Arthritis Of Shoulder Research Articles

Early Follow-up of Reverse Total Shoulder Arthroplasty in Patients Sixty Years of Age or Younger

Reverse shoulder arthroplasty (RSA) is an accepted treatment that provides reproducible results in the treatment of shoulder arthritis and rotator cuff deficiency. Concerns over the longevity of the prosthesis have resulted in this procedure being reserved for the elderly. There are limited data in the literature with regard to outcomes in younger patients. We report on the early outcomes of RSA in a group of patients who were sixty years or younger and who were followed for a minimum of two years. A retrospective multicenter review of sixty-six patients (sixty-seven RSAs) with a mean age of 52.2 years was performed. The indications included rotator cuff insufficiency (twenty-nine), massive rotator cuff disorder with osteoarthritis (eleven), failed primary shoulder arthroplasty (nine), rheumatoid arthritis (six), posttraumatic arthritis (four), and other diagnoses (eight). Forty-five shoulders (67%) had at least one prior surgical intervention, and thirty-one shoulders (46%) had multiple prior surgical procedures. At a mean follow-up time of 36.5 months, mean active forward elevation of the arm as measured at the shoulder improved from 54.6° to 134.0° and average active external rotation improved from 10.0° to 19.6°. A total of 81% of patients were either very satisfied or satisfied. The mean American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) score for pain improved from 40.0 to 72.4 and 7.5 to 3.0, respectively. The ability to achieve postoperative forward arm elevation of at least 100° was the only significant predictor of overall patient satisfaction (p < 0.05) that was identified in this group. There was a 15% complication rate postoperatively, and twenty-nine shoulders (43%) had evidence of scapular notching at the time of the latest follow-up. RSA as a reconstructive procedure improved function at the time of short-term follow-up in our young patients with glenohumeral arthritis and rotator cuff deficiency. Objective outcomes in our patient cohort were similar to those in previously reported studies. However, overall satisfaction was much lower in this patient population (81%) compared with that in the older patient population as reported in the literature (90% to 96%).

Suprascapular Nerve Block for Shoulder Pain in the First Year After Stroke

Shoulder pain is a common complication after stroke that can impede participation in rehabilitation and has been associated with poorer outcomes. Evidence-based treatments for hemiplegic shoulder pain are limited. Suprascapular nerve block (SSNB) is a safe and effective treatment of shoulder pain associated with arthritic shoulder conditions, but its usefulness in a stroke population is unclear. We undertook a randomized controlled trial assessing the effectiveness of SSNB in a population of 64 stroke patients (onset < 1 year) with hemiplegic shoulder pain. The primary outcome was pain measured on a visual analogue scale (VAS). Secondary outcomes were disability (Modified Rankin Scale, Croft Disability Index) and quality of life (EuroQol Health Questionnaire). All participants were assessed before randomization, and at 1, 4, and 12 weeks postintervention. Both groups continued with routine therapy. Although both intervention and control groups demonstrated reduction in pain score, participants who received SSNB consistently demonstrated superior, statistically significant pain reduction compared with placebo. Mean VAS reduction in the SSNB group was >18 mm greater than participants receiving placebo injection. The number needed to treat with SSNB to reduce 1 stroke survivor's pain by 50% at 4 weeks is 4. No significant differences in function or quality of life were observed. No adverse events were reported. Suprascapular nerve block is a safe and effective treatment for patients with hemiplegic shoulder pain. http://www.anzctr.org.au. Unique identifier: ACTRN12609000621213.

Shoulder Arthritis Can Be Classified Radiographically and with Reliability No Matter Which System Is Used

Shoulder Arthritis Can Be Classified Radiographically and with Reliability No Matter Which System Is Used

Total shoulder arthroplasty versus hemiarthroplasty in patients with shoulder osteoarthritis: A meta-analysis of randomized controlled trials

