Alexandre Lädermann

Objective evaluation of lengthening in reverse shoulder arthroplasty

BACKGROUND Reverse shoulder arthroplasty requires a re-tensioning of the deltoid to obtain active elevation and implant stability. Currently, there is no objective and reliable technique described for the preoperative planning of reverse shoulder prosthesis or the postoperative evaluation of deltoid tension and arm lengthening. The purpose of this investigation was to outline a standardized technique for measuring deltoid length and to preoperatively plan a reverse shoulder arthroplasty, and to determine whether complications are related to inadequate deltoid lengthening. METHODS Fifty-eight patients were included in this radiographic review. Variations in humeral length, overall arm length, and the height of the subacromial space were evaluated before and after reverse shoulder arthroplasty. RESULTS The average postoperative lengthening of the humerus was 2 +/- 7 mm (range, -9-16, P = .243) and the arm was lengthened 23 +/- 12 mm (range, 1-47, P <.001). Measured preoperative and postoperative differences of the subacromial space were statistically significant when comparing the operated and contralateral arm (P < .0001). Lengthening was not correlated to sex (P = .242), acromial fractures, or neurological complications (P = .83). However, in cases of postoperative instability, both humeral and overall arm lengthening were statistically lower (P < .0001). CONCLUSION A technique to preoperatively plan adequate deltoid tensioning using radiographs of the contralateral arm is described. This technique is critical in challenging cases and postoperatively in cases of complication to assess the deltoid length. Subjective intraoperative criteria to evaluate deltoid tension should be replaced by objective measures to prevent insufficient or excessive deltoid tension. LEVEL OF EVIDENCE Level 3.

Prevalence of Neurologic Lesions After Total Shoulder Arthroplasty

BACKGROUND Clinically evident neurologic injury of the involved limb after total shoulder arthroplasty is not uncommon, but the subclinical prevalence is unknown. The purposes of this prospective study were to determine the subclinical prevalence of neurologic lesions after reverse shoulder arthroplasty and anatomic shoulder arthroplasty, and to evaluate the correlation of neurologic injury to postoperative lengthening of the arm. METHODS All patients undergoing either a reverse or an anatomic shoulder arthroplasty were included during the period studied. This study focused on the clinical, radiographic, and preoperative and postoperative electromyographic evaluation, with measurement of arm lengthening in patients who had reverse shoulder arthroplasty according to a previously validated protocol. RESULTS Between November 2007 and February 2009, forty-one patients (forty-two shoulders) underwent reverse shoulder arthroplasty (nineteen shoulders) or anatomic primary shoulder arthroplasty (twenty-three shoulders). The two groups were similar with respect to sex distribution, preoperative neurologic lesions, and Constant score. Electromyography performed at a mean of 3.6 weeks postoperatively in the reverse shoulder arthroplasty group showed subclinical electromyographic changes in nine shoulders, involving mainly the axillary nerve; eight resolved in less than six months. In the anatomic shoulder arthroplasty group, a brachial plexus lesion was evident in one shoulder. The prevalence of acute postoperative nerve injury was significantly more frequent in the reverse shoulder arthroplasty group (p = 0.002), with a 10.9 times higher risk (95% confidence interval, 1.5 to 78.5). Mean lengthening (and standard deviation) of the arm after reverse shoulder arthroplasty was 2.7 ± 1.8 cm (range, 0 to 5.9 cm) compared with the normal, contralateral side. CONCLUSIONS The occurrence of peripheral neurologic lesions following reverse shoulder arthroplasty is relatively common, but usually transient. Arm lengthening with a reverse shoulder arthroplasty may be responsible for these nerve injuries.

Long-Term Outcome of Arthroscopic Massive Rotator Cuff Repair: The Importance of Double-Row Fixation

PURPOSE The purpose of this study was to (1) evaluate the long-term functional outcome of arthroscopic rotator cuff repair of massive rotator cuff tears (RCTs) and (2) compare double-row (DR) and single-row (SR) repairs. METHODS This was a retrospective review of massive RCTs treated with an arthroscopic rotator cuff repair over an 8-year period. Minimum 5-year follow-up was available for 126 repairs at a mean of 99 months. Among 107 complete repairs, there were 62 SR and 45 DR repairs. Functional outcome was determined by University of California, Los Angeles (UCLA) and American Shoulder and Elbow Surgeons scores. A multivariate analysis was performed to examine the role of a DR repair. RESULTS For all repairs combined, improvements were observed in forward flexion (132° v 168°), pain (6.3 v 1.3), UCLA score (15.7 v 30.7), and American Shoulder and Elbow Surgeons score (41.7 v 85.7) (P < .001). A good or excellent outcome, obtained in 78% of cases, was associated with a complete repair (P = .035) and a DR repair (P = .008). When we excluded partial repairs, postoperative UCLA gain was greater after a DR repair (P = .007). Patients reported their shoulder as feeling closer to normal after a DR repair compared with an SR repair (93.5% v 84.4%, P = .006). A DR repair was 4.9 times more likely to lead to a good or excellent outcome (P = .021). CONCLUSIONS When a DR repair of a massive RCT is possible, on the basis of the ability to mobilize the tendons, a better long-term functional outcome can be expected compared with an SR repair. Given the known high risk of recurrence after repair of massive RCTs and the knowledge that functional outcome is related to recurrence, a DR repair of massive RCTs should be performed when there is sufficient tendon mobility.

