Purpose

While reverse shoulder arthroplasty (RSA) corrects vertical muscle imbalance, it cannot restore the horizontal imbalance seen in cuff-deficient shoulders with combined loss of active elevation and external rotation (CLEER). We report the medium-term results of the modified latissimus dorsi/teres major tendon transfer (L'Episcopo procedure) associated with RSA, performed via a single deltopectoral approach.

Purpose: We hypothesized that lateralization of the RSA, with a glenoid bone graft taken from the osteotomised humeral head, would prevent those problems without increasing torque on the glenoid component by keeping the center of rotation within the glenoid. The objectives of this study were to describe the results of the first 12 patients that underwent a bony increased-offset RSA (BIO RSA).

Method: Thirty-six shoulders in 34 consecutive patients with cuff tear arthritis (mean age 72 years, range 52–86 years) received a BIO RSA, consisted of a RSA incorporating an autogenous humeral head bone graft placed beneath the glenoid baseplate. A baseplate with a lengthened central peg (+25 mm) was inserted in the glenoid vault, securing the bone graft beneath the baseplate and screws. All patients underwent clinical and radiographic (computed tomography) review at a minimum 1-year follow-up.

Results: All patients were satisfied or very satisfied and all had no or slight pain. Mean active elevation increased from 72° to 142° (p< 0.05), external rotation from 10° to 18° (p< 0.05) and internal rotation from L4 to L3 (p> 0.05). Constant Score improved from 27 to 63 points (p< 0.05). The Subjective Shoulder Value (SSV) increased from 27% to 73% (p< 0.05). Radiographically, the graft healed to the native glenoid in all cases and no graft resorption under the baseplate was observed. Complications included one patient with scapular notching (stage 1) and one patient with previous radiotherapy had a deep infection. No postoperative instability, and no glenoid loosening were observed.

Conclusion: The use of an autologous bone graft harvested from the humeral head can lateralize the center of rotation of a RSA while keeping the center of rotation at the glenoid bone-prosthesis interface. The clinical advantages of a BIO RSA are a decrease in scapular notching, enhanced stability and mobility, and improved shoulder contour while keeping the center of rotation at the glenoid bone-prosthesis interface. This bony lateralization allows maintenance of the principles of Grammont and seems to be more appropriate than prosthetic lateralization. These promising early results of this novel procedure warrant further investigation.

Purpose: Shoulder pain in the young athlete is often a diagnostic challenge. It is our experience that this pain can be related to a so-called “unstable painful shoulder” (UPS), defined as instability presenting in a purely painful form, without any history of instability but with anatomical (soft tissue or bony) ‘roll-over’ lesions. The objectives are to describe the epidemiology and diagnostic criteria and to report the results of surgical treatment.

Method: A prospective review was performed of 20 patients (mean age 22 ± 8 years). Inclusion criteria: a painful shoulder and “roll-over lesions” on imaging or at surgery. Exclusion criteria: a dislocation/subluxation; associated pathology; previous shoulder surgery.

Results: Most patients were male (60%), athletes (85%) and involved the dominant arm (80%). All patients denied a feeling of instability and only complained of deep, anterior pain. Most had a history of trauma (80%). All patients had rehabilitation without success and 30% had subacromial injections. All had to stop sports. Most (85%) had anterior or inferior hyperlaxity. All had pain with an anterior apprehension test and relieved by relocation test. ‘Roll-over’ lesions included: labrum detachment (90%), capsular distension (75%), HAGL lesion (10%), glenoid fracture (20%) or Hill-Sachs (40%). Time from symptoms to surgery was 25 ± 23 months. All patients had arthroscopic treatment. Mean follow-up was 38 ± 14 months. Eighteen patients (90%) were very satisfied/satisfied. None had pain at rest, but one (5%) had pain with apprehension test. There was no change in elevation, external or internal rotation (p> 0.05). There were no cases of instability. Rowe and Duplay scores improved (p< 0.05).

Conclusion: Instability of the shoulder can present in a purely painful form, without any history of dislocations or subluxations. Diagnosis can be difficult, and should be suspected in young patients and athletes. Most patients have deep anterior pain and pain with apprehension test. ‘Roll-over’ lesions are necessary to confirm the diagnosis. Arthroscopic repair is effective.

Purpose: Partial rotator cuff tears are a frequent source of shoulder pain. At times, diagnosis is difficult and treatment unsuccessful. Historical treatment has involved open debridement when conservative treatment has failed. The purpose of this study was to evaluate the results of arthroscopic treatment of deep partial thickness tears of the supraspinatus tendon in patients over 40 years and to assess the healing radiographically.

