Primary Glenohumeral Osteoarthritis Research Articles

Predictive factors of intraoperative conversion to reverse total shoulder arthroplasty in patients with anatomic total shoulder arthroplasty

BackgroundMany factors play a role in decision-making for arthroplasty type in patients with glenohumeral osteoarthritis (GHOA). The purpose of this study was to evaluate preoperative and intraoperative factors that might predict the need for Reverse Total Shoulder Arthroplasty (rTSA) versus Anatomic Total Shoulder Arthroplasty (aTSA) for patients with primary GHOA. Secondarily, American Shoulder and Elbow Surgeons (ASES) were compared. MethodsPatients with primary GHOA indicated for aTSA versus rTSA were identified. Preoperative records were reviewed for demographics, range of motion, rotator cuff strength, and glenoid morphology. Operative reports were assessed to identify intraoperatively rotator cuff pathology and glenoid deficiency. ASES scores at 2-years postoperative were collected. Results111 patients were included from 2018-2021. 94 patients underwent aTSA, while 17 were intraoperatively converted to rTSA. There were no significant differences in age, BMI, or preoperative Walch classification between cohorts. rTSA patients had significantly decreased preoperative external rotation (p=0.006). External rotation ≤30 degrees was the only preoperative predictive factor for performing rTSA versus aTSA (p=0.0004). The most common reason for intraoperative transition to rTSA was rotator cuff deficiency. At 2-year follow-up, median ASES scores were 94.2 (IQR 85-96.7) and 88.3 (IQR 73.3-94.5) for aTSA and rTSA, respectively (p=0.097). ConclusionMany patients with primary GHOA are well-served with aTSA. However, there are patients with primary GHOA in which rTSA may be ideal given rotator cuff deficiency or glenoid defects felt to limit aTSA glenoid component placement. This study highlights the need for preoperative external rotation and intraoperative evaluation of rotator cuff integrity and glenoid bone stock.

Preoperative rotator cuff fatty infiltration and muscle atrophy do not negatively influence outcomes following anatomic total shoulder arthroplasty

BackgroundAnatomic total shoulder arthroplasty (TSA) is an effective surgical option for the treatment of primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff. While an intact rotator cuff is essential to the success of TSA, little is known about how preoperative rotator cuff muscle quality may impact clinical outcomes. In this study, we sought to determine the effects of rotator cuff fatty infiltration (FI) and muscle atrophy (MA) on clinical outcomes following TSA. MethodsA retrospective review of a prospectively maintained, single-surgeon registry was used to identify patients undergoing TSA for GHOA between April 2015 and March 2020. Patients were included if they had preoperative magnetic resonance imaging available, an intact rotator cuff, and complete preoperative and minimum 2-year postoperative patient-reported outcome measures (PROMs) and active range of motion (ROM) measurements. Preoperative MA and FI of the rotator cuff were assessed on magnetic resonance imaging by measuring muscle cross-sectional area and using the Goutallier classification system, respectively. Pearson’s correlation was used to determine any relationship between MA and clinical outcomes. Univariate analysis was used to compare clinical outcomes of patients with moderate-to-severe FI to those with minimal-to-mild FI. ResultsThere were 163 shoulders from 154 patients with a mean age of 62.5 (standard deviation = 7.4) and a mean follow-up of 2.9 years (standard deviation 1.2) that met inclusion criteria. Rotator cuff muscle area was not correlated with any preoperative or postoperative ROM or PROMs (P > .05). However, the ratio of infraspinatus and teres minor (posterior cuff) to subscapularis muscle area was minimally negatively correlated with change in Single Assessment Numerical Evaluation (r = −0.171, P = .029) and change in internal rotation (r = −0.207, P = .008), although the clinical relevance is unclear. No significant differences in preoperative ROM or PROMs were found between patients with minimal-to-mild and moderate-to-severe FI (P > .05). ConclusionPreoperative rotator cuff muscle volume and FI do not impact clinical outcomes following TSA in patients with GHOA and intact rotator cuffs. TSA remains a viable surgical treatment for individuals with GHOA and an intact rotator cuff, provided the MA and FI are not so severe that a patient may be indicated for another type of treatment.

The association of rotator cuff muscle morphology and glenoid morphology in primary glenohumeral osteoarthritis

The association of rotator cuff muscle morphology and glenoid morphology in primary glenohumeral osteoarthritis

