Gilles Walch

Grammont inverted total shoulder arthroplasty in the treatment of glenohumeral osteoarthritis with massive rupture of the cuff: RESULTS OF A MULTICENTRE STUDY OF 80 SHOULDERS

We reviewed 80 shoulders (77 patients) at a mean follow-up of 44 months after insertion of a Grammont inverted shoulder prosthesis. Three implants had failed and had been revised. The mean Constant score had increased from 22.6 points pre-operatively to 65.6 points at review. In 96% of these shoulders there was no or only minimal pain. The mean active forward elevation increased from 73 degrees to 138 degrees. The integrity of teres minor is essential for the recovery of external rotation and significantly influenced the Constant score. Five cases of aseptic loosening of the glenoid and seven of dissociation of the glenoid component were noted. This study confirms the promising early results obtained with the inverted prosthesis in the treatment of a cuff-tear arthropathy. It should be considered in the treatment of osteoarthritis with a massive tear of the cuff but should be reserved for elderly patients.

Reverse Total Shoulder Arthroplasty: A Review of Results According to Etiology

BACKGROUND Reverse total shoulder arthroplasty provides a surgical alternative to standard total shoulder arthroplasty for the treatment of selected complex shoulder problems. The purpose of the present study was to evaluate the effects of etiology on the results of reverse total shoulder arthroplasty. METHODS Between May 1995 and June 2003, 240 consecutive reverse total shoulder arthroplasties were performed in 232 patients with an average age of 72.7 years. Patients were grouped according to etiology, and the clinical and radiographic outcomes for each group were measured and compared. RESULTS One hundred and eighty-six patients with 191 retained reverse total shoulder arthroplasty prostheses were followed for an average of 39.9 months. Overall, the average Constant score improved from 23 points before surgery to 60 points at the time of follow-up and 173 of the 186 patients were satisfied or very satisfied with the result. Although substantial clinical and functional improvement was observed in all etiology groups, patients with primary rotator cuff tear arthropathy, primary osteoarthritis with a rotator cuff tear, and a massive rotator cuff tear had better outcomes, on average, than patients who had posttraumatic arthritis and those managed with revision arthroplasty. Dislocation (fifteen cases) and infection (eight cases) were the most common complications among the 199 shoulders that were followed for two years or were revised prior to the minimum two-year follow-up. Patients who received the reverse prosthesis at the time of a revision arthroplasty had a higher complication rate than did those who received the reverse prosthesis at the time of a primary arthroplasty. CONCLUSIONS The reverse total shoulder arthroplasty prosthesis can produce good results when used for the treatment of a number of other complex shoulder problems in addition to cuff tear arthropathy. Patients with posttraumatic arthritis and those undergoing revision arthroplasty may have less improvement and higher complication rates in comparison with patients with other etiologies. The advanced age of the patients in the present series and the relatively short duration of follow-up suggest that the prosthesis should continue to be used judiciously.

Morphologic Study of the Glenoid in Primary Glenohumeral Osteoarthritis

We studied the natural course and the possibility of making a prognostic classification of glenoid morphology in primary glenohumeral osteoarthritis (GHOA). For this purpose, serial computed tomography scans of 113 osteoarthritic shoulders were reviewed. The position of the humeral head with respect to the glenoid seems to be an important predictor of the glenoid morphologic evolution. Three main glenoid types were defined: Type A, Type B, Type C. Type A (59%) was marked by a well-centered humeral head and a balanced distribution of strengths against the surface of the glenoid. The symmetric erosion was explained by the absence of subluxation. In Type B (32%), the posterior subluxation of the humeral head was responsible for the asymmetric load against the glenoid and was implicated in the development of primary GHOA, particularly the exaggerated posterior wear pattern. Type C (9%) was defined by a glenoid retroversion of more than 25 degrees, regardless of erosion; retroversion was primarily of dysplastic origin and explained the early event of osteoarthritis. In primary GHOA, this classification of the glenoid can discriminate retroversion between posterior erosion and dysplasia.