Method: Forty-nine patients (mean age: 55 years) underwent treatment of a deep partial thickness tear of the supraspinatus tendon. Exclusion criteria: age < 40 years, associated instability, posterosuperior impingement or previous shoulder surgery. Patients were re-examined with a mean 32 months follow-up. For lesions involving less than 50% of the tendon thickness, an acromioplasty and either a debridement (n=39) or a side-to-side repair (n=3) was performed. For lesions involving greater than 50% of the tendon thickness (n=7), an acromioplasty and a trans-osseous repair was performed after completion of the tear. Twenty patients (41%) had an assessment of tendon healing by CT arthrogram, MRI or MR arthrogram, at a minimum 12 months post-operatively.

Results: Results were good or excellent in 90% of patients, and 94% were satisfied. The Constant score improved from 56 to 82 points (p< 0.0001) and the UCLA score improved from 15 to 30 points (p< 0.0001). Of the 31 patients employed preoperatively, three did not return to work; an occupational injury was predictive of a lower Constant score (p=0.02). Four out of 13 (31%) cases involving less than 50% of the tendon thickness healed and all cases (n=7) involving greater than 50% had healed.

Conclusion: Patients over 40 years with an isolated deep partial thickness tear of the supraspinatus tendon benefited both subjectively and objectively from arthroscopic intervention. For deep tears involving < 50% of the tendon thickness, resolution of pain and return to work is possible after acromioplasty and debridement. For deeper tears, completion of the tendon and reattachment to the greater tuberosity enables tendon healing.

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.

The purpose of this study was two-fold: 1) to examine perioperative prospective changes in pain, disability and psychosocial variables in ACL reconstructed recreational athletes over the pre-op to eight week post-op period. 2) to see what variables will predict greatest disability at eight weeks post-op.

All participants were recreational athletes at the time of their injuries who had patella-autograft procedure at the the Queen Elizabeth II Health Sciences Centre. Fifty-four patients (twenty-nine males; mean age = 25.4 years, SD = 8.08). Mean education was fourteen years (SD = 2.08), 32%(17) were married, 67%(36) single, and 1% was divorced. 94%(51) of the sample was Caucasian, 3%(2) Black, and 1% Asian. One quarter reported their ACL injury was due to sport-based contact, with non-contact sporting activity reported at 76%(41). All participants completed measures of pain, depression, pain catastrophizing, state anxiety pre-op, on days one and two following surgery and again at eight weeks post-op. Disability was assessed pre-op and eight weeks post-op.

Pain was varied across comparisons with preoperative pain increased twenty-four and forty-eight-hour post-op. Pain at forty-eight-hours postoperative was significantly higher than pain reported at eight-weeks post-op. Catastrophizing did not differ from the pre-op to twenty-four-hour post-op but did drop from twenty-four to forty-eight-hours and forty-eight-hours to eight-weeks post-op. Pre-op depression increased twenty-four-hour post-op, but not from twenty-four to forty-eight-hours and declined at eight-weeks. Anxiety increase pre-op to twenty-four-hours but not from twenty-four to forty-eight-hours but did drop from forty-eight-hours to eight-weeks.Disability did not change over time. Regression showed age or gender did not predict disability but forty-eight hour pain and catastrophizing did.

These data indicate that pain and psychological variables change over time of ACL recovery. Results suggest that pain and distress peek during acute post-op period. As well, post-op catastrophizing predicts disability at eight weeks post-op which may indicate that catastrophizing may be related to behaviours related to slower recovery following ACL reconstructive surgery.

The purpose of this study was to review the results of biceps tenodesis and biceps reinsertion in the treatment of type II SLAP lesions.

We conducted a retrospective cohort study of a continuous series of patients. Only isolated type II SLAP lesions were included: twenty-five cases from January 2000 to April 2004. Exclusion criteria included associated instability, rotator cuff rupture and previous shoulder surgery. Ten patients (ten men) with an average age of thirty-seven years (range, 19–57) had a reinsertion of the long head of the biceps tendon (LHB) to the labrum with two suture anchors. Fifteen patients (nine men and six women) with an average age of fifty-two years (range, 28–64) underwent biceps tenodesis in the bicipital groove. All patients were reviewed by an independent examiner.

In the reattachment group, the average follow-up was thirty-five months (range, 24–69); three patients underwent subsequent biceps tenodesis for persistent pain, three others were disappointed because of an inability to return to their previous level of sport, and the remaining four were very satisfied. The average Constant score improved from sixty-five to eighty-three points. In the tenodesis group, the average follow-up was thirty-four months (range, 24–68). No patient required revision surgery. Subjectively, one patient was disappointed (atypical residual pain), two were satisfied and twelve were very satisfied. All patients returned to their previous level of sports, and the average Constant score improved from fifty-nine to eighty-nine points.

The results of labral reattachment were disappointing in comparison to biceps tenodesis. Thus, arthroscopic biceps tenodesis can be considered as an effective alternative to reattachment in the treatment of isolated type II SLAP lesions. By moving the origin of the biceps to an extra-articular position, we eliminated the traction on the superior labrum and the source of pain; furthermore, range of motion and strength are unaltered allowing for a return to a pre-surgical level of activity.

