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The Bone & Joint Journal
Vol. 104-B, Issue 1 | Pages 76 - 82
1 Jan 2022
ten Brinke B Hesseling B Eygendaal D Hoelen MA Mathijssen NMC

Aims. Stemless humeral implants have been developed to overcome stem-related complications in total shoulder arthroplasty (TSA). However, stemless implant designs may hypothetically result in less stable initial fixation, potentially affecting long-term survival. The aim of this study is to investigate early fixation and migration patterns of the stemless humeral component of the Simpliciti Shoulder System and to evaluate clinical outcomes. Methods. In this prospective cohort study, radiostereometric analysis (RSA) radiographs were obtained in 24 patients at one day, six weeks, six months, one year, and two years postoperatively. Migration was calculated using model-based RSA. Clinical outcomes were evaluated using the visual analogue scale (VAS), the Oxford Shoulder Score (OSS), the Constant-Murley Score (CMS), and the Disabilities of the Arm, Shoulder and Hand (DASH) score. Results. At two years, median translation along the x-, y-, and z-axis was -0.12 mm (interquartile range (IQR) -0.18 to 0.02), -0.17 mm (IQR -0.27 to -0.09), and 0.09 mm (IQR 0.02 to 0.31). Median rotation around the x-, y-, and z-axis was 0.12° (IQR -0.50 to 0.57), -0.98° (IQR -1.83 to 1.23), and 0.09° (IQR -0.76 to 0.30). Overall, 20 prostheses stabilized within 12 months postoperatively. Four prostheses showed continuous migration between 12 and 24 months. At two-year follow-up, with the exception of one revised prosthesis, all clinical scores improved significantly (median VAS difference at rest: -3.0 (IQR -1.5 to -6.0); OSS 22.0 (IQR 15.0 to 25.0); CMS 29.5 (IQR 15.0 to 35.75); and DASH -30.0 (IQR -20.6 to -41.67) (all p < 0.001)) with the exception of one revised prosthesis. Conclusion. In conclusion, we found that 20 out of 24 implants stabilized within 12 months postoperatively. The significance of continuous migration in four implants is unclear and future research on the predictive value of early migration for future loosening in TSA is required. Clinical results revealed a clinically relevant improvement. Cite this article: Bone Joint J 2022;104-B(1):76–82


The Bone & Joint Journal
Vol. 103-B, Issue 5 | Pages 958 - 963
3 May 2021
Nguyen NTV Martinez-Catalan N Songy CE Sanchez-Sotelo J

Aims. The purpose of this study was to report bone adaptive changes after anatomical total shoulder arthroplasty (TSA) using a standard-length hydroxyapatite (HA)-coated humeral component, and to report on a computer-based analysis of radiographs to determine changes in peri-implant bone density objectively. Methods. A total of 44 TSAs, performed between 2011 and 2014 using a cementless standard-length humeral component proximally coated with HA, were included. There were 23 males and 21 females with a mean age of 65 years (17 to 65). All shoulders had good quality radiographs at six weeks and five years postoperatively. Three observers graded bone adaptive changes. All radiographs were uploaded into a commercially available photographic software program. The grey value density of humeral radiological areas was corrected to the grey value density of the humeral component and compared over time. Results. Stress shielding was graded as mild in 14 shoulders and moderate in three; the greater tuberosity was the predominant site for stress shielding. The mean metaphyseal and diaphyseal fill-fit ratios were 0.56 (SD 0.1) and 0.5 (SD 0.07), respectively. For shoulders with no radiologically visible stress shielding, the mean decrease in grey value in zones 1 and 7 was 20%, compared with 38% in shoulders with radiologically visible stress shielding. Conclusion. The rate of moderate stress shielding was 7%, five years after implantation of a cementless standard-length HA-coated humeral component. Clinical observation of stress shielding identified on radiographs seems to represent a decrease in grey value of 25% or more. Cite this article: Bone Joint J 2021;103-B(5):958–963


The Bone & Joint Journal
Vol. 101-B, Issue 5 | Pages 610 - 614
1 May 2019
Aibinder WR Bartels DW Sperling JW Sanchez-Sotelo J

Aims. Shoulder arthroplasty using short humeral components is becoming increasingly popular. Some such components have been associated with relatively high rates of adverse radiological findings. The aim of this retrospective review was to evaluate the radiological humeral bone changes and mechanical failure rates with implantation of a short cementless humeral component in anatomical (TSA) and reverse shoulder arthroplasty (RSA). Patients and Methods. A total of 100 shoulder arthroplasties (35 TSA and 65 RSA) were evaluated at a mean of 3.8 years (3 to 8.3). The mean age at the time of surgery was 68 years (31 to 90). The mean body mass index was 32.7 kg/m. 2. (17.3 to 66.4). Results. Greater tuberosity stress shielding was noted in 14 shoulders (two TSA and 12 RSA) and was graded as mild in nine, moderate in two, and severe in three. Medial calcar resorption was noted in 23 shoulders (seven TSA and 16 RSA), and was graded as mild in 21 and moderate in two. No humeral components were revised for loosening or considered to be loose radiologically. Nine shoulders underwent reoperation for infection (n = 3), fracture of the humeral tray (n = 2), aseptic glenoid loosening (n = 1), and instability (n = 3). No periprosthetic fractures occurred. Conclusion. Implantation of this particular short cementless humeral component at the time of TSA or RSA was associated with a low rate of adverse radiological findings on the humeral side at mid-term follow-up. Our data do not raise any concerns regarding the use of a short stem in TSA or RSA. Cite this article: Bone Joint J 2019;101-B:610–614


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 2 | Pages 235 - 241
1 Feb 2010
van der Lugt JCT Valstar ER Witvoet-Braam SW Nelissen RGHH

Mechanical loosening which begins with early-onset migration of the prosthesis is the major reason for failure of the Souter-Strathclyde elbow replacement. In a prospective study of 18 Souter-Strathclyde replacements we evaluated the patterns of migration using roentgen stereophotogrammetric analysis. We had previously reported the short-term results after a follow-up of two years which we have now extended to a mean follow-up of 8.2 years (1 to 11.3). Migration was assessed along the co-ordinal axes and overall micromovement was expressed as the maximum total point movement. The alignment of the prosthesis and the presence of radiolucent lines were examined on conventional standardised radiographs. All the humeral components showed increased and variable patterns of migration at the extended follow-up and four humeral components were revised. The maximum total point movement at two years in the revised prostheses was 1.8 mm (. sd. 1.0) and in the non-revised 0.7 mm (. sd. 0.5, p = 0.01). Most humeral components migrated into external rotation resulting in an anterior and varus tilt. The ulnar components remained stable


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 1 | Pages 75 - 81
1 Jan 2009
Cil A Veillette CJH Sanchez-Sotelo J Sperling JW Schleck C Cofield RH

Between 1976 and 2004, 38 revision arthroplasties (35 patients) were performed for aseptic loosening of the humeral component. The mean interval from primary arthroplasty to revision was 7.1 years (0.4 to 16.6). A total of 35 shoulders (32 patients) were available for review at a mean follow-up of seven years (2 to 19.3). Pre-operatively, 34 patients (97%) had moderate or severe pain; at final follow-up, 29 (83%) had no or only mild pain (p < 0.0001). The mean active abduction improved from 88° to 107° (p < 0.01); and the mean external rotation from 37° to 46° (p = 0.27). Excellent or satisfactory results were achieved in 25 patients (71%) according to the modified Neer rating system. Humeral components were cemented in 29, with ingrowth implants used in nine cases. There were 19 of standard length and 17 were longer (two were custom replacements and are not included). Bone grafting was required for defects in 11 humeri. Only two glenoid components were left unrevised. Intra-operative complications included cement extrusion in eight cases, fracture of the shaft of the humerus is two and of the tuberosity in four. There were four re-operations, one for recurrent humeral loosening, with 89% survival free of re-operations at ten years. Revision surgery for aseptic loosening of the humeral component provides reliable pain relief and modest improvement of movement, although there is a substantial risk of intra-operative complications. Revision to a total shoulder replacement gives better results than to a hemiarthroplasty


The Bone & Joint Journal
Vol. 105-B, Issue 6 | Pages 668 - 678
1 Jun 2023
Friedman RJ Boettcher ML Grey S Flurin P Wright TW Zuckerman JD Eichinger JK Roche C

Aims

The aim of this study was to longitudinally compare the clinical and radiological outcomes of anatomical total shoulder arthroplasty (aTSA) up to long-term follow-up, when using cemented keel, cemented peg, and hybrid cage peg glenoid components and the same humeral system.

Methods

We retrospectively analyzed a multicentre, international clinical database of a single platform shoulder system to compare the short-, mid-, and long-term clinical outcomes associated with three designs of aTSA glenoid components: 294 cemented keel, 527 cemented peg, and 981 hybrid cage glenoids. Outcomes were evaluated at 4,746 postoperative timepoints for 1,802 primary aTSA, with a mean follow-up of 65 months (24 to 217).


The Bone & Joint Journal
Vol. 96-B, Issue 2 | Pages 229 - 236
1 Feb 2014
deVos MJ Verdonschot N Luites JWH Anderson PG Eygendaal D

We determined the short-term clinical outcome and migration within the bone of the humeral cementless component of the Instrumented Bone Preserving (IBP) total elbow replacement in a series of 16 patients. There were four men and 12 women with a mean age at operation of 63 years (40 to 81). Migration was calculated using radiostereometric analysis. There were no intra-operative complications and no revisions. At two-year follow-up, all patients showed a significant reduction in pain and functional improvement of the elbow (both p < 0.001). Although ten components (63%) showed movement or micromovement during the first six weeks, 14 (88%) were stable at one year post-operatively. Translation was primarily found in the proximal direction (median 0.3 mm (interquartile range (IQR) -0.09 to 0.8); the major rotational movement was an anterior tilt (median 0.7° (IQR 0.4° to 1.6°)). One malaligned component continued to migrate during the second year, and one component could not be followed beyond three months because migration had caused the markers to break off the prosthesis.

This study shows promising early results for the cementless humeral component of the IBP total elbow replacement. All patients had a good clinical outcome, and most components stabilised within six months of the operation.

Cite this article: Bone Joint J 2014;96-B:229–36.


The Bone & Joint Journal
Vol. 100-B, Issue 5 | Pages 603 - 609
1 May 2018
Schnetzke M Rick S Raiss P Walch G Loew M

Aims

The aim of this study was to evaluate the clinical and radiological outcome of using an anatomical short-stem shoulder prosthesis to treat primary osteoarthritis of the glenohumeral joint.

Patients and Methods

A total of 66 patients (67 shoulders) with a mean age of 76 years (63 to 92) were available for clinical and radiological follow-up at two different timepoints (T1, mean 2.6 years, sd 0.5; T2, mean 5.3 years, sd 0.7). Postoperative radiographs were analyzed for stem angle, cortical contact, and filling ratio of the stem. Follow-up radiographs were analyzed for timing and location of bone adaptation (cortical bone narrowing, osteopenia, spot welds, and condensation lines). The bone adaptation was classified as low (between zero and three features of bone remodelling around the humeral stem) or high (four or more features).


The Bone & Joint Journal
Vol. 104-B, Issue 1 | Pages 83 - 90
1 Jan 2022
Batten TJ Gallacher S Evans JP Harding RJ Kitson J Smith CD Thomas WJ

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. Methods. Outcomes of 143 procedures undertaken for all indications in 131 patients were reviewed, with subset analysis of those for osteoarthritis (OA) (n = 99). The primary outcome was the Oxford Shoulder Score (OSS) at a minimum of five years. Secondary outcomes were ranges of motion and radiological analysis of humeral radiolucency, rotator cuff failure, and glenoid loosening. Results. Mean OSS at mean follow-up of 6.67 years (5.0 to 10.74) was 40.12 (9 to 48), with no statistically significant difference between those implanted for a non-OA indication and those for OA (p = 0.056) or time-dependent deterioration between two years and five years (p = 0.206). Ranges of motion significantly improved compared with preoperative findings and were maintained between two and five years with a mean external rotation of 38° (SD 18.1, 0 to 100) and forward elevation of 152° (SD 29.9, 90 to 180). Of those components with radiographs suitable for analysis (n = 83), 23 (28%) were found to have a least one humeral radiolucent line, which were predominantly incomplete, less than 2 mm, and in a single anatomical zone. No humeral components were loose. A radiolucent line was present around 22 (15%) of glenoid components, and 15 (10%) of components had failed. Rotator cuff failure was found in 21 (15%) components. The mean time to either glenoid or rotator cuff failure was greater than three years following implantation. Survivorship was 96.4% (95% CI 91.6 to 98.5, number at risk 128) at five years, and 94.3% (95% CI 88.2 to 97.3, number at risk 76) at seven years, both of which compare favourably with best results taken from available registries. Conclusion. Functional and radiological outcomes of the Eclipse stemless TSA are excellent, with no loose humeral components at minimum five-year follow-up. The presence of radiolucent lines is of interest and requires long-term observation but does not impact on the clinical results. Of the eight revisions required, this was predominantly for glenoid and rotator cuff failure. Cite this article: Bone Joint J 2022;104-B(1):83–90


The Bone & Joint Journal
Vol. 99-B, Issue 5 | Pages 666 - 673
1 May 2017
Werthel J Lonjon G Jo S Cofield R Sperling JW Elhassan BT

