T. Bradley Edwards

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.

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.

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.

Radiographic analysis of bone defects in chronic anterior shoulder instability

PURPOSE To describe the incidence of bony lesions accompanying chronic anterior shoulder instability using fluoroscopically controlled radiography. TYPE OF STUDY Case series of radiographic findings of patients with chronic anterior shoulder instability. METHODS Radiographs of 160 shoulders in 156 patients with recurrent anterior shoulder instability were retrospectively evaluated; 132 shoulders had experienced recurrent dislocations, 18 shoulders had experienced recurrent subluxations, and 10 shoulders showed evidence of anterior instability at arthroscopy despite no reported history of instability. Fluoroscopically controlled radiographic views included an anteroposterior view with the humeral head in 3 rotations and a glenoid profile view with a comparison view of the contralateral shoulder. RESULTS A humeral impaction fracture was identified on the anteroposterior radiographs in 117 of 160 shoulders (73.1%). The glenoid profile view showed an osseous lesion of the glenoid in 126 of 160 shoulders (78.8%). The anteroposterior radiograph showed an osseous lesion of the glenoid in an additional 13 shoulders (8.2%). Overall, an osseous lesion, either humeral or glenoid, was identified in 152 of 160 shoulders (95.0%). CONCLUSIONS This study shows the frequent presence of bony lesions in patients with anterior shoulder instability.

The effect of placing a tensioned graft across open growth plates. A gross and histologic analysis.

Background: Midsubstance tears of the anterior cruciate ligament in skeletally immature patients are increasingly common and are a challenging problem. The results of nonoperative treatment are no better in children than they are in adults. Physeal-sparing reconstructive procedures have yielded poor results. Reconstructive procedures that are utilized in adults violate the physis, potentially resulting in growth abnormalities. The objective of this study was to provide a model for reconstruction of the anterior cruciate ligament in skeletally immature patients by evaluating the effects of a tensioned connective-tissue graft placed across the canine physis. Methods: Twelve ten-week-old beagles underwent reconstruction of the anterior cruciate ligament consisting of placement of fascia lata autograft through drill-holes across the femoral and tibial physes, tensioning of the graft to 80 N, and fixing it with screws and washers. The contralateral limb served as a control. One dog was eliminated from the study secondary to a postoperative infection. Four months postoperatively, the dogs were killed and were inspected grossly, radiographically, and histologically for any evidence of growth disturbance. Results: Significant valgus deformity of the distal part of the femur (p < 0.001) and significant varus deformity of the proximal part of the tibia (p = 0.03) developed in the treated limbs. Neither radiographic nor histologic examination demonstrated any evidence of physeal bar formation.Conclusions: Significant growth disturbances occur with excessively tensioned transphyseal reconstruction of the anterior cruciate ligament in the canine model. These growth disturbances occur without radiographic or histologic evidence of physeal bar formation. Clinical Relevance: This study illustrates the risk to the physis associated with transphyseal reconstruction of the anterior cruciate ligament with the use of a tensioned connective-tissue graft in skeletally immature patients. We do not recommend transphyseal reconstruction of the anterior cruciate ligament in this patient population.

