Aims

In the initial development of total shoulder arthroplasty (TSA), the humeral component was usually fixed with cement. Cementless components were subsequently introduced. The aim of this study was to compare the long-term outcome of cemented and cementless humeral components in arthroplasty of the shoulder.

Purpose: The indication to perform a total shoulder arthroplasty (TSA) versus a hemiarthroplasty is guided by a patient’s intended level of activity after surgery. It is unclear what activities patients actually perform following shoulder replacement, therefore, the purpose of this study was to compare the self-reported activities of patients following either a TSA or hemiarthroplasty.

Method: Two groups of 75 patients each, following TSA or hemiarthroplasty, were matched for a variety of demographic variables. A mailed activity questionnaire asked patients to report their level of pain, motion, strength, and a choice of 70 different activities. Reported activities were classified as high (i.e. tennis) or low (i.e. fishing) demand, and categorized as household (i.e. cooking), yard work (i.e. gardening), sporting (i.e. golf), or musical (i.e. piano).

Results: Ninety-six (64%) patients completed the survey, 50 in the TSA group (27F:19M, avg. 53.2 yrs), and 46 in the HA group (29F:21M, avg. 53.5 yrs). Pain was not different between groups (3.6/10 TSA: 3.9/10 HA), yet a significant difference was reported in forward flexion (145° TSA: 120° HA, P< .002) and strength (6.3/10 TSA: 5.3/10 HA, P< .01). Across all categories whether it be high or low demand, the TSA group (10.4 activities/person) reported more activities compared with the hemiarthroplasty group (8.6 activities/person).

Conclusion: The conventional understanding that a hemiarthroplasty provides the possibility for more activity following surgery is not supported by our data. Patients following a TSA reported better motion and strength and were more active than the hemiarthroplasty group.

Purpose: We conducted a retrospective review to evaluate outcomes, complications and implant survival after shoulder reconstruction for bone neoplasm using anatomic shoulder prostheses.

Method: Thirty-four anatomic shoulder prostheses were reviewed at an average follow-up of 51 (range, 6 to 143) months. The mean age at the time of surgery was 47 (range, 15 to 74) years. Twenty-five patients (74%) had reconstruction with an allograft-prosthetic composite (APC). The average amount of humerus resected in patients with an APC was 13 cm (range, 5 to 36 cm).

Results: At most recent follow-up, 82% of patients had no pain (11), slight pain (12) or moderate pain with strenuous activities (5). Twenty-eight patients (82%) were subjectively satisfied despite only 29% being satisfactory according to Neer rating. Sixteen complications occurred in 13 patients, including instability (5), host/graft non-union (3), aseptic loosening (3), arthrofibrosis (1), tumor recurrence (2) and superficial infection (1). Host/graft nonunion occurred in 3/9 patients with an APC using press-fit or plate fixation for distal humeral fixation and 0/16 shoulders with cemented distal humeral fixation (p=0.02). Three implants required revision for aseptic loosening (1), host/graft nonunion (1) and instability (1). Kaplan-Meier survivorship at 10 years was 88% for implant revision and 80% for mechanical failure.

Conclusion: Reconstruction of the proximal humerus using an anatomic prosthesis after resection of bone neoplasms is associated with a low rate of mechanical failure but a moderate rate of shoulder instability. Cement fixation into the native distal humerus should be considered when reconstruction using an APC is required.

Purpose: Loosening of the humeral component is rarely a cause for revision shoulder surgery. Most long-term series are not large enough to stratify the many risk factors that might influence the survivorship of humeral component designs. The purpose of this study was to determine long-term survivorship of the Neer and Cofield humeral components and to define the risk factors associated with humeral component removal or revision.

Method: 1584 primary Neer and Cofield shoulder arthroplasties (1423 patients) were performed at our institution from 1984 to 2004. There were 619 men (694 shoulders) and 804 women (890 shoulders), with a mean age at arthroplasty of 65.6 years (range, 16–94 years). Kaplan-Meier survivorship analysis was used to determine the effect of etiology of the disease, gender, age, surgery type (hemi versus total), fixation type (cemented versus noncemented), and the humeral component type (Neer II, Cofield I or II) on the estimated survival free of humeral component revision or removal.

