Search

Hypothesis: Chronic epilepsy may cause important bipolar bony lesions. We aim to compare the specific pathoanatomic metrics of the bony lesions in chronic shoulder anterior instability that occur in patients with epilepsy vs. patients without epilepsy., Methods: From 2006 to 2020, we included epileptic and nonepileptic patients with anterior recurrent shoulder instability. We randomly adjusted the patients of the 2 groups according to the sex, age, and type of management. We included 50 patients. For each included patient, we performed an in-depth analysis and comparison of the glenoid bone loss based on the computed tomography scan: PICO method (patient/population, intervention, comparison and outcomes) using the best-fit circle; and the Hill-Sachs lesion: the depth and width were given as a percentage of the humeral head diameter on an axial view. We also evaluated the engaging character of the involved lesion using the on-track vs. off-track analysis. Those characteristics were compared between the 2 groups., Results: We found a glenoid bone loss in 32 patients. Glenoid bone loss was not significantly greater in patients with epilepsy (P = .052). A Hill-Sachs lesion was found in 42 patients (22 in the group with epilepsy and 20 in the group without epilepsy). Hill-Sachs lesions were significantly deeper and larger in the group with epilepsy (depth: 22% vs. 9%, P < .001; width: 43% vs. 28%, P = .003). In the group with epilepsy, 90% of the bone lesions were off-track vs. 30% in the group without epilepsy. Thus, the patients with epilepsy presented more engaging bony lesions than patients without epilepsy (P = .001) (OR = 23)., Conclusions: In a population of patients with epilepsy who had shoulder instability, Hill-Sachs lesions are larger and deeper than in normal patients with shoulder instability. By contrast, there is no significant difference regarding the characteristics of the glenoid bone loss if present. This implies that bone lesions in instable shoulders of patients with epilepsy need at least a bony stabilization procedure on the humeral side in the majority of cases., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: We aim to predict a clinical difference in the postoperative range of motion (RoM) between 2 reverse shoulder arthroplasty (RSA) stem designs (Inlay-155° and Onlay-145°) using preoperative planning software. We hypothesized that preoperative 3D planning could anticipate the differences in postoperative clinical RoM between 2 humeral stem designs and by keeping the same glenoid implant., Methods: Thirty-seven patients (14 men and 23 women, 76 ± 7 years) underwent a BIO-RSA (bony increased offset-RSA) with the use of preoperative planning and an intraoperative 3-dimensional-printed patient-specific guide for glenoid component implantation between January 2014 and September 2019 with a minimum follow-up of 2 years. Two types of humeral implants were used: Inlay with a 155° inclination (Inlay-155°) and Onlay with a 145°inclination (Onlay-145°). Glenoid implants remained unchanged. The postoperative RSA angle (inclination of the area in which the glenoid component of the RSA is implanted) and the lateralization shoulder angle were measured to confirm the good positioning of the glenoid implant and the global lateralization on postoperative X-rays. A correlation between simulated and clinical RoM was studied. Simulated and last follow-up active forward flexion (AFE), abduction, and external rotation (ER) were compared between the 2 types of implants., Results: No significant difference in RSA and lateralization shoulder angle was found between planned and postoperative radiological implants' position. Clinical RoM at the last follow-up was always significantly different from simulated preoperative RoM. A low-to-moderate but significant correlation existed for AFE, abduction, and ER (r = 0.45, r = 0.47, and r = 0.57, respectively; P < .01). AFE and abduction were systematically underestimated (126° ± 16° and 95° ± 13° simulated vs. 150° ± 24° and 114° ± 13° postoperatively; P < .001), whereas ER was systematically overestimated (50° ± 19° simulated vs. 36° ± 19° postoperatively; P < .001). Simulated abduction and ER highlighted a significant difference between Inlay-155° and Onlay-145° (12° ± 2°, P = .01, and 23° ± 3°, P < .001), and this was also retrieved clinically at the last follow-up (23° ± 2°, P = .02, and 22° ± 2°, P < .001)., Conclusions: This study is the first to evaluate the clinical relevance of predicted RoM for RSA preoperative planning. Motion that involves the scapulothoracic joint (AFE and abduction) is underestimated, while ER is overestimated. However, preoperative