Luc Favard

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. 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.

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.

A multicentre study of the long-term results of using a flat-back polyethylene glenoid component in shoulder replacement for primary osteoarthritis

We report the long-term clinical and radiological outcomes of the Aequalis total shoulder replacement with a cemented all-polyethylene flat-back keeled glenoid component implanted for primary osteoarthritis between 1991 and 2003 in nine European centres. A total of 226 shoulders in 210 patients were retrospectively reviewed at a mean of 122.7 months (61 to 219) or at revision. Clinical outcome was assessed using the Constant score, patient satisfaction score and range of movement. Kaplan-Meier survivorship analysis was performed with glenoid revision for loosening and radiological glenoid loosening (SD) as endpoints. The Constant score was found to improve from a mean of 26.8 (SD 10.3) pre-operatively to 57.6 (SD 20.0) post-operatively (p < 0.001). Active forward flexion improved from a mean of 85.3° (SD 27.4) pre-operatively to 125° (SD 37.3) postoperatively (p < 0.001). External rotation improved from a mean of 7° (SD 6.5) pre-operatively to 30.3° (SD 21.8°) post-operatively (p < 0.001). Survivorship with revision of the glenoid component as the endpoint was 99.1% at five years, 94.5% at ten years and 79.4% at 15 years. Survivorship with radiological loosening as the endpoint was 99.1% at five years, 80.3% at ten years and 33.6% at 15 years. Younger patient age and the curettage technique for glenoid preparation correlated with loosening. The rate of glenoid revision and radiological loosening increased with duration of follow-up, but not until a follow-up of five years. Therefore, we recommend that future studies reporting radiological outcomes of new glenoid designs should report follow-up of at least five to ten years.

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).

Glenoid loosening and failure in anatomical total shoulder arthroplasty: is revision with a reverse shoulder arthroplasty a reliable option?

INTRODUCTION Our purpose was to evaluate if, in case of aseptic glenoid loosening and failure in anatomical total shoulder arthroplasty (TSA), revision by a reverse shoulder arthroplasty (RSA) is a reliable therapeutic option. METHODS Retrospective multicenter cohort study of 37 consecutive anatomical TSA revised by RSA for aseptic glenoid loosening or failure. The decision to implant a RSA was related to the presence of associated complications: rotator cuff tears (n = 24), subscapularis insufficiency (n = 29), prosthetic instability (n = 13), and glenoid bone deficiency (n = 37). The patients were reviewed clinically and radiographically at a mean follow-up of 47 months (range, 24-104). RESULTS Eighty-six percent of the patients were satisfied or very satisfied. The average Constant score increased from 24 to 55 pts (P < .0001) and active anterior elevation from 68° to 121° (P < .0001). Twenty-two of the 29 (76%) associated bone grafts were incorporated in the glenoid. Eight patients (21%) needed a subsequent reoperation because of recurrent or new complications: glenoid loosening (n = 3), prosthetic anterior instability (n = 3), and humeral subsidence (n = 2); the reverse prosthesis had to be converted to a hemiarthroplasty in 1 patient and removed in another. CONCLUSION Revision with a RSA is a reliable therapeutic option which provides the double benefit of glenoid bone stock reconstruction by fixing the bone graft with the help of the baseplate and screws and of solving the problem of soft tissue insufficiency and prosthetic instability. However, surgeons should be aware that the rate of postoperative complications and subsequent reoperations is high, and that the surgical technique is demanding.

Secondary rotator cuff dysfunction following total shoulder arthroplasty for primary glenohumeral osteoarthritis: results of a multicenter study with more than five years of follow-up.

