Methodology Score (CMS) was computed for clinical articles. Statistical analysis of variance and correlation coefficients were used to investigate the relationship between different variables.

Results

Out of the selected 50 studies on SA, 26% were nonclinical. There were 15,393 citations overall (mean 307.8), with a mean 19.5 citations per year (range 48.3-6.7). Thirty or 60% of all articles were LoE IV. All studies were published between 1984 and 2011 in 8 journals. Reverse SA (RSA) was the most common subject (36% of studies). The United States was the country responsible for most contributions (50% of studies). CMS ranged from 81 to 38 (mean 59.6). RSA received the highest number of citations (P < .001), independently from country of origin (P = .137) and LoE (P = .723). CMS correlated with citation rate (r = 0.397; P = .013) and publication year (tau = 0.397; P = .013), but not with LoE (P = .204).

Conclusion

In SA literature, citation rate positively correlates with methodological quality of a study, independently from publication country and LoE. Among most-cited papers, RSA is the most common standalone subject.

Preoperative factors affecting the quality of life after arthroscopic rotator cuff repair: a prospective study

Background

Rotator cuff tears are well known to cause significant pain and disability, having a marked impact on an individual's quality of life. This prospective study aimed to analyze the various patient factors and their impact on health-related quality of life (HrQoL) post arthroscopic rotator cuff repair (RCR).

Material and Methods

We prospectively analyzed 95 patients at one year and 81 patients at two years, with complete rotator cuff tear, who underwent arthroscopic repair of the same. The 36-Item Short Form Survey (physical and mental component score), visual analog scale (pain, function), and QuickDASH questionnaires were administered to all the patients preoperatively and at one- and two-year follow-ups. Relationships between various patient factors (age, gender, side, duration of symptoms, pseudoparalysis, diabetes mellitus [DM], type, and size of tear) and outcome measures were analyzed.

Results

All outcome parameters showed significant improvement at one- and two-year follow-ups. Patient factors, such as gender, tear type (traumatic vs degenerative), and DM, affected all outcome parameters and were significant even in the regression analysis model at a 2-year follow-up. Factors such as age and symptoms duration were significant only at 1-year follow-up, with older age and patients with symptoms > 6 weeks showing more disability. Side (dominant or nondominant), tear size, and pseudoparalysis do not affect outcomes.

Conclusions

This study showed that arthroscopic RCR significantly improved HrQoL post arthroscopic RCRs. Factors independently affecting HrQoL were noted as gender, tear type, and DM. On the other hand, age, side involved, duration of symptoms, pseudoparalysis, and tear size had no independent effect on HrQoL at a two-year follow-up.

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%).

Present situation and development prospects of the diagnosis and treatment of rotator cuff tears

Rotator cuff tears are an important cause of shoulder pain and are caused by degeneration or trauma of the shoulder tendon at the anatomical neck of the humeral head. The understanding and research of rotator cuff tears have a history of hundreds of years, and their etiology, diagnosis, and treatment have a complete system, but some detailed rules of diagnosis and treatment still have room for development. This research paper briefly introduces the diagnosis and treatment of rotator cuff tears. The current situation and its valuable research direction are described.

Clinical and functional outcomes of reverse total shoulder arthroplasty supplemented with latissimus dorsi transfer: a systematic review and meta-analysis

Background

To optimize patients' functional external rotation outcomes, reverse total shoulder arthroplasties (rTSAs) including a latissimus dorsi tendon transfer were undertaken with promising early results and no significant increase in complications in comparison to traditional rTSAs. This was especially utilized for patients with a pronounced combined loss of elevation and external rotation. The purpose of this study is to evaluate and synthesize the findings of all relevant publications assessing the outcomes of rTSAs with associated latissimus dorsi transfer.

Methods

We thoroughly searched the literature within the PubMed database using a standardized methodology. For our inclusion criteria, we included any study regarding rTSAs that contained functional outcome scores for postoperative range of motion (such as elevation, external rotation, etc.) or postoperative outcomes such as complications (reoperation, infection, etc.) and patient satisfaction. For the extraction of data, we used pilot-tested Google Forms to record extracted data. These data were then converted to spreadsheets (Microsoft Excel [Microsoft, Redmond, WA, USA]). This was done on 2 separate scenarios by 2 authors to ensure accuracy. We used the modified Coleman Methodology Score to assess the methodological quality of the studies in our samples. Meta-analysis mathematics and statistical analysis were performed using Stata software 17 (StataCorp, College Station, TX, USA).

Results

Our search returned a total of 12 studies containing data of 213 shoulders receiving RTSAs with a latissimus dorsi transfer. Functional outcomes were available for 160 shoulders. The mean preoperative elevation of the affected shoulder was 73.57 degrees, and the mean postoperative elevation was 141.80 degrees. For external rotation, the mean preoperative average was -6.71 degrees, and the mean postoperative average was 22.73 degrees. The absolute Constant score average was 31.56 preoperatively, while the postoperative value was 68.93. In our sample, 25 patients (11.73%) required a revision of the RTSA implant due to complications.

Discussion

Combined loss of elevation and external rotation can be a severely debilitating condition for those with a glenohumeral pathology. Latissimus dorsi transfer for this condition has been proven to be an effective modality. The reoperation and complication rate appears to be sizable, and as such surgeons should consider this when considering this modality for their patients.

Risk Factors for Dislocation After Reverse Total Shoulder Arthroplasty: A Systematic Review and Meta-Analysis

Instability after reverse total shoulder arthroplasty (RTSA) is a dreaded complication. Risk factors for postoperative instability are uncertain. The goal of this systematic review was to quantitatively and qualitatively analyze the risk factors for instability after RTSA. Of 1183 studies identified, 12 studies involving 3810 patients were included. The mean age was 68.8 years, and the mean follow-up was 46 months. The pooled rate of dislocation after RTSA was 4.0%. Several patient-specific and implant-specific risk factors have been identified, and especially the implant-specific risk factors appear avoidable with current knowledge, implant design, and technology. [Orthopedics. 2022;45(6):e303-e308.].

Subscapularis repair in reverse total shoulder arthroplasty: a systematic review and descriptive synthesis of cadaveric biomechanical strength outcomes

Hypothesis/Background

There is no consensus on whether to repair the subscapularis in the setting of reverse total shoulder arthroplasty (rTSA). There have been an assortment of studies showing mixed results regarding shoulder stability and postoperative strength outcomes when looking at subscapularis repair in rTSA. The purpose of this systematic review was to investigate differences in biomechanical strength outcomes of cadaveric subscapularis repair vs. no repair in rTSA.Increased force will be required to move the shoulder through normal range of motion (ROM) in cadaveric rTSA shoulders with the subscapularis repaired when compared with no subscapularis repair.

Methods

A comprehensive literature review was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The databases used to search the keywords used for the concepts of subscapularis, reverse total shoulder arthroplasty, and muscle strength were PubMed (includes MEDLINE), Embase, Web of Science, Cochrane Reviews and Trials, and Scopus. Original, English-language cadaveric studies evaluating rTSA and subscapularis management were included, with subscapularis repair surgical techniques and strength outcomes being evaluated for each article meeting inclusion criteria.

Results

The search yielded 4113 articles that were screened for inclusion criteria by 4 authors. Two articles met inclusion criteria and were subsequently included in the final full-text review. A total of 11 shoulders were represented between these 2 studies. Heterogeneity of the data across the 2 studies did not allow for meta-analysis. Hansen et al found that repair of the subscapularis with rTSA significantly increased the mean joint reaction force and the force required by the posterior deltoid, total deltoid, infraspinatus, teres minor, total posterior rotator cuff, and pectoralis major muscles. Giles et al found that rotator cuff repair and glenosphere lateralization both increased total joint load.

Conclusion

The present review of biomechanical literature shows that repair of the subscapularis in the setting of rTSA can effectively restore shoulder strength by increasing joint reactive forces and ROM force requirements of other rotator cuff muscles and of the deltoid muscle. Available biomechanical evidence is limited, and further biomechanical studies evaluating the strength of various subscapularis repair techniques are needed to evaluate the effects of these techniques on joint reactive forces and muscle forces required for ROM.

