Charles A. Rockwood

Complications of total shoulder arthroplasty.

umeroscapular arthrodesis is a well-established operative procedure that involves fusion of the humeral head to the glenoid. In some procedures, the fusion also includes an acromiohumeral arthrodesis. Humeroscapular arthrodesis is commonly called “shoulder arthrodesis,” and we use that term in this paper for simplicity. Indications for this procedure early in the twentieth century included the treatment of residual glenohumeral destruction resulting from tuberculosis and the treatment of upper-extremity paralysis resulting from poliomyelitis. Additional historical indications included osteoarthritis, rheumatoid arthritis, irreparable injury of the rotator cuff, and severely comminuted fracture of the proximal aspect of the humerus. The advent of shoulder arthroplasty has resulted in a marked reduction in the number of shoulder arthrodeses performed, although there are instances when arthrodesis is favored over joint-replacement arthroplasty. This article reviews the indications for shoulder arthrodesis, the pertinent features of the preoperative evaluation, the controversial issue of the desirable position of the arthrodesis, the various techniques for shoulder arthrodesis, and the management of complications.Total shoulder arthroplasty, originally used by Pean in 1893 to treat tuberculous arthritis1 and subsequently modernized by Neer et al. in the 1950s for the treatment of three and four-part proximal humeral fractures2, has demonstrated clinical efficacy when used for the treatment of primary and secondary degenerative conditions of the shoulder. The overall number of shoulder replacements has increased in parallel to the total number of total joint arthroplasties. Approximately 7000 total shoulder replacements were performed annually in the United States from 1996 through 2002. This represents a 40% increase compared with the 5000 arthroplasties per year performed from 1990 through 19923-11. Despite the increase in the annual volume of shoulder arthroplasties, data have suggested that nearly three-fourths of the operations are performed by surgeons who do two or fewer procedures a year12,13. The favorability of the clinical outcomes of total shoulder arthroplasty as well as the decision to proceed with a total shoulder replacement instead of a hemiarthroplasty have been shown to depend on surgeon experience and hospital volume12-16. Patient readmission rates, complication rates, and lengths of hospital stays have all been shown to …

Treatment of instability of the shoulder with an exercise program.

One hundred and forty shoulders in 115 patients that had a diagnosis of traumatic or atraumatic recurrent anterior, posterior, or multidirectional subluxation were treated with a specific set of muscle-strengthening exercises. Only twelve (16 per cent) of the seventy-four shoulders (sixty-eight patients) that had traumatic subluxation had a good or excellent result from the exercises, compared with fifty-three (80 per cent) of the sixty-six shoulders that had atraumatic subluxation. For this reason, each patient who has instability of the shoulder should be thoroughly evaluated if a successful result from conservative treatment is to be expected. Every effort must be made to identify the etiology of the instability through careful history-taking, physical examination, and radiographic evaluation.

Current Concepts Review - Complications of Total Shoulder-Replacement Arthroplasty*

Complications associated with orthopaedic prostheses or implants account for approximately 5 per cent of the more than 3.5 million hospitalizations for musculoskeletal conditions82. This is important in light of the increasing number of patients who receive prostheses and the fact that the average age of patients who have a total shoulder arthroplasty is the lowest among those for all major joint replacements28,73. Like replacement procedures in other major joints, total shoulder arthroplasty is associated with numerous complications, including prosthetic loosening, glenohumeral instability, tears of the rotator cuff, periprosthetic fracture, infection, neural injury, and dysfunction of the deltoid. In recent years, mirroring the increase in the number of total joint arthroplasties in general, the number of shoulder-replacement procedures has increased substantially28,71-73. However, despite this growth, fewer than 5000 total shoulder replacements were performed annually in the United States from 1990 through 1992, compared with 136,000 total hip and total knee arthroplasties28,71-73. Although the short-term (less than two-year) and mid-term (two to five-year) results of total shoulder arthroplasties have been encouraging, with some authors reporting good and excellent results in more than 90 per cent of shoulders, widespread experience and long-term evaluations approaching those for joint replacements in the lower extremities have not been published1,5,6,13,23,44,53,64,65,78. Our review of forty-one series involving 1858 total shoulder arthroplasties reported from 1975 through 1995 revealed an average duration of follow-up of only 3.5 years3-6,12,13,15,16,19,25,26,32,34,38,40-42,44,48,53, …

Débridement of degenerative, irreparable lesions of the rotator cuff.