The purpose was to evaluate the results of reverse shoulder arthroplasty (RSA) in proximal humerus fracture sequelae (FS).

Multicenter retrospective series of forty-five consecutive patients operated between 1995 and 2003. Types of FS included: cephalic collapse and necrosis (n=8), chronic locked dislocation (n=5), surgical neck nonunion (n=7), severe malunion (twenty), and isolated greater tuberosity malunion (n=3). Twenty-six patients had surgical treatment of the initial fracture and seventeen had non-surgical treatment; thirty-three Delta and ten Aequalis reverse prosthesis were implanted. Mean age at surgery was seventy-three years (range, fifty-seven to eighty-six). Forty-three patients were available for clinical and radiologic evaluation with a mean follow-up of thirty-nine months (range, twenty-four to ninety-five).

Nine re-operations (21%) and ten complications (23%) were encountered, including four infections (leading to two resection-arthroplasties), two instabilities, one glenoid fracture (converted to hemiarthroplasty) and one axillary nerve palsy. Thirty-six patients (83%) were satisfied or very satisfied with their result. The adjusted Constant score improved from 29% preoperatively to 75% postoperatively (p< 0.0001), the Constant score for pain from fou to twelve points (p< 0.0001), and active anterior elevation from 59° to 114° (p< 0.0001). Active rotations were limited. A positive postoperative hornblower test negatively influenced Constant score (forty-two points compared to 61.5 points, p=0.004) and external rotation (−6° compared to 15°, p=0.004). The lowest functional results were observed in surgical neck nonunions (with five complications) and isolated greater tuberosity malunions. In type four fracture sequelae, patients who had an osteotomy or resection of the GT (n=9) had better forward flexion (140° compared to 110°, p=0.026) and better Constant score (sixty-three points compared to forty-six points, p=0.07).

RSA can be a surgical option in elderly patients with FS, specifically for those with severe malunion (type four fracture sequelae) where hemiarthroplasty gives poor results. By contrast, surgical neck nonunions (type three) and isolated greater tuberosity malunions are at risk for low functional results. The surgical technique and the remaining cuff muscles (teres minor) are important prognostic factors. Functional results are lower and complications/reoperations rates are higher than those reported for RSA in cuff tear arthritis.

The purpose of this study is to report the results of arthroscopic Bankart repair following failed open treatment of anterior instability.

We performed a retrospective review of twenty-two patients with recurrent anterior shoulder instability (i.e. subluxations or dislocations, with or without pain) after open surgical stabilization. There were seventeen men and five women with an average age of thirty-one years (range, 15–65). The most recent interventions consisted of sixteen osseous transfers (twelve Latarjet and four Eden-Hybinette), three open Bankart repairs and three capsular shifts. The causes of failure were additional trauma in twelve patients and complications related to the bone-block in thirteen (poor position, fracture, pseudarthrosis or lysis). All patients were noted to have distension of the anterior-inferior capsular structures. Labral re-attachment and capsulo-ligamentous re-tensioning with suture anchors was performed in all cases with an additional rotator interval closure in four patients and an inferior capsular plication in twelve patients; the bone block screws were removed in eight patients.

At an average follow-up of forty-three months (range, twenty-four to seventy-two months), nineteen patients were evaluated by two independent observers. One patient had recurrent subluxation, and two patients had persistent apprehension. Anterior elevation was unchanged, and loss of external rotation (RE1) was 6°. Nine patients returned to sport at the same level; all patients returned to their previous occupations, including the six cases of work-related injury. Eighty-nine percent were satisfied or very satisfied; the subjective shoulder value (SSV) was 83% ± 23%; the Walch-Duplay, Rowe and UCLA scores were 85 ± 21, 81 ± 23 and 30 ± 7 points respectively. The number of previous interventions did not influence the results. Eight patients (42%) were still painful (six with light pain and two with moderate pain).

Arthroscopic revision of open anterior shoulder stabilization gives satisfactory results. The shoulders are both stable and functional. While the stability obtained with this approach is encouraging, our enthusiasm is tempered by some cases of persistent pain.

The complications of prostheses for fractures of the proximal humerus are understudied because the experience of each shoulder surgeon is limited and a standardised registration protocol is not yet available. A prospective study on complications in shoulder arthroplasty for fracture is, therefore, essential to explore variables that influence outcome. The purpose of this study is to report our experience with complications following arthroplasty for proximal humeral fractures.

In a multicenter study, four hundred and six patients treated with arthroplasty for proximal humeral fracture were prospectively followed during a nine year period; three hundred patients with a minimum of two years follow-up, at an average of forty-five months (range, 24–117), were available for review. Objective results were graded with the Constant score and range of motion. Subjective results were reported according to patient satisfaction.

