Aims. Favourable short-term outcomes have been reported following latissimus dorsi tendon transfer for patients with an irreparable subscapularis (SSC) tendon tear. The aim of this study was to investigate the long-term outcomes of this transfer in these patients. Methods. This was a retrospective study involving 30 patients with an irreparable SSC tear and those with a SSC tear combined with a reparable supraspinatus tear, who underwent a latissimus dorsi tendon transfer. Clinical scores and active range of motion (aROM), SSC-specific physical examination and the rate of return to work were assessed. Radiological assessment included recording the acromiohumeral distance (AHD), the Hamada grade of cuff tear arthropathy and the integrity of the transferred tendon. Statistical analysis compared preoperative, short-term (two years), and final follow-up at a mean of 8.7 years (7 to 10). Results. There were significant improvements in clinical scores, in the range and strength of internal rotation and aROM compared with the preoperative values in the 26 patients (87%) who were available for long-term follow-up. These improvements were maintained between short- and long-term follow-ups. Although there was a decreased mean AHD of 7.3 mm (SD 1.5) and an increased mean Hamada grade of 1.7 (SD 0.5) at final follow-up, the rate of progression of cuff tear arthropathy remained low-grade. Comparison between the isolated SSC and combined SSC and reparable supraspinatus tear groups showed no significant differences. At final follow-up, one patient (3.8%) had undergone revision surgery to a reverse shoulder arthroplasty (RSA). No neurological complications were associated with the procedure. Conclusion. Latissimus dorsi transfer for an irreparable SSC tendon tear resulted in a significant clinical improvement, particularly in pain, range and strength of internal rotation and aROM, which were maintained over a mean of 8.7 years following surgery. Given that this was a long-term outcome study, there was a low-grade progression in the rate of cuff tear arthropathy. Thus, the long-term clinical efficacy of latissimus dorsi tendon transfer in patients with irreparable SSC was confirmed as a joint-preserving procedure for these patients, suggesting it as an effective alternative to RSA in young, active patients without degenerative changes of the glenohumeral joint. Cite this article: Bone Joint J 2024;106-B(9):957–963

Aims

The use and variety of stemless humeral components in anatomical total shoulder arthroplasty (TSA) have proliferated since their advent in 2004. Early outcomes are reassuring but independent mid-term results are scarce. This independent study reports a consecutive series of 143 Eclipse stemless shoulder prostheses with a minimum five-year (5 to 10) follow-up.

Aims

The aim of this study is to provide a detailed description of cases combining bridging patch repair with artificial ligament “internal brace” reinforcement to treat irreparable massive rotator cuff tears, and report the preliminary results.

Aims

The Mathys Affinis Short is the most frequently used stemless total shoulder prosthesis in the UK. The purpose of this prospective cohort study is to report the survivorship, clinical, and radiological outcomes of the first independent series of the Affinis Short prosthesis.

Aims

In patients with a rotator cuff tear, tear pattern and tendon involvement are known risk factors for the development of pseudoparalysis of the shoulder. It remains unclear, however, why similar tears often have very different functional consequences. The present study hypothesizes that individual shoulder anatomy, specifically the moment arms (MAs) of the rotator cuff (RC) and the deltoid muscle, as well as their relative recruitment during shoulder abduction, plays a central role in pseudoparalysis.

The purpose of this study was to evaluate the natural history of rheumatoid disease of the shoulder over an eight-year period. Our hypothesis was that progression of the disease is associated with a decrease in function with time.

A total of 22 patients (44 shoulders; 17 women, 5 men, (mean age 63)) with rheumatoid arthritis were followed for eight years. All shoulders were assessed using the Constant score, anteroposterior radiographs (Larsen score, Upward-Migration-Index (UMI)) and ultrasound (US). At final follow-up, the Short Form-36, disabilities of the arm, shoulder and hand (DASH) Score, erythrocyte sedimentation rate and use of anti-rheumatic medication were determined.

The mean Constant score was 72 points (50 to 88) at baseline and 69 points (25 to 100) at final follow-up. Radiological evaluation showed progressive destruction of the peri-articular structures with time. This progression of joint and rotator cuff destruction was significantly associated with the Constant score. However, at baseline only the extent of rotator cuff disease and the UMI could predict the Constant score at final follow-up.

