Aims

Heterotopic ossification (HO) occurs after arthroplasty, especially total hip arthroplasty. In this study we describe the incidence, evolution, morphology and clinical consequences of HO following reverse shoulder arthroplasty.

BACKGROUND

Abnormal glenoid version positioning has been recognized as a cause of glenoid component failure caused by the rocking horse phenomenon. In contrast, the importance of the glenoid inclination has not been investigated.

Background:

The balance between the subscapularis muscle and the infraspinatus/teres minor muscles, often referred to as the rotator cuff ‘force couple’, has been proposed to be critical component for glenohumeral stability. Function of these muscles can be estimated with the evaluation of muscle atrophy. In clinical practice, muscle cross-sectional area (CSA) rather than 3D muscle volume measurement have been used because it is less time consuming. Because combined anthropometric measures of length and width more accurately define the muscular volume it seems logical to study the transversal rotator cuff force couple in the transversal plane an not in the sagittal plane of the body because both parameters can be included. But is it not clear which transversal CSA has the best correlation with muscle volume

Introduction

Humeral head subluxation in patients with cuff tear arthropathy (CTA) and in patients with primary arthrosis has been classified by Hamada and by Walch (type B). These classifications are based on 2D evaluation techniques (AP X-ray view, axial CT images). To our knowledge no 3D evaluation of the direction of humeral head subluxation has been described

INTRODUCTION

Glenosphere disengagement can be a potential serious default in reverse shoulder arthroplasty [1]. To ensure a good clinical outcome, it is important for the surgeon to obtain an optimal assembly of the glenosphere - base plate system during surgery. However interpositioning of material particles (bone, soft tissue) between the contact surface of the glenosphere and the base plate and/or a misalignment of the glenosphere relative to the base plate can result in a suboptimal assembly of the glenosphere – base plate system [2]. This misalignment is typically caused by unwanted contact between the glenosphere and the scapula due to inadequate reaming. Both defects prevent the Morse taper from fully engaging, leading to a system configuration for which the assembly was not designed to be loaded in vivo. This study quantifies the influence these defects have on the relative movement between the glenosphere and metaglene.

Background

There is no consensus on which glenoid plane should be used in total shoulder arthroplasty. Nevertheless, anatomical reconstruction of this plane is imperative for the success of a total shoulder arthroplasty.

Purpose: Despite good clinical results of the reverse total shoulder arthroplasty inferior scapular notching remains a concern. The aim of this study was to evaluate the effect of 6 different parameters on notching.

Materials and Methods: An average shape A-P view 2-D computer model of scapula was created, using data from 200 scapulae, so that the position of the glenoid and humeral component could be changed, as well as design features such as depth of the polyethylene insert, size of glenosphere and centre of rotation. The model calculates the maximum adduction (notch angle).

Results: A change in humeral neck shaft inclination from 155° to 145° resulted in a gain of 10° in notch angle. A change in cup depth from 8mm to 5mm resulted in a maximum gain of 12°. With no inferior prosthetic overhang a lateralisation of the centre of rotation from 0 to 5mm resulted in a maximum gain of 15° on notch angle. More lateralization resulted in increased gain in notch angle. With an inferior overhang of only 1 mm no effect of lateralizing the centre of rotation was calculated. Glenoid varus of 0 to 10°, without inferior overhang, results in a gain of 10° on notch angle. A change in glenosphere radius from 18 to 21mm resulted in no gain of notch angle without prosthetic overhang. A prosthetic overhang to the bone from 0 to 5mm results in a maximum gain on notch angle of 39°.

Conclusion: To prevent an inferior scapular conflict in reverse total shoulder arthroplasty the change in neck-shaft angle or depth of the polyethylene insert had a modest gain in notch angle. The effect of lateralization of the centre of rotation and putting the glenosphere in more varus was completely eliminated by adding a small inferior overhang. The main effect of increasing the size of the glenosphere was if it created a prosthetic overhang. Of all 6 tested parameters the prosthetic overhang resulted in the biggest gain in notch angle and this should be considered when designing the reverse arthroplasty and defining optimal surgical technique.

Aims of the study: To assess the results of one-stage revision of infected reverse total shoulder arthroplasty as a new treatment for this major surgical complication.

Materials: 11 consecutive patients with infected reverse shoulder prosthesis (DePuy International Ltd, Leeds, UK) were treated with a direct-exchange reverse total shoulder arthroplasty between March 2005 and June 2007. These patients were retrospectively followed.

Methods: Via a superior extended deltoideopectoral, clavicular osteotomy approach, according to Redfern-Wallace, a removal of the prosthesis is performed. Multiple operative specimens (4 to 8) are taken and cultured. A thorough synovectomy is performed before implanting a new reverse total shoulder arthroplasty (7 Delta^® 3.2 tsp and 4 DeltaXtend^® tsp). A gentamycine (Duracol^®) impregnated membrane is interpositioned between baseplate and glenosphere. Immediate postoperative passive and active mobilisation is permitted if no pain is present.