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. Patients and Methods. All patients who underwent primary arthroplasty of the shoulder at our institution between 1970 and 2012 were included in the study. There were 4636 patients with 1167 cemented humeral components and 3469 cementless components. Patients with the two types of fixation were matched for nine different covariates using a propensity score analysis. A total of 551 well-balanced pairs of patients with cemented and cementless components were available after matching for comparison of the outcomes. The clinical outcomes which were analysed included loosening of the humeral component determined at revision surgery, periprosthetic fractures, post-operative infection and operating time. Results. The overall five-, ten-, 15- and 20-year rates of survival were 98.9%, 97.2%, 95.5%, and 94.4%, respectively. Survival without loosening at 20 years was 98% for cemented components and 92.4% for cementless components. After propensity score matching including fixation as determined by the design of the component, humeral loosening was also found to be significantly higher in the cementless group. Survival without humeral loosening at 20 years was 98.7% for cemented components and 91.0% for cementless components. There was no significant difference in the risk of intra- or post-operative fracture. The rate of survival without deep infection and the mean operating time were significantly higher in the cemented group. Conclusion. Both types of fixation give rates of long-term survival of > 90%. Cemented components have better rates of survival without loosening but this should be weighed against increased operating time and the risk of bony destruction of the proximal humerus at the time of revision of a cemented humeral component. Cite this article: Bone Joint J 2017;99-B:666–73


The Bone & Joint Journal
Vol. 101-B, Issue 10 | Pages 1280 - 1284
1 Oct 2019
Kang JR Logli AL Tagliero AJ Sperling JW

Aims. A number of methods have been described to remove a well-fixed humeral implant as part of revision shoulder arthroplasty. These include the use of cortical windows and humeral osteotomies. The router bit extraction technique uses a high-speed router bit to disrupt the bone-implant interface. The implant is then struck in a retrograde fashion with a square-tip impactor and mallet. The purpose of this study was to determine the characteristics and frequency of the different techniques needed for the removal of a well-fixed humeral stem in revision shoulder arthroplasty. Patients and Methods. Between 2010 and 2018, 288 revision shoulder arthroplasty procedures requiring removal of a well-fixed humeral component were carried out at a tertiary referral centre by a single surgeon. The patient demographics, indications for surgery, and method of extraction were collected. Results. Of the 288 revisions, 284 humeral stems (98.6%) were removed using the router bit extraction technique alone. Four humeral stems (1.39%) required an additional cortical window. Humeral osteotomy was not necessary in any procedure. Most of the humeral stems removed (78.8%) were cementless. Of the four humeral stems that required a cortical window, three involved removal of a hemiarthroplasty. Two were cemented and two were cementless. Conclusion. The router bit extraction technique removed a well-fixed humeral component in a very high proportion of patients (98.6%). This method allows surgeons to avoid more invasive approaches involving a cortical window or humeral osteotomy, and their associated complications. Cite this article: Bone Joint J 2019;101-B:1280–1284


The Bone & Joint Journal
Vol. 103-B, Issue 7 | Pages 1292 - 1300
1 Jul 2021
Märtens N Heinze M Awiszus F Bertrand J Lohmann CH Berth A

Aims. The purpose of this study was to compare clinical results, long-term survival, and complication rates of stemless shoulder prosthesis with stemmed anatomical shoulder prostheses for treatment of osteoarthritis and to analyze radiological bone changes around the implants during follow-up. Methods. A total of 161 patients treated with either a stemmed or a stemless shoulder arthroplasty for primary osteoarthritis of the shoulder were evaluated with a mean follow-up of 118 months (102 to 158). The Constant score (CS), the Disabilities of the Arm, Shoulder and Hand (DASH) score, and active range of motion (ROM) were recorded. Radiological analysis for bone adaptations was performed by plain radiographs. A Kaplan-Meier survivorship analysis was calculated and complications were noted. Results. The ROM (p < 0.001), CS (p < 0.001), and DASH score (p < 0.001) showed significant improvements after shoulder arthroplasty for both implants. There were no differences between the groups treated with stemmed or stemless shoulder prosthesis with respect to the mean CS (79.2 (35 to 118) vs 74.4 (31 to 99); p = 0.519) and DASH scores (11.4 (8 to 29) vs 13.2 (7 to 23); p = 0.210). The ten-year unadjusted cumulative survival rate was 95.3% for the stemmed anatomical shoulder prosthesis and 91.5% for the stemless shoulder prosthesis and did not differ between the treatment groups (p = 0.251). The radiological evaluation of the humeral components in both groups did not show loosening of the humeral implant. The main reason for revision for each type of arthroplasties were complications related to the glenoid. Conclusion. The use of anatomical stemless shoulder prosthesis yielded good and reliable results and did not differ from anatomical stemmed shoulder prosthesis over a mean period of ten years. The differences in periprosthetic humeral bone adaptations between both implants have no clinical impact during the follow-up. Cite this article: Bone Joint J 2021;103-B(7):1292–1300


The Bone & Joint Journal
Vol. 104-B, Issue 3 | Pages 401 - 407
1 Mar 2022
Kriechling P Zaleski M Loucas R Loucas M Fleischmann M Wieser K

Aims. The aim of this study was to report the incidence of implant-related complications, further operations, and their influence on the outcome in a series of patients who underwent primary reverse total shoulder arthroplasty (RTSA). Methods. The prospectively collected clinical and radiological data of 797 patients who underwent 854 primary RTSAs between January 2005 and August 2018 were analyzed. The hypothesis was that the presence of complications would adversely affect the outcome. Further procedures were defined as all necessary operations, including reoperations without change of components, and partial or total revisions. The clinical outcome was evaluated using the absolute and relative Constant Scores (aCS, rCS), the Subjective Shoulder Value (SSV) scores, range of motion, and pain. Results. The overall surgical site complication rate was 22% (188 complications) in 152 patients (156 RTSAs; 18%) at a mean follow-up of 46 months (0 to 169). The most common complications were acromial fracture (in 44 patients, 45 RTSAs; 5.3%), glenoid loosening (in 37 patients, 37 RTSAs; 4.3%), instability (in 23 patients, 23 RTSAs; 2.7%), humeral fracture or loosening of the humeral component (in 21 patients, 21 RTSAs; 2.5%), and periprosthetic infection (in 14 patients, 14 RTSAs; 1.6%). Further surgery was undertaken in 79 patients (82 RTSAs) requiring a total of 135 procedures (41% revision rate). The most common indications for further surgery were glenoid-related complications (in 23 patients, 23 RTSAs; 2.7%), instability (in 15 patients, 15 RTSAs; 1.8%), acromial fractures (in 11 patients, 11 RTSAs; 1.3%), pain and severe scarring (in 13 patients, 13 RTSAs; 1.5%), and infection (in 8 patients, 8 RTSAs; 0.9%). Patients who had a complication had significantly worse mean rCS scores (57% (SD 24%) vs 81% (SD 16%)) and SSV scores (53% (SD 27%) vs 80% (SD 20%)) compared with those without a complication. If revision surgery was necessary, the outcome was even further compromised (mean rCS score: 51% (SD 23%) vs 63% (SD 23%); SSV score: 4% (SD 25%) vs 61% (SD 27%). Conclusion. Although the indications for, and use of, a RTSA are increasing, it remains a demanding surgical procedure. We found that about one in five patients had a complication and one in ten required further surgery. Both adversely affected the outcome. Cite this article: Bone Joint J 2022;104-B(3):401–407


The Bone & Joint Journal
Vol. 99-B, Issue 6 | Pages 818 - 823
1 Jun 2017
Kodama A Mizuseki T Adachi N

Aims. We assessed the long-term (more than ten-year) outcomes of the Kudo type-5 elbow prosthesis in patients with rheumatoid arthritis (RA). Materials and Methods. We reviewed 41 elbows (Larsen Grade IV, n = 21; Grade V, n = 20) in 31 patients with RA who had undergone a Kudo type-5 total elbow arthroplasty (TEA) between 1994 and 2003, and had been followed up for more than ten years. The humeral component was cementless and the all-polyethylene ulnar component cemented in every patient. Clinical outcome was assessed using the Mayo elbow performance score. We calculated the revision rate and evaluated potential risk factors for revision. The duration of follow-up was a mean 141 months (120 to 203). Results. Aseptic loosening of the ulnar component occurred in 11 elbows. There was no radiolucency around any humeral component. There was one deep infection. The survival rate according to Kaplan-Meier survivorship analysis was 87.8% after five years and 70.7% after ten years. The range of extension/flexion was a mean -38° (-80° to 0°)/105° (30° to 150°) before surgery and -40° (-70° to -20°)/132° (100° to 150°) at the final follow-up, while the mean Mayo elbow performance score was 43 before surgery and 80 at final follow-up. Disease duration of RA up to the TEA of < 15 years and a pre-operative range of movement (ROM) of > 85° were significant risk factors for revision or aseptic loosening. Conclusion. Although Kudo type-5 prostheses gave satisfactory results in the short-term, aseptic loosening increased after five years. In most cases, elbow function was maintained in the long-term without loosening of the implant. A short duration from the onset of RA to TEA and a large pre-operative ROM were significant risk factors for revision or aseptic loosening. Cite this article: Bone Joint J 2017;99-B:818–23


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 9 | Pages 1197 - 1200
1 Sep 2009
Betts HM Abu-Rajab R Nunn T Brooksbank AJ

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


The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 10 | Pages 1382 - 1389
1 Oct 2012
Sewell MD Kang SN Al-Hadithy N Higgs DS Bayley I Falworth M Lambert SM

There is little information about the management of peri-prosthetic fracture of the humerus after total shoulder replacement (TSR). This is a retrospective review of 22 patients who underwent a revision of their original shoulder replacement for peri-prosthetic fracture of the humerus with bone loss and/or loose components. There were 20 women and two men with a mean age of 75 years (61 to 90) and a mean follow-up 42 months (12 to 91): 16 of these had undergone a previous revision TSR. Of the 22 patients, 12 were treated with a long-stemmed humeral component that bypassed the fracture. All their fractures united after a mean of 27 weeks (13 to 94). Eight patients underwent resection of the proximal humerus with endoprosthetic replacement to the level of the fracture. Two patients were managed with a clam-shell prosthesis that retained the original components. The mean Oxford shoulder score (OSS) of the original TSRs before peri-prosthetic fracture was 33 (14 to 48). The mean OSS after revision for fracture was 25 (9 to 31). Kaplan-Meier survival using re-intervention for any reason as the endpoint was 91% (95% confidence interval (CI) 68 to 98) and 60% (95% CI 30 to 80) at one and five years, respectively. There were two revisions for dislocation of the humeral head, one open reduction for modular humeral component dissociation, one internal fixation for nonunion, one trimming of a prominent screw and one re-cementation for aseptic loosening complicated by infection, ultimately requiring excision arthroplasty. Two patients sustained nerve palsies. Revision TSR after a peri-prosthetic humeral fracture associated with bone loss and/or loose components is a salvage procedure that can provide a stable platform for elbow and hand function. Good rates of union can be achieved using a stem that bypasses the fracture. There is a high rate of complications and function is not as good as with the original replacement


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 3 | Pages 341 - 344
1 Mar 2006
Tanaka N Sakahashi H Ishii S Kudo H

The purpose of this study was to assess the long-term results (more than ten years) of two types of cemented ulnar component with type-5 Kudo total elbow arthroplasty in a consecutive series of 56 patients (60 elbows) with rheumatoid arthritis, and to compare the results in elbows above and below a Larsen grade IV. There was no radiolucency around the humeral component. Patients in whom a metal-backed ulnar component and a porous-coated stem were used had better clinical results and significantly less progression of radiolucent line formation around the ulnar component. They also had a significantly better long-term survival than patients with an all-polyethylene ulnar component. The clinical results of arthroplasty using all-polyethylene ulnar components were inferior, regardless of the degree of joint destruction. We conclude that the type-5 Kudo total elbow arthroplasty with cementless fixation of the porous-coated humeral component and cemented fixation of a metal-backed ulnar component is acceptable and well-tolerated by rheumatoid patients


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 12 | Pages 1594 - 1600
1 Dec 2009
Khan A Bunker TD Kitson JB

There are no long-term published results on the survival of a third-generation cemented total shoulder replacement. We describe a clinical and radiological study of the Aequalis total shoulder replacement for a minimum of ten years. Between September 1996 and May 1998, 39 consecutive patients underwent a primary cemented total shoulder replacement using this prosthesis. Data were collected prospectively on all patients each year, for a minimum of ten years, or until death or failure of the prosthesis. At a follow-up of at least ten years, 12 patients had died with the prosthesis intact and two had emigrated, leaving 25 available for clinical review. Of these, 13 had rheumatoid arthritis and 12 osteoarthritis. One refused radiological review leaving 24 with fresh radiographs. Survivorship at ten years was 100% for the humeral component and 92% for the glenoid component. The incidence of lucent lines was low. No humeral component was thought to be at risk and only two glenoid components. The osteoarthritic group gained a mean 65° in forward flexion and their Constant score improved by a mean 41.4 points (13 to 55). The rheumatoid group gained a mean of 24° in flexion and their Constant score improved by 29.4 points. This difference may have been due to failure of the rotator cuff in 75% of the patients with rheumatoid arthritis. Thus a third-generation total shoulder replacement gives an excellent result in patients with osteoarthritis and an intact rotator cuff. Patients with rheumatoid arthritis have a 75% risk of failure of the rotator cuff at ten years


The Bone & Joint Journal
Vol. 100-B, Issue 11 | Pages 1493 - 1498
1 Nov 2018
Wagner ER Hevesi M Houdek MT Cofield RH Sperling JW Sanchez-Sotelo J