A modified Neer acromioplasty, subacromial decompression, and débridement of massive, irreparable lesions of the supraspinatus and infraspinatus tendons was performed in fifty-seven patients. Fifty patients (fifty-three shoulders) were followed for an average of six and one-half years. The average age of the patients was sixty years (range, thirty-eight to seventy-four years). The results, as rated on the basis of pain, function, range of motion, strength, and satisfaction of the patient, were satisfactory in forty-four shoulders (83 per cent) and unsatisfactory in nine (17 per cent). A favorable outcome was observed in shoulders in which both the anterior portion of the deltoid muscle and the long head of the biceps tendon were intact and in which a previous acromioplasties or operations on the rotator cuff had been performed. An unsatisfactory outcome was observed in shoulders in which the anterior part of the deltoid muscle was weak or absent or in which a previous acromioplasty and attempted repair of the rotator cuff had been performed. The active forward flexion of the shoulder improved from an average of 105 degrees preoperatively to an average of 140 degrees postoperatively. The results of the present study suggest that, with proper rehabilitation, adequate decompression of the subacromial space, anterior acromioplasty, and débridement of massive tears of the rotator cuff can lead to the relief of pain and the restoration of shoulder function.

Complications of a failed Bristow procedure and their management.

The management of patients who have a failed Bristow reconstruction of the shoulder is very complex. In order to determine the complications that occur when a Bristow procedure fails, and how they should be managed, we retrospectively evaluated forty shoulders in thirty-nine patients who had been treated by the senior one of us for a failed Bristow procedure from 1977 to 1987. The complications of the index Bristow procedures included recurrent painful anterior instability, injury to the articular cartilage, failure of the coracoid bone-block to unite with the glenoid, loosening of the screw, neurovascular injury, and posterior instability. The primary etiology of failure of the index Bristow procedure was excessive laxity of the capsule in thirty-two shoulders (80 per cent) that were affected by chronic, painful anterior or posterior instability. An untreated Perthes-Bankart lesion was present in the remaining eight shoulders (20 per cent). The use of anterior reconstruction for the revision of a failed Bristow procedure is a difficult operation that necessitates meticulous technique. As our over-all plan of treatment resulted in a good or excellent outcome in only 50 per cent of the patients, we do not recommend the Bristow procedure for primary treatment of symptomatic anterior instability of the shoulder.

The American academy of orthopaedic surgeons

The American Academy of Orthopaedic Surgeons (AAOS, or the Academy) was formed in 1933 by a group of orthopaedic surgeons who recognized the need for a national organization (Figure 55). (See chapter two for a more detailed accounting of the Academy’s founding.) Without it, orthopaedics surely would have remained a small subset of general surgery and the revolution in musculoskeletal surgery in the last half of the 20th century would have occurred in a much different fashion. The Academy’s inclusive fellowship of musculoskeletal surgeons facilitated this revolution, providing a forum for its participants to exchange new methods and advance the interests of orthopaedics. Like any large organization, however, it has had to balance the interests of the membership as a whole against the subspecialty interests of some members within it. The orthopaedic specialty societies have provided a powerful magnet to attract members seeking the fellowship of orthopaedic surgeons interested in narrower segments of orthopaedics. Thus, the Academy has worked to communicate the importance of membership in broad-based regional and national organizations. The Academy has encouraged the growth of state and regional orthopaedic societies. Also, in 1973, it formed the Board of Councilors that now consists of delegates from all 50 states in numbers proportional to the numbers of orthopaedic surgeons in each state, in the territories, and the military. In 1984, it formed the Council of Musculoskeletal Specialty Societies (COMSS) with representatives from the various subspecialty groups. In 2006, COMSS was renamed the Board of Orthopaedic Specialty Societies (BOS). Both the Board of Councilors and the Board of Orthopaedic Specialty Societies appoint members to the Board of Directors of the Academy. The AAOS also offers support services to other health care professional groups such as orthopaedic nurses, administrators, physician assistants, and special identity societies such as the Society of Military Orthopaedic Surgeons, the Ruth Jackson Orthopaedic Society, most of whose members are women, and the J. Robert Gladden Society, most of whose members are from racial and cultural minority groups.

