We present a retrospective analysis of 50 cases of cuff tear arthropathy, treated over a seven year period by use of reverse geometry shoulder prosthesis. 98% follow-up was achieved with average follow up of 3 years. Mean (SD) age was 81.3 (9.2) years and female to male ratio was 5:1. Six patients had bilateral reverse geometry shoulder replacements. Patients were assessed with pre-operative American Shoulder and Elbow Score (pre-op ASES) and post-operative American Shoulder and Elbow Scores (post-op ASES), Oxford, Constant and SF36 scores. Mean pre-op ASES was 22.29 (95%CI: 9.1 – 37.9) and post-op ASES score was 65.2 (95%CI: 48.5 – 81.9), (P< 0.001, Paired t-test). Mean post operative Oxford score was 27.25 (95% CI: 18.4 – 27.6). Mean post operative Constant score was 63.2 (95% CI: 52.6 – 79.6). X-ray review was performed to assess scapular notching and Sirveaux score was used to grade extent of notching. 11 patients had Sirveaux grade 0, 5 had grade 1, 6 had grade 2, 12 had grade 3 and 8 had grade 4 notching. Intra-operative complications included 2 glenoid fractures. Post-operative complications included 2 acromion fractures and 2 episodes of subsidence with dislocation. None of the patients developed post operative haematoma. There was one episode of infection in one patient that required further surgery. Iteration of approach with increasing experience over the years will be discussed. Ours is the biggest series of reverse geometry prosthesis used for irreparable rotator cuff tear arthropathy published so far in the literature and our results have shown superior results in terms of improvement in function and complications. We recommend reverse geometry shoulder replacement is the way forward to treat irreparable cuff tear arthropathy of shoulder

The surgical technique for treatment of massive rotator cuff tears, more than 5 cm, with loss of substance and tendon retraction, is still not well defined by the international orthopaedic community. A specific rehabilitation regimen or arthroscopic débridement may be insufficient in active patients who continue to suffer from pain and muscular fatigue in active forward elevation. We treated 20 patients, 14 men and 6 women, with an average age of 52 years (range 40–69) with the surgical technique consisting in acromion decompression, stabilisation of the cuff lesion with anchors, application of a prolene membrane and using a deltoid muscular flap as reinforcement. Deltoid flap is created by splitting the deltoid muscular fibres in front of the anterior border of the acromion. The inferior part of deltoid is sutured to the tendon above the synthetic membrane.

The mean patient follow-up was 24 months. The pain was completely relieved in 85% of subjects, The joint mobility increased significantly in flexion, abduction and external rotation; however, the internal rotation did not improve.

We propose this surgical technique as the procedure of choice for treating retracted ruptures of the supraspinatus associated with lesions of the supra- and the infra-spinatus.

We wished to assess the usefulness of Inspace balloon arthroplasty (IBA), in our Upper limb unit by regular patient reviews prospectively. This prospective study was started adhering to local approval process. Patients were identified in routine clinical practice by three upper limb consultants presenting with pain and disability and diagnosis of cuff tear was established clinically and on MRI. The patients were explained of ‘available’ treatment options and an information leaflet about balloon arthroplasty provided. Patients were seen in 4 weeks, in a dedicated clinic to find out their willingness to participate. Consultant shoulder surgeons carried out all Balloon arthroplasties and where the cuff was reparable or contraindications identified were excluded from study.

All the patients were reviewed by an independent clinician pre-operatively and post operatively using the assessment tools of Oxford Shoulder Scores (OSS), SF12 and VAS at 6 weeks, followed by 3, 6, 12 months and annually after.

We performed a total of 32 IBA procedures. At the latest follow-up we identified that 24 patients have completed 2 years post procedure. Of these patients 1 deceased after 6 months, 3 were lost to follow up one each at 6, 12 and 24 months. Three were revised to reverse TSA. The OSS reflects that the positive difference of 10 in the average scores (24 pre-operative versus 34 at 2 years) noted at one year follow up were maintained at 2 years. Similar observations made analysing at 12 months and 2 years scores for the VAS pain scores of 3 at 2 years compared to pre-operative score of 6 and so were improvements in both physical & mental components of SF12.

Our study observes that the IBA provides a sustainable pain relief and functional improvements over 2 years and may be a suitable alternative in physiologically compromised patients with irreparable RCT.