Aims. Patients with a failed reverse shoulder arthroplasty (RSA) have limited salvage options. The aim of this study was to determine the outcome of revision RSA when used as a salvage procedure for a failed primary RSA. Patients and Methods. We reviewed all revision RSAs performed for a failed primary RSA between 2006 and 2012, excluding patients with a follow-up of less than two years. A total of 27 revision RSAs were included in the study. The mean age of the patients at the time of revision was 70 years (58 to 82). Of the 27 patients, 14 (52% were female). The mean follow-up was 4.4 years (2 to 10). Results. Six patients (22%) developed complications requiring further revision surgery, at a mean of 1.7 years (0.1 to 5.3) postoperatively. The indication for further revision was dislocation in two, glenoid loosening in one, fracture of the humeral component in one, disassociation of the glenosphere in one, and infection in one. The five-year survival free of further revision was 85%. Five additional RSAs developed complications that did not need surgery, including dislocation in three and periprosthetic fracture in two. Overall, patients who did not require further revision had excellent pain relief, and significant improvements in elevation and external rotation of the shoulder (p < 0.01). The mean postoperative American Shoulder and Elbow Surgeons (ASES), and simple shoulder test (SST) scores were 66 and 7, respectively. Radiological results were available in 26 patients (96.3%) at a mean of 4.3 years (1.5 to 9.5). At the most recent follow-up, six patients (23%) had glenoid lucency, which were classified as grade III or higher in three (12%). Smokers had a significantly increased risk of glenoid lucency (p < 0.01). Conclusion. Revision RSA, when used to salvage a failed primary RSA, can be a successful procedure. At intermediate follow-up, survival rates are reasonable, but dislocation and glenoid lucency remain a concern, particularly in smokers. Cite this article: Bone Joint J 2018;100-B:1493–98


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 1 | Pages 68 - 72
1 Jan 1997
Stewart MPM Kelly IG

We made a prospective study of 58 consecutive Neer II total shoulder replacements in 49 rheumatoid patients. Cemented glenoid and press-fit humeral components had been used. After a mean follow-up of 9.5 years (7 to 13), 11 patients (15 shoulders) had died, one shoulder had been arthrodesed and five patients (five shoulders) had been lost to follow-up. Of the remaining 37 shoulders 29 were painfree or had only slight discomfort, four had pain on unusual activity, and four had moderate or severe pain. There were satisfactory improvements in the mean range of active elevation (53° to 75°) and external rotation (5° to 38°); satisfactory performance of the activities of daily living had been maintained throughout follow-up. Radiographs showed loosening in ten shoulders of nine glenoid and nine humeral components but of these only three had significant symptoms. Three loose glenoid components and two loose humeral components required revision. We consider that the Neer total shoulder replacement provides a reasonable medium to long-term outcome in rheumatoid arthritis, but recommend that the humeral component should be routinely cemented


The Journal of Bone & Joint Surgery British Volume
Vol. 66-B, Issue 5 | Pages 737 - 741
1 Nov 1984
Rydholm U Tjornstrand B Pettersson H Lidgren L

Fifteen patients with rheumatoid arthritis had 19 elbow arthroplasties with the Wadsworth type of surface replacement prosthesis. After a follow-up period averaging 30 months, 11 patients with 15 elbow arthroplasties were entirely satisfied with their freedom from pain and range of movement. Radiologically, however, the humeral component was loose in 10 of the 19 elbows and the ulnar component in 5. Two patients had reoperation, one to remove a prosthesis for early deep infection and one to exchange a humeral component which was loose. The risk of mechanical loosening is reduced by accurate positioning of the humeral component, but there is a high potential for failure. Changes in the design of the prosthesis and better instrumentation for alignment of the components are desirable. Prosthetic replacement of the elbow should still be regarded as experimental


The Bone & Joint Journal
Vol. 98-B, Issue 1 | Pages 75 - 80
1 Jan 2016
Merolla G Chin P Sasyniuk TM Paladini P Porcellini G

Aims. We evaluated clinical and radiographic outcomes of total shoulder arthroplasty (TSA) using the second-generation Trabecular Metal (TM) Glenoid component. The first generation component was withdrawn in 2005 after a series of failures were reported. Between 2009 and 2012, 40 consecutive patients with unilateral TSA using the second-generation component were enrolled in this clinical study. The mean age of the patients was 63.8 years (40 to 75) and the mean follow-up was 38 months (24 to 42). Methods. Patients were evaluated using the Constant score (CS), the American Shoulder and Elbow Surgeons (ASES) score and routine radiographs. Results. Significant differences were found between the pre- and post-operative CS (p = 0.003), ASES (p = 0.009) scores and CS subscores of pain (p < 0.001), strength (p < 0.001) and mobility items (p < 0.05). No glenoid or humeral components migrated. Posterior thinning of the keel and slight wear at the polyethylene-TM interface was observed in one patient but was asymptomatic. Radiolucent lines were found around three humeral (< 1.5 mm) and two glenoid components (< 1 mm) and all were asymptomatic. Discussion. TSA with the second-generation TM Glenoid component results in satisfactory to excellent clinical performance, function, and subjective satisfaction at a mean follow-up of about three years. Radiographic changes were few and did not affect the outcome. Take home message: This paper highlights that the second generation Trabecular Metal Glenoid has better outcomes than those reported with the first-generation component.  . Cite this article: Bone Joint J 2016;98-B:75–80


The Bone & Joint Journal
Vol. 97-B, Issue 7 | Pages 967 - 972
1 Jul 2015
Hussey MM Hussey SE Mighell MA

Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory. . An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure. Cite this article: Bone Joint J 2015;97-B:967–72


The Bone & Joint Journal
Vol. 97-B, Issue 11 | Pages 1539 - 1545
1 Nov 2015
Lenoir H Chammas M Micallef JP Lazerges C Waitzenegger T Coulet B

Determining and accurately restoring the flexion-extension axis of the elbow is essential for functional recovery after total elbow arthroplasty (TEA). We evaluated the effect of morphological features of the elbow on variations of alignment of the components at TEA. Morphological and positioning variables were compared by systematic CT scans of 22 elbows in 21 patients after TEA. There were five men and 16 women, and the mean age was 63 years (38 to 80). The mean follow-up was 22 months (11 to 44). The anterior offset and version of the humeral components were significantly affected by the anterior angulation of the humerus (p = 0.052 and p = 0.004, respectively). The anterior offset and version of the ulnar components were strongly significantly affected by the anterior angulation of the ulna (p < 0.001 and p < 0.001). The closer the anterior angulation of the ulna was to the joint, the lower the ulnar anterior offset (p = 0.030) and version of the ulnar component (p = 0.010). The distance from the joint to the varus angulation also affected the lateral offset of the ulnar component (p = 0.046). Anatomical variations at the distal humerus and proximal ulna affect the alignment of the components at TEA. This is explained by abutment of the stems of the components and is particularly severe when there are substantial deformities or the deformities are close to the joint. Cite this article: Bone Joint J 2015;97-B:1539–45


The Bone & Joint Journal
Vol. 97-B, Issue 8 | Pages 1096 - 1101
1 Aug 2015
Oizumi N Suenaga N Yoshioka C Yamane S

To prevent insufficiency of the triceps after total elbow arthroplasty, we have, since 2008, used a triceps-sparing ulnar approach. This study evaluates the clinical results and post-operative alignment of the prosthesis using this approach. We reviewed 25 elbows in 23 patients. There were five men and 18 women with a mean age of 69 years (54 to 83). There were 18 elbows with rheumatoid arthritis, six with a fracture or pseudoarthrosis and one elbow with osteoarthritis. Post-operative complications included one intra-operative fracture, one elbow with heterotopic ossification, one transient ulnar nerve palsy, and one elbow with skin necrosis, but no elbow was affected by insufficiency of the triceps. Patients were followed for a mean of 42 months (24 to 77). The mean post-operative Japanese Orthopaedic Association Elbow Score was 90.8 (51 to 100) and the mean Mayo Elbow Performance score 93.8 (65 to 100). The mean post-operative flexion/extension of the elbow was 135°/-8°. The Manual Muscle Testing score of the triceps was 5 in 23 elbows and 2 in two elbows (one patient). The mean alignment of the implants examined by 3D-CT was 2.8° pronation (standard deviation (. sd). 5.5), 0.3° valgus (. sd. 2.7), and 0.7° extension (. sd. 3.2) for the humeral component, and 9.3° pronation (. sd. 9.7), 0.3° valgus (. sd. 4.0), and 8.6° extension (. sd. 3.1) for the ulnar component. There was no radiolucent line or loosening of the implants on the final radiographs. . The triceps-sparing ulnar approach allows satisfactory alignment of the implants, is effective in preventing post-operative triceps insufficiency, and gives satisfactory short-term results. . Cite this article: 2015;97-B:1096–1101


The Bone & Joint Journal
Vol. 96-B, Issue 10 | Pages 1359 - 1365
1 Oct 2014
Large R Tambe A Cresswell T Espag M Clark DI

Medium-term results of the Discovery elbow replacement are presented. We reviewed 51 consecutive primary Discovery total elbow replacements (TERs) implanted in 48 patients. The mean age of the patients was 69.2 years (49 to 92), there were 19 males and 32 females (37%:63%) The mean follow-up was 40.6 months (24 to 69). A total of six patients were lost to follow-up. Statistically significant improvements in range movement and Oxford Elbow Score were found (p < 0.001). Radiolucent lines were much more common in, and aseptic loosening was exclusive to, the humeral component. Kaplan–Meier survivorship at five years was 92.2% (95% CI 74.5% to 96.4%) for aseptic loosening. In four TERs, periprosthetic infection occurred resulting in failure. A statistically significant association between infection and increased BMI was found (p = 0.0268). Triceps failure was more frequent after the Mayo surgical approach and TER performed after previous trauma surgery. No failures of the implant were noted. . Our comparison shows that the Discovery has early clinical results that are similar to other semi-constrained TERs. We found continued radiological surveillance with particular focus on humeral lucency is warranted and has not previously been reported. Despite advances in the design of total elbow replacement prostheses, rates of complication remain high. Cite this article: Bone Joint J 2014;96-B:1359–65


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 5 | Pages 656 - 660
1 May 2010
Ikävalko M Tiihonen R Skyttä ET Belt EA

Between 1982 and 1997, 403 consecutive patients (522 elbows) with rheumatoid arthritis underwent Souter-Strathclyde total elbow replacement. By the end of 2007, there had been 66 revisions for aseptic loosening in 60 patients. The mean time of follow-up was 10.6 years (0 to 25) The survival rates at five-, ten, 15 and 19 years were 96% (95%, confidence interval (CI) 95 to 98), 89% (95% CI 86 to 92), 83% (95% CI 78 to 87), and 77% (95% CI 69 to 85), respectively. The small and medium-sized short-stemmed primary humeral components had a 5.6-fold and 3.6-fold risk of revision for aseptic loosening respectively, compared to the medium-sized long-stemmed component. The small and medium-sized all-polyethylene ulnar components had respectively a 28.2-fold and 8.4-fold risk of revision for aseptic loosening, compared to the metal-backed ulnar components. The use of retentive ulnar components was not associated with an increased risk of aseptic loosening compared to non-retentive implants


The Bone & Joint Journal
Vol. 106-B, Issue 5 | Pages 482 - 491
1 May 2024
Davies A Sabharwal S Liddle AD Zamora Talaya MB Rangan A Reilly P

Aims

Metal and ceramic humeral head bearing surfaces are available choices in anatomical shoulder arthroplasties. Wear studies have shown superior performance of ceramic heads, however comparison of clinical outcomes according to bearing surface in total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) is limited. This study aimed to compare the rates of revision and reoperation following metal and ceramic humeral head TSA and HA using data from the National Joint Registry (NJR), which collects data from England, Wales, Northern Ireland, Isle of Man and the States of Guernsey.

Methods

NJR shoulder arthroplasty records were linked to Hospital Episode Statistics and the National Mortality Register. TSA and HA performed for osteoarthritis (OA) in patients with an intact rotator cuff were included. Metal and ceramic humeral head prostheses were matched within separate TSA and HA groups using propensity scores based on 12 and 11 characteristics, respectively. The primary outcome was time to first revision and the secondary outcome was non-revision reoperation.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 4 | Pages 502 - 505
1 Apr 2008
Khan WS Agarwal M Malik AA Cox AG Denton J Holt EM

Metallosis after shoulder replacement has not previously been described in the literature. We report a patient who developed extensive metallosis after implantation of an uncemented Nottingham shoulder replacement. He underwent a revision procedure. Examination of the retrieved prosthesis showed that the titanium porous coating was separating from the humeral stem and becoming embedded in the ultra-high-molecular-weight polyethylene glenoid component, resulting in abrasive wear of the humeral component. There was metallosis despite exchange of the modular humeral head. Both components had to be exchanged to resolve the problem


The Journal of Bone & Joint Surgery British Volume
Vol. 81-B, Issue 1 | Pages 80 - 84
1 Jan 1999
Trail IA Nuttall D Stanley JK

We undertook a radiological analysis of 186 standard Souter implants to determine survivorship and to analyse the pattern of failure in those needing revision. The implants had been inserted as a primary procedure in patients with rheumatoid arthritis of the elbow at our hospital over the last 12 years. Taking revision as an endpoint, the survivorship after 12 years was 87%. If, however, revision and loosening, defined as the Hindex value equivalent to demarcation of 1 mm around the whole implant, are also included, the survivorship falls to 80%. Of the 24 implants revised, 18 (75%) were for problems with the humeral component, three (12.5%) with the ulnar component and three (12.5%) for instability. Loosening of the humeral component occurred when the implant extended into the humerus, with the tip moving anteriorly on to the anterior humeral cortex. Our study indicates that loosening can be predicted by the rate of change in this angle of extension of the prosthesis


The Bone & Joint Journal
Vol. 105-B, Issue 8 | Pages 912 - 919
1 Aug 2023
Cunningham LJ Walton M Bale S Trail IA

Aims

Reverse total shoulder arthroplasty (rTSA) can be used in complex cases when the glenoid requires reconstruction. In this study, a baseplate with composite bone autograft and a central trabecular titanium peg was implanted, and its migration was assessed for two years postoperatively using radiostereometric analysis (RSA).