Results: Clinical symptoms are seldom severe pain (3) or severe limitation of function (3). A fistula is mainly present (8) without alterating the function. No prosthetic loosening was present at the humeral and glenoid site confirming the absence of radiological infectious signs. All but one patient are considered free of infection at mean follow up of 24 months (12m – 36m) and without antibiotic treatment for minimum 6 months. In only 1 patient the infection persisted necessitating a two-stage revision, unfortunately without definitive cure. Only three early complications are seen (< 2 months: posterior dislocation, postoperative haematoma and clavicle fracture). The mean postoperative Constant-Murley score was 52 (14–81) at latest follow up.

Peroperative samples identified Propionbacterium species (5), Coagulase-negative staphylococci (4), MRSA (1) and with E.Coli (1) infection. Monobacterial infection was seen in 6 shoulders, multibacterial in 2 shoulders and in 2 shoulders cultures were negative.

Discussion: This cohort of patients has a different syndrome than the known infected anatomical prosthesis. This pathology seems to be rarely associated with severe pain (3) or limitation of function (3). Draining fistulas without alterating the function of the shoulder [CS: mean 43 (3–63)] are more frequently present making a preoperative diagnosis easier and more certain.

Recurrence rate of infection is comparable to the classical two-stage revision. Preoperative stiff and painful shoulders seems to have a bad prognosis despite definite cure of the infection. Supple shoulders (mainly associated with a fistula) can be treated with a good functional result.

Conclusion: One-stage revision arthroplasty is an attractive alternative treatment for infected reverse total shoulder arthroplasty.

We retrospectively reviewed 11 consecutive patients with an infected reverse shoulder prosthesis. Patients were assessed clinically and radiologically, and standard laboratory tests were carried out. Peroperative samples showed Propionbacterium acnes in seven, coagulase-negative Staphylococcus in five, methicillin-resistant staphylococcus aureus in one and Escherichia coli in one. Two multibacterial and nine monobacterial infections were seen. Post-operatively, patients were treated with intravenous cefazolin for at least three days and in all antibiotic therapy was given for at least three months. Severe pain (3 of 11) or severe limitation of function (3 of 11) are not necessarily seen. A fistula was present in eight, but function was not affected. All but one patient were considered free of infection after one-stage revision at a median follow-up of 24 months, and without antibiotic treatment for a minimum of six months. One patient had a persistent infection despite a second staged revision, but is now free of infection with a spacer. Complications included posterior dislocation in one, haematoma in one and a clavicular fracture in one. At the most recent follow-up the median post-operative Constant-Murley score was 55, 6% adjusted for age, gender and dominance.

A one-stage revision arthroplasty reduces the cost and duration of treatment. It is reliable in eradicating infection and good functional outcomes can be achieved.

Objective: This study evaluates the preoperative conventional anteroposterior radiography in non-operated patients with cuff tear arthropathy. It analyses the radiological findings in relation to the status of the rotator cuff and clinical outcome. The aim of the study is to define the usefulness of this radiographical examination in cuff tear arthropathy.

Methodology: This study analyses the preoperative radiological (AP-view, (Artro-)CT-scan or MRI-scan) and clinical characteristics (Constant-Murley-score plus active and passive mobility testing) and the peroperative findings in a cohort of 315 patients of which 282 had eccentric omarthrosis according to the classification of Hamada and 33 patients with centered omarthrosis who have at least two irreparable tendon tears. Those patients were part of a multicenter, retrospective, consecutive study of the French Orthopaedic Society (SOFCOT-2006). All patients had no surgical antecedents and were all treated with prosthetic shoulder surgery for a painful irreparable cuff tear arthropathy (reverse -(84%) or hemi-(8%) or double cup prosthesis (8%)).

Results: Fatty degeneration of a rotator cuff muscle decreases its strength (p < 0.0001).

In the presence of tendons lesser bony wear is seen at the acromion (acetabularisation, (p< 0.005), the glenoid (superomedial wear p=0.005) as well as the humeral head (femoralization, p=0.002).

The radiological classifications according to Hamada and Favard seem not to be as appropriate to reflect accurately the location and extent of the tendino-muscular degeneration as the acromial acetabularization and humeral sphericity.

The acromio-humeral distance is a good indicator for the location and the extend of the cuff tear arthropathy. A smaller acromio-humeral distance (95% CI: 4mm + 1) is only present if the postero-superior muscles are fatty degenerated (Goutallier stade III & IV) and a larger distance is calculated (95% CI: 7mm + 3) when only the antero-superior muscles are diseased.

The coracoid tip in cuff tear arthropathy-patients is almost always positioned in the inferior half of the glenoid (84%).

A bigger supero-inferior distance of the glenoid in relation to the radius of the humeral head indicates more structural destruction of rotator cuff status (tendinous and muscular) and a worse clinical outcome.

