Search

Background Wedge-shaped porous metal augments were used to address bone deficiency in shoulder arthroplasty as part of a hybrid combination of high-density polyethylene, polymethyl methacrylate bone cement, and porous metal implant. This article presents an ongoing review of the use of the generically designed augments in the shoulder to address glenoid retroversion as part of anatomic total shoulder arthroplasty (aTSA). Materials Seventy-five shoulders in 66 patients (23 women and 43 men, aged 42-85 years) with Walch grade B2 or C glenoids underwent porous metal glenoid augment (PMGA) insertion as part of aTSA. Patients underwent preoperative 3-dimensional (3D) templating; based on that planning, patients received either a 15° or 30° PMGA wedge (secured by screws to the native glenoid) to correct excessive glenoid retroversion before a standard glenoid component was implanted using bone cement. Neither patient-specific guides nor navigation were used. Intraoperative glenoid alignment was assessed using a reusable guide that referenced the anterior scapular neck. Patients were prospectively assessed using shoulder functional assessments (Oxford Shoulder Score [OSS], American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], visual analog scale [VAS] pain scores, and forward elevation [FE]) preoperatively; at 3, 6, and 12 months postoperation; and yearly thereafter, with similar radiologic surveillance. Results Of the total consecutive series, 49 shoulders had a follow-up of greater than 24 months, with a median follow-up of 48 months (range: 24-87 months). For this cohort, median outcome scores improved for OSS (21 to 44), ASES (24 to 92), VAS (7 to 0), and FE (90° to 140°) from preoperative outcomes to the most recent review, respectively. Four patients died, but no others were lost to follow-up. Apart from 1 infection at 18 months postoperatively and 1 minor peg perforation, there were no complications, hardware failures, implant displacements, significant lucency, or posterior resubluxations. Radiographs showed good incorporation of the wedge augment, with correction of glenoid retroversion from median 22° (13° to 46°) to 4° (17° to anteversion 16°). All but 4 glenoids were corrected to within the target range (less than 10° retroversion), and only 2 glenoid components were implanted outside 15° of neutral glenoid version. Conclusions The porous metal wedge–shaped augments effectively addressed posterior glenoid deficiency as part of aTSA for rotator cuff intact osteoarthritis, producing satisfactory clinical outcomes with no signs of impending future failure.

Background This article reviews the clinical and radiographic outcomes in a noninferiority trial use of a transosseous knotless anchor to perform arthroscopic rotator cuff repairs in a patient cohort that have an increased incidence of osteoporosis. Methods Patients aged over 60 with a documented rotator cuff tear and who failed a rehab program underwent repair using an arthroscopic transosseous knotless (ATOK) anchor. Patients were prospectively reviewed using shoulder functional assessments (age-adjusted Constant score, Oxford Shoulder Score, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], visual analog scale [VAS] pain scores), and underwent preoperative as well as 1-, 3-, and 12-month postoperative magnetic resonance imaging. Results 15 patients had undergone rotator cuff repair using the ATOK and were followed for a minimum of 24 months (range 24-30 months). From preoperative to 24 months post repair, median scores improved for ASES (61-89), Oxford (26-44), Constant (62-91), and VAS Pain (5-0.5). Four patients developed a partial retear of their repair, but only 1 patient sustained a complete retear: Sugaya type I, 10; type II, 1; type III, 2; type IV, 1; and type V, 1. No anchors were displaced, and there were no osteolysis, neurologic, or technique-related complications. Conclusions Arthroscopic rotator cuff repairs using a transosseous knotless technique has achieved a satisfactory outcome in this group of patients, who typically have poor bone quality, increasing the risk of antegrade anchor pullout. This approach would appear to combine the potential biomechanical and biological advantages of a transosseous repair technique, with the benefits of the lower morbidity arthroscopic surgical approach.

