In older patients (>75 years of age), with an intact rotator cuff, requiring a total shoulder replacement (TSR) there is, at present, uncertainty whether an anatomic TSR (aTSR) or a reverse TSR (rTSR) is best for the patient. This comparison study of same age patients aims to assess clinical and radiological outcomes of older patients (≥75 years) who received either an aTSR or a rTSA. Consecutive patients with a minimum age of 75 years who received an aTSR (n=44) or rTSR (n=51) were prospectively studied. Pre- and postoperative clinical evaluations included the ASES score, Constant score, SPADI score, DASH score, range of motion (ROM) and pain and patient satisfaction for a follow-up of 2 years. Radiological assessment identified glenoid and humeral component osteolysis, including notching with a rTSR. Postoperative improvement for ROM and all clinical assessment scores for both groups was found. There were significantly better patient reported outcome scores (PROMs) in the aTSR group compared with the rTSR patients (p<0.001). Both groups had only minor osteolysis on radiographs. No revisions were required in either group. The main complications were scapular stress fractures for the rTSR patients and acromioclavicular joint pain for both groups. This study of older patients (>75 years) demonstrated that an aTSR for a judiciously selected patient with good rotator cuff muscles can lead to a better clinical outcome and less early complications than a rTSR

This study aims to investigate the mechanical properties of a rotator cuff tear repaired with a polypropylene interposition graft in an ovine infraspinatus ex-vivo model. Twenty fresh shoulders from skeletally mature sheep were used in this study. A tear size of 20 mm from the tendon joint was created in the infraspinatus tendon to simulate a large tear in fifteen specimens. This was repaired with a polypropylene mesh used as an interposition graft between the ends of the tendon. Eight specimens were secured with mattress stitches while seven were secured to the remnant tendon on the greater tuberosity side by continuous stitching. Remaining five specimens with an intact tendon served as a control group. All specimens underwent cyclic loading with a universal testing machine to determine the ultimate failure load and gap distance. Gap distance increased with progressive cyclic loading through 3000 cycles for all repaired specimens. Mean gap distance after 3000 cycles for both continuous and mattress groups are 1.7 mm and 4.2 mm respectively (P = .001). Significantly higher mean ultimate failure load was also observed with 549.2 N in the continuous group, 426.6 N in the mattress group and 370 N in the intact group. The use of a polypropylene mesh as an interposition graft for large irreparable rotator cuff tears is biomechanically suitable and results in a robust repair that is comparable to an intact rotator cuff tendon. When paired with a continuous suturing technique, it demonstrates significantly resultant superior biomechanical properties that may potentially reduce re-tear rates after repairing large or massive rotator cuff tears

Between January 1, 1976 and December 31, 1991, 195 total shoulder arthroplasties and 108 hemiarthroplasties were performed by the senior author in patients with rheumatoid arthritis. One hundred eighty-seven total shoulder arthroplasties and 95 hemiarthroplasties with complete preoperative evaluation, operative records, and minimum 2-year follow-up (mean 11.6 years) or follow-up until revision were included in the clinical analysis. Twenty patients died and one was lost to follow-up. All 303 shoulders were included in the survival analysis. There was significant long term pain relief (P< .0001), improvement in active abduction (P< .0001), and external rotation (P< .0001) with both, hemiarthroplasty and total shoulder arthroplasty. There was not a significant difference in improvement in pain and motion comparing hemiarthroplasty and total shoulder arthroplasty for patients with a thin or torn rotator cuff. However, among patients with an intact rotator cuff, improvement in pain and abduction were significantly greater with total shoulder arthroplasty. Additionally, among patients with an intact rotator cuff, the risk for revision was significantly lower for total shoulder arthroplasty (p=0.04). Radiographs were available for 152 total shoulder arthroplasties and 63 hemiarthroplasties with a minimum 2 year follow-up. Glenoid erosion was present in 62 of 63 hemiarthroplasties (98%). Glenoid periprosthetic lucency was present in 110 of 152 total shoulder arthroplasties (72%). The data from this study indicate there is marked long term pain relief and improvement in motion with shoulder arthroplasty. Among patients with an intact rotator cuff, total shoulder arthroplasty appears to be the preferred procedure for pain relief, improvement in abduction, and lower risk of revision surgery