Short-Term Results after Reversed Total Shoulder Arthroplasty

Abstract Purpose Massive rotator cuff tear, with or without arthritis and proximal humerus fracture non-union or malunion, lead to the loss of center of rotation of shoulder, while anatomical total shoulder arthroplasty does not provide a stable center of rotation, Therefor reversed total shoulder arthroplasty (RTSA) is the suitable method for these indications, as well as in elderly patients with primary glenohumeralosteoarthritis because anatomical total shoulder arthroplasty has the risk of failure either due to loosening of glenoid component or cuff tear. This study aimed to determine the short-term results after RTSA in patients a with massive cuff tear, acute proximal humerus fracture, proximal humerus fracture malunion or non- union, and primary glenohumeralosteoarthritis. Methods This one arm clinical trial (interventional study) conducted in Ain Shams University Hospitals included 16 patients who underwent RTSA. Short-term outcomes included constant score, American Shoulder and Elbow Surgeon (ASES) score, and range of motion (ROM). Patients with rotator cuff arthropathy, massive irreparable cuff tear with or without glenohumeralarthritis, elderly patients with acute complex proximal humerus fracture, malunited or nonunited proximal humerus fracture, and patients with glenohumeralosteoarthritis were included. Patients who were aged <50 years were excluded, as well as patients with axillary nerve injury or deltoid muscle dysfunction. Results This study included 16 patients, including 8 males and 8 females. The mean age was 64.19 years and the duration of follow up-was 1 year postoperatively. Seven Patients with massive irreparable cuff tear were included, of them, 1 had associated anterior shoulder instability and recurrent anterior dislocation, 3 had a four-part proximal humerus fracture, 2 had fracture dislocation, 2 had proximal humerus fracture non –union, 1had neglected dislocation, and 2 had glenohumeralosteoarthritis. Outcomes were followed using constant and ASES scoring systems, and ROM. The global postoperative gain was statistically significant (p < 0.001). Complication in the form of dislocation occurred in one case that had RTSA after fracture non-union. Conclusion Good clinical and functional outcomes were achieved after RTSA, not only for classic massive cuff tear indication, but for other disorders, such as acute proximal humerus fracture, fracture non-union, and primary glenohumeralosteoarthritis. However, the outcomes after irreparable cuff tear were the best among all indications, while fracture non-union had the least improvement in clinical outcomes. Improvements in prosthesis design, surgeon’s experience, and clinical results are necessary to optimize this treatment for many shoulder conditions.

Short-Term Results after Reverse Total Shoulder Arthroplasty

Abstract Background: The loss of the shoulder’s center of rotation is caused by massive rotator cuff tears, which can occur with or without arthritis and proximal humerus fractures that are nonunion or malunion. Because anatomical total shoulder arthroplasty cannot provide a stable center of rotation, reverse total shoulder arthroplasty (RTSA) is the appropriate procedure for these indications and in older patients who have primary glenohumeral osteoarthritis. Anatomical total shoulder arthroplasty carries a risk of failure because of the loosening of the glenoid component or cuff tear. The purpose of this study was to determine the short-term outcomes following RTSA in patients who had primary glenohumeral osteoarthritis, acute proximal humerus fractures, malunited or nonunited proximal humerus fractures, and massive cuff tears. Materials and Methods: This single-arm clinical trial (interventional study) was done in Ain Shams University Hospitals; 16 patients were included who underwent RTSA. Constant score, American Shoulder and Elbow Surgeon score, Visual Analog Scale score, and range of motion (ROM) were the short-term outcomes. Patients with cuff tear arthropathy, irreparable cuff tear with or without glenohumeral arthritis, elderly patients with unreconstructable proximal humerus fracture, proximal humerus fracture malunion or nonunion, and patients with glenohumeral osteoarthritis were included. Patients under the age of 50, as well as those with deltoid muscle dysfunction or injuries to the axillary nerve, were excluded. Results: There were 16 patients in this study, 8 of whom were male and 8 of whom were female. The follow-up period lasted 2 years following surgery, with a mean age of 64.19 years. The study included 7 patients with irreparable cuff tears one of them had associated anterior shoulder instability and recurrent anterior shoulder dislocation. One patient had a neglected shoulder dislocation, two patients had proximal humerus fracture dislocation, two patients had a nonunited proximal humerus fracture, three patients had unreconstructable proximal humerus fracture, and two had glenohumeral osteoarthritis. Conclusion: Not only did RTSA provide good clinical and functional outcomes for the standard indication of a massive cuff tear, but it also proved beneficial for other disorders such as primary glenohumeral osteoarthritis, nonunited fracture, and acute proximal humerus fracture. Among all indications, irreparable cuff tears yielded the highest results; nonunited fractures displayed the least improvement regarding clinical outcomes. Enhancements in the design of prostheses, the expertise of surgeons, and clinical outcomes are crucial to maximize their effectiveness in treating various shoulder disorders.

Anatomic total shoulder arthroplasty using hybrid glenoid fixation with a porous-coated titanium post. Two- to ten-year follow-up of 256 cases with primary glenohumeral osteoarthritis

