Mark A. Mighell

The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency : A minimum two-year follow-up study of sixty patients

BACKGROUND Patients who have pain and dysfunction from glenohumeral arthritis associated with severe rotator cuff deficiency have few treatment options. The goal of this study was to retrospectively evaluate the short-term results of arthroplasty with use of the Reverse Shoulder Prosthesis in the management of this problem. METHODS We report the results for sixty patients (sixty shoulders) with a rotator cuff deficiency and glenohumeral arthritis who were followed for a minimum of two years. Thirty-five patients had no previous shoulder surgery, whereas twenty-three had had either an open or arthroscopic rotator cuff repair, one had had a subacromial decompression, and one had had a biceps tendon repair. All patients were assessed preoperatively and postoperatively with the American Shoulder and Elbow Surgeons scoring system for pain and function and with visual analog scales for pain and function. They were also asked to rate their satisfaction with the outcome. The shoulder range of motion was measured preoperatively and postoperatively. RESULTS The average age of the patients was seventy-one years. The average duration of follow-up was thirty-three months. All measures improved significantly (p < 0.0001). The mean total score on the American Shoulder and Elbow Surgeons system improved from 34.3 to 68.2; the mean function score, from 16.1 to 29.4; and the mean pain score, from 18.2 to 38.7. The score for function on the visual analog scale improved from 2.7 to 6.0, and the score for pain on the visual analog scale improved from 6.3 to 2.2. Forward flexion increased from 55.0 degrees to 105.1 degrees, and abduction increased from 41.4 degrees to 101.8 degrees. Forty-one of the sixty patients rated the outcome as good or excellent; sixteen were satisfied, and three were dissatisfied. There were a total of thirteen complications in ten patients (17%). Seven patients (12%) had eight failures, requiring revision surgery to another Reverse Shoulder Prosthesis in five patients (one shoulder had two revisions) and revision to a hemiarthroplasty in two patients because of deep infection. CONCLUSIONS The data from this study suggest that arthroplasty with the Reverse Shoulder Prosthesis may be a viable treatment for patients with glenohumeral arthritis and a massive rotator cuff tear. However, future studies will be necessary to determine the longevity of the implant and whether it will provide continued improvement in function.

The reverse shoulder prosthesis for glenohumeral arthritis associated with severe rotator cuff deficiency. a minimum two-year follow-up study of sixty patients surgical technique.

BACKGROUND Patients who have pain and dysfunction from glenohumeral arthritis associated with severe rotator cuff deficiency have few treatment options. The goal of this study was to retrospectively evaluate the short-term results of arthroplasty with use of the Reverse Shoulder Prosthesis in the management of this problem. METHODS We report the results for sixty patients (sixty shoulders) with a rotator cuff deficiency and glenohumeral arthritis who were followed for a minimum of two years. Thirty-five patients had no previous shoulder surgery, whereas twenty-three had had either an open or arthroscopic rotator cuff repair, one had had a subacromial decompression, and one had had a biceps tendon repair. All patients were assessed preoperatively and postoperatively with the American Shoulder and Elbow Surgeons scoring system for pain and function and with visual analog scales for pain and function. They were also asked to rate their satisfaction with the outcome. The shoulder range of motion was measured preoperatively and postoperatively. RESULTS The average age of the patients was seventy-one years. The average duration of follow-up was thirty-three months. All measures improved significantly (p < 0.0001). The mean total score on the American Shoulder and Elbow Surgeons system improved from 34.3 to 68.2; the mean function score, from 16.1 to 29.4; and the mean pain score, from 18.2 to 38.7. The score for function on the visual analog scale improved from 2.7 to 6.0, and the score for pain on the visual analog scale improved from 6.3 to 2.2. Forward flexion increased from 55.0 degrees to 105.1 degrees , and abduction increased from 41.4 degrees to 101.8 degrees . Forty-one of the sixty patients rated the outcome as good or excellent; sixteen were satisfied, and three were dissatisfied. There were a total of thirteen complications in ten patients (17%). Seven patients (12%) had eight failures, requiring revision surgery to another Reverse Shoulder Prosthesis in five patients (one shoulder had two revisions) and revision to a hemiarthroplasty in two patients because of deep infection. CONCLUSIONS The data from this study suggest that arthroplasty with the Reverse Shoulder Prosthesis may be a viable treatment for patients with glenohumeral arthritis and a massive rotator cuff tear. However, future studies will be necessary to determine the longevity of the implant and whether it will provide continued improvement in function.