Recent studies on animal models focused on the effect of preserving tendon remnant of rotator cuff on tendon healing. A positive effect by combining tendon remnant preservation and small bone vents on the greater tuberosity in comparison with standard tendon-to-bone repair has been shown. The purpose of the present clinical study was to evaluate the efficacy of biologic augmentation of arthroscopic rotator cuff repair by maintaining tendon remnant on rotator cuff footprint combined with small bone vents of the greater tuberosity. A retrospective study was conducted. All patients who underwent arthroscopic rotator cuff repair associated with small bone vents (nanofractures) and tendon footprint preservation were considered eligible for the study. Inclusion criteria were: diagnosis of full-thickness rotator cuff tear as diagnosed at preoperative magnetic resonance imaging (MRI) and confirmed at the time of surgery; minimum 24-month of follow-up and availability of post-operative MRI performed not earlier than 6 months after surgery. Exclusion criteria were: partial thickness tears, irreparable tears, capsulo-labral pathologies, calcific tendonitis, gleno-humeral osteoarthritis and/or previous surgery. Primary outcome was the ASES score. Secondary outcomes were: Quick-DASH and WORC scores, and structural integrity of repaired tendons by magnetic resonance imaging (MRI) performed six months after surgery. A paired t-test was used to compare pre- and postoperative clinical outcomes. Subgroup analysis was performed according to tear size. Significance was set at p < 0.05. The study included 29 patients (M:F = 15:14). Mean age (+ SD) of patients was 61.7 + 8.9 years. Mean follow-up was 27.4 ± 2.3 months. Comparison between pre- and postoperative functional scores showed significant clinical improvement (p < 0.001). Subgroup analysis for tear size showed significant differences in the QuickDASH score (0.04). Particularly, a significant difference in the QuickDASH score could be detected between medium and large tears (p=0.008) as well as medium and massive lesions (p=0.04). No differences could be detected between large and massive tears (p= 0.35). Postoperative imaging showed healed tendons in 21 out of 29 (72%) cases. Preservation of tendon remnant combined with small bone vents in the repair of medium-to-massive full-thickness rotator cuff tears provided significant improvement in clinical outcome compared to baseline conditions with complete structural integrity in 72% of the cases

The aim of this study is to assess the clinical outcome following latissiumus dorsi transfer for massive irreparable tears of the rotator cuff. Between 1996 and 2002 seven patients with massive irreparable rotator cuff tears were treated by transfer of the latissimus dorsi by a single surgeon. Their mean age at time of surgery was 65 years. Five patients were female, five were primary procedures and two were revisions. Patients were assessed with MRI pre-operatively; the decision to plan a transfer was made clinically. At time of operation all were found to massive irreparable tears of the cuff including Supraspinatus and Infraspinatus, Subscapularis was intact in all cases. Five of the transfers were implanted to a bone trough, one was sutured to a tendon stump, and one was augmented with a Teflon patch. Mean time to follow up was 21 months. All patients were assessed by the lead author or by his Specialist Registrar. Six patients had a good result, one had a poor result this was a revision procedure resulting in deltoid origin detachment. Functional outcome significantly improved post-transfer. Constant score 62.1% vs 36.1% (p< 0.0005, Paired t-test), Pain was also significantly reduced post-transfer, both when active 7.1 vs. 2.2 p (< 0.005) and when at rest 3.7 vs. 1.2 (p< 0.005). Conclusion: These results are compatible with those published for Latissimus Dorsi Transfer. Latissimus Dorsi Transfer can be effective in restoring shoulder function and reducing pain following massive irreparable tears of the rotator cuff