BACKGROUND Secondary rotator cuff dysfunction is a recognized complication following shoulder arthroplasty. We hypothesized that the rate of secondary rotator cuff dysfunction would increase with follow-up and result in less satisfactory clinical and radiographic outcomes. Our aim was to investigate the rate of secondary rotator cuff dysfunction following shoulder arthroplasty for primary osteoarthritis and identify factors associated with the dysfunction. METHODS Between 1991 and 2003, in ten European centers, 704 total shoulder arthroplasties were performed for primary glenohumeral osteoarthritis. Complete radiographic and clinical follow-up of more than five years was available for 518 shoulders. The diagnosis of secondary rotator cuff dysfunction was made when moderate or severe superior subluxation of the prosthetic humeral head was present on radiographs. Multivariate logistic regression identified factors associated with the development of rotator cuff dysfunction. Kaplan-Meier survivorship analysis was performed, with the end point being secondary rotator cuff failure. Clinical outcome was assessed with use of the Constant score, a subjective assessment of the shoulder, and an evaluation of shoulder motion. RESULTS At an average of 103.6 months (range, sixty to 219 months) after shoulder arthroplasty, the rate of secondary rotator cuff dysfunction was 16.8%. Survivorship free of secondary cuff dysfunction was 100% at five years, 84% at ten years, and 45% at fifteen years. Duration of follow-up (p < 0.0001), implantation of the glenoid implant with superior tilt (p < 0.001), and fatty infiltration of the infraspinatus muscle (p < 0.05) were risk factors for the development of secondary cuff dysfunction. Patients with secondary rotator cuff dysfunction had significantly worse clinical outcomes (Constant score, subjective assessment, and range of motion; p < 0.0001) and radiographic results (radiolucent line score, radiographic loosening, glenoid component migration; p < 0.0001). CONCLUSIONS In this study, rates of secondary rotator cuff dysfunction with moderate or severe superior subluxation of the prosthetic humeral head increased with the duration of follow-up and significantly influenced the clinical and radiographic outcome of total shoulder arthroplasty performed for primary glenohumeral osteoarthritis. Preoperative fatty infiltration of the infraspinatus muscle and implantation of the glenoid component with superior tilt were prognostic factors.

Acromial insufficiency in reverse shoulder arthroplasties

HYPOTHESIS Reverse shoulder prostheses depend on deltoid function. An injury to the acromion, either fracture or meso-acromion, or deltoid injury, may affect the outcomes of patients after receiving a reverse shoulder prosthesis. METHODS Four-hundred and fifty-seven consecutive reverse shoulder prostheses were implanted between January 1992 and June 2003 by one of seven surgeons in five separate centers. Forty-one patients were noted to have a pre-operative lesion of the acromion or scapular spine. Twenty-three presented with an os acromiale (meso-acromion). Seventeen had fracture or fragmentation of the acromion. One patient had a pseudarthrosis of the scapular spine. RESULTS Preoperative acromial pathology, surgical approach, and amount of inferior acromial tilt did not diminished postoperative range of motion, Constant score, or subjective results when compared to patients without acromial pathology. In contrast, the four patients with postoperative acromial spine fractures had inferior results with respect to functional and subjective results. CONCLUSION Preoperative acromial lesions are not a contraindication to reverse shoulder arthroplasty. Postoperative fracture of the acromial spine has a significant effect on results and treatment is uncertain.

