Sabrina Catanzaro

Latissimus Dorsi Tendon Transfer for Treatment of Irreparable Posterosuperior Rotator Cuff Tears Long-Term Results at a Minimum Follow-up of Ten Years

BACKGROUND Transfer of the latissimus dorsi tendon to the greater tuberosity of the humerus for treatment of an irreparable rotator cuff tear has been reported to yield good-to-excellent short to intermediate-term results in well-selected patients. The purpose of this study was to evaluate the long-term outcome of such transfers for irreparable posterosuperior rotator cuff tears to determine the durability of the results and to identify risk factors for an unfavorable outcome. METHODS Fifty-seven shoulders in fifty-five patients (seventeen women and thirty-eight men with a mean age of fifty-six years) were managed with latissimus dorsi tendon transfer. Final follow-up was performed at a mean of 147 months. Outcome measures included the Constant score and the Subjective Shoulder Value (SSV). Osteoarthritis, the acromiohumeral distance, and the so-called critical shoulder angle were assessed on standardized radiographs. RESULTS Forty-six shoulders in forty-four patients were available at the time of final follow-up. The mean SSV increased from 29% preoperatively to 70% at the time of final follow-up, the relative Constant score improved from 56% to 80%, and the pain score improved from 7 to 13 points (p < 0.0001 for all). Mean flexion increased from 118° to 132°, abduction increased from 112° to 123°, and external rotation increased from 18° to 33°. Mean abduction strength increased from 1.2 to 2.0 kg (p = 0.001). There was a slight but significant increase in osteoarthritic changes. Inferior results occurred in shoulders with insufficiency of the subscapularis muscle and fatty infiltration of the teres minor muscle. Superior functional results were observed in shoulders with a small postoperative critical shoulder angle. CONCLUSIONS Latissimus dorsi tendon transfer offered an effective treatment for irreparable posterosuperior rotator cuff tears, with substantial and durable improvements in shoulder function and pain relief. Shoulders with fatty infiltration of the teres minor muscle and insufficiency of the subscapularis muscle tended to have inferior results, as did those with a large critical shoulder angle. LEVEL OF EVIDENCE Therapeutic level IV. See Instructions for Authors for a complete description of levels of evidence.

The Latarjet procedure for the treatment of recurrence of anterior instability of the shoulder after operative repair: a retrospective case series of forty-nine consecutive patients.

BACKGROUND Recurrence of anterior shoulder instability after operative repair is an uncommon but disabling condition for which treatment options have been insufficiently studied. Coracoid transfer as described by Latarjet is a highly successful primary operation for recurrent anterior shoulder instability. The purpose of this study was to verify the hypothesis that this procedure is also effective for treating recurrent glenohumeral instability after previous operative repair. METHODS Forty-nine consecutive patients with either one (n = 32), two (n = 12), or at least three (n = 5) previous stabilizations other than a Latarjet procedure and recurrence of anterior glenohumeral instability associated with a lesion of the anterior aspect of the glenoid rim had revision with a coracoid transfer as described by Latarjet. Clinical outcomes at a mean of thirty-eight months postoperatively included the subjective shoulder value, the Constant-Murley score, and glenohumeral stability. Standardized anteroposterior and axial radiographs before and after the Latarjet revision were used to grade the degree of glenohumeral osteoarthritis. RESULTS The results in all forty-nine patients were reviewed. No shoulder redislocated, subluxations recurred in two patients, and five patients reported slight, unspecified shoulder symptoms. No revision surgery was needed. Forty-three shoulders (88%) were subjectively graded as excellent or good; three, fair; and three, poor. Dissatisfaction was associated with persistent pain, and patients with preoperative pain had a twentyfold higher probability of having postoperative pain. The mean subjective shoulder value increased from 53% preoperatively to 79% at the time of follow-up (p < 0.001), and the Constant-Murley score remained high (80% preoperatively and 85% at the time of follow-up; p = 0.061). Optimal graft placement was obtained in thirty cases and was related to better clinical outcome and less progression of osteoarthritis than was suboptimal graft placement. CONCLUSIONS Coracoid transfer as described by Latarjet can effectively restore anterior glenohumeral shoulder stability if previous operation(s) have failed to do so. If recurrence is associated with chronic pain, the pain is likely to persist and compromise the subjective outcome.

