Stephen A. Copeland

Cementless surface replacement arthroplasty of the shoulder. 5- to 10-year results with the Copeland mark-2 prosthesis.

Cementless surface replacement arthroplasty of the shoulder is designed to replace the damaged joint surfaces and restore normal anatomy with minimal resection of bone. We have used the Copeland shoulder arthroplasty for 14 years. Between 1986 and 2000, 285 surface replacement arthroplasties were implanted in our unit. The prosthesis has evolved during this time, but the principle of minimal bone resection has remained the same. Between 1990 and 1994, 103 Mark-2 prostheses were inserted into 94 patients (9 bilateral). The operations were carried out for the treatment of osteoarthritis, rheumatoid arthritis, avascular necrosis, instability arthropathy, post-traumatic arthropathy and cuff arthropathy. The mean follow-up was for 6.8 years (5 to 10). The best results were achieved in primary osteoarthritis, with Constant scores of 93.7% for total shoulder replacement and 73.5% for hemiarthroplasty. The poorest results were seen in patients with cuff arthropathy and post-traumatic arthropathy with adjusted Constant scores of 61.3% and 62.7%, respectively. Most patients (93.9%) considered their shoulder to be much better or better than before the operation. Of the 88 humeral implants available for radiological review, 61 (69.3%) showed no evidence of radiolucency, nor did 21 (35.6%) of the 59 glenoid prostheses. Three were definitely loose, and eight shoulders required revision (7.7%), two (1.9%) for primary loosening. The results of this series are comparable with those for stemmed prostheses with a similar follow-up and case mix. The cementless surface replacement arthroplasty diminishes the risk of complications involving the humeral shaft and periprosthetic fractures. Revision or arthrodesis can be undertaken easily since the bone stock has been maintained with no loss of length.

Copeland surface replacement arthroplasty of the shoulder in rheumatoid arthritis.

BACKGROUND Shoulder arthroplasty with a stemmed prosthesis is a recognized treatment for rheumatoid arthritis of the shoulder. The humeral component of the Copeland cementless surface replacement arthroplasty consists of a cup for surface replacement with a short central peg for primary fixation to the bone. We hypothesized that surface replacement may offer some advantages over stemmed prostheses. METHODS Between 1986 and 1998, seventy-five shoulders underwent surface replacement arthroplasty (thirty-three hemiarthroplasties and forty-two total shoulder arthroplasties) for the treatment of rheumatoid arthritis. The results of these procedures were reviewed after an average duration of follow-up of 6.5 years. Patients were assessed with use of the Constant score, a patient satisfaction score, and radiographs. RESULTS The average Constant score was 47.9 points (age and sex-adjusted score, 71%) in the hemiarthroplasty group and 53.4 points (age and sex-adjusted score, 76%) in the total shoulder replacement group. The mean range of active flexion improved from 50 degrees in the hemiarthroplasty group and 47 degrees in the total shoulder replacement group to 101 degrees and 104 degrees, respectively. Seventy-two of the seventy-five shoulders were considered by the patients to be much better or better at the time of the review. Of the sixty-eight humeral implants that were evaluated radiographically, fifty-six (82%) showed no lucencies, eleven (16%) showed localized lucencies of <1 mm in width, and one was definitely loose. Of the thirty-nine glenoid implants that were evaluated radiographically, nineteen (49%) showed no lucencies, nineteen showed localized lucencies of <1 mm, and one was definitely loose. No lucencies were observed adjacent to the hydroxyapatite-coated implants. Thirty-nine (57%) of the sixty-eight shoulders showed some degree of superior subluxation. Three patients required a major reoperation: two required a revision because of loosening of both components, and one patient with pain at the site of a hemiarthroplasty had a revision to a total shoulder arthroplasty to provide relief. CONCLUSIONS The indications for this surface replacement are the same as those for the conventional stemmed prostheses, but the surface replacement has the advantage of bone preservation as well as avoidance of the potential complications associated with a long humeral stem in rheumatoid bone. This procedure is not suitable for severely damaged joints in which the humeral head is insufficient or too soft. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