The Use of the Reverse Shoulder Prosthesis for the Treatment of Failed Hemiarthroplasty for Proximal Humeral Fracture

BACKGROUND Humeral hemiarthroplasty is an established treatment for patients with selected fractures of the proximal part of the humerus. However, a subset of patients have development of glenoid arthritis and rotator cuff deficiency due to tuberosity failure. To date, there has been no reliable salvage procedure for this problem. METHODS Over a period of five years, twenty-nine patients (twenty-five women and four men) with a mean age of sixty-nine years (range, forty-two to eighty years) were managed with removal of a hemiarthroplasty prosthesis and revision with a Reverse Shoulder Prosthesis alone or in combination with a proximal humeral allograft. Patients were followed clinically and radiographically for an average of thirty-five months. All patients were evaluated with use of the American Shoulder and Elbow Surgeons score; the Simple Shoulder Test; range-of-motion measurements, including abduction, forward flexion, and external rotation; and a rating scale for overall satisfaction with the outcome of the surgery. Patients were assessed preoperatively and at all follow-up points beginning at three months postoperatively. RESULTS The average total American Shoulder and Elbow Surgeons score improved from 22.3 preoperatively to 52.1 at the time of the last follow-up (p < 0.001). The average American Shoulder and Elbow Surgeons pain score improved from 12.2 to 34.4 (p < 0.001), and the average American Shoulder and Elbow Surgeons function score improved from 10.1 to 17.7 (p = 0.058). The average Simple Shoulder Test score improved from 0.9 to 2.6 (p = 0.004). Forward flexion improved from 38.1 degrees to 72.7 degrees (p < 0.001), and abduction improved from 34.1 degrees to 70.4 degrees (p < 0.001). The overall complication rate was 28% (eight of twenty-nine). At the time of the latest follow-up, sixteen patients rated the outcome as good or excellent, seven rated it as satisfactory, and six were dissatisfied. Four of the six patients who were dissatisfied had been managed with a Reverse Shoulder Prosthesis alone. CONCLUSIONS The Reverse Shoulder Prosthesis offers a salvage-type solution to the problem of failed hemiarthroplasty due to glenoid arthritis and rotator cuff deficiency following tuberosity failure. The early results reported here are promising. In cases of severe proximal humeral bone deficiency, augmentation of the Reverse Shoulder Prosthesis with a proximal humeral allograft may improve patient satisfaction.

Outcomes of hemiarthroplasty for fractures of the proximal humerus

We reviewed 80 shoulders (72 shoulders in 71 patients) treated with hemiarthroplasty. At follow-up, 66 patients (93%) were pain-free and satisfied with their results; the mean American Shoulder and Elbow Surgeons score was 76.6, the mean Simple Shoulder Test score was 7.5, the average forward flexion was 128 degrees, external rotation was 43 degrees, and internal rotation was to L2. Radiographic analyses revealed nearly anatomic tuberosity reconstruction in 58 shoulders, heterotopic ossification in 18, pseudosubluxation in 10, and superior migration in 15. Patients with superior migration had statistically lower mean American Shoulder and Elbow Surgeons scores, mean Simple Shoulder Test scores, and decreased forward flexion. Tuberosity complications occurred in 16 shoulders. Malunion of the greater tuberosity was the most common complication. Healing of the greater tuberosity more than 2 cm below the humeral head correlated with a worse functional result. Hemiarthroplasty for indicated fractures of the proximal humerus results in shoulder-level function and reproducible pain relief.

