Aims

The aim of this study was to describe a quantitative 3D CT method to measure rotator cuff muscle volume, atrophy, and balance in healthy controls and in three pathological shoulder cohorts.

Aims

The aim of this study was to report the outcomes of different treatment options for glenoid loosening following reverse shoulder arthroplasty (RSA) at a minimum follow-up of two years.

BACKGROUND:

Bony healing of tuberosities around shoulder prostheses is difficult to obtain in the elderly patient. We hypothesized that reattachment of the tuberosities, performed in combination with bone grafting, around a specific reverse shoulder fracture-prosthesis (RSFP) would favour improved tuberosity healing and shoulder mobility in elderly patients with displaced proximal humerus fractures.

Purpose

to analyze the survivorship of the RSA with a minimum 10 years follow up.

Purpose of the study: For patients aged less than 65 years who have a large rotator cuff tear, potential solutions include anatomic repair, palliative treatment, non-anatomic repair with flaps or cuff prosthesis, and reversed prosthesis. The later solution is not recommended at this age and anatomic repair is not always possible. In this situation, what is best, palliative treatment or flap or prosthesis repair?

Material and method: This retrospective multicentric study included 142 patients, 74 men and 68 women with a large or massive cuff tear. Palliative treatment (group A) involved acromioplasty (n=48) associated as needed with a biceps procedure and partial repair (n=41). Non-anatomic repair (group B) included supra-spinatous translation (n=16), deltoid flaps (n=22), and cuff prostheses (n=15). Preoperatively, the two groups were not statistically different for acromiohumeral height (AH, 6 mm in group A versus 7.5 mm in group B) and percent of fatty infiltration of the infraspinatus > II (55% in group A versus 26% in group B). The Constant score, active and passive range of motion, gain in elevation and external rotation were noted.

Results: Mean follow-up was 74 months in group A and 90 months in group B; the Constant score was 64 and 65, active elevation 145 and 147 and external rotation 17 and 26 respectively. The two groups were not significantly different. For patients with deficient elevation (n=46), the gain was 62 without any difference between the two groups. For patients with deficient external rotation (n=37), the gain was nil in both groups.

Discussion: Although group A had a more severe condition than group B (narrower AH and more advanced fatty degeneration, the final outcome as assessed by the Constant score and range of motion was similar. Both groups recovered active elevation well, but not external rotation. Nevertheless, there were no cases of latissimus dorsi transfer in this series. Repair with a deltoid flap, supraspinatus translation, or cuff prosthesis does not appear to add any supplementary benefit despite the more aggressive surgery.

Purpose of the study: Little is known about the clinical profile of patients aged less than 65 years who present a large or massive rotator cuff tear. We hypothesized that this clinical profile depends on the type of tear.

Material and method: This was a prospective descriptive multicentric study over a period of six months which included 112 patients aged less than 65 years, 66 men and 46 women, mean age 56.3 years (range 35–65) who had a large or massive rotator cuff tear. The Constant score and active and passive range of motion, subacromial height and fatty infiltration according to the Goutallier classification were noted. Patients were divided into four classes according to deficit in active elevation and external rotation: class A (n=55, no deficit), class B (n=19, deficient elevation alone), class C (n=28, deficient external rotation alone), class C (n=10, deficient elevation and external rotation).

Results: These classes were not significantly different for age, sex-ratio, duration of symptoms, or presence of subscapular involvement. Trauma was involved more often in patients in class B and class D. The mean absolute Constant score was significantly lower in patients in class B (30.2) or D (23.5) than in class A (53.3) or C (44.7). The subacromial space was significantly narrower in group D (5 mm) than in the other groups. Fatty infiltration of the infraspinatus scores > II was significantly more common in groups C and D. Severe fatty degeneration of the subscapular (> II) was found in only eight shoulders and was not correlated with defective active elevation.

