Humeral Radiolucency Research Articles

Anatomic total shoulder arthroplasty for B2 glenoids treated with asymmetric reaming has equivalent survivorship and patient outcomes compared with type A glenoids at a mean 9-year follow-up

BackgroundWalch B2 glenoids can present a challenge to shoulder arthroplasty surgeons. Short-term studies have demonstrated that corrective reaming to 10° of retroversion in anatomic total shoulder arthroplasty (aTSA) can result in good outcomes, however there is little data reporting the long-term outcomes in this cohort. B2 glenoids treated with high-side reaming present a theoretical risk of early glenoid component failure as one may ream into the subchondral bone. This study aimed to demonstrate that 1) B2 glenoids treated with corrective reaming have durable results and 2) offer similar results to Walch A1/2 in long-term follow-up. MethodsPatients who underwent aTSA by a single surgeon (E.L.F.) were identified from a shoulder arthroplasty registry. Inclusion criteria included Walch A1, A2 or B2 glenoid, a diagnosis of primary shoulder osteoarthritis, and a minimum radiographic and clinical follow-up of 5 years. 43 patients with B2 glenoids were compared to a cohort of 42 patients with A1 or A2 glenoids. Preoperative computed tomography (CT) and radiographs were utilized to assess deformity, glenoid version, and posterior subluxation of the humeral head. Postoperatively, patients were assessed with radiographs and patient-reported outcome measures including American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, and Visual Analog Scale (VAS). Results85 shoulders (82 patients, 42 B2 and 43 A1/A2 glenoids) with an average follow-up of 9.4 years were included. In the B2 cohort, the average retroversion was 21.1° and posterior subluxation was 69.4% compared with 10.6°(p<0.001) and 57.5% (p<0.001) in the A1 or A2 cohort. The cohort demographics were similar except for male sex (B2 69.8% vs A1 or A2 37.2%, p=0.008). There was no difference between the cohorts in their improvement in ASES (p=0.807), SST (p=0.586), or VAS (p=0.930) scores. There was no difference in lateral humeral offset (p=0.889) or acromial humeral interval (p=0.468) between initial postoperative and final follow-up visits. Survivorship for B2 glenoids was 97.6%, 94.1% and 73.3% at 5, 10 and 15 years, respectively compared to 97.6%, 91.9% and 83.5% in type A glenoids. The revision rate was similar between the two groups (p=0.432). Lazarus score (p=0.682) and rates of humeral radiolucency (p=0.366) and humeral osteolysis (p=0.194) were similar between the two cohorts at final follow-up. ConclusionAsymmetric reaming of patients with B2 glenoids is a reliable method of glenoid preparation with excellent mid- to long-term clinical results, patient reported outcomes, and low revision rates similar to their A1 and A2 counterparts.

Prognostic value of the Favard classification for patients before and after reverse shoulder arthroplasty performed for rotator cuff tear arthropathy