Clinical outcome of reverse total shoulder arthroplasty combined with latissimus dorsi transfer for the treatment of chronic combined pseudoparesis of elevation and external rotation of the shoulder

BACKGROUND Reverse total shoulder arthroplasty (RTSA) allows correction of pseudoparesis of elevation caused by irreparable rotator cuff tear but does not address loss of active external rotation. Latissimus dorsi transfer (LDT) is an established procedure for correction of pseudoparesis of external rotation. METHODS Forty-one shoulders of 40 consecutive patients, who were a mean age of 70 years old (range 47-85 years), underwent RTSA combined with LDT for irreparable rotator cuff failure with severe shoulder dysfunction. RESULTS Nine orthopedic complications occurred in 7 of the 41 shoulders. Four shoulders were lost to follow-up, and 5 were excluded from the functional analysis. The mean follow-up of the eligible 32 shoulders with the prosthesis still in place was 53 months (range, 24-105 months). The age-related Constant score increased significantly from a preoperative mean of 45% (range, 16%-80%) to 89% (range, 25%-100%). The mean subjective shoulder value increased from 33% (range, 0%-70%) to 75% (range, 30%-100%). Active external rotation significantly improved from a mean of 4° (range, -30° to 40°) to 27° (range, -10° to 70°). A preoperative external rotation lag sign could be corrected in 25 of the 32 shoulders. For the 16 shoulders with at least 5 years of follow-up, the Constant scores were 47% (range, 16%-80%) preoperatively, 92% (range, 51%-100%) at 2 years, and 94% (range, 57%-100%) at the latest follow-up, and the respective subjective shoulder values were 32% (range, 0%-70%), 73% (range, 30%-100%), and 80% (range, 60%-100%). CONCLUSION If treated with RTSA combined with LDT, patients with pseudoparesis of elevation and pseudoparesis of external rotation can expect an excellent clinical outcome for a period beyond 5 years, provided that complications that require removal of the prosthesis can be prevented.

Long-term Restoration of Anterior Shoulder Stability: A Retrospective Analysis of Arthroscopic Bankart Repair Versus Open Latarjet Procedure.

BACKGROUND Various operative techniques are used for treating recurrent anterior shoulder instability, and good mid-term results have been reported. The purpose of this study was to compare shoulder stability after treatment with the 2 commonly performed procedures, the arthroscopic Bankart soft-tissue repair and the open coracoid transfer according to Latarjet. METHODS A comparative, retrospective case-cohort analysis of 360 patients (364 shoulders) who had primary repair for recurrent anterior shoulder instability between 1998 and 2007 was performed. The minimum duration of follow-up was 6 years. Reoperations, overt recurrent instability (defined as recurrent dislocation or subluxation), apprehension, the subjective shoulder value (SSV), sports participation, and overall satisfaction were recorded. RESULTS An open Latarjet procedure was performed in 93 shoulders, and an arthroscopic Bankart repair was done in 271 shoulders. Instability or apprehension persisted or recurred after 11% (10) of the 93 Latarjet procedures and after 41.7% (113) of the 271 arthroscopic Bankart procedures. Overt instability recurred after 3% of the Latarjet procedures and after 28.4% (77) of the Bankart procedures. In the Latarjet group, 3.2% of the patients were not satisfied with their result compared with 13.2% in the Bankart group (p = 0.007). Kaplan-Meier analysis of survivorship, with apprehension (p < 0.001), redislocation (p = 0.01), and operative revision (p < 0.001) as the end points, documented the substantial superiority of the Latarjet procedure and the decreasing effectiveness of the arthroscopic Bankart repair over time. Twenty percent of the first recurrences after arthroscopic Bankart occurred no earlier than 91 months postoperatively, as opposed to the rare recurrences after osseous reconstruction, which occurred in the early postoperative period, with only rare late failures. CONCLUSIONS In this retrospective cohort study, the arthroscopic Bankart procedure was inferior to the open Latarjet procedure for repair of recurrent anterior shoulder dislocation. The difference between the 2 procedures with respect to the quality of outcomes significantly increased with follow-up time. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Long-term outcome of segmental reconstruction of the humeral head for the treatment of locked posterior dislocation of the shoulder