ObjectivesTotal shoulder arthroplasty (TSA) and hemiarthroplasty (HA) are treatment choices for end-stage shoulder osteoarthritis. The decision of whether to use TSA or HA is controversial. The objective of this study was to compare the effects of TSA and HA for shoulder osteoarthritis. MethodsWe conducted a search for clinical studies that had been published in any language in December 2012 or before. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and several other databases. Randomized and quasi-randomized controlled clinical studies that evaluated different methods were included. At least two review authors independently performed the study selection, data collection, and data extraction. The software Revman 5.1 was used for the statistical analysis. ResultsThis study included 4 clinical trials. Two of the trials were published clinical trials, and the other 2 clinical trials were presented as unpublished abstracts. A total of 146 patients with 153 shoulders were included in the trials. Compared with HA, TSA presents with a higher UCLA shoulder scale (MD 3.10, 95% CI 1.13–5.08) and a higher ASES (MD 10.17, 95% CI 1.40–18.87). There was no significant difference between TSA and HA for revision (RR 0.35, 95% CI 0.10–1.19), WOOS (MD 9.10, 95% CI −2.72 to 20.92), and incidence of instability (RR 0.88, 95% CI 0.19–3.98). HA had a lower operation time (MD 39.00, 95% CI 17.05–60.95). ConclusionThe available evidence suggests that TSA is more effective than HA for patients with shoulder arthritis.

Is Premorbid Glenoid Anatomy Altered in Patients with Glenohumeral Osteoarthritis?

Restoration of native, premorbid glenoid anatomy may be a goal in component placement during total shoulder arthroplasty. However, if patients with unilateral glenohumeral osteoarthritis are predisposed to the development of arthritis owing to abnormal native glenoid anatomy, this recommendation may be inappropriate. The purpose of this study was to determine if patients with glenohumeral osteoarthritis have abnormal premorbid glenoid version or inclination, thereby predisposing them to subsequent glenoid disorders. We specifically tested whether: (1) premorbid glenoid version or inclination in the pathologic shoulder of patients with unilateral osteoarthritis, as determined by the glenoid vault model, is different from glenoid version or inclination in the contralateral nonpathologic shoulder of these patients; (2) there are differences between glenoid version or inclination in normal cadaver shoulders and the nonpathologic side of patients with unilateral osteoarthritis; and (3) there are differences between glenoid version or inclination in normal cadaver shoulders and the premorbid glenoid version and inclination in the pathologic shoulder of patients with unilateral osteoarthritis, as determined by the glenoid vault model. Bilateral CT scans were obtained in 27 patients with unilateral glenohumeral osteoarthritis. Thirty normal cadaver control shoulders also underwent CT scans. Premorbid glenoid version and inclination in the pathologic shoulder, as measured by the glenoid vault model, were compared with the contralateral nonpathologic shoulder and the normal cadaver control shoulders. Glenoid version and inclination of the normal shoulders were compared with the nonpathologic side from patients with unilateral osteoarthritis. Measurements were made by two different methods using three-dimensional surgical simulation software: (1) a direct measurement technique and (2) measurements derived from placement of a glenoid vault model. Mean differences in these parameters were compared between shoulder groups using paired and unpaired Student's t-tests. Premorbid glenoid version and inclination in the pathologic shoulder as measured by the vault model averaged -7° (SD, 5) and 10° (SD, 6), respectively, compared with -7° (SD, 5) and 12° (SD, 6) as directly measured on the nonpathologic side, and -7° (SD, 4) and 12° (SD, 5) as directly measured in the normal cadaver control shoulders. There were no differences in glenoid version or inclination between the normal shoulders and the nonpathologic side of patients with unilateral osteoarthritis or between these shoulders and the premorbid version and inclination of the arthritic shoulder as measured by the vault model. Patients with glenohumeral osteoarthritis do not appear to have abnormal premorbid glenoid retroversion or inclination. The glenoid vault model can be used to determine premorbid glenoid version and inclination. The glenoid vault model may be a clinically useful tool to estimate patient-specific premorbid glenoid anatomy, which may help in preoperative or intraoperative surgical planning for total shoulder arthroplasty.