At follow-up, the average Constant score was fifty-four points (range, 14–95) and active forward elevation was 103° (range, 10°–180°). Eighty-one percent of patients were satisfied or very satisfied. We observed a 59% rate of late (after three months) complications, including a high rate of tuberosity-related complications (72% malunion or nonunion). Initial tuberosity malposition was present in 35% of the patients. Secondary migration despite initial good positioning was observed in 24%.

Tuberosity complications were associated with poor final Constant score, poor range of motion and shoulder pain (p=0.001 for all items). A re-operation was performed in 5.3% of the cases. Patients who were mobilised according to the ‘early passive motion’ concept had double the incidence of secondary tuberosity migration, compared to those that were initially immobilised (14% versus 27%, p=0.004). Tuberosity complications are the most frequent late complication and they are associated with poor functional results. It is, therefore, incumbent upon the surgeon to maximise healing with adequate fixation of the tuberosities, followed by sufficient immobilization.

The objective of this study is to report the epidemiology and results of treatment of deep infection after a reverse shoulder arthroplasty.

This is a multicenter retrospective study involving 457 reverse prostheses performed between 1992 and 2002. Fifteen patients (3%) (mean age 71 ± 9 years) presented with a deep infection. Eight were primary arthroplasties and seven were revision procedures. There were five associated peri-operative fractures and three early postoperative complications requiring surgical treatment. Infection was treated by debridement (n=4), prosthetic resection (n=10) or two-stage revision (n=1).

The infection rate was 2% (8/363) for a primary reverse arthroplasty and 7% (7/94) for revisions. The infection was diagnosed at a mean of seventeen months (range, one to fifty-seven) post-operatively, corresponding to two acute, five sub-acute and eight chronic infections. The most common pathogen was P. acnes in six cases (40%). At a mean follow-up of thirty-four ± nineteen months, there were twelve remissions (80%) and three recurrent infections. The two acute infections (one debridement and one resection) and the eight chronic infections (seven resections and one two-stage revision) were in remission. Among the five sub-acute infections, the two resections were in remission, whereas the three debridements recurred. Overall, the ten resections were in remission with seven patients disappointed and three satisfied, a mean Constant score of thirty-one ± eight points and a mean active anterior elevation of 53 ± 15°. The two-stage exchange was in remission but remained disappointed with a Constant score of twenty-seven points and an active anterior elevation of 90°.

Infection compromises the functional results of the reverse prosthesis whatever the treatment performed. Acute infections appear to be satisfactorily treated by debridement or resection. Both resection and two-stage revision can successfully treat sub-acute and chronic infection; however, debridement alone is ineffective and not recommended. There is a high rate of infection when the reverse prosthesis is used in revision arthroplasty. Prevention, by looking for such infection before surgery and by performing a two-stage procedure is recommended in the case of any uncertainty.

The purpose of this study is to catalogue humeral problems with reverse total shoulder arthroplasty and define their influence on outcome.

A multicenter retrospective review of 399 reverse humeral arthroplasties implanted between January 1994 and April 2003, yielded seventy-nine patients with humeral problems. We define a clinical humeral problem as an event that alters the expected rehab or postoperative course. Perioperative problems are fractures within the stem zone while postoperative problems involve fractures distal to the stem, prosthetic disassembly and subsidence. Radiologic problems include humeral loosening and radiolucencies of greater than 2 mm that have not had a clinical impact. All radiographs were available and reviewed by three orthopaedic surgeons. Objective results were rated according to the Constant score; active forward flexion and external rotation were recorded; and subjective outcome was noted.

We identified twenty-six intra-operative fractures and eleven postoperative fractures. There were four cases of disassembly, three cases of subsidence, and fifteen cases of radiographic loosening. At a mean follow-up of forty-seven months, average active elevation was 111.3 degrees, external rotation was 7.0 degrees, and absolute Constant score improved from 21.9 to 50.1 points. Seventy-one percent of the patients were satisfied or very satisfied. Intra-operative humeral fractures were associated with poor final Constant score (42.3), poor range of motion and increased shoulder pain (p=0.001 for all items). Constant score for those revision patients who experienced a fracture was lower by 9.6 points (p=0.0347) than those patients who underwent a reverse prosthesis for revision surgery without a fracture. Constant score for those patients with a postoperative fracture averaged 47.2 (range, 8–70). A re-operation was performed in seven of the cases (9%).

Intra-operative humeral fractures occur commonly when a reverse prosthesis is indicated for revision; humerotomy is not protective, however, and is not recommended for all humeral revisions. Fractures, either intraoperative or post-operative, result in lower Constant scores. Any patient who received an intervention for a humeral problem yielded a lower constant score. While postoperative Constant scores improved in all categories, they were lower than those patients who did not sustain a humeral complication.

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.