BACKGROUND Locked posterior glenohumeral dislocations with impaction fractures involving less than 30% to 35% of the humeral head are most frequently treated with lesser tuberosity transfer into the defect, whereas those involving more than 35% to 40% are treated with humeral head arthroplasty. As an alternative, reconstruction of the defect with segmental femoral or humeral head allograft has been proposed, but the long-term outcome of this joint-preserving procedure is unknown. METHODS Twenty-two shoulders in 21 patients with a locked posterior shoulder dislocation and an impaction of at least 30% (mean, 43%) of the humeral head were treated with segmental reconstruction of the humeral head defect. They were reviewed clinically and radiographically at a minimum follow-up of 5 years. RESULTS Of the 22 shoulders, 19 could be followed up at 128 months (range, 60-294 months) postoperatively. Only 2 of the 19 patients needed a prosthesis more than 180 months after the index operation. Of the other 17, 4 had radiographically advanced osteoarthritis (OA), 4 had mild OA, and 9 had no or minimal OA. Eighteen shoulders were rated as subjectively excellent, none were rated as good, and one was rated as fair. The final Constant-Murley score averaged 77 points (range, 52-98 points), the Subjective Shoulder Value averaged 88% (range, 75%-100%), and only 2 patients had mild to moderate pain. Mean active anterior elevation was 145°, and mean external rotation with the arm at the side was 42°. CONCLUSION Segmental reconstruction of humeral head defects for large anteromedial impaction fractures caused by locked posterior dislocations durably restores stability and freedom from pain with an excellent subjective long-term outcome.

Revision of reversed total shoulder arthroplasty. Indications and outcome.

BackgroundThe complications of reversed total shoulder arthroplasty (RTSA) requiring an additional intervention, their treatment options and outcome are poorly known. It was therefore the purpose of this retrospective study, to identify the reasons for revision of RTSA and to report outcomes.MethodsFour hundred and forty-one performed RTSA implanted between 1999 and 2008 were screened. Sixty-seven of these cases had an additional intervention to treat a complication. Causes were identified in these 67 cases and the outcome of the first 37 patients who could be followed for more than two years after their first additional intervention was analyzed.ResultsOf 441 RTSA, 67 cases (15%) needed at least one additional intervention to treat a complication, 30 of them needed a second, eleven a third and four a fourth additional intervention. The most common complication requiring a first intervention was instability (18%) followed by hematoma or superficial wound complications (15%) and complications of the glenoid component (12%). Patients benefitted from RTSA despite the need of additional interventions as indicated by a mean increase in total Constant-Murley score from 23 points before RTSA to 46 points at final follow-up (p < 0.0001).ConclusionsInstability, hematoma or superficial wound complications and complications of the glenoid component are the most common reasons for an additional intervention after RTSA. Patients undergoing an additional intervention as treatment of these complications profit significantly as long as the prosthesis remains in place.

Reverse total shoulder arthroplasty for acute head-splitting, 3- and 4-part fractures of the proximal humerus in the elderly.

BACKGROUND Anatomic reduction and stable internal fixation of complex proximal humeral fractures in the elderly is challenging. Secondary displacement, screw perforation, and humeral head necrosis are common complications. The outcome of hemiarthroplasty is unpredictable and strongly dependent on the uncertain healing of the greater tuberosity. This multicenter study retrospectively analyzes the midterm results of primary reverse total shoulder arthroplasty for the treatment of acute, complex fractures of the humerus in an elderly population. METHODS Fifty-two shoulders in 51 patients with a mean age of 77 years treated with reverse total shoulder arthroplasty for an acute, complex fracture of the proximal humerus were clinically and radiographically analyzed after a mean follow-up period of 35 months (range, 12-90 months). RESULTS There were no intraoperative complications. Revision surgery was performed in 4 shoulders. At final follow-up, the absolute and relative Constant scores averaged 62 points (range, 21-83 points) and 86% (range, 30%-100%), respectively, with a mean Subjective Shoulder Value of 83% (range, 30%-100%). Of the patients, 92% rated the treatment outcome as excellent or good. Patients with a resected or secondarily displaced greater tuberosity had an inferior clinical outcome to those with a healed greater tuberosity. CONCLUSION The midterm clinical results are predictably good, with low complication rates and a rapid postoperative recovery of painfree everyday function. If secondary displacement of the greater tuberosity occurs, revision surgery may warrant consideration in view of potential improvement of ultimate outcome.

