Aseptic Glenoid Loosening Research Articles

Clinical and radiographic comparison of a hybrid cage glenoid to a cemented polyethylene glenoid in anatomic total shoulder arthroplasty

This study reports the clinical and radiographic outcomes of a hybrid cage glenoid compared with an age-matched, sex-matched, and follow-up-matched cohort of cemented all-polyethylene peg glenoids in patients undergoing anatomic total shoulder arthroplastywith 2 years' minimum follow-up. We reviewed 632 primary anatomic total shoulder arthroplasty patients from an international multi-institutional database; 316 patients received hybrid cage glenoids and were matched for age, sex, and follow-up with 316 patients with cemented all-polyethylene peg glenoids. Each cohort received the same humeral component. Scoring was performed in all patients preoperatively and at latest follow-up using 5 outcome scoring metrics and 4 active range-of-motion measurements. A Student 2-tailed unpaired t test identified differences in outcomes; P < .05 denoted a significant difference. Cage glenoid patients had significantly lower rates of radiolucent glenoid lines (9.0% vs. 37.6%, P < .0001) and radiolucent humeral lines (3.0% vs. 9.1%, P = .0088) than all-polyethylene peg glenoid patients. In the cage glenoid cohort, 4 cases of aseptic glenoid loosening (1.3%) and 4 cases of articular surface dissociation (1.3%) occurred. In the all-polyethylene peg cohort, 12 cases of aseptic loosening (3.8%) occurred. Cage glenoid patients had a significantly lower revision rate than all-polyethylene peg glenoid patients (2.5% vs. 6.9%, P = .0088). At 50 months' mean follow-up, cage glenoids demonstrated equally good clinical outcomes to all-polyethylene peg glenoids. Cage glenoids had significantly fewer radiolucent lines around both the glenoid and humeral components and a lower revision rate. Longer-term follow-up is required to confirm these promising short-term results.

Mid-term radiological results of a cementless short humeral component in anatomical and reverse shoulder arthroplasty.

Shoulder arthroplasty using short humeral components is becoming increasingly popular. Some such components have been associated with relatively high rates of adverse radiological findings. The aim of this retrospective review was to evaluate the radiological humeral bone changes and mechanical failure rates with implantation of a short cementless humeral component in anatomical (TSA) and reverse shoulder arthroplasty (RSA). A total of 100 shoulder arthroplasties (35 TSA and 65 RSA) were evaluated at a mean of 3.8 years (3 to 8.3). The mean age at the time of surgery was 68 years (31 to 90). The mean body mass index was 32.7 kg/m2 (17.3 to 66.4). Greater tuberosity stress shielding was noted in 14 shoulders (two TSA and 12 RSA) and was graded as mild in nine, moderate in two, and severe in three. Medial calcar resorption was noted in 23 shoulders (seven TSA and 16 RSA), and was graded as mild in 21 and moderate in two. No humeral components were revised for loosening or considered to be loose radiologically. Nine shoulders underwent reoperation for infection (n = 3), fracture of the humeral tray (n = 2), aseptic glenoid loosening (n = 1), and instability (n = 3). No periprosthetic fractures occurred. Implantation of this particular short cementless humeral component at the time of TSA or RSA was associated with a low rate of adverse radiological findings on the humeral side at mid-term follow-up. Our data do not raise any concerns regarding the use of a short stem in TSA or RSA. Cite this article: Bone Joint J 2019;101-B:610-614.

Paper #3 - Hybrid Cage Glenoids Compared to Cemented Peg Glenoids in Anatomic Total Shoulder Arthroplasty

Introduction: Aseptic glenoid loosening remains a long-term complication of total shoulder arthroplasty (TSA). To improve long-term fixation and decrease the risk of aseptic loosening, glenoid components with hybrid fixation, consisting of a large metal ingrowth central peg and cemented peripheral pegs, have been developed. The purpose of this prospective study is to determine the clinical and radiographic outcomes of a hybrid cage glenoid component compared to an age and gender matched polyethylene (PE) peg glenoid component with a minimum tow year follow-up.