There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis. This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomized controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardized mean difference (SMD) and a random effects model. Secondary outcome measures included pain (visual analogue scale VAS), rate of Popeye deformity, and operative time. 860 patients from 11 RCTs (426 tenotomy vs 434 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.14, 95% CI −0.04 to 0.32; p=0.13). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. There was no significant difference for pain (VAS). Tenodesis resulted in a lower rate of Popeye deformity (OR 0.29, 95% CI 0.19 to 0.45, p < 0.00001). Tenotomy demonstrated a shorter operative time (MD 15.21, 95% CI 1.06 to 29.36, p < 0.00001). Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. A large multi-centre clinical effectiveness randomised controlled trial is needed to provide clarity in this area

Glutamate regulates the expression of apoptosis-related genes and triggers the apoptosis of fibroblasts in rotator cuff tendons. Subacromial bursitis is always accompanied by symptomatic rotator cuff tear (RCT). However, no study has been reported on the presence of glutamate in subacromial bursa and on its involvement of shoulder pain in patients who had RCT. The purposes of this study were to determine whether the glutamate expression in subacromial bursa is associated with the presence of RCT and with the severity of shoulder pain accompanying RCT. Subacromial bursal tissues were harvested from patients who underwent arthroscopic rotator cuff tendon repair or glenoid labral repair with intact rotator cuff tendon. Glutamate tissue concentrations were measured, using a glutamate assay kit. Expressions of glutamate and its receptors in subacromial bursae were histologically determined. The sizes of RCT were determined by arthroscopic findings, using the DeOrio and Cofield classification. The severity of shoulder pain was determined, using visual analog scale (VAS). Any associations between glutamate concentrations and the size of RCT were evaluated, using logistic regression analysis. The correlation between glutamate concentrations and the severity of pain was determined, using the Pearson correlation coefficient. Differences with a probability <0.05 were considered statistically significant. Glutamate concentrations showed significant differences between the torn tendon group and the intact tendon group (P = 0.009). Concentrations of glutamate significantly increased according to increases in tear size (P < 0.001). In histological studies, the expressions of glutamate and of its ionotropic and metabotropic receptors have been confirmed in subacromial bursa. Glutamate concentrations were significantly correlated with pain on VAS (Rho=0.56 and P =0.01). The expression of glutamate in subacromial bursa is significantly associated with the presence of RCT and significantly correlated with its accompanying shoulder pain. Acknowledgements: This research was supported by the Basic Science Research Program, through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2015R1D1A3A01018955 and 2017R1D1A1B03035232)

Massive irreparable rotator cuff tears often lead to superior migration of the humeral head, which can markedly impair glenohumeral kinematics and function. Although treatments currently exist for treating such pathology, no clear choice exists for the middle-aged patient demographic. Therefore, a metallic subacromial implant was developed for the purpose of restoring normal glenohumeral kinematics and function. The objective of this study was to determine this implant's ability in restoring normal humeral head position. It was hypothesized that (1) the implant would restore near normal humeral head position and (2) the implant shape could be optimized to improve restoration of the normal humeral head position. A titanium implant was designed and 3D printed. It consisted of four design variables that varied in both implant thickness (5mm and 8mm) and curvature of the humeral articulating surface (high constraint and low constraint. To assess these different designs, these implants were sequentially assessed in a cadaver-based biomechanical testing protocol. Eight cadaver specimens (64 ± 13 years old) were loaded at 0, 30, and 60 degrees of glenohumeral abduction using a previously developed shoulder simulator. An 80N load was equally distributed across all three deltoid heads while a 10N load was applied to each rotator cuff muscle. Testing states included a fully intact rotator cuff state, a posterosuperior massive rotator cuff tear state (cuff deficient state), and the four implant designs. An optical tracking system (Northern Digital, Ontario, Canada) was used to record the translation of the humeral head relative to the glenoid in both superior-inferior and anterior-posterior directions. Superior-Inferior Translation. The creation of a posterosuperior massive rotator cuff tear resulted in significant superior translation of the humeral head relative to the intact cuff state (P=0.016). No significant differences were observed between each implant design and the intact cuff state as all implants decreased the superior migration of the humeral head that was observed in the cuff deficient state. On average, the 5mm low and high constraint implant models were most effective at restoring normal humeral head position to that of the intact cuff state (-1.3 ± 2.0mm, P=0.223; and −1.5 ± 2.3mm, P=0.928 respectively). Anterior-Posterior Translation. No significant differences were observed across all test states for anterior-posterior translation of the humeral head. The cuff deficient on average resulted in posterior translation of the humeral head, however, this was not statistically significant (P=0.128). Both low and high constraint implant designs were found to be most effective at restoring humeral head position to that of the intact cuff state, on average resulting in a small anterior offset (5mm high constraint: 2.0 ± 4.7mm, P=1.000; 8mm high constraint: 1.6 ± 4.9mm, P=1.000). The 5mm high constraint implant was most effective in restoring normal humeral head position in both the superior-inferior and anterior-posterior directions. The results from this study suggest the implant may be an effective treatment for restoring normal glenohumeral kinematics and function in patients with massive irreparable rotator cuff tears. Future studies are needed to address the mechanical efficiency related to arm abduction which is a significant issue related to patient outcomes