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).

Do the indications, results, and complications of reverse shoulder arthroplasty change with surgeon's experience?

BACKGROUND The goal of this study was to compare 2 consecutive series of 240 reverse total shoulder arthroplasties (TSA) in order to evaluate if the increase in surgeon experience modified the indications, clinical and radiographic results, and rate of complications. MATERIAL AND METHODS Two hundred forty reverse TSA performed between July 2003 and March 2007 were clinically and radiographically evaluated by an independent examiner with a minimum follow-up of 2 years and compared with a previous published study (240 cases implanted by the same 2 surgeons between May 1995 and June 2003). RESULTS The main etiology remained cuff tear arthropathy with an increase noted between the 2 studies. The rate of revision arthroplasty as an etiology decreased from 22.5% to 9.1%. Conversely, the rate of rheumatoid arthritis increased from 0.4% to 6.3%. The average postoperative Constant score was significantly better than the first series (66.9 vs 59.7, P < .001). The postoperative complication rate decreased with increased experience (from 19% to 10.8%), with dislocations reducing (from 7% to 3.2%), and infections reducing (from 4% to 0.9%). However, the number of nerve palsies increased. The revision rate decreased from 7.5% to 5%. The rate of glenoid notching remained stable, but the severity of notching decreased. CONCLUSION Experience did not lead us to operate on younger patients, but significantly modified patient selection, results, and complications. Increased experience with the reverse shoulder arthroplasty did not reduce the rate of glenoid notching.

Acromioclavicular and coracoclavicular cerclage reconstruction for acute acromioclavicular joint dislocations

BACKGROUND Little information is available on the results of the different stabilization techniques described for treatment of acute acromioclavicular (AC) joint injuries. Additionally, no studies have analyzed isometric performance of the shoulder after AC stabilization. The objective of our study was to present functional outcome including isokinetic testing and radiographic evaluation of patients treated with stabilization of AC joint dislocations. PATIENTS AND METHODS Thirty-seven patients with acute type III to V AC joint disruption underwent open coracoclavicular (CC) and AC stabilization with nonabsorbable sutures. RESULTS The mean follow-up was 4.5 ± 2.5 years (range, 2-10.5). The mean Constant score (CS) was 96. There were 34 (91.9%) excellent results, 1 good (2.7%), 1 satisfactory (2.7%), and 1 fair (2.7%). The disabilities of the arm, shoulder, and hand (DASH) questionnaire revealed good overall subjective evaluation with a mean of 7 points. The mean visual analog scale (VAS) pain score was 0.8. Patients with a CC distance <5 mm, or an anterosuperior AC reduction less than 50%, showed significantly better results in CS and DASH score in comparison to patients with a subluxated AC joint (P < .005). Twenty-two patients agreed to undergo isokinetic evaluation. We were unable to demonstrate any clinically significant difference between the involved and the uninvolved side. DISCUSSION The described technique of cerclage augmentation offers an attractive alternative in AC joint stabilization, with good to excellent results. In comparison to other techniques, there were no complications related to any implants, no graft donor site morbidity, or need for implant removal.

Fatty infiltration of the supraspinatus: A reliability study

BACKGROUND The Goutallier classification of rotator cuff fatty infiltration is an accepted standard, yet no recommendations exist for which computed tomography plane is best to identify fatty infiltration of the supraspinatus. Our purpose was to determine the most reliable plane to evaluate supraspinatus fatty infiltration, assess reliability of the tangent sign, and to correlate fatty infiltration and muscle atrophy. METHODS Fatty infiltration in 87 computed tomography scans was reviewed by 3 shoulder surgeons using the 5-tiered Goutallier classification and a separate 3-grade scale. The supraspinatus muscle was evaluated in the axial, coronal, and sagittal plane. The tangent sign was used to assess muscle atrophy. RESULTS The axial plane produced the highest agreement for both the 5-tiered and 3-tiered systems. An objective radiographic marker was described to reliably determine grade 3 fatty infiltration. The tangent sign produced excellent agreement for the presence of muscle atrophy. A significant relationship between the tangent sign and fatty infiltration was discovered (P < .0001); grades 3 and 4 fatty infiltration correlated statistically with supraspinatus atrophy. CONCLUSION The tangent sign is acceptable for determining the presence of muscle atrophy and clinical decision making. A positive tangent sign is an indicator of advanced fatty infiltration. The axial computed tomography plane should be used when evaluating fatty infiltration. LEVEL OF EVIDENCE Level 3; Diagnostic study.