BackgroundAlthough the Favard classification is commonly utilized by surgeons to describe the supero-inferior morphology of the glenoid when treating rotator cuff arthropathy (RCA), its utility in prognosticating patients’ clinical state before and after reverse shoulder arthroplasty (RSA) remains unproven. We assessed the prognostic value of the Favard glenoid classification on preoperative clinical state and postoperative clinical and radiographic outcomes in RSA. MethodsA prospectively collected, multicenter database for a single-platform shoulder arthroplasty system was queried for patients with RCA who underwent RSA with a minimum 2-year clinical follow-up. Differences in patient reported outcome scores (PROMs) (Simple Shoulder Test, American Shoulder and Elbow Surgeons, Shoulder Pain and Disability Index, visual analog scale pain, Shoulder Function score), combined patient-reported and clinical-input scores (Constant, University of California Los Angeles, Shoulder Arthroplasty Smart), active range of motion values (forward elevation, abduction, external rotation [ER], internal rotation [IR]), radiographic outcomes (humeral radiolucency line rates, scapular notching rate), and the incidence of postoperative complications and revision surgery were compared by glenoid deformity type per the Favard classification. Comparisons were performed to assess the ability of the Favard classification to prognosticate the preoperative, postoperative, and improved state after RSA. Results400 RSAs performed for RCA were included. Comparison of outcomes between Favard glenoid types resulted in 6 pairwise comparisons of 12 clinical outcome metrics, yielding 72 total Favard glenoid pairwise comparisons for each clinical state (preoperative, postoperative, improvement). Of the 216 possible pairwise Favard glenoid type/metric comparisons, statistical significance was only reached for 3% of the combinations (7/216). Among E0, E1, and E2 glenoids, the only statistically significant pairwise comparison identified among all three clinical states was a more favorable preoperative American Shoulder and Elbow Surgeons score for E0 vs. E2 glenoids. Preoperatively, E3 glenoids had poorer ER, IR, and Shoulder Arthroplasty Smart scores compared to E0 glenoids and poorer ER compared to E2 glenoids. Postoperatively, E3 glenoids had a poorer IR score compared to E0 glenoids and poorer ER compared to E1 glenoids. No pairwise differences in preoperative to postoperative improvement were found. There were no statistically significant pairwise differences in humeral lucency rate, scapular notching rate, complication rates, or revision rates between Favard glenoid types. ConclusionAlthough useful for describing degenerative changes to the glenohumeral joint, the Favard classification offers little prognostic information regarding patient outcomes before and after RSA aside from poorer preoperative and postoperative axial rotation in E3 glenoids. Alternative glenoid classification systems or predictive models should be considered for more precise prognoses of patients undergoing RSA for RCA.

Hemiarthroplasty for proximal humerus fractures: clinical and radiographic outcomes after an average of 19 years

BackgroundThe main objective of this retrospective analysis was to report on the long-term clinical and radiographic outcomes (>10 years) in a series of patients who have previously undergone hemiarthroplasty for proximal humerus fracture. Materials and methodsThe charts of 11 patients (12 shoulders) who underwent hemiarthroplasty for proximal humerus fractures were retrospectively analyzed and stratified based on tuberosity healed (TH) or tuberosity resorption (TR). The primary end points included range of motion measurements and patient-reported outcome scores. We obtained forward elevation, exterx nal rotation, internal rotation, Simple Shoulder Test, American Shoulder and Elbow Surgeons scores, and Visual Analog Scale (VAS) scores. Tuberosity healing or resorption, acromiohumeral interval, subluxation, and humeral radiolucency were analyzed separately by 2 fellowship-trained orthopedic surgeons. ResultsThe mean age at surgery for TH patients was 60.0 ± 9.8 years and for TR patients was 57.7 ± 4.3 years. There were 7 cases in tuberosity healing cohort and 5 cases in the tuberosity resorption cohort. Implant survivorship at final follow-up was 100% (7/7) for TH and 60% (3/5) for TR; 2 patients who failed hemiarthroplasty were converted to reverse total shoulder arthroplasty. Mean postoperative forward elevation (TH: 155°, TR: 36°; P value < .01), external rotation (TH: 59°, TR: 28°; P value < .01), and internal rotation (TH:T12, TR:L3; P value = .08) were higher in the TH cohort. American Shoulder and Elbow Surgeons scores (TH: 90, TR: 40; P value < .01) and Simple Shoulder Test scores (TH: 9, TR: 2; P value < .01) were statistically significant between the 2 cohorts while VAS scores approached significance (mean VAS [TH: 1, TR: 4; P value = .08]). DiscussionTo our knowledge, this study provides the longest follow-up to date for outcomes following hemiarthroplasty with fracture. Significant improvements in shoulder function and reduction in pain levels are sustainable even after 19 years in patients whose tuberosity heals. Hemiarthroplasty remains a viable option for younger candidates whose tuberosity will heal postoperatively.

Does humeral fixation technique affect long-term outcomes of total shoulder arthroplasty?