BackgroundAnatomic total shoulder arthroplasty is one of the recommended surgical treatments for severe glenohumeral osteoarthritis, providing good pain relief and function. Aseptic loosening of the glenoid component, however, is a major cause for revision. Hybrid components have been introduced, combining traditional cemented fixation with porous titanium bone ingrowth to improve fixation. The purpose of this study was to report our midterm to longterm experience using such a component, including clinical outcomes and implant survival. MethodsWe reviewed all patients who were operated for primary osteoarthritis during the period 2011-19, leaving a minimum of 2-year follow-up. The severity of the osteoarthritis was graded using Samilson-Prieto score, while glenoid morphology was graded using the modified Walch classification. Clinical outcomes included Western Ontario Osteoarthritis of the Shoulder (WOOS) index, EQ-5D-5L, and Constant-Murley score. Postoperative radiographs were analyzed for radiolucent lines. Patient records were studied for complications including revisions. Supplementary data for revision and outcome were obtained from the Danish Shoulder Arthroplasty Registry. Kaplan-Meier estimates for implant survival were calculated. ResultsA total of 256 arthroplasties in 224 patients were included (mean age: 69 years ± 9 years, 149 females). 81% of cases were graded radiographically as severe osteoarthritis, according to Samilson-Prieto. Walch type B1 was most commonly followed by B2 (29% and 28% respectively). The mean follow-up time was 49 months (range 24-127). The response rate for patient reported outcomes was 91%. The median WOOS index was 94% (81%-99%), the median EQ-5D-5L was 0.87 (0.69-0.95), and the mean Constant-Murley score was 75 (SD 17.7). 13 cases (6%) had a WOOS index below 50%. 8.2% had complications related to surgery. A radiolucent line had developed around the central post in six cases and at the bone-cement interface in three cases at follow-up. Six cases had been revised (2.3%); three due to aseptic loosening of the glenoid. The 10-year survival estimate was 95.6 % (95% CI: 87.9%-98.5%). ConclusionAnatomic total shoulder arthroplasty with hybrid glenoid fixation provides excellent clinical outcome with a low complication rate in patients, with primary glenohumeral osteoarthritis. The 10-year survival rate is high and comparable to that reported for the best- performing all-polyethylene components. Longer observation is needed to see if hybrid fixation will outperform standard all-cemented components.

Pharmacologic interventions for primary glenohumeral osteoarthritis.

Primary glenohumeral osteoarthritis is a multifactorial condition with a complex cause that affects patients across different age groups, impairing physiologic and psychologic well-being, and substantially reducing patient quality of life and overall productivity. To effectively manage this condition, healthcare providers need to be well informed about treatment guidelines, as well as the available therapeutic options and the evidence supporting their use. Nonsurgical interventions should be regarded as the primary treatment option, particularly for patients in the initial phases of this condition. No conclusive guidelines exist for treating young and active patients, and the literature lacks high-quality data to evaluate the efficacy, safety, and long-term consequences of several interventions, regardless of patient characteristics and expectations.

Effect of glenosphere diameter and lateralization in primary reverse shoulder arthroplasty: a randomized clinical trial

BackgroundWithin reverse total shoulder arthroplasty (RSA), prior studies have suggested that smaller glenosphere diameters may result in higher rates of scapular notching and polyethylene wear, while lateralized glenospheres may allow for better range of motion (ROM); however, supportive data remains limited. Therefore, the purpose of this study was to report the outcomes of a prospective randomized clinical trial comparing 4 different glenosphere configurations based on diameter and lateral offset. MethodsBetween 2016 and 2020, 113 primary RSAs with a diagnosis of either rotator cuff tear arthropathy (n = 48, 42%), irreparable rotator cuff tears (n = 22, 19%), or primary glenohumeral osteoarthritis with subluxation or glenoid bone loss (n = 43, 38%) were enrolled into a blinded prospective randomized clinical trial. The mean age of the patients included in the study was 73 ± 7 (range, 50-89) years, and 58 (51.3%) were males. All procedures were performed by two surgeons utilizing the ReUnion RSA system (Stryker, Mahwah, NJ, USA). Patients were randomized into four possible groups based on the diameter and lateral offset of the glenosphere implanted: 36 mm diameter with 2 mm (n = 34, 30.1%) or 6 mm (n = 28, 24.8%) of lateralization and 40 mm diameter with 2 mm (n = 29, 25.7%) or 6 mm (n = 22, 19.5%) of lateralization. Outcomes collected included pain, active ROM, strength, satisfaction, patient-reported outcome measures (PROMs), complications, reoperations, and revisions. PROMs included the Oxford Shoulder Score, the American Shoulder and Elbow Surgeons, and the quick Disabilities of the Arm, Shoulder and Hand questionnaire. All patients were followed for a minimum of 2 years. ResultsWith the numbers available, glenosphere diameter and lateralization resulted in no differences in pain, ROM, strength, satisfaction, and PROMs at 1 year, 2 years, or final follow-up (All P > .05). However, all 3 complications (10.7% vs. 0% vs. 0% vs. 0%; P = .025) and 2 revision surgeries (7.1% vs. 0% vs. 0% vs. 0%; P = .103) occurred in males, with the 36 + 6 cohort. ConclusionsUsing this particular RSA design, implantation of glenospheres with 36 mm or 40 mm of diameter and 2 mm or 6 mm of sphere lateralization did not translate into significant differences when primary RSA was performed in shoulders with rotator cuff tear arthropathy, irreparable cuff tears, or primary glenohumeral osteoarthritis. However, all observed complications occurred in males with the smallest diameter and lateralized glenosphere.