Background Options to address glenoid retroversion include eccentric reaming, bone grafting, modifications to component shape, and reverse shoulder arthroplasty. Trabecular metal (TM) augments have been used extensively in the hip and knee to address bone deficiency in arthroplasty as part of a hybrid combination of high-density polyethylene, polymethyl methacrylate, and TM. This study presents the initial results of the use of specifically designed augments in the shoulder to address glenoid retroversion as part of total shoulder arthroplasty (TSA). Materials Ten patients (4 women and 6 men; aged 60 to 79 years) with Walch grade B2 or C glenoids have undergone TM glenoid augment insertion as part of a TSA, with a longer than 24-month follow-up. Patients received a 15° or 30° TM wedge to correct excessive glenoid retroversion before the glenoid component was cemented. Outcome analysis was performed preoperatively, at 3, 6, and 12 months, and yearly thereafter. Results All patients have been satisfied, and all scores have improved. There have been no complications and no hardware failures or displacement. All glenoid components were implanted to within 10° of neutral glenoid version. Radiographs at 24 months show good incorporation of the TM augment and the glenoid component. Conclusions The TM augments have the advantage of immediate secure fixation, no tendency to collapse, and the ability to correct retroversion of 25° or more. This study confirms the successful short-term outcome of wedge-shaped TM augments to correct glenoid retroversion as part of TSA.

Balanced forces around the shoulder are important for normal function; however, rehabilitation guidelines are not well defined because the muscle contributions and optimal exercise technique to recruit them are poorly understood. This study aimed to determine (1) the conditions of resisted isometric external rotation that optimized the contribution of infraspinatus and (2) the load of external rotation at which the adduction strategy was most effective at reducing deltoid contributions. Eighteen subjects with healthy shoulders (n = 36) performed resisted isometric external rotation at 3 increasing loads--10%, 40%, and 70% of their maximal resisted external rotation voluntary isometric contraction--with and without adduction. Surface electromyographic activity of the infraspinatus, posterior and middle deltoid, and pectoralis major was recorded and normalized against the average activity of all 4 muscles, representing each muscle's relative contribution to the task. To optimize the relative contribution of the infraspinatus with the least deltoid involvement during isometric external rotation, a load between 10% and 40% maximal voluntary isometric contraction is appropriate. At low loads, use of the adduction strategy during external rotation reduces middle deltoid involvement. In contrast, the posterior deltoid is activated in parallel with the infraspinatus at low loads and may even act as an adductor with the arm by the side. This study provides a useful guide to optimize rehabilitative exercises for rotator cuff dysfunction; in particular, highlighting that activation of the deltoid could be counterproductive to infraspinatus retraining.

We compared hemiarthroplasty (HA) and total shoulder replacement (TSR) for the treatment of osteoarthritis at minimum of 10 years from primary arthroplasty.Thirty-three patients (13 HA and 20 TSR) were intraoperatively randomized to HA or TSR after glenoid exposure and were assessed to a minimum of 10 years postoperatively. Apart from those who died, no patients were lost to follow-up.At 6 months and 1 year, the TSR patients had less pain than the HA patients (P.05), and this became more apparent at 2 years postoperatively (P.02). There were no statistically significant differences between the groups at 10 years with respect to pain, function, and daily activities. No patients in the HA group rated their shoulders as pain-free at 10 years; however, 42% of the surviving TSR patients rated their shoulders as pain-free at 10 years. Four HA patients were revised to TSR due to severe pain secondary to glenoid erosion. Two shoulders in the TSR group have been revised. Nine of the 13 HA patients (69%) and 18 of the 20 TSR patients (90%) remained in situ at death or at the 10-year review.TSR has advantages over HA with respect to pain and function at 2 years, and there has not been a reversal of the outcomes on longer follow-up. This longer-term review does not support the contention that HA will avoid later TSR complications, and in particular, an unacceptable rate of glenoid component failure.

