Constrained acetabular inserts provide a solution for both complex primary and revision hip arthroplasty, but there have been ongoing concerns for high risk of failure and their longevity. The Stryker® Trident acetabular insert is pre-assembled with its constrained ring. We believe this to be the largest series of constrained acetabular inserts with a minimum of 5 year follow-up. We retrospectively reviewed all Stryker® Trident ‘All-Poly’ constrained acetabular inserts cemented into bone in our unit between 2008 and 2016. We collated demographic details and reviewed all patients’ radiographs and clinical notes. Indications for surgery, latest Oxford Hip Scores (OHS) and clinical and radiographic complications were identified. 117 consecutive Stryker® Trident ‘All-Poly’ constrained inserts were cemented into bone in 115 patients during the study period with a mean age of 80 (47–97). Most common indications for surgery were recurrent dislocation (47), complex primary arthroplasty (23), revision arthroplasty (19) and failed hemiarthroplasty (12). 41 patients required revision of the acetabular component only. Follow-up was a minimum of 5 years (mean 8.6, range 5–13). There were three 30-day mortalities and six 1-year mortalities. The mean latest OHS was 37 (24–45). Four cups failed in three patients, one at the cement-bone interface, two at the cement-prosthesis interface and one at the bipolar interface. These were treated conservatively in three patient and with excision arthroplasty in one patient. There were four peri-prosthetic fractures, one Vancouver C distal femur fracture treated conservatively and three Vancouver B1 fractures, two treated conservatively and one treated with open reduction internal fixation. There was breakage of one constrained ring with no adverse effects and one superficial wound infection requiring oral antibiotics only. This series demonstrated that despite the elderly and complex nature of these patients’ clinical situations, constrained acetabular inserts offer a useful and pragmatic solution, with relatively low complications, including in our series a cup failure rate of 3% and peri-prosthetic fracture rate of 3%

A reverse total shoulder arthroplasty (RSA) is frequently performed in the revision setting. The purpose of this study was to report the clinical outcomes and complication rates following revision RSA (RRSA) stratified according to the primary shoulder procedure undergoing revision, including failed hemiarthroplasty (HA), anatomic total shoulder arthroplasty (TSA), RSA, soft tissue repair (i.e., rotator cuff repair), and open reduction internal fixation (ORIF). A systematic review of the literature was performed using four databases (EMBASE, Medline, SportDISCUS, and Cochrane Controlled Trials Register) between January 1985 and September 2017. The primary outcomes of interest included active range-of-motion (ROM), pain, and functional outcome measures including the American Shoulder and Elbow Surgeons Score (ASES), Simple Shoulder Test (SST), and Constant-Murley (CS) Score. Secondary outcomes included complication rates, such as infection, dislocation, perioperative fracture, base plate failure, neurovascular injury, soft tissue injury, and radiological evidence of scapular notching. Clinical outcome data was assessed for differences between preoperative and postoperative results and complication results were reported as pooled complication rates. Forty-five studies met the inclusion criteria for analysis, which included 1,016 shoulder arthroplasties with a mean follow-up of 45.2 months (range, 31.1 to 57.2 months) (Fig. 1). The mean patient age at revision was 60.2 years (range, 36 to 65.2 years). Overall, RSA as a revision procedure for failed HA revealed favorable outcomes with respect to forward elevation (FE), CS pain, ASES, SST, and CS outcome assessment scores, with mean improvements of 52.5° ± 21.8° (P = < 0 .001), 6.41 ± 4.01 SD (P = 0.031), 20.1 ± 21.5 (P = 0.02), 5.2 ± 8.7 (P = 0.008), and 30.7 ± 9.4 (P = < 0 .001), respectively. RSA performed as a revision procedure for failed TSA demonstrated an improvement in the CS outcome score (33.8 ± 12.4, P = 0.016). RSA performed as a revision procedure for failed soft tissue repair demonstrated significant improvements in FE (60.2° ± 21.2°, P = 0.031) and external rotation (20.8° ± 18°, P = 0.016), respectively. Lastly, RSA performed as a revision procedure for failed ORIF revealed favorable outcomes in FE (61° ± 20.2°, P = 0.031). There were no significant differences noted in RSA performed as a revision procedure for failed RSA, or when performed for a failed TSA, soft tissue repair, and ORIF in any other outcome of interest. Pooled complication rates were found to be highest in failed RSA (10.9%), followed by soft tissue repair (7.1%), HA (6.8%), TSA (5.4%) and ORIF (4.7%). When compared to other revision indications, RRSA for failed HA demonstrated the most favorable outcomes, with significant improvements in ROM, pain, and in several outcome assessments. Complication rates were determined and stratified as per the index procedure undergoing RRSA, patients undergoing revision of a failed RSA were found to have the highest complication rates. With this additional information, orthopaedic surgeons will be better equipped to provide preoperative education regarding the risks, benefits and complication rates to those patients undergoing a RRSA. For any figures or tables, please contact authors directly