Limited preoperative forward flexion does not impact outcomes between anatomic or reverse shoulder arthroplasty for primary glenohumeral arthritis

BackgroundAnatomic total shoulder arthroplasty (TSA) remains the treatment of choice for primary glenohumeral osteoarthritis with an intact rotator cuff (PGHOA). However, reverse total shoulder arthroplasty (RSA) has gained popularity as a primary procedure in selected patients who may be at risk for postoperative rotator cuff dysfunction or glenoid loosening. The purpose of this study was to compare short-term outcomes between TSA and RSA in patients with PGHOA and limited preoperative forward flexion (FF). MethodsA retrospective review was performed on a multi-institutional registry of patients to identify patients aged less than 80 years undergoing TSA or RSA for PGHOA with preoperative FF ≤ 90°. Forty-five TSAs were identified and matched by age and sex to 45 patients undergoing RSA. A subset of 22 TSAs and 24 RSAs with severely limited preoperative FF of ≤ 70° was also analyzed. Range of motion including FF, external rotation and internal rotation, strength, and patient-reported outcomes including visual analog scale pain score, Western Ontario Osteoarthritis of the Shoulder index score, Veterans RAND 12 mental score, American Shoulder and Elbow Surgeons score, and Constant-Murley score were evaluated at a minimum of 2 years postoperative. ResultsNo significant differences were observed in postoperative FF, external rotation, or strength measurements between groups. The limited FF TSA group achieved significantly improved internal rotation compared to the RSA group (L2 vs. L4, P < .002). No significant differences were observed between TSA and RSA in American Shoulder and Elbow Surgeons, visual analog scale, Constant, or Single Assessment Numeric Evaluation scores (P > .05) for both the overall comparison and subset of patients with FF of ≤ 70°. However, patients in the RSA cohort showed a significantly higher return to normal sporting activities than the TSA group. ConclusionPatients aged less than 80 years with PGHOA and limited preoperative FF achieve similar postoperative range of motion and patient-reported outcomes whether treated with TSA or RSA. Therefore, limited preoperative FF does not appear to be a major determinant of outcomes for PGHOA.

Total Shoulder Arthroplasty Versus Reverse Shoulder Arthroplasty in Primary Glenohumeral Osteoarthritis With Intact Rotator Cuffs: A Meta-Analyses.

Traditional practice favors total shoulder arthroplasty (TSA) for the treatment of primary glenohumeral osteoarthritis (PGHO) with an intact rotator cuff; however, the indications for reverse shoulder arthroplasty (RSA) have expanded to include PGHO. The purpose of this systematic review is to compare the mean differences in the range of motion and patient-reported outcomes between the TSA and RSA with an intact rotator cuff and to analyze the subgroup of the Walch type B2 glenoid. This IRB-exempt, PROSPERO-registered systematic review strictly followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) guidelines. A literature search of five databases revealed 493 articles, of which 10 were included for quantitative synthesis. Level III evidence studies with the diagnosis of PGHO and ≥2 years of follow-up were included. Studies without preoperative and postoperative data were excluded. The Newcastle-Ottawa scale was used to evaluate the methodologic quality of the included studies. Preoperative and postoperative range of motion and patient-reported outcomes were collected. The random-effects model was employed, and p < 0.05 was considered statistically significant. There were a total of 544 and 329 studies in the TSA group and RSA group, respectively. The mean age in the TSA group and RSA groups were 65.36 ± 7.06 and 73.12 ± 2.40, respectively (p = 0.008). The percentages of males in the TSA and RSA groups were 73.2% and 51.1%, respectively (p = 0.02). The mean differences in forward elevation, external rotation in adduction, internal rotation scale, visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and Single AssessmentNumericEvaluation (SANE) scores were improved for both groups with no significant differences between the two. There were 9.6 times the revisions in the TSA group (8.8% vs. 0.91%; p = 0.014) and 1.5 times the complications in the TSA group (3.68% vs. 2.4%; p = 0.0096). Two hundred and forty-two glenoids were identified as Walch type B2 (126 in the TSA groupand 116 in the RSA group). The mean ages in the B2 subgroup were 68.20 ± 3.25 and 73.03 ± 1.49 for the TSA and RSA, respectively (p = 0.25). The percentages of males in the B2 subgroup were 74.6% and 46.5% for the TSA and RSA groups, respectively (p = 0.0003). The ASES, SANE, forward elevation, and external rotation in the adduction results were descriptively summarized for this subgroup, with average mean differences of 49.0 and 51.2, 45.7 and 66.1, 77.6° and 58.6°, and 38.6° and 34.1° for the TSA and RSA groups, respectively. In the setting of primary glenohumeral osteoarthritis with an intact rotator cuff, the RSA has a similar range of motion and clinical outcomesbut lower complication and revision rates as compared to the TSA. This may hold true in the setting of the B2 glenoid, although a high-powered study on this subgroup is required. Anatomic shoulder arthroplasty maintains an important role in select patients. Further studies are required to better elucidate the role of glenoid bone loss and posterior humeral head subluxation with regard to implant choice.

Three-dimensional scapular orientation: a comparison of glenohumeral osteoarthritis and cuff tear arthropathy to the unaffected shoulder