The 50 Highest Cited Papers on Shoulder Arthroplasty

The purpose of this study was to determine the 50 most cited articles on shoulder arthroplasty (SA) and their characteristics. The Thomson ISIWeb of Science was searched with the following search terms: "shoulder arthroplasty", "shoulder replacement", "shoulder prosthesis" and "shoulder implant". All papers dealing with SA, including its perioperative and postoperative management, were included in this study. Citations ranged from 797 to 52 for the 50 highest cited papers on SA. According to absolute numbers, the top 10 papers were cited at least 118 times. Overall, 78% (n = 43) were clinical and the remaining articles were basic science research (one anatomic, six biomechanical). The most prevalent level of evidence was IV (72%). The Journal of Shoulder and Elbow Surgery published 40% of the studies. The majority of studies were conducted in the United States and eight other countries. The publication years of the most-cited articles ranged from 1991 to 2020, with the 2000s accounting for the most articles (96%) and the period from 2006 to 2010 with the absolute largest number of articles (17). This article provides a building block in the SA surgery.

Inverted-Bearing Reverse Shoulder Arthroplasty: Consequences on Scapular Notching and Clinical Results at Mid-Term Follow-Up

Background: Scapular notching following reverse shoulder arthroplasty (RSA) is caused by both biological and mechanical mechanisms. Some authors postulated that osteolysis that extends over the inferior screw is caused mainly by biological notching. Inverted-bearing RSA (IB-RSA) is characterized by a polyethylene glenosphere and a metallic humeral liner, decreasing the poly debris formation and potentially reducing high grades of notching. This study aims to report the results of IB-RSA on a consecutive series of patients at mid-term follow-up, focusing on the incidence of Sirveaux grade 3 and 4 scapular notching. Methods: A retrospective study on 78 consecutive patients who underwent primary IB-RSA between 2015−2017 was performed. At a 4 years minimum follow-up, 49 patients were evaluated clinically with Constant score (CS), Subjective shoulder value (SSV), American Shoulder and Elbow score (ASES), pain and range of motion, and with an X-ray assessing baseplate position (high, low), implant loosening, and scapular notching. Results: At a mean follow-up of 5.0 ± 0.9, all the clinical parameters improved (p < 0.05). One patient was revised for an infection and was excluded from the evaluation, two patients had an acromial fracture, and one had an axillary neuropraxia. Scapular notching was present in 13 (27%) patients (six grade 1, seven grade 2) and no cases of grade 3 and 4 were observed. Scapular nothing was significantly associated with high glenoid position (p < 0.001) and with lower CS (70 ± 15 vs. 58 ± 20; p = 0.046), SSV (81 ± 14 vs. 68 ± 20; p = 0.027), ASES (86 ± 14 vs. 70 ± 22; p = 0.031), and anterior elevation (148 ± 23 vs. 115 ± 37; p = 0.006). A 44 mm- compared to 40 mm-glenosphere was associate with better CS (63 ± 17 vs. 78 ± 11; p = 0.006), external (23 ± 17 vs. 36 ± 17; p = 0.036), and internal rotation (4.8 ± 2.7 vs. 7.8 ± 2.2; p = 0.011). Conclusions: IB-RSA is a safe and effective procedure for mid-term follow-up. Inverting biomaterials leads to a distinct kind of notching with mainly mechanical features. Scapular notching is associated with a high baseplate position and has a negative influence on range of motion and clinical outcome.

Medium- to Long-Term Outcomes after Reverse Total Shoulder Arthroplasty with a Standard Long Stem

Background: Long-term clinical and radiographic outcome data after standard cemented long-stem reverse shoulder arthroplasty (RSA) remain underreported. The aim of this study is to report on medium- to long-term data of patients over 60 years of age. Methods: The same type of RSA (Aequalis Reverse II, Memphis, TN, USA) was implanted in 27 patients with a mean age of 73 years (range 61−84). Indications for RSA were cuff tear arthropathy (CTA) in 25 cases and osteoarthritis (OA) in two cases. Pre- and postoperative Constant Score was assessed and component loosening, polyethylene wear, scapular notching and revision rates were recorded at a mean clinical follow-up (FU) of 127.6 months (SD ± 33.7; range 83−185). Results: The mean-adjusted CS (aCS) improved from 30.0 (range 10−59) to 95.0 (range 33−141) points (p < 0.001). Glenoid loosening was found in two (9.1%) and stem loosening was found in three (13.6%) cases. Polyethylene wear was observed in four (18.2%) cases. Scapular notching appeared in 15 (68.2%) cases but was not associated with poor aCS (p = 0.423), high levels of pain (p = 0.798) or external rotation (p = 0.229). Revision surgery was necessary in three (11.1%) cases. Conclusions: RSA with a cemented standard long stem leads to improvement in forward elevation, abduction and pain after a mean FU of 10 years. However, external rotation does not improve with this prosthetic design. Moreover, scapular notching is observed in the majority of cases, and revision rates (11.1%) as well as humeral loosening rates (13.6%) remain a concern. Level of evidence: Level 4, retrospective cohort study.

The Evolution of Reverse Total Shoulder Arthroplasty-From the First Steps to Novel Implant Designs and Surgical Techniques

Purpose of Review: The purpose of this review is to summarize recent literature regarding the latest design modifications and biomechanical evolutions of reverse total shoulder arthroplasty and their impact on postoperative outcomes. Recent findings: Over the past decade, worldwide implantation rates of reverse total shoulder arthroplasty have drastically increased for various shoulder pathologies. While Paul Grammont’s design principles first published in 1985 for reverse total shoulder arthroplasty remained unchanged, several adjustments were made to address postoperative clinical and biomechanical challenges such as implant glenoid loosening, scapular notching, or limited range of motion in order to maximize functional outcomes and increase the longevity of reverse total shoulder arthroplasty. However, the adequate and stable fixation of prosthetic components can be challenging, especially in massive osteoarthritis with concomitant bone loss. To overcome such issues, surgical navigation and patient-specific instruments may be a viable tool to improve accurate prosthetic component positioning. Nevertheless, larger clinical series on the accuracy and possible complications of this novel technique are still missing.

Reverse Shoulder Arthroplasty Biomechanics

The reverse total shoulder arthroplasty (rTSA) prosthesis has been demonstrated to be a viable treatment option for a variety of end-stage degenerative conditions of the shoulder. The clinical success of this prosthesis is at least partially due to its unique biomechanical advantages. As taught by Paul Grammont, the medialized center of rotation fixed-fulcrum prosthesis increases the deltoid abductor moment arm lengths and improves deltoid efficiency relative to the native shoulder. All modern reverse shoulder prostheses utilize this medialized center of rotation (CoR) design concept; however, some differences in outcomes and complications have been observed between rTSA prostheses. Such differences in outcomes can at least partially be explained by the impact of glenoid and humeral prosthesis design parameters, surgical technique, implant positioning, patient-specific bone morphology, and usage in humeral and glenoid bone loss situations on reverse shoulder biomechanics. Ultimately, a better understanding of the reverse shoulder biomechanical principles will guide future innovations and further improve clinical outcomes.

Maximizing Muscle Function in Cuff-Deficient Shoulders: A Rehabilitation Proposal for Reverse Arthroplasty

Purpose

The purpose of this review is to describe the role of altered joint biomechanics in reverse shoulder arthroplasty and to propose a rehabilitation protocol for a cuff-deficient glenohumeral joint based on the current evidence.Methods and Materials: The proposed rehabilitation incorporates the principles of pertinent muscle loading while considering risk factors and surgical complications.

Results

In light of altered function of shoulder muscles in reverse arthroplasty, scapular plane abduction should be more often utilized as it better activates deltoid, teres minor, upper trapezius, and serratus anterior. Given the absence of supraspinatus and infraspinatus and reduction of external rotation moment arm of the deltoid in reverse arthroplasty, significant recovery of external rotation may not occur, although an intact teres minor may assist external rotation in the elevated position.

Conclusion

Improving the efficiency of deltoid function before and after reverse shoulder arthroplasty is a key factor in the rehabilitation of the cuff deficient shoulders. Performing exercises in scapular plane and higher abduction angles activates deltoid and other important muscles more efficiently and optimizes surgical outcomes.

Is reverse total shoulder arthroplasty (rTSA) more advantageous than anatomic TSA (aTSA) for osteoarthritis with intact cuff tendon? A systematic review and meta-analysis

PURPOSE

We aimed to compare the outcomes and complications of anatomical shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA) for primary glenohumeral osteoarthritis with intact cuff tissue.