planning provides clinically relevant RoM prediction with a significant correlation between both and brings reliable data when comparing 2 different types of humeral implants (Inlay-155° and Onlay-145°) for abduction and ER. Thus, RoM simulation is a valuable tool to optimize implant selection and choose RSA implants to reach the optimal RoM., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: There are some major controversies surrounding the use and longevity of pyrocarbon interposition shoulder arthroplasty (PISA). The objective of this study was to investigate the long-term survival and outcomes (minimum 10-year) following PISA for osteoarthritis (OA) in young and active patients., Methods: This was a retrospective review of prospectively collected data of patients who underwent PISA (InSpyre; Tornier-Stryker) for OA between 2009 and 2012. Arthroplasty survival was known for 71 patients followed longitudinally for a minimum of 10 years. The clinical and radiologic outcomes were assessed in 62 patients (62 shoulders) reviewed with radiographs. The mean age at surgery was 60 years (range, 23-72 years), and 31 shoulders (50%) underwent prior surgery before PISA. The diagnosis was primary osteoarthritis (POA = 29), post-traumatic osteoarthritis (PTOA = 23), and postinstability osterarthritis (PIOA = 10). Clinical failure was defined as repeat surgical intervention involving prosthesis revision. Clinical outcomes were assessed with the Constant score (CS) and Subjective Shoulder Value (SSV). The mean duration of follow-up was 11 ± 0.6 years (range, 10-14 years)., Results: Overall, the survival rate was 90% (95% confidence interval [CI] 82.8-96.8) at 5 years and 87% (95% CI 79-94.8) at a 10-year follow-up. Survival was 100% in PTOA (type 1 fracture sequelae) and in PIOA as well as 95% in primary OA with type A glenoid. Revision surgery was significantly higher in biconcave (type B2) glenoid (44%) compared with concentric (type A) glenoid (2%), respectively (P = .002). Among the 7 patients who were revised to reverse shoulder arthroplasty, 5 had painful glenoid erosion and 2 had bipolar (glenoid and humeral) erosion with thinning and finally fracture of the greater tuberosity. Two shoulders with glenohumeral erosion were associated with secondary rotator cuff tears (1 supraspinatus and 1 subscapularis tear). The mean time to revision and revision was 4 ± 1.7 years. Glenoid wear was more often superior (81%) than central (19%), P < .001. For those shoulders not revised, the mean CS and SSV significantly increased from 39 ± 14 to 70 ± 14 points and 34% ± 15% to 75% ± 17%, respectively (P < .001)., Conclusion: PISA is an efficient and durable surgical procedure for the treatment of young and active patients with post-traumatic OA, postinstability OA, and primary OA with concentric (type A) glenoid erosion, but not for those with biconcave (type B2) glenoid. Biconcave (type B2) glenoid and subscapularis tear or insufficiency are risk factors for failure and revision., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Primary glenohumeral osteoarthritis is associated with both excessive posterior humeral subluxation (PHS) and excessive glenoid retroversion in 40% of cases. These morphometric abnormalities are a particular issue because they may be responsible for a deterioration in long-term clinical and radiologic outcomes. The aim of this study was to perform a computed tomographic (CT) analysis of patients who underwent total shoulder arthroplasty (TSA) for primary osteoarthritis (OA) with B2-, B3-, or C-type glenoids in whom an attempt was made to correct for excessive glenoid retroversion and excessive posterior humeral subluxation intraoperatively., Material: We performed a retrospective, single-center study including 62 TSA patients with a preoperative PHS of the glenohumeral joint (31 men, 31 women, 70 ± 9 years) between January 2000 and January 2014. Glenoids were classified as B2 (32 cases), B3 (13 cases), or C (17 cases). Glenoid retroversion was corrected by anterior asymmetric reaming. Patients were reviewed for clinical and CT scan assessment with a mean follow-up of 8.3 years (minimum 5 years). At final follow-up, the CT images were reconstructed in the scapular plane. A PHS index >65% defined persistence., Results: The revision-free rate was estimated at 93%. Correlation between PHS and retroversion was moderate preoperatively (ρ = 0.58) and strong at final follow-up (ρ = 0.73). Postoperative CT scans on average showed a surgical correction of PHS compared to preoperatively (79% vs. 65% respectively, P < .05) and retroversion (20° vs. 10° respectively, P < .05). At final follow-up, 25 of 62 