BackgroundScapular orientation may play an important role in preoperative planning for shoulder arthroplasty; however, there is currently no defined method for producing standardized three-dimensional measurements. The purpose of this study is to develop a reproducible measurement system of scapular orientation and to evaluate differences between unaffected shoulders and those with diagnoses of primary glenohumeral osteoarthritis (GHOA) and rotator cuff tear arthropathy (CTA). MethodsPatients receiving computed tomography scans for preoperative shoulder arthroplasty planning were enrolled prospectively. Thin sliced axial images that included bilateral shoulders and the thorax were reformatted. The pathology of the bilateral glenohumeral joints was defined as GHOA, CTA, or unaffected. Scapular orientation was defined relative to the thorax using three-dimensional models to define the protraction, rotation, and tilt angles in the supine position. Univariate analysis was performed to compare demographics and scapular measurements between patients with GHOA, CTA, and unaffected shoulder pathology. Multivariate linear regression analysis was performed to identify independent predictors of scapular orientation. ResultsOne hundred fifty-eight shoulders, comprising 79 patients were included. Twenty-seven percent (n = 21/79) of patients had an unaffected contralateral shoulder. Shoulders with GHOA had significantly greater downward scapular rotation (-14 ± 7 degrees) than both unaffected shoulders (-8 ± 7 degrees; P < .001) and those with CTA (-7 ± 8 degrees; P < .001). Increased downward scapular rotation was predicted by a shoulder pathology of GHOA in multivariate analysis (beta -7.09; P < .001). The magnitude of side-to-side difference was greatest in scapular rotation for patients with GHOA compared to CTA, with no significant differences in tilt or protraction. ConclusionScapular rotation in the supine position varies by shoulder pathology, with greater downward rotation seen in patients with primary GHOA. These findings underscore the need for awareness of scapular orientation in addition to glenoid morphology when evaluating and planning shoulder arthroplasty cases.

How anatomic should anatomic total shoulder arthroplasty be? Evaluation of humeral head reconstruction with the best-fit circle

IntroductionHumeral implant designs for anatomic total shoulder arthroplasty (aTSA) focus on anatomic reconstruction of the articular segment. Likewise, the pathoanatomy of advanced glenohumeral osteoarthritis (GHOA) often results in humeral head deformity. We hypothesized the anatomic reconstruction of the humeral head in aTSA risks overstuffing the glenohumeral joint. Methods97 cases (52 females) of primary GHOA in patients treated with aTSA were evaluated. Preoperative computed tomography (CT) scans were used to classify glenoid morphology according to the Walch classification. Coronal plane images in the plane of the humerus were used to determine the anatomic perfect circle as described by Youderian et al. Humeral head thinning was determined as the distance from the center of rotation (COR) of the perfect circle to the nearest point along the humeral articular surface. aTSA was modeled with a predicted anatomic humeral head and a simulated 4 mm polyethylene glenoid component. The change in the position of the native humerus was determined. Wilcoxon Rank Sum tests were used to evaluate differences in humeral head thinning and humeral lateralization between monoconcave and biconcave glenoid morphologies. Spearman’s rank correlation coefficients were used to assess the relationship between humeral head thinning with preoperative active forward elevation and external rotation. ResultsThe mean radius of the perfect circle was 25.0±2.1 mm. There was a mean thinning of 2.4±2.0 mm (Range -1.7–8.3). Mean percent thinning of the humeral head was 9.4%±7.7%. The mean humeral lateralization was 6.4±2.0 mm. Humeral head thinning was not significantly associated with active forward elevation (r=-0.15, p=0.14) or active external rotation (r= -0.12, p=0.25). There were no significant differences in the percentage of humeral head thinning (p=0.324) or humeral lateralization (p=0.350) between concentric and eccentric glenoid wear patterns ConclusionsUtilization of the perfect circle as a guide in aTSA may risk excessive lateralization of the humerus and overstuffing the glenohumeral joint. This may have implications for subscapularis repair and healing, as well as glenoid implant and rotator cuff longevity. These findings call into question whether recreation of normal glenohumeral anatomy in aTSA is appropriate for all patients. Humeral head reconstruction in aTSA should account for glenohumeral joint volume and soft tissue contracture.

Is preoperative 3D planning reliable for predicting postoperative clinical differences in range of motion between two stem designs in reverse shoulder arthroplasty

Primary gleno-humeral osteoarthritis is associated with both excessive posterior humeral subluxation (PHS) and excessive glenoid retroversion in 40% of cases. These morphometric abnormalities are a particular issue since they may be responsible for a deterioration in long term clinical and radiological outcomes. The aim of this study was to perform a CT-analysis of patients who underwent Total Shoulder Arthroplasty (TSA) for primary osteoarthritis (OA) with B2-, B3- or C-type glenoids in whom an attempt was made to correct for excessive glenoid retroversion and excessive posterior humeral subluxation intraoperatively. We performed a retrospective, single-center study including 62 TSA patients with a pre-operative PHS of the glenohumeral joint (31 men, 31 women, 70±9 years) between January 2000 and January 2014. Glenoids were classified as B2 (32 cases), B3 (13 cases) or C (17 cases). Glenoid retroversion was corrected by anterior asymmetric reaming. Patients were reviewed for clinical and CT-scan assessment with a mean follow-up of 8.3 years (minimum 5 years). At final follow-up the CT-images were reconstructed in a scapular plan. A PHS index of >65% defined persistence. The revision free rate was estimated at 93%. Correlation between PHS and retroversion was moderate preoperatively (ρ=0.58) and strong at final follow-up (ρ=0.73). Postoperative CT-scans on average showed a surgical correction of PHS compared to preoperatively (79% vs 65% respectively, p<0.05) and retroversion (20° vs 10° respectively, p<0.05). At final follow-up, 25/62 patients had a persistence in 2D model and 41/62 in 2D corrected model. Persistence of PHS had no influence on clinical outcomes but did demonstrate a significantly higher glenoid loosening rate (20% vs 59%, p<0.05). Correlation between PHS and retroversion was moderate preoperatively and strengthened at long-term follow up. Anterior asymmetric reaming allowed for a surgical improvement of both PHS and retroversion, but it was not sufficient to maintain a correction over time. Glenoid loosening was more frequent in case of PHS persistence but seemingly without clinical relevance.