Reverse total shoulder arthroplasty. Survivorship analysis of eighty replacements followed for five to ten years.

BACKGROUND Reverse total shoulder arthroplasty is currently being used to treat selected patients with disabling shoulder arthropathy. The purposes of this study were to investigate the medium-term results of reverse total shoulder arthroplasty and to analyze the influence of etiology on the result. METHODS We carried out a multicenter study with a minimum follow-up of five years and determined the survival rate of the prosthesis according to the initial etiology of the shoulder arthropathy. Eighty prostheses were implanted in seventy-seven patients between 1992 and 1998. Sixty-six shoulders had an arthropathy with a massive rotator cuff tear, and fourteen shoulders had a disorder with another etiology (rheumatoid arthritis, trauma, or revision arthropathy). At the time of review, eighteen patients had died and two were lost to follow-up. The remaining fifty-seven patients (sixty shoulders) were examined or interviewed by telephone at a mean follow-up of 69.6 months. Cumulative survival curves were generated with replacement of the prosthesis, glenoid loosening, and a functional Constant score of <30 as the end points. RESULTS The survival rate with replacement of the prosthesis and glenoid loosening as the end points were 91% and 84%, respectively, at 120 months, with shoulders that had arthropathy with a massive rotator cuff tear demonstrating a significantly better result than those that had a disorder with another etiology (p < 0.05). On the other hand, the survival rate with an absolute Constant score of <30 as an end point was 58% at 120 months, with no significant difference with respect to etiology. Two breaks were observed in the survival curves. The first concerned survival until replacement of the prosthesis and occurred at around three years, reflecting early loosening of the prosthesis. The curve then became stable. A second break started at around six years and reflected progressive deterioration of the functional result. CONCLUSIONS Our findings indicate that the reverse total prosthesis should be reserved for the treatment of very disabling shoulder arthropathy with a massive rotator cuff rupture, and it should be used exclusively in patients over seventy years old with low functional demands.

THE THREE-DIMENSIONAL GEOMETRY OF THE PROXIMAL HUMERUS: IMPLICATIONS FOR SURGICAL TECHNIQUE AND PROSTHETIC DESIGN

We have studied the three-dimensional geometry of the proximal humerus on human cadaver specimens using a digitised measuring device linked to a computer. Our findings demonstrated the variable shape of the proximal humerus as well as its variable dimensions. The articular surface, which is part of a sphere varies individually in its orientation as regards inclination and retroversion, and it has variable medial and posterior offsets. These variations cannot be accommodated by the designs of most contemporary humeral components. Although good clinical results can be achieved with current modular and non-modular components their relatively fixed geometry prevents truly anatomical restoration in many cases. To try to restore the original three-dimensional geometry of the proximal humerus, we have developed a new type of humeral component which is modular and adaptable to the individual anatomy. Such adaptability allows correct positioning of the prosthetic head in relation to an individual anatomical neck, after removal of the marginal osteophytes. The design of this third-generation prosthesis respects the four geometrical variations which have been demonstrated in the present study. These are inclination, retroversion, medial offset and posterior offset.

The Three-Dimensional Geometry of the Proximal Humerus: Implications for Surgical Technique and Prosthetic Design

We have studied the three-dimensional geometry of the proximal humerus on human cadaver specimens using a digitised measuring device linked to a computer. Our findings demonstrated the variable shape of the proximal humerus as well as its variable dimensions. The articular surface, which is part of a sphere varies individually in its orientation as regards inclination and retroversion, and it has variable medial and posterior offsets. These variations cannot be accommodated by the designs of most contemporary humeral components. Although good clinical results can be achieved with current modular and non-modular components their relatively fixed geometry prevents truly anatomical restoration in many cases. To try to restore the original three-dimensional geometry of the proximal humerus, we have developed a new type of humeral component which is modular and adaptable to the individual anatomy. Such adaptability allows correct positioning of the prosthetic head in relation to an individual anatomical neck, after removal of the marginal osteophytes. The design of this third-generation prosthesis respects the four geometrical variations which have been demonstrated in the present study. These are inclination, retroversion, medial offset and posterior offset.