A plain anteroposterior radiograph of the shoulder is sufficient to assess any progression of rheumatoid disease and to predict functional outcome in the long term by using the UMI as an indicator of rotator cuff degeneration.

Cite this article: Bone Joint J 2014;96-B:1520–4.

We assessed the clinical results, radiographic outcomes and complications of patients undergoing total shoulder replacement (TSR) for osteoarthritis with concurrent repair of a full-thickness rotator cuff tear. Between 1996 and 2010, 45 of 932 patients (4.8%) undergoing TSR for osteoarthritis underwent rotator cuff repair. The final study group comprised 33 patients with a mean follow-up of 4.7 years (3 months to 13 years). Tears were classified into small (10), medium (14), large (9) or massive (0). On a scale of 1 to 5, pain decreased from a mean of 4.7 to 1.7 (p = < 0.0001), the mean forward elevation improved from 99° to 139° (p = < 0.0001), and the mean external rotation improved from 20° (0° to 75°) to 49° (20° to 80°) (p = < 0.0001). The improvement in elevation was greater in those with a small tear (p = 0.03). Radiographic evidence of instability developed in six patients with medium or large tears, indicating lack of rotator cuff healing. In all, six glenoid components, including one with instability, were radiologically at risk of loosening. Complications were noted in five patients, all with medium or large tears; four of these had symptomatic instability and one sustained a late peri-prosthetic fracture. Four patients (12%) required further surgery, three with instability and one with a peri-prosthetic humeral fracture.

Consideration should be given to performing rotator cuff repair for stable shoulders during anatomical TSR, but reverse replacement should be considered for older, less active patients with larger tears.

Cite this article: Bone Joint J 2014;96-B:224–8.

Background. Accurate and reproducible radiological assessment of shoulder replacement prostheses over time is important for identifying failure or to provide reassurance. A number of clearly defined radiological parameters have been described to help standardise the radiological assessment of prostheses. To our knowledge, this is the first study conducted to test the reproducibility and reliability of these measurements. Aim. The aim of this work was to test intraobserver reproducibility and interobserver reliability in the measurement of humeral component orientation (HCO), humeral head offset (HHO), humeral head size (HHS), humeral head height (HHH), and acromiohumeral distance (AHD.). Materials and methods. A cohort of 67 patients who had previously undergone shoulder replacement was identified. Two independent reviewers studied the same AP radiograph of each patient on two occasions, at an interval of one month. Results. There was strong agreement for measurements of humeral head size (ICC=0.83), moderate agreement for humeral head offset (0.66), humeral head height (0.68) and acromio-humeral distance (0.66) and fair agreement for humeral component orientation (0.44). Conclusions. Interobserver reliability and intraobserver reproducibility of radiological measurements are important factors to consider when designing longitudinal or multi-centre studies of shoulder replacement prostheses

Introduction. Latissimus dorsi transfer is a procedure used in massive irreparable posterosuperior rotator cuff tears, in young patient with severe pain and significant functional impairment. The purpose of this retrospective study was to evaluate its clinical, radiological and electromyographic results. Methods. Forteen massive irreparable posterosuperior rotator cuff tears were performed with latissimus dorsi transfer between 2000 and 2008, and were reviewed at an average follow-up of 56 months and minimum of 19 months. Five transfers were primary reconstructions, and nine were revision surgeries. Patients’ mean age was 52.7 years. Clinical outcomes were measured by the Constant score, pain level, active range of motion, and strength. Osteoarthritis and acromiohumeral distance were measured on standardized radiographs. Ultrasound examination evaluate the integrity of the tendon. Axial images in CT-scan looked for muscle atrophy of latissimus dorsi in comparison with the controlateral. Electromyographic activity was measured during active flexion, abduction, adduction and rotations. Results. Twelve patients were satisfied. At the last follow-up, the average pain level according to a 100 mm visual analog scale was 31. The mean age and gender-matched Constant and Murley score improved from 34 to 60 % (p=0.003), forward elevation from 89° to 132° (p=0.006), abduction from 92° to 104°, external rotation from 12° to 24° (p=0.015). Mean abduction and external rotation strength were measured at 2.5 kg. Osteoarthritis progressed, and mean acromio-humeral distance has a significant decrease from 7.5 mm to 4.4 mm (p=0.003). Ultrasound examination showed twelve transferred tendons healed to the greater tuberosity. CT-scan showed a small atrophy of the transferred muscle, with a measurement of the cross-sectional area of the muscle belly at the inferior angle of the scapula at 1405 mm2, versus 1644 mm2 for the controlateral (p=0.06). Electromyographic analysis demonstrated a significant higher electric activity on the operative side during abduction and external rotation, and significant lower activity during adduction and internal rotation in comparison with the nonoperative side. Conclusions. Latissimus dorsi transfer allows for significant pain relief and function improvement in irreparable posterosuperior rotator cuff tears at young patients. Its electric activity increase in abduction and external rotation shows that the transferred muscle can integrate a new function and act like an active muscle transfer, in addition to an interposition or tenodesis effect. However we didn't find any depression of the humeral head or strength improvement