Dynamic Imaging and Function of Partial Supraspinatus Tendon Tears

PURPOSE It was the purpose of this study to identify and document normal and abnormal supraspinatus tendon function in vivo using real-time ultrasound. METHODS We defined 4 groups of 20 individuals each: partial tear (group 1), full-thickness tear (group 2), successfully repaired tear (group 3), and healthy asymptomatic controls (group 4). Except for group 4, all patients underwent magnetic resonance arthrography to confirm the diagnosis. All underwent ultrasound imaging of the supraspinatus tendon with the adducted arm at rest and under maximal isometric abduction. Tendon deformation was dynamically assessed and measured with tendon thickness changes at 0.5, 1, 1.5, and 2 cm from the tendon insertion. The clinical assessment consisted of absolute and relative Constant score, subjective shoulder value, and strength measurements. RESULTS Without muscle contraction, the tendons of the 4 groups were not of significantly different thickness, with the least variation at 1.5 cm from the insertion site. On contraction, the normal tendon thickness significantly increased at a distance of 2 cm, whereas it did not for the full-thickness and partial supraspinatus tears. Thus contraction of the muscle resulted in measurable deformation of the tendon. CONCLUSIONS Partially torn supraspinatus tendons can be functionally incompetent, leading to a biomechanical deformation of the musculotendinous unit that is not different from that of a unit with a full-thickness tendon tear. The dynamic sonographic finding of a successful repair of a supraspinatus tendon is similar to that of a normal tendon, even though the previously injured muscle appears unable to generate the same strength as a normal muscle. LEVEL OF EVIDENCE Level III, case-control study.

Reverse total shoulder arthroplasty for failed open reduction and internal fixation of fractures of the proximal humerus

BACKGROUND Open reduction and internal fixation (ORIF) of complex fractures of the proximal humerus may yield unsatisfactory results. This study analyzed the results obtained after revision of failed ORIF of proximal humeral fractures using reverse total shoulder arthroplasty (RTSA). METHODS Fifty-four shoulders of 53 patients with a subjectively unacceptable outcome after ORIF of a complex fracture of the proximal humerus were revised with RTSA. At a minimum follow-up of 2 years (mean follow-up, 46 months; range, 24-108 months), 44 shoulders were clinically and radiographically reviewed for the purpose of this study. Six patients had been lost to follow-up, and 4 patients (7%) were excluded from functional analysis because of revision surgeries. RESULTS The mean absolute Constant score improved from 26 (range, 4-54) to 55 (range, 19-80) points; the mean relative Constant score improved from 32% (range, 4%-85%) to 67% (range, 27%-94%) of an age- and gender-matched, normal shoulder. The mean subjective shoulder value improved from 29% (range, 0%-90%) preoperatively to 67% (range, 5%-95%) at final follow-up. Nineteen patients rated their outcome excellent, 16 good, and 7 fair; 2 patients were dissatisfied. CONCLUSION RTSA is a valuable salvage procedure after failed ORIF of a proximal humeral fracture with relatively low revision rates. Shoulder function, patient satisfaction, and pain levels can be reliably improved.

Reverse total shoulder arthroplasty for massive, irreparable rotator cuff tears before the age of 60 years: long-term results

Background: There has been serious concern regarding the longevity and durability of outcomes of reverse total shoulder arthroplasty (RTSA) in younger patients. It was the purpose of this study to analyze long-term outcomes and complications of RTSA for irreparable rotator cuff tears in patients younger than 60 years. Methods: Twenty patients (23 shoulders) with a mean age of 57 years (range, 47 to 59 years) were evaluated at a mean of 11.7 years (range, 8 to 19 years) after RTSA. Fifteen shoulders (65%) had undergone previous non-arthroplasty surgery. Longitudinal clinical and radiographic outcomes were assessed. Results: At the time of final follow-up, the mean absolute and relative preoperative Constant score (CS) (and standard deviation) had improved from 24 ± 9 to 59 ± 19 points (p < 0.001) and from 29% ± 11% to 69% ± 21% (p < 0.001), respectively. The mean Subjective Shoulder Value (SSV) had increased from 20% ± 13% to 71% ± 27% (p < 0.001). There were also significant improvements in the mean active anterior elevation (from 64° to 117°), active abduction (from 58° to 111°), pain scores, and strength (all p ⩽ 0.001). Clinical outcomes did not significantly deteriorate beyond 10 years and the functional results of patients with previous surgical procedures were not significantly inferior to the results of those with primary RTSA. The grade of, and number of patients with, radiographically apparent notching increased over time; the mean relative CS was lower in patients in whom the notching was grade 2 or higher (57%) than it was in those with no or grade-1 notching (81%; p = 0.006). Nine (39%) had ≥1 complication, with 2 failed RTSAs (9%). Conclusions: RTSA in patients younger than 60 years leads to substantial subjective and functional improvement without clinical deterioration beyond 10 years. It is associated with a substantial complication rate, and complications compromise ultimate subjective and objective outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.