Deep vein thrombosis in shoulder arthroplasty – a prospective study

BackgroundShoulder arthritis of varied aetiology is often disabling and patients seek treatment for pain relief and restricted movements. Though non operative measures in the form of analgesics, physiotherapy and joint injections offer satisfactory results in the early stages; operative treatment in the form of joint replacements becomes necessary in late and advanced stages. The above operations are being performed more frequently in the recent years across the National Health Service [NHS] in the UK with increasing success in specialised units and the outcome of the operation is often rewarding. In addition to the other complications, risks of Deep vein thrombosis [DVT] and pulmonary embolism [PE] exists. Available evidence suggests a low incidence but the true risk has only been partially addressed. The final decision to consider thromboprophylaxis rests with the operating surgeon. It is important to carefully balance the clinical decision of thromboprophylaxis and bleeding with wound complications, which add considerable morbidity and mortality. To define the risk of DVT in this subgroup of patients is the initial step to enable better use of resources and achieve cost effectiveness. This we believe will provide robust evidence to help formulate guidelines for thromboprophylaxis in shoulder arthroplasty.Methods/designThe aim will be to determine whether shoulder arthroplasties carry a risk of DVT. A cohort of 100 consecutive patients being considered for shoulder arthroplasty for degenerative arthritis, rotator cuff arthropathy, inflammatory arthropathy including rheumatoid arthritis will be prospectively included for the study. All eligible patients will be assessed clinically and screened for DVT in all 4 limbs both pre and postoperative with Doppler scans within a 6 week perioperative period. We aim to include the reasons for non inclusion of eligible patients and patient’s perspective of their general well being in relation to DVT.DiscussionWe present the risk of DVT associated with shoulder arthroplasties to establish a good quality evidence for thromboprophylaxis. The study is underway and we would further be able to define whether the general risk factors for DVT are relevant to shoulder replacements.

Osteomyelitis of scapula with secondary septic arthritis of shoulder joint in a six month old child.

We report a case of delayed diagnosis of osteomyelitis of the scapula extending to glenoid, with secondary septic arthritis of glenohumeral joint in a 6-month-old female infant. We performed urgent arthrotomy of the shoulder joint through an anterior approach with drainage of pus from the scapula through a posterior approach and prescribed intravenous antibiotics. Diagnosis was delayed as the patient initially presented with pneumonia, for which she was treated in the neonatal intensive care unit; at that time, all medical efforts were directed toward saving her life. Had the diagnosis been made earlier, septic arthritis of the shoulder might have been prevented. Diagnosis of septic shoulder arthritis is rare and difficult, requiring a high index of suspicion. septic arthritis, infection, scapular osteomyelitis.

Management of failed metal-backed glenoid component in patients with bilateral total shoulder arthroplasty

Total shoulder arthroplasty (TSA) is successful in providing pain relief and functional improvements for patients with shoulder arthritis. Outcomes are directly correlated with implant position and fixation, which ultimately affects wear and longevity. Metal-backed glenoid components were introduced as an alternative to the standard cemented glenoid fixation. Early loosening and cavitary glenoid bone loss has been reported as a major complication associated with these metal-backed glenoids, which presents the surgeon with a challenging revision situation. Furthermore, failure of bilateral TSA in patients with metal-backed glenoids is extremely rare. We present two patients with early failure of bilateral TSA secondary to loosening of the metal-backed glenoids. Both patients had significant glenoid bone loss and were treated with four different types of revision techniques. A description of treatments and outcomes of both patients are reported along with the simple shoulder test and American Shoulder and Elbow Surgeons scores. One patient underwent revision to bilateral reverse prosthesis and experienced a much-improved outcome in comparison to the patient revised to a hemiarthroplasty and resection arthroplasty, for each shoulder respectively. In patients who present with failed TSA, revision to a reverse prosthesis with or without staged glenoid bone graft should be considered as an option of treatment. It is also important to rule out infection with intraoperative tissue biopsy before proceeding to revision surgery. However, in patients with catastrophic glenoid bone loss, both hemiarthroplasty and resection arthroplasty can provide an alternative treatment option, but they are associated with a poorer functional outcome and pain relief.