Discussion: This study demonstrates that deficient external rotation is correlated with the type of tear but has little impact on the Constant score. Conversely, patients with deficient active elevation have a lower Constant score but do not exhibit characteristically different tears than patients without deficient active elevation. Thus, the management scheme should be no different in patients with deficient elevation than in patients with out deficient elevation, excepting cases with a major lesion of the subscapularis.

Background: The orientation and the position of glenoid are two factors which have been pointed out as a cause of notch in case of reverse shoulder arthroplasty (RSA). Our hypothesis is that the notch is mostly depending on the relationship between the humerus and the glenoid.

Material and method: The inclusion criteria of this prospective study were: RSA with a 2 years minimum follow up, pre and post op x-rays of good quality to allow accurate measurements, a minimum of 3 x-rays regularly separated in the first 2 years. On these x-rays, done at rest, we have analyzed: the vertical orientation of the glenoid, the degree of abduction of the humerus, the gleno-metaphyseal angle (GMA) which represents the relationship between glenoid and humerus. Sixty one shoulders in 60 patients (57 females, 7 males) have been included. The mean age was 74,6 y.o (56–82) and the mean body mass index (BMI) was 25,4 (16–36).

Results: The patients with a notch had a significant correlation with a lower BMI (p< 0,001), a more upward pre op orientation of glenoid (p< 0,01), a less downward post op orientation of the glenoid, a lower degree of abduction of the humerus (p< 0,01), a lower GMA (p< 0,001) that means either that the humerus is less abducted or that the glenoid is orientated more upward or both. In addition we found a strongly correlation between the BMI and the degree of abduction of humerus which is lower if the BMI is low (p< 0,001). We studied the evolution of the angles and we noted that there was no difference during the first 3 months. After 3 months, the GMA stayed stable in patients without notch but was decreasing during the first year in those with a notch.

Discussion: The occurrence of a notch is strongly increased in patients with a lower BMI because of a less degree of abduction of the humerus, mostly if the glenoid is orientated upward. So the relationship between humerus and glenoid is more important to analyse than position of glenoid alone. The BMI is another important factor to take into account in case of indication of RSA because the risk of occurrence of a notch is quite higher.

Objective: This study evaluates the preoperative conventional anteroposterior radiography in non-operated patients with cuff tear arthropathy. It analyses the radiological findings in relation to the status of the rotator cuff and clinical outcome. The aim of the study is to define the usefulness of this radiographical examination in cuff tear arthropathy.

Methodology: This study analyses the preoperative radiological (AP-view, (Artro-)CT-scan or MRI-scan) and clinical characteristics (Constant-Murley-score plus active and passive mobility testing) and the peroperative findings in a cohort of 315 patients of which 282 had eccentric omarthrosis according to the classification of Hamada and 33 patients with centered omarthrosis who have at least two irreparable tendon tears. Those patients were part of a multicenter, retrospective, consecutive study of the French Orthopaedic Society (SOFCOT-2006). All patients had no surgical antecedents and were all treated with prosthetic shoulder surgery for a painful irreparable cuff tear arthropathy (reverse -(84%) or hemi-(8%) or double cup prosthesis (8%)).

Results: Fatty degeneration of a rotator cuff muscle decreases its strength (p < 0.0001).

In the presence of tendons lesser bony wear is seen at the acromion (acetabularisation, (p< 0.005), the glenoid (superomedial wear p=0.005) as well as the humeral head (femoralization, p=0.002).

The radiological classifications according to Hamada and Favard seem not to be as appropriate to reflect accurately the location and extent of the tendino-muscular degeneration as the acromial acetabularization and humeral sphericity.

The acromio-humeral distance is a good indicator for the location and the extend of the cuff tear arthropathy. A smaller acromio-humeral distance (95% CI: 4mm + 1) is only present if the postero-superior muscles are fatty degenerated (Goutallier stade III & IV) and a larger distance is calculated (95% CI: 7mm + 3) when only the antero-superior muscles are diseased.

The coracoid tip in cuff tear arthropathy-patients is almost always positioned in the inferior half of the glenoid (84%).