The role of anterior deltoid reeducation in patients with massive irreparable degenerative rotator cuff tears

The management of massive rotator cuff tears in medically unfit, elderly patients is difficult. We prospectively assessed 17 patients with radiologically confirmed, nontraumatic, massive rotator cuff tears who were treated with an anterior deltoid rehabilitation program. All patients were medically unfit, with an average age of 80 years (range, 70-96 years). Patients were given standard detailed instruction and an illustrated guide. A video recording of shoulder motion was made before and after treatment. The Constant score increased from a mean of 26 (range, 8-41) before treatment to a mean of 60 (range, 43-77) at a minimum of 9 months after treatment. Range of motion in forward elevation improved from a mean of 40 degrees (range, 30 degrees -60 degrees ) at presentation to a mean of 160 degrees (range 150 degrees -180 degrees ) after the deltoid rehabilitation course. We recommend that a structured deltoid rehabilitation program is suitable for elderly patients with massive rotator cuff tears.

Wear in the Prosthetic Shoulder: Association With Design Parameters

Total replacement of the glenohumeral joint provides an effective means for treating a variety of pathologies of the shoulder. However, several studies indicate that the procedure has not yet been entirely optimized. Loosening of the glenoid component remains the most likely cause of implant failure, and generally this is believed to stem from either mechanical failure of the fixation in response to high tensile stresses, or through osteolysis of the surrounding bone stock in response to particulate wear debris. Many computational studies have considered the potential for the former, although only few have attempted to tackle the latter. Using finite-element analysis an investigation, taking into account contact pressures as well as glenohumeral kinematics, has thus been conducted, to assess the potential for polyethylene wear within the artificial shoulder. The relationships between three different aspects of glenohumeral design and the potential for wear have been considered, these being conformity, polyethylene thickness, and fixation type. The results of the current study indicate that the use of conforming designs are likely to produce slightly elevated amounts of wear debris particles when compared with less conforming joints, but that the latter would be more likely to cause material failure of the polyethylene. The volume of wear debris predicted was highly influenced by the rate of loading, however qualitatively it was found that wear predictions were not influenced by the use of different polyethylene thicknesses nor fixation type while the depth of wearing was. With the thinnest polyethylene designs (2 mm) the maximum depth of the wear scar was seen to be upwards of 20% higher with a metal-backed fixation as opposed to a cemented design. In all-polyethylene designs peak polymethyl methacrylate tensile stresses were seen to reduce with increasing polyethylene thickness. Irrespective of the rate of loading of the shoulder joint, the current study indicates that it is possible to optimize glenoid component design against abrasive wear through the use of high conformity designs, possessing a polyethylene thickness of at least 6 mm.

Subacromial decompression: TREATMENT FOR SMALL- AND MEDIUM-SIZED TEARS OF THE ROTATOR CUFF

We report the results of arthroscopic subacromial decompression and debridement of the rotator cuff for chronic small- and medium-sized tears in 114 patients (118 shoulders) between two and five years after surgery. The mean Constant score was improved to 69.8, and 88 shoulders (74.6%) had a satisfactory outcome. Of patients under the age of 60 years the outcome was satisfactory in 59.3%, and in those over 60 years, in 87.5% (p < 0.001). An unsatisfactory outcome was related to manual work (p < 0.001) and a duration of symptoms of more than 12 months (p < 0.05). The outcome was not related to the size of the tear, the muscles involved or biceps pathology. Further surgery was required in 25 patients after a mean of 13.7 months (3 to 35); ten tears had progressed in size, but none became irreparable. There was no relationship between the increase in the size of the tear and its initial size, the muscles involved or the presence of biceps pathology. No tear became smaller with time.