Methods

A total of 14 patients who underwent a rTSA with an autograft consented to participate. Of these, 11 had a primary rTSA using humeral head autograft and three had a revision rTSA with autograft harvested from the iliac crest. The mean age of the patients was 66 years (39 to 81). Tantalum beads were implanted in the scapula around the glenoid. RSA imaging (stereographic radiographs) was undertaken immediately postoperatively and at three, six, 12, and 24 months. Analysis was completed using model-based RSA software. Outcomes were collected preoperatively and at two years postoperatively, including the Oxford Shoulder Score, the American Shoulder and Elbow Score, and a visual analogue score for pain. A Constant score was also obtained for the assessment of strength and range of motion.


The Bone & Joint Journal
Vol. 105-B, Issue 9 | Pages 1000 - 1006
1 Sep 2023
Macken AA Haagmans-Suman A Spekenbrink-Spooren A van Noort A van den Bekerom MPJ Eygendaal D Buijze GA

Aims

The current evidence comparing the two most common approaches for reverse total shoulder arthroplasty (rTSA), the deltopectoral and anterosuperior approach, is limited. This study aims to compare the rate of loosening, instability, and implant survival between the two approaches for rTSA using data from the Dutch National Arthroplasty Registry with a minimum follow-up of five years.

Methods

All patients in the registry who underwent a primary rTSA between January 2014 and December 2016 using an anterosuperior or deltopectoral approach were included, with a minimum follow-up of five years. Cox and logistic regression models were used to assess the association between the approach and the implant survival, instability, and glenoid loosening, independent of confounders.


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 5 | Pages 857 - 865
1 Sep 1997
Boileau P Walch G

We have studied the three-dimensional geometry of the proximal humerus on human cadaver specimens using a digitised measuring device linked to a computer. Our findings demonstrated the variable shape of the proximal humerus as well as its variable dimensions. The articular surface, which is part of a sphere varies individually in its orientation as regards inclination and retroversion, and it has variable medial and posterior offsets. These variations cannot be accommodated by the designs of most contemporary humeral components. Although good clinical results can be achieved with current modular and non-modular components their relatively fixed geometry prevents truly anatomical restoration in many cases. To try to restore the original three-dimensional geometry of the proximal humerus, we have developed a new type of humeral component which is modular and adaptable to the individual anatomy. Such adaptability allows correct positioning of the prosthetic head in relation to an individual anatomical neck, after removal of the marginal osteophytes. The design of this third-generation prosthesis respects the four geometrical variations which have been demonstrated in the present study. These are inclination, retroversion, medial offset and posterior offset


The Journal of Bone & Joint Surgery British Volume
Vol. 82-B, Issue 5 | Pages 705 - 710
1 Jul 2000
Yanni ON Fearn CBD Gallannaugh SC Joshi R

We report the results of a series of 59 unconstrained total arthroplasties of the elbow after a mean follow-up of 6.5 years (4 to 10). All the patients had rheumatoid arthritis. The indication for surgery was pain in all but one. Outcome was assessed by the Mayo Elbow Performance Index (MEPI). Of the 59 arthroplasties, two were lost to follow-up. Ten patients died, but as two of their arthroplasties were failures we included them in the results. The outcome in the remaining 49 was excellent in 26 (53%), good in 15 (31%), fair in one (2%) and poor or a failure in seven (14%). There was an improvement in the pain score (p < 0.001), movement (p < 0.001) and function (p < 0.001). Two patients developed instability, but neither required further surgery. There was a mean increase of 21° in flexion and of 7° in extension. The overall rate of complications was 33.9%. Lesions of the ulnar nerve, one of which did not recover, occurred in four patients, deep infection in two and stiffness in five. The rates of complications were similar to those in recent reports of other elbow arthroplasties. We carried out a radiological analysis of 39 arthroplasties which showed radiolucent lines around the humeral component in 22 and the ulnar component in 15. There were lower scores on the MEPI for those with radiolucent lines around the humeral component


The Bone & Joint Journal
Vol. 106-B, Issue 3 | Pages 268 - 276
1 Mar 2024
Park JH Lee JH Kim DY Kim HG Kim JS Lee SM Kim SC Yoo JC

Aims

This study aimed to assess the impact of using the metal-augmented glenoid baseplate (AGB) on improving clinical and radiological outcomes, as well as reducing complications, in patients with superior glenoid wear undergoing reverse shoulder arthroplasty (RSA).

Methods

From January 2016 to June 2021, out of 235 patients who underwent primary RSA, 24 received a superior-AGB after off-axis reaming (Group A). Subsequently, we conducted propensity score matching in a 1:3 ratio, considering sex, age, follow-up duration, and glenoid wear (superior-inclination and retroversion), and selected 72 well-balanced matched patients who received a standard glenoid baseplate (STB) after eccentric reaming (Group B). Superior-inclination, retroversion, and lateral humeral offset (LHO) were measured to assess preoperative glenoid wear and postoperative correction, as well as to identify any complications. Clinical outcomes were measured at each outpatient visit before and after surgery.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 7 | Pages 946 - 949
1 Jul 2005
Talwalkar SC Givissis PK Trail IA Nuttall D Stanley JK

We divided 309 patients with an inflammatory arthritis who had undergone primary elbow replacement using the Souter-Strathclyde implant into two groups according to their age. The mean follow-up in the older group (mean age 64 years) was 7.3 years while in the younger patients (mean age 42 years) it was 12 years. Survivorship for three different failure end-points (revision, revision because of aseptic loosening of the humeral component, and gross loosening of the humeral implant), was compared in both groups. Our findings showed that there was no significant difference in the incidence of loosening when young rheumatoid patients were compared with an older age group


The Bone & Joint Journal
Vol. 104-B, Issue 6 | Pages 747 - 757
1 Jun 2022
Liang H Yang Y Guo W Yan L Tang X Li D Qu H Zang J Du Z

Aims

The aim of this study was to investigate the feasibility of application of a 3D-printed megaprosthesis with hemiarthroplasty design for defects of the distal humerus or proximal ulna following tumour resection.

Methods

From June 2018 to January 2020, 13 patients with aggressive or malignant tumours involving the distal humerus (n = 8) or proximal ulna (n = 5) were treated by en bloc resection and reconstruction with a 3D-printed megaprosthesis with hemiarthroplasty, designed in our centre. In this paper, we summarize the baseline and operative data, oncological outcome, complication profiles, and functional status of these patients.


The Bone & Joint Journal
Vol. 103-B, Issue 8 | Pages 1333 - 1338
2 Aug 2021
Kankanalu P Borton ZM Morgan ML Cresswell T Espag MP Tambe AA Clark DI

Aims

Reverse total shoulder arthroplasty (RTSA) using trabecular metal (TM)-backed glenoid implants has been introduced with the aim to increase implant survival. Only short-term reports on the outcomes of TM-RTSA have been published to date. We aim to present the seven-year survival of TM-backed glenoid implants along with minimum five-year clinical and radiological outcomes.

Methods

All consecutive elective RTSAs performed at a single centre between November 2008 and October 2014 were reviewed. Patients who had primary TM-RTSA for rotator cuff arthropathy and osteoarthritis with deficient cuff were included. A total of 190 shoulders in 168 patients (41 male, 127 female) were identified for inclusion at a mean of 7.27 years (SD 1.4) from surgery. The primary outcome was survival of the implant with all-cause revision and aseptic glenoid loosening as endpoints. Secondary outcomes were clinical, radiological, and patient-related outcomes with a five-year minimum follow-up.


The Journal of Bone & Joint Surgery British Volume
Vol. 78-B, Issue 1 | Pages 124 - 127
1 Jan 1996
Watson M

A bipolar spacer was inserted for severe arthritic destruction of the shoulder in 14 patients, and followed up for a mean of 5.9 years. In one patient the operation failed because of infection. Two others required revision for loss of low-friction properties which caused loosening of the humeral component. At the end of the follow-up all the patients showed improvement. The Hospital for Special Surgery pain score had increased from 5.3 to 18.9 and the movement score from 7.5 to 20.1


The Bone & Joint Journal
Vol. 103-B, Issue 5 | Pages 813 - 821
1 May 2021
Burden EG Batten TJ Smith CD Evans JP

Aims

This systematic review asked which patterns of complications are associated with the three reverse total shoulder arthroplasty (RTSA) prosthetic designs, as classified by Routman et al, in patients undergoing RTSA for the management of cuff tear arthropathy, massive cuff tear, osteoarthritis, and rheumatoid arthritis. The three implant design philosophies investigated were medial glenoid/medial humerus (MGMH), medial glenoid/lateral humerus (MGLH), and lateral glenoid/medial humerus (LGMH).

Methods

A systematic review of the literature was performed via a search of MEDLINE and Embase. Two reviewers extracted data on complication occurrence and patient-reported outcome measures (PROMs). Meta-analysis was conducted on the reported proportion of complications, weighted by sample size, and PROMs were pooled using the reported standardized mean difference (SMD). Quality of methodology was assessed using Wylde’s non-summative four-point system. The study was registered with PROSPERO (CRD42020193041).


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 6 | Pages 757 - 761
1 Jun 2009
Nuttall D Haines JF Trail IA

In a prospective study between 2000 and 2005, 22 patients with primary osteoarthritis of the shoulder had a total shoulder arthroplasty with a standard five-pegged glenoid component, 12 with non-offset humeral head and ten with offset humeral head components. Over a period of 24 months the relative movement of the glenoid component with respect to the scapula was measured using radiostereometric analysis. Nine glenoids needed reaming for erosion. There was a significant increase in rotation about all three axes with time (p < 0.001), the largest occurring about the longitudinal axis (anteversion-retroversion), with mean values of 3.8° and 1.9° for the non-offset and offset humeral head eroded subgroups, respectively. There was also a significant difference in rotation about the anteversion-retroversion axis (p = 0.01) and the varus-valgus (p < 0.001) z-axis between the two groups. The offset humeral head group reached a plateau at early follow-up with rotation about the z-axis, whereas the mean of the non-offset humeral head group at 24 months was three times greater than that of the offset group accounting for the highly significant difference between them


The Journal of Bone & Joint Surgery British Volume
Vol. 77-B, Issue 6 | Pages 937 - 942
1 Nov 1995
Ljung P Jonsson K Rydholm U

We reviewed 50 capitellocondylar elbow replacements performed by the lateral approach in 42 rheumatoid patients, at a median follow-up of three years. There were two major and 17 minor complications; 18 were early and one was late. Eight elbows required reoperation: soft-tissue surgery was performed in seven and prosthesis removal in one because of a deep infection. There were few problems of instability, but one patient sustained a traumatic dislocation which was stabilised after ligament reconstruction. Wound healing was delayed in two of five elbows which had been immobilised postoperatively for only five days, but healing was rapid in 45 elbows immobilised for 12 days. There was transient ulnar-nerve palsy postoperatively in 11 patients, with permanent palsy in three. All elbows were painfree or only slightly painful at follow-up; 49 were stable and 43 had a range of motion sufficient for activities of daily living. Radiological loosening of the humeral component was suspected in one asymptomatic elbow. The lateral approach is recommended for use with the capitellocondylar type of prosthesis in rheumatoid elbows with reasonably well-preserved bone stock


The Journal of Bone & Joint Surgery British Volume
Vol. 85-B, Issue 3 | Pages 354 - 357
1 Apr 2003
Potter D Claydon P Stanley D

Between 1993 and 1996, we undertook 35 Kudo 5 total elbow replacements in a consecutive series of 31 rheumatoid patients. A total of 25 patients (29 procedures) was evaluated at a mean follow-up of six years (5 to 7.5) using the Mayo Clinic performance index. In addition, all patients were assessed for loosening using standard anteroposterior and lateral radiographs. At review, 19 elbows (65%) had either no pain or mild pain, ten (35%) had moderate pain and none had severe pain. The mean arc of flexion/extension was 94° (35 to 130) and supination/pronation was 128° (30 to 165). A fracture of the medial epicondyle occurred during surgery in one patient. This was successfully treated with a single AO screw and a standard Kudo 5 implant was inserted. Postoperatively, there were no infections. One patient had a dislocation which was treated by closed reduction and five had neurapraxia of the ulnar nerve. Radiologically, there was no evidence of loosening of the humeral component, but two ulnar components had progressive radiolucent lines suggestive of loosening. Two other ulnar components had incomplete and non-progressive radiolucent lines. With definite radiological loosening as the endpoint, the probability of survival of the Kudo 5 prosthesis at five years using the Kaplan-Meier method was 89%


The Journal of Bone & Joint Surgery British Volume
Vol. 84-B, Issue 8 | Pages 1121 - 1125
1 Nov 2002
Trail IA Nuttall D

We have performed a clinical and radiological analysis of 105 shoulder arthroplasties in patients with rheumatoid arthritis. The clinical results showed improvements in the Constant-Murley and Association of Shoulder and Elbow Surgeons score of 21 and 35, respectively. Both were statistically significant (p < 0.001). This improvement was maintained over a period of 8.8 years. There was no statistically significant difference in the scores after hemiarthroplasty and those after total arthroplasty. The presence of an intact rotator cuff was associated with improved function in both groups. In spite of the use of an uncemented humeral stem, no implant was radiologically loose or at risk. There was lucency in a single zone in 14 implants. One glenoid component was at risk and 16 had lucency in a single zone. There was, however, a significant difference in the amount of lucency which was associated with pegged and keeled glenoid components (p = 0.005). In the group with hemiarthroplasty, two or more years after surgery there was superior migration of the humeral component by more than 5 mm in 18 shoulders (28%) and medial migration by more than 2 mm in eight (16%). Both superior and medial migration had an effect on the outcome. Revision was undertaken in four patients for persistent pain relating to medial migration. With revision taken as the endpoint for survival after eight years, 92% were found to be still in situ


The Bone & Joint Journal
Vol. 102-B, Issue 11 | Pages 1438 - 1445
1 Nov 2020
Jang YH Lee JH Kim SH

Aims

Scapular notching is thought to have an adverse effect on the outcome of reverse total shoulder arthroplasty (RTSA). However, the matter is still controversial. The aim of this study was to determine the clinical impact of scapular notching on outcomes after RTSA.