Arthroscopic treatment of early glenohumeral arthritis

BackgroundThe articular cartilage of the shoulder is not endowed with intrinsic repair abilities, so the detection of chondral lesions during arthroscopy may indicate that additional articular procedures are needed. The aim of the current study was to evaluate the benefits of arthroscopy in patients with early shoulder arthritis, and to assess which clinical and radiological features are correlated with better arthroscopic outcomes.Materials and methodsOut of a total of 2,707 shoulders, 61 arthroscopies were performed on patients aged 30–55 years suffering from a painful early arthritic shoulder. We performed a retrospective study of 47 of those 61 patients with osteoarthritis at Samilson–Prieto stage I or II. SST and Constant score were used as outcome measures. Arthroscopic circumferential capsulotomy was performed to release the soft tissues and increase the joint space. Glenoid chondral lesions were caregorized according to location (anterior, posterior, centered) and size (small, large, total) and treated with microfractures; in the last 11 patients, we placed a engineered hyaluronic acid membrane, Hyalograft® C, on the surface of the glenoid. Postoperative care included mobilization the day after surgery, with the arm protected in a sling for two weeks. Follow-up examinations were performed at 3, 6, 12, and 24 months after surgery. The clinical and radiographic data collected were compared with those obtained at the last examination.ResultsThe mean Constant score increased from 43.8 points to 79.1, and the mean SST score increased from 4.9 points to 9.4 points. Clinical outcomes improved significantly in 44 patients (93.6 %). The three patients (6.4 %) with the lowest scores showed progression of arthritis. Age, gender, glenohumeral distance, and presence of engineered hyaluronic acid membrane were not related to clinical scores. Recovery of range of motion as well as small and centered cartilage lesions were statistically associated with improved outcome.ConclusionThe main finding was that soft tissue procedures (including capsulotomy and synovectomy) associated with glenoid microfractures are only suitable for patients with early arthritis and preserved humeral head shape, particularly in cases with small and centered glenoid cartilage lesions.

A Review of Shoulder Replacement Surgery

Shoulder replacement surgery is employed in the treatment of severe shoulder arthritis and following some proximal humeral fractures. Three different replacements are available: hemiarthroplasty (HAS), total shoulder replacement (TSR) and reverse shoulder replacement (RSR). HAS and TSR are indicated in patients with intact rotator cuffs and RSR for cuff deficient older patients. Outcomes are favourable, with the majority of patients having improvements in shoulder pain and function.

Propionibacterium acnes: an underestimated etiology in the pathogenesis of osteoarthritis?

Propionibacterium acnes is a common pathogen in infections after shoulder surgery. Recent reports found positive P acnes cultures in a high percentage of patients who had revision shoulder arthroplasty for "aseptic loosening" without any overt signs of infection. Isolation of P acnes is difficult, and by use of conventional microbiological protocols of 48-hour incubation, a considerable proportion of patients with possible P acnes infection may remain unidentified. We recently noted P acnes in shoulder joint cultures in patients undergoing primary shoulder replacement for glenohumeral arthropathy without any signs of infection. We collected aspirates and biopsy specimens from 55 consecutive patients with arthritic shoulders undergoing primary joint replacement and examined them for the presence of P acnes. Special measures were taken to ensure that the specimens were carefully taken from within the joint to reduce the risk of contamination to minimal. In 23 of 55 consecutive patients (41.8%) undergoing primary shoulder joint replacement, P acnes was found in the joint fluid and tissues taken before the insertion of the implants. All these patients were treated early postoperatively with pathogen-directed specific dual oral antibiotic treatment for 4 weeks. In none have any signs of infection developed. This finding of a high incidence of P acnes in joints before arthroplasty may suggest a role of P acnes in the pathogenesis of glenohumeral arthropathy. In addition, it raises the question of whether development of painful joint replacement later on and presumed aseptic loosening do, in fact, comprise an unrecognized low-grade infection that has been present since before the index operation.

An association between the inferior humeral head osteophyte and teres minor fatty infiltration: evidence for axillary nerve entrapment in glenohumeral osteoarthritis