Radiographic comparison of finned, cementless central pegged glenoid component and conventional cemented pegged glenoid component in total shoulder arthroplasty: a prospective randomized study

Radiographic lucency of the glenoid component remains a problem after cement fixation in primary total shoulder arthroplasty. Glenoid component design likely contributes to rates of glenoid lucency. The purpose of this study was to prospectively compare radiographic lucency between a finned, cementless central pegged glenoid component (CL component) and a conventional cemented pegged glenoid component (P component) on immediate postoperative and minimum 2-year follow-up radiographs. Fifty-four patients undergoing total shoulder arthroplasty were prospectively randomized to receive an all-polyethylene CL component or a conventional all-polyethylene P component. Three raters graded glenoid lucency and bone interdigitation on immediate postoperative and latest follow-up radiographs. Patients who had undergone revision surgery or had died before evaluation were excluded. Minimum 2-year follow-up was required for inclusion of radiographic evaluation. Fifty patients met inclusion criteria; 42 patients (84%; 20 CL and 22 P) were available for follow-up with the original glenoid implant in place. The mean follow-up duration was 35 months (24-64 months). There were no significant differences in glenoid radiolucency between CL (1/20 [5%]) and P (2/22 [9%]) components at last follow-up (P = .999). Five patients (25%) in the CL group had bone interdigitation. No instances of aseptic glenoid loosening occurred. There were no significant differences in the rate of glenoid lucency between the 2 groups at immediate or an average 35-month follow-up. Both techniques appear to be viable options for initial glenoid component fixation, with CL components allowing possible osseointegration, imparting potential long-term stability.

Shoulder arthroplasty following gastric bypass, do complications follow?

Previous reports have shown an increased risk of complications after arthroplasty in the obese population. It remains unclear if gastric bypass surgery prior to shoulder arthroplasty modifies the complication and failure rate. The purpose of this study is to assess the complication and re-operation rates following shoulder arthroplasty in this population. Between 2002 and 2012, 39 shoulders with prior gastric bypass underwent shoulder arthroplasty (3 HA, 16 TSA, 20 RSA). The mean time from the gastric bypass to arthroplasty was 13years (range, 0.7-32). Shoulders were followed for a minimum of twoyears (mean, 3.8years) or until re-operation. Outcome measures included pain, range of motion, satisfaction, modified Neer ratings, and ASES scores. Complications occurred in seven shoulders (18%), with five requiring re-operation. There was no common failure mechanism. Re-operations occurred for aseptic glenoid loosening, periprosthetic fracture, and unexplained pain. Those shoulders with complications were similar to those without in regard to age, sex, and BMI. Complications were more common following anatomic arthroplasty compared to reverse arthroplasty (5 vs 1, p=0.06); however, complications were not improved compared to historical controls with morbid obesity. Overall, pain improved significantly from 4.8 pre-operatively to 2.3 postoperatively (p<0.001). All groups, regardless of arthroplasty type, demonstrated significant improvements in forward elevation and external rotation. Gastric bypass surgery prior to shoulder arthroplasty leads to clinical improvement in both pain and range of motion. Prior gastric bypass surgery does not result in a lower surgical complication rate compared to previously published reports in the morbidly obese population. Level 4, case series.

Two-stage reimplantation for the treatment of deep infection after shoulder arthroplasty