A comparison of hemiarthroplasty and total shoulder arthroplasty in the treatment of primary glenohumeral osteoarthritis: results of a multicenter study☆

Six hundred one total shoulder arthroplasties and eighty-nine hemiarthroplasties were performed for primary osteoarthritis of the shoulder. Patients were evaluated with a physical examination, Constant score, and radiographic evaluation. The minimum follow-up was 2 years. At follow-up, the Constant score averaged 64 points, the adjusted Constant score averaged 86%, active anterior elevation averaged 130 degrees, and active external rotation averaged 36 degrees for the hemiarthroplasties. The Constant score averaged 70 points, the adjusted Constant score averaged 96%, active anterior elevation averaged 145 degrees, and active external rotation averaged 42 degrees for the total shoulder arthroplasties. Eighty-six percent of hemiarthroplasties and ninety-four percent of total shoulder arthroplasties had good or excellent results. Differences were statistically significant for all parameters. Total shoulder arthroplasty provided better scores for pain, mobility, and activity than hemiarthroplasty. Fifty-six percent of total shoulder arthroplasties had a radiolucent line around the glenoid component. Total shoulder arthroplasty provides results superior to those of hemiarthroplasty in primary osteoarthritis.

Scapular notching in reverse shoulder arthroplasty

The causes and consequences of scapular notching after reverse shoulder arthroplasty (RSA) were investigated in 326 consecutive patients (337 shoulders) undergoing RSA between 1991 and 2003. Patients underwent 269 (80%) primary RSAs and 68 revisions of unconstrained shoulder prosthesis. At last follow-up (average, 47 months; range, 24-120 months) 62% had scapular notching. Notching frequency and extension were correlated to the length of follow-up (P = .0005). Notching was more frequent in cuff tear arthropathy (P = .0004), grade 3 or 4 fatty infiltration of the infraspinatus (P = .01), and narrowed acromiohumeral distance (P < .0001). Glenoids preoperatively oriented superiorly were more at risk for notching (P = .006). More notching occurred when the RSA was implanted using an anterosuperior approach vs a deltopectoral approach (P < .0001). Notching was correlated with humeral radiolucencies in proximal zones (P < .0001) and with glenoid radiolucent lines (P < .0001). Positioning of the baseplate definitely influences scapular notching. High positioning of the baseplate and superior tilting must be avoided.

Early Results of a Reverse Design Prosthesis in the Treatment of Arthritis of the Shoulder in Elderly Patients With a Large Rotator Cuff Tear

Results of shoulder arthroplasty in patients with a deficient rotator cuff often are suboptimal with significant limitations in postoperative active mobility. Short-term results using a reverse design prosthesis in the treatment of the cuff-deficient arthritic shoulder are encouraging. This prosthesis compares favorably, particularly with regard to postoperative active anterior elevation, to other treatment options in this challenging patient population.

The ‘dropping’ and ‘hornblower’s’ signs in evaluation of rotator-cuff tears

We studied 54 patients operated on for combined supraspinatus and infraspinatus rotator-cuff tears. The presence or absence of the dropping and hornblowers clinical signs of impaired external rotation were correlated with Goutallier stage-3 or stage-4 fatty degeneration of infraspinatus and teres minor. These grades of fatty degeneration have previously been correlated with a poorer outcome from reconstructive surgery. We found that hornblowers sign had 100% sensitivity and 93% specificity for irreparable degeneration of teres minor and the dropping sign 100% sensitivity and 100% specificity for similar degeneration of infraspinatus. In seven patients, teres minor showed hypertrophy. This muscle can give useful function for the activities of daily living in patients with rotator-cuff tears in whom it is intact.