Methods

Three electronic databases (PubMed, Cochrane Database, and EMBASE) were searched for studies which evaluated the influence of scapular notching on clinical outcome after RTSA. The quality of each study was assessed. Functional outcome scores (the Constant-Murley scores (CMS), and the American Shoulder and Elbow Surgeons (ASES) scores), and postoperative range of movement (forward flexion (FF), abduction, and external rotation (ER)) were extracted and subjected to meta-analysis. Effect sizes were expressed as weighted mean differences (WMD).


The Journal of Bone & Joint Surgery British Volume
Vol. 66-B, Issue 2 | Pages 248 - 253
1 Mar 1984
Soni R Cavendish M

Eighty elbows in 65 patients with an average age of 57 years have had two-part non-constrained Liverpool elbow arthroplasties performed since 1974. Fifty-five had rheumatoid arthritis, eight osteoarthritis or ankylosis secondary to injury, one osteochondritis dissecans and one pyknodysostosis. The average preoperative range of movement was 42 degrees to 112 degrees with 47 degrees of pronation and 42 degrees of supination. There was significant gain in the arc of movements at follow-up: 32 degrees in the extension-flexion range (average range 32 degrees to 134 degrees of flexion) and 42 degrees in forearm rotation (average pronation 69 degrees and supination 62 degrees). Before operation severe pain was the predominating symptom in 43 elbows (53.8%) but after replacement there was only moderate pain in five elbows (6.2%). The results were excellent in 42 (52.5%), good in 15 (18.7%), fair in 9 (11.3%) and unsatisfactory or poor in 14 (17.5%). Eight elbows required revision of the arthroplasty: three were post-traumatic, disorganised or osteoarthritic joints, three rheumatoid and both elbows in the patient with pyknodysostosis. Loosening of the prosthesis (particularly the humeral component) was the common factor necessitating revision. Of six rheumatoid elbows needing removal of the implant, four had deep infection, one had a dislodged humeral component as a result of injury and in one a divided olecranon had developed non-union. Rheumatoid elbows benefited more than post-traumatic arthritic elbows from the operation. (ABSTRACT TRUNCATED AT 250 WORDS)


The Bone & Joint Journal
Vol. 102-B, Issue 11 | Pages 1555 - 1559
1 Nov 2020
Sebastia-Forcada E Lizaur-Utrilla A Mahiques-Segura G Ruiz-Lozano M Lopez-Prats FA Alonso-Montero C

Aims

The purpose of this study was to determine whether there were long-term differences in outcomes of reverse shoulder arthroplasty (RSA) undertaken for acute proximal humeral fracture versus rotator cuff deficiency with a minimum follow-up of five years.

Methods

This was a prospective cohort study comparing 67 patients with acute complex proximal humeral fracture and 64 patients with irreparable rotator cuff deficiency who underwent primary RSA. In the fracture group, there were 52 (77.6%) females and 15 (22.4%) males, with a mean age of 73.5 years (51 to 85), while in the arthropathy group, there were 43 (67.1%) females and 21 (32.9%) males, with a mean age of 70.6 years (50 to 84). Patients were assessed by the Constant score, University of California Los Angeles shoulder score (UCLA), short version of the Disability of the Arm Shoulder and Hand score (QuickDASH), and visual analogue scales (VAS) for pain and satisfaction. Radiological evaluation was also performed.


The Bone & Joint Journal
Vol. 103-B, Issue 2 | Pages 360 - 365
1 Feb 2021
Mahendraraj KA Shields MV Grubhofer F Golenbock SW Jawa A

Aims

Existing literature indicates that inferiorly inclined glenoid baseplates following reverse total shoulder arthroplasty (RSA) produce better outcomes compared to superiorly inclined baseplates. We aim to compare clinical outcomes for RSAs with superiorly and neutrally/inferiorly inclined lateralized glenospheres.

Methods

We retrospectively reviewed 154 consecutive patients undergoing RSA between July 2015 and July 2017 by one single-fellowship trained surgeon (AJ). Two raters (KAM and MVS) independently measured glenoid inclination in preoperative and minimum two year follow-up radiographs (anteroposterior/Grashey) using the RSA angle. Inclination was then compared to patient-reported outcomes, range of motion (ROM), and independently assessed degree of scapular notching and staging of heterotopic ossification at two year follow-up.


The Bone & Joint Journal
Vol. 101-B, Issue 11 | Pages 1362 - 1369
1 Nov 2019
Giannicola G Calella P Bigazzi P Mantovani A Spinello P Cinotti G

Aims

The aim of this study was to analyze the results of two radiocapitellar prostheses in a large case series followed prospectively, with medium-term follow-up.

Patients and Methods

A total of 31 patients with a mean age of 54 years (27 to 73) were analyzed; nine had primary osteoarthritis (OA) and 17 had post-traumatic OA, three had capitellar osteonecrosis, and two had a fracture. Overall, 17 Lateral Resurfacing Elbow (LRE) and 14 Uni-Elbow Radio-Capitellum Implant (UNI-E) arthroplasties were performed. Pre- and postoperative assessment involved the Mayo Elbow Performance Score (MEPS), the Quick Disabilities of the Arm, Shoulder and Hand (Q-DASH) score, and the modified American Shoulder Elbow Surgeons (m-ASES) score.


The Bone & Joint Journal
Vol. 101-B, Issue 9 | Pages 1107 - 1114
1 Sep 2019
Uy M Wang J Horner NS Bedi A Leroux T Alolabi B Khan M

Aims

The aim of this study was to evaluate the differences in revision and complication rates, functional outcomes, and radiological outcomes between cemented and press-fit humeral stems in primary anatomical total shoulder arthroplasty (TSA).

Materials and Methods

A comprehensive systematic review and meta-analysis was conducted searching for studies that included patients who underwent primary anatomical TSA for primary osteoarthritis or rheumatoid arthritis.


The Bone & Joint Journal
Vol. 101-B, Issue 12 | Pages 1520 - 1525
1 Dec 2019
Clark NJ Samuelsen BT Alentorn-Geli E Assenmacher AT Cofield RH Sperling JW Sánchez-Sotelo J

Aims

Reverse shoulder arthroplasty (RSA) reliably improves shoulder pain and function for a variety of indications. However, the safety and efficacy of RSA in elderly patients is largely unknown. The purpose of this study was to report the mortality, morbidity, complications, reoperations, and outcomes of primary RSA in patients aged > 80 years.

Patients and Methods

Between 2004 and 2013, 242 consecutive primary RSAs were performed in patients aged > 80 years (mean 83.3 years (sd 3.1)). Of these, 53 were lost to follow-up before two years and ten had died within two years of surgery, leaving 179 for analysis of survivorship, pain, motion, and strength at a minimum of two years or until revision surgery. All 242 patients were considered for the analysis of 90-day, one-year, and overall mortality, medical complications (90-day and overall), surgical complications, and reoperations. The indications for surgery included rotator cuff arthropathy, osteoarthritis, fracture, the sequela of trauma, avascular necrosis, and rheumatoid arthritis. A retrospective review of the medical records was performed to collect all variables. Survivorship free of revision surgery was calculated at two and five years.


The Bone & Joint Journal
Vol. 100-B, Issue 8 | Pages 1066 - 1073
1 Aug 2018
Nishida K Hashizume K Nasu Y Ozawa M Fujiwara K Inoue H Ozaki T

Aims

The aim of this study was to report the mid-term clinical outcome of cemented unlinked J-alumina ceramic elbow (JACE) arthroplasties when used in patients with rheumatoid arthritis (RA).

Patients and Methods

We retrospectively reviewed 87 elbows, in 75 patients with RA, which was replaced using a cemented JACE total elbow arthroplasty (TEA) between August 2003 and December 2012, with a follow-up of 96%. There were 72 women and three men, with a mean age of 62 years (35 to 79). The mean follow-up was nine years (2 to 14). The clinical condition of each elbow before and after surgery was assessed using the Mayo Elbow Performance Index (MEPI, 0 to 100 points). Radiographic loosening was defined as a progressive radiolucent line of >1 mm that was completely circumferential around the prosthesis.


The Bone & Joint Journal
Vol. 101-B, Issue 10 | Pages 1272 - 1279
1 Oct 2019
Nowak LL Hall J McKee MD Schemitsch EH

Aims

To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) versus secondary arthroplasty for failed open reduction and internal fixation (ORIF).

Patients and Methods

We identified patients aged 50 years and over, who sustained a PHF between 2004 and 2015, from linkable datasets. We used intervention codes to identify patients treated with initial ORIF or arthroplasty, and those treated with ORIF who returned for revision arthroplasty within two years. We used multilevel logistic regression to compare reoperations between groups.


The Bone & Joint Journal
Vol. 100-B, Issue 9 | Pages 1182 - 1186
1 Sep 2018
Werner BS Chaoui J Walch G

Aims

Scapular notching is a frequently observed radiographic phenomenon in reverse shoulder arthroplasty (RSA), signifying impingement of components. The purposes of this study were to evaluate the effect of glenoid component size and glenosphere type on impingement-free range of movement (ROM) for extension and internal and external rotation in a virtual RSA model, and to determine the optimal configuration to reduce the incidence of friction-type scapular notching.

Materials and Methods

Preoperative CT scans obtained in 21 patients (three male, 18 female) with primary osteoarthritis were analyzed using modelling software. Two concurrent factors were tested for impingement-free ROM and translation of the centre of rotation: glenosphere diameter (36 mm vs 39 mm) and type (centred, 2 mm inferior eccentric offset, 10° inferior tilt).


The Bone & Joint Journal
Vol. 101-B, Issue 6 | Pages 627 - 634
1 Jun 2019
King JJ Dalton SS Gulotta LV Wright TW Schoch BS

Aims

Acromial fractures following reverse shoulder arthroplasty (RSA) have a wide range of incidences in reported case series. This study evaluates their incidence following RSA by systematically reviewing the current literature.

Materials and Methods

A systematic review using the search terms “reverse shoulder”, “reverse total shoulder”, or “inverted shoulder” was performed using PubMed, Web of Science, and Cochrane databases between 1 January 2010 and 31 March 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Studies were included if they reported on RSA outcomes and the incidence rate of acromial and/or scapular spine fractures. The rate of these fractures was evaluated for primary RSA, revision RSA, RSA indications, and RSA implant design.


The Bone & Joint Journal
Vol. 99-B, Issue 7 | Pages 939 - 943
1 Jul 2017
Sowa B Bochenek M Bülhoff M Zeifang F Loew M Bruckner T Raiss P

Aims

Promising medium-term results from total shoulder arthroplasty (TSA) have been reported for the treatment of primary osteoarthritis in young and middle-aged patients. The aim of this study was to evaluate the long-term functional and radiological outcome of TSA in the middle-aged patient.

Patients and Methods

The data of all patients from the previous medium-term study were available. At a mean follow-up of 13 years (8 to 17), we reviewed 21 patients (12 men, nine women, 21 shoulders) with a mean age of 55 years (37 to 60). The Constant-Murley score (CS) with its subgroups and subjective satisfaction were measured. Radiological signs of implant loosening were analysed.


The Bone & Joint Journal
Vol. 98-B, Issue 8 | Pages 1086 - 1092
1 Aug 2016
de Vos MJ Wagener ML Hannink G van der Pluijm M Verdonschot N Eygendaal D

Aims

Revision total elbow arthroplasty (TEA) is often challenging. The aim of this study was to report on the clinical and radiological results of revision arthroplasty of the elbow with the Latitude TEA.

Patients and Methods

Between 2006 and 2010 we used the Latitude TEA for revision in 18 consecutive elbows (17 patients); mean age 53 years (28 to 80); 14 women. A Kudo TEA was revised in 15 elbows and a Souter-Strathclyde TEA in three.

Stability, range of movement (ROM), visual analogue score (VAS) for pain and functional scores, Elbow Functional Assessment Scale (EFAS), the Functional Rating Index of Broberg and Morrey (FRIBM) and the Modified Andrews’ Elbow Scoring System (MAESS) were assessed pre-operatively and at each post-operative follow-up visit (six, 12 months and biennially thereafter). Radiographs were analysed for loosening, fractures and dislocation. The mean follow-up was 59 months (26 to 89).


The Bone & Joint Journal
Vol. 100-B, Issue 12 | Pages 1609 - 1617
1 Dec 2018
Malhas AM Granville-Chapman J Robinson PM Brookes-Fazakerley S Walton M Monga P Bale S Trail I

Aims

We present our experience of using a metal-backed prosthesis and autologous bone graft to treat gross glenoid bone deficiency.

Patients and Methods

A prospective cohort study of the first 45 shoulder arthroplasties using the SMR Axioma Trabecular Titanium (TT) metal-backed glenoid with autologous bone graft. Between May 2013 and December 2014, 45 shoulder arthroplasties were carried out in 44 patients with a mean age of 64 years (35 to 89). The indications were 23 complex primary arthroplasties, 12 to revise a hemiarthroplasty or resurfacing, five for aseptic loosening of the glenoid, and five for infection.


The Bone & Joint Journal
Vol. 100-B, Issue 6 | Pages 761 - 766
1 Jun 2018
Holschen M Siemes M Witt K Steinbeck J

Aims

The reasons for failure of a hemirthroplasty (HA) when used to treat a proximal humeral fracture include displaced or necrotic tuberosities, insufficient metaphyseal bone-stock, and rotator cuff tears. Reverse total shoulder arthroplasty (rTSA) is often the only remaining form of treatment in these patients. The aim of this study was to evaluate the clinical outcome after conversions from a failed HA to rTSA.