Two-stage reimplantation is the most common treatment modality considered for periprosthetic shoulder infection (PSI). Most studies to date have reported on a relatively small number of shoulders. The purpose of this study was to determine the outcome of 2-stage reimplantation for PSI in terms of both eradication of infection and restoration of function. Between 1980 and 2010, 40 shoulders (39 patients) underwent a 2-stage reimplantation for PSI; 35 shoulders (34 patients) met inclusion criteria (10 hemiarthroplasties, 24 anatomic total shoulder arthroplasties, 1 reverse total shoulder arthroplasty). Outcome data included pain, motion, Neer rating, and complications. At most recent follow-up (4.1 years), 2-stage reimplantation had resulted in significant improvements in pain (from 4.4 to 2 on a 5-point scale; P < .0001), mean forward elevation (64°-118°; P < .0001), and mean external rotation (14°-41°; P < .0001). Preoperative testing showed leukocytosis in 1 patient, elevated C-reactive protein concentration in 67%, elevated erythrocyte sedimentation rate in 61%, and positive preoperative aspiration in 69%. Persistent infection, defined as positive cultures in samples obtained at the time of reimplantation, was identified in 5 shoulders (15%); 50% of persistent infections grew Propionibacterium acnes. Reoperations for infection included irrigation and débridement (1), a second 2-stage reimplantation (2), and resection arthroplasty (1); 2 additional patients were treated with chronic suppression. Reoperation for aseptic glenoid loosening was performed in 2 additional shoulders. Results were graded excellent in 10 (28%), satisfactory in 12 (33%), and unsatisfactory in 13 (39%) shoulders. Two-stage reimplantation eradicated PSI in 85% of the shoulders. Pain relief and good arcs of motion were achieved in many patients, but there was an overall rate of unsatisfactory results approaching 40%. Preoperative testing was not always reliable for the diagnosis of PSI.

Revisions for aseptic glenoid component loosening after anatomic shoulder arthroplasty

Glenoid component loosening is a common indication for revision shoulder arthroplasty. The objective of this study is to assess the longer-term outcomes of patients undergoing revision specifically for aseptic loosening. Between 1985 and 2005, 34 revision shoulder arthroplasties were performed for aseptic glenoid loosening. Three patients were lost to follow-up. Treatment included component reimplantation in 20 shoulders (group I) or component removal with bone grafting in 11 shoulders (group II). We identified 9 cases of instability with or without rotator cuff tearing prior to revision. The mean follow-up period was 8.3 years. The rate of survival free of reoperation at 10 years was 78.9% in group I and 83.9% in group II (P = .5). Pain relief occurred in 26 of 31 shoulders, with no difference between groups (P > .99). Active elevation and external rotation improved in both groups (P = .8). Five shoulders in group I had radiographically loose glenoids, with two requiring reoperation. Nine shoulders in group II had medial glenoid erosion, with two requiring reoperation for pain. There was a trend toward reoperation in those with preoperative instability (5 of 8 re-revisions). Glenoid revision surgery in the absence of infection provides satisfactory results, especially when instability is not coexisting. When glenoid bone stock permits, reimplantation of a new glenoid component in an active patient with an intact rotator cuff and no instability is reasonable. When the remaining glenoid bone will not support a new component, conversion to a hemiarthroplasty is also reasonable.

Safety and efficacy of shoulder arthroplasty following lower extremity periprosthetic joint infection

The safety of arthroplasty in patients with a previous periprosthetic joint infection (PJI) remains unclear. The objective of this study was to determine whether patients with a history of a properly treated PJI complicating lower extremity arthroplasty can safely undergo shoulder arthroplasty without an increased risk of shoulder infection or compromise in their clinical outcomes. Between 2002 and 2013, 36 patients with successful treatment of an infected lower extremity arthroplasty underwent a subsequent primary shoulder arthroplasty. Three were lost to follow-up. The remaining 33 shoulders were analyzed at a mean follow-up of 3.5 years for radiographic, clinical, and functional outcomes. Nine patients were receiving chronic antibiotic suppression at the time of their index shoulder arthroplasty. The mean time between PJI treatment and shoulder arthroplasty was 4.7 years (range, 0.7-13.1 years). Shoulder arthroplasty led to improved pain scores and range of motion. Excellent or satisfactory modified Neer ratings were achieved in 78.8% of patients. There was no difference in American Shoulder and Elbow Surgeons scores between the groups with and without chronic antibiotic suppression. There were 2 reoperations, both in patients not receiving chronic suppression. The indications were aseptic glenoid loosening and infection after a periprosthetic fracture. The final estimated survival free of infection was 93.3%. Shoulder arthroplasty in patients with a history of PJI complicating hip or knee arthroplasty seems to be safe, with a low rate of infection. Thus, previous lower extremity PJI should not be considered a relative contraindication to shoulder arthroplasty.