Surface replacement arthroplasty for glenohumeral arthropathy in patients aged younger than fifty years: results after a minimum ten-year follow-up

BACKGROUND The role of cementless surface replacement arthroplasty (CSRA) in young individuals is currently unclear. The aim of this study was to evaluate CSRA long-term results for glenohumeral arthritis in young patients. METHODS Between 1990 and 2003, 54 CSRAs were performed on 49 patients (25 men, 24 women) aged younger than 50 years. Mean age was 38.9 years (range, 22-50 years). Three patients (4 shoulders) died over time and 8 were lost to follow-up, leaving 38 patients (42 shoulders) with a mean follow-up of 14.5 years (range, 10-25 years). There were 17 total shoulder replacements with metal back glenoid, and 37 underwent humeral head resurfacing with microfracture of the glenoid. RESULTS The indications were avascular necrosis, 16; rheumatoid arthritis, 20; instability arthropathy, 7; primary osteoarthritis, 5; fracture sequelae, 3; postinfection arthritis, 2; and psoriatic arthritis, 1. The mean relative Constant score increased from 11.5% to 71.8% (P < .0001), and the mean patient satisfaction at final follow-up was 8.7 of 10. The mean relative Constant score for the humeral head resurfacing with microfracture of the glenoid improved to 77.7% compared with 58.1% for total resurfacing arthroplasty. Two required early arthrodesis due to instability and deep infection. Seven were revised to stemmed prosthesis: 1 for traumatic fracture and 1 for glenoid erosion 16 years after the index procedure. Five shoulders in 4 patients (4 rheumatoid arthritis, 1 avascular necrosis) were revised at 8 to 14 years after surgery for cuff failure and loosening. Three were revised to stemless reverse total shoulder arthroplasty due to rotator cuff failure at 23, 16, and 13 years after surgery. CONCLUSIONS CSRA provides good long-term symptomatic and functional results in the treatment of glenohumeral arthropathy in patients aged younger than 50 years in 81.6% of the patients. This improvement is maintained over more than 10 years after surgery, with high patient satisfaction (8.7 of 10). However, 10 shoulders (of 54) (18.5%) underwent revision arthroplasty. Resurfacing offers a valuable tool in treating young patients with glenohumeral arthritis, providing reasonably good long-term results in 81.6% of the patients, while allowing preservation of bone stock if the need for revision arises. All the revision arthroplasty options are preserved, including less invasive procedures.

Arthroscopic capsular release for posttraumatic shoulder stiffness

Severe pain and shoulder stiffness after soft tissue trauma or fracture is a major cause of dysfunction. Some patients may have residual, resistant, significant shoulder stiffness that causes long-term functional impairment. This study reports the results of arthroscopic capsular release in 21 patients who presented with posttraumatic stiff shoulders resistant to nonoperative therapy. They underwent arthroscopic circumferential capsular and subacromial release of adhesions under interscalene block, followed with immediate regular physiotherapy. A highly significant improvement in the range of motion (ROM) was achieved immediately postoperatively (P < .0001). At 6 months, a mean 48% of the ROM gain was lost. Thereafter, ROM steadily improved to a mean net gain of 110% compared with the immediate postoperative time (mean follow-up, 33 months). Most patients (95%) expressed satisfaction with their outcome. Arthroscopic capsular release is a useful treatment for resistant posttraumatic stiff shoulder, particularly to alleviate of pain and restore a functional ROM.

Resurfacing Arthroplasty of the Shoulder

The design of the Copeland surface replacement arthroplasty has evolved over the past 20 years but the basic concept and design of the surface replacement, including minimal removal of bone and cementless fixation, has remained constant. The indications and surgical technique have been refined over this period. The surface replacement prosthesis has demonstrated clinical results at least equal to those of conventional stemmed prostheses. The specific advantages of a surface replacement over a stemmed prosthesis include minimal bone resection, which aids revision surgery, and the absence of a stem avoids shaft stress fractures. The indications, surgical technique and results of the Copeland surface replacement arthroplasty are presented.