A bigger supero-inferior distance of the glenoid in relation to the radius of the humeral head indicates more structural destruction of rotator cuff status (tendinous and muscular) and a worse clinical outcome.

Conclusion: This study defines the use of a conventional radiological antero-posterior view to evaluate eccentric omarthrosis as very useful. The direction of eccentricity in the scapular plane of the body and type of wear, situated either at the glenoïd, acromion or humeral head are determined by the location and extent of the tendinous lesion and the degree of fatty degeneration of the rotator cuff muscle.

Scapular notching is of concern in reverse shoulder arthroplasty and has been suggested as a cause of glenoid loosening. Our purpose was to analyze in a large series the characteristics and the consequences of the notch and then to enlighten the causes in order to seek some solutions to avoid it. 430 consecutive patients (457 shoulders) were treated by a reverse prosthesis for various etiologies between 1991 and 2003 and analyzed for this retrospective multicenter study. Adequate evaluation of the notch was available in 337 shoulders with a follow-up of 47 months (range, 24–120 months). The notch has been diagnosed in 62% cases at the last follow-up. Intermediate reviews show that the notch is already visible within the first postoperative year in 82% of these cases. Frequency and grade extension of the notch increase significantly with follow-up (p< 0.0001) but notch, when present, is not always evolutive. At this point of follow-up, scapular notch is not correlated with clinical outcome. There is a correlation with humeral radiolucent lines, particularly in metaphyseal zones (p=0.005) and with glenoid radiolucent lines around the fixation screws (p=0.006). Significant preoperative factors are: cuff tear arthropathy (p=0.0004), muscular fatty infiltration of infraspinatus (p=0.01), narrowing of acromio-humeral distance (p< 0.0001) and superior erosion of the glenoid (p=0.006). It was more frequent with superolateral approach than with deltopectoral approach (p< 0.0001) and with standard cup than with lateralized cup (p=0.02). We conclude that scapular notching is frequent, early and sometimes evolutive but not unavoidable. Preoperative superior glenoid erosion is significantly associated with a scapular notch, possibly due to the surgical tendency to position the baseplate with superior tilt and/or in high position which has been demonstrated to be an impingement factor. Preoperative radiographic planning and adapted glenoid preparation are of concern.

Over the long term, the results of the insertion of a Grammont inverted shoulder prothesis are unknown. The present study reports survivorship curves and the role of the initial aetiology in patients re-examined after 5 to 10 years.

Patients and methods Eighty prostheses (for 77 patients) were implanted between 1992 and 1998: 66 cases of massive cuff tear arthropathy (MCTA) and 24 cases for another aetiology (mainly rheumatoid arthritis and revision).

At the time of follow-up, 18 patients had died and 2 could not be traced. The remaining patients (57 representing 60 prostheses) were seen by an independent examiner. The minimum follow-up was 5 years. The average follow-up was 69,6 months.

Kaplan-Meir survivorship curves for the 60 prostheses were established in order to show the probability of failure as defined by: revision of the prothesis, glenoid loosening, and a functional level< 30 points according to the Constant score.

Results The survivorship curves were as follow:

- for non revision of the prosthesis at 10 years: 91% overall; after 9 years: 95% for MCTA, and 77 % for the others aetiologies. This difference was statistically significant (p< 0,01) ; 6 implants were revised: 3 for MCTA and 3 for other aetiologies.

Discussion

According to revision of the prosthesis, there is a clear rupture in the survivorship curve about 3 years after insertion in aetiologies other than MCTA. This suggests that Grammont inverted total shoulder arthroplasty is not appropriate in these aetiologies (particularly in cases of rheumatoid arthritis).

Purpose: Preoperative morphology must be carefully assessed for proper surgical planning for patients with arthroplasty with massive rotator cuff tears, but many morphological aspects are poorly understood. The purpose of this study was to assess the technical implications of this situation.

Material and methods: We included patients with arthropathy with massive rotator cuff tears who had a complete clinical and radiographic preoperative work-up. We analysed the morphological aspects of the acromion, the humerus and the glenoid cavity.