Paper #3 - Comparison of cemented polyethylene peg and hybrid cage glenoids in total shoulder arthroplasty

Introduction: Aseptic glenoid loosening remains a long-term complication of total shoulder arthroplasty (TSA). To improve long-term fixation and decrease the risk of aseptic loosening, glenoid components with hybrid fixation, consisting of a large metal ingrowth central peg and cemented peripheral pegs, have been developed. The purpose of this prospective study is to determine the clinical and radiographic outcomes of a hybrid cage glenoid component compared to an age and gender matched polyethylene (PE) peg glenoid component with a minimum tow year follow-up. Methods: Ninety-two patients with a mean age of 63 years were treated with a TSA for osteoarthritis by 7 surgeons using either a cemented pegged glenoid or a hybrid fixation cage glenoid. Forty-six patients who received a cage glenoid (19 female and 27 males) were matched for sex and age with 46 patients who received a peg glenoid, and all had a minimum 2 year follow-up. The patients were scored preoperatively and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI metrics; active abduction, forward flexion, and active and passive external rotation were also measured. The average follow-up for all patients was 26 months (cage 25 months; peg 26 months). A Student's two-tailed, unpaired t-test was used to identify differences in preoperative, postoperative, and pre-to-post-operative improvements in results, where P < .05 denoted a significant difference. IRB approval was obtained at each institution. Results: All patients demonstrated significant improvements in pain and function following TSA with a cage or peg glenoid (P < .0001). For the cage prosthesis, ASES scores improved from 37 to 89, Constant scores from 39 to 76 (P < .0001). Significant improvements were also seen in the SST, UCLA and SPADI scores (P < .001). For the peg glenoid, ASES scores improved from 35 to 84, Constant scores from 39 to 69 (P < .0001), and significant improvements were also seen in the SST, UCLA and SPADI scores (P < .0001). Active forward flexion for a cage glenoid improved from 104° to 149° and active external rotation from 22° to 49°. Active forward flexion for a peg prosthesis improved from 92° to 135° and active external rotation from 16° to 47° (all P < .0001). Cemented peg glenoids were noted to have significantly lower preoperative abduction measurements; however, no significant differences were observed in any postoperative clinical metric or motion measurement except for the SPADI score (P = .0497) and active forward flexion (P = .0427). Cage prostheses were associated with significantly less blood loss than a peg glenoid (mean blood loss, 242 cc vs 337 cc; P = .022). Radiolucent lines were noted in 14% of cage glenoid patients and 28% of peg patients. There were no cases of radiographic or clinical loosening, clinical failures or revisions in either cohort. There were 3 complications in the cage glenoid group and 4 complications in the peg patients. Discussion: Similar clinical outcomes were found at a minimum two years follow-up comparing a standard cemented peg glenoid with a hybrid cage glenoid prosthesis. The 50% reduction in radiolucent lines for the cage relative to the cemented peg glenoid is significant. This is a proof of concept study demonstrating statistically significant clinical improvements and a significant decrease in the incidence of radiolucent lines following implantation of a hybrid cage glenoid component. Additional and longer-term follow-up is needed to confirm these early outcomes.

Radiographic and clinical outcomes of total shoulder arthroplasty with an all-polyethylene pegged bone ingrowth glenoid component: prospective short- to medium-term follow-up

Glenoid components often cause total shoulder arthroplasty failure. This study examines short-term to midterm radiographic and clinical results of a hybrid glenoid component with 3 cemented peripheral pegs and a central peg, which allows biologic fixation with use of native humeral head autograft. In 4 years, 80 glenoid components were implanted during primary total shoulder arthroplasty with at least 2-year follow-up data. Within 12 months, 4 shoulders were revised and excluded from final analyses. Seven patients did not complete their questionnaires. Outcomes data included the American Shoulder and Elbow Surgeons (ASES) questionnaire, Constant score, and satisfaction score. A shoulder and elbow fellowship-trained surgeon, not involved in the care of these patients, analyzed radiographs for radiolucent lines, glenoid seating, and radiodensity in between the flanges of the central peg. Only 1 of 80 shoulders was revised for aseptic glenoid loosening. At final follow-up, 81.6% had a radiolucency grade of 0 or 1. Nearly 90% had a glenoid seating grade of A or B. Grade 2 or 3 bone around the central peg was seen in 88.2%. No statistical association existed between Walch glenoid types and radiolucency grades, bone grades around the central peg, perfect radiolucency grade, seating grade, and grade 3 bone around the central peg. There was significant improvement in mean ASES score, adjusted ASES pain score, Constant score, and satisfaction score as well as in forward flexion, abduction, and external rotation. The hybrid glenoid can produce stable radiographic and clinical outcomes at short- to medium-term follow-up.