For anatomic total arthroscopic repair, cementless humeral fixation has recently gained popularity. However, few studies have compared clinical, radiographic, and patient-reported outcomes between cemented and press-fit humeral fixation, and none have performed follow-up for longer than 5 years. In this study, we compared long-term postoperative outcomes in patients receiving a cemented versus press-fit humeral stem anatomic arthroscopic repair. This study retrospectively analyzed 169 shoulders that required primary anatomic total shoulder arthroplasty (aTSA). Shoulders were stratified by humeral stem fixation technique: cementation or press-fit. Data were collected pre- and postoperatively. Primary outcome measures included range of motion, patient reported outcomes, and radiographic measures. One hundred thirty-eight cemented humeral stems and 31 press-fit stems were included. Significant improvements in range of motion were seen in all aTSA patients with no significant differences between final cemented and press-fit stems (forward elevation: P=0.12, external rotation: P=0.60, and internal rotation: P=0.77). Patient reported outcome metrics also exhibited sustained improvement through final follow-up. However, at final follow-up, the press-fit stem cohort had significantly better overall scores when compared to the cemented cohort (visual analog score: P=0.04, American Shoulder and Elbow Surgeon Score: P<0.01, Simple Shoulder Test score: P=0.03). Humeral radiolucency was noted in two cemented implants and one press-fit implant. No significant differences in implant survival were observed between the two cohorts (P=0.75). In this series, we found that irrespective of humeral fixation technique, aTSA significantly improves shoulder function. However, within this cohort, press-fit stems provided significantly better outcomes than cemented stems in terms of patient reported outcome scores. Level of evidence: III.

Mid-term results of Eclipse total shoulder arthroplasty.

The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up. Outcomes of 143 procedures undertaken for all indications in 131 patients were reviewed, with subset analysis of those for osteoarthritis (OA) (n = 99). The primary outcome was the Oxford Shoulder Score (OSS) at a minimum of five years. Secondary outcomes were ranges of motion and radiological analysis of humeral radiolucency, rotator cuff failure, and glenoid loosening. Mean OSS at mean follow-up of 6.67 years (5.0 to 10.74) was 40.12 (9 to 48), with no statistically significant difference between those implanted for a non-OA indication and those for OA (p = 0.056) or time-dependent deterioration between two years and five years (p = 0.206). Ranges of motion significantly improved compared with preoperative findings and were maintained between two and five years with a mean external rotation of 38° (SD 18.1, 0 to 100) and forward elevation of 152° (SD 29.9, 90 to 180). Of those components with radiographs suitable for analysis (n = 83), 23 (28%) were found to have a least one humeral radiolucent line, which were predominantly incomplete, less than 2 mm, and in a single anatomical zone. No humeral components were loose. A radiolucent line was present around 22 (15%) of glenoid components, and 15 (10%) of components had failed. Rotator cuff failure was found in 21 (15%) components. The mean time to either glenoid or rotator cuff failure was greater than three years following implantation. Survivorship was 96.4% (95% CI 91.6 to 98.5, number at risk 128) at five years, and 94.3% (95% CI 88.2 to 97.3, number at risk 76) at seven years, both of which compare favourably with best results taken from available registries. Functional and radiological outcomes of the Eclipse stemless TSA are excellent, with no loose humeral components at minimum five-year follow-up. The presence of radiolucent lines is of interest and requires long-term observation but does not impact on the clinical results. Of the eight revisions required, this was predominantly for glenoid and rotator cuff failure. Cite this article: Bone Joint J2022;104-B(1):83-90.

Clinical results and 10-year survivorship of the Synthes Epoca resurfacing total shoulder arthroplasty.

This prospective cohort study reports the 10-year survivorship, patient-reported outcome measures and radiographic outcomes of the first series of the Epoca resurfacing head total shoulder arthroplasty. From July 2008 to July 2014, 59 Epoca resurfacing head total shoulder arthroplasties were implanted in 50 patients by a single surgeon. Minimum 4.8 year and maximum 11.3 year follow-up (mean: 7.9 years) was analysed using the latest available Oxford Shoulder Score. Kaplan-Meier survivorship analysis was performed with revision as the end point. Most recent radiographs were reviewed for component radiolucency, osteolysis and proximal humeral migration. Two shoulders underwent revision (3.4%); one for pain with posterior subluxation following a fall, the other for pain with failure of the glenoid. Kaplan-Meier analysis revealed 10-year survivorship of 98.2% (95% confidence intervals: 88.0%-99.8%). Mean Oxford Shoulder Score improved significantly compared to pre-operative values from 18.2 (5-45) to 46.6 (36-48) (p < 0.001). Fifty-three shoulders underwent radiographic analysis (89.8%). This revealed humeral radiolucency in two cases (3.8%), glenoid radiolucency in three cases (5.7%) and radiographic rotator cuff failure in eight cases (15.1%). This prospective cohort study shows excellent 10-year survivorship, medium to long-term clinical and radiological results and for the Synthes Epoca resurfacing head total shoulder arthroplasty. IV.

