Adam Rumian

Revision surgery of reverse shoulder arthroplasty

BACKGROUND There is limited knowledge regarding revision of reverse shoulder arthroplasty (RSA). This study assesses reasons for failure in RSA and evaluates the outcomes of revision RSA. MATERIALS AND METHODS Between 1997 and 2009, 37 patients with RSA had revision surgery. Clinical and radiologic examinations performed preoperatively and at 3 months, at 6 months, and then annually postoperatively were analyzed retrospectively. Patients were reviewed with a minimum 2-year follow-up. RESULTS The most common causes for RSA revision were prosthetic instability (48%); humeral loosening, derotation, or fracture (21%); and infection (19%). Only 2 patients (3%) had to be reoperated on for glenoid loosening. More than 1 re-intervention was performed in 11 patients (30%) because of recurrence of the same complication or appearance of a new complication. Underestimation of humeral shortening and excessive medialization were common causes of recurrent prosthetic instability. Proximal humeral bone loss was found to be a cause for humeral loosening or derotation. Previous surgery was found as a potential cause of low-grade infection. At a mean follow-up of 34 months, 32 patients (86%) had retained the RSA whereas 2 patients (6%) had undergone conversion to humeral hemiarthroplasty and 3 (8%) to a resection arthroplasty. The mean Constant score in patients who retained the RSA increased from 19 points before revision to 47 points at last follow-up (P < .001). CONCLUSIONS Even if revision may lead to several procedures in the same patient, preservation or replacement of the RSA is largely possible, allowing for a functional shoulder. Full-length scaled radiographs of both humeri are recommended to properly assess humeral shortening and excessive medialization before revision.

Increased vascularization during early healing after biologic augmentation in repair of chronic rotator cuff tears using autologous leukocyte- and platelet-rich fibrin (L-PRF): a prospective randomized controlled pilot trial

HYPOTHESIS We hypothesized that arthroscopic rotator cuff repairs using leukocyte- and platelet-rich fibrin (L-PRF) in a standardized, modified protocol is technically feasible and results in a higher vascularization response and watertight healing rate during early healing. METHODS Twenty patients with chronic rotator cuff tears were randomly assigned to 2 treatment groups. In the test group (N = 10), L-PRF was added in between the tendon and the bone during arthroscopic rotator cuff repair. The second group served as control (N = 10). They received the same arthroscopic treatment without the use of L-PRF. We used a double-row tension band technique. Clinical examinations including subjective shoulder value, visual analog scale, Constant, and Simple Shoulder Test scores and measurement of the vascularization with power Doppler ultrasonography were made at 6 and 12 weeks. RESULTS There have been no postoperative complications. At 6 and 12 weeks, there was no significant difference in the clinical scores between the test and the control groups. The mean vascularization index of the surgical tendon-to-bone insertions was always significantly higher in the L-PRF group than in the contralateral healthy shoulders at 6 and 12 weeks (P = .0001). Whereas the L-PRF group showed a higher vascularization compared with the control group at 6 weeks (P = .001), there was no difference after 12 weeks of follow-up (P = .889). Watertight healing was obtained in 89% of the repaired cuffs. DISCUSSION/CONCLUSIONS Arthroscopic rotator cuff repair with the application of L-PRF is technically feasible and yields higher early vascularization. Increased vascularization may potentially predispose to an increased and earlier cellular response and an increased healing rate.

Prognostic Factors and Limitations of Anatomic Shoulder Arthroplasty for the Treatment of Posttraumatic Cephalic Collapse or Necrosis (Type-1 Proximal Humeral Fracture Sequelae)

BACKGROUND The aim of this study was to evaluate the prognostic factors and limitations of anatomic unconstrained shoulder arthroplasty, performed without tuberosity osteotomy, for the treatment of secondary glenohumeral arthritis following posttraumatic cephalic collapse or necrosis of the humeral head, defined as type-1 fracture sequelae. METHODS Fifty-five patients with type-1 fracture sequelae treated with anatomic shoulder arthroplasty were included in this retrospective single-center cohort study. All anatomic humeral prostheses were implanted without performing a greater tuberosity osteotomy. Glenoid resurfacing was performed in forty-four patients (80%). Clinical and radiographic analysis was performed at a mean of fifty-two months (range, twenty-four to 180 months) postoperatively. RESULTS Four reoperations (7%) were performed, including two revisions in patients who required glenoid resurfacing because of glenoid erosion after hemiarthroplasty. At the time of the latest follow-up, 93% of patients were satisfied or very satisfied, and the mean Subjective Shoulder Value (SSV) was 81%. There were significant improvements in the mean Constant score (from 32 to 69 points), active anterior elevation (from 88° to 141°), external rotation (from 6° to 34°), and internal rotation (from the buttock to L3). Significantly poorer results were associated with proximal humeral deformity in varus and with fatty infiltration of the rotator cuff muscles. Patients with proximal humeral deformity, specifically varus or valgus malunion of the greater tuberosity, had a mean Constant score that was 10 points lower and active elevation that was almost 20° less than patients with no such deformity. The poorest results were observed in patients with varus malunion. CONCLUSIONS Our study confirmed that the outcomes of anatomic shoulder arthroplasty for the treatment of type-1 fracture sequelae are good and predictable when deformation of the proximal humerus is acceptable(i.e., when no greater tuberosity osteotomy is necessary). The results were negatively affected by proximal humeral varus deformity and by fatty infiltration of the rotator cuff on imaging studies. In such cases, reverse shoulder arthroplasty may be more appropriate, especially in elderly patients.

SECEC Research Grant 2008 II: Use of platelet- and leucocyte-rich fibrin (L-PRF) does not affect late rotator cuff tendon healing: a prospective randomized controlled study

BACKGROUND Because the retear rate after rotator cuff repairs remains high, methods to improve healing are very much needed. Platelet-rich concentrates have been shown to enhance tenocyte proliferation and promote extracellular matrix synthesis in vitro; however, their clinical benefit remains unclear. We hypothesized that arthroscopic rotator cuff repair with leucocyte- and platelet-rich fibrin (L-PRF) results in better clinical and radiographic outcome at 12 months of follow-up than without L-PRF. METHODS Thirty-five patients were randomized to receive arthroscopic rotator cuff repair with L-PRF locally applied to the repair site (L-PRF+ group, n = 17) or without L-PRF (L-PRF- group, n = 18). Preoperative and postoperative clinical evaluation included the Subjective Shoulder Value, visual analog score for pain, Simple Shoulder Test, and Constant-Murley score. The anatomic watertight healing, tendon thickness, and tendon quality was evaluated using magnetic resonance arthrography at 12 months of follow-up. RESULTS No complications were reported in either group. The mean Subjective Shoulder Value, Simple Shoulder Test, and Constant-Murley scores increased from preoperatively to postoperatively, showing no significant differences between the groups. Complete anatomic watertight healing was found in 11 of 17 in the L-PRF+ group and in 11 of 18 in the L-PRP- group (P = .73). The mean postoperative defect size (214 ± 130 mm(2) in the L-PRF+ group vs 161 ± 149 mm(2) in the L-PRF- group; P = .391) and the mean postoperative tendon quality according to Sugaya (L-PRF+ group: 3.0 ± 1.4, L-PRF- group: 3.0 ± 0.9) were similar in both groups at 12 months of follow-up. CONCLUSION Arthroscopic rotator cuff repair with application of L-PRF yields no beneficial effect in clinical outcome, anatomic healing rate, mean postoperative defect size, and tendon quality at 12 months of follow-up.