Uncemented metal-back glenoid component in revision of aseptic glenoid loosening: a prospective study of 10 cases with a minimum follow-up of 2 years.

Glenoid component loosening comprises 25 % of all complications related to total shoulder arthroplasties (TSA). This prospective study was undertaken to assess the accuracy of an uncemented metal-back glenoid component in cases of revision of aseptic glenoid loosening. Between September 2007 and January 2010, a total of ten patients with symptomatic glenoid loosening after TSA (7 cemented and 3 non-cemented) underwent revision surgery with an uncemented metal-back glenoid component (MB). The rotator cuff was functional in all cases. The reconstruction of the glenoid was obtained using an iliac crest graft (8 patients) or synthetic bone substitute (2 patients). The non-cemented glenoid component was fixed into the glenoid native bone, thus stabilizing the graft reconstruction. A clinical and radiological checkup was performed at the long-term follow-up and compared with the preoperative values. The patients were also asked to quantify their pain and satisfaction. There were no intraoperative complications. In all cases, the radiological evaluation showed a good integration of the bone graft with no radiolucency or new glenoid loosening. In one patient, the revision surgery was indicated for the dissociation between MB and polyethylene. After more than 2 years of follow-up, all patients were satisfied or highly satisfied with the outcomes. The pain VAS score (0-10) decreased from 5.1 to 0.6 (p < 0.001). The simple shoulder test increased from 3.4 to 7.9 points (gain 4.5; p < 0.001). The Constant and Murley score increased from 39.4 to 71 points (gain 31.6; p < 0.001). The gain in anterior elevation was 31°, from 118° to 149° (p < 0.001). External rotation elbow to the body (ER1) increased from an average of 34° preoperatively to 47° after surgery (p < 0.001) and external rotation at 90° of abduction from 43° to 66° (p < 0.001). This study suggests that revision with a non-cemented glenoid component associated with a bone graft can solve the difficult challenge of glenoid loosening, provided that the rotator cuff is functional and the glenoid is reconstructable. Cohort studies (prospective) without controls, Level IV.

Achieving fixation in glenoids with superior wear using reverse shoulder arthroplasty

Superior glenoid wear is a common challenge with reverse shoulder arthroplasty and, if left uncorrected, can result in superior glenoid tilt, which increases the risk of aseptic glenoid loosening. This study evaluates the impact of an E2 superior defect on reverse shoulder glenoid fixation in composite scapulae after correction of glenoid tilt by use of 2 different glenoid reaming techniques: eccentric reaming and off-axis reaming. A superior glenoid defect was created in 14 composite scapulae. The superior defect was corrected by 2 different glenoid reaming techniques: (1) eccentric reaming with implantation of a standard glenoid baseplate and (2) off-axis reaming with implantation of a superior-augment glenoid baseplate. Each corrected superior-defect scapula was then cyclically loaded (along with a control group consisting of 7 non-worn scapulae) for 10,000 cycles at 750 N; glenoid baseplate displacement was measured for each group to quantify fixation before and after cyclic loading. Regardless of the glenoid reaming technique or the glenoid baseplate type, each standard and superior-augment glenoid baseplate remained well fixed in this superior-defect model scenario after cyclic loading. No differences in baseplate displacement were observed either before or after cyclic loading between groups. Our results suggest that either glenoid reaming technique may be used to achieve fixation in the clinically challenging situation of superior wear with reverse shoulder arthroplasty. Basic science, biomechanical study.