Conclusion: This study defines the use of a conventional radiological antero-posterior view to evaluate eccentric omarthrosis as very useful. The direction of eccentricity in the scapular plane of the body and type of wear, situated either at the glenoïd, acromion or humeral head are determined by the location and extent of the tendinous lesion and the degree of fatty degeneration of the rotator cuff muscle.

The concept of non-anatomic reversed arthroplasty is becoming increasingly popular. The design medializes and stabilizes the center of rotation, and lowers the humerus relative to the acromion, and lengthens the deltoid muscle up to 18%. Such a surgically created global distraction of muscles is likely to affect nervous structures. When nerves are stretched up to 5–10%, axonal transport and nerve conduction starts to be impaired. At 8% of elongation, venous blood flow starts to diminish and at 15% all circulation in and out of the nerve is obstructed. [1] To understand nerve dynamics following reversed arthroplasty, we investigated nerve strain and excursion in a cadaver model.

In a formalin-embalmed female cadaver specimen, the brachial plexus en peripheral upper limb nerves were carefully dissected and injected with an iodine containing contrast medium. At the same time 1.2 mm-diameter leaded markers were implanted at topographically crucial via points for later enhanced recognition on CT reconstructions. After the first session of CT scanning a plastic replica of the Delta reversed shoulder prosthesis® was surgically placed followed by re-injection of the plexus with the same solution. The preoperative and the postoperative specimen were studied using a helical CT scan with a 0,5 mm slice increment. The Mimics® (Materialise NV, Belgium) software package was used for visualization and segmentation of CT images and 3D rendering of the brachial plexus and peripheral nerves.

After surgery, there was an average increase in nerve strain below physiologically relevant amplitudes. In a few local segments of the brachial plexus an increase in nerve strain exceeding 5–10 % was calculated. The largest increase in strain (up to 19%) was observed in a segment of the medial cord. These results suggest there might be a clinically relevant increase in nerve strain following reversed shoulder arthroplasty.

Physiological studies have revealed that the central nervous system controls groups of muscle fibers in a very efficient manner. Within a single skeletal muscle, the central nervous system independently controls individual muscle segments to produce a particular motor outcome. Mechanomyographic studies on the deltoid muscle have revealed that the deltoid muscle, commonly described as having three anatomical segments, is composed of at least seven functional muscle segments, which all have the potential to be at an important level independently coordinated by the central nervous system.[1] In this study we tried to anatomically describe and quantify these different functional segments within the deltoid muscle, based on the branching out pattern of the axillary nerve.

Forty-four deltoids of 22 embalmed adult cadavers, were analyzed. The axillary nerve was carefully dissected together with his anterior and posterior branch upon invasion into the muscle. According to the pattern of fiber distribution and their fascial embalmment, we then carefully splitted the deltoid muscle into different portions each being innervated by a major branch of the axillary nerve. The position and volume of each segment in relation to the whole muscle was derived.

In 3 cases the axillary nerve branched out in 8 major divisions. In 22 out of 44 cases (50%), the axillary nerve branched out in 7 principal parts. A branching out pattern of 6 major divisions occurred in 14 out of 44 cases. Finally we found a division in 5 major branches in 5 of the specimens. In general, both posterior and anterior peripheral segments seemed to have the largest volume. In nearly all (93%) cases, the central segments were smaller in weight and volume compared to the more peripheral segments.

Based on the innervation pattern of the deltoid muscle a segmentation in 5 up to 8 major segments seem to be found. This confirms from anatomical point of view earlier reports of functional differentiation within the deltoid muscle.

Biomechanical models have been successfully applied to screen potential risk factors for injuries and to plan and evaluate the effects of orthopedic surgical procedures.[1] These models have made apparent the feasibility and necessity for the generation of subject specific models that are aimed at custom clinical applications. In order to develop such models a methods needs to be developed that allows accurate geometrical visualization and reconstruction of position and characteristics of bone and soft tissues, including neurovascular structures.[2] In this study, we present our approach to obtain both bony as soft tissue features necessary for upper limb modeling from computer tomography alone. As a case study the techniques were applied in a non-anatomic shoulder reconstruction.

In order to determine the muscles of the shoulder girdle, ultrathin flexible metallic markers were sutured from origin to insertion according to the fiber directions in all muscles involved in shoulder movement on a total of ten different cadaver shoulders. The plexus brachialis and upper limb nerves were dissected and injected with a iodium contrast containing mixture. A Ct multi-slice image reconstruction was performed from occiput to the hip joint. The software package Mimics® (Materialise NV, Heverlee, Belgium) was used to segment and reconstruct the different anatomical models that included bone, muscle features, nerves and vascular structures. A clustering method algorithm, was used to filter interruptions of the different masks, scattering rustle and small irregularities due to the different contrasting markers used. Vascular tissue could be reconstructed and segmented as air filled structures. We were able to accurately reconstruct nerve tissue in an highly complex configuration such as the plexus brachialis.

Analysis of the representations showed that the different morphologic parameters were within the normal anatomical ranges and that our method is suitable to create complete anatomical models based on Ct-imaging alone.