Repair of Tears of the Subscapularis

BACKGROUND Rotator cuff tears involving the subscapularis are less common than those involving the superior aspect of the rotator cuff. The purpose of the present study was to report the results of repair of isolated tears of the subscapularis. METHODS The records on eighty-four shoulders that had undergone open repair of the subscapularis tendon were reviewed. The mean age of the patients at the time of surgery was 53.2 years. The mean interval from the onset of symptoms to the time of surgery was 12.5 months. Fifty-seven tears were traumatic, and twenty-seven were degenerative. Twenty-three tears involved the superior one-third of the subscapularis tendon, forty-one tears involved the superior two-thirds, and twenty tears were complete. Fifty-four shoulders had a dislocation or subluxation of the long head of the biceps tendon, and ten shoulders had a rupture of the long head of the biceps tendon. Forty-eight shoulders underwent concomitant biceps tenodesis, thirteen shoulders underwent concomitant biceps tenotomy, and four shoulders underwent concomitant recentering of the biceps. Patients were evaluated clinically and radiographically at a mean of forty-five months (range, twenty-four to 132 months) postoperatively. RESULTS The mean Constant score increased from 55.0 points preoperatively to 79.5 points postoperatively. Seventy-five patients were satisfied or very satisfied with the result. Preoperatively, four shoulders had mild glenohumeral arthritis. Postoperatively, twenty-five shoulders had mild glenohumeral arthritis and two shoulders had moderate glenohumeral arthritis. Tenodesis or tenotomy of the biceps tendon at the time of subscapularis repair was associated with improved subjective and objective results, independent of the preoperative condition of the biceps tendon. CONCLUSIONS Repair of isolated subscapularis tears yields acceptable improvement in shoulder function in selected patients. Additionally, the results of the present study support routine tenodesis or tenotomy of the long head of the biceps tendon at the time of subscapularis repair.

The influence of rotator cuff disease on the results of shoulder arthroplasty for primary osteoarthritis: results of a multicenter study.

Background: Rotator cuff disease is uncommon in primary glenohumeral osteoarthritis. Consequently, the prognostic implications of rotator cuff disease in patients undergoing prosthetic replacement for the treatment of primary glenohumeral osteoarthritis are uncertain. The purpose of this study was to report the effects of the condition of the supraspinatus tendon and the rotator cuff musculature on the results of shoulder arthroplasty in the treatment of primary osteoarthritis.Methods: Five hundred and fifty-five shoulders in 514 patients who had an arthroplasty for the treatment of primary glenohumeral osteoarthritis as part of a multicenter study were evaluated. Forty-one shoulders had a partial-thickness tear of the supraspinatus, and forty-two had a full-thickness tear. Ninety shoulders had moderate (stage-2) fatty degeneration of the infraspinatus, and nineteen had severe (stage-3 or 4) degeneration. Eighty-four shoulders had moderate fatty degeneration of the subscapularis, and fifteen had severe degeneration. The influence of the condition of the supraspinatus tendon and the infraspinatus and subscapularis musculature on the postoperative outcome was evaluated with respect to the scores according to the system of Constant and Murley, active mobility, subjective satisfaction, radiographic result, and rate of complications.Results: The shoulders were evaluated at a mean of 43.1 months postoperatively. With the numbers available, supraspinatus tears were not found to influence the postoperative outcome with respect to the total Constant score, active mobility, subjective satisfaction, radiographic result, or rate of complications. Additionally, the treatment of these tears did not markedly influence the outcome parameters. Conversely, both shoulders with moderate fatty degeneration and those with severe degeneration of the infraspinatus were associated with poorer results than those with no degeneration with respect to the total Constant score (p < 0.0005), active external rotation (p < 0.0005), active forward flexion (p = 0.001), and subjective satisfaction (p = 0.031). Similar although less dramatic results were seen with fatty degeneration of the subscapularis.Conclusions: This study demonstrates that minimally retracted or nonretracted rotator cuff tears that are limited to the supraspinatus tendon do not appreciably affect most shoulder-specific outcome parameters in shoulder arthroplasty performed for the treatment of primary osteoarthritis. Conversely, fatty degeneration of the infraspinatus and, less importantly, subscapularis musculature adversely affects many of these parameters.

The Influence Of Glenohumeral Prosthetic Mismatch On Glenoid Radiolucent Lines: Results Of A Multicenter Study