patients had a persistence in the 2-dimensional (2D) model and 41 of 62 in the corrected 2D model. Persistence of PHS had no influence on clinical outcomes but did demonstrate a significantly higher glenoid loosening rate (20% vs. 59%, P < .05)., Conclusion: Correlation between PHS and retroversion was moderate preoperatively and strengthened at long-term follow-up. Anterior asymmetric reaming allowed for a surgical improvement of both PHS and retroversion, but it was not sufficient to maintain a correction over time. Glenoid loosening was more frequent in case of PHS persistence but seemingly without clinical relevance., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The etiology of humeral posterior subluxation remains unknown, and it has been hypothesized that horizontal muscle imbalance could cause this condition. The objective of this study was to compare the ratio of anterior-to-posterior rotator cuff and deltoid muscle volume as a function of humeral subluxation and glenoid morphology when analyzed as a continuous variable in arthritic shoulders., Methods: In total, 333 computed tomography scans of shoulders (273 arthritic shoulders and 60 healthy controls) were included in this study and were segmented automatically. For each muscle, the volume of muscle fibers without intramuscular fat was measured. The ratio between the volume of the subscapularis and the volume of the infraspinatus plus teres minor (AP ratio) and the ratio between the anterior and posterior deltoids (AP deltoid ) were calculated. Statistical analyses were performed to determine whether a correlation could be found between these ratios and glenoid version, humeral subluxation, and/or glenoid type per the Walch classification., Results: Within the arthritic cohort, no statistically significant difference in the AP ratio was found between type A glenoids (1.09 ± 0.22) and type B glenoids (1.03 ± 0.16, P = .09), type D glenoids (1.12 ± 0.27, P = .77), or type C glenoids (1.10 ± 0.19, P > .999). No correlation was found between the AP ratio and glenoid version (ρ = -0.0360, P = .55) or humeral subluxation (ρ = 0.076, P = .21). The AP deltoid ratio of type A glenoids (0.48 ± 0.15) was significantly greater than that of type B glenoids (0.35 ± 0.16, P < .01) and type C glenoids (0.21 ± 0.10, P < .01) but was not significantly different from that of type D glenoids (0.64 ± 0.34, P > .999). When evaluating both healthy control and arthritic shoulders, moderate correlations were found between the AP deltoid ratio and both glenoid version (ρ = 0.55, P < .01) and humeral subluxation (ρ = -0.61, P < .01)., Conclusion: This in vitro study supports the use of software for fully automated 3-dimensional reconstruction of the 4 rotator cuff muscles and the deltoid. Compared with previous 2-dimensional computed tomography scan studies, our study did not find any correlation between the anteroposterior muscle volume ratio and glenoid parameters in arthritic shoulders. However, once deformity occurred, the observed AP deltoid ratio was lower with type B and C glenoids. These findings suggest that rotator cuff muscle imbalance may not be the precipitating etiology for the posterior humeral subluxation and secondary posterior glenoid erosion characteristic of Walch type B glenoids., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: The etiology of humeral posterior subluxation remains unknown, and it has been hypothesized that horizontal muscle imbalance could cause this condition. The objective of this study was to compare the ratio of anterior to posterior rotator cuff muscle and deltoid volumes as a function of humeral subluxation and glenoid morphology when analyzed as continuous variable in arthritic shoulders., Methods: Three hundred and thirty-three (273 arthritic and 60 healthy controls) CT scans of shoulders were included in this study and were segmented automatically. For each muscle, the volume of muscle fibers without intra-muscular fat was then measured. The ratio between the volume of the subscapularis and the volume of the infraspinatus + teres minor (AP ratio) and the ratio between the anterior and posterior deltoid (AP deltoid ) were calculated. Statistical analyses were performed to determine whether a correlation could be found between these ratios and glenoid version/ humeral subluxation/glenoid type in the Walch classification., Results: Within the arthritic cohort, no statistically significant difference was found between the AP ratio between A and type B glenoids (1.09 ± 0.22 versus 1.03 ± 0.16 p=0.09), between A and D type glenoids (1.09 ± 0.22 versus 1.12 ± 0.27, p=0.77) nor between the A and C type glenoids (1.09 ± 0.22 versus 