The outcome of an anatomical shoulder replacement depends on an intact rotator cuff. In 1981 Grammont designed a novel large-head reverse shoulder replacement for patients with cuff deficiency. Such has been the success of this replacement that it has led to a rapid expansion of the indications. We performed a systematic review of the literature to evaluate the functional outcome of each indication for the reverse shoulder replacement. Secondary outcome measures of range of movement, pain scores and complication rates are also presented.

The long head of the biceps tendon has been proposed as a source of pain in patients with rotator cuff tears. The purpose of this study is to evaluate the objective, subjective, and radiographic results of arthroscopic biceps tenotomy in selected patients with rotator cuff tears. Three hundred seven arthroscopic biceps tenotomies were performed in patients with full thickness rotator cuff tears. All patients had previously failed appropriate nonoperative management. Patients were selected for arthroscopic tenotomy if the tear was thought to be irreparable or the patient was older and not willing to participate in the rehabilitation required following rotator cuff repair. One hundred eleven shoulders underwent a concomitant acromioplasty. The mean age at surgery was 64.3 years. The mean preoperative radiographic acromiohumeral interval measured 6.6 mm. Patients were evaluated clinically and radiographically at a mean 57 months follow-up (range 24 to 168 months). The mean Constant score increased from 48.4 points preoperatively to 67.6 points postoperatively (p < 0.0001). Eighty-seven percent of patients were satisfied or very satisfied with the result. Nine patients underwent an additional surgical procedure (three for attempt at rotator cuff repair and six for reverse prostheses for cuff tear arthropathy). The acromiohumeral interval decreased by a mean. 1.3 mm during the follow-up period and was associated with longer duration of follow-up (p < 0.0001). Preoperatively, 38% of patients had glenohumeral arthritis; postoperatively, 67% of patients had glenohumeral arthritis. Concomitant acromioplasty was statistically associated with better subjective and objective results only in patients with an acromiohumeral distance greater than 6 mm. Fatty infiltration of the rotator cuff musculature had a negative influence on both the functional and radiographic results (p < 0.0001). Arthroscopic biceps tenotomy in the treatment of rotator cuff tears in selected patients yields good objective improvement and a high degree of patient satisfaction. Despite these improvements, arthroscopic tenotomy does not appear to alter the progressive radiographic changes that occur with long standing rotator cuff tears

We reviewed the outcome of 28 patients who had been treated using the Aequalis fracture prosthesis for an acute fracture of the proximal humerus at a mean follow-up of 39.3 months (24 to 63). The mean age of the patients at the time of the fracture was 66.3 years (38 to 80). The mean Constant score was 68.2 (37 to 84) for the operated shoulder, which represented 89.5% of the mean score for the uninjured side (p < 0.001). The quality of the reconstruction as shown on the immediate post-operative radiographs was categorised into three types, anatomical, acceptable, and unacceptable, depending on the position of the tuberosities relative to the prosthetic head and the humeral shaft. Anatomical reconstruction was associated with a higher mean Constant score as well as higher mean values of anterior forward elevation, abduction and external rotation than the other types, but the differences were not statistically significant (p > 0.231).

A total of 18 patients had active anterior elevation ≥150°. Their mean active abduction and external rotation were 163.6° and 31.3°, respectively. In seven of the 28 patients, the mean active anterior elevation, abduction and external rotation were 130.7°, 129.2° and 22.8°, respectively. In all, 12 patients were very satisfied with the results, 12 were satisfied, two were dissatisfied and two were disappointed; 26 reported no or only mild pain while only two had moderate pain. In five patients proximal migration of the humeral head was shown on the anteroposterior radiographs of the shoulder. No evidence of loosening was found in any prosthesis.