We present a series of 18 consecutive cases of primary reverse total shoulder arthroplasty for irreparable proximal humerus fractures in patients over 70. Failure of tuberosity union and poor cuff function leads to unsatisfactory results in over half the patients with hemiarthroplasty. Reverse total shoulder arthroplasty does not depend upon a functional rotator cuff and requires little formal rehabilitation. Patients over 70 with irreparable proximal humerus fractures treated with a reverse total shoulder arthroplasty were included in this study. Only primary arthroplasties were included. Reverse arthroplasties for failed hemiarthroplasties were excluded. All arthroplasties were performed using either a deltoid split direct lateral (superior) approach or the antero-lateral MacKenzie approach. The SMR reverse total shoulder prothesis was implanted in all cases using a press-fit glenoid base plate and glenosphere, and press-fit or cemented humerus stem. Tuberosity repair was attempted in 10 cases. The supraspinatus was excised from the greater tuberosity. Patients were allowed self-mobilisation after two weeks in a sling. Patients were recruited and followed up per ethics approved protocol. Outcome measures used were range of motion, dislocation and revision rates radiological signs of loosening and glenoid notching, DASH and Constant scores. Results were compared to another series of cases of reverse shoulder arthroplasty for sequelae of trauma and failed hemiarthroplasties, as well as a series of primary hemiarthroplasties. At an average follow-up of 30 months (minimum 12 months) all patients were satisfied with their results. Average forward elevation was 132 deg. and abduction 108 deg. There was not deterioration of movement at 12 or 24 months. No patient had ongoing pain. The average constant score was 62. There was no evidence of humeral stem loosening apart from one case of early subsidence in a press fit stem. Eleven cases showed glenoid notching, four Nerot grade 1, six Nerot grade 2 and one Nerot grade 3. All notching had stabilised after 12 months. There were no cases of dislocation. No case needed revision, or awaits revision. All cases were pain-free at last review. Overall results for this group of primary reverse arthroplasties for fractures was much better than for reverse arthroplasties for sequelae of trauma. The results were also better than for primary hemiarthroplasties. Irreparable three and four part fractures of the proximal humerus pose management challenges in the elderly. The reverse total shoulder arthroplasty is very attractive option for elderly patients with irreparable proximal humerus fractures. They require little rehabilitation and can give reproducibly good functional results, which do not deteriorate with time

Age is the most accurate surrogate for bone density and poor bone density is the reason for many fracture repairs to fail. Hemiarthroplasty has demonstrated consistently inconsistent results in terms for restoration of function. Most recently, with the evolution of reverse prostheses, prospective studies which are, in many cases, randomised and Level 2, have clearly shown reverse prostheses to be the most consistently reliable treatment in the patient noted above. It is with a high degree of certainty that we can inform such a patient that their function will be restored and their pain minimal with such treatment