Introduction and Objective. There remains much debate regarding the optimal method for surgical management of patients with long head of biceps pathology. The aim of this study was to compare the outcomes of tenotomy versus tenodesis. Materials and Methods. This systematic review and meta-analysis was registered on PROSPERO (ref: CRD42020198658). Electronic databases searched included EMBASE, Medline, PsycINFO, and Cochrane Library. Randomized controlled trials (RCTs) comparing tenotomy versus tenodesis were included. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and the Jadad score. The primary outcome included patient reported functional outcome measures pooled using standardized mean difference (SMD) and a random effects model. Secondary outcome measures included visual analogue scale (VAS), rate of cosmetic deformity (Popeye sign), range of motion, operative time, and elbow flexion strength. Results. 751 patients from 10 RCTs demonstrated (369 tenotomy vs 382 tenodesis) were included in the meta-analysis. Pooled analysis of all PROMs data demonstrated comparable outcomes between tenotomy vs tenodesis (SMD 0.17 95% CI −0.02 to 0.36, p=0.09). Sensitivity analysis comparing RCTs involving patients with and without an intact rotator cuff did not change the primary outcome. Secondary outcomes including VAS, shoulder external rotation, and elbow flexion strength did not reveal any significant difference. Tenodesis resulted in a lower rate of Popeye deformity (OR 0.27 95% CI 0.16 to 0.45, p<0.00001). Conclusions. Aside from a lower rate of cosmetic deformity, tenodesis yielded no measurable significant benefit to tenotomy for addressing pathology in the long head of biceps. This finding was irrespective of the whether the rotator cuff was intact

Critical shoulder angle (CSA), lateral acromial angle (LAA), and acromion index (AI) are common radiologic parameters used to distinguish between patients with rotator cuff tears (RCT) and those with an intact rotator cuff. This study aims to assess the predictive power of these parameters in degenerative RCT. This retrospective study included data from 92 patients who were divided into two groups: the RCT group, which included 47 patients with degenerative full-thickness supraspinatus tendon tears, and a control group of 45 subjects without tears. CSA, AI, and LAA measurements from standardized true anteroposterior radiographs were independently derived and analyzed by two orthopedic surgeons. Receiver operating characteristic (ROC) analyses were performed to determine the cutoff values. No significant differences were found between patients in the RCT and control groups in age (p = 0.079), gender (p = 0.804), or injury side (p = 0.552). Excellent inter-observer reliability was seen for CSA, LAA, and AI values. Mean CSA (38.1°) and AI (0.72) values were significantly larger in the RCT group than in the control group (34.56° and 0.67°, respectively, p < 0.001) with no significant difference between groups for LAA (RCT, 77.99° vs. control, 79.82°; p = 0.056). ROC analysis yielded an area under the curve (AUC) of 0.815 for CSA with a cutoff value of 37.95°, and CSA was found to be the strongest predictor of the presence of a RCT, followed by AI with an AUC of 0.783 and a cutoff value of 0.705. We conclude that CSA and AI may be useful predictive factors for degenerative RCT in the Turkish population