Material and Methods

A total of 35 patients, in whom a HA, as treatment for a fracture of the proximal humerus, had failed, underwent conversion to a rTSA. A total of 28 were available for follow-up at a mean of 61 months (37 to 91), having been initially reviewed at a mean of 20 months (12 to 36) postoperatively. Having a convertible design, the humeral stem could be preserved in nine patients. The stem was removed in the other 19 patients and a conventional rTSA was implanted. At final follow-up, patients were assessed using the American Shoulder and Elbow Surgeons (ASES) score, the Constant Score, and plain radiographs.


The Bone & Joint Journal
Vol. 98-B, Issue 3 | Pages 381 - 386
1 Mar 2016
Prasad N Ali A Stanley D

Aims

We review our experience of Coonrad-Morrey total elbow arthroplasty (TEA) for fractures of the distal humerus in non-rheumatoid patients with a minimum of ten years follow-up.

Patients and Methods

TEA through a triceps splitting approach was peformed in 37 non-rheumatoid patients for a fracture of the distal humerus between 1996 and 2004. One patient could not be traced and 17 had died before the tenth anniversary of their surgery. This left 19 patients with a minimum follow-up of ten years to form the study group. Of these, 13 patients were alive at the time of final review. The other six had died, but after the tenth anniversary of their elbow arthroplasty. Their clinical and radiological data were included in the study.


The Bone & Joint Journal
Vol. 98-B, Issue 9 | Pages 1215 - 1221
1 Sep 2016
Verhofste B Decock T Van Tongel A De Wilde L

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.

Patients and Methods

This is a single-centre retrospective study of 132 consecutive patients who received a Delta III or Delta Xtend reverse total shoulder arthroplasty between 2006 and 2013 for the treatment of cuff tear arthropathy. There were 96 women and 36 men. Their mean age at the time of surgery was 69 years (49 to 89) and the mean follow-up was 36 months (12 to 84). The incidence, evolution, morphology and clinical consequences of HO using the Constant-Murley score (CS) were analysed. A modified Brooker classification of HO of the hip was used.


The Bone & Joint Journal
Vol. 99-B, Issue 5 | Pages 674 - 679
1 May 2017
Nuttall D Birch A Haines JF Watts AC Trail IA

Aims

Radiostereometric analysis (RSA) allows an extremely accurate measurement of early micromotion of components following arthroplasty.

Patients and Methods

In this study, RSA was used to measure the migration of 11 partially cemented fluted pegged glenoid components in patients with osteoarthritis who underwent total shoulder arthroplasty using an improved surgical technique (seven men, four women, mean age 68). Patients were evaluated clinically using the American Shoulder and Elbow Surgeons (ASES) and Constant-Murley scores and by CT scans two years post-operatively.


The Bone & Joint Journal
Vol. 96-B, Issue 4 | Pages 526 - 529
1 Apr 2014
Giuseffi SA Streubel P Sperling J Sanchez-Sotelo J

Short uncemented humeral stems can preserve humeral bone stock and facilitate revision surgery but may be prone to malalignment or loosening, especially when used in reverse total shoulder replacement (TSR). We undertook a retrospective review of 44 patients with a mean age of 76 years (59 to 92) who underwent primary reverse TSR with a short uncemented humeral stem. There were 29 females. The indications for joint replacement included cuff tear associated arthropathy (33), avascular necrosis (six), post-traumatic arthritis (two), and inflammatory arthritis (three). At a mean follow-up of 27 months (24 to 40), pain was rated as mild or none in 43 shoulders (97.7%). The mean active elevation improved from 54° (sd 20°) to 142° (sd 25°) and the mean active external rotation from 14° (sd 13°) to 45° (sd 9°). The outcome, as assessed by the modified Neer score, was excellent in 27 (61.3%), satisfactory in 15 (34.1%), and unsatisfactory in two shoulders (4.5%). Stems were well-positioned, without evidence of significant valgus or varus malalignment in 42 TSRs (95.5%). There was no radiological evidence of loosening of the humeral stem in any patient; 13 TSRs (29.5%) had evidence of proximal humeral remodelling and scapular notching was noted in three (6.8%).

Cite this article: Bone Joint J 2014;96-B:526–9.


The Bone & Joint Journal
Vol. 96-B, Issue 2 | Pages 224 - 228
1 Feb 2014
Simone JP Streubel PH Athwal GS Sperling JW Schleck CD Cofield RH

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.


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 9 | Pages 1240 - 1246
1 Sep 2011
Melis B DeFranco M Lädermann A Molé D Favard L Nérot C Maynou C Walch G

Radiological changes and differences between cemented and uncemented components of Grammont reverse shoulder arthroplasties (DePuy) were analysed at a mean follow-up of 9.6 years (8 to 12). Of 122 reverse shoulder arthroplasties implanted in five shoulder centres between 1993 and 2000, a total of 68 (65 patients) were available for study. The indications for reversed shoulder arthroplasty were cuff tear arthropathy in 48 shoulders, revision of shoulder prostheses of various types in 11 and massive cuff tear in nine. The development of scapular notching, bony scapular spur formation, heterotopic ossification, glenoid and humeral radiolucencies, stem subsidence, radiological signs of stress shielding and resorption of the tuberosities were assessed on standardised true anteroposterior and axillary radiographs.

A scapular notch was observed in 60 shoulders (88%) and was associated with the superolateral approach (p = 0.009). Glenoid radiolucency was present in 11 (16%), bony scapular spur and/or ossifications in 51 (75%), and subsidence of the stem and humeral radiolucency in more than three zones were present in three (8.8%) and in four (11.8%) of 34 cemented components, respectively, and in one (2.9%) and two (5.9%) of 34 uncemented components, respectively. Radiological signs of stress shielding were significantly more frequent with uncemented components (p < 0.001), as was resorption of the greater (p < 0.001) and lesser tuberosities (p = 0.009).


The Bone & Joint Journal
Vol. 97-B, Issue 5 | Pages 681 - 688
1 May 2015
Wagener ML de Vos MJ Hannink G van der Pluijm M Verdonschot N Eygendaal D

Unlinked, linked and convertible total elbow arthroplasties (TEAs) are currently available. This study is the first to report the clinical results of the convertible Latitude TEA. This was a retrospective study of a consecutive cohort of 63 patients (69 primary TEAs) with a mean age of 60 years (23 to 87). Between 2006 and 2008 a total of 19 men and 50 women underwent surgery. The mean follow-up was 43 months (8 to 84). The range of movement, function and pain all improved six months post-operatively and either continued to improve slightly or reached a plateau thereafter. The complication rate is similar to that reported for other TEA systems. No loosening was seen. Remarkable is the disengagement of the radial head component in 13 TEAs (31%) with a radial head component implanted.

Implantation of both the linked and the unlinked versions of the Latitude TEA results in improvement of function and decreased pain, and shows high patient satisfaction at mid-term follow-up.

Cite this article: Bone Joint J 2015; 97-B:681–8.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 4 | Pages 535 - 539
1 Apr 2010
Cazeneuve JF Cristofari D

We have previously described the short-term outcome of the use of reverse shoulder arthroplasty in the treatment of acute complex proximal humeral fractures in the elderly. We now report the clinical and radiological outcome of 36 fractures at a mean of 6.6 years (1 to 16). Previously, at a mean follow-up of 6 years (1 to 12) the mean Constant score was 58.5; this was reduced to 53 points with the further follow-up. A total of 23 patients (63%) had radiological evidence of loosening of the glenoid component. Nevertheless, only one patient had aseptic loosening of the baseplate at 12 years’ follow-up.

The reduction in the mean Constant score with longer follow-up and the further development of scapular notching is worrying.

New developments in design, bearing surfaces and surgical technique, and further follow-up, will determine whether reverse shoulder arthroplasty has a place in the management of complex proximal humeral fractures in the elderly.


The Bone & Joint Journal
Vol. 99-B, Issue 8 | Pages 1073 - 1079
1 Aug 2017
Pauzenberger L Domej MA Heuberer PR Hexel M Grieb A Laky B Blasl J Anderl W

Aims

The purpose of the present study was to evaluate the impact of intravenous tranexamic acid on the reduction of blood loss, transfusion rate, and early post-operative clinical outcome in total shoulder arthroplasty.

Patients and Methods

A randomised, placebo-controlled trial which included 54 patients undergoing unilateral primary stemless anatomical or stemmed reverse total shoulder arthroplasty was undertaken. Patients received either 100 ml saline (placebo, n = 27), or 100 ml saline together with 1000 mg of tranexamic acid (TXA, n = 27) intravenously prior to skin incision and during wound closure. Peri-operative blood loss via an intra-articular drain was recorded and total blood loss was calculated. The post-operative transfusion rate was documented. Assessment of early clinical parameters included the visual analogue scale for pain (VAS), documentation of haematoma formation and adverse events.


The Bone & Joint Journal
Vol. 98-B, Issue 7 | Pages 969 - 975
1 Jul 2016
Theivendran K Varghese M Large R Bateman M Morgan M Tambe A Espag M Cresswell T Clark DI

Aim

We present the medium-term clinical results of a reverse total shoulder arthroplasty with a trabecular metal glenoid base plate.

Patients and Methods

We reviewed 125 consecutive primary reverse total shoulder arthroplasties (RTSA) implanted in 124 patients for rotator cuff arthropathy. There were 100 women and 24 men in the study group with a mean age of 76 years (58 to 89). The mean follow-up was 32 months (24 to 60). No patient was lost to follow-up.


The Bone & Joint Journal
Vol. 96-B, Issue 9 | Pages 1239 - 1243
1 Sep 2014
Zafra M Uceda P Flores M Carpintero P

Patients with pain and loss of shoulder function due to nonunion of a fracture of the proximal third of the humerus may benefit from reverse total shoulder replacement. This paper reports a prospective, multicentre study, involving three hospitals and three surgeons, of 35 patients (28 women, seven men) with a mean age of 69 years (46 to 83) who underwent a reverse total shoulder replacement for the treatment of nonunion of a fracture of the proximal humerus. Using Checchia’s classification, nine nonunions were type I, eight as type II, 12 as type III and six as type IV. The mean follow-up was 51 months (24 to 99). Post-operatively, the patients had a significant decrease in pain (p < 0.001), and a significant improvement in flexion, abduction, external rotation and Constant score (p < 0.001), but not in internal rotation. A total of nine complications were recorded in seven patients: six dislocations, one glenoid loosening in a patient who had previously suffered dislocation, one transitory paresis of the axillary nerve and one infection.

Reverse total shoulder replacement may lead to a significant reduction in pain, improvement in function and a high degree of satisfaction. However, the rate of complications, particularly dislocation, was high.

Cite this article: Bone Joint J 2014;96-B:1239–43.


The Bone & Joint Journal
Vol. 98-B, Issue 2 | Pages 218 - 223
1 Feb 2016
Scalise J Jaczynski A Jacofsky M

Aims

The eccentric glenosphere was principally introduced into reverse shoulder arthroplasty to reduce the incidence of scapular notching. There is only limited information about the influence of its design on deltoid power and joint reaction forces.

The aim of our study was to investigate how the diameter and eccentricity of the glenosphere affect the biomechanics of the deltoid and the resultant joint reaction forces.

Methods

Different sizes of glenosphere and eccentricity were serially tested in ten cadaveric shoulders using a custom shoulder movement simulator.


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 3 | Pages 399 - 403
1 Mar 2011
Griffiths D Gikas PD Jowett C Bayliss L Aston W Skinner J Cannon S Blunn G Briggs TWR Pollock R

Between 1997 and 2007, 68 consecutive patients underwent replacement of the proximal humerus for tumour using a fixed-fulcrum massive endoprosthesis. Their mean age was 46 years (7 to 87). Ten patients were lost to follow-up and 16 patients died. The 42 surviving patients were assessed using the Musculoskeletal Tumor Society (MSTS) Score and the Toronto Extremity Salvage Score (TESS) at a mean follow-up of five years and 11 months (one year to ten years and nine months). The mean MSTS score was 72.3% (53.3% to 100%) and the mean TESS was 77.2% (58.6% to 100%).

Four of 42 patients received a new constrained humeral liner to reduce the risk of dislocation. This subgroup had a mean MSTS score of 77.7% and a mean TESS of 80.0%. The dislocation rate for the original prosthesis was 25.9; none of the patients with the new liner had a dislocation at a mean of 14.5 months (12 to 18).

Endoprosthetic replacement for tumours of the proximal humerus using this prosthesis is a reliable operation yielding good results without the documented problems of unconstrained prostheses. The performance of this prosthesis is expected to improve further with a new constrained humeral liner, which reduces the risk of dislocation.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 4 | Pages 496 - 500
1 Apr 2005
Mileti J Sperling JW Cofield RH Harrington JR Hoskin TL

There are theoretical and practical advantages to modular rather than monoblock designs of prostheses for shoulder arthroplasty, but there are no reported studies which specifically compare the clinical and radiological results of their use. We have compared the results of unconstrained total shoulder arthroplasty for osteoarthritis using both types of implant. The monoblock design was used between 1992 and 1995 and the modular design after 1995. Both had cemented all-polyethylene glenoids, the monoblock with matched and the modular with mismatched radii of curvature. There were 34 consecutive shoulders in each group with a mean follow-up of 6.1 years in the first and 5.2 years in the second.

There were no significant differences in improvement of pain scores, active elevation, external rotation, internal rotation, patient satisfaction, or the Neer ratings between the two groups. Two of 28 glenoid components in the first group and six of 30 in the second met the criteria for being radiologically at risk for loosening (p = 0.25). There were no significant differences in clinical outcome or radiological changes between the first- and second-generation designs of implant for shoulder arthroplasty.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 6 | Pages 764 - 769
1 Jun 2008
Raiss P Aldinger PR Kasten P Rickert M Loew M

Our aim in this prospective study was to evaluate the outcome of total shoulder replacement in the treatment of young and middle-aged active patients with primary glenohumeral osteoarthritis. We reviewed 21 patients (21 shoulders) with a mean age of 55 years (37 to 60). The mean follow-up was seven years (5 to 9). The same anatomical, third-generation, cemented implant had been used in all patients. All the patients were evaluated radiologically and clinically using the Constant and Murley score.

