Scapular notching in reverse shoulder arthroplasty Lévigne, Christophe, MD; Boileau, Pascal, MD; Favard, Luc, MD ...
Journal of shoulder and elbow surgery,
11/2008, Volume:
17, Issue:
6
Journal Article
Peer reviewed
The causes and consequences of scapular notching after reverse shoulder arthroplasty (RSA) were investigated in 326 consecutive patients (337 shoulders) undergoing RSA between 1991 and 2003. Patients ...underwent 269 (80%) primary RSAs and 68 revisions of unconstrained shoulder prosthesis. At last follow-up (average, 47 months; range, 24-120 months) 62% had scapular notching. Notching frequency and extension were correlated to the length of follow-up ( P = .0005). Notching was more frequent in cuff tear arthropathy ( P = .0004), grade 3 or 4 fatty infiltration of the infraspinatus ( P = .01), and narrowed acromiohumeral distance ( P < .0001). Glenoids preoperatively oriented superiorly were more at risk for notching ( P = .006). More notching occurred when the RSA was implanted using an anterosuperior approach vs a deltopectoral approach ( P < .0001). Notching was correlated with humeral radiolucencies in proximal zones ( P < .0001) and with glenoid radiolucent lines ( P < .0001). Positioning of the baseplate definitely influences scapular notching. High positioning of the baseplate and superior tilting must be avoided.
Background In a retrospective multicenter study, we evaluated the efficiency and outcomes of the different therapeutic options for infection after reversed shoulder arthroplasty. Methods Thirty-two ...patients were reoperated on for infection after reversed shoulder arthroplasty between 1996 and 2011. The mean age was 71 (55-83) years. The involved implants were primary prostheses in 23 cases and revision prostheses in 9 cases. The average preoperative Constant score was 34 (11-69). Six of these patients needed 2 successive procedures. A total of 38 procedures were performed: débridement (13), 1-stage (5) or 2-stage revision (14), or implant removal (6). At last follow-up (mean, 36 months; range, 12-137 months), every patient had clinical, biologic, and radiographic evaluation. Results Infections were largely caused by coagulase-negative staphylococci (56%) and Propionibacterium acnes (59%). The complication rate was 26%. At last follow-up, 26 patients were free of infection (81%). The final Constant score was 46 (12-75). After débridement with implant retention, the mean Constant score was 51 (29-75), but the healing rate was only 54%. Implant revision (1 or 2 stage) led to better functional results than implant removal (46 vs. 25; P = .001), with similar healing rates (73% and 67%, respectively). Patients with low initial impairment (Constant score > 30) were not significantly improved by surgical treatment. Conclusion Débridement is the less aggressive option but exposes patients to healing failure. It should be proposed as a first treatment attempt. Revision of the implant is technically challenging but preserves shoulder function, with no higher rate of residual infection compared with implant removal.
Background The concept of free interposition arthroplasty proved successful for small joints of the hand, wrist, and foot, particularly after the use of implants coated with pyrocarbon, which ...enhanced their tribologic and elastic properties. The present study reports preliminary outcomes of a pyrocarbon-coated interposition shoulder arthroplasty (PISA) implant. Methods This was a prospective study of 67 consecutive patients who underwent shoulder PISA at 9 centers. The mean age at surgery was 51 years, with only 12 patients older than 60 years. The indications for surgery were primary glenohumeral arthritis in 42, avascular necrosis in 13, and secondary arthritis in 12 patients. Results Revision surgery was performed in 7 patients (10.4%), 2 (3.0%) were lost to follow-up, and the outcome assessments were incomplete in 3 (4.4%). This left 55 patients, aged 49.3 ± 12.0 years, with complete outcomes assessments at a mean follow-up of 26.8 ± 3.4 months. The Constant score improved from 34.1 ± 15.1 preoperatively to 66.1 ± 19.7 postoperatively. The radiographic findings revealed erosion in 6 glenoids and thinning of 3 humeral tuberosities. Conclusion In a cohort of young arthritic patients, PISA renders clinical scores and implant survival comparable to those of hemishoulder arthroplasty but remain inferior to those results reported for total shoulder arthroplasty. The study enabled identification of contraindications and potential causes of failure that wererelated to the concept of free interposition and smaller radius of curvature of the sphere. Until long-term results are available, this type of innovative implant should remain to be tested in a few specialized shoulder centers.
Background Reverse shoulder arthroplasty (RSA) can improve anterior active elevation (AAE) by lengthening of the deltoid and hence increasing its lever arm. However, evaluations of functional ...outcomes of RSA have shown variable improvements in the range of motion. The aim of our study was to correlate humeral and arm lengthening to postoperative AAE. Methods We reviewed 183 RSAs with a minimum follow-up of 1 year. Lengthening of the humerus and the arm was evaluated in relation to the contralateral side. Results We observed mean humeral lengthening of 0.2 ± 1.4 cm (range, −4.7 to +5.2 cm) and mean arm lengthening of 1.6 ± 1.9 cm (range, −5.1 to +5.4 cm). Postoperative AAE was 140° ± 27° (range, 30° to 180°). We found no significant correlation between lengthening or shortening of the humerus and AAE ( P = .169). Shortening of the arm led to a mean AAE value of 122°; lengthening of 0 and 1 cm, mean AAE of 140°; lengthening of greater than 1 cm to 2.5 cm, mean AAE of 144°; and lengthening of greater than 2.5 cm, mean AAE of 147°. When we compared patients with lengthening of the arm and those with shortening, the postoperative AAE was significantly greater after arm lengthening, 145° versus 122°, with a mean difference of 23° (95% confidence interval, 13° to 33°) ( P < .001). Conclusion This study shows that shortening of the arm reduced AAE. With respect to arm lengthening, a lengthening threshold was not found. An objective assessment of deltoid lengthening is possible preoperatively, intraoperatively, and postoperatively, and this measure seems to correlate with the functional outcome.