Total hip arthroplasty (THA) continues moving to the outpatient arena, and may be feasible for some conversion and revision scenarios. Controversy surrounds appropriate patient selection. The purpose of this study is to report complications associated with outpatient revision and conversion THA, and to determine if comorbidities are associated with complications or overnight stay. From June 2013 through March 2018, 43 patients (44 hips) underwent conversion (n=12) or revision (n=32) THA at a free-standing ambulatory surgery center. Mean patient age was 58.4 years, and 52% of patients were male. Conversion procedures were for failed resurfacing in two, failed hemiarthroplasty in one, and failed fracture fixation with retained hardware in 9. Revision procedures involved head only in one, head and liner in 20, cup and head in 7, stem only in 2, and stem and liner in 2. Forty-four (93%) were discharged same day without incident, none required transfer to acute facility, and 3 required overnight stay with 2 of these for convenience and only one for a medical reason, urinary retention. Three patients with early superficial infection were successfully treated with oral antibiotics. There were no major complications, readmissions, or subsequent surgeries within 90 days. One or more major comorbidities were present in 17 patients (39%) including 1 valvular disease, 8 arrhythmia, 2 thromboembolism history, 3 obstructive sleep apnea, 6 chronic obstructive pulmonary disease, 2 asthma, 4 frequent urination, and 1 renal disease. The single patient who stayed overnight for a medical reason had no major medical comorbidities. Outpatient arthroplasty, including revision THA in some scenarios, is safe for many patients. Presence of medical comorbidities was not associated with risk of complications. The paradigm change of patient education, medical optimization, and a multimodal program to mitigate risk of blood loss and reduce need for narcotics facilitates performing arthroplasty safely in an outpatient setting

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

Management of 4-part fractures of the proximal humerus continues to challenge orthopaedic surgeons, shoulder surgeons, and trauma surgeons. Truly displaced 4-part fractures typically require surgery if the patient is medically able to undergo a surgical procedure. However, outcomes following surgery are not always as predictable as we would like. Results following hemiarthroplasty have led to more predictable pain relief than predictable functional recovery relying exclusively on the fate of tuberosity healing. Tuberosity healing failure leads to nearly universal catastrophic results with pain, dysfunction, and pseudoparalysis. Furthermore, conversion of failed hemiarthroplasty to reverse total shoulder arthroplasty leads to the highest incidence of complications and poorest outcomes of all groups of patients undergoing reverse total shoulder replacement. This is countered by the knowledge that if tuberosity healing occurs the outcome can be reliable with regard to pain relief and functional restoration. Reverse total shoulder arthroplasty, on the other hand, has emerged as a preferred surgical option for many surgeons due to the issues following hemiarthroplasty. The increased prevalence of RTSA for the management of 4-part fractures has come without overwhelming evidence that outcomes are superior especially in light of the increased cost, life-time weight bearing restrictions, and uncertain long-term durability. Long-term follow-up of patients treated with RTSA for 4-part fracture has shown concerning degradation of function and outcomes and remains a valid concern about the long-term durability. We must remain diligent therefore in continuing to better understand which fractures should be treated non-operatively and those that may be amenable to anatomic hemiarthroplasty and finally those which may be better served by using a reverse total shoulder replacement

Massive uncontained glenoid defects are a difficult surgical problem requiring reconstruction in the setting of either primary or revision total shoulder arthroplasty. Our aim is to present a new one-stage technique that has been developed in our institution for glenoid reconstruction in the setting of massive uncontained glenoid bone loss. We utilise a modified delto-pectoral approach to perform our dual biology allograft autograft glenoid reconstruction. The native glenoid and proximal femoral allograft are prepared and shaped to create a precisely matched contact surface, which permits axial compression to secure fixation. The surface of the glenoid is lateralised to at least the level of the coracoid. The central cancellous femoral allograft is removed and impaction autografting is performed prior to implantation of a glenoid base plate with 25-mm long centre peg. Two screws are inserted into the best quality native scapular bone available to ensure compression. A reverse shoulder arthroplasty is implanted. We have performed our dual-biology reconstruction of the glenoid in combination with reverse total shoulder arthroplasty in 8 patients to date. The technique has been performed in the setting of massive uncontained glenoid defects without prostheses as well as in revisions from failed hemiarthroplasties and total shoulder arthroplasties. Our post-operative follow-up is now up to 32 months. CT scanning as early as 6 months demonstrates incorporation of the graft. There has been no evidence of loosening. None of our cases have been complicated by infection or peri-prosthetic fracture and there have been no dislocations. One patient sustained an acromial stress fracture at 9 months post-operatively after lifting a 100-pound gas cylinder. This was diagnosed on bone scan, had no impact on the construct and was managed in a sling for comfort. Another patient has developed Nerot grade I notching which substantially in all patients, with an average improvement of 6.6 on a 10-point scale. Our dual biology allograft-autograft reconstruction is a useful and elegant technique in the setting of massive uncontained defects of the glenoid, which permits the implantation of a reverse total shoulder arthroplasty. We believe this technique to be reproducible and uses materials that are both readily available and familiar