Total shoulder arthroplasty for primary glenohumeral osteoarthritis: does posterior humeral subluxation persist after correction of the glenoid version at 5 years minimum?

Primary glenohumeral osteoarthritis is associated with both excessive posterior humeral subluxation (PHS) and excessive glenoid retroversion in 40% of cases. These morphometric abnormalities are a particular issue because they may be responsible for a deterioration in long-term clinical and radiologic outcomes. The aim of this study was to perform a computed tomographic (CT) analysis of patients who underwent total shoulder arthroplasty (TSA) for primary osteoarthritis (OA) with B2-, B3-, or C-type glenoids in whom an attempt was made to correct for excessive glenoid retroversion and excessive posterior humeral subluxation intraoperatively. We performed a retrospective, single-center study including 62 TSA patients with a preoperative PHS of the glenohumeral joint (31 men, 31 women, 70±9 years) between January 2000 and January 2014. Glenoids were classified as B2 (32 cases), B3 (13 cases), or C (17 cases). Glenoid retroversion was corrected by anterior asymmetric reaming. Patients were reviewed for clinical and CT scan assessment with a mean follow-up of 8.3 years (minimum 5 years). At final follow-up, the CT images were reconstructed in the scapular plane. A PHS index >65% defined persistence. The revision-free rate was estimated at 93%. Correlation between PHS and retroversion was moderate preoperatively (ρ=0.58) and strong at final follow-up (ρ=0.73). Postoperative CT scans on average showed a surgical correction of PHS compared to preoperatively (79% vs. 65% respectively, P<.05) and retroversion (20° vs. 10° respectively, P<.05). At final follow-up, 25 of 62 patients had a persistence in the 2-dimensional (2D) model and 41 of 62 in the corrected 2D model. Persistence of PHS had no influence on clinical outcomes but did demonstrate a significantly higher glenoid loosening rate (20% vs. 59%, P<.05). Correlation between PHS and retroversion was moderate preoperatively and strengthened at long-term follow-up. Anterior asymmetric reaming allowed for a surgical improvement of both PHS and retroversion, but it was not sufficient to maintain a correction over time. Glenoid loosening was more frequent in case of PHS persistence but seemingly without clinical relevance.

External Rotation Strength After TSA in Osteoarthritic Shoulders with Eccentric Deformity Is Not Impacted by Posterior Rotator Cuff Deficiency.

Patients with persistent glenohumeral osteoarthritis symptoms despite nonoperative management may pursue anatomic total shoulder arthroplasty (TSA). TSA revision rates are higher in patients with preoperative eccentric (asymmetric posterior erosion) compared with concentric (symmetric) glenoid deformity. If posterior rotator cuff deficiency demonstrated preoperatively in patients with eccentric deformity persists after TSA, it may manifest as relative weakness in external compared with internal rotation secondary to deficient activity of the shoulder external rotator muscles. Persistent posterior rotator cuff deficiency is hypothesized to contribute to TSA failures. However, it remains unknown whether rotational strength is impaired after TSA in patients with eccentric deformity. Our goal was to determine if patients with eccentric deformity exhibit relative external rotation weakness that may be explained by posterior rotator cuff deficiency after TSA. Patients who were >1 year after TSA for primary glenohumeral osteoarthritis and had had preoperative eccentric or concentric deformity were prospectively recruited. Torque was measured and electromyography was performed during maximal isometric contractions in 26 three-dimensional direction combinations. Relative strength in opposing directions (strength balance) and muscle activity of 6 shoulder rotators were compared between groups. The internal (+) and external (-) rotation component of strength balance did not differ in patients with eccentric (mean internal-external rotation component of strength balance: -7.6% ± 7.4%) compared with concentric deformity (-10.3% ± 6.8%) (mean difference: 2.7% [95% confidence interval (CI), -1.3% to 6.7%]; p = 0.59), suggesting no relative external rotation weakness. Infraspinatus activity was reduced in patients with eccentric (43.9% ± 10.4% of maximum voluntary contraction [MVC]) compared with concentric (51.3% ± 10.4% of MVC) deformity (mean difference: -7.4% [95% CI, -13.4% to -1.4%] of MVC; p = 0.04). A relative external rotation strength deficit following TSA was not found, despite evidence of reduced infraspinatus activity, in the eccentric-deformity group. Reduced infraspinatus activity suggests that posterior rotator cuff deficiencies may persist following TSA in patients with eccentric deformities. Longitudinal study is necessary to evaluate muscle imbalance as a contributor to higher TSA failure rates. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

EPIDEMIOLOGICAL DATA REVIEW OF PRIMARY REVERSE TOTAL SHOULDER ARTHROPLASTY AT A SINGLE TERTIARY ACADEMIC HOSPITAL IN SOUTH AFRICA: A FOUR-YEAR RETROSPECTIVE REVIEW