Reverse shoulder arthroplasty for massive irreparable rotator cuff tears: a reliable treatment method

BackgroundMassive irreparable rotator cuff tears (MIRCT) are challenging problems for both patients and surgeons. Reverse total shoulder arthroplasty (RTSA) is a treatment option for patients with MIRCTs. However, previous reports have shown inconsistent results, varying patient satisfaction, and higher complication rates. MethodsThis is a retrospective multi-institutional study (22 institutions, 24 surgeons) of 203 patients (average age, 71 years) who underwent RTSA for MIRCT without glenohumeral arthritis with a mean follow-up of 50 months. Patients were divided into 4 groups based on preoperative shoulder active forward elevation (aFE) (<60°, <90°, ≥90°, >120°). Clinical outcomes were assessed using multiple patient-reported outcome measures (PROs), postoperative range of motion (ROM), patient satisfaction, and complication rate. Radiographic outcomes assessment included evaluation of postoperative scapular notching and humeral radiolucent lines. ResultsPatients in each group had significant (P≤ 0.02) improvements in PROs and ROM postoperatively. Patient satisfaction was highest in the group with >120° preoperative aFE (44/44, 100%). Scapular notching and humeral radiolucency were noted in 6% and 7% of patients, respectively. There were only 3 complications that required 2 revision surgeries. Overall, the complication rate (1.6%) and reoperation rate (1.1%) were considerably lower than previously reported. ConclusionRTSA is a reliable treatment for MIRCTs without glenohumeral arthritis that results in significant improvements in PROs and shoulder ROM. Compared to previous studies, we report a substantially higher satisfaction rates in all patients, especially in those with better preoperative ROM (aFE >120°), and a lower overall complication rate. Level of evidenceLevel IV, retrospective case series.

Clinical and Radiological Outcomes in Reverse Total Shoulder Arthroplasty by Inclination Angle With a Modular Prosthesis.

The influence of the humeral inclination in reverse total shoulder arthroplasty (RTSA) is not well understood. The purpose of this study was to determine outcomes and complications after RTSA with an inclination of 135° or 155° in a modular prosthesis. American Shoulder and Elbow Surgeons (ASES), visual analog scale (VAS), Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST) scores, as well as forward elevation (FE), abduction (ABD), and external rotation (ER), were assessed after a minimum 2-year follow-up. Scapular notching and radiolucency were assessed according to Sirveaux and Lévigne. A total of 121 patients with a mean age of 69.7±7.3 years were evaluated after a mean of 36.5±8 months. The inclination was set to 135° in 80.2% and to 155° in 19.8% of patients. There was no significant difference between the groups for ASES, VAS, SANE, and SST scores. The FE (P=.022) and ABD (P=.002) were significantly higher for the 155° inclination group. Complication rates were not significantly different between the groups. Scapular notching was significantly more common with a 155° inclination (P=.01), whereas humeral radiolucency was not correlated. All outcome scores improved significantly from pre- to postoperative (P≤.001). Reverse total shoulder arthroplasty leads to significant improvements in pain, range of motion, and outcome scores after mid-term follow-up. Overall, the inclination angle does not significantly affect clinical outcomes or the complication rate after RTSA at mid-term follow-up. However, an inclination of 155° shows significantly greater FE and ABD, although it results in a significantly higher rate of scapular notching. Cases with scapular notching are associated with significantly reduced mean ASES scores and ER as well as significantly higher VAS scores. [Orthopedics. 2021;44(4):e527-e533.].