We describe the longer term clinical and radiological findings in a prospectively followed series of 49 rheumatoid patients (58 shoulders) who had undergone Neer II total shoulder replacement. The early and intermediate results have been published previously.

At a mean follow-up of 19.8 years (16.5 to 23.8) 14 shoulders survived. Proximal migration of the humeral component was associated with progressive loosening of the glenoid and humeral components, but was independent of the state of the rotator cuff at the time of operation. Despite these changes the range of movement was preserved. Most patients had little or no pain in the shoulder, could sleep undisturbed and could attend to personal hygiene and grooming.

In 100 patients the fulcrum axis which is the line connecting the anterior tip of the coracoid and the posterolateral angle of the acromion, was used to position true anteroposterior radiographs of the shoulder. This method was then compared with the conventional radiological technique in a further 100 patients.

Three orthopaedic surgeons counted the number of images without overlap between the humeral head and glenoid and calculated the amount of the glenoid surface visible in each radiograph. The analysis was repeated for intraobserver reliability. The learning curves of both techniques were studied.

The amount of free visible glenoid space was significantly higher using the fulcrum-axis method (64 vs 31) and the comparable glenoid size increased significantly (8.56 vs 6.47). Thus the accuracy of the anteroposterior radiographs of the shoulder is impaired by using this technique. The intra and interobserver reliability showed a high consistency. No learning curve was observed for either technique.

The purpose of this study was to evaluate outcome following arthroscopic biceps tenotomy or tenodesis for massive irreparable rotator cuff tears associated with biceps lesions. This is a retrospective study of sixty-eight consecutive patients (mean age 68 ± 6 years) with seventy-two irreparable rotator cuff tears treated with arthroscopic biceps tenotomy (thirty-nine cases) or tenodesis (thirty-three cases). All patients were evaluated clinically and radiographically at a mean follow-up of thirty-five months (range, 24–52). Fifty-three patients (78%) were satisfied. Constant score improved from forty-six to sixty-seven points (p< 0.001). Presence of a healthy, intact teres minor on preoperative imaging correlated with increased postoperative external rotation (40 vs. 18°, p< 0.05) and higher Constant score (p< 0.05). Three patients with a pseudoparalyzed shoulder did not benefit from the procedure and did not regain active elevation above the horizontal level. By contrast, fifteen patients with painful loss of active elevation recovered active elevation. The acromiohumeral distance decreased 1 mm on average, and only one patient developed glenohumeral osteoarthritis. There was no difference between tenotomy and tenodesis (Constant Score sixty-one vs. seventy-three). A “Popeye” sign was clinically apparent in twenty-four tenotomy patients (61%), but none were bothered by it. Two patients required reoperation with a reverse prosthesis. Arthroscopic biceps tenotomy and tenodesis effectively treats severe pain or dysfunction caused by an irreparable rotator cuff tear associated with biceps pathology. Shoulder function is significantly lower if the teres minor is atrophic or fatty infiltrated. Pseudoparalysis or severe cuff arthropathy are contraindications

Background: An acromiohumeral interval narrower than six millimeters has been considered pathologic and strongly indicative for rotator cuff tears by numerous authors. This prospective study was conducted as an assessment of inter- and intraobserver variation in the radiographic measurement of the acromiohumeral interval and its critical value. Material and Methods: Thirty blinded, standardized anteroposterior shoulder radiographs were independently reviewed by five board certified orthopedic shoulder surgeons. The acromiohumeral distance, from the inferior anterior acromial aspect to the humeral head was measured in millimeters. The five investigators classified each film a second time in random order. Results: Finally the same 27 radiographs (90%) have been evaluated by five investigators at both examination time points. The results of three investigators showed significant intra-observer variation ranging from 4 to 11 millimeters for the same radiograph. Six investigator pairs showed significant inter-observer variation at both examination time points (p< 0.05). The maximum inter-observer difference for the same radiograph was 11 millimeters (ranging from 1 to 11, SD 0.3 – 4.2). Conclusion: In view of our results the assessment of the acromiohumeral interval using anteroposterior x-rays does not seem to be a reproducible method of measurement. Further investigations in combination with CT or MRI are necessary to ensure our findings