Results: One hundred forty-two patients (148 shoulders) were included. The acromion presented a fracture or lysis in 13 shoulders and was thinned or had an imprint in 37. It was normal in 70 and hypertrophic in 16. The humerus showed signs of necrosis in 31 shoulders, with a washed out trochiter in 7. Glenoid wear was classed in four stages: E0 or normal glenoid (n=51), E1 or centred wear (n=32), E2 or biconcave aspect (n=46), and E3 or major wear with superior concavity (n=13). Inverted prostheses were implanted in 80 shoulders and non-constrained prostheses in 68. The non-constrained prostheses exhibited progressive ascension of the humeral head in 63% with wear of the glenoid vault. Clinical deterioration led to revision in two patients. The non-constrained prostheses inserted in patients with an E2 glenoid had a significantly lower Constant score (p< 0.05) than the others. A notch appeared in the scapular column in 65%; of the constrained prostheses. This notch was favoured significantly in glenoids classed E2 or E3 preoperatively. The preoperative aspect of the humerus did not appear to affect clinical and radiographic outcome.

Discussion: A thin or lysed acromion associated with an E2 glenoid constitutes a poor indication for non-constrained prosthesis. In this situation, an inverted prosthesis should be used taking care to avoid orienting the glenosphere upwardly, a technically difficult task. Good indications for non-contrained prostheses should probably be limited to shoulders with a normal or thickened acromion and and E1 glenoid.

Purpose: The aim of this work was to assess retrospectively osteofixation and survival of a long custom-made femoral stem with complete hydroxyapatite coating and without locking for replacement of the femoral implant.

Material and methods: From 1990 to 1999, 89 stems were implanted for revision total hip arthroplasty. Seventy-five hips were reviewed at one to ten years (mean four years). Radiographic analysis searched for bone damage, osteofixation and implant migration. All measures were taken on the AP views postoperatively and at last follow-up.

Results: Revision was performed for aseptic loosening in 75%, for septic loosening in 12%, for fracture in 11% and for instability in 2%. Destruction was SOFCOT stage I in 36%, stage II in 44%, stage III in 17% and could not be assessed in 3%. The femorotomy approach was used in 60% and trochanterotomy in 32% and endofemoral assess in 8%. There were 18% intraoperative fractures, 4.8% postoperative infections and 2.4% dislocations. At last follow-up, the Postel Merle d’Aubigné score was 15.3 and the Harris Hip Score was 77.9. Thigh pain was present in 4%. Bone fixation was considered good in 48%, partial but better than 50% contact in 36% and could not be interpreted in 16%. Complete metaphyseal reconstruction was present in 8%. A piecemeal allograft was used in 89%. Between the postoperative and last follow-up films, 16% of the stems descended a mean 11 mm. Five percent of the stems were removed for infection and one (1.3%) for non-fixation. At five years, 95% of the stems was still in place and 80% at ten years, including removals for infection. All revisions for septic loosening had comparable clinical and radiological results in this series and did not develop secondary infection.

Discussion: These results demonstrate the usefulness of the uncemented stems for replacement compared with cemented stems which have a 10% revision rate at five years (SOFCOT 1999). The complete hydroxyapatite coating improves distal fixation of the stem in a healthy zone without compromising secondary proximal fixation and authorising spontaneous metaphyseal bone reconstructions. This may explain the low rate of painful thighs. Modularity and locking could improve the primary fixation and limit descent.

Aim: To compare results of hemi arthroplasty (Aequalis) and reverse arthroplasty (Delta) in treatment of arthropathy with massive cuff tear.

Methods: This was a multicentric study included 142 shoulder arthroplasties (80 reverse and 62 hemiarthroplasties). The pre-op. status was similar in two population according to Constant score, active anterior elevation (AAE) and active external rotation (AER).