Background: In shoulder arthroplasty, mismatch is defined as the difference in the radius or diameter of curvature between the humeral head and glenoid components. Recommendations for mismatch have not been substantiated scientifically. The purpose of this study was to evaluate the effect of mismatch on glenoid radiolucent lines.Methods: The results of 319 total shoulder arthroplasties performed for the treatment of primary osteoarthritis were evaluated. All of the arthroplasties were performed with a single type of prosthesis (Aequalis; Tornier, Montbonnot, France) that included a cemented, all-polyethylene glenoid component. Three sizes of glenoid components and seven humeral head diameters were utilized. Radial mismatch was categorized as ≤4 mm, 4.5 to 5.5 mm, 6 to 7 mm, or >7 to 10 mm. Radiographs were evaluated at a mean of 53.5 months (range, twenty-four to 110 months) postoperatively. Glenoid radiolucent lines were scored with a scale ranging from 0 points for no radiolucency to 18 points for radiolucent lines exceeding 2 mm in six zones. Variance, linear contrasts polynomial, quadratic polynomial contrast statistical, and linear regression analyses were performed to evaluate the relationship between radial mismatch and glenoid radiolucent lines.Results: A significant linear relationship was found between mismatch and the glenoid radiolucency score (p < 0.0001), with significantly lower (better) radiolucency scores associated with radial mismatches of >5.5 mm.Conclusions: In this study of glenohumeral prosthetic mismatch ranging from 0 to 10 mm, the mismatch had a significant influence on the scores for the glenoid radiolucent lines, which were best when the radial mismatch was between 6 and 10 mm. The theoretical risk of prosthetic instability with larger mismatch values was not demonstrated within the range of mismatch values evaluated in this series.

Subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty

HYPOTHESIS Dislocation is the most common serious complication after reverse shoulder arthroplasty. One theorized cause is subscapularis insufficiency because the tendon cannot be repaired at the time of surgery. There are no documented risk assessments of reverse total shoulder arthroplasty dislocation related to this cause. The study objective was to quantify the risk of postoperative dislocation after reverse total shoulder arthroplasty in patients with a subscapularis tendon that was irreparable at the time of surgery. METHOD A prospective evaluation was done of 138 consecutive reverse arthroplasties performed through a deltopectoral approach by a single surgeon (average follow-up, 36 months). RESULTS The subscapularis was reparable in 62 patients and irreparable in 76 at the conclusion of the procedure. Seven postoperative dislocations occurred; all dislocations were in patients whose subscapularis was irreparable (P = .012). Dislocations were more likely in patients with complex diagnoses, including proximal humeral nonunion, fixed glenohumeral dislocation, and failed prior arthroplasty. CONCLUSIONS This report documents that an irreparable subscapularis tendon at the time of reverse total shoulder arthroplasty using a deltopectoral approach results in a statistically significant risk for postoperative dislocation. LEVEL OF EVIDENCE Level IV, Case Series, Treatment Study.

Indications for Reverse Total Shoulder Arthroplasty in Rotator Cuff Disease

BackgroundReverse total shoulder arthroplasty (RTSA) was introduced to treat rotator cuff tear arthropathy but is now used to treat a variety of problems. Although its use has expanded substantially since the FDA’s approval in 2004, the appropriateness in patients with rotator cuff disease is unclear.Questions/purposesWe review the use of RTSA in patients with rotator cuff disease to (1) describe classification of rotator cuff tear reparability and the concept of a balanced shoulder; (2) explore the theory behind RTSA design relative to rotator cuff arthropathy; (3) discuss the indications and contraindications for RTSA; and (4) review published outcomes of RTSA for rotator cuff arthropathy.MethodsWe performed a selective review of the literature on the use of RTSA in the treatment of rotator cuff disease.ResultsModern RTSA designs restore deltoid tension and a functional fulcrum to the rotator cuff deficient shoulder, which allows recovery of active shoulder elevation and effectively restores function in short- and medium-term followup studies.ConclusionsIn short-term followup the RTSA relieves symptoms and restores function for patients with cuff tear arthropathy and irreparable rotator cuff tears with pseudoparalysis (preserved deltoid contraction but loss of active elevation). Severely impaired deltoid function, an isolated supraspinatus tear, and the presence of full active shoulder elevation with a massive rotator cuff tear and arthritis are contraindications to RTSA.Clinical RelevanceFor properly selected patients who have symptomatic and disabling rotator cuff deficiency, RTSA can result in life-changing improvements in pain, motion, function, and patient satisfaction.Level of EvidenceLevel V therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.