1.10 ± 0.19, p=1). No correlation was found between AP ratio and glenoid version/humeral subluxation (rho =-0.0360, p=0.55; rho = 0.076; p=0.21). The AP deltoid ratio of type A glenoids was significantly greater than that of type B glenoids (0.48 ± 0.15 versus 0.35 ± 0.16, p< 0.01), and type C glenoids (0.48 ± 0.15 versus 0.21±0.10, p < 0.01) but not significantly different from the AP deltoid ratio of type D glenoids (0.48 ± 0.15 versus 0.64 ± 0.34, p=1). When evaluating both healthy control and arthritic shoulders, moderate correlations were found between AP deltoid ratio and glenoid version/humeral subluxation (rho=0.55, p<0.01; rho=-0.61, p<0.01)., Conclusion: As opposed to previous two-dimensional CT scan studies, we did not find any correlation between AP muscle volume ratio and glenoid parameters in arthritic shoulders. Therefore, rotator cuff muscle imbalance does not seem to be associated with posterior humeral subluxation leading to posterior glenoid erosion and subsequent retroversion characteristic of Walch B glenoids. However, our results could suggest that a larger posterior deltoid pulls the humerus posteriorly into posterior subluxation, but this requires further evaluation as the deltoid follows the humerus possibly leading to secondary asymmetry between the anterior and the posterior deltoid., (Copyright © 2023. Published by Elsevier Inc.)

Background: Variations in humeral component designs in hemiarthroplasty and anatomic total shoulder arthroplasty cases can impact the degree of difficulty during a revision surgery that necessitates the removal of the humeral stem. However, no metric exists to define stem extraction effort nor to identify associated factors that contribute to extraction difficulty. The purpose of this study is to describe a method to quantify stem extraction difficulty and to define features that will impact the effort during stem removal., Methods: This was a retrospective review of 58 patients undergoing revision of hemiarthroplasty or anatomic total shoulder arthroplasty requiring stem extraction. Each included patient had existing preoperative radiographic examination, an intraoperative video of the stem removal process, and explants available for analysis by 3 surgeons. The following factors were assessed for the impact on extraction difficulty: (1) preoperative features such as cement use, fill of proximal humerus, and stem design features; (2) intraoperative data on extraction time and bone removal; and (3) postoperative findings related to extraction artifacts (EAs). A scoring system was established to distinguish easy (Easy group) and difficult (Difficult group) stem removal cases and further used to identify the features that may affect intraoperative difficulty of stem removal., Results: The Difficult group accounted for 26% (15/58) of the study population with an 18-minute average stem extraction time, average EA count of 69, and 35 mm of bone removed. The Easy group accounted for 74% (43/58) of patients, with a 4-minute average extraction time, average EA count of 23, and 10 mm of bone removed. Logistic regression model was able to correctly classify 82% of the cases, explaining 26.7% of the variance in humeral stem removal with cement and proximal coating variables. The likelihood of cemented stem removal being difficult is 5 times greater compared to an uncemented stem, and having proximal coating doubles the likelihood of a difficult stem removal compared to cases with no coating., Conclusions: Quantifying stem extraction difficulty is possible with intraoperative video as well as explant analysis. Preoperative features of the fixation type and specific features of stem design such as proximal coating will impact difficulty of stem extraction., (Copyright © 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Hypothesis: The purpose was to report the short-term outcomes and survival of hemiarthroplasty with a pyrocarbon head (HA-PYC) for the treatment of shoulder osteoarthritis in patients aged ≤ 60 years. We hypothesized that HA-PYC could be an alternative to hemi-metal (avoiding the risk of rapid glenoid erosion) and total shoulder arthroplasty (TSA) (avoiding the risk of rapid glenoid loosening) in an active patient population., Methods: Sixty-four consecutive patients (mean age, 53 years) who underwent HA-PYC for glenohumeral osteoarthritis were included. The primary outcome was revision to TSA or reverse shoulder arthroplasty. Secondary outcome measures included functional outcome scores; return to work and sports; and radiographic evaluation of humeral reconstruction quality using the "circle method" of Mears, as well as glenoid erosion severity and