Results: The patients were evaluated with a mean follow-up of 44 months. There were 7 failures needed 5 revisions (2 in hemi group and 3 in reverse one). The Constant score was significantly better (p< 0,01) in reverse group (65.6) than in hemi group (46.2). AAE was significantly better (p< 0,01) in reverse group (138°) than in hemi group (96°). AER was significantly better (p< 0,05) in hemi group (22°) than in reverse group (11°) but external rotation in elevated position and internal rotation were not different. These results stay similar even with a follow up over 5 years. In reverse group, partial glenoid unscrewing was observed in 3 patients, and a notch in pillar of scapula in 50 cases. In hemi group, upward migration was observed in 32 cases.

Conclusions: We found significantly better results for reverse prostheses. The inherent risk of hemiarthroplasties is upward migration wearing the coraco acromialarch. The inherent risk of reverse prosthesis is the notch in scapula, and the strain on glenoid fixation, but the results over 5 years stay satisfactory.

Purpose: The purpose of this multicentric study was to report results obtained with the Aequalis system using the simple humeral or total prosthesis, at at least two years follow-up in patients with shoulder joint degeneration and non-repairable rotator cuff tears.

Material and methods: Sixty-eight Aequalis arthroplasties were performed between 1992 and 1998. Outcome was assessed on the basis of the Constant score and radiological findings. Female gender predominated (78%) in this series with a mean age of 72 years. There were 62 simple humeral implantations and six total shoulder arthroplasties. The deltopectoral approach was used in 63 cases and the superior approach in five. All stems and sockets were cemented. There were no neurological or infectious complications.

Results: Two humeral stem implants were failures and required revision with a Grammont prosthesis. There was also one reoperation for arthrolysis with preservation of the implant; the outcome was fair.

Functional outcome: Sixty-six patients were reviewed with a mean follow-up of 45 months. All implantations except one were performed to achieve pain relief. The absolute Constant score improved by 20 points (from 25 to 46) with a 7-point gain for pain (3 to 10), a 20° gain for active elevation, an 18° gain for external rotation, and a 0.4 point gain for force. Pain relief was greater with total prostheses. Only five patients stated they were dissatis-fied with the outcome despite the fact that 18 reported significant persistent pain. The Constant score was analysed as a function of follow-up, size of the humeral head, and preoperative morphology of the glenoid surface. Radiological outcome: Certain loosening was recognised for one glenoid and one humeral stem. Among 52 shoulders with strictly identical radiological results, 33 exhibited deterioration either for the vault or the glenoid or both, with no effect on the Constant score.

Discussion: In this indication the Adqualis prosthesis is implanted to achieve a “limited” objective: pain relief. The deltopectoral approach is preferable in order to preserve elements inhibiting superior migration of the humerus (in a parallel study, the absence of these elements explains the poor outcome observed in 3 out of 9 patients). Unlike other series, the present series exhibited a significant effect of a type E2 biconcave glenoid surface. The pain score was better with total shoulder prostheses than with humeral stems alone and four of the six glenoid sockets remained perfectly fixed. The long-term outcome of these glenoid surfaces remains unknown so it would be inappropriate to advise systematic use. Clinical outcome did not show any deterioration over time despite deterioration of the vault, the glenoid, or both. Indications for non-constrained pros-theses should however be retained with caution due to open questions concerning long-term outcome, particularly for shoulders which have already been operated on or with type E2 glenoids. Considering these reservations, the Aequalis prosthesis has reached, at nearly five years follow-up, the assigned objectives: significant pain relief, satisfactory overall shoulder function.

Purpose: The purpose of this study was to analyse outcome of shoulder prostheses after radiotherapy, to define a specific clinicoradiological entity, and evaluate incidence of complications.

Material and methods: Fourteen shoulder prostheses were implanted in 13 women who had been treated for breast cancer with complementary radiotherapy and one man treated for Hodgkin’s lymphoma. The time from radiothearpy to implantation was 16 years, seven months. Two forms were identified on the preoperative x-rays: seven cases with typical avascular osteonecrosis according to the Arlet and Ficat classification, and seven cases with a radiographic presentation of arthritis or degenerative disease. Humeral prostheses were used in five cases and a total shoulder arthroplasty in nine.