MATERIALS AND METHODS

The MEDLINE, Embase, and Cochrane Library databases were systematically searched for studies published before March 2, 2021 using the PRISMA guidelines. Studies were included if they directly compared aTSA and rTSA for treating primary glenohumeral arthritis. A meta-analysis was performed using six studies that compared radiologic outcomes, functional scores, and range of motion (ROM). All the data were pooled using a random-effects model. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated as dichotomous data, while continuous data were analyzed using mean differences with 95% CIs.

RESULTS

Two independent researchers reviewed 1,061 studies. Six studies met the inclusion criteria. The range of motion, especially external rotation, was better for aTSA than for rTSA (MD = - 10.28, 95% CI: - 16.69 to - 3.88, P = 0.002). Functional scores showed no difference between aTSA and rTSA. Glenoid loosening (OR = 0.17, 95% CI: 0.06-0.50, P = 0.001) was more common with aTSA, and scapula notching (OR = 10.63, 95% CI: 1.73-65.27, P = 0.01) with rTSA. In the mid-term follow-up, the overall revision rate showed no difference between aTSA and rTSA, with a pooled OR of 0.33 (95% CI: 0.07-1.57, P = 0.16).

CONCLUSION

A better ROM was achieved after aTSA than after rTSA. There was no difference in the revision rate at mid-term follow-up between aTSA and rTSA. Glenoid loosening was more common with aTSA, and scapula notching with rTSA.

LEVEL OF EVIDENCE

Level IV, Meta-analysis.

Complications and Intraoperative Fractures in Reverse Shoulder Arthroplasty: A Systematic Review

Introduction

The reverse shoulder arthroplasty is nowadays a treatment option for a variety of shoulder problems. As its incidence rose, also the number of complications increased, including intraoperative fractures.

Significance

We performed a systematic review and critical analysis of the current literature following the PRISMA guidelines. Our purpose was to: 1) determine incidence, causes, and characteristics of intraoperative fractures; 2) evaluate their current treatment options, possible related complications, reoperation rates, and the patients’ outcome; and 3) determine the overall incidence of each complication related to reverse shoulder arthroplasty. The articles were selected from PubMed medical database in April 2020 using a comprehensive search strategy. Rayyan software was used to support the selection process of the records. A descriptive and critical analysis of the results was performed.

Results

The study group included a total of 13,513 reverse shoulder arthroplasty procedures. The total number of complications was 1647 (rate 12.1%). The most common complication was dislocation (340 cases, rate 2.5%). Forty-six studies reported a total of 188 intraoperative fractures among the complications (rate 1.4%). The intraoperative fracture rate was 2.9% and 13.6% in primary and revision settings, respectively. There were 136 humeral fractures, 60% of them occurred in revision RSAs, during the removal of the previous implant, and involved the shaft in the majority of cases (39%). Glenoid fractures were 51 and occurred mostly during the reaming of the glenoid. We observed 7 further related complications (rate of 4%) and 3 reoperations (rate of 1.5%). The outcome was satisfactory in the majority of cases.

Conclusions

A comprehensive review on intraoperative fractures in reverse shoulder arthroplasties is presented. Results suggest favorable outcomes for all treatment methods, with a modest further complication rate. This investigation may aid in the treatment decision-making for these complications.

Does Humeral Component Version Affect Range of Motion and Clinical Outcomes in Reverse Total Shoulder Arthroplasty? A Systematic Review

BACKGROUND

Prosthesis selection, design, and placement in reverse total shoulder arthroplasty (RTSA) affect post-operative results. The aim of this systematic review was to evaluate the influence of the humeral stem version and prosthesis design (inlay vs. onlay) on shoulder function following RTSA.

METHODS

A systematic review of the literature on post-operative range of motion (ROM) and functional scores following RTSA with specifically known humeral stem implantations was performed using MEDLINE, Pubmed, and Embase databases, and the Cochrane Library. Functional scores included were Constant scores (CSs) and/or American Shoulder and Elbow Surgeons (ASES) scores. The patients were organised into three separate groups based on the implanted version of their humeral stem: (1) less than 20° of retroversion, (2) 20° of retroversion, and (3) greater than 20° of retroversion.

RESULTS

Data from 14 studies and a total of 1221 shoulders were eligible for analysis. Patients with a humeral stem implanted at 20° of retroversion had similar post-operative mean ASES (75.8 points) and absolute CS (68.1 points) compared to the group with humeral stems implanted at less than 20° of retroversion (76 points and 62.5 points; p = 0.956 and p = 0.153) and those implanted at more than 20° of retroversion (73.3 points; p = 0.682). Subjects with humeral stem retroversion at greater than 20° tended towards greater active forward elevation and external rotation compared with the group at 20° of retroversion (p = 0.462) and those with less than 20° of retroversion (p = 0.192). Patients with an onlay-type RTSA showed statistically significantly higher mean post-operative internal rotation compared to patients with inlay-type RTSA designs (p = 0.048). Other functional scores and forward elevation results favoured the onlay-types, but greater external rotation was seen in inlay-type RTSA designs (p = 0.382).

CONCLUSIONS

Humeral stem implantation in RTSA at 20° of retroversion and greater appears to be associated with higher post-operative outcome scores and a greater range of motion when compared with a retroversion of less than 20°. Within these studies, onlay-type RTSA designs were associated with greater forward elevation but less external rotation when compared to inlay-type designs. However, none of the differences in outcome scores and range of motion between the humeral version groups were statistically significant.

Long-term Reverse Total Shoulder Arthroplasty Outcomes: The Effect of the Inferior Shifting of Glenoid Component Fixation

Backgroud

The 155° Grammont reverse shoulder replacement has a long track record of success, but also a high radiographic notching rate. The increased distance between the scapular pillar and the humeral component theoretically decreases postoperative notching. The glenoid component can be shifted inferiorly relative to the glenoid; however, there also is some concern that shifting the glenoid component too far inferiorly (inferior glenoid component overhang > 3.5 mm) may compromise long-term stability of the glenoid component. This study was conducted to determine if clinical outcomes, scapular notching, and complications vary with more inferior placement of the glenoid component.

Methods

A retrospective analysis of prospectively collected data was performed in order to compare radiographic outcomes (notching rate and signs of glenoid loosening or component disassembly) and clinical outcomes (range of motion, Constant score, subjective shoulder value, and complication rate) of all patients who underwent reverse shoulder replacement with the glenosphere positioned either flush with the inferior rim of the glenoid (flush group) or with at least 3.5 mm of inferior overhang (overhang group) at a minimum follow-up of 60 months. Ninety-seven patients ultimately met the inclusion criteria, with 41 patients with flush glenoid component and 56 patients with at least 3.5 mm of inferior overhang.

Results

Average follow-up was 97.8 months. The overhang group had a lower rate of radiographic notching (37% vs. 82.5%, p < 0.05), better clinical outcomes (improvement in Constant score: +40 vs. +32, p = 0.036), and higher subjective shoulder value (79 vs. 69, p = 0.026) than the flush group. No difference in complications between groups was found.

Conclusions

In this study, at least 3.5 mm of inferior glenosphere overhang relative to the inferior rim of the glenoid was associated with the lower notching rate without negative effect on the clinical outcomes in 155° Grammont-style reverse shoulder replacement. Therefore, no increase in complications should be expected when using this surgical technique.

Problems, complications, and reinterventions in 4893 onlay humeral lateralized reverse shoulder arthroplasties, a systematic review: part II-problems and reinterventions

BACKGROUND

Several modifications to the original Grammont reverse shoulder arthroplasty (RSA) design have been proposed to prevent distinctive issues, such as both glenoid and humeral lateralization. The aim of this systematic review was to determine rates of problems, complications, reoperations, and revisions after onlay lateralized humeral stem RSA, hypothesizing that these are design related.

METHODS

This systematic review was performed in accordance with the PRISMA statement guidelines. A literature search was conducted (1 January 2000 to 14 April 2020) using PubMed, Cochrane Reviews, Scopus, and Google Scholar, employing several combinations of keywords: "reverse shoulder arthroplasty," "reverse shoulder prosthesis," "inverse shoulder arthroplasty," "inverse shoulder prosthesis," "problems," "complications," "results," "outcomes," "reoperation," and "revision."