Glenohumeral osteoarthritis often results in inferior humeral osteophytes. Anatomic studies suggest that the axillary neurovascular bundle is in close proximity to the glenohumeral capsule. We therefore hypothesize that an inferior humeral osteophyte of sufficient magnitude could encroach on the axillary nerve and result in measurable fatty infiltration of the teres minor muscle. Preoperative magnetic resonance imaging studies of 91 consecutive arthritic shoulders were retrospectively reviewed. Two cohorts were established based on the presence of a humeral osteophyte. The distances from the axillary neurovascular bundle to various osseous structures were measured using calibrated software. Objective quantitative measurements of the degree of fatty infiltration of the teres minor muscles were obtained with image analysis software. Results were compared between cohorts. The distance between the inferior humerus and axillary neurovascular bundle was inversely correlated to the size of the inferior humeral osteophyte (ρ = -0.631, P < .001). Fatty infiltration of the teres minor was greater when an inferior osteophyte was present (11.9%) than when an osteophyte was not present (4.4%) (P = .004). A statistically significant correlation between the size of the humeral head spur and quantity of fat in the teres minor muscle belly (ρ = 0.297, P = .005) was identified. These data are consistent with our hypothesis that the axillary nerve may be entrapped by the inferior humeral osteophyte often presenting with glenohumeral osteoarthritis. Entrapment may affect axillary nerve function and lead to changes in the teres minor muscle. Axillary neuropathy from an inferior humeral osteophyte may represent a contributing and treatable cause of pain in patients with glenohumeral osteoarthritis.

Reverse Shoulder Replacement for Patients With Inflammatory Arthritis

Patients with inflammatory arthritis frequently develop destructive shoulder arthritis and rotator cuff tearing. Reconstruction with anatomical shoulder replacement produces lesser results than for other etiologies such as osteoarthritis. We postulated that reconstruction with reverse shoulder prostheses would lead to early satisfactory results for these patients. We carried out a retrospective review of 19 shoulders treated with reverse shoulder prostheses at a mean follow-up of 37 months. We rated patients' pain using a visual analog pain scale (VAPS) and noted active range of motion in forward elevation, abduction, and external rotation. American Shoulder and Elbow Society and Simple Shoulder Test SST scores were available for 12 patients preoperatively and 16 postoperatively. We graded final results using the modified Neer scale. Preoperatively, the mean VAPS was 6.5, with average flexion of 68, abduction 66, and external rotation 23°. The American Shoulder and Elbow Society score averaged 27 and the SST 1. Postoperatively, the VAPS was 1 and flexion was 138°, abduction 134°, and external rotation 52°. The mean ASES score increased to 76 and the SST to 8. There were 12 excellent, 5 satisfactory, and 2 unsatisfactory results. Complications included 2 scapular spine fractures, 1 acromial fracture, 1 dislocation, and 1 ulnar neuropathy. We found scapular notching in 42% of the shoulders. Six shoulders had grade 1 notching, and 2 shoulders grade 2 notching. There was no evidence of glenoid loosening, but we saw complete bone-cement radiolucency around 2 cemented stems. At early follow-up, reverse shoulder arthroplasty for the shoulder damaged by inflammatory arthritis and with a deficient rotator cuff can provide noteworthy improvement for most patients.

Intraoperative Issues Dictated by Diagnosis: Cuff Deficiency: Allograft, Transfer, or Advance

A deficient rotator cuff in an arthritic shoulder is one of the most challenging problems that a surgeon faces in shoulder arthroplasty. Regardless of whether the cuff deficiency is identified preoperatively or intraoperatively, the reconstructive challenges—namely restoring static and dynamic balance to the shoulder, alleviating pain, and optimizing function—remain the same. The existing literature on the surgical treatment of this difficult problem has defined certain principles of management, but many questions remain. Patients with small rotator cuff tears can successfully undergo a total shoulder arthroplasty, provided a secure rotator cuff repair can be performed. Patients with larger irreparable tears should not undergo total shoulder arthroplasty, given a high rate of glenoid loosening. For patients with irreparable rotator cuff tears and glenohumeral arthropathy, the appropriate surgical procedure is indicated by age and functional level. Patients younger than 70 years old with preserved forward elevation >90° are best treated with humeral resurfacing arthroplasty; the role of tendon advancement in conjunction with humeral resurfacing is controversial. Patients older than 70 years old, with or without a pseudoparalytic shoulder, are best treated with reverse shoulder arthroplasty. Concomitant latissimus and teres major transfer with reverse shoulder arthroplasty may expand the indications for reverse shoulder arthroplasty in the future; however, caution must be exercised until more long-term outcome data are obtained. Given the dramatic failure of allograft augmentation in primary rotator cuff repair, there is little, if any, role for allograft augmentation in a cuff-deficient arthroplasty.