Reverse Total shoulder arthroplasty (RTSA) was initially introduced to treat rotator cuff arthropathy. With proven successful long-term outcomes, it has gained a noteworthy surge in popularity with its indications consequently being extended to treating various traumatic glenohumeral diseases.Several countries holding national registries remain a guide to the use the prosthesis, however a notable lack of epidemiological data still exists. More so in South Africa where the spectrum of joint disease related to communicable diseases such as HIV and tuberculosis may influence indications and patient demographics. By analysing the epidemiology of patients who underwent RTSA at our institution, we aimed to outline the local disease spectrum, the patients afflicted and indications for surgery.A retrospective review of all patients operated within the sports unit between 1 January 2019 and 31 December 2022 was conducted. An analysis of the epidemiological data pertaining to patient demographics, diagnosis, indications for surgery and complications were recorded.Included in the review were 58 patients who underwent primary RTSA over the 4-year period. There were 41 females and 17 male patients, age &lt;55 years (n= 14) &gt;55 years (n=44). The indications included 23 rotator cuff arthropathy (40%), 12 primary glenohumeral osteoarthritis (OA) (20%), 10 avascular necrosis (AVN) humeral head (17%), 7 inflammatory OA (12%), 4 chronic shoulder dislocation (7%) and 2 sequalae of proximal humerus fractures (4%).The study revealed RTSA being performed in patients older than 55 years of age, the main pathologies included rotator cuff arthropathy and primary OA, however AVN and shoulder dislocations secondary to trauma contributed significantly to the total tally of surgeries undertaken. This highlights the disease burden of developing countries contributing to patients presenting for RTSA

Incongruity of the scapulohumeral arch: an indirect sign of posterior subluxation of the humeral head in primary glenohumeral osteoarthritis.

In symptomatic glenohumeral osteoarthritis, arthroplasty is the gold standard to restore a mobile and painless shoulder. The kind of arthroplasty chosen is based mainly on the evaluation of the rotator cuff and the type of glenoid. The aim of this study was to analyze the scapulohumeral arch in primary glenohumeral osteoarthritis (PGHOA) with a non-injured cuff and to determine whether posterior humeral subluxation influences Moloney's line, which corresponds to an intact scapulohumeral arch. Between 2017 and 2020, 58 anatomic total shoulder arthroplasties were implanted in the same center. We included all patients with complete preoperative imaging (X-rays and MRI or arthro-CT scan) assessing an intact rotator cuff. A total of 55 shoulders that had undergone surgery for a total anatomical shoulder prosthesis were analyzed after determining the type of glenoid in the frontal plane according to the Favard classification on an anteroposterior X-ray and in the axial plane according to the Walch classification on CT scan. The grade of osteoarthritis was evaluated according to Samilson. We analyzed whether there was a rupture of Moloney's line on the frontal radiograph and assessed the acromiohumeral distance. After preoperative analysis of 55 shoulders, 24 shoulders had a type A glenoid and 31 a type B glenoid. Twenty-two shoulders had a scapulohumeral arch rupture and 31 had a posterior subluxation of the humeral head: 25 shoulders had a type B1 glenoid and 6 had a type B2 glenoid according to the Walch classification. Most glenoids were E0 (n=47, 85%). The incongruity of Moloney's line was more frequent with type B than A glenoids (20/31, 65%, vs 2/24, 8%, p<0.001). No patient (0/15) with a type A1 glenoid had rupture of Moloney's line, and only two patients (2/9) with a type A2 glenoid had incongruency of the scapulohumeral arch. In PGHOA, the rupture of the scapulohumeral arch seen in anteroposterior X-rays, also known as Moloney's line, may be an indirect sign of posterior humeral subluxation, corresponding to a type B glenoid in the Walch classification. Incongruity of Moloney's line may indicate a rotator cuff injury or posterior glenohumeral subluxation with an intact cuff in PGHOA.

Glenoid-based reference system to differentiate shoulder pathologies on plain radiographs

Shoulder radiographs are utilized for evaluation and the planning of treatment of various pathologies. Making a diagnosis of these pathologies on plain radiographs occurs by recognizing the relationship of the humeral head on the registry of the glenoid. Quantification of these changes in registry does not currently exist. We hypothesize that a geometric relationship of the humeral head and the glenoid exists that is defined on an anteroposterior Grashey view radiograph by the relationship of the best-fit circle of the humeral head relative to the best-fit circle of the glenoid such that relative measurements will define the normal shoulder and the pathologic shoulder. One hundred fifty-six shoulders were included: 53 normal shoulders, 51 with primary glenohumeral osteoarthritis (GHOA), and 52 with cuff-tear arthropathy (CTA). Humeral head best-fit circle was utilized to define the Circle of the Humeral Head (cHH). A glenoid best-fit circle (cG) was defined by the following rules: (1) best-fit of the glenoid articular surface, (2) defined by the acromion such that it either (a) reaches maximal interaction with the inferior surface of the acromion, or (b) the perimeter of the circle is at the lateral-most point of the acromion. The relationship between cHH and cG is defined by measurement of cHH in horizontal and vertical planes relative to the glenoid circle reference. The Horizontal Displacement Angle (HDA) measures the horizontal position of cHH relative to cG, representing degree of medialization towards the glenoid. The Vertical Displacement Angle (VDA) measures the vertical position of cHH relative to cG, representing degree of superiorization towards the acromion. Angles were compared by diagnosis and sex. The average HDA was 61.0 (60.3-61.7, 95% CI) degrees in normal shoulders, 79.9 (76.9-82.9, 95% CI) degrees in GHOA, and 63.4 (61.7-65.1, 95% CI) degree in CTA (p < 0.001). The average VDA was 43.1 (42.2-44.0, 95% CI) degrees in normal shoulders, 40.9 (39.9-42.0, 95% CI) degrees in GHOA, and 59.7 (57.6-61.7, 95% CI) degrees in CTA (p < 0.001). Interobserver reliability was 0.991 (0.94-1.0, 95% CI) and intraobserver reliability was 0.998 (0.99-1.0, 95% CI). The geometric relationship of cHH to the Glenoid Circle reference was plotted for each group. A geometric relationship exists of the humeral head in reference to the glenoid circle. Together, the Horizontal Displacement Angle and the Vertical Displacement Angle distinguish between a normal shoulder, GHOA, and CTA. This suggests that this novel methodology may provide a preoperative planning tool that is easily accessible.