Aims

Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

The purpose of this study is to report our experience with revision of total elbow arthroplasty by exchange cementation. Between 1982 and 2004 at our institution, forty six elbows were treated with exchange cementation of a total elbow arthroplasty into the existing cement mantle or debrided bone interface, without the use of an osteotomy, bone graft or prosthetic augmentation. Indications for the procedure were aseptic loosening (17), second stage after septic loosening (14), instability (7), prosthetic fracture (4), periprosthetic fracture (2), failed hemiarthroplasty (1) and ulnar component wear (1). Both components were exchanged in 18 elbows, the humerus alone in 25 and the ulna in 3. Mean follow up was 90.5 months (10 to 266 months);18 patients had died with the prosthesis in situ. Complications were noted in 22 elbows; periprosthetic fracture of ulna (6) and humerus (2), humeral component fracture (1), aseptic loosening (4), non-union (1), heterotrophic ossification (2), soft tissue contracture (2) and soft tissue failure (2), delayed wound healing (1) and bushing failure (1). Reoperation was required in 10 elbows for revision of both components (2), ulna (3), humerus (1), bushing revision (2), soft tissue debridement (1) and soft tissue repair (1). There were no septic recurrences in previously infected elbows; however the reoperation rate in this group was 29% versus 19% after re-cementation for other causes. Revision of total elbow arthroplasty by exchange cementation is a reasonable treatment for those elbows with adequate bone stock for secure prosthetic fixation; however careful consideration should be given to augmentation of the ulna due to the high rate of periprosthetic fracture in this series. Re-cementation following débridement for infection is effective despite having a higher rate of revision operation compared to re-cementation in the aseptic elbow

The Delta total shoulder replacement is a reversed, semi-constrained prosthesis and is recommended for the management of rotator cuff arthropathy and other difficult reconstructive shoulder problems. It was initially advised to use this prosthesis in patients older than 75. There were reports saying the complication rates of this prosthesis are high and patients' satisfaction and functional outcome is far from being satisfactory. In our study we wanted to evaluate results and complications of reverse shoulder arthroplasty in practice of single surgeon. In our study we reviewed patients who had reverse shoulder arthroplasty performed between 2001 and 2009. We evaluated them clinically and radiologically. We measured functional outcome using Constant score, we used Oxford Shoulder score to measure patients' subjective outcome. We compared our results to pre-operative Oxford Shoulder score (unfortunately no pre-op constant score was done). X-rays were assessed by independent surgeon who was not involved in care of the patients. Out of 36 reverse shoulder replacements performed by Mr. Sinha from 2001 to 2009 we managed to review in clinic 29 shoulders. 3 patients died from causes not related to surgery, 3 patients were too unwell to attend clinic, we lost 1 patient to follow up. Mean time from operation to follow up was 33 months (range 6 to 82 months). Average patients' age at time of surgery was 73,4 years (range: 44 to 90). Indications included rotator cuff arthropathy (86%), other indications were trauma (10%) and revision of failed hemiarthroplasty (4%). There were neither revisions nor infections in our group. There was 1 dislocation that occurred after operation, this was reduced under GA and never re-dislocated again. 12 patients (41%) were very pleased with result of surgery, 15 patients (52%) were satisfied and 2 patients said surgery did not meet their expectations. Mean Shoulder Oxford score improved from 20.8 (range 2 to 36) pre-operatively to 36.7 (range 20 to 48) during follow up. 3 patients had Oxford Shoulder score of 48 (maximum). Oxford shoulder score deteriorated in 2 cases (one in case when replacement was done to treat fracture). Post operative Constant score was 65.5. All patients but one declared overall improvement. 10 patients (34%) reported no pain at all. 5 patients who were 65 years old or younger at time of surgery did well and improved their shoulder function. In our experience reverse geometry shoulder replacement is a very good solution for rotator cuff arthropathy. Results in proximal humeral fracture are worse, but the number of patients we had was small and our experience is limited. Mid term results are very satisfactory overall, even in younger and more demanding patients. The complications were rare and overall patients' satisfaction very high. We think more research needs to be done to asses long term results, especially in younger population