Background. Rotator cuff atrophy evaluated with computed tomography scans has been associated with asymmetric glenoid wear and humeral head subluxation in glenohumeral arthritis. Magnetic resonance imaging has increased sensitivity for identifying rotator cuff pathology and has not been used to investigate this relationship. The purpose of this study was to use MRI to assess the association of rotator cuff muscle atrophy and glenoid morphology in primary glenohumeral arthritis. Methods. 132 shoulders from 129 patients with primary GHOA were retrospectively reviewed and basic demographic information was collected. All patients had MRIs that included appropriate orthogonal imaging to assess glenoid morphology and rotator cuff pathology and were reviewed by two senior surgeons. All patients had intact rotator cuff tendons. Glenoid morphology was assigned using the modified-Walch classification system (types A1, A2, B1, B2, B3, C, and D) and rotator cuff fatty infiltration was assigned using Goutallier scores. Results. 46 (35%) of the shoulders had posterior wear patterns (23 type B2s, 23 type B3s). Both the infraspinatus and teres minor independently had significantly more fatty infiltration in B2 and B3 type glenoids compared to type A glenoids (p<0.001). There was a greater imbalance in posterior rotator cuff muscle fatty atrophy in B2 and B3 type glenoids compared to type A glenoids (p<0.001). However, there was no difference in axial plane imbalance between B2 and B3 glenoids (p=1.00). There was increased amount fatty infiltration of the infraspinatus among B2 and B3-type glenoids compared to type A glenoids on multivariate analysis controlling for age and gender (p<0.001). Conclusions. These results identify significant axial plane rotator cuff muscle imbalances in B2 and B3-type glenoids compared to concentrically worn glenoids, favoring a relative increase in fatty infiltration of the infraspinatus and teres minor compared to the subscapularis in glenoids with patterns of posterior wear. For any figures or tables, please contact authors directly

Severe glenoid bone loss in patients with osteoarthritis with intact rotator cuff is associated with posterior glenoid bone loss and posterior humeral subluxation. Management of severe glenoid bone loss during shoulder arthroplasty is controversial and technically challenging and options range from humeral hemiarthroplasty, anatomic shoulder replacement with glenoid bone grafting or augmented glenoid component implantation, to reverse replacement with reaming to correct version or structural bone grafting or metallic augmentation of the bone deficiency. Shoulder replacement with severe glenoid bone loss is technically challenging and characterised by higher rates of complications and revisions. Hemiarthroplasty has limited benefit for pain relief and function especially if eccentric glenoid wear exists. Bone loss with >15 degrees of retroversion likely requires version correction include bone-grafting, augmented glenoid components, or reverse total shoulder replacement. Asymmetric reaming may improve version but is limited to 15 degrees of version correction in order to preserve subchondral bone and glenoid bone vault depth. Bone-grafting of glenoid wear and defects has had mixed results with graft-related complications, periprosthetic radiolucent lines, and glenoid component failure of fixation. Implantation of an augmented wedge or step polyethylene glenoid component improves joint version while preserving subchondral bone, but is technically demanding and with minimal short term clinical follow-up. A Mayo study demonstrated roughly 50% of patients with posteriorly augmented polyethylene had radiolucent lines and 1/3 had posterior subluxation. Another wedge polyethylene design had 66% with bone ingrowth around polyethylene fins at 3 years. Long term outcomes are unknown for these new wedge augmented glenoid components. Reverse shoulder arthroplasty avoids many risks of anatomic replacement glenoid component fixation and stability but is associated with a high complication rate (15%) including neurologic and baseplate loosening and often requires structural bone grafting behind the baseplate with suboptimal outcomes or metallic augmented baseplates with limited evidence and short term outcomes. Reverse replacement with baseplate bone grafting or metal augmentation is technically challenging due to limited native glenoid bone stock available for baseplate component ingrowth and long term fixation. Failure to correct glenoid superior inclination and restore neutral version within 10 degrees increases the risks of reverse baseplate failure of fixation, pull out, and failure of reverse replacement. Reverse baseplate failure rates in patients with severe glenoid bone loss and concomitant glenoid bone grafting range from 5–11%. The minimum native glenoid bony contact with the baseplate is unknown but likely is approximately 1cm of native bone contacting a central ingrowth post and a minority (∼15–25%) of native glenoid contacting the backside of the baseplate. Failure to correct posterior bone loss can lead to retroversion of the baseplate, reduced external rotation, posterior scapular notching, and posteromedial polyethylene wear. In summary, shoulder replacement with severe glenoid bone loss is technically challenging and characterised by higher rates of complication and revision