Minimum 10-year follow-up of anatomic total shoulder arthroplasty and ream-and-run arthroplasty for primary glenohumeral osteoarthritis

Reports on long term outcomes and failures of shoulder arthroplasty are uncommon. The purpose of this study is to present minimum 10-year outcomes in consecutive patients undergoing ream-and-run and anatomic total shoulder arthroplasty (TSA) for primary glenohumeral arthritis. This study analyzed consecutive patients that had undergone a ream-and-run or TSA with minimum 10-year follow-up. Pain scores and Simple Shoulder Test (SST) values were obtained preoperatively and at a minimum of 10 years postoperatively via e-mail or mail-in response. Percentage of maximum possible improvement (%MPI) was also calculated. Of 127 eligible patients, 63 (50%) responded to a 10-year survey. This included 34 patients undergoing ream-and-run arthroplasty and 29 patients undergoing TSA. The ream-and-run patients were significantly younger than the TSA patients (60 ± 7 vs 68 ± 8, p<0.001), predominantly male (97% vs 41%, p<0.001), and had a lower American Society of Anesthesiologists classification (p=0.018). In the ream-and run group, the mean pain score improved from a preoperative value of 6.5 ± 1.9 to 0.9 ± 1.3 (p < 0.001), and the mean SST score improved from 5.4 ± 2.4 to 10.3 ± 2.1 at 10-year follow-up (p < 0.001). Twenty-eight (82%) achieved an SST improvement above the MCID of 2.6. Four patients (12%) underwent single-stage exchange to another hemiarthroplasty, while 1 (3%) required manipulation under anesthesia. In the TSA group, the pain score improved from a preoperative value of 6.6 ± 2.2 to 1.2 ± 2.3 (p < 0.001), and the SST score improved from 3.8 ± 2.6 to 8.9 ± 2.6 at 10-year follow-up. (p < 0.001). Of the 29 patients who underwent a TSA, 27 (93%) achieved an SST improvement above the MCID of 1.6. No patient in the TSA group required reoperation. While the characteristics of the patients differ between the two groups, excellent functional results can be obtained with the ream-and-run arthroplasty and total shoulder arthroplasty for glenohumeral osteoarthritis.

Reverse shoulder arthroplasty for primary glenohumeral osteoarthritis: significantly different characteristics and outcomes in shoulders with intact vs. torn rotator cuff

To compare outcomes of reverse shoulder arthroplasty (RSA) for primary osteoarthritis (OA) with and without rotator cuff (RC) tears to those with secondary OA due to RC tears. We reviewed records of all patients who received RSA for primary OA or secondary OA. All patients had preoperative radiographs, computed tomographic arthrography (CTA), and/or magnetic resonance imaging (MRI) scans of their shoulders to assess their etiology, glenoid morphology, and fatty infiltration. Pre- and postoperative (at minimum follow-up of 2 years) Constant scores and range of motion were compared between patients who had RSA for primary OA with and without RC tears to those with secondary OA due to RC tears. Of the initial cohort of 605 shoulders (583 patients), 153 were lost to follow-up (25.3%), 25 required revision with implant removal (4.1%), and 13 died of causes unrelated to the surgery (2.1%), and left a final cohort of 414 patients. Of the final cohort, 97 had primary OA with intact RC, 62 had primary OA with RC tears, and 255 had secondary OA. Postoperative Constant scores were significantly higher for primary OA with intact RC (73.8±14.3), compared with both primary OA with RC tears (66.1±14.6, P<.001) and secondary OA (64.1±14.8, P<.001). There were no differences in pre- or postoperative scores between primary OA with RC tears and secondary OA. At 2 or more years following RSA, Constant scores were significantly higher for primary OA with intact RC, compared to either primary OA with RC tears or secondary OA, whereas there were no differences in pre- or postoperative scores of shoulders that had primary OA with RC tears vs. secondary OA. The authors recommend distinguishing primary OA with intact RC from primary OA with RC tears, as the two have considerably different characteristics and prognosis following RSA.