Introduction As the revision number of shoulder arthroplasties increases, we focused on the difficulties of extracting or converting the humeral stem. The purpose of this multicentric study was to ...assess the outcomes and the radiographic results of a new, short, and convertible humeral stem (Aequalis Ascend™ Flex, Tornier SAS–Wright Medical Inc®, Bloomington, MN, USA), which could settle these complex revision problems. Methods Sixty-six primary shoulder replacements were enrolled with an average follow-up of 25.6 months (24–30.8 months). There were 24 reversed shoulder arthroplasty (RSA) and 42 anatomical shoulder arthroplasty. The functional outcomes were evaluated with the Constant-Murley score (CS) and the active range of motion. Humeral stems were radiologically analyzed at the last follow-up with special care to mechanical complications and bone resorption. Results The average CS improved from 30 preoperatively to 74 postoperatively (P < .0001) for anatomical shoulder replacements and from 21 to 63 (P < .0001) for RSA. The active anterior elevation and external rotation improved from 97° and 6° to 163° and 46°, respectively, for anatomical prosthesis (P < .0001) and from 79° and 10° to 139° and 28°, respectively, for RSA (P < .0001). No mechanical complication or loosening was reported. The comparison between postoperative and last follow-up X-rays showed a tendency to medial cortical bone thinning in some cases without any clinical relevance. Conclusion Two years follow-up of this short stem showed promising clinical and radiographic results without implant-related complication. Further X-rays study would be necessary. Level of evidence: IV
In vitro data demonstrate the potential benefits of the pyrocarbon as a bearing material against cartilage or bone. And pyrocarbon-free interposition arthroplasty has been used with positive outcomes ...for over 10 years for hand and wrist joint replacements. This study reports the midterm results of a Pyrocarbon Interposition Shoulder Arthroplasty (PISA) in primary and secondary glenohumeral osteoarthritis and in avascular osteonecrosis.
This prospective noncontrolled, multicenter study included 67 consecutive patients who underwent PISA in France and Sweden.
A cohort of 48 patients, aged 50 ± 12 years, was available for clinical assessment at a mean follow-up of 67.6 ± 9.3 months. A favorable change was reported with a mean absolute Constant score improvement of 32 ± 20 points. The highest Constant score improvement was observed in patients with avascular osteonecrosis (42 ± 18 points; P ≤ .0001). Between the earliest and the latest follow-up, radiographic analyses revealed only 2 major glenoid erosions and 4 tuberosity thinnings and thus that 86.4% of 44 shoulders remained stable with no or minor radiologic evolutions. The survival rate was 84 % at 65 months of follow-up considering all causes of revision.
The radiographic findings seem to confirm the interest of pyrocarbon in preserving bony surfaces. But the risk of tuberosity thinning suggests considering the use of PISA with caution in most degenerative glenohumeral joint pathologies, although the midterm outcomes highlight PISA as a suitable solution for patients presenting with posttraumatic osteonecrosis without malunion of the tuberosities and with an intact rotator cuff.
To determine, from a sizable cohort of reverse shoulder arthroplasty (RSA), whether the deltopectoral (DP) or anterosuperior (AS) approach grant better outcomes at a minimum follow-up of 24 months.
...The authors reviewed 743 RSAs in patients with primary osteoarthritis (OA) with or without rotator cuff lesions and secondary OA due to rotator cuff tears. The DP approach was used in 540 and the AS approach in 203. Pre- and post-operative constant scores (CSs) and shoulder range of motion were recorded.
Of the initial cohort of 743 shoulders, 193 (25.7%) were lost to follow-up, 16 (2.1%) died, and 33 (4.4%) were revised; 540 shoulders were operated using DP approach (73%), of which 22 were revised (4.1%), while 203 were operated using the AS approach (27%), of which 11 were revised (5.4%). Propensity score matching resulted in two groups: 172 shoulders operated by DP approach, and 88 shoulders operated by AS approach. Comparing outcomes of the matched groups at 2 or more years also revealed that, compared to the AS approach, the DP approach resulted in significantly better post-operative CSs (67.3 ± 14.0° vs 60.8 ± 18.3,
= 0.017), active forward elevation (137° ± 27.4° vs 129° ± 29.8;
= 0.031).
At 2 or more years following RSA, the DP approach granted significantly better CS (by 6.5 points) and active forward elevation (by 8°) compared to the AS approach. The differences observed are clinically relevant and must be considered to manage patient expectations following RSA and for selecting surgical approach depending on their functional needs.
III, comparative study.
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