Eclipse stemless shoulder prosthesis vs. Univers II shoulder prosthesis: a multicenter, prospective randomized controlled trial

Total shoulder arthroplasty is an accepted treatment for glenohumeral osteoarthritis. The Arthrex Eclipse shoulder prosthesis is a stemless, canal-sparing humeral prosthesis with bone ingrowth capacity on the trunnion, as well as through the fenestrated hollow screw, that provides both diaphyseal and metaphyseal load sharing and fixation. Between 2013 and 2018, 16 sites in the United States enrolled 327 patients (Eclipse in 237 and Arthrex Univers II in 90). All patients had glenohumeral arthritis refractory to nonsurgical care. Strict exclusion criteria were applied to avoid confounding factors such as severe patient comorbidities, arthritis not consistent with osteoarthritis, and medical or prior surgical treatments that may have affected outcomes. Patients were randomized to the Eclipse or Univers II group via block randomization. In total, 149 Eclipse and 76 Univers II patients reached 2-year follow-up (139 Eclipse patients [93.3%] and 68 Univers II patients [89.5%] had complete data). The success rate using the Composite Clinical Success score was 95% in the Eclipse group vs. 89.7% in the Univers II group. No patient exhibited radiographic evidence of substantial humeral radiolucency, humeral migration, or subsidence at any point. Reoperations were performed in 7 patients (3.2%) in the Eclipse group and 3 (3.8%) in the Univers II group. The Arthrex Eclipse shoulder prosthesis is a safe and effective humeral implant for patients with glenohumeral arthritis at 2-year follow-up, with no differences in outcomes compared with the Univers II shoulder prosthesis.

Primary Monoblock Inset Reverse Shoulder Arthroplasty Resulted in Decreased Pain and Improved Function

The first-generation, lateral-center-of-rotation reverse shoulder arthroplasty (RSA) modular design has demonstrated durable early-, mid-, and long-term outcomes. The second-generation monoblock implant shares a similar design but eliminates the modular junction and facilitates inset placement within the metaphysis to avoid humeral-sided junctional failures and facilitate metaphyseal press-fit. However, no paper has specifically examined the radiographic findings and improvements in pain and function after the use of this next generation design. (1) After second-generation, lateral-center-of-rotation monoblock RSA, what are the improvements in shoulder scores, general health scores, and ROM at a minimum of 2 years of followup? (2) Are the differences in shoulder scores, health scores, and ROM associated with fixation (cemented versus cementless components)? (3) How frequently do complications occur (defined as humeral loosening, dislocation, baseplate failure, scapular notching, acromial fractures, and revision surgery) after inset monoblock RSA? We retrospectively studied patients undergoing primary RSA between 2010 and 2015 with preoperative data and a minimum of 2 years of clinical followup. Of the 329 primary RSA performed during this period, 125 were excluded based on the use of a different generation humeral stem of the same design, three based on need for a nickel-free implant, and 39 due to a lack of preoperative shoulder scores. Of the remaining 162 patients, 137 patients (85%) met the inclusion criteria with a mean age of 74 years (range, 46-90 years). The predominant indications were osteoarthritis with a massive rotator cuff tear (74%) and fracture sequelae (16%). During the study, humeral implants were typically inserted using an uncemented press-fit technique (85%), with only 21 patients requiring a cemented humeral stem. The mean clinical and radiographic followup period was 37 months (range, 24-82 months). Patient-reported outcome measures (PROMs) including the Simple Shoulder Test, American Shoulder and Elbow Surgeons Total, VAS for pain, SF-12, Single Assessment Numeric Evaluation, and measured active motion (forward elevation and external and internal rotation) were recorded at pre- and postoperative intervals. Postoperative radiographs were evaluated for baseplate failure, glenoid and humeral loosening, scapular notching, and acromion fractures. Complications were recorded in the longitudinally maintained institutional repository. At the most recent followup examination, there were improvements in measured motion, general health outcomes, and all PROMs. There were no differences between the cemented and press-fit techniques. Complications observed included 17 of 137 patients (12%) with scapular notching, six postoperative acromion fractures (4%), and two revision procedures (1%). No patients experienced gross humeral loosening or baseplate failure. Primary RSA using a second-generation monoblock inset humeral component resulted in improvements in pain and functional outcomes as well as low rates of acromion fractures, humeral radiolucency, and complications. Future studies are needed to provide a more definitive analysis on the use of an uncemented technique for humeral stem fixation and the effect of an inset stem on postoperative acromion fractures. Level IV, therapeutic study.