Aseptic glenoid loosening or failure in total shoulder arthroplasty: revision with glenoid reimplantation

Reimplantation of a new glenoid component for symptomatic glenoid failure after total shoulder arthroplasty (TSA) is a well-established surgical strategy. In case of aseptic glenoid loosening or failure, revision of TSA by reimplantation of a cemented glenoid implant would be a reliable therapeutic option. This retrospective multicenter study included 42 TSAs with symptomatic failed glenoids revised by reimplantation of an all-polyethylene (PE), cemented glenoid component. All patients were reviewed clinically and radiologically, with a mean follow-up of 74 months. The failed initial glenoid component was metal backed in 32 cases and PE cemented in 10. The main cause of glenoid failure was component loosening in 19 cases (46%) and PE wear or dissociation in 23 (54%). Associated complications were very frequent, including rotator cuff tears, subscapularis insufficiency, and prosthesis instability. At last follow-up, 7 patients (17%) had already been re-revised because of symptomatic recurrent glenoid loosening. The overall rate of recurrent glenoid loosening (re-revision plus radiologic loosening) was 67%. Soft-tissue problems and prosthetic instability were significantly associated with recurrent loosening. Of the 10 associated bone grafts performed during the revision procedure, all were partially or totally lysed. At follow-up, the mean Constant score was 57 points (gain of 16 points) and the mean active anterior elevation was 125° (gain of 19°). This study suggests that revision of a TSA with reimplantation of an all-PE cemented glenoid component does not solve the problem of glenoid loosening. Soft-tissue failure and prosthetic instability are underestimated preoperatively and may explain, in part, the high rate of recurrent glenoid loosening.

Glenoid loosening and failure in anatomical total shoulder arthroplasty: is revision with a reverse shoulder arthroplasty a reliable option?

Our purpose was to evaluate if, in case of aseptic glenoid loosening and failure in anatomical total shoulder arthroplasty (TSA), revision by a reverse shoulder arthroplasty (RSA) is a reliable therapeutic option. Retrospective multicenter cohort study of 37 consecutive anatomical TSA revised by RSA for aseptic glenoid loosening or failure. The decision to implant a RSA was related to the presence of associated complications: rotator cuff tears (n = 24), subscapularis insufficiency (n = 29), prosthetic instability (n = 13), and glenoid bone deficiency (n = 37). The patients were reviewed clinically and radiographically at a mean follow-up of 47 months (range, 24-104). Eighty-six percent of the patients were satisfied or very satisfied. The average Constant score increased from 24 to 55 pts (P < .0001) and active anterior elevation from 68° to 121° (P < .0001). Twenty-two of the 29 (76%) associated bone grafts were incorporated in the glenoid. Eight patients (21%) needed a subsequent reoperation because of recurrent or new complications: glenoid loosening (n = 3), prosthetic anterior instability (n = 3), and humeral subsidence (n = 2); the reverse prosthesis had to be converted to a hemiarthroplasty in 1 patient and removed in another. Revision with a RSA is a reliable therapeutic option which provides the double benefit of glenoid bone stock reconstruction by fixing the bone graft with the help of the baseplate and screws and of solving the problem of soft tissue insufficiency and prosthetic instability. However, surgeons should be aware that the rate of postoperative complications and subsequent reoperations is high, and that the surgical technique is demanding.

Glenoid Tricortical Iliac Crest Structural Bone Graft Enhanced With Resorbable Cement for the Treatment ofAseptic Glenoid Loosening

Aseptic glenoid loosening is the most frequent cause of revision and can be associated with severe cavitary, segmental, or combined glenoid bone defects. In this study, we describe a glenoid reconstruction technique using tricortical iliac crest graft supplemented with resorbable bone cement. We report on the results of this technique in 6 patients with an average follow-up of 15 months. The average Constant score improved from 36.8 to 59.8 points after revision. Subjectively, 5 of the 6 patients were satisfied with their results and 1 patient was disappointed. We observed satisfactory healing of the graft and maintained homogenous density of the graft in 5 of 6 cases. There was severe erosion of the graft in the case with poor healing and graft resorption, possibly due to a low-grade infection, although this was not proven. There was a partial erosion of the graft observed in 2 additional cases, whereas the remaining 3 cases had no, or only minimal, erosion. Although long-term follow-up is necessary, we have been pleased with the early results of this technique for glenoid reconstruction in the presence of severe glenoid bone loss, an extremely difficult and challenging surgical problem. Level of Evidence: Case series IV.