RESULTS

Thirty-one studies with 4893 RSA met inclusion criteria. The 892 postoperative problems and 296 postoperative complications represented overall problem and complication rates of 22.7% and 7.5%, respectively. Forty-one reoperations and 63 revisions resulted, with overall reoperation and revision rates of 1.7% and 2.6%, respectively.

CONCLUSIONS

Problem, complication, and reintervention rates proved acceptable when implanting a high humeral lateralization stem RSA. The most frequent problem was scapular notching (12.6%), and the most common postoperative complication was scapular stress fracture (1.8%). An overall humeral complication rate of 1.9% was identified, whereas no humeral fractures or stem loosening were reported with short stems. Infections (1.3%) were the most common reason for component revision, followed by instability (0.8%).

LEVEL OF EVIDENCE

Systematic review IV.

Outcomes After Arthroscopic Rotator Cuff Repair Using Margin Convergence Versus Superior Capsular Reconstruction: Should Candidates for Margin Convergence Be Treated With Superior Capsular Reconstruction?

Background

Both margin convergence rotator cuff repair (MC-RCR) and superior capsular reconstruction (SCR) result in improved clinical outcomes in the treatment of massive rotator cuff tears (RCTs). The question remains whether it is better to perform MC-RCR using native, albeit occasionally deficient, tissues or to perform primary SCR.

Purpose/Hypothesis

To compare the clinical results of MC-RCR versus SCR for the treatment of massive RCTs. It was hypothesized that SCR would yield better outcomes.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were patients who underwent arthroscopic MC-RCR or SCR for massive RCTs performed by a single surgeon between 2014 and 2019. MC-RCR was performed if it was technically possible to close the defect; otherwise, SCR was performed. Outcomes were assessed at 6 months and then annually using American Shoulder and Elbow Surgeons; Single Assessment Numerical Evaluation; shortened version of Disabilities of the Arm, Shoulder and Hand; 12-Item Short Form Health Survey Physical Component Summary; and patient satisfaction scores. The minimal clinically important difference (MCID), substantial clinical benefit (SCB), and Patient Acceptable Symptom State (PASS) were compared between groups. Revision surgeries and complications were reported.

Results

Included were 46 patients in the MC-RCR group (mean age, 59 ± 8 years) and 46 patients in the SCR group (mean age, 57 ± 7 years); 29 patients in each group were available at 2-year follow-up. Preoperative outcome scores were not significantly different between groups. Within groups, all outcome scores improved from pre- to postoperatively (P < .05), with no significant differences in postoperative scores or patient satisfaction between groups. No significant between-group differences were noted in the percentage of patients who reached the MCID, SCB, and PASS (MCID, 92.3% vs 84.6%; SCB, 80.8% vs 80.8%; and PASS, 66.7% vs 66.7%). SCR had a significantly lower survivorship rate compared with MC-RCR (84.7% vs 100%) (P = .026).

Conclusion

Both MC-RCR and SCR provided similar improvement in outcomes; however, SCR resulted in a significantly lower survivorship rate at 2 years postoperatively. If an RCT is technically repairable, we recommend that it be repaired primarily, even if MC techniques are needed to close the defect. SCR remains a good option for massive RCTs that are not technically repairable.

Complications of Reverse Total Shoulder Arthroplasty: A Computational Modelling Perspective

Reverse total shoulder arthroplasty (RTSA) is an established treatment for elderly patients with irreparable rotator cuff tears, complex proximal humerus fractures, and revision arthroplasty; however, with the increasing indications for RTSA over the last decade and younger implant recipients, post-operative complications have become more frequent, which has driven advances in computational modeling and simulation of reverse shoulder biomechanics. The objective of this study was to provide a review of previously published studies that employed computational modeling to investigate complications associated with RTSA. Models and applications were reviewed and categorized into four possible complications that included scapular notching, component loosening, glenohumeral joint instability, and acromial and scapular spine fracture, all of which remain a common cause of significant functional impairment and revision surgery. The computational shoulder modeling studies reviewed were primarily used to investigate the effects of implant design, intraoperative component placement, and surgical technique on postoperative shoulder biomechanics after RTSA, with the findings ultimately used to elucidate and mitigate complications. The most significant challenge associated with the development of computational models is in the encapsulation of patient-specific anatomy and surgical planning. The findings of this review provide a basis for future direction in computational modeling of the reverse shoulder.

Mechanical complications and fractures after reverse shoulder arthroplasty related to different design types and their rates: part I

The initial reverse shoulder arthroplasty (RSA), designed by Paul Grammont, was intended to treat rotator cuff tear arthropathy in elderly patients. In the early experience, high complication rates (up to 24%) and revision rates (up to 50%) were reported.The most common complications reported were scapular notching, whereas clinically more relevant complications such as instability and acromial fractures were less commonly described.Zumstein et al defined a 'complication' following RSA as any intraoperative or postoperative event that was likely to have a negative influence on the patient's final outcome.High rates of complications related to the Grammont RSA design led to development of non-Grammont designs, with 135 or 145 degrees of humeral inclination, multiple options for glenosphere size and eccentricity, improved baseplate fixation which facilitated glenoid-sided lateralization, and the option of humeral-sided lateralization.Improved implant characteristics combined with surgeon experience led to a dramatic fall in the majority of complications. However, we still lack a suitable solution for several complications, such as acromial stress fracture. Cite this article: EFORT Open Rev 2021;6:1097-1108. DOI: 10.1302/2058-5241.6.210039.

Reverse shoulder arthroplasty used for revision of reverse shoulder arthroplasty: a systematic review

Background

As reverse shoulder arthroplasty (RSA) cases increase, so too will the need to revise subsequent failures. Many of the complications associated with revising anatomic total shoulder and hemiarthroplasty have been adequately addressed by RSA including glenoid bone deficiency, instability, and functional outcomes. However, the risk for complication when revising a failed reverse prosthesis may be more pronounced with increased bone and soft tissue deficiency. The ability for the reversed prosthesis to accommodate these insufficiencies following a prior reversed prosthesis is unclear.

Methods

PubMed, Embase, and Google Scholar were queried for articles which fit the inclusion criteria of a reversed prosthesis used to revise a failed primary reverse prosthesis with a minimum follow-up of 12 months and clinical outcome reporting.

Results

After exclusions, 9 studies reporting on 242 reverse shoulders with a mean follow-up of 40.29 months were analyzed. The differences between preoperative and postoperative weighted means were not significant for Constant (P = .26), American Shoulder and Elbow Surgeons Shoulder score (P = .61), SSV (P = .57), and visual analog scale for pain (P = .48). Functional improvements in elevation (74°-102°) and external rotation (18°-21°) were consistent with those reported for primary reverse procedures, although differences in preoperative and postoperative measures were not statistically significant. Patient satisfaction was 89% with a major complication rate of 25%.

Discussion

The reverse shoulder prosthesis has proven satisfactory in revising hemiarthroplasty and anatomic total shoulder arthroplasty. The current results indicate RSA is also a satisfactory treatment option when revising a prior reverse prosthesis. Inherent to revision shoulder surgery is the obstacle of humeral and glenoid bone loss, an attenuated soft-tissue envelope, and instability. The reverse prosthesis may adequately address these commonly confronted difficulties with its inherent design characteristics. RSA provides a secure glenoid fixation for bone grafting, the ability to increase construct stability with component sizing, and a reliance on the deltoid for function. As our learning about revision of RSA improves, so will our ability to preemptively address potential issues which may lead to decreased complications in these cases. Despite the 25% rate of major complication, patients reported satisfaction of 89% which demonstrates the improvements in function and pain relief that are provided by the reverse prosthesis.

Magnetic resonance imaging of deltoid muscle/tendon tears: a descriptive study

OBJECTIVE

To describe the MRI features of deltoid tears and to evaluate tear characteristics in patient groups based on history of trauma and rotator cuff tear (RCT).

MATERIALS AND METHODS

The records of patients who underwent shoulder MRI at our institution between July 2007 and June 2018 were retrospectively reviewed to identify deltoid tears, and patients were divided into groups based on history of recent trauma and presence of RCT. Images were reviewed to identify the location and size of the deltoid tear; the presence or absence of RCT, muscle atrophy, tendon retraction, humeral head subluxation, soft tissue edema, and additional pathologies were also noted. Medical records were reviewed for information about history of steroid injection, previous rotator cuff surgery, and treatments used.