Background This study assessed the intraobserver and interobserver reliability of a binary classification system using an easy-to-remember acronym (the HGLS system—based on the reappraisal of Codman's description by Hertel et al) and compared it with the AO and Neer systems. Materials and methods Forty-seven proximal humeral fractures in 47 patients treated at the Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia, were identified in the period from July 2007 until January 2008. Fractures of the proximal humerus were examined with anteroposterior, lateral, and axillary radiographs. Three independent reviewers classified the fractures using the AO, Neer, and HGLS systems. Reclassification of the same fractures was undertaken after a 6-month interval, and interobserver and intraobserver correlation, by use of the κ statistic, was calculated for all 3 classification systems. Results The mean age of patients was 64.5 years (range, 16-95 years). The interobserver correlations for the AO system (κ value, 0.47) and Neer system (κ value, 0.44) were graded as poor and were consistent with the values of previously published studies. The HGLS classification showed good interobserver agreement for all 3 examiners at the first interpretation (κ value, 0.73) and second interpretation (κ value, 0.61). Good intraobserver agreement after a 6-month period was also seen for the HGLS classification (κ values, 0.87-0.92) compared with the AO system (κ, 0.61-0.71) and Neer system (κ, 0.42-0.77). Conclusion The HGLS system provided a more reliable description of fractures of the proximal humerus compared with the Neer and AO systems. Further studies are necessary to assess the validity of the HGLS system.

Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, South Australia, AustraliaSoft-tissue sarcomas are the most common malignancyof the extremities. Treatment is intense, and morbidity andmortality rates are high. The upper extremity accounts foraround 20% of all soft-tissue sarcomas

A principal cause of subacromial impingement (SAI) is failure of the rotator cuff to center the humeral head in the glenoid during shoulder motion, counteracting the effect of the deltoid. As rehabilitation of the rotator cuff endeavors to restore balance between these muscle groups, the purpose of this companion study was to evaluate, in the symptomatic shoulders of patients with SAI, (1) the conditions of resisted isometric external rotation (ER) that optimized the contribution of the infraspinatus and (2) the load of ER at which adduction was most effective at reducing the deltoid contribution and then to compare this with the relative contribution of the infraspinatus and the posterior and middle deltoid in asymptomatic shoulders. In 14 subjects (18 shoulders) with SAI, surface electromyographic activity of the infraspinatus and the posterior and middle deltoid and pectoralis major was recorded at low, medium, and high loads of resisted isometric ER, with and without adduction. These data were normalized to find each muscle's relative contribution to the task and were compared with normalized data from subjects with healthy shoulders. In subjects with SAI, low loads of isometric ER (10%-40% maximum voluntary isometric contraction) optimized the relative contribution of the infraspinatus. Adduction with isometric ER at 10% maximum voluntary isometric contraction reduced the middle deltoid involvement. Higher loads preferentially activated the middle deltoid over the infraspinatus and may have effected unwanted humeral head superior translation, counteracting the presumed benefits of rotator cuff ER exercises. An individualized loading regimen and the use of surface electromyography may have significant implications during rotator cuff rehabilitation. Refereed/Peer-reviewed

Selective denervation of the infraspinatus muscle producing weakness and wasting has been reported in certain sports (eg, volleyball and baseball). Nerve kinking or friction caused by excessive infraspinatus motion and compression by superior or inferior transverse scapular ligament or ganglions have been proposed as possible causes. However, in extreme abduction with full external rotation of the shoulder, the medial tendinous margin between the infraspinatus and supraspinatus muscles impinges strongly against the lateral edge of scapular spine, compressing the intervening infraspinatus branch of the suprascapular nerve. Spinaglenoid notchplasty has been performed in 5 elite volleyball players with infraspinatus neuropathy, allowing recovery of shoulder function in all patients and correction of infraspinatus muscle wasting. All returned to the same or higher level of volleyball by 8 months after surgery. An alternative cause of infraspinatus compromise in volleyball players is proposed and has been treated surgically with satisfactory outcome.