Fixed-bearing versus mobile-bearing total knee arthroplasty: A prospective randomised, clinical and radiological study with mid-term results at 7 years

Mobile-bearing (MB) total knee arthroplasty (TKA) was developed as an alternative to the established fixed-bearing (FB) design because of theoretical advantages. Short-term studies comparing these designs have not shown any differences in clinical and radiographic results. We compared the results at 7 years of a randomised study of patients undergoing TKA using either a FB or a MB variant of the same prosthesis. Fifty-two patients (52 knees) with an average age of 70 years received a FB posterior-stabilized prosthesis, and 50 patients (52 knees) with an average age of 72 years, a MB prosthesis. All implants were cemented and the patella was routinely resurfaced. Preoperatively, there were no differences between the two groups, and surgical procedure and postoperative protocol were the same for both. At an average follow-up of 7.1 years, no significant differences of FB over MB design could be demonstrated with respect to the American Knee Society score (AKSS), pain score, a questionnaire of general health (SF-12 score), range of motion (ROM), or complication rates. Radiographs showed no significant difference in prosthetic alignment or evidence of loosening. Two knees with a MB design required reoperation, one for persistent joint stiffness and another to treat septic loosening. One patient with a MB prosthesis with signs of tibial component loosening was asymptomatic. We conclude that at mid-term follow-up there is no evidence to prove the superiority of MB over FB TKA with regard to the clinical and radiographic results.

Relationship between massive chronic rotator cuff tear pattern and loss of active shoulder range of motion.

BACKGROUND Management of massive chronic rotator cuff tears remains controversial, with no clearly defined clinical presentation as yet. The purpose of the study was to evaluate the effect of tear size and location on active motion in patients with chronic and massive rotator cuff tears with severe muscle degeneration. METHODS One hundred patients with massive rotator cuff tears accompanied by muscle fatty infiltration beyond Goutallier stage 3 were prospectively included in this study. All patients were divided into 5 groups on the basis of tear pattern (supraspinatus, superior subscapularis, inferior subscapularis, infraspinatus, and teres minor). Active range of shoulder motion was assessed in each group and differences were analyzed. RESULTS Active elevation was significantly decreased in patients with 3 tear patterns involved. Pseudoparalysis was found in 80% of the cases with supraspinatus and complete subscapularis tears and in 45% of the cases with tears involving the supraspinatus, infraspinatus, and superior subscapularis. Loss of active external rotation was related to tears involving the infraspinatus and teres minor; loss of active internal rotation was related to tears of the subscapularis. CONCLUSIONS This study revealed that dysfunction of the entire subscapularis and supraspinatus or 3 rotator cuff muscles is a risk factor for pseudoparalysis. For function to be preserved in patients with massive chronic rotator cuff tears, it may be important to avoid fatty infiltration with anterior extension into the lower subscapularis or involvement of more than 2 rotator cuff muscles.

Injury of the Suprascapular Nerve During Latarjet Procedure: An Anatomic Study

PURPOSE The purpose of this study was to evaluate the relation between the specific exit point of the screws securing the coracoid graft and the suprascapular nerve during the Latarjet procedure. METHODS Ten fresh-frozen shoulder specimens were dissected after having undergone an open Latarjet procedure. RESULTS The mean distance from the posterior exit site of the superior screw to the suprascapular nerve at the base of the scapular spine was only 4 mm. Two of the superior screws were directly in contact with the major branch of the suprascapular nerve, and 2 screws were also in contact with minor branches of the suprascapular nerve. As for the inferior screw, there was contact with the major branch in 1 case and with minor branches of the suprascapular nerve in 6 cases. In the axial plane, the screws were not in contact with the suprascapular nerve if the angle relative to the glenoid was less than or equal to 10°. CONCLUSIONS The proximity of the suprascapular nerve to the posterior glenoid rim puts this nerve at risk during insertion of the screws used for the Latarjet procedure. Placement of screws within 10° of the face of the glenoid in the axial plane is safe and will avoid the potential for suprascapular nerve injury. CLINICAL RELEVANCE This study quantifies the relative risk of injury to the suprascapular nerve during the Latarjet procedure.