RESULTS

Among 69 patients with deltoid tears (45 men; mean age, 65.2 years; range, 19-89 years), patients with RCTs and no trauma had the highest frequency of deltoid tears in the middle portion (p = 0.005). Only patients with RCTs had undergone steroid injection or rotator cuff surgery. Two patients had deltoid tear without RCT and without recent trauma; these patients demonstrated evidence of calcific tendinopathy and chronic subacromial-subdeltoid bursitis.

CONCLUSION

The middle (acromial) portion of the deltoid is more frequently affected in patients with RCTs than in those with trauma. Although deltoid tears are commonly associated with RCT, calcific tendinopathy and chronic bursitis may also be seen in patients with deltoid tears.

Case Report: Watching and Waiting? A Case of Incomplete Glenosphere Seating With Spontaneous Reversal in Reverse Shoulder Arthroplasty

Introduction: Reverse shoulder arthroplasty is a useful procedure with broadening applications, but it has the best outcomes when used for rotator cuff tear arthropathy. However, this procedure is not without complications. While scapular notching and aseptic loosening are more common complications that have been extensively studied in the literature, dissociation of the glenoid component and incomplete glenosphere seating has not received much attention. Specifically, little research has explored appropriate management of incomplete seating of the glenosphere component, and no gold standard for treatment of this complication has emerged.

Methods: In the case described here, an elderly patient with an incompletely seated glenosphere component post-operatively opted to pursue conservative management in order to avoid revision surgery if possible.

Results: The partially engaged, superiorly directed components in this case exhibited spontaneous complete and symmetric seating of the glenosphere between six and twelve months post-operatively, indicating that conservative management of this complication in low-demand patients may be a viable option to avoid the risks associated with revision surgery.

Conclusion: Further research should be pursued to explore what patient and prosthesis design factors may be suited to observation with serial radiographs when incomplete seating of the glenosphere component occurs.

Lateralized versus nonlateralized reverse total shoulder arthroplasty

Throughout the history of reverse total shoulder arthroplasty, the extent of lateral offset has changed considerably from "too lateral" to "too medial" and has been lately swinging back towards a point somewhere in between. Nonlateralized designs minimize shear forces on the glenoid and decrease force required by the deltoid. Glenoid lateralization decreases impingement and scapular notching and improves range of motion. Humeral lateralization achieves a more anatomic position of the tuberosities while maintaining a nonlateralized center of rotation. Several factors play a role in choosing the extent of lateral offset and method of lateralization.

Outcome and complications following revision shoulder arthroplasty : a systematic review and meta-analysis

AIMS

It is important to understand the rate of complications associated with the increasing burden of revision shoulder arthroplasty. Currently, this has not been well quantified. This review aims to address that deficiency with a focus on complication and reoperation rates, shoulder outcome scores, and comparison of anatomical and reverse prostheses when used in revision surgery.

METHODS

A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) systematic review was performed to identify clinical data for patients undergoing revision shoulder arthroplasty. Data were extracted from the literature and pooled for analysis. Complication and reoperation rates were analyzed using a meta-analysis of proportion, and continuous variables underwent comparative subgroup analysis.

RESULTS

A total of 112 studies (5,379 shoulders) were eligible for inclusion, although complete clinical data was not ubiquitous. Indications for revision included component loosening 20% (601/3,041), instability 19% (577/3,041), rotator cuff failure 17% (528/3,041), and infection 16% (490/3,041). Intraoperative complication and postoperative complication and reoperation rates were 8% (230/2,915), 22% (825/3,843), and 13% (584/3,843) respectively. Intraoperative and postoperative complications included iatrogenic humeral fractures (91/230, 40%) and instability (215/825, 26%). Revision to reverse total shoulder arthroplasty (TSA), rather than revision to anatomical TSA from any index prosthesis, resulted in lower complication rates and superior Constant scores, although there was no difference in American Shoulder and Elbow Surgeons scores.

CONCLUSION

Satisfactory improvement in patient-reported outcome measures are reported following revision shoulder arthroplasty; however, revision surgery is associated with high complication rates and better outcomes may be evident following revision to reverse TSA. Cite this article: Bone Jt Open 2021;2(8):618-630.

Bilateral total shoulder arthroplasty: A systematic review of clinical outcomes

BACKGROUND

The purpose of this study was to describe the clinical outcomes following bilateral total shoulder arthroplasty (TSA).

METHODS

A systematic search of the PubMed, Embase, and Cochrane Library databases following PRISMA guidelines was performed. English-language literature published from 2010 to 2018 analyzing bilateral TSA (anatomic and/or reverse) with a minimum one-year follow-up was reviewed by two independent reviewers. Study quality was evaluated with the Modified Coleman Methodology Score and the methodological index for non-randomized studies score.

RESULTS

Eleven studies (1 Level II, 3 Level III, 7 Level IV) with 292 patients were included. Two studies reported on bilateral anatomic TSA (n = 54), six reported on bilateral reverse TSA (RTSA; n = 168), two reported on anatomic TSA with contralateral RTSA (TSA/RTSA; n = 31), and one compared bilateral anatomic TSA (n = 26) and bilateral RTSA (n = 13). Among studies, mean revision rate ranged from 0% to 10.53% and mean complication rate ranged from 4.9% to 31.3%. At final follow-up, patients experienced significant overall improvements in range of motion and patient-reported outcome score measurements. However, bilateral anatomic TSA resulted in greater improvements in external rotation compared to bilateral RTSA. Overall patient satisfaction was 91.0%.

CONCLUSION

The available data indicate that bilateral TSA allows for functional and pain improvements and result in high patient satisfaction.

LEVEL OF EVIDENCE

IV.

Problems, complications, and reinterventions in 4893 onlay humeral lateralized reverse shoulder arthroplasties: a systematic review (part I-complications)

Background

Several modifications to the original Grammont reverse shoulder arthroplasty (RSA) design have been proposed to prevent distinctive issues, such as both glenoid and humeral lateralization. The aim of this systematic review was to determine rates of problems, complications, reoperations, and revisions after onlay lateralized humeral stem RSA, hypothesizing that these are design related.

Methods

This systematic review was performed in accordance with the PRISMA statement guidelines. A literature search was conducted (01.01.2000–14.04.2020) using PubMed, Cochrane Reviews, Scopus, and Google Scholar employing several combinations of keywords: “reverse shoulder arthroplasty,” “reverse shoulder prosthesis,” “inverse shoulder arthroplasty,” “inverse shoulder prosthesis,” “problems,” “complications,” “results,” “outcomes,” “reoperation,” “revision.”

Results

Thirty-one studies with 4893 RSA met inclusion criteria. The 892 postoperative problems and 296 postoperative complications represented overall problem and complication rates of 22.7% and 7.5%, respectively. Forty-one reoperations and 63 revisions resulted, with an overall reoperation rate of 1.7% and overall revision rate of 2.6%.

Conclusions

Problem, complication, and reintervention rates proved acceptable when implanting a high humeral lateralization stem in RSA. The most frequent problem was scapular notching (12.6%), and the most common postoperative complication was scapular stress fracture (1.8%). An overall humeral complication rate of 1.9% was identified, whereas short stems reported no humeral fractures or stem loosening. Infections (1.3%) proved to be the most common reason for component revision, and instability had a complication rate of 0.8%.

Level of evidence

Systematic review IV

The best options in superior capsular reconstruction

Irreparable massive rotator cuff tears cause pain, loss of function, and a decrease in range of motion, which cause serious disturbances in daily life. Young patients, in particular, are active and have relatively high functional requirements, and their surgical options are limited. Superior capsular reconstruction (SCR) was first proposed for irreparable massive rotator cuff tears, good clinical results have been reported in short-term follow up. Since then, SCR has been used increasingly worldwide for irreparable massive rotator cuff tears, and various studies have been published on clinical outcomes, biomechanical outcomes, surgical techniques, and graft types. This article reviews the optimal graft and surgical options for improving clinical outcomes in SCR.

Trends in rotator cuff surgery: Research through the decades

INTRODUCTION

The aim of this study is to analyse the most cited articles in rotator cuff surgery and identify trends in topics by decade to see which areas may still need further investigation.