Results: There were 108 revisions and 17 removals of the humeral component. The overall rate of removal or revision of the humeral component was 7.9% with an average followup of 8.1 years. The rates of survivorship free of revision or removal of the humeral component for any reason was 94.8% at 5 years, 92% at 10 years, 86.7% at 15 years and 82.8% at 20 years. Seventy-one of 632 shoulders (11.2%) in patients younger than 65 years required humeral component revision or removal, whereas only 54 of 952 shoulders (5.7%) in patients 65 years and older required humeral component revision or removal (Odds ratio=2.1; 95% confidence interval, 1.5–3, p=0.001). Patients with posttraumatic arthritis had a higher risk of needing revision or removal of the humeral component (Odds ratio=2.1, 95% confidence interval 1.3–3.3) compared to osteoarthritis. Eighty-four of 526 shoulders (16.0%) with metal-back glenoid components required humeral component revision or removal, whereas only 41 of 1058 shoulders (3.9%) with non metal-backed glenoid components required humeral component revision or removal (Odds ratio=4.7; 95% confidence interval, 3.2–7, p=0.001).

Conclusion: Younger age, replacement due to post-traumatic arthritis and presence of a metal-backed glenoid increased the likelihood of humeral component failure. Similar short-term survival can be achieved with Cofield II and Neer II humeral components.

Purpose: Currently, there is little information available concerning the outcome of patients with infection following rotator cuff repair. Therefore, the purpose of this study was to review the incidence, management and outcomes of patients with rotator cuff repair complicated with deep infection.

Methods: Between 1975 and 2003, 39 cases of deep infection following rotator cuff repair were identified. The medical records and radiographs were retrospectively examined. At a mean follow-up of 8.2 years, seven patients had died and two patients had been lost to follow-up leaving 30 cases for outcome evaluation.

Results: The incidence of deep infection after rotator cuff repairs that were performed at our institution was 0.43% (21 of 4886 cases). The mean interval from rotator cuff repair to the time of infection diagnosis was 49 days. ESR and C-reactive protein were elevated in only 60% and 50% of patients, respectively. Propionibacterium was the most common organism isolated, infecting 51% of cases. A mean of 3.3 surgical debridements were necessary for the eradication of infection. At final follow-up, mean active abduction was 121° and mean external rotation was 44°. The ASES score averaged 67 points and the Simple Shoulder Test score averaged 7.3 points.

Conclusions: The data from this study suggests that the eradication of deep infection following rotator cuff repair is possible, however, substantial functional limitations are not unusual. Additionally, the treating surgeon should be aware of the high incidence of Propionibacterium and the importance of allowing a minimum of seven days of culture to identify this organism.

Between January 1, 1976 and December 31, 1991, 195 total shoulder arthroplasties and 108 hemiarthroplasties were performed by the senior author in patients with rheumatoid arthritis. One hundred eighty-seven total shoulder arthroplasties and 95 hemiarthroplasties with complete preoperative evaluation, operative records, and minimum 2-year follow-up (mean 11.6 years) or follow-up until revision were included in the clinical analysis. Twenty patients died and one was lost to follow-up. All 303 shoulders were included in the survival analysis.

There was significant long term pain relief (P< .0001), improvement in active abduction (P< .0001), and external rotation (P< .0001) with both, hemiarthroplasty and total shoulder arthroplasty. There was not a significant difference in improvement in pain and motion comparing hemiarthroplasty and total shoulder arthroplasty for patients with a thin or torn rotator cuff. However, among patients with an intact rotator cuff, improvement in pain and abduction were significantly greater with total shoulder arthroplasty. Additionally, among patients with an intact rotator cuff, the risk for revision was significantly lower for total shoulder arthroplasty (p=0.04).

Radiographs were available for 152 total shoulder arthroplasties and 63 hemiarthroplasties with a minimum 2 year follow-up. Glenoid erosion was present in 62 of 63 hemiarthroplasties (98%). Glenoid periprosthetic lucency was present in 110 of 152 total shoulder arthroplasties (72%).

The data from this study indicate there is marked long term pain relief and improvement in motion with shoulder arthroplasty. Among patients with an intact rotator cuff, total shoulder arthroplasty appears to be the preferred procedure for pain relief, improvement in abduction, and lower risk of revision surgery.