Aims

Advances in surgical technique and implant design may influence the incidence and mechanism of failure resulting in revision total hip arthroplasty (rTHA). The purpose of the current study was to characterize aetiologies requiring rTHA, and to determine whether temporal changes existed in these aetiologies over a ten-year period.

Hypothesis. Reverse shoulder arthroplasty has good mid-term results for rotator cuff deficient arthritic conditions. Methods and Analysis. 103 reverse shoulder arthroplasties were performed in 91 patients from January 2003 to September 2009. Twelve patients had bilateral reverse shoulder arthroplasties. Results. Average clinical follow-up was 13 months (range 3-72 months). There were 38% left and 62% right shoulders. Sixty-eight percent were women and 32% were men. The average age was 72 years (range 47-88 years). Indications included: rotator cuff arthropathies (79%), failed previous hemiarthroplasties and total shoulder arthroplasties (9%), rheumatoid arthritis (5%). Fractures accounted for 7% of cases, including acute 4-part fractures in the elderly, revision of fractures with deficient cuffs, malunion and nonunion cases with deficient cuffs. There was a significant improvement in quality of life. The Constant Score increased by an average of 46 points. 62 radiographs were reviewed. 75% of these showed notching of the inferior glenoid, 53% had notching of the posterior glenoid, 10 % had heterotrophic ossification inferior to the glenoid, and 40% had an inferior glenoid spur. Complications included: 2 dislocations, 1 massive heterotrophic ossification, 3 deep infections, 1 loose glenoid related to a fall, 3 acromial fractures, and 3 scapula spine fractures (all trauma related). Conclusion. Reverse shoulder arthroplasty is a good salvage procedure for cuff deficient arthritic conditions. Clinical mid-term results are good, but notching inferiorly and posteriorly may lead to deterioration over time. Fractures of the scapula appear to originate from either the superior or posterior screws which act as stress risers and an external rotation force of the greater tuberosity against the spine of the scapula in a fall may contribute to these fractures

Objective. To evaluate the volume of cases, causes of failure, complications in patients with a failed Thompson hemiarthroplasty. Methods. A retrospective review was undertaken between 2005–11, of all Thompson implant revised in the trust. Patients were identified by clinical coding. All case notes were reviewed. Data collection included patients demographic, time to revision, reason for revision, type of revision implant, surgical time and technique, transfusion, complications, HDU stay, mobility pre and post revision,. Results. 23 patients were identified, age 81 years (range 76–90). male to female ratio was 2:21, 11 right and 12 left hip. Mean time to failure was 50 months (1–104 m) range, mean follow up post revision surgery 26 months (3–77). Reason for revision was dislocation in 3 patients (13%), femoral loosening 5 (21%), peri-prosthetic fracture 3 (13%), Infection 6 (26%) and acetabular erosion 6 (26%). There were six infected cases in the study which was all aspirated preoperatively off which only 4 were positive. All infected cases grew an organism from intra-operative specimens. (80% cases) were coagulase negative Staphylococcus aureus. 35% only positive on enrichment cultures. 4 infected Thompsons were revised successfully with 2 stage revisions. One patient died after 1. st. stage and another was able to mobilise after the first stage with a cement spacer and refused further surgery. Mean surgical time was 3.5 hours (range 2.5–5.5). HDU stay 1.3 days (range 0–6). 6 deaths in total, 3 unrelated, 3 post operative. Complications included 1 fracture requiring revision, 1 dislocation, 1 foot drop and 4 chest infection of which two patients died from this. Conclusion. We identified a revision rate of 1.2%, complication occurred in 43% of cases with a one year mortality of 26%. Failed Thompson revision surgery is rare, challenging and patient selection is important to reduce postoperative morbidity and mortality