Purpose of the study: Old tears of the subscapular muscle situated in the glenoid area are not accessible to direct repair and require locoregional muscle plasty. The clavicular portion of the pectoralis major can be used for reconstruction. The purpose of this study was to describe the operative technique and examine short-term outcome. Material and methods: Five patients, mean age 54 years (45–71 years) with an irreparable tear of the subscapularis in the glenoid area with fatty degeneration greater than grade two in the Goutallier classification were treated. Four had had previous surgery for acromioplasty associated with rotator cuff repair in two or implantation of a humeral prosthesis in one. The preoperative Constant score was 27.5 (mean, range = 8.5–54) due to invalidating pain, limited active mobility and reduced muscle force. Gerber’s lift-off test was positive for those patients for whom it could be performed. Plain x-rays evidenced anterior subdislocation of the humeral head in one case. Subscapular reconstruction was achieved using the entire clavicular portion of the pectoralis major which was dissected and sectioned at its distal insertion on the humerus then reinserted by transosseous suture onto the lesser tuberosity. The rehabilitation program started with active and passive mobility against gravity within a few days of surgery using biofeedback contraction of the muscle flap then active contractions two months postoperatively. Patients were reviewed at a mean 19 months (6–42 months) for clinical and radiological assessment. Results: Four patients had a painless shoulder with a negative lift-off test. The gain in active mobility was predominantly achieved with anterior elevation and abduction. Muscle force was weak leading to a low overall Constant score at revision (mean = 50, range = 30–63). Radiographically, the humeral head was centered exactly as on the preoperative films. There were no cases with a new anterior subdislocation nor an aggravation of a former subdislocation. Functional outcome was better in cases with a unique tear of the subscapularis. Discussion and conclusion: Open surgery is used for primary repair of recent tears of the subscapularis. This technique gives 80 p. 100 good and very good results. In case of symptomatic acromioclavicular osteoarthtisis, better long-term results can be obtained by using a tendodesis of the long biceps and resecting the lateral centimeter of the clavicle. In case of irreparable tears in the glenoid area, reconstruction by transfer of the clavicular portion of the pectoralis major can produce a stable painless shoulder with improved active moblity and normal clinical tests. This method provides anterior stability of the glenohumeral articulation and prevents any anterior subdislocation of the humeral head, thus protecting the joint from secondary degeneration

Various arthroscopic techniques using differing graft materials have been described and present a potential alternative to arthroplasty for rotator cuff arthropathy. We describe the short-term outcomes of allograft reconstruction, having evolved of our surgical technique from graft interposition to superior capsule reconstruction (SCR). All patients with an irreparable tear, in the absence of clinical and radiograph evidence of osteoarthritis, who underwent an allograft (Graft Jacket. TM. ) reconstruction with either an arthroscopic interposition or SCR technique within our institution were included. A retrospective case note analysis was performed to ascertain perioperative details including total operating and consumable implant costs. 15 patients were in the interposition group, mean age 66 years (48–77). Mean postoperative follow-up time was 17 months (1.9 −27.8). The mean OSS improved from 30.6 to 35.7 (p<0.05). Additionally, mean pain scores out of 10 improved from 7.7 to 1.5 (p<0.01). Mean satisfaction for the surgery was 7.8 out of 10. Complications included 2 re-ruptures (13.3%), 1 infection (6.7%) and 1 case of no improvement (6.7%). In the SCR group, there were 10 patients, mean age 64.5 (56– 68 years). Half of these patients had previous rotator cuff surgery. Mean postoperative follow-up time was 8.7 months (1.9 – 16.3). The mean OSS improved from 24 to 32.9 (p<0.01). Similarly, pain scores decreased from 7.9 to 3.5 (p<0.01). Mean satisfaction was 7.2. Complications included 1 case of no improvement (10%) resulting in a reverse TSR and 1 re-rupture (10%). A formal, prospective comparison trial is advocated to determine if SCR is superior

Arthritis of the glenohumeral joint accompanied by an irreparable tear of the rotator cuff can cause severe pain, disability and loss of function, particularly in the elderly population. Anatomical shoulder arthroplasty requires a functioning rotator cuff, however, reverse shoulder arthroplasty is capable of addressing both rotator cuff disorders and glenohumeral deficiencies. The Aequalis Reversed Shoulder Prosthesis design is based on two bio-mechanical principles by Grammont; a medialized center of rotation located inside the glenoid bone surface and second, a 155 degree angle of inclination. Combined, they increase the deltoid lever arm by distalizing the humerus and make the prosthesis inherently stable. 24 consecutive primary reverse total shoulder arthroplasties were performed by a single surgeon for arthritis with rotator cuff compromise and 1 as a revision for a failed primary total shoulder replacement between December 2009 and October 2012. Patients were assessed postoperatively with the use of the DASH score, Oxford shoulder score, range of shoulder motion and plain radiography with Sirveaux score for scapular notching. Mean age at the time of surgery was 72.5 years (range 59 to 86). Average follow up time was 19.4 months (range 4 to 38). Functional outcome scores from our series were comparable with patients from other follow up studies of similar prosthesis design. All patients showed improvement in range of shoulder movement postoperatively. Complications included one dislocation, one acromion fracture and one humeral shaft fracture. No cases of deep infection were recorded. Overall, the short-term clinical results were promising for this series of patients and indicate reverse shoulder arthroplasty as an appropriate treatment for this group of patients