METHODS

Journal Citation Index was searched to find articles using the search terms pertaining to "rotator cuff repair". All articles were ranked according to most cited, and then further analysed to find most cited articles in each decade. Articles were grouped into topics to find themes for each decade.

RESULTS

All the most cited articles were published in 6 orthopaedic journals. Only 4 of the top 30 citations provided level I evidence. Each decade's most cited articles seemed to fit into a broad topic, with platelet-rich plasma and biologic augmentation being prominent in the last decade.

CONCLUSION

There are still many unanswered questions in rotator cuff surgery, but this may be because success of certain treatment options are highly dependent on patient selection. Despite growing numbers of articles being published on rotator cuff repairs, the level of evidence remains low. Larger, collaborative projects may help in answering the common dilemmas that still face shoulder surgeons.

The glenoid-intramedullary humeral angle: a measurement of compensatory scapular abduction in advanced rotator cuff arthropathy and its potential effects on implant choice

Background

This study establishes measurements to evaluate pathologic compensation in rotator cuff tear arthropathy and resultant considerations for reverse shoulder arthroplasty.

Methods

Radiographs of patients with intact rotator cuffs were measured establishing interobserver and intraobserver reliability. Reverse shoulder arthroplasty cases performed by a single surgeon were then retrospectively reviewed. One year of follow-up radiographs were required for inclusion. Preoperative radiographs were analyzed for relative humeral head elevation ratio and humeral abduction relative to the glenoid face, termed the glenoid-intramedullary humeral angle. Statistical analyses assessed associations for radiographic measurements with presence and severity of scapular notching based on the Nerot-Sirveaux classification system.

Results

A total of 221 patients met inclusion criteria. At the 1-year follow-up, 61 (27.6%) shoulders had radiographic notching. There was a moderately strong (r = -0.56) negative correlation between glenoid-intramedullary humeral angle and humeral head elevation ratio. Patients with humeral head elevation ratio ≥ 20% were significantly (P = .024) and 9.2 times more likely to have notching of any grade. Patients with glenoid-intramedullary humeral angle ≤ 5 degrees were significant (P < .0001) and 6.7 times more likely to have notching of any grade and significantly (P = .00018) and 145 times more likely to have high-grade (3 and 4) notching.

Conclusions

Preoperative humeral head elevation and compensatory scapular rotation with relative adduction of the humerus have significant associations with high-grade notching. These radiographic findings have potential to help surgeons in preoperative decision-making regarding implant choice and patient education.

Is limited shoulder abduction associated with poor scapulothoracic mobility after reverse shoulder arthroplasty?

INTRODUCTION

The contribution of the glenohumeral joint to shoulder abduction is acknowledged as an important factor for reverse total shoulder arthroplasty (RTSA) patients. In contrast, the degree of scapulothoracic joint contribution and its relation to RTSA patients with poor to excellent shoulder abduction are unclear.

MATERIALS AND METHODS

Twenty-three selectively recruited patients (74 ± 7 years, 11 males) with shoulder abduction ranging from poor to excellent at least 6 months after primary, unilateral RTSA participated in this study. Individual scapulothoracic and glenohumeral contributions at maximum shoulder abduction in the scapular plane were measured using 3D motion capture and correlations between scapulothoracic and glenohumeral contributions to shoulder abduction were assessed. Multiple regression analysis was used to determine the influence of age, body mass index, follow-up period, abduction strength and passive glenohumeral mobility on scapulothoracic and glenohumeral function.

RESULTS

Maximum shoulder abduction (range 48°-140°) was not significantly correlated with the scapulothoracic contribution (range 39°-75°, r = 0.40, p = 0.06), but there was a strong and significant correlation with the glenohumeral contribution (range - 9°-83°, r = 0.91, p < 0.001). Abduction strength was strongly associated with glenohumeral (p = 0.006) but not scapulothoracic (p = 0.34) joint contributions.

CONCLUSIONS

Limited shoulder abduction is not associated with insufficient scapulothoracic mobility, which rather provides a basic level of function for RTSA patients. Good to excellent shoulder abduction could only be achieved by increasing the glenohumeral contribution that was associated with postoperative abduction strength.

Decreased complication profile and improved clinical outcomes of primary reverse total shoulder arthroplasty after 2010: A systematic review

The purpose of this review was to update the complication profile of reverse total shoulder arthroplasty (rTSA) post-2010, given greater procedural familiarity, improved learning curves, enhanced implant designs, and increased attention to the nuances of patient selection. Three electronic databases were searched and screened in duplicate from 1 January 2010 to 16 December 2018 based on predetermined criteria. Twenty-two studies examining 1455 patients (26% male; mean age: 73.4 ± 3.6; mean follow-up: 23.4 ± 14.3 months) were reviewed. Post-operative motion ranged a mean 122.4° ± 11.5° flexion, 109° ± 19.4° abduction, and 33° ± 11.2°/41° ± 5° external/internal rotation. Post-operative mean Constant score was 58.9 ± 10.1, American Shoulder Elbow Surgeon score was 73.4 ± 6.1, Simple Shoulder Test score was 63.5 ± 6.5, and a Visual Analog Scale pain score was 1.6 ± 0.9. The overall complication rate was 18.2% and major complication rate was 15.4%. Compared to pre-2010, the overall complication rate of 18.2% is lower than previous rates of 19%-68%, with the rate of "major" complications dropping three-fold from 15.4% to 4.6%. The data suggest that rTSA is a safe and efficacious alternative to aTSA and HA, and the "stale" nature of previous complication profiles are points fundamental to perioperative discussions surrounding rTSA.

Long-term impact of scapular notching after reverse shoulder arthroplasty

BACKGROUND

Because it medializes the centre of rotation, one of the drawbacks of reverse shoulder arthroplasty (RSA) is the risk of impingement between the humerus and lateral border of the scapula resulting in scapular notching. The long-term impact of this notching is not well known, either on function or the risk of glenoid loosening. The aim of this longitudinal study was to analyze the drawbacks of this notching.

METHODS

Between 1993 and 2006, 81 patients (91 shoulders) underwent RSA for primary glenohumeral osteoarthritis or massive cuff tear with or without osteoarthritis. This cohort was followed longitudinally with post-operative assessments done at one to two  years (T1), three to eight  years (T2), and nine+ years (T3). Before T3, 25 patients had died, nine were lost to follow-up, five  had the implants changed, and seven  had incomplete records. Thus, 45 shoulders were available for follow-up beyond nine years (mean follow-up of 12 years) and were used to determine the long-term impact of notching. Survival curves were generated using the occurrence of Sirveaux grade 3 or 4 notching and the presence of aseptic glenoid loosening as endpoints.

RESULTS

The survivorship before grade 3 or 4 notching developed was 83% at five years, 60% at 10 years, and 43% at 15 years. In the end, aseptic glenoid loosening occurred in four shoulders, all of which had developed grade 4 notching. No glenoid loosening occurred in the population with grade 0, 1, 2, or 3 notching (p = 0.02). The Constant score significantly decreased between T2 and T3, although it was not different between shoulders with and without advanced notching.

CONCLUSIONS

Beyond the second year post-RSA, the number of shoulders with grade 3 or 4 notching increases steadily up to the longest follow-up. Grade 4 notching always preceded the occurrence of late glenoid loosening. The functional outcomes become significantly worse after the 9th year post-RSA, although they were not correlated to the presence of high-grade scapular notching.

An update on reverse total shoulder arthroplasty: current indications, new designs, same old problems

Reverse total shoulder arthroplasty (RTSA) was originally developed because of unsatisfactory results with anatomic shoulder arthroplasty options for the majority of degenerative shoulder conditions and fractures.

After initial concerns about RTSA longevity, indications were extended to primary osteoarthritis with glenoid deficiency, massive cuff tears in younger patients, fracture, tumour and failed anatomic total shoulder replacement.

Traditional RTSA by Grammont has undergone a number of iterations such as glenoid lateralization, reduced neck-shaft angle, modular, stemless components and onlay systems.

The incidence of complications such as dislocation, notching and acromial fractures has also evolved.

Computer navigation, 3D planning and patient-specific implantation have been in use for several years and mixed-reality guided implantation is currently being trialled.