Introduction. In the case of bipolar hemiarthroplasty, surgeons are often faced with only migration of outer head and severe osteolysis in acetabulum without loosening of femoral component. There has been much debate regarding the merits of removing or retaining stable femoral components in such cases. The purpose of this study was to determine whether revision of an isolated acetabular component without the removal of a well-fixed femoral component [Fig. 1] could be successfully performed. Materials and methods. Thirty-four hips of 33 patients who were followed up for a minimum of 1 year were examined. There were 29 women and 4 men. The average time from primary operation to revision surgery was 12.5 years (range, 0.0 to 17.9 years), and the average follow-up time after revision was 5 years (range, 1.1 to 15.2 years). The average age of the patients at the time of the index revision was sixty-four years (range, thirty-two to seventy-eight years). The reason for acetabular revision was migration of outer head in twenty-eight hips, disassembly of bipolar cup in four hips and recurrent dislocation in two hips. Of the thirty-four femoral components, twenty-seven were cementless and seven were cemented. In nine hips, we performed bone grafting to osteolysis of the proximal femur around the stem. Acetabular components were revised to an acetabular reinforcement ring with a cemented cup in 26 hips, to cementless acetabular components in 8 hips, and to cemented cup in 1 hip. Results. The average Japan Orthopaedic Association hip score improved from 50.7 to 86.1 points after revision surgery. One femoral component (3%) was revised because of periprosthetic fracture, three years after the index acetabular revision and eighteen years after the initial bipolar hemiarthroplasty. Radiographic evaluation of the thirty-three femoral components that were not revised demonstrated no evidence of loosening or subsidence. There were no dislocation or deep infection. Thirty-three (97%) of the acetabular components were judged to be stable at the final follow-up. A nonprogressive radiolucent line of less than 2 mm was observed in one case. Conclusion. We recommend that isolated acetabular revision be considered in cases of failed bipolar hemiarthroplasty with a well-fixed femoral component

Introduction: The reverse shoulder arthroplasty (RSA) is becoming increasingly common and the indications expanded. The objective of this study is to report the indications and results of RSA in a large multicenter study. Methodology: A retrospective, multicenter study was conducted including all RSA implanted between 1992 and 2002 in five centers in France. Of 457 patients involved in this study, 243 patients (53%) had cuff pathology: 149 had cuff tear arthropathy, 48 had massive cuff tears, and 45 had failed cuff surgery. Ninety-nine (22%) had revision of previous prostheses. Sixty (13%) had fracture-related problems. Twenty-six (6%) had osteoarthritis and two percent each had rheumatoid arthritis, tumors or other conditions. Three hundred and eighty-nine (85%) shoulders were available for review with greater than 2 years follow-up. The average age at review was 75.6 years (range, 22–92). The average follow-up was 43.5 months (range, 24–142). Results: Significant improvement was noted in Constant scores for pain (3.5 to 12.1), activity (5.8 to 15.1), mobility (12.1 to 24.5), and strength (1.3 to 6.1) (p< .0001). Active elevation improved, but active internal and external rotation did not. The results were dependent on the indication. Cuff tear arthropathy had the best results while revision procedures had the worst. Young age, preoperative stiffness, teres minor deficiency, tuberosity non-union and preoperative complaints of pain rather than loss of function tended to be associated with inferior results. The deltopectoral approach tended toward greater active elevation but greater risk of instability. Survivorship to the endpoints of revision and loosening was better for patients with rotator cuff problems than for patients with failed prior hemiarthroplasty. The functional results were noted to deteriorate progressively after six years in the cuff tear group, after five years in the revision hemiarthroplasty group, after three years in the osteoarthritis group, and after one year in the revision total shoulder arthroplasty group. Conclusions: The overall results of RSA are satisfactory and predictable. Functional results improved with improved active elevation, but no improvement in active internal and external rotation. However, results are dependent on the etiology