progression using the Sperling classification. Patients were reviewed and underwent radiography at an average follow-up of 33 months (range, 24-60 months)., Results: At last follow-up, the rate of survival of the HA-PYC prosthesis was 92%. Revision was performed in 5 patients, with a mean delay of 24 months (range, 15-37 months): 1 conversion to TSA and 4 conversions to reverse shoulder arthroplasty. The Constant score and Subjective Shoulder Value increased from 36 points (range, 26-50 points) to 75 points (range, 69-81 points) and from 35% (range, 20%-50%) to 80% (range, 75%-90%), respectively (P < .001). Postoperatively, 91% of the patients (42 of 46) returned to work and 88% (15 of 17) returned to sport. The severity of preoperative and postoperative glenoid wear (Sperling grade 3 or 4) had no influence on the functional results. Patients who underwent associated concentric glenoid reaming (n = 23) had similar Constant scores and Subjective Shoulder Values (P = .95) to other patients and did not show more progression of glenoid wear. Nonanatomic reconstruction of the proximal humerus (center of rotation of the prosthesis > 3 mm from the anatomic center) occurred in 29% (18 of 62 patients) and was associated with significantly lower functional and subjective results, more complications (subscapularis insufficiency and/or symptomatic glenoid erosion), and a higher risk of revision. The additional 1.5-mm thickness of the metal disc under the pyrocarbon head was found to be the main reason for oversizing of the prosthetic head., Conclusion: HA-PYC is a reliable procedure to treat shoulder osteoarthritis and allows return to work and sports in a young (≤60 years) and active patient population. The severity of glenoid bone erosion or the association with glenoid reaming does not affect functional outcomes and failure risk. By contrast, nonanatomic reconstruction of the proximal humerus after HA-PYC (because of humeral head oversizing) occurred in one-third of the cases and is associated with lower functional outcomes, as well as higher risks of complications and revision., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Several studies have already reported good short-term results with a pyrocarbon unipolar radial head prosthesis (Pyc-uRHP). The aim was to evaluate the evolution from mid- to long-term clinical and radiographic outcomes of a Pyc-uRHP., Methods: This was a retrospective, single-center study. We followed up all the patients who underwent Pyc-uRHP surgery in our original study at 2 years of follow-up (52 patients), reaching a minimum of 7 years of clinical and radiologic follow-up. This study included 26 patients who underwent a clinical examination assessing mobility, the Mayo Elbow Performance Score, and the visual analog scale score and radiologic evaluation with anteroposterior and profile radiographs at a mean follow-up of 110 months (range, 78-162 months). The radiologic study analyzed signs of proximal osteolysis, stem loosening, capitellar wear, and humeroulnar osteoarthritis., Results: No patients required revision. Eight patients required reoperation: coronoid screw removal in 1 and arthrolysis for stiffness in 7. The mean time to reoperation was 11 months. The mean Mayo Elbow Performance Score at last follow-up was 96 ± 9 (of 100), with a pain score of 42 ± 7 (of 45), mobility score of 19 ± 2 (of 20), stability score of 10 (of 10), and function score of 25 (of 25). Comparison with clinical data from the mid-term delay did not reveal any significant difference. All patients presented with proximal osteolysis around the neck but without progression. No stem loosening was noted. The rates of humeroulnar osteoarthritis (12% at mid-term vs. 80% at last follow-up, P < .0001) and capitellar lesions (34% at mid-term vs. 80% at last follow-up, P = .001) increased significantly., Conclusion: We have shown that a Pyc-uRHP at 9 years' follow-up provided stable and satisfactory clinical results. Osteolysis of the radial neck was always present but it did not evolve, and no stem loosening was noted. Finally, we have shown a clear worsening of radiologic humeroulnar osteoarthritis and capitellar lesions that remained asymptomatic., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: An assessment of the pathoanatomic parameters of the arthritic glenohumeral joint (GHJ) has the potential to identify discriminating metrics to differentiate glenoid types in shoulders with primary glenohumeral osteoarthritis (PGHOA). The aim was to identify the morphometric differences and threshold values between glenoid types including normal and arthritic glenoids with the various types in the Walch classification. We hypