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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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