The long head of biceps tendon has been proposed as one of the pain generators in patients with rotator cuff tears. Many surgeons routinely perform tenotomy or tenodesis of the LHB especially in cases of large or massive RC tears. Purpose of this study is to evaluate the condition and position of the tenotomised LHB at a minimum of one year postoperatively. Between 2006 and 2008 96 patients (41 men and 55 women) with RC tears were treated arthroscopically in our clinic, with an average age of 61.2 years (56–80). In 57 cases we proceeded to tenotomy of the LHB. Thirty one of them were available for ultrasound evaluation of the condition and the position of the tenotomised LHB one year post –tenotomy. Intraoperatively the lesions of the LHB varied in degrees from significant hypertrophy- Hourglass deformity (6 cases), subluxation (10 cases), tendinitis (25 cases) to fraying (10 cases). Twelve months postoperatively all the patients reported pain relief and satisfaction from the operation, even in irreparable tears. On ultrasound control the tendon was not found in the bicipital groove or was at its peripheral margin in 10 cases (31%) with only 3 patients having a positive Popeye sign. In the remaining patients the tendon was adhered on the wall of the groove (natural tenodesis). Our results suggest that simple tenotomy of LHB results in pain relief and maintenance of muscle strength. The low percentage of Popeye Sign disputes the necessity for tenodesis, even in younger patients

The December 2012 Shoulder & Elbow Roundup. 360. looks at: whether allograft is biomechanically superior in large Hill-Sachs defects; glenoid bone loss in shoulder dislocators; repairing irreparable cuff tears; acromioclavicular joint injuries; whether more radiographs equals more surgery; whether reverse TSR is cheaper than hemiarthroplasty; autologous chondrocyte implantation in the shoulder; and fracture of the clavicle

Introduction: The suspension bridge principle relies on a firm fixation of the torn rotator cuff at the anterior and posterior margins of the greater tuberosity leaving a mobile section between the two points. In massive rotator cuff tears which cannot be approximated, a partial repair can be performed using the above principle. The aim of this study is to evaluate the functional and radiological results using the above technique with bio-absorbable anchors. Materials and Methods: This is a prospective study of a consecutive series of 59 patients who were found intraoperatively to have a rotator cuff tear of greater than 5cm. There were 41 men and 18 women with an average age of 68 years (range). The average length of follow up was 16 months (12 to 26 months). Patients were assessed objectively with the Constant score, and subjectively with the Oxford questionnaire. Cuff integrity was evaluated using ultrasound. Results: Using the Constant score, the outcome was excellent in 30(51.5%), fair in 24(40.5%) and poor in 5(8.5%). 55(93%) patients had an improvement in pain whilst all had increased movement. 51(86%) had improved activities of daily living, whilst 43(72.3%) had improvement in recreational activities. Ultrasound demonstrated the repair remained firmly anchored in position in 54 patients (91.5%). Five patients showed complete disruption and represented poor functional outcome. Patient satisfaction was 94.9%. Conclusion: Our results confirm that a water tight repair is not necessary for a good functional outcome for massive irreparable tears. The biodegradable anchors have been shown to be holding the repairs well at medium term follow up. In patients with a massive irreparable rotator cuff tear, the suspension bridge principle is a valuable technique

Aim: Chronic rotator cuff tears raise a difþcult problem for treatment. The purpose of the study is to evaluate the results of surgical treatment of 96 full thickness rotator cuff tears. Method: There were 59 males and 37 females with average age of 56 years (35–78). The dominant shoulder was involved in 70% of the cases. Most of the patients had weakness and all of them had pain during the night. The duration of symptoms was more than 4months. 22 tears were small, 38 medium, 28 large and 8 massive. All of the patients had positive arthrogram or MRI. Surgical management consisted of deltoid splitting approach, anterior Neerñs acromioplasty modiþed by Rockwood and repair of the tear. In 6 cases dislocation long head of the biceps was found and repaired. In two cases the long head of biceps was incorporated in the repair. In 5 cases full coverage of the head could not be achieved. Results: F.U. averaged six years. The results were granted according to Wolfgang scale. There were 46 excellent, 39 good, 7 fair and 4 poor. Signiþcant improvement in pain achieved in 90% of the cases and strength improved in 78%. Postoperatively three patients had drop arm sign and one had developed ectopic ossiþcation. Negative prognostic factor was the dislocation of long head of biceps in combination with irreparable tears. The quality of the repair correlated with þnal outcome. Conclusions: The results of this study conþrm the view that operative management of rotator cuff tears offers reliable results and indicated in relatively young patients. Release of coracohumeral ligament and mobilization of supraspinatus decreased the need for tendon transfer