Patients over 70 years old have subclinical or impending rotator cuff dysfunction, raising concern about TSA in this population. The purpose of this study is to examine whether reverse total shoulder arthroplasty (RTSA) should be considered for the treatment of glenohumeral osteoarthritis in the presence of an intact rotator cuff (GHOA+IRC in patients older than 70 years of age. Twenty-five elderly (>70 years) patients at least one year status-post RTSA for GHOA+IRC were matched via age, sex, body mass index, smoking status, and whether the procedure involved the dominant extremity with 25 GHOA+IRC patients who received anatomic total shoulder arthroplasty (TSA). Standardised outcome measures, range of motion, and treatment costs were compared between the two groups. Treatment cost was assessed using implant and physical therapy costs as well as reimbursement. Patients who received RTSA for GHO+IRC had significantly lower pre-operative active forward elevation (AFE, 69° vs. 98°, p <0.001) and experienced a greater change in AFE (p=0.01), but had equivalent AFE at final follow-up (140° vs. 142°, p=0.71). Outcomes were otherwise equivalent between groups with no differences. In both those patients who underwent TSA and those that underwent RTSA, significant improvements between pre-operative and final follow-up were seen in all standardised outcome measures and in AFE (p<0.001 in all cases). RTSA provided these outcomes at a cost savings of $2,025 in Medicare reimbursement due to decreased physical therapy costs. In patients over the age of 70 with GHOA+IRC, RTSA provides similar improvement in clinical outcomes to TSA at a reduced cost while avoiding issues related to the potential for subclinical or impending rotator cuff dysfunction

Aim. Biomechanical models of the shoulder have been used to measure forces and glenohumeral pressures. Their results have been found to vary. The aim of this study was to produce a biomechanical model to replicate the biomechanical principles of the glenohumeral joint and to measure the centre of pressure on the glenoid through a mid-range of arm movement with an intact and a compromised rotator cuff. Method. The model consisted of anatomic saw-bones of a scapula and proximal humerus with calibrated extension springs to mimic rotator cuff muscles. Glenoid pressures were measured using pressure sensitive film. The joint was examined through a mid-range of movement with an intact rotator cuff and a supraspinatus deficiency. Results. In the normal cuff model, in neutral, the centre of pressure was in the centre of the glenoid and migrated inferiorly on abduction, rotation and 45° of flexion. The only exception to this was 90° flexion and 35° extension. Concavity compression force rose in internal/external rotation, was steady on flexion/extension but dropped on abduction. In the supraspinatus-deficient model, the centre of pressure dropped to the inferior lip in neutral and rose on any movement with extremes of flexion and abduction, resulting in subacromial impingement. Concavity compression force rose slightly on flexion and extension. On abduction, the force rose as much as three times that of the normal cuff. Discussion. The results suggest that the humeral joint reaction force rests in the centre of the glenoid and is driven inferiorly on arm movement. Loss of supraspinatus reverses this pattern and leads to impingement. These results would be in keeping with osteoarthritic patterns in vivo and may have a bearing on glenoid prosthesis design. Conclusion. The glenohumeral joint demonstrated inferior migration of the humeral reaction force on elevation of the arm. Cuff pathology leads to breakdown of this mechanism

The recommended surgical treatment of osteoarthritis (OA) of the shoulder remains controversial. Recent published and presented trials evaluating hemiarthroplasty (HA) vs total shoulder arthroplasty (TSA) have been underpowered to detect a clinically relevant difference between the treatments. A meta-analysis was carried out using methodology as described by the Cochrane Collaboration. Comprehensive search strategy was used including Medline, Science Citation Index, a review of references of relevant papers and abstracts of recent orthopaedic meetings. All articles were reviewed in a blinded fashion to select qualified articles based on population, intervention, outcome and methodological rigor. 4 RCT’s were identified. One was excluded due to selection bias introduced by the timing of randomization. The data of the 3 remaining trials was combined for analysis. In each trial multiple tools were used to assess patient outcome however, the UCLA score was the only one consistent to all 3 studies. The results demonstrated a statistically significant difference in change scores from baseline to 1 year (TSA 15.6; HA 11.2, p=0.012) in favour of the total shoulder arthroplasty group. This meta analysis demonstrated that in this selected group of patients, (primary osteoarthritis with intact rotator cuff and without excessive glenoid erosion), total shoulder arthroplasty provided a more predictable improvement in pain and function than hemiarthroplasty at 2 years