Controversies in RTSA include lateralization, stemless humeral components, subscapularis repair and treatment of acromial fractures.

Cite this article: EFORT Open Rev 2021;6:189-201. DOI: 10.1302/2058-5241.6.200085

Consider Long Head of Biceps Tendon for Reconstruction of Massive, Irreparable Rotator Cuff Tear

Despite the different treatment options for irreparable and massive rotator cuff tears (RCTs), there is no optimal treatment. Thirty percent of total RCTs can be classified as irreparable because of the massive tear size and severe muscle atrophy. The reported treatment failure rate is approximately 40% for massive RCTs. RCTs may be treated conservatively or surgically depending on pain, disability, and functional demands. The surgical treatment options are many, but decision making is a challenge; the real challenge is to apply the correct procedure for the correct indication in each patient. The long head of the biceps tendon (LHBT) was used for augmentation to bridge the gap in immobile, massive RCTs. An arthroscopic biceps-incorporating technique was used for repair of large and massive RCTs, avoiding undue tension on the rotator cuff (RC). Recently, the LHBT was used for superior capsular reconstruction. This article describes the use of the LHBT for reconstruction of massive and irreparable RCTs through the following steps: (1) open exposure of the RCT, (2) debridement and subacromial decompression, (3) biceps tenotomy at the LHBT's origin on the glenoid, (4) LHBT and RC cuff mobilization, (5) passage of the LHBT through the mobilized RC and reflection onto itself, (6) tuberoplasty, and (7) fixation of the RC complex at the RC footprint.

Restoration of External Rotation Following a Lateral Approach for Glenoid Bony Increased-Offset Reverse Shoulder Arthroplasty

Reverse shoulder arthroplasty (RSA) is a recognized therapeutic modality for a massive rotator cuff tear. Some authors recommend lateralization of the center of rotation by bony increased offset (BIO) of the glenoid for improvement of external rotation, while others refute its effects. RSA through the conventional deltopectoral approach sacrifices the subscapularis tendon during the approach. We hypothesized that a lateral approach (LA) for RSA, with less soft-tissue resection, would restore external rotation by allowing retensioning of the remaining rotator cuff with use of a BIO graft.

Treatment of non-arthritic pseudoparetic shoulders with irreparable massive rotator cuff tears: arthroscopic procedures yield comparable midterm results to reverse arthroplasty

Background

Irreparable massive rotator cuff tears (IMRCTs) are a well-known cause for functional limitation and difficult to treat. Although several joint-preserving as well as joint-replacing procedures were found to provide pain relief and gain of function, midterm results are scarce, particularly in pseudoparetic shoulder joints unaccompanied by severe osteoarthritis. The purpose of this study was to compare the midterm functional outcomes of arthroscopic procedures to those of reverse total shoulder arthroplasty (RTSA) in pseudoparetic shoulders with IMRCTs unaccompanied by severe osteoarthritis.

Methods

All patients who underwent either joint-preserving (group A) or joint-replacing (group B) procedures for IMRCT unaccompanied by severe osteoarthritis with a pseudoparetic shoulder function were retrospectively included. Clinical assessment included the Constant Score (CS), the Subjective Shoulder Value (SSV) and the Visual Analog Score (VAS) at baseline and at latest follow-up. Furthermore, the complication and revision rates were assessed.

Results

Overall, a total 56 patients were included of whom each 28 patients formed group A (male, 36%) and B (male, 53%) with a mean patient age at time of surgery of 70 ± 7 years and 72 ± 7 years, respectively. The mean follow-up period was 56 ± 17 months. At final follow-up, the total CS (group A: 66 ± 14 points; group B 54 ± 15 points) was significantly increased after arthroscopic treatment when compared to RTSA (p=0.011). However, no significant differences were detected with SSV (p=0.583) and VAS (p=0.536). Although complication rate (11% versus 18%) was not significantly different (p=0.705), number of revision surgeries was significantly higher in group B when compared to group A (p=0.041).

Conclusions

In non-arthritic pseudoparetic shoulders, both joint-preserving and joint-replacing procedures yielded good clinical midterm outcomes for the treatment of degenerative IMRCTs. Despite of comparable functional and satisfactory functional improvement, increased complication rates and surgical invasiveness outweigh the benefits of primary RTSA and therefore reserve this procedure to a second-line treatment in pseudoparetic patients without any signs of severe cuff arthropathy.

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.

Larger polyethylene glenospheres in reverse shoulder arthroplasty: are they safe?

Background

Reverse shoulder arthroplasty is gaining popularity owing to its proven longevity and good outcome scores. Scapular notching remains a concern. This study aimed to assess the safety of larger polyethylene glenospheres with increased eccentricity in comparison with the more conventional metal bearings. The secondary effects on scapular notching, clinical outcomes, range of movement, and complications were also analyzed.

Methods

We conducted a 10-year retrospective review of 145 SMR reverse shoulder arthroplasties (LimaCorporate, Udine, Italy) in 132 patients with radiographs at a minimum of 2 years postoperatively. The primary outcome measure was the survivorship of the larger polyethylene glenospheres. Secondary outcomes were the presence and size of notching, subjective satisfaction score, American Shoulder and Elbow Surgeons score, Oxford Shoulder Score, range of motion, and shoulder-related complications.

Results

No failures of the polyethylene glenospheres were noted in the 10-year period. At a minimum of 2 years’ follow-up, notching was noted in 16 (25%) of the metal glenospheres vs. 9 (11.1%) of the polyethylene glenospheres (P = .028). The mean Oxford Shoulder Score was lower for the metal glenospheres (P = .005). Range of motion, complications, and overall satisfaction were similar in both groups.

Conclusion

The inverted bearing configuration demonstrated no failures at a minimum of 2 years’ follow-up. A larger study is required to determine whether the decreased incidence and size of early notching are related to the bearing size or material.

Intraoperative measurements of reverse total shoulder arthroplasty contact forces

Purpose

Instability and fractures may result from tensioning errors during reverse total shoulder arthroplasty (RTSA). To help understand tension, we measured intraoperative glenohumeral contact forces (GHCF) during RTSA.

Methods

Twenty-six patients underwent RTSA, and a strain gauge was attached to a baseplate, along with a trial glenosphere. GHCF were measured in passive neutral, flexion, abduction, scaption, and external rotation (ER). Five patients were excluded due to wire issues. The average age was 70 (range, 54–84), the average height was 169.5 cm (range, 154.9–182.9), and the average weight was 82.7 kg (range, 45.4–129.3). There were 11 females and 10 males, and thirteen 42 mm and 8 38 mm glenospheres.

Results

The mean GHCF values were 135 N at neutral, 123 N at ER, 165 N in flexion, 110 N in scaption, and 205 N in abduction. The mean force at terminal abduction is significantly greater than at terminal ER and scaption (p < 0.05).

Conclusions

These findings could help reduce inappropriate tensioning.

Survivorship of a Medialized Glenoid and Lateralized Onlay Humerus Reverse Shoulder Arthroplasty Is High at Midterm Follow-up

BACKGROUND

Reverse shoulder arthroplasty (RSA) is a common treatment of a variety of disabling shoulder conditions. The purpose of this study was to determine revision-free survivorship after RSA using a medialized glenoid and lateralized onlay-type humerus implant and to identify etiologies of revision.

METHODS

All RSAs performed using the Comprehensive^® Reverse Shoulder System (Zimmer Biomet, Inc.; Warsaw, IN, USA) at one institution from 2008 to 2014 were identified through a retrospective review. Charts were reviewed to determine whether the RSA was a primary or revision surgery. Patients were contacted by telephone, and survivorship was defined as no subsequent surgery after RSA. Of the 526 RSAs performed, responses were obtained from 403 patients (77%). A Kaplan-Meier analysis was performed to determine survivorship over time. A χ ² test was used to determine differences between revision rates after RSA.

RESULTS

Minimum follow-up was 3 years, and average follow-up was 4.83 ± 1.60 years. Survivorship was 96% at 2 years and 93% at 5 years after RSA. Revisions were performed for instability (n = 8), humeral tray-taper junction failure (n = 5), acute fracture (n = 4), infection (n = 3), glenoid loosening (n = 3), osteolysis (n = 1), or notching (n = 1). Fourteen of the 151 patients (9.2%) who had surgery prior to RSA required revision after RSA. Having shoulder surgery prior to RSA was associated with higher rates of subsequent revision after RSA.