Omarthrose ecentrée: symposium

Cuff tear arthropathy is defined as the combination of a gleno-humeral arthritis and a massive rotators cuff tear. It is generally admitted that the cuff tear, or its deficiency jeopardises the results of anatomic prosthesis. Grammont imagined and grew the concept of the reverse prosthesis whose aim was to remedy the insufficiency of the rotator cuff and whose use has dramatically modified the therapeutic approach in these complicated situations. The aim of this symposium is to analyse the results of shoulder arthroplasty (anatomic prosthesis, bipolar or reverse) in cuff tear arthropathy, in massive and isolated cuff tears which justify the use of prosthetic surgery, and in centered osteoarthritis with deficient cuff also justifying this use. Massive cuff tears and cuff tear arthropathy have been considered as the stages of a same pathology by Hamada whose classification has been used for the purposes of this study. Out of the 738 initial prosthesis, 111 have been eliminated because of death, incomplete files or lost of sight, without any known complication. Out of the remaining 627 who were used as a basis for this symposium (representing 85% of initial cases), 570 who still had their prosthesis were reviewed and their functional results analysed after 2 years or more. The population was mainly female (72%) who were injured on the dominant side (75%) with a mean age of 72 years. The preoperative Constant score was in average 24 and 24% of the patients had already been operated on their shoulder. For those who had an acetabulization of the acromion, the strength in external rotation was significantly less satisfying and the lesion of the infraspinatus and the teres minor were more frequent. 48 hemiarthroplasties, 52 bipolar and 527 reverse prosthesis were studied. At revision, with an average follow up of 52 months, the revision rate was 23% for hemiarthroplasties, 14% for reversed prosthesis and only 8% for bipolar prosthesis. The prosthesis was removed in 21% of hemiarthroplasties, 5% of reverse and 2% of bipolar. No infection to report in the hemi group or the bipolar group, whereas there was an infection rate of 5% in the reverse group. Nevertheless, the Constant score was significantly better with reverse (62) than with bipolar (45) or hemi (44). The active elevation was also better with the reverse whereas the external rotation was not as good as with anatomic prosthesis. The analytic study of the results of the reverse prosthesis shows a negative influence of the lesion of the sub-scapularis and the teres minor. The results are disappointing with young patients and those who had surgical precedents. On X-ray, we can notice 0.5% of humeral loosening withouth any correlation to the fact that the implant is cemented or not, 3.6% of glenoid loosening and 68% of scapular notches without any significant change on the Constant score. Their occurrence is correlated to a preoperative rising of the humeral head and a superior glenoid lesion. It is observed more frequently with the supero-lateral approach compared to the delto-pectoral one. The frequency of these notches grows with the follow up and their occurrence is often associated to humeral radiolucent lines. On the long term, the survival rate of these prosthesis is 89% at 10 years. The Constant score deteriorates gradually after 7 years; this seems to be linked to the occurrence of x-ray modifications in the years that followed. The main complications observed with reverse prosthesis were the infections (5.1%), the glenoid problems (5.1%), the instabilities (3.6%), the acromion fractures (3.0%). Infections can be treated by a wash out and antibiotics in the first 3 months, then the removal of the prosthesis becomes necessary. The instabilities occur more often for males, with delto-pectoral approach and with 36mm diameter glenoids. The glenoid problems are frequent in the first years and often due to technical errors or material defects (unscrewing of the glenosphere). Acromion fractures have an important clinical impact when they concern the spine and there healing is difficult to obtain, whichever method is used. In conclusion, the use of a prosthesis for cuff tear arthropathies must be thought about, especially in massive cuff tear without osteoarthritis, in patients with previous surgery, and in patients younger than 70. If the active elevation is conserved and the patient is young, the use of an hemi or a bipolar prosthesis can be debated. In other cases, the indication of a reverse prosthesis is preferable given that the clinical results are better. In these cases, the surgical technique must be accurate, bearing in mind the advantages and disadvantages of the two possible approaches, the type of implant (36 vs 42), the position and orientation of the glenoid baseplate according to the pre-operative bone wear, the orientation of the humeral implant, the need for reinsertion of the subscapularis and, maybe, the possibility of an associated transfer of the latissimus dorsi.Cuff tear arthropathy is defined as the combination of a gleno-humeral arthritis and a massive rotators cuff tear. It is generally admitted that the cuff tear, or its deficiency jeopardises the results of anatomic prosthesis. Grammont imagined and grew the concept of the reverse prosthesis whose aim was to remedy the insufficiency of the rotator cuff and whose use has dramatically modified the therapeutic approach in these complicated situations. The aim of this symposium is to analyse the results of shoulder arthroplasty (anatomic prosthesis, bipolar or reverse) in cuff tear arthropathy, in massive and isolated cuff tears which justify the use of prosthetic surgery, and in centered osteoarthritis with deficient cuff also justifying this use. Massive cuff tears and cuff tear arthropathy have been considered as the stages of a same pathology by Hamada whose classification has been used for the purposes of this study. Out of the 738 initial prosthesis, 111 have been eliminated because of death, incomplete files or lost of sight, without any known complication. Out of the remaining 627 who were used as a basis for this symposium (representing 85% of initial cases), 570 who still had their prosthesis were reviewed and their functional results analysed after 2 years or more. The population was mainly female (72%) who were injured on the dominant side (75%) with a mean age of 72 years. The preoperative Constant score was in average 24 and 24% of the patients had already been operated on their shoulder. For those who had an acetabulization of the acromion, the strength in external rotation was significantly less satisfying and the lesion of the infraspinatus and the teres minor were more frequent. 48 hemiarthroplasties, 52 bipolar and 527 reverse prosthesis were studied. At revision, with an average follow up of 52 months, the revision rate was 23% for hemiarthroplasties, 14% for reversed prosthesis and only 8% for bipolar prosthesis. The prosthesis was removed in 21% of hemiarthroplasties, 5% of reverse and 2% of bipolar. No infection to report in the hemi group or the bipolar group, whereas there was an infection rate of 5% in the reverse group. Nevertheless, the Constant score was significantly better with reverse (62) than with bipolar (45) or hemi (44). The active elevation was also better with the reverse whereas the external rotation was not as good as with anatomic prosthesis. The analytic study of the results of the reverse prosthesis shows a negative influence of the lesion of the sub-scapularis and the teres minor. The results are disappointing with young patients and those who had surgical precedents. On X-ray, we can notice 0.5% of humeral loosening withouth any correlation to the fact that the implant is cemented or not, 3.6% of glenoid loosening and 68% of scapular notches without any significant change on the Constant score. Their occurrence is correlated to a preoperative rising of the humeral head and a superior glenoid lesion. It is observed more frequently with the supero-lateral approach compared to the delto-pectoral one. The frequency of these notches grows with the follow up and their occurrence is often associated to humeral radiolucent lines. On the long term, the survival rate of these prosthesis is 89% at 10 years. The Constant score deteriorates gradually after 7 years; this seems to be linked to the occurrence of x-ray modifications in the years that followed. The main complications observed with reverse prosthesis were the infections (5.1%), the glenoid problems (5.1%), the instabilities (3.6%), the acromion fractures (3.0%). Infections can be treated by a wash out and antibiotics in the first 3 months, then the removal of the prosthesis becomes necessary. The instabilities occur more often for males, with delto-pectoral approach and with 36mm diameter glenoids. The glenoid problems are frequent in the first years and often due to technical errors or material defects (unscrewing of the glenosphere). Acromion fractures have an important clinical impact when they concern the spine and there healing is difficult to obtain, whichever method is used. In conclusion, the use of a prosthesis for cuff tear arthropathies must be thought about, especially in massive cuff tear without osteoarthritis, in patients with previous surgery, and in patients younger than 70. If the active elevation is conserved and the patient is young, the use of an hemi or a bipolar prosthesis can be debated. In other cases, the indication of a reverse prosthesis is preferable given that the clinical results are better. In these cases, the surgical technique must be accurate, bearing in mind the advantages and disadvantages of the two possible approaches, the type of implant (36 vs 42), the position and orientation of the glenoid baseplate according to the pre-operative bone wear, the orientation of the humeral implant, the need for reinsertion of the subscapularis and, maybe, the possibility of an associated transfer of the latissimus dorsi.