Arthroplastie inversée de Grammont pour fracture récente de l’humérus proximal chez la personne âgée avec un recul de 5 à 12 ans

Purpose of the study Aim of this retrospective study was to analyze outcome in 23 cases of Delta III reverse ball-and-socket total shoulder prosthesis for acute complex fractures of the proximal humerus in an elderly population with poor bone quality. In such a population, this procedure could escape the difficulties of a reliable and efficient refixation of the tubercles. Material and methods From 1993 to 2000, 23 Delta III prostheses were implanted by a single operator for acute injury: 18 three-part and four-part fractures and 5 fracture-dislocations. The study population included two men and 21 women, mean age 75 years, 10 dominant sides. Surgery was performed under general anesthesia in the semi-sitting position via the anterolateral approach without osteotomy of the acromion, with 10-20̊ retroversion of the humeral stem (except in one shoulder) and cement fixation in two. For five shoulders, the tubercles could be re-fixed. Postoperative physiotherapy was not possible in all patients. Outcome was assessed with the Constant score and with ap and lateral Lamy radiographs. Results Seven patients died so the series included sixteen cases for analysis. Complications were: reflex sympathetic dystrophy (n=2), postoperative Acinetobacer infection (n=1) requiring revision to clean and drain allowing preservation of the prosthesis, and early postoperative anterior dislocation (n=1) (10̊ stem anteversion) with surgical revision to re-orient the stem. At mean follow-up of 86 months, the Constant score was 60 points (contralateral shoulder 83 points). Outcome, influenced in case of re-fixation of the tubercles, was good for pain (14.1), activity (13.3), strength (16.1), anterior elevation (6.5), and abduction (6.5), but very poor for external (1.1) and internal (2.4) rotations. The radiographs showed: aseptic glenoid loosening (n=1) at 12 years with surgical revision in 2005 with Constant score at 6 months follow-up of 48 points, inferior scapular notching (n=11) according the the Nérot classification (six stage 1, four stage 2, one stage 3, at 2, 4.3 and 5 years follow-up), inferior spurs (n=9) appearing at mean 2.5 years follow-up (stable after emergence without clinical impact), proximal humeral resorption (n=4) (medially for three at mean 8 year follow-up and one laterally at 10 years), and a humeral radiolucent line (n=1) at 5 years follow-up. Discussion For acute complex fractures of the proximal humerus in elderly subjects with poor bone quality, when an efficient and reliable re-fixation of the tubercles is difficult or impossible, reverse ball-and-socket shoulder prosthesis is a possible alternative providing good functional outcome except for rotations but with the risk of inferior scapular notching. Although not problematic in the mid term, these notches may contribute to glenoid loosening with bone loss in the long-term. Nevertheless, this procedure seems to improve the status of patients with such fractures.

Grammont reverse total shoulder arthroplasty in patients with rheumatoid arthritis and nonreconstructible rotator cuff lesions

This study was undertaken to determine whether patients with severe rheumatoid arthritis and irreparable rotator cuff rupture can be treated successfully with the Grammont shoulder arthroplasty. Seven patients with rheumatoid arthritis (8 shoulders) with nonreconstructible rotator cuff lesions and Larsen stage-V radiographic changes of the glenoid and the humeral head underwent a Grammont reverse shoulder arthroplasty. The Constant score improved from a mean of 17 points (range 4 to 25) preoperatively to a mean of 63 points (range 41 to 79) at a mean of 54 months (range 48 to 73) after shoulder arthroplasty. The mean strength at 90° of abduction measured 3.6 kg (range 1 to 6). Shoulder instability was not observed. Complications included septic implant loosening (1 shoulder), aseptic glenoid loosening (2), and failed acromion osteosynthesis following the transacromial approach (3). These data of Grammont arthroplasty are encouraging with respect to restoration of stability and satisfactory function in rheumatoid, cuff-deficient shoulders. However, glenoid loosening remained a serious problem, and transacromial approaches were complicated by failure of acromial fixation. (J Shoulder Elbow Surg 2001;10:17-22.)