Radiological changes do not influence clinical mid-term outcome in stemless humeral head replacements with hollow screw fixation: a prospective radiological and clinical evaluation

BackgroundStemless shoulder arthroplasty is a fairly new concept. Clinical and radiological follow-up is essential to prove implant safety and concept. This prospective single-centre study was performed to evaluate the influence of radiological changes on clinical mid-term outcome following stemless humeral head replacement with hollow screw fixation.MethodsShort- and mid-term radiological and clinical evaluations were performed in 73 consecutive shoulders treated mainly for idiopathic and posttraumatic osteoarthritis with stemless humeral head arthroplasty including 40 hemi- (HSA) and 33 total shoulder arthroplasties (TSA). Operating times of stemless implantations were compared to 110 stemmed anatomical shoulder prostheses. Appearances of humeral radiolucencies or radiological signs of osteolysis or stress shielding were assessed on standardized radiographs. Patients’ clinical outcome was evaluated using the Constant score and patients’ satisfaction was documented.ResultsRadiological changes, detected in 37.0%, did not affect clinical outcome. Constant scores significantly improved from baseline to short and mid-term follow-up (p < 0.001). The majority of patients (96.2%) were satisfied with the procedure. No loosening of the humeral head component was detected during a mean follow-up of 58 months. Operating times were significantly shorter with stemless compared to stemmed implants (p < 0.001).ConclusionsClinical mid-term outcome after stemless humeral head replacement was not affected by radiological changes.Trial registrationThe institutional review board (St. Vincent Hospital Vienna; 201212_EK01; date of issue: 11.12.2012) approved the study. The trial was registered at ClinicalTrials.gov (NCT02754024). Retrospective registration.

Proximal ingrowth coating decreases risk of loosening following uncemented shoulder arthroplasty using mini-stem humeral components and lesser tuberosity osteotomy

Mini-stem humeral component (MSHC) use during total shoulder arthroplasty (TSA) provides bone preservation and ease of revision. MSHCs rely solely on proximal metaphyseal fixation; some early reports have demonstrated an unacceptably high rate of early loosening. To our knowledge, no study analyzing the effect of proximal porous coating on MSHCs has been performed. We performed a retrospective review of consecutive patients who underwent anatomic TSA using coated or uncoated MSHCs with minimum 2-year follow-up. Postoperative radiographs were assessed for risk of or frank stem loosening, subsidence, and presence of radiolucencies. Range of motion, outcome scores (visual analog scale pain, American Shoulder and Elbow Surgeons, and Single Assessment Numeric Evaluation), and any complications were noted. We analyzed 68 shoulders with a mean follow-up of 27.3 months (range, 24-50 months). Of these, 34 had proximal coating and 34 were uncoated. In the coated group, no stems loosened, 1 (2.9%) subsided, and 7 (20.6%) developed radiolucencies. In the uncoated group, 1 stem (2.9%) became aseptically loose (requiring revision after 26 months), 7 (20.6%) were judged at risk of loosening (2 because of subsidence), and 15 (44.1%) developed radiolucencies. There was also an increased risk of proximal medial humeral radiolucencies among uncoated MSHCs. There were no significant differences in final range of motion or outcome scores. MSHC use is appropriate for TSA, achieving desired pain relief and functional improvement. Overall, component loosening appears uncommon at early follow-up; however, uncoated stems appear to be at greater risk of loosening and developing radiolucencies. Selecting an MSHC with proximal porous coating may decrease the risk of implant-related complications.

Impact of scapular notching on clinical outcomes after reverse total shoulder arthroplasty: an analysis of 476 shoulders