Repair of the Anterior Cruciate Ligament in Dogs

1. No transected anterior cruciate ligament healed unless the ligament ends were held in complete apposition by suture. 2. Excessive tension on the suture line of the primarily repaired anterior cruciate ligament resulted in necrosis of the ligament and failure of the repair. 3. The divided anterior cruciate ligament in thirty consecutive dogs healed when treated by surgical repair apposing the severed ends under proper tension. 4. Prompt absorption and shortening of the ligament followed section of the anterior cruciate ligament without repair to the extent that apposition was impossible as early as two weeks after section. 5. Sectioned and repaired anterior cruciate ligaments showed microscopic evidence of complete fibrous healing by ten weeks, but there was still minimum residual fibroblastic activity at this time. 6. Tensile strength of the healed repaired ligament remained substantially less than that of normal ligaments at ten weeks. 7. When the anterior cruciate ligament was replaced with a graft composed of the iliotibial tract, a fibroblastic response occurred throughout the entire graft. It may be this response that converts the graft into a ligamentous structure. 8. The grafts were shown to survive as ligamentous structure up to four years after operation. 9. In our series the reconstructed ligament did not seem to provide stability comparable with that provided by the healed primarily repaired ligament, but there were insufficient animals in this series to reach valid conclusions in this regard.

Operative treatment of irreparable rupture of the subscapularis.

Between 1980 and 1994, 221 shoulders with recurrent anterior glenohumeral subluxation or dislocation were reconstructed at our institution. At the time of the operation, thirteen shoulders were found to have an irreparable injury of the subscapularis muscle, which we believed to be a contributing factor to the ongoing instability. All but three of the thirteen patients had had two to six previous reconstructions. Operative treatment of the irreparable rupture included a dynamic muscle transfer using the pectoralis major in seven shoulders, the pectoralis minor in five, and both of these muscles in one. According to a modification of the grading system of Neer and Foster, the result was satisfactory for ten shoulders and unsatisfactory for three at a mean of five years after the operation. All shoulders with a satisfactory result demonstrated active contraction of the transferred pectoralis muscle and diminished anterior glenohumeral translation. On the basis of our analysis, we concluded that transfer of the pectoralis muscle is effective for reconstruction of the shoulder in patients who have loss of the subscapularis muscle.

Shoulder impingement syndrome: diagnosis, radiographic evaluation, and treatment with a modified Neer acromioplasty.

Seventy-one patients who had shoulder impingement syndrome were managed operatively with a modified Neer acromioplasty: thirty-seven, who had an intact rotator cuff, had a modified acromioplasty, and thirty-four, who had a torn cuff, had a modified acromioplasty and repair of the cuff. In the classic anterior acromioplasty as described by Neer, emphasis is placed on resection of the inferior prominence of the acromion. We believe that the removal of only the inferior prominence is insufficient, as often too much of the anterior aspect of the acromion protrudes beyond the anterior border of the clavicle. This portion of the acromion continues to irritate the subacromial bursa and the rotator cuff and to produce symptoms of impingement. Our modified acromioplasty is done in two steps: the portion of the acromion that projects anteriorly beyond the anterior border of the clavicle is resected vertically and then an anteroinferior acromioplasty is performed. We studied the results in patients who had been operated on by the senior one of us and who had been followed clinically for a minimum of two years. At the most recent follow-up visit, no difference in terms of pain and function was found between the patients who had had the modified acromioplasty only (Group I) and the patients who had had the modified acromioplasty and repair of the rotator cuff (Group II); thirty-three (89 per cent) of the patients in Group I and thirty (88 per cent) of those in Group II had a good or excellent result.

Loss of external rotation following anterior capsulorrhaphy of the shoulder

A retrospective study was performed on twenty shoulders in nineteen patients who had been managed for severe loss of external rotation of the glenohumeral joint after a previous anterior capsulorrhaphy for recurrent instability. All patients had noted a restricted range of motion, and seventeen shoulders had been painful. In seven shoulders, the humeral head had been subluxated or dislocated posteriorly, and sixteen shoulders had been affected by mild to severe glenohumeral osteoarthrosis. All twenty shoulders were treated with a reoperation, which consisted of a release of the anterior soft tissue. In addition, eight shoulders had a total arthroplasty and one had a hemiarthroplasty. At an average duration of follow-up of forty-eight months, all shoulders had an improvement in the ratings for pain and range of motion. The average increase in external rotation was 45 degrees (range, 25 to 65 degrees). Patients who have a major loss of external rotation following anterior capsulorrhaphy of the shoulder may be at risk for the development of posterior subluxation and glenohumeral osteoarthrosis. The performance of an anterior release should be considered for these patients.