Purpose of the study: Latissimus dorsi transfer is proposed for irreparable superior and posterior rotator cuff tears, particularly in the effect of deficient active external rotation. The purpose of this study was to analyzed outcome at minimum two years follow-up. Material and methods: Between 2001 and 2002, eleven patients underwent latissimus dorsi transfer for an irreparable tear of the supraspinatus and infraspinatus. Surgery was proposed because of the patient’s young age and occupational activity level, or because of a disabling deficit of active external rotation. There were six men and five women, mean age 52.5 years (range 36–66 years). There were seven right shoulders and nine dominant shoulders. Symptom onset was progressive in seven with a mean duration of 33 months (range 2–144 months). Active external rotation was measured at −14° to 29° in five patients with a positive dropping test. Three patients presented pseudoparalysis. The preoperative Constant score was 52±12 points. Preoperative the subacromial space measured less than 6 mm in all patients. Muscle degeneration of the infraspinatus was noted grade 2 or greater (Goutallier). Results: Mean follow-up was 26 months (range 24–36). Subjective outcome was very satisfactory for eight patients, satisfactory for one and disappointing for two. Seven of nine patients resumed their occupational activity. The postoperative Constant score was 73±10 points. None of the patients presented pseudoparalysis at review. Pain was improved in all. Active external rotation was significantly improved in six. Postoperative, the dropping test persisted in two patients. The subacromial space was still 6 mm. Better results were obtained when active deficit was predominant than when anterior elevation (pseudoparalytic shoulder) or external rotation (positive dropping test) were predominant. Discussion and conclusion: Latissimus dorsi transfer provides a solution for irreparable superior and posterior rotator cuff tears. The pain relief is significant. Active external rotation is improved. This is an interesting alternative in young patients or when the motor deficit is a severe handicap

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

Introduction:. Reverse shoulder arthroplasty (RSA) is a reasonable treatment modality in patients with Cuff Tear Arthropaty and massive irreparable cuff tears. RSA has been shown to increase patient function and decrease pain. The aim of this study is to evaluate the clinical and radiographic results of a 44 polyethylene glenosphere. Methods:. Since 2008 we treated 88 patients with cuff tear arthropaty and irreparable massive cuff tear, using an RSA. We selected 80 patients with minimum FU of 24 months in which we used an implant with polyethylene glenosphere and metal humeral insert. Size of the glenosphere used was 44. All patients were assessed with the Constant score and with VAS. The shoulder ROM was measured preoperatively and postoperatively. Results:. Average age of the patients was 71 years old. Average duration of FU was 34 months. All measures improved significantly (p < 0.0001). The mean Constant improved from 15.6 to 60.2. VAS improved from 6 to 2,5. Forward flexion increased from 40 ° to 126,4 °, abduction from 41 ° to 103 °, external rotation from 15.1 to 17.3 and internal rotation increased by two level. We report 22 cases of scapular notching without clinical influence and without implant mobilization. Conclusion:. This is the first report of the use of a polyethylene glenosphere. Data from this study suggest that RSA with a polyethylene glenosphere may be a viable treatment for patients with glenohumeral arthritis and a massive rotator cuff tear. Future studies will be necessary to determine the longevity of the implant and whether it will provide continued improvement in function