Scapular notching is a complication unique to reverse total shoulder arthroplasty (rTSA), although its clinical implications are unclear and remains controversial. We retrospectively reviewed rTSA patients of a single implant design in 476 shoulders with a minimum 2-year clinical and radiographic follow-up. Clinical measures included active range of motion and American Shoulder and Elbow Surgeons scores, in addition to one or more of the Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test (SST), and University of California, Los Angeles Shoulder Rating Scale. Complications and rates of humeral radiolucencies were also recorded. Scapular notching was observed in 10.1% (48 of 476) of rTSAs and was associated with a longer clinical follow-up, lower body weight, lower body mass index, and when the operative side was the nondominant extremity. Patients with scapular notching had significantly lower postoperative scores on the Shoulder Pain and Disability Index, Constant, Simple Shoulder Test, and University of California, Los Angeles, Shoulder Rating Scale compared with patients without scapular notching. Patients with scapular notching also had significantly lower active abduction, significantly less strength, and trended toward significantly less active forward flexion (P = .0527). Finally, patients with scapular notching had a significantly higher complication rate and trended toward a significantly higher rate of humeral radiolucent lines (P = .0896) than patients without scapular notching. This large-scale outcome study demonstrates that patients with scapular notching have significantly poorer clinical outcomes, significantly less strength and active range of motion, and a significantly higher complication rate than patients without scapular notching. Longer-term follow-up is necessary to confirm that these statistical observations in the short-term will result in greater clinically meaningful differences over time.

Long-term analysis of revision reverse shoulder arthroplasty using cemented long stems

Revision of failed shoulder arthroplasty is often associated with poor results and a high rate of complications. Significant humeral bone loss after removal of long stems poses a considerable surgical challenge. Therefore, the aim of our study was the evaluation of the clinical and radiologic outcome of cemented long-stem humeral components in revision reverse shoulder arthroplasty with a minimum 5 years' follow-up. Between June 2001 and June 2009, revision reverse shoulder arthroplasty using long-stem cemented humeral components was performed in 124 patients. Mean age at time of surgery was 69.6 years (range, 42-87 years). Complete clinical and radiographic data were available in 50 patients at a mean of 7 years (range, 5-11.6 years). Postoperative radiographs were evaluated for radiolucent lines, implant migration, fracture, and glenoid notching. The mean Constant score improved from 11.1 points (range, 0-27 points) to 39.5 points (range, 14-73 points) at the latest follow-up. Progressive humeral radiolucency was present in 24 patients, including 6 patients demonstrating complete loosening or progressive distal migration of the humeral stem. We noted an overall of 12 additional complications in 8 patients, necessitating revision surgery in 16. The use of long-stem humeral components is a beneficial treatment in revision reverse shoulder arthroplasty. Nevertheless, the high percentage of patients with humeral loosening is concerning. Modular cementless revision stems that are adapted to the distal humeral medullary canal and additional distal screw and cable fixation might enhance durable distal fixation in case of advanced bone loss.

An evaluation of the radiological changes around the Grammont reverse geometry shoulder arthroplasty after eight to 12 years

Radiological changes and differences between cemented and uncemented components of Grammont reverse shoulder arthroplasties (DePuy) were analysed at a mean follow-up of 9.6 years (8 to 12). Of 122 reverse shoulder arthroplasties implanted in five shoulder centres between 1993 and 2000, a total of 68 (65 patients) were available for study. The indications for reversed shoulder arthroplasty were cuff tear arthropathy in 48 shoulders, revision of shoulder prostheses of various types in 11 and massive cuff tear in nine. The development of scapular notching, bony scapular spur formation, heterotopic ossification, glenoid and humeral radiolucencies, stem subsidence, radiological signs of stress shielding and resorption of the tuberosities were assessed on standardised true anteroposterior and axillary radiographs. A scapular notch was observed in 60 shoulders (88%) and was associated with the superolateral approach (p = 0.009). Glenoid radiolucency was present in 11 (16%), bony scapular spur and/or ossifications in 51 (75%), and subsidence of the stem and humeral radiolucency in more than three zones were present in three (8.8%) and in four (11.8%) of 34 cemented components, respectively, and in one (2.9%) and two (5.9%) of 34 uncemented components, respectively. Radiological signs of stress shielding were significantly more frequent with uncemented components (p < 0.001), as was resorption of the greater (p < 0.001) and lesser tuberosities (p = 0.009).