What is the current practice in Europe when difficult shoulder injuries are treated?

In this issue of the journal, a group of Italian researchers discusses the European orthopedic surgeon’s management of choice for several difficult clinical scenarios of shoulder pathologies [1]. They divided their survey into four scenarios; i.e., anterior shoulder dislocation, shoulder arthritis combined with rotator cuff tear, large rotator cuff tendon tears combined with major fatty infiltration of the infraspinatus muscle and instability of the long head of the biceps and finally adhesive capsulitis. It might be claimed that at least three out of four are difficult cases. Therefore, the answers are of great interest. The authors used an online Web-based questionnaire and it is obvious that a questionnaire of this kind has the potential to improve our knowledge about the current trends in modern technology and ultimately might be helpful in creating clinical guidelines on a large scale. The first scenario was related to anterior dislocation of the shoulder. Interestingly, more than 70 % of the orthopedic surgeons recommended arthroscopic Bankart reconstruction, approximately half as an acute procedure and the rest as a planned procedure. This is the case description: ‘‘21-year-old male, recreational soccer player, first-time shoulder dislocation, with a minimal Hill-Sachs lesion, and a Bankart lesion’’… Less than 30 % of the surgeons recommended non-surgical treatment, which is of interest. The question is whether we really know that an acute/ semi-acute surgical procedure is the correct way to approach this particular—and in fact very common— problem. There might be arguments for instance for a more conservative approach. Also interesting is the recommendation for a brace in internal or external rotation in almost 75 %. The second scenario is a 55-year-old female with painful shoulder arthritis, total supraspinatus tear and infraspinatus fatty infiltration. In this case, the majority of surgeons (more than 60 %) recommended surgical treatment, while less than 40 % would favor a conservative regimen. Supraspinatus tendon repair/reconstruction was recommended by 85 % of all surgeons, with or without biceps tenodesis/tenotomy. The question is whether we really know if biceps tenodesis/tenotomy is needed in a case like this? Again, the dominance of surgical approach is of great interest. Only few surgeons recommended either debridement or shoulder replacement (15 %) in this patient. The third scenario is a 65-year-old male manual worker,

Gastrointestinal Bleeding and Possible Hypothyroidism

An 88-year-old female, living independently in the community, developed duodenal and gastric ulcers from using overthe-counter naproxen sodium for pain related to a shoulder fracture and arthritis of the knees. She was hospitalized and received packed red blood cells and intravenous proton pump inhibitor therapy. During her hospitalization, she developed atrial fibrillation (AF). Warfarin was not prescribed for stroke prevention because of the gastrointestinal (GI) bleeding. The patient was initially placed on atenolol, and then amiodarone was added. After a two-week hospital stay she was discharged to a nursing facility to gain strength, further correct her anemia, and receive physical therapy for the shoulder and ambulation problems from arthritis of the knees. The amiodarone was continued in the nursing facility. After 15 days of amiodarone therapy (hospital and nursing facility), a laboratory report indicated an elevated thyroid-stimulating hormone level. Levothyroxine was prescribed. The patient was eventually discharged to an assisted living facility once her strength returned and her ambulation improved. GI bleeding with anemia and weakness from nonsteroidal anti-inflammatory drug use and changes in thyroid function with amiodarone therapy for AF will be discussed.

Revisited: Walch Classification of the Glenoid in Glenohumeral Osteoarthritis

Background Shoulder osteoarthritis is characterized by progressive wear of the joint. To grade the degree of joint deformity, the Walch classification of glenohumeral arthritis has been proposed. This classification is based on five categories (A1, A2, B1, B2, C), although its validity has been questioned. Methods The present study proposed a new classification in three categories and compared it in terms of inter- and intra-observer reliability with the complete Walch classification and regroup classification (A, B, C). Results One hundred and sixteen computed tomography scans of patients with shoulder arthritis were revised by three independent evaluators and were classified according to the three classifications. The kappa statistics were identical between the new classification and the complete Walch classification (0.87 and 0.874). The regroup Walch classification (A, B, C) demonstrated higher reliability (kappa = 0.92). Most of the disagreement between observers was observed between glenoid B1 and B2. Discussion We report the first study on the Walch classification to use a large number of patients and challenge its reliability. According to the results obtained, there is no advantage in changing the classification. Therefore, surgeons must be aware of higher risk of mistake for glenoid type B. The superiority of a classification in terms of the prediction of surgical decisions and outcome has to be determined.