Reverse shoulder arthroplasty in patients with rheumatoid arthritis

BACKGROUND The purpose of this study was to describe the pathoanatomy of patients diagnosed with rheumatoid arthritis and rotator cuff deficiency and report their outcomes following reverse shoulder arthroplasty. METHODS Twenty-one shoulders were evaluated prospectively. Nine had no prior surgery, 9 had a failed rotator cuff repair, and 3 had a failed arthroplasty. Patients were followed for a minimum of 2 years (average, 36 months). All patients had preoperative radiographs and 19 shoulders had an MRI or CT available for evaluation of muscular and bony deficiency. Radiographs at most recent follow-up were evaluated for loosening and scapular notching. RESULTS All outcome measures improved significantly: ASES scores improved from 28 preoperatively to 82 postoperatively (P < .0001); SST scores improved from 1 to 7 (P < .0001); VAS pain scores improved from 7 to 1 (P < .0001); VAS function scores improved from 3 to 6 (P=.0058); elevation improved from 52° to 126° (P < .0001); abduction improved from 55° to 116° (P=.0002); external rotation improved from 19° to 33° (P=.02); and internal rotation improved from S1 to L4 (P=.02). Twelve patients rated their outcome as excellent, 6 as good, 2 as satisfactory, and 1 as unsatisfactory. Severe glenoid erosion was seen in 10 of the shoulders and 5 of the defects required structural grafting. Three patients (14%) sustained a complication that required reoperation: 2 for infection and 1 for periprosthetic fracture. CONCLUSIONS In patients with rheumatoid arthritis and rotator cuff deficiency, reverse shoulder arthroplasty can provide improvement in function and decreased pain.

Humeral shaft fractures: a review

Summary Humeral shaft fractures are common orthopaedicinjuries that can often be managed nonoperatively withhigh union rates and excellent results as the generaloutcome. Specific indications exist for operativemanagement and include polytrauma patients, openfractures, certain fracture patterns, and failure to main-tain an acceptable closed reduction. Plate fixation ofhumeral shaft fractures has historically been consideredthe gold standard of operative management based ona lower complication rate; however, newer intra-medullary devices may prove as effective in fracturemanagement pending future prospective analysis.Although radial nerve palsy remains a vexing andcommon comorbidity of humeral shaft fracturemanagement, recovery can be expected in mostcircumstances. Disclaimer The authors, their immediate families, and any researchfoundations with which they are affiliated have notreceived any financial payments or other benefits fromany commercial entity related to the subject of thisarticle.

Techniques and principles of tuberosity fixation for proximal humeral fractures treated with hemiarthroplasty

In 1970 Neer42,43 first published his results on humeral head replacement for proximal humeral fractures. During the past 3 decades, our ability to treat these fractures with arthroplasty has evolved as a result of our better understanding of proximal humeral anatomy, innovations in prosthetic design, and meticulous surgical technique. Fracture reduction with stable internal fixation is a basic surgical principle for all fractures. When this is achieved, early mobilization of the injured extremity can minimize joint stiffness and muscle atrophy. When prosthetic arthroplasty is the preferred treatment of a proximal humeral fracture, correct height and version are necessary with cement fixation of the stem. Many fracture systems now incorporate internal and external guides that can help place the prosthesis in correct version and height. The current challenge is to restore proximal humeral geometry with stable internal fixation of the tuberosities. At present, tuberosity complications account for the majority of early failures and poor outcomes (Table I and Table II). This article reviews the pertinent anatomic landmarks that help achieve a proper reduction of the tuberosities and defines the biomechanical and clinical consequences of malunion and nonunion.