CONCLUSION

Overall, survivorship after RSA using a medialized glenoid and lateralized onlay-type humerus RSA is high, and prostheses implanted in native shoulders have lower rates of revision at midterm follow-up. Instability (1.9%) was the most common reason for revision.

Superior Capsule Reconstruction: A Glimpse into the Future?

The recent study by Mihata et al., [10] "Five-year follow-up of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears" (J Bone Joint Surg Am. 2019;101:1921-1930), was the first case series published examining long-term clinical and radiographic outcomes of superior capsule reconstruction (SCR) for irreparable rotator cuff tears. This article is a critical review of how the aforementioned study fits into a growing literature surrounding the use of SCR for irreparable rotator cuff tears and how these results may impact clinical and operative decision-making for this patient population. The series compares clinical and radiographic data taken pre-operatively with data taken at 1 year and 5 years post-operatively in a group of 30 patients who underwent SCR utilizing tensor fascia lata autograft. While the results of the study suggest that a healed SCR graft utilizing this specific technique successfully restored shoulder function and prevented progression of rotator cuff arthropathy, it is important to appreciate the limitations of this small, retrospective case series. Nonetheless, the study represents an important addition to the expanding literature surrounding this significant topic. In this report, we shed light on the current state of this novel operative technique and the ongoing controversies revolving around graft material and thickness.

Acromial fracture after reverse total shoulder arthroplasty: a systematic review

BACKGROUND

The reverse total shoulder arthroplasty has become the most common method of arthroplasty of the shoulder. The complication of acromial or scapular stress fracture deserves consideration to describe incidence and determine whether prosthetic design or patient factors act as risk factors.

METHODS

A systematic review of the literature was performed including the EMBASE, Medline and the Cochrane Library in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

The search returned 565 articles. After exclusion, 25 papers remained. In total, 208 fractures were reported in the literature, with an overall incidence of 5% and stress fractures were more common than post-traumatic ones; 24 fractures underwent osteosynthesis and there were nine revision arthroplasty surgeries. Outcomes worsened after fracture - whether treated with surgery or not. In patients with scapular base fractures, there was an improvement in functional outcome scores after surgery. Heterogeneous reporting of the risk factors prior to fractures, treatment methods and outcomes made recommendations weak.

DISCUSSION

Acromial stress fracture after reverse total shoulder arthroplasty occurs relatively commonly but is poorly reported in the literature. It is unclear whether immobilisation, fixation or revision arthroplasty is the best treatment, although fixation may offer a better outcome. In future, reports should aim for greater consistency to allow a better understanding of this condition.

Effect of scapular notching on clinical outcomes after reverse total shoulder arthroplasty

Aims

Scapular notching is thought to have an adverse effect on the outcome of reverse total shoulder arthroplasty (RTSA). However, the matter is still controversial. The aim of this study was to determine the clinical impact of scapular notching on outcomes after RTSA.

Methods

Three electronic databases (PubMed, Cochrane Database, and EMBASE) were searched for studies which evaluated the influence of scapular notching on clinical outcome after RTSA. The quality of each study was assessed. Functional outcome scores (the Constant-Murley scores (CMS), and the American Shoulder and Elbow Surgeons (ASES) scores), and postoperative range of movement (forward flexion (FF), abduction, and external rotation (ER)) were extracted and subjected to meta-analysis. Effect sizes were expressed as weighted mean differences (WMD).

Results

In all, 11 studies (two level III and nine level IV) were included in the meta-analysis. All analyzed variables indicated that scapular notching has a negative effect on the outcome of RTSA . Statistical significance was found for the CMS (WMD –3.11; 95% confidence interval (CI) –4.98 to –1.23), the ASES score (WMD –6.50; 95% CI –10.80 to –2.19), FF (WMD –6.3°; 95% CI –9.9° to –2.6°), and abduction (WMD –9.4°; 95% CI –17.8° to –1.0°), but not for ER (WMD –0.6°; 95% CI –3.7° to 2.5°).

Conclusion

The current literature suggests that patients with scapular notching after RTSA have significantly worse results when evaluated by the CMS, ASES score, and range of movement in flexion and abduction.

Cite this article: Bone Joint J 2020;102-B(11):1438–1445.

Salvage Procedures of the Shoulder: Glenohumeral Arthrodesis and Resection Arthroplasty

BACKGROUND

With the advances of modern medicine and technology there has been an increase of indications of shoulder reconstruction techniques and shoulder arthroplasty. Consequently, the number of complications and failures have increased in parallel. Not negligible number of cases are driven to an end-stage situation where salvage procedures, such as glenohumeral arthrodesis (GHA) and shoulder resection arthroplasty (SRA), are the only remaining solution.

METHODS

The current literature on glenohumeral arthrodesis and shoulder resection arthroplasty was reviewed to determine the indications, surgical technique, complications and outcomes. The electronic search was conducted using the MEDLINE and EMBASE databases and the strategies used were "glenohumeral arthrodesis", "glenohumeral fusion", "shoulder arthrodesis" and "shoulder resection arthroplasty".

RESULTS

Indications for glenohumeral arthrodesis (GHA) include brachial plexus injury, tumor resections, chronic infection, failed prosthetic arthroplasty, persistent refractory instability or pseudoparalysis of the shoulder with combined irreparable rotator cuff and deltoid injuries. GHA provides good stability, pain resolution, although function is markedly compromised and relying mostly on scapulothoracic joint. The gold standard surgical technique continues to be open shoulder arthrodesis and still has a high complication rate. Shoulder resection arthroplasty (SRA) indications have evolved through the years, being nowadays a salvage procedure for recalcitrant infection of shoulder arthroplasty the main indication. Shoulder function after SRA is often severely compromised, but has a high infection rate resolution. SRA is not technically demanding and complications are rare, being the persistence of infection the most common one.

DISCUSSION

Despite GHA and SRA having negative connotations, in selected patients, these procedures can diminish pain, resolve persistent infections and provide an acceptable shoulder function. Hence, they should be retained as part of the treatment algorithm for complex shoulder pathology.

The effect of critical shoulder angle on functional compensation in the setting of cuff tear arthropathy

Introduction

Critical shoulder angle (CSA) has been shown to influence rates of rotator cuff tears and glenohumeral arthritis with a larger CSA associated with rotator cuff tears and a smaller CSA associated with glenohumeral arthritis. There has been no study to determine whether such radiographic measurement influences the function of patients with demonstrated cuff tear arthropathy (CTA). The purpose of this study was to examine whether smaller CSAs were associated with greater range of motion (ROM) in patients diagnosed with CTA.

Materials and methods

Ninety-three patients with a diagnosis of CTA with adequate anteroposterior shoulder radiographs were included in the study. Patient demographics were recorded. The presence of a rotator cuff tear was confirmed via advanced imaging or when applicable via the operative report. Patients' ROM was evaluated through the physician's office note. Shoulder radiographs were used to measure CSA, glenoid inclination, acromial index (AI), and acromiohumeral interval. Patient ROM was measured and grouped into 2 different tiered cohorts: cohort 1 had 4 subgroups of forward elevation (FE) (ie, ≤45°, 45°-90°, 91°-135°, and 136°-180°) and cohort 2 had 2 subgroups of FE (ie, ≤90° and >90°). We then analyzed FE between these groups in the context of their radiographic measurements.

Results

The average patient age was 73.8 ± 8.0 years. There was no significant difference in acromiohumeral interval. AI was found to be significantly different between patients presenting with ≤90° in FE compared with those >90° (P = .02). Average CSA was significantly lower in patients with FE greater than 90° at 33.7° ± 3.9° compared with patients with FE less than 90° at 37.1° ± 6.3° (P = .002). There was also a significant difference with regard to CSAs, with those patients with FE ≤ 45° having a mean CSA of 38.2° ± 8.3° compared with those patients with FE ≥ 135° having a mean CSA of 33.3° ± 4.3° (P = .02).

Conclusion

Patients diagnosed with CTA can significantly vary in their shoulder function and ability to forward elevate. Lower CSA was found to be associated with higher FE in patients with CTA preoperatively. In addition, patients with a smaller AI were also found to have better overhead function. Analyzing CSA on plain radiographs may help manage functional expectations in patients with CTA.