No patients required revision. In one a tear of the supraspinatus tendon occurred. Overall, 20 patients (95%) were either very satisfied (n = 18) or satisfied (n = 2) with the outcome. Significant differences (p < 0.0001) were found for all categories of the Constant and Murley score pre- and post-operatively. The mean Constant and Murley score increased from 24.1 points (10 to 45) to 64.5 points (39 to 93), and the relative score from 30.4% (11% to 50%) to 83% (54% to 116%). No clinical or radiological signs of loosening of the implant were seen.

For young and middle-aged patients with osteoarthritis, third-generation total shoulder replacement is a viable method of treatment with a low rate of complications and excellent results in the mid-term.


The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 1 | Pages 80 - 85
1 Jan 2012
Malone AA Sanchez JS Adams R Morrey B

We report the effectiveness of revision of total elbow replacement by re-cementing. Between 1982 and 2004, 53 elbows in 52 patients were treated with re-cementing of a total elbow replacement into part or all of the existing cement mantle or into the debrided host-bone interface, without the use of structural bone augmentation or a custom prosthesis. The original implant revision was still in situ and functional in 42 of 53 elbows (79%) at a mean of 94.5 months (26 to 266) after surgery. In 31 of these 42 elbows (74%) the Mayo Elbow Performance Score was good or excellent. Overall, of the 53 elbows, 18 (34%) required re-operation, ten (19%) for loosening. A classification system was developed to identify those not suitable for revision by this technique, and using this we have showed that successful re-implantation is statistically correlated to properly addressing the bone deficiency for both the humeral (p = 0.005) and the ulnar (p = 0.039) components.


The Bone & Joint Journal
Vol. 97-B, Issue 12 | Pages 1662 - 1667
1 Dec 2015
Weber-Spickschen TS Alfke D Agneskirchner JD

If a modular convertible total shoulder system is used as a primary implant for an anatomical total shoulder arthroplasty, failure of the prosthesis or the rotator cuff can be addressed by converting it to a reverse shoulder arthroplasty (RSA), with retention of the humeral stem and glenoid baseplate. This has the potential to reduce morbidity and improve the results.

In a retrospective study of 14 patients (15 shoulders) with a mean age of 70 years (47 to 83) we reviewed the clinical and radiological outcome of converting an anatomical shoulder arthroplasty (ASA) to a RSA using a convertible prosthetic system (SMR system, Lima, San Daniele, Italy).

The mean operating time was 64 minutes (45 to 75). All humeral stems and glenoid baseplates were found to be well-fixed and could be retained. There were no intra-operative or early post-operative complications and no post-operative infection.

The mean follow-up was 43 months (21 to 83), by which time the mean visual analogue scale for pain had decreased from 8 pre-operatively to 1, the mean American Shoulder and Elbow Surgeons Score from 12 to 76, the mean Oxford shoulder score from 3 to 39, the mean Western Ontario Osteoarthritis of the Shoulder Score from 1618 to 418 and the mean Subjective shoulder value from 15 to 61.

On radiological review, one patient had a lucency around the humeral stem, two had stress shielding. There were no fatigue fractures of the acromion but four cases of grade 1 scapular notching.

The use of a convertible prosthetic system to revise a failed ASA reduces morbidity and minimises the rate of complications. The mid-term clinical and radiological results of this technique are promising.

Cite this article: Bone Joint J 2015;97-B:1662–7.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 10 | Pages 1416 - 1421
1 Oct 2010
Qureshi F Draviaraj KP Stanley D

Between September 1993 and September 1996, we performed 34 Kudo 5 total elbow replacements in 31 rheumatoid patients. All 22 surviving patients were reviewed at a mean of 11.9 years (10 to 14). Their mean age was 56 years (37 to 78) at the time of operation. All had Larsen grade IV or V rheumatoid changes on X-ray. Nine (three bilateral replacements and six unilateral) had died from unrelated causes. One who had died before ten years underwent revision for dislocation.

Of the 22 total elbow replacements reviewed six had required revision, four for aseptic loosening (one humeral and three ulnar) and two for infection. Post-operatively, one patient had neuropraxia of the ulnar nerve and one of the radial nerve. Two patients had valgus tilting of the ulnar component.

With revision as the endpoint, the mean survival time for the prosthesis was 11.3 years (95% confidence interval (10 to 13) and the estimated survival of the prosthesis at 12 years according to Kaplan-Meier survival analysis was 74% (95% confidence interval 0.53 to 0.91).

Of the 16 surviving implants, ten were free from pain, four had mild pain and two moderate. The mean arc of flexion/extension of the elbow was 106° (65° to 130°) with pronation/supination of 90° (30° to 150°) with the joint at 90° of flexion. The mean Mayo elbow performance score was 82 (60 to 100) with five excellent, ten good and one fair result.

Good long-term results can be expected using the Kudo 5 total elbow replacement in patients with rheumatoid disease, with a low incidence of loosening of the components.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 6 | Pages 751 - 756
1 Jun 2008
Terrier A Reist A Merlini F Farron A

Reversed shoulder prostheses are increasingly being used for the treatment of glenohumeral arthropathy associated with a deficient rotator cuff. These non-anatomical implants attempt to balance the joint forces by means of a semi-constrained articular surface and a medialised centre of rotation. A finite element model was used to compare a reversed prosthesis with an anatomical implant. Active abduction was simulated from 0° to 150° of elevation. With the anatomical prosthesis, the joint force almost reached the equivalence of body weight. The joint force was half this for the reversed prosthesis. The direction of force was much more vertically aligned for the reverse prosthesis, in the first 90° of abduction. With the reversed prosthesis, abduction was possible without rotator cuff muscles and required 20% less deltoid force to achieve it.

This force analysis confirms the potential mechanical advantage of reversed prostheses when rotator cuff muscles are deficient.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 5 | Pages 562 - 575
1 May 2006
Boileau P Sinnerton RJ Chuinard C Walch G


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 11 | Pages 1460 - 1463
1 Nov 2006
Landor I Vavrik P Jahoda D Guttler K Sosna A

We assessed the long-term results of 58 Souter-Strathclyde total elbow replacements in 49 patients with rheumatoid arthritis. The mean length of follow-up was 9.5 years (0.7 to 16.7). The mean pre-operative Mayo Elbow Performance Score was 30 (15 to 80) and at final follow-up was 82 (60 to 95). A total of 13 elbows (22.4%) were revised, ten (17.2%) for aseptic loosening, one (1.7%) for instability, one (1.7%) for secondary loosening after fracture, and one elbow (1.7%) was removed because of deep infection. The Kaplan-Meier survival rate was 70% and 53% at ten and 16 years, respectively. Failure of the ulnar component was found to be the main problem in relation to the loosening. Anterior transposition of the ulnar nerve had no influence on ulnar nerve paresthaesiae in these patients.


The Bone & Joint Journal
Vol. 98-B, Issue 1 | Pages 65 - 74
1 Jan 2016
Phadnis J Huang T Watts A Krishnan J Bain GI

Aims

To date, there is insufficient evidence available to compare the outcome of cemented and uncemented fixation of the humeral stem in reverse shoulder arthroplasty (RSA).

Methods

A systemic review comprising 41 clinical studies was performed to compare the functional outcome and rate of complications of cemented and uncemented stems in RSA. These included 1455 cemented and 329 uncemented shoulders. The clinical characteristics of the two groups were similar.

Variables were compared using pooled frequency-weighted means and relative risk ratios (RR).


The Bone & Joint Journal
Vol. 97-B, Issue 8 | Pages 1090 - 1095
1 Aug 2015
Urita A Funakoshi T Suenaga N Oizumi N Iwasaki N

This pilot study reports the clinical outcomes of a combination of partial subscapularis tendon transfer and small-head hemiarthroplasty in patients with rotatator cuff arthropathy. A total of 30 patients (30 shoulders; eight men and 22 women) with a mean age of 74 years (55 to 84) were assessed at a mean follow-up of 31 months (24 to 60). The inclusion criteria were painful cuff tear arthropathy with normal deltoid function and a non-degenerative subscapularis muscle and tendon and a preserved teres minor.

Outcome was assessed using the University of California Los Angeles score, the Japanese Orthopaedic Association score, and the Oxford Shoulder Score. Radiographic measurements included the centre of rotation distance and the length of the deltoid.

All clinical scores were significantly improved post-operatively. The active flexion and external rotation improved significantly at the most recent follow-up (p < 0.035). Although the mean centre of rotation distance changed significantly (p < 0.001), the mean length of the deltoid did not change significantly from the pre-operative value (p = 0.29). The change in the length of the deltoid with < 100° flexion was significantly less than that with > 100° (p < 0.001).

Progressive erosion of the glenoid was seen in four patients. No patient required revision or further surgery.

A combination of partial subscapularis tendon transfer and small-head hemiarthroplasty effectively restored function and relieved pain in patients with rotator cuff arthropathy.

Cite this article: 2015;97-B:1090–5.


The Bone & Joint Journal
Vol. 95-B, Issue 5 | Pages 668 - 672
1 May 2013
Abdel MP Hattrup SJ Sperling JW Cofield RH Kreofsky CR Sanchez-Sotelo J

Instability after arthroplasty of the shoulder is difficult to correct surgically. Soft-tissue procedures and revision surgery using unconstrained anatomical components are associated with a high rate of failure. The purpose of this study was to determine the results of revision of an unstable anatomical shoulder arthroplasty to a reverse design prosthesis. Between 2004 and 2007, 33 unstable anatomical shoulder arthroplasties were revised to a reverse design. The mean age of the patients was 71 years (53 to 86) and their mean follow-up was 42 months (25 to 71). The mean time to revision was 26 months (4 to 164). Pain scores improved significantly (pre-operative visual analogue scale (VAS) of 7.2 (sd 1.6); most recent VAS 2.2 (sd 1.9); p = 0.001). There was a statistically significant increase in mean active forward elevation from 40.2° (sd 27.3) to 97.0° (sd 36.2) (p = 0.001). There was no significant difference in internal (p = 0.93) or external rotation (p = 0.40). Radiological findings included notching in five shoulders (15%) and heterotopic ossification of the inferior capsular region in three (9%). At the last follow-up 31 shoulders (94%) were stable. The remaining two shoulders dislocated at 2.5 weeks and three months post-operatively, respectively. According to the Neer rating system, there were 13 excellent (40%), ten satisfactory (30%) and ten unsatisfactory results (30%). Revision of hemiarthroplasty or anatomical total shoulder replacement for instability using a reverse design prosthesis gives good short-term results.

Cite this article: Bone Joint J 2013;95-B:668–72.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 7 | Pages 970 - 974
1 Jul 2010
Foruria AM Sperling JW Ankem HK Oh LS Cofield RH

This study was performed to review the safety and outcome of total shoulder replacements in patients who are ≥ 80 years of age. A total of 50 total shoulder replacements in 44 patients at a mean age of 82 years (80 to 89) were studied. Their health and shoulder status, the operation and post-operative course were analysed, including pain, movement, patient satisfaction, medical and surgical complications, radiographs, the need for revision surgery, and implant and patient survival. A total of 27 patients had an ASA classification of III or IV and medical abnormalities were common. Of the 13 shoulders with bony deficiency of the glenoid, nine required grafting. The duration of hospital stay was prolonged and blood transfusions were common. There were no peri-operative deaths. The mean follow-up was for 5.5 years (2 to 12). Pain was significantly reduced (p < 0.001) and movement improved in active elevation and both external and internal rotation (p < 0.001). Using the Neer scale for assessing outcome, 40 (80%) shoulders had an excellent or satisfactory result. There were medical or surgical complications in 17 cases. Four shoulders developed radiological evidence of loosened glenoid components, and three of these had a poor outcome. Three other shoulders required revision, two for instability. By the time of this review 39 of the patients had died from unrelated causes at a mean of 7.5 years (0.8 to 16.4) after surgery.

Total shoulder replacement is a relatively effective treatment in this elderly group of patients. However, there is a requirement for more intense patient care in the peri-operative period, and non-fatal medical or surgical complications are common. Most of these elderly patients will have a comfortable functional shoulder for the rest of their lives.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 7 | Pages 950 - 954
1 Jul 2005
Khatri M Stirrat AN

We present the outcome of 47 Souter-Strathclyde replacements of the elbow with a mean follow-up of 82 months (12 to 129). The clinical results were assessed using a condition-specific outcome measure. The mean total score (maximum 100) before the operation was 47.21 and improved to 79.92 (p < 0.001). The mean pain score (maximum 50) improved from 21.41 to 46.70 (p < 0.001) and the mean functional component of the score (maximum 30) from 11.19 to 18.65 (p < 0.001). There was negligible change in the score for the range of movement although a significant improvement in mean flexion from 124° to 136° was noted (p < 0.001).

Revision surgery was required in four patients, for dislocation, wound dehiscence and early infection in one, late infection in two and aseptic loosening in one. The cumulative survival was 75% at nine years for all causes of failure and 97% at ten years for aseptic loosening alone. Our study demonstrates the value of the Souter-Strathclyde total elbow arthroplasty in providing relief from pain and functional improvement in rheumatoid patients.