Aim To evaluate the functional results of rotator cuff function and integrity after arthroscopic excision of calcium and decompression with a minimum follow up of two years. Methods Between 2002 and 2004, sixty consecutive patients with calcific tendinitis underwent arthroscopic excision of calcium and subacromial decompression. Their average age was 51 years (range 28 to 78). The male to female ratio was 2:3. All patients were retrospectively reviewed by an independent observer. Functional outcome was assessed objectively by Constant scoring system and subjectively by Oxford Shoulder Questionnaire. The integrity of the rotator cuff was assessed by ultrasound scan. (Sonosite). Operative technique After arthroscopic subacromial decompression, all calcific deposits were excised with an arthroscopic rotating blade. The resultant cuff defect was left to heal and no cuff repair was performed. Other intra-articular pathology including SLAP lesions were treated at the same time. Postoperatively, early mobilization of the shoulder was encouraged. Results The mean Constant score at follow-up was 82 (range 63 to 100). Fifty-four patients (90%) had good or excellent results and six patients (10%) had a fair score. Ultrasound assessment showed intact rotator cuff with no residual defect in forty-three patients, partial thickness tears in twelve, and small full thickness tears in three. Two patients had recurrence of calcium. Only four of the fifteen patients who had ultrasound evidence of rotator cuff tear were symptomatic. Conclusion Arthroscopic excision of calcium and subacromial decompression is an effective method of pain relief in calcific tendinitis of the shoulder. 75% of the rotator cuff appeared to have healed after two years. Of the remaining 25% patients who had a defect in their supraspinatus tendon, only 6% remain symptomatic

This in-vitro study was conducted to determine the effect of rotator cuff tears on joint kinematics. A shoulder simulator produced unconstrained active abduction of the humerus. Three sequential 1cm lesions were created, the first two in the supraspinatus tendon and the third in the subscapularis tendon. The plane of abduction moved posteriorly and became more abnormal throughout abduction as the size of the tear increased. It is concluded that in order to generate the same motions achieved by the intact joint other muscle groups must be employed, inevitably resulting in altered joint loading. This in-vitro study was conducted to determine the effect of simulated progressive tears of the rotator cuff on active glenohumeral joint kinematics. Five cadaveric shoulders were tested using a shoulder simulator designed to produce unconstrained active motion of the humerus. Forces were applied to simulate loading of the supraspinatus, subscapularis, infraspinatus/teres minor, anterior, middle, and posterior deltoid muscles based upon variable ratios of electromyographic data and average physiological cross-sectional area of the muscles. Three sequential 1cm lesions were created, the first two in the supraspinatus tendon and the third in the subscapularis tendon. Simulated active glenohumeral abduction was performed following the creation of each lesion. Five successive tests were performed to quantify repeatability. The plane of abduction moved posteriorly and became more abnormal throughout abduction as the size of the lesion increased (p=0.01) (Figure 1). In order to generate the same motions achieved with an intact rotator cuff other muscle groups must be employed, inevitably resulting in altered joint loading. A better understanding of the effects that rotator cuff tears have on the kinematics of the glenohumeral joint may result in the development of innovative rehabilitation strategies to compensate for this change in muscle balance and improve the clinical outcomes. Please contact author for diagram and/or graph