Large coronal shear fractures of the capitellum and trochlea treated with headless compression screws

BACKGROUND The purpose of this study is to retrospectively evaluate the clinical outcomes of 18 patients with large coronal shear fractures of the capitellum and lateral trochlea that underwent open reduction and internal fixation with headless compression screws. METHODS Eighteen patients were identified (16 women, 2 men) with an average age of 45 years and an average follow-up of 26 months. Fractures were classified according to the Dubberley classification as 11 type-1A injuries and 7 type-2A injuries. RESULTS All patients, with the exception of 1, had good to excellent functional results by the Broberg-Morrey scale (mean score, 93.3). Average arc of motion was 128 degrees in flexion/extension and 176 degrees in pronation/supination. Radiographically, 3 patients had subsequent development of avascular necrosis and 5 developed arthrosis. No significant negative correlation was noted between the development of avascular necrosis and clinical outcome. Minor complications occurred in 2 patients, but there were no re-operations. CONCLUSION Headless compression screw fixation allows for stable fixation in patients with large coronal shear fractures of the distal humerus without posterior comminution. LEVEL OF EVIDENCE 4.

Surgically treated humeral shaft fractures following shoulder arthroplasty.

BACKGROUND We reviewed a consecutive series of patients with a humeral fracture around either an anatomic or a reverse shoulder prosthesis treated with either open reduction and internal fixation (ORIF) or revision shoulder arthroplasty. The purposes of the study were to (1) describe the treatment of these fractures by either method, (2) report the outcomes, and (3) assess the validity of a current classification system. METHODS Indications for surgery were a displaced unstable fracture, a fracture around a loose humeral stem, or a patient who was unable to tolerate conservative treatment. Outcomes were reported for two groups (patients treated with revision arthroplasty and those treated only with ORIF) and included American Shoulder and Elbow Surgeons (ASES) scores, radiographic evidence of fracture union, and complications. RESULTS The mean ASES score for the entire cohort was 50.3 (95% confidence interval: 41.2 to 59.5). Thirty-five of the thirty-six fractures healed, in a mean of 7.2 months (range, 3.25 to 13.5 months). Complications occurred in fourteen (39%) of the thirty-six patients. Our ability to classify these fractures with a previously defined system had a low interobserver reliability (mean kappa, 0.37; range, 0.24 to 0.50) and a high intraobserver reliability (mean kappa, 0.69; range, 0.52 to 0.89). CONCLUSIONS Periprosthetic fracture around a humeral stem implant is a difficult clinical problem involving complex decision-making. Fracture union occurred in 97% of our patients. Complications were frequent, and a reoperation was required in 19% of the patients. More than half of the patients in our study had a loose humeral component that required revision.

Fixed-angle locked plating of two-, three-, and four-part proximal humerus fractures.

Proximal humerus fractures are relatively common, accounting for 5% to 9% of all fractures.1-3 These fractures can pose a challenge for the treating orthopaedist because of the generally osteoporotic nature of bone in the elderly and the relative deforming forces of the surrounding muscles. Fractures are classified according to the Neer criteria, and treatment is often guided by the relative displacement of the anatomic fragments. Nondisplaced fractures have historically been treated conservatively, with generally good outcomes.4 Displaced fractures with angulation of the articular surface >45° and displacement of the major segments >1 cm have been treated surgically, as have fractures with substantial valgus impaction, all with mixed results.5-23 Surgical techniques have included percutaneous fixation, standard plate-and-screw fixation, intramedullary fixation with rods or pins, the use of tension bands with and without plates or rods, standard plate modification into blade plate constructs, and hemiarthroplasty.4-23 Many of these alternative open techniques were developed because of the high failure rates noted initially with standard plating. The inherent difficulties with internal fixation have led several authors to recommend hemiarthroplasty for the treatment of most threeand four-part humerus fractures.5,9,19,24,25 However, locked plates allow for more secure fixation in compromised bone, thereby possibly leading to reduced incidence of failure of internal fixation. Newer plates also incorporate suture eyelets that further enhance the fixation construct and resist deforming muscular forces. Additional investigation is necessary, but early results with locked plate fixation for the treatment of proximal humerus fractures have been encouraging. It is anticipated that this technique will provide another potentially viable alternative to prosthetic replacement for the treatment of these difficult injuries.