Observations on retrieved humeral polyethylene components from reverse total shoulder arthroplasty

Analyses of polyethylene components retrieved at revision of total knee, hip, and shoulder replacements have been used to study the effect of design, patient, and surgical factors on initial implant performance, but no studies have reported similar types of findings in retrieved humeral polyethylene components in reverse total shoulder arthroplasty. Our hypothesis is that while the conforming surface of the humeral polyethylene may predispose it to surface wear modalities, as seen in total hip arthroplasty, the presence of clinical instability may also increase the occurrence of focal contact stresses leading to subsurface fatigue failure. Fourteen humeral polyethylene components were retrieved from revision surgery at a single institution. Each polyethylene was analyzed for 9 modes of damage in each of 4 quadrants into which the bearing surface was divided. For each implant, the most recent radiographs before removal were scored using an adapted radiolucency score, and glenosphere positioning was measured. Despite the short mean length of implantation (0.46 ± 0.5 years), scratching and abrasion were seen in 14 and 13 components, respectively, followed by third-body debris and pitting. The modes of damage observed were most severe in the inferior quadrant of the humeral polyethylene. Scapular notching, glenoid, and humeral radiolucencies were prevalent on preoperative radiographs, but their long-term significance has not yet been elucidated. Increased glenosphere inclination was associated with decreased superior and total glenoid radiolucency, along with total polyethylene wear scores. Promising early, functional results with the use of reverse total shoulder arthroplasty has led to the increased expansion of its use, but high complication and revision rates continue to raise concerns regarding implant longevity. The presence of a clinical, adduction deficit may predispose patients to inferior quadrant polyethylene wear. Impingement of the humeral polyethylene at the lateral edge of the scapula leads to inferior quadrant wear and associated polyethylene failure, and implant instability may predispose the components to fatigue wear mechanisms. Analysis of retrieved humeral polyethylene components, along with patient, design, and surgical factors, provide important information on the causes of component failure.

Concordance and reproducibility in the assessment of humeral radiolucencies in cemented shoulder hemiarthroplasties

Purpose To assess concordance and reproducibility in the observation of radiolucent lines of the humeral prosthetic component in cemented shoulder hemiarthroplasties. Materials and methods Five observers evaluated 128 X-rays obtained from 32 cemented shoulder hemiarthroplasties at 2 points of time during follow-up in anteroposterior and scapular Y views; a re-evaluation was made after 3 weeks. Radiolucent lines were studied in 7 areas around the implant at the cement-bone and cement-implant interfaces. Radiolucencies were classified into 4 categories according to their size in millimeters. Results were assessed with the kappa statistical method. Results In the study of intraobserver reproducibility kappa indices of 0 to 0.6 were obtained for the implant-cement and cement-bone interfaces. In the study of interobserver concordance for each of the areas and interfaces, 65% of kappa indices obtained range between 0 and 0.4. Intraobserver capacity to follow up one same patient in time was assessed on the basis of the percentage of possible responses by each observer, which ranged between 85 and 90%. Conclusions A low rate of concordance and reproducibility is obtained when analyzing radiolucencies both at the bone-cement and at the cement-implant interfaces. There is also a low error index when analyzing the evolution of radiolucencies in 2 X-rays of the same implant obtained at 2 different points in time.

Scapular notching in reverse shoulder arthroplasty

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.

Custom total shoulder arthroplasty in inflammatory arthritis: Preliminary results

Twenty-three patients with inflammatory arthritis and rotator cuff deficiency have undergone 27 custom-fit total shoulder arthroplasties. The design used included a short-stem humeral component and a metal-backed glenoid component with an offset keel. The glenoid component was custom-fit to provide maximum coverage of the glenoid surface. The average age of the patients at the time of surgery was 55 years (range, 20–75 years). All patients had inflammatory arthritis, 16 were on steroids, and all had some degree of rotator cuff involvement ranging from small to complete tears. The average length of follow-up study was 5 years (range, 3–7 years). The average preoperative shoulder score was 36 points (range, 15–50 points) with an average pain score of 7 (of 30) points. Postoperatively, the shoulder score improved to 85 points with a pain score of 28 points. Twenty-one shoulders scored a good to excellent result. Two patients required reoperation, both for recurrent rotator cuff tears, one of which occurred after a fall. Radiographic analysis revealed no incidence of humeral radiolucency and six cases of glenoid radiolucency. Only two of these were progressive and both were associated with irreparable rotator cuff tears. Thus, in the early follow-up, this design of glenoid has decreased the incidence of glenoid radiolucency in this difficult patient population.