Total shoulder arthroplasty - arthroplasty for glenohumeral arthropathies: results and complications after a minimum follow-up of 8 years according to the type of arthroplasty and etiology.

INTRODUCTION Arthroplasty for glenohumeral arthropathies have specific complications and the final results are sometimes more dependent upon the type of shoulder arthroplasty than the initial etiology. The aim of our study was to evaluate the rate of complications and the functional improvement with different types of shoulder arthroplasties after a minimum follow-up of 8 years. MATERIALS AND METHODS This was a multicenter retrospective study of 198 shoulders including 85 primary osteoarthritis of the shoulder, 76 cuff tear arthropathies, 19 avascular necrosis and 18 rheumatoid arthritis. Arthroplasties included 104 anatomic total shoulder arthroplasties (TSA), 77 reverse arthroplasties and 17 hemiarthroplasties. Ten patients had their arthroplasty revised, and 134 patients with TSA were able to be present at the final follow-up or provide information on their case. Function was evaluated by the Constant-Murley score and loosening by standard radiographs. RESULTS In the group with primary osteoarthritis of the shoulder, there were eight complications (11%) including six (8.3%) requiring implant revision. In the group of rotator cuff arthropathies, there were nine (14.7%) complications including four (6.5%) requiring implant revision. In the group with rheumatoid arthritis, there was one complication, and no surgical revision was necessary. There were no complications in the group with avascular necrosis. Glenoid migration occurred in 28.5% of anatomic TSA, and 3.4% of reverse arthroplasties. This difference was significant (P<0.001). The Constant-Murley score was significantly improved in all etiologies. CONCLUSIONS Glenohumeral arthropathies can be successfully treated by arthroplasty. Anatomic TSA was shown to be associated with a high risk of glenoid loosening at radiographic follow-up, which makes us hesitate to use the cemented polyethylene implant, especially in young patients. LEVEL OF EVIDENCE IV - Retrospective study.