Results: Four implants had to be removed, three for sepsis, and five patients required revision surgery. The mean postoperative Constant score for the ten prostheses still in place was 53.1 points with a mean elevation of 111° at three years seven months follow-up. The gain in pain score was 8.5 points with a mean result of 10.9 points. The results were different depending on the initial radiological form, with less favourable outcome observed in typical osteonecrosis.

Discussion: This study demonstrated a particular radio-clinical entity independent of classical osteonecrosis of the humeral head. The surgical procedure was more difficult and the outcome was less satisfactory than in the classical forms with a high rate of complications.

Purpose: Wear of prosthetic implants, especially the metal-polyethylene head-cup couple, and dissemination of wear particles throughout the organisms the dominant long-term complication of total hip arthroplasty. We determined serum concentrations of chromium, cobalt, nickel, and molybdenum in patients bearing a total hip prosthesis with a chromium-cobalt metal-poly-ethylene head-cup couple. The purpose of our work was first to compare the levels observed with those found in a control population and then to study variations in these levels as a function of clinical and radiological signs commonly searched for during the follow-up of patients with a total hip arthroplasty.

Material and methods: During a period of 30 months, a total hip arthroplasty (PVL®) was implanted in 53 patients suffering from degenerative hip disease. Forty-eight patients were assessed at a minimum follow-up of 32 months with physical examination and standard x-rays as well as serum assay of the specified metals using mass spectrometry on whole blood samples. The control group was composed of 56 patients scheduled for total hip arthroplasty.

Results: At a mean follow-up of 44 months, 17% of the patients had a fair or poor functional score and 37% had radiological signs suggestive of femoral stem loosening. There was a significant increase in the serum level of cobalt compared with the control group. This increase was greater in patients with radiological signs of loosening.

Discussion: The metal-on-metal couple does not appear to be the only couple which increases serum metal levels. Serum metal assay could be a diagnostic tool useful for following patients with total hip prostheses.

Purpose: The purpose of this work was to compare outcome after hemiarthroplasty and after inverted arthroplasty for the treatment of excentred degeneration of the shoulder joint.

Material and methods: This multicentric study inclued 136 patients, 110 women and 26 men, mean age 72.4 years (range 55 – 86 years) with 142 shoulder prostheses. Among the 142 shoulders operated on, 62 underwent Aequalis hemiarthroplasty and 80 inverted arthroplasty. The preoperative handicap was more severe in the hemiarthroplasty group (Constant score 26) than in the inverted arthroplasty group (Constant score 23).

Results: Clinical and radiological follow-up data were collected at a mean follow-up of 44 months for the Aequalis prostheses and at 45 months for the inverted prostheses. There were seven failures requiring five revision procedures: three in the hemiarthroplasty group and four in the inverted arthroplasty group.

The differences between the hemi- and inverted arthroplasty groups concerned the Constant score, which was significantly better in the inverted prostheses (65.5) than in the hemiarthroplasties (46.1), for all subscores. Active elevation was 138° for the inverted prostheses and 97° for the Aequalis prostheses (p < 0.01). Mean external rotation in position 1 was 22° for the Aequalis prostheses and 11° for the inverted prostheses (p < 0.01) with no difference in elevation rotation. These results remained equivalent and significant over time, even beyond five years.

Radiographically, there was one case with an anomalous humeral component (impaction) in the inverted group. For the inverted prostheses, there were three migrations that have not been revised to date and three partial screw loosenings. The main problem was the development of notches in the scapular column observed in 50% of the cases including 20% which reached the lower screw. For the Aequalis prostheses, the main problem was deterioration of the acromial vault observed in 50% of the cases leading to altered function.

Discussion: Inverted prostheses provide clearly better mid-term results, even after five years. With hemiarthroplasty there is a long-term risk of vault wear. The long-term course of the inverted prostheses is worrisome due to the notches in the scapular column and the stress on the fixation. These prostheses should be used preferably for old persons with a deteriorated vault.