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 7 | Pages 977 - 982
1 Jul 2009
Terrier A Merlini F Pioletti DP Farron A

Wear of polyethylene is associated with aseptic loosening of orthopaedic implants and has been observed in hip and knee prostheses and anatomical implants for the shoulder. The reversed shoulder prostheses have not been assessed as yet. We investigated the volumetric polyethylene wear of the reversed and anatomical Aequalis shoulder prostheses using a mathematical musculoskeletal model. Movement and joint stability were achieved by EMG-controlled activation of the muscles. A non-constant wear factor was considered. Simulated activities of daily living were estimated from in vivo recorded data.

After one year of use, the volumetric wear was 8.4 mm3 for the anatomical prosthesis, but 44.6 mm3 for the reversed version. For the anatomical prosthesis the predictions for contact pressure and wear were consistent with biomechanical and clinical data. The abrasive wear of the polyethylene in reversed prostheses should not be underestimated, and further analysis, both experimental and clinical, is required.


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 1 | Pages 62 - 65
1 Jan 2007
Ito H Matsumoto T Yoshitomi H Kakinoki R Nakamura T

We compared the outcome of peri-operative humeral condylar fractures in patients undergoing a Coonrad-Morrey semiconstrained total elbow replacement with that of patients with rheumatoid arthritis undergoing the same procedure without fractures. In a consecutive series of 40 elbows in 33 patients, 13 elbows had a fracture in either condyle peri-operatively, and 27 elbows were intact. The fractured condyle was either fixed internally or excised. We found no statistical difference in the patients’ background, such as age, length of follow-up, immobilisation period, Larsen’s radiological grade, or Steinbrocker’s stage and functional class. There was also no statistical difference between the groups in relation to the Mayo Elbow Performance Score, muscle strength, range of movement, or radiolucency around the implants at a mean of 4.8 years (1.1 to 8.0) follow-up.

We conclude that fractured condyles can be successfully treated with either internal fixation or excision, and cause no harmful effect.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 4 | Pages 496 - 501
1 Apr 2006
Haines JF Trail IA Nuttall D Birch A Barrow A

We have undertaken a prospective clinical and radiological analysis of 124 shoulder arthroplasties (113 patients) carried out for osteoarthritis. The clinical results showed improvement in the absolute Constant score and the American Shoulder and Elbow Surgeons score of 22 and 43, respectively. Both were statistically significant (p < 0.001). There was no significant difference in the scores after hemiarthroplasty and total arthroplasty in those patients with an intact rotator cuff.

When revision was used as the end-point for survival at ten years, survival of 86%, or 90% if glenoid components made of Hylamer sterilised in air were omitted, was obtained in primary osteoarthritis. The most common cause for revision in the hemiarthroplasty group was glenoid pain at a mean of 1.5 years; in the total arthroplasty group it was loosening of the glenoid at a mean of 4.5 years. Analysis of pre-operative factors showed that the risk of gross loosening of the glenoid increased threefold when there was evidence of erosion of the glenoid at operation. Shoulder arthroplasty should not be delayed once symptomatic osteoarthritis has been established and should be undertaken before failure of the cuff or erosion of the glenoid are present.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 3 | Pages 336 - 342
1 Mar 2008
Cuff DJ Virani NA Levy J Frankle MA Derasari A Hines B Pupello DR Cancio M Mighell M

We retrospectively reviewed 21 patients (22 shoulders) who presented with deep infection after surgery to the shoulder, 17 having previously undergone hemiarthroplasty and five open repair of the rotator cuff. Nine shoulders had undergone previous surgical attempts to eradicate their infection. The diagnosis of infection was based on a combination of clinical suspicion (16 shoulders), positive frozen sections (> 5 polymorphonuclear leukocytes per high-power field) at the time of revision (15 shoulders), positive intra-operative cultures (18 shoulders) or the pre-operative radiological appearances. The patients were treated by an extensive debridement, intravenous antibiotics, and conversion to a reverse shoulder prosthesis in either a single- (10 shoulders) or a two-stage (12 shoulders) procedure.

At a mean follow-up of 43 months (25 to 66) there was no evidence of recurrent infection. All outcome measures showed statistically significant improvements. Mean abduction improved from 36.1° (sd 27.8) pre-operatively to 75.7° (sd 36.0) (p < 0.0001), the mean forward flexion from 43.1° (sd 33.5) to 79.5° (sd 43.2) (p = 0.0003), and mean external rotation from 10.2° (sd 18.7) to 25.4° (sd 23.5) (p = 0.0037). There was no statistically significant difference in any outcome between the single-stage and the two-stage group.


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 4 | Pages 516 - 520
1 Apr 2007
Bufquin T Hersan A Hubert L Massin P

We used an inverted shoulder arthroplasty in 43 consecutive patients with a mean age of 78 years (65 to 97) who had sustained a three- or four-part fracture of the upper humerus. All except two were reviewed with a mean follow-up of 22 months (6 to 58).

The clinical outcome was satisfactory with a mean active anterior elevation of 97° (35° to 160°) and a mean active external rotation in abduction of 30° (0° to 80°). The mean Constant and the mean modified Constant scores were respectively 44 (16 to 69) and 66% (25% to 97%). Complications included three patients with reflex sympathetic dystrophy, five with neurological complications, most of which resolved, and one with an anterior dislocation. Radiography showed peri-prosthetic calcification in 36 patients (90%), displacement of the tuberosities in 19 (53%) and a scapular notch in ten (25%). Compared with conventional hemiarthroplasty, satisfactory mobility was obtained despite frequent migration of the tuberosities. However, long-term results are required before reverse shoulder arthroplasty can be recommended as a routine procedure in complex fractures of the upper humerus in the elderly.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 5 | Pages 668 - 671
1 May 2010
Naqui SZ Rajpura A Nuttall D Prasad P Trail IA

This is a retrospective review of the results of the Acclaim total elbow replacement in 11 older patients aged ≥ 65 years with primary osteoarthritis of the elbow, with a mean follow-up of 57.6 months (30 to 86.4).

Significant reductions in pain and improvement in range of movement and function were recorded. Radiological review revealed two patients with 1 mm lucencies in a single zone, and one patient with 1 mm lucencies in two zones. No components required revision. There were no deep infections, dislocations or mechanical failures. Complications included one intra-operative medial condylar fracture and one post-operative transient ulnar neuropathy, which resolved.

This study demonstrates that the Acclaim prosthesis provides good symptomatic relief and improvement of function in patients with primary osteoarthritis, with low rates of loosening or other complications. This prosthesis can therefore be considered for patients aged ≥ 65 years with primary osteoarthritis of the elbow.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 10 | Pages 1410 - 1415
1 Oct 2010
Castagna A Randelli M Garofalo R Maradei L Giardella A Borroni M

Total shoulder replacement is a successful procedure for degenerative or some inflammatory diseases of the shoulder. However, fixation of the glenoid seems to be the main weakness with a high rate of loosening. The results using all-polyethylene components have been better than those using metal-backed components. We describe our experience with 35 consecutive total shoulder replacements using a new metal-backed glenoid component with a mean follow-up of 75.4 months (48 to 154).

Our implant differs from others because of its mechanism of fixation. It has a convex metal-backed bone interface and the main stabilising factor is a large hollow central peg. The patients were evaulated with standard radiographs and with the Constant Score, the Simple Shoulder Test and a visual analogue scale. All the scores improved and there was no loosening, no polyethylene-glenoid disassembly and no other implant-related complications.

We conclude that a metal-backed glenoid component is a good option in total shoulder replacement with no worse results than of those using a cemented all-polyethylene prosthesis.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 4 | Pages 460 - 465
1 Apr 2008
Strickland JP Sperling JW Cofield RH

While frequently discussed as a standard treatment for the management of an infected shoulder replacement, there is little information on the outcome of two-stage re-implantation.

We examined the outcome of 17 consecutive patients (19 shoulders) who were treated between 1995 and 2004 with a two-stage re-implantation for the treatment of a deep-infection after shoulder replacement. All 19 shoulders were followed for a minimum of two years or until the time of further revision surgery. The mean clinical follow-up was for 35 months (24 to 80). The mean radiological follow-up was 27 months (7 to 80). There were two excellent results, four satisfactory and 13 unsatisfactory. In 12 of the 19 shoulders (63%) infection was considered to be eradicated. The mean pain score improved from 4.2 (3 to 5 (out of 5)) to 1.8 (1 to 4). The mean elevation improved from 42° (0° to 140°) to 89° (0° to 165°), mean external rotation from 30° (0° to 90°) to 43° (0° to 90°), and mean internal rotation from the sacrum to L5. There were 14 complications.

Our study suggests that two-stage re-implantation for an infected shoulder replacement is associated with a high rate of unsatisfactory results, marginal success at eradicating infection and a high complication rate.


The Journal of Bone & Joint Surgery British Volume
Vol. 92-B, Issue 6 | Pages 817 - 822
1 Jun 2010
Beekman PDA Katusic D Berghs BM Karelse A De Wilde L

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.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 10 | Pages 1369 - 1374
1 Oct 2005
Athwal GS Chin PY Adams RA Morrey BF

We reviewed 20 patients who had undergone a Coonrad-Morrey total elbow arthroplasty after resection of a primary or metastatic tumour from the elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192).

Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both.

The Coonrad-Morrey total elbow arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern.


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 3 | Pages 330 - 334
1 Mar 2007
Cesar M Roussanne Y Bonnel F Canovas F

Between 1993 and 2002, 58 GSB III total elbow replacements were implanted in 45 patients with rheumatoid arthritis by the same surgeon. At the most recent follow-up, five patients had died (five elbows) and six (nine elbows) had been lost to follow-up, leaving 44 total elbow replacements in 34 patients available for clinical and radiological review at a mean follow-up of 74 months (25 to 143). There were 26 women and eight men with a mean age at operation of 55.7 years (24 to 77).

At the latest follow-up, 31 excellent (70%), six good (14%), three fair (7%) and four poor (9%) results were noted according to the Mayo elbow performance score. Five humeral (11%) and one ulnar (2%) component were loose according to radiological criteria (type III or type IV). Of the 44 prostheses, two (5%) had been revised, one for type-IV humeral loosening after follow-up for ten years and one for fracture of the ulnar component. Seven elbows had post-operative dysfunction of the ulnar nerve, which was transient in five and permanent in two.

Despite an increased incidence of loosening with time, the GSB III prosthesis has given favourable mid-term results in patients with rheumatoid arthritis.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 7 | Pages 920 - 924
1 Jul 2006
Mori T Kudo H Iwano K Juji T

We studied 11 patients (14 elbows) with gross rheumatoid deformity of the elbow, treated by total arthroplasty using the Kudo type-5 unlinked prosthesis, and who were evaluated between five and 11 years after operation. Massive bone defects were augmented by autogenous bone grafts. There were no major complications such as infection, subluxation or loosening. In most elbows relief from pain and stability were achieved. The results, according to the Mayo Elbow Performance Score, were excellent in eight, good in five and fair in one. In most elbows there was minimal or no resorption of the grafted bone. There were no radiolucent lines around the stems of the cementless components. This study shows that even highly unstable rheumatoid elbows can be replaced successfully using an unlinked prosthesis, with augmentation by grafting for major defects of bone.


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 1 | Pages 78 - 83
1 Jan 2006
Sneftrup SB Jensen SL Johannsen HV Søjbjerg JO

We studied retrospectively the results of revision arthroplasty of the elbow using a linked Coonrad-Morrey implant in 23 patients (24 elbows) after a mean follow-up period of 55 months. According to the Mayo Elbow Performance Score, 19 elbows were satisfactory, nine were excellent and ten good. The median total score had improved from 35 points (20 to 75) before the primary arthroplasty to 85 points (40 to 100) at the latest follow-up. There was a marked relief of pain, but the range of movement showed no overall improvement. Two patients had a second revision because of infection and two for aseptic loosening. The estimated five-year survival rate of the prosthesis was 83.1% (95% confidence interval 61.1 to 93.3). Revision elbow arthroplasty using the Coonrad-Morrey implant provided satisfactory results but with complications occurring in 13 cases.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 1 | Pages 47 - 53
1 Jan 2005
Whaley A Morrey BF Adams R

We examined the effects of previous resection of the radial head and synovectomy on the outcome of subsequent total elbow arthroplasty in patients with rheumatoid arthritis.

Fifteen elbows with a history of resection and synovectomy were compared with a control group of patients who had elbow arthroplasty with an implant of the same design. The mean age in both groups was 63 years. In the study group, resection of the radial head and synovectomy had been undertaken at a mean of 8.9 years before arthroplasty. The mean radiological follow-up for the 13 available patients in the study group was 5.89 years (0.3 to 11.0) and in the control group was 6.6 years (2.2 to 12.6). There were no revisions in either group. The mean Mayo elbow performance score improved from 29 to 96 in the study group, with similar improvement in the control group (28 to 87). The study group had excellent results in 13 elbows and good results in two. The control group had excellent results in seven and good results in six.

Our experience indicates that previous resection of the radial head and synovectomy are not associated with an increased rate of revision following subsequent arthroplasty of the elbow. However, there was a higher rate of complication in the study group compared with the control group.


The Bone & Joint Journal
Vol. 96-B, Issue 7 | Pages 936 - 942
1 Jul 2014
Middleton C Uri O Phillips S Barmpagiannis K Higgs D Falworth M Bayley I Lambert S

Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley–Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p <  0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42°(sd 30) and 9° (sd 15) respectively pre-operatively to 78° (sd 39) and 24° (sd 17) post-operatively (p < 0.001). A total of 20 patients required further surgery for complications; 13 required revision of components. No patient developed scapular notching.

The Bayley–Walker prosthesis provides reliable pain relief and reasonable functional improvement for patients with symptomatic cuff-deficient shoulders. Compared with other designs of RSA, it offers a modest improvement in forward elevation, but restores external rotation to some extent and prevents scapular notching. A longer follow-up is required to assess the survival of the prosthesis and the clinical performance over time.

Cite this article: Bone Joint J 2014;96-B:936–42.