Introduction:. Lateralization of reversed shoulder arthroplasty provides improvement in range of motion and decreases inferior scapular notching. The purpose of this study was to verify if the autologous cancelous bone graft harvested from the humeral head does heal constantly in a large cohort of patients followed for a long time. Methods:. Cohort of 92 consecutive patients operated between 2006 and 2010 with a BIORSA for definitive shoulder pseudoparalysis, secondary to cuff tear arthropathy (CTA) or massive, irreparable cuff tear (MCT). The autogenous cancelous graft was harvested from humeral head in all cases. Eight patients were lost for follow up, and four died before 2 years. The remaining 80 patients underwent clinical, radiographic and CT assessment at a minimum FU of 24 months. Mean age was 73 years. Three independent observers evaluated notching, partial or total glenoid or humeral loosening and viability of the graft. Constant-Murley score, range of motion and subjective shoulder value (SSV) were recorded. The mean follow up was 39 months (range 24–74 months). Results:. The bone graft did healed completely in 96% of the cases (77/80); the thickness of the graft remained stable through the years. There were two cases of glenoid loosening: one nonunion of the graft at the scapular side was due to an important superior tilt of the glenosphere; one failure of fixation at the baseplate side was related to a low-grade infection. Another patient had a partial radiolucent line between graft and native glenoid located only above the central peg. No other radiolucent line around peg, screws or baseplate was found. Inferior scapula notching was observed in 19% of the cases (mainly grade 1 and 2). Each parameters of Constant score improved, and the mean SSV increased from 27% to 78%. Conclusion:. This study shows that: (1) autologous cancellous bone graft, harvested from the humeral head, does heal to the native glenoid despite the advanced age of the patients; and (2) BIO-RSA allows improvement of shoulder function (mobility, pain, strength, subjective value) with a low rate of scapular notching

Introduction. Reverse total shoulder replacement is performed for the treatment of rotator cuff arthropathy, massive irreparable cuff tears and failed shoulder hemiarthroplasty with irreparable rotator cuff tears. The aim of this study was to assess the clinical and radiological outcome of single surgeon series of Equinoxe® reverse total shoulder replacement at a district general hospital. Materials/Methods. Consecutive patients who underwent Equinoxe® reverse total shoulder replacement at our unit from Jun 2008 to Dec 2010 were retrospectively reviewed. Indications for surgery, complications and radiological outcomes were assessed. Oxford shoulder score was used to assess the functional outcome. Results. Between Jun 2008 and Dec 2012, forty-one reverse total shoulder replacements were performed by the senior author in 37 patients. Of these, Equinoxe® prostheses were used in 27 operations (26 patients). These included 22 female and 4 male patients. Cuff arthropathy was the commonest preoperative diagnosis (23 patients), followed by proximal humeral fracture non-union (2 patients), failed hemiarthroplasty (one patient) and failed resurfacing (one patient). The mean follow up was 10 months (3 to 17 months). At the time of the study, three patients had died due to unrelated causes, two were not contactable and the remaining 21 patients were analysed. The mean oxford shoulder score was 35.8 (21–48). Nineteen patients (90.5%) graded their outcome a good to excellent while 2 patients (9.5%) graded as poor. Seventeen patients (81%) expressed that they would recommend this operation. One patient (4.7%) had infection and another had dislocation. Overall, there were 3 reoperations (14.3%); first washout, second change of humeral tray and third excision of lateral end of clavicle and reattachment of deltoid. Two patients (9.5%) had small glenoid notching. There was no loosening, neurovascular injury or postoperative haematoma. Conclusion. Early outcome of Equinoxe reverse shoulder replacement is promising. Longer follow-up is required to further assess the outcome

The treatment of patients with arthritis of the glenohumeral joint with an associated massive irreparable cuff tear is challenging. Since these patients usually have proximal migration of the humerus, the CTA extended head allows a surface with a low coefficient of friction to articulate with the acromion. Between 2001 and 2006 a total of 48 patients with arthritis of the shoulder joint associated with a massive cuff tear, were treated with a CTA head. The indications for use being Seebauer Type 1a and 1b appearances on x-ray and active abduction of the arm to more than 60° with appropriate analgesia. Preoperatively, a Constant score and an ASES pain and function score were completed as well as standard radiological assessment. These were repeated at follow up. Paired t tests were carried out for all the variables. A Kaplan-Meier survival analysis was performed. Follow up varied between 2 and 8 years. Improvements in pain, function and all movement parameters were significant at p< 0.001. There was no change in the strength component. Survival analysis showed 94% survival at 8 years (95% CL 8%) there were 2 revisions and 5 deaths. Radiological assessment at follow up revealed no evidence of humeral stem loosening. In 5 (17%) cases however there was evidence of erosion in the surface of the acromion and in 13 (45%) erosion of the glenoid. Finally one component was also seen to have subluxed anteriorly. This head design has been in use for a number of years. To date there appears to be no reported outcome of their use. This series shows that in an appropriately selected patient a satisfactory clinical outcome can be maintained in the short to medium term. The presence of erosion of the glenoid but also the under surface of the acromion does require continuing monitoring