Medium to long-term outcome of thoracoscapular arthrodesis with screw fixation for facioscapulohumeral muscular dystrophy

BACKGROUND Shoulder girdle muscle weakness is the most constant feature of facioscapulohumeral muscular dystrophy and leads to scapular winging. Mechanical fixation of the scapula to the thoracic wall provides a stable fulcrum on which the deltoid muscle can exert its action on the humerus. The aim of this study was to evaluate the medium to long-term outcome of thoracoscapular arthrodesis with screw fixation (the modified Howard-Copeland technique). METHODS All patients with facioscapulohumeral dystrophy who underwent thoracoscapular arthrodesis with screw fixation and bone-grafting from July 1997 to July 2010 were retrospectively reviewed. Preoperative and postoperative clinical assessment included active shoulder elevation, the Constant score, a patient satisfaction score, and cosmetic satisfaction. Union was determined both clinically and radiographically. RESULTS Thoracoscapular arthrodesis was performed in thirty-five shoulders in twenty-four patients; eleven patients underwent bilateral procedures. The principal study group consisted of thirty-two shoulders in twenty-one patients with a minimum follow-up of twenty-four months (mean, eighty-eight months; range, twenty-four to 174 months). The mean Constant score increased from 30 (range, 17 to 41) preoperatively to 61 (range, 30 to 90) postoperatively. The mean satisfaction score increased from 1 (range, 0 to 4) to 8.4 (range, 4 to 10). Early complications consisted of one pneumothorax, one superficial wound infection, and four early failures, two of which were associated with noncompliance with the postoperative regimen. Late complications consisted of one posttraumatic fracture resulting in loosening and one painful nonunion; both were treated successfully with revision. CONCLUSIONS Thoracoscapular arthrodesis with screw fixation prevented scapular winging and improved short-term and long-term shoulder function in patients with facioscapulohumeral dystrophy. LEVEL OF EVIDENCE Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

Suturing arthroscopy wounds: brief report

The number of arthroscopic procedures has increased dramatically durlng recent years. One of their advantages is that complications are rare ; those that do occur (a stitch abscess or a haematoma) are usually related to the small puncture wounds. Since a 5 mm wound of the knee presenting as an injury would not be sutured, it was felt to be illogical to suture an arthroscopy incision ; a sutureless technique was therefore tested. Method and results. Over a one-year period, a sutureless technique was used in all 140 patients undergoing arthroscopic procedures of the knee under the care of one surgeon (SC). The vast majority were done through standard anteromedial and anterolateral portals, although occasionally a third (posteromedial or transpatellar ligament) was used. Gravity-feed irrigation only was employed. At the end of the arthroscopic procedure but before removing the tourniquet, a gauze dressing and wool-and-crepe pressure bandage were applied. Postoperatively the patients were taught exercises and were mobilised the same day. They were not given antiinflammatory drugs and were subsequently reviewed at two weeks and at two months. There were no complications related to the wounds and, in particular, no haematomas or infection. In a number of cases inspection of the gauze dressing at two weeks revealed a significant blood seepage which could well have resulted in the formation of a haematoma predisposing to subsequent wound infection had the wound been sutured. The cosmetic results were excellent ; in a few patients one puncture wound was sutured and the other left open ; the unsutured wound was definitely neater. Discussion. Standard orthopaedic texts advocate the use of a single stitch to close an arthroscopy wound (Edmonson and Crenshaw 1980 ; Dandy 1981 ; Apley and Solomon 1982). Dandy (1981) states that “a stitch will close the deeper layers of the wound more effectively and reduce the risk of a haematoma developing “. It is our view that a large and deep stitch would be necessary to achieve this objective. Leaving the wound open allows any potential haematoma to evacuate into the dressings so that blood cannot accumulate and cannot be the potential site of infection. This is borne out by the results of our series. The possibility of stitch-abscess formation is also obviously averted if no stitch is used. Arthroscopy wounds rarely cause a cosmetic prob1cm, but they can be significant in an adolescent girl’s knee or in those prone to keloid formation. Often the ugliest part of the scar is the cross-hatching from the suture. With the sutureless technique the cosmetic appearance of the wounds was excellent ; they closed in a linear fashion and were unobtrusive. Savings in the cost of suture materials are a bonus. Leaving arthroscopy wounds open is safe, cosmetic, effective and economical.