Purpose: The reverse shoulder arthroplasty (RSA) is becoming increasingly common and the indications expanded. The objective of this study is to report the indications and results of RSA in a large multicenter study. Method: A retrospective, multicenter study was conducted including all RSA implanted between 1992 and 2002 in five centers in France. Of 457 patients involved in this study, 243 patients (53%) had cuff pathology: 149 had cuff tear arthropathy, 48 had massive cuff tears, and 45 had failed cuff surgery. Ninety-nine (22%) had revision of a previous arthroplasty. Sixty (13%) had fracture-related problems. Twenty-six (6%) had osteoarthritis and two percent each had rheumatoid arthritis, tumors or other conditions. Three hundred and eighty-nine (85%) shoulders were available for review at a mean follow-up of 44 months (range, 24–142). The average age at review was 76 years (range, 22–92). Results: Overall, significant improvement was noted in Constant scores for pain (3.5 to 12.1), activity (5.8 to 15.1), mobility (12.1 to 24.5) and strength (1.3 to 6.1) (p< 0.0001). Active elevation improved (p< 0.0001), but active internal and external rotation did not. The results were dependent on the indication. Cuff tear arthropathy had the best results while revision procedures had the worst. Young age, preoperative stiffness, teres minor deficiency, tuberosity non-union and preoperative complaints of pain rather than loss of function tended to be associated with inferior results. The deltopectoral approach tended toward greater active elevation but greater risk of instability. Survivorship to the endpoints of revision and loosening was better for patients with cuff tear pathology than for patients with failed prior hemiarthroplasty. The functional results were noted to deteriorate progressively after six years in the cuff tear pathology group, after five years in the revision hemiarthroplasty group, after three years in the osteoarthritis group, and after one year in the revision total shoulder arthroplasty group. Conclusion: Overall results of RSA are satisfactory and predictable. Functional results improved with improved active elevation, but no improvement in active internal and external rotation. However, results are dependent on etiology

This study examines patient characteristics, indications for conversion, surgical and anaesthetic technique, peri-operative management and complications of surgery in this small and challenging group of patients. In the six years from 1994 to 1999, 33 conversion arthroplasties were performed for failed femoral hemiarthroplasty. The average age at conversion surgery was 75.5 years (range 65–90). The female to male ratio was 6:1. Primary hemiarthroplasties comprised 24 Austin-Moore, 6 Thompson & 3 Bipolar prostheses. The average interval from primary to conversion surgery was 50 months (6 months to 17 years). The average age at primary surgery was 71.2 years (62–88) – AMP:71.4 years, Thompson’s: 74.2 years, Bipolar: 63.5 years. All hemiarthroplasties were performed for fractured femoral necks. 62% of patients came from the Eastern Health Board area, while 38% were tertiary are referrals from other Health Boards. The average length of stay was 17.5 days (3–24). Indications for conversion included gross loosening/acetabular erosion in 9 cases, suspected infection in 4 cases and abscess/septicaemia in 1 case. All but 3 patients had significant pain (night pain etc.) and/or severely impaired mobility. We also looked at anaesthetic and analgesic practice, surgical technique and prostheses used. Post-operatively, mean total blood loss was 1430 ml (420–2280) with an average of 1.4 units of blood transfused (0–5). Intraoperative complications included acetabular & femoral perforation, periprosthetic fracture and cement reactions. Complications post-op (in hospital) included cardiac arrhythmia’s, cerebrovascular accidents, pulmonary embolus, myocardial infarct, respiratory & urinary tract infections, constipation, nausea & vomiting. The elderly nature of these patients and the physiological stress of what is major surgery allied with multiple co-morbidities make their care especially challenging. A conversion arthroplasty is a procedure with a significant risk of considerable morbidity. Primary total hip replacement or bipolar hemiarthroplasty are options which, therefore, should be seriously considered in the case of fractured femoral necks to minimise the need for further surgery in the future, with all its attendant risks