We evaluated the results of Cementless Surface Replacement Arthroplasty (CSRA) of the shoulder in 67 patients with advanced glenohumeral destruction who have an intact rotator cuff. Between november 2002 and december 2008, 70 CSRA (32 Copeland/ Biomet and 38 SMRR/ Lima) were implanted in 67 patients. A deltopectoral approach was used in 34 cases and an anterosuperior approach in 36 cases. Patients were assessed using Constant score, a patient satisfaction score and a detailed radiographic analysis. The mean follow up was 3.4 years (range 1 to 7.5 years). The mean Constant score improved preoperatively from 17.6 points (range 2–55) to an average postoperative score of 66.1 (range 13–91). The pain score improved from 1.13 points (range 0–6) to 12.3 points (range 3–15). The forward flexion and external rotation improved from 71° (range 20 to 140) and 0° (range −40 to +45) to 143° (range 60 to180) and 34.4° (range −20 to +60) respectively. Complications included: 1 subscapularis detachment, 5 secondary rotator cuff tear, 1sepsis, 3 patients with shoulder stiffness. No shift in implant position was observed. 11 humeral components developed radiolucencies at the prosthesis-bone interface. The radiographic analysis involved a system of dividing the prosthesis/bone interface into 5 zones. The best clinical results were significantly achieved in patients with necrosis compared with osteoarthritis (Constant Score, ant. elevation, ext. Rotation). Using regression analysis we found that changes in the head-shaft angle position of the implant (valgus/varus placement of the CSRA) significantly predicted the age and sex adjusted Constant score. When the inclination angle of the humeral head decreases, the adjusted Constant score increases. In the same model, we also found that the lateral offset of the humerus significantly predicted the adjusted Constant score. When the lateral offset of the humerus decreases, the adjusted Constant score increases. The medialization of the glenoid significantly and negatively predicted the Constant score. Conclusion. CSRA of the shoulder outcomes have been comparable with those of stemmed arthroplasties. Radiolucent lines occur with follow up and most of the time located in the S1 area. Glenoid wear and humeral head lateralization negatively impact the clinical score. Cementless Shoulder resurfacing is a viable alternative to conventional shoulder arthroplasty

Background: Subacromial decompression surgery is associated with significant postoperative pain. We compared the effect of intrascalene block (ISB) and sub-acromial bursa block (SBB) with simple opiate based analgesia. Methods: In a prospective, randomised controlled trial, fifty-three (n = 53) patients scheduled for arthroscopic subacromial decompression were randomised into three groups receiving Intrascalene block (n =19), Subacromial Bursa block (n =19) or neither of the two blocks (n =15 controls). Patients with cuff pathology were excluded. ISB was performed preoperatively with 20 mls of 1% Prilocaine and 10 mls of 0.5 % Bupivacaine. SBB was given with 20 mls of 0.5% Bupivacaine postoperatively. All patients received standardised general anaesthetic and postoperative analgesia. Pain, sickness and sedation scores were noted at 1, 2, 4, 8, 12 and 24 hours postoperatively. The postoperative consumption of morphine and the time when the first bolus of morphine was required were also noted. Results: The visual analogue pain scores in the ISB and SBB group were lower than the control group in the first twelve hours postoperatively achieving statistical significance but there were no significant differences between the SBB and ISB groups. The controls consumed more morphine postoperatively (mean 32.3 mls) than SBB (21.21 mls) and ISB groups (14.00 mls) (p < 0.001). The time for first bolus was earlier in the controls (mean 30.2 mins) as compared to both SBB (72.7 mins) and ISB groups (105.8 mins) (p< 0.001). The oral analgesic intake was less in the SBB and ISB groups than the controls (p = 0.004), but there was no difference between the two treatment groups. Conclusion: Whilst intrascalene block remains the gold standard where expertise is available for its administration, subacromial bursa block is a safe alternative in patients with intact rotator cuff undergoing arthroscopic subacromial decompression

To compare the effect of standard non-offset and offset humeral heads on early glenoid loosening. From 2002–2004 in a prospective study, 12 patients with osteoarthritis and intact rotator cuff had a TSR with an offset humeral head matching normal anatomy. Five tantalum markers were introduced into the scapula and acromion, spaced widely apart; four markers were placed in a pegged glenoid component. RSA radiographs were taken postoperatively, three, six, twelve months. The micromotion of this offset head group was compared with a baseline series of TSRs with standard non offset humeral head implants which had previously been measured over 24 months. At 24 months, the largest segment translation for the offset head group was in the anterior/posterior direction with a mean of 0.24mm, the standard head group mean was 0.61mm, t=1.3,P=0.21. Proximal/distal translation gave means of 0.51mm (standard head) and 0.17mm (offset head), t=1.3,P=0.21. Medial/lateral translation was smallest for the offset group with mean 0.16mm this is less than half the standard group mean 0.57mm and is significant, t=1.4,P=0.19. The largest rotation was anteversion/retroversion with a mean of 1.50 (offset) compared to 4.40 (standard), t=2.3, P=0.04. Varus/valgus tilt differed significantly with means 0.90 (offset) and 2.50 (standard), t=3.8,P=0.001; and finally anterior/posterior tilt had smallest means of 0.70 (offset) and 1.00 (standard), t=1.2,P=0.25. Maximum total point motion was also significantly different at 24 months, means of 0.66mm (offset) compared to 1.65mm (standard), t=2.3,P=0.04. Early migration occurs in both groups of pegged components. A principal component micromotion index illustrates the complexity of micromotion. Offset heads move significantly less than the standard type, the significant differences in MTPM movement and in rotation (varus/valgus tilt) suggest that the offset head may decrease eccentric loading