Streptococcus agalactiaeSeptic Arthritis of the Shoulder and the Sacroiliac Joints: A Case Report

Invasive group beta-streptococcal arthritis is being increasingly diagnosed as suggested by recent data. We report a case of a middle-aged lady from Sri Lanka who developed septic arthritis of the right shoulder and the left sacroiliac joint as well as an iliopsoas collection caused by Streptococcus agalactiae shortly after labor at Hamad General Hospital in Doha, Qatar. We conclude that Streptococcus agalactiae septic arthritis is rare. It can present with invasive disease in adults. It usually targets older females and immuno compromised patients especially those with risk factors for bacteraemia. Therefore a high index of suspicion is needed. Shoulder and sacroiliac joint affection is not uncommon for unknown reasons. Utilizing imaging modalities such as ultrasonography and magnetic resonance imaging is helpful.

Glenoid morphology rather than version predicts humeral subluxation: a different perspective on the glenoid in total shoulder arthroplasty

Glenoid retroversion is thought be important in shoulder stability before and after shoulder arthroplasty; thus, many authors recommend glenoid reaming to correct retroversion and improve stability. Genetic analysis has revealed that glenoid vault and scapular development are controlled by different genes and environmental factors, resulting in diverse glenoid morphologies. We therefore analyzed the relative contribution of glenoid morphology and version to humeral head position. We obtained 121 shoulder computed tomography scans preoperatively for shoulder arthroplasty. Humeral subluxation and glenoid version were measured on the axial image at the middle of each glenoid. Glenoid morphology was characterized as biconcave, worn, displaced, dysplastic, angled, or neutral. The strength of the correlation between humeral subluxation, glenoid version, and glenoid morphology was analyzed. Glenoid version did not correlate with humeral subluxation. The highest frequency of posterior subluxation was noted in biconcave glenoids. Shoulders with other glenoid morphologies were more likely to have anterior or central positioning of the humerus. The mean subluxation ratio for biconcave glenoids was 0.56 and was significantly different from all other morphologies (P < .02). Even in the arthritic shoulder, glenoid orientation does not appear to explain the complex biomechanics of shoulder stability. The causes of humeral head subluxation before and after total shoulder arthroplasty are likely multifactorial and may include static and dynamic soft-tissue forces. The biconcave glenoid deserves more attention at surgery because of the high association with posterior subluxation.

Current practice in shoulder pathology: results of a web-based survey among a community of 1,084 orthopedic surgeons

The aim of this study was to report orthopedic surgeons' management of choice for difficult clinical scenarios of shoulder pathologies. A web questionnaire was developed including four clinical scenarios of shoulder pathologies. Subsequently, opinions were solicited from more than 1,000 members of an international association of surgeons specialized in sports traumatology and knee surgery (ESSKA). The response rate was 40% (412 questionnaires). For scenario 1, first anterior dislocation of the shoulder, the most indicated treatment for 71% of respondents was an arthroscopic Bankart repair (P < 0.001). For scenario 2, shoulder arthritis with concentric erosion and cuff tear, 38% chose a shoulder replacement, while 37% preferred a supraspinatus tendon repair in combination with long head of biceps (LHB) tenodesis or tenotomy. For scenario 3, large tendon tears with 70% fatty infiltration of the infraspinatus tendon and lateral LHB instability, 70% of surgeons considered that, among conservative treatments, hyaluronic acid injection was not an appropriate management. Arthroscopic rotator cuff repair, arthroscopic acromioplasty, and LHB tenotomy gained larger consensus (81, 80, and 79% of respondents, respectively). A double-row technique for rotator cuff repair was preferred to a single-row technique (P = 0.02). Scenario 4, adhesive capsulitis, split the respondents equally, with 51% in favor of a surgical approach and 49% in favor of a conservative approach (N.S.). On-line questionnaires have the potential to improve knowledge about current trends in clinical practice and can help orthopedic surgeons to develop guidelines. Cross-sectional; Level V (expert opinion).