Purpose of the study: The purpose of this work was to report the clinical outcomes observed after great pectoral transfer (clavicular head in 8 cases and sterna head in 7) behind the coracoids for irreparable subscapular tears. Material and method: This was a retrospective analysis of 15 patients, mean age 57 years, with retracted subscapular tears with fatty degeneration grade 3 or greater, associated with a supspinatus tear for 12 cases. The Constant score was not pre and postoperatively. The lift-off test was positive in all patients. The clavicular head (n=8) and the sterna head (n=7) were positioned under the coracoids and fixed with anchors in the trochin using the double row technique. Biceps tenodesis was associated in 12 cases. Immobilisation was maintained for six weeks in neutral rotation with passive mobilization immediately postop and active rehabilitation after the sixth week. Results: At mean 24 months follow-up (range 12–50), nine patients were very satisfied, three were satisfied, and three were disappointed; one patient had revision with a reverse prosthesis due to anteroposterior instability; one patient developed an infection after a haematoma and retained an elevation deficit and a painful shoulder. The gain was 11 points (2.66 to 13.6 ([p< 0.001]) for pain and 4.5 points (3.2 to 7.7 [p< 0.001]) for force. The gain was non significant for active elevation (7 points) and external rotation (6 points). The lift-off test was negative in 11 of the 15 shoulders. There was no significant difference between the two pectoral heads. This series is limited by the small number of shoulders. Discussion: Greater pectoral transfer for unreparable tears of the subscapularis improves force and reduces pain. However, compared with data in the literature, outcome is not different if the entire muscle is used or if only the sterna or clavicular heads are used, whether inserted anteriorly or posteriorly on the coracoids

Introduction. In recently, Reverse shoulder arthroplasty (RSA) in patients with irreparable rotator cuff tear has been worldwidely performed. Many studies on RSA reported a good improvement in flexion of the sholulder, however, no improvement in external rotation (ER)and internal rotation motion (IR). Additionally, RSA has some risks to perform especially in younger patients, because high rates of complications such as deltoid stretching and loosening, infection, neurologic injury, dislocation, acromial fracture, and breakage of the prosthesis after long-term use were reported. Favard et al noted a 72% survival with a Constant-Murley score of <30 at 10 years with a marked break occurring at 8 years. Boileau et al noted caution is required, as such patients are often younger, and informed consent must obviously cover the high complication rate in this group, as well as the unknown longer-term outcome. Its use should be limited to elderly patients, arguably those aged over 70 years, with poor function and severe pain related to cuff deficiency. We developed a novel strategy in 2001, in which we used the humeral head to close the cuff defect and move the center of rotation medially and distally to increase the lever arm of the deltoid muscle. Aim. The aim of this study was to investigate clinical outcome of our strategy for younger patients with an irreparable rotator cuff tear. Materials and Methods. Eighteen shoulders (9 of male patients, 9 of female patients) of patients under 70 years old with an irreparable cuff tears and who were treated with Humeral Head Replacement (HHR) and cuff reconstruction were followed up for more than 12 months. The average age was 63.9 years (range, 58–69 years). The average follow-up period was 27.3 months (range, 12–76 months). The cuff defect was successfully closed in 8 shoulders, whereas 8 shoulders required a Latissimus Dorsi transfer; one other shoulder required a Pectralis Major transfer, and one required both Latissimus dorsi and pectoralis major transfers. Range of motion (flexion, ER), the shoulder score of Japanese Orthopaedic Association (JOA score), and complications were evaluated. Results. Shoulder pain decreased in all patients after surgery. JOA score was improved from 41.1 to 82.6 points after surgery, Flexion motion improved from 72.5 to 145.6 degrees postoperatively and ER increased from 17.5 to 37.8 degrees postoperatively. There were no complications. Conclusion. In our study, HHR using the small head of the humerus and cuff reconstruction for patients under 70 years old with an irreparable rotator cuff tear yielded favorable results as compared to RSA, especially in terms of the ER Furthermore, the advantages of our strategy is able to keep bone stock of the glenoid after surgery. If revision surgery is required, RSA can be performed. Since the patients included in our study were relatively active, long-term follow-up will be required to assess their progress