Introduction: Successful shoulder arthroplasty is based on restoration of the individual’s proximal humeral morphology with a precise osteotomy of the humeral head at the level of the anatomical neck. The objective of this study was to determine the geometry of the articular portion of the humeral head in contact with the glenoid in the neutral position and compare the orientation to the geometry of the humeral head determined using the cartilage/calcar interface of the anatomical neck. Methods: An intact rotator cuff and joint capsule were exposed for six cadaveric full arms. Precision perspex reference cubes were attached to the greater tuberosity of the humerus and to the coracoid process of the scapula on each specimen. Each shoulder was mounted in a custom built jig with the arm fixed in the neutral position and a Microscribe 3D-X digitizer used to digitize three faces of each precision cube. The shoulder joint was then disarticulated and both the humerus and scapula re-mounted on the same jig, independently. The cube faces were re-digitized and relevant points, lines and surfaces were identified and digitized on each humerus and scapula. The humeri were then scanned using a high precision surface laser scanner. The data collected from both digitizing tools were merged into the same coordinate system and graphically represented. Paired Student’s t-tests were used to compare the inclination and retroversion angles for the two techniques. Results and discussion: The study found a significant difference in inclination (p less than 0.02) and no difference in retroversion (p equal to 0.75) when the glenoid position was used to calculate humeral head orientation (Inclination: Mean 11.5 deg., StD. 11.2 deg.; Retroversion: Mean 20.5 deg., StD. 6.6 deg.) when compared to using the cartilage/calcar interface (Inclination: Mean 134.1 deg., StD. 1.9 deg.; Retroversion Mean 21.7 deg., StD. 13.9 deg.). Small deviations in the recovery of head orientation in shoulder arthroplasty may impact on the longevity of an implant. The differences in inclination and retroversion noted in this study may alter the load on the glenoid and/or rotator cuff mechanism in joint replacement. Further research is necessary

Restoring of anatomic footprint may improve the healing and mechanical strength of repaired tendons. A double row of suture anchors increases the tendon-bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint. We aimed to investigate if there were differences in clinical and imaging outcome between single row and double row suture anchor technique repairs of rotator cuff tears. We recruited 60 patients affected by a rotator cuff tear diagnosed on clinical grounds, magnetic resonance imaging evidence of cuff tear and inadequate response to nonoperative management, an unretracted and sufficiently mobile full-thickness rotator cuff lesion to allow a double row repair found at the time of surgery. In 30 patients, rotator cuff repair was performed with single row suture anchor technique (Group 1). In the other 30 patients, rotator cuff repair was performed with double row suture anchor technique (Group 2). 8 patients (4 in the single row anchor repair group and 4 in the double row anchor repair group) were lost at follow up. A modified UCLA shoulder rating scale was used to evaluate preoperative and postoperative shoulder pain, function and range of motion, strength and patient satisfaction. All patients received a post-operative MR arthrography at the final follow up appointment. At the 2 year follow-up, no statistically significant differences were seen with respect to the UCLA score and ROM values. Post-operative MR arthrography at 2 years of follow up in group 1 showed intact tendons in 14 patients, partial thickness defects in 10 patients and full thickness defects in 2 patients. In group 2, MR arthrography showed an intact rotator cuff in 18 patients, partial thickness defects in 7 patients, and full thickness defects in 1 patient. Biomechanical studies comparing single versus double row suture anchor technique for rotator cuff repair show that a double row of suture anchors increases the tendonbone contact area and restores the anatomic rotator cuff footprint, providing a better environment for tendon healing. Our study shows that there are no advantages in using a double row suture anchor technique to restore the anatomical footprint. The mechanical advantages evidenced in cadaveric studies do not translate into superior clinical performance when compared with the more traditionally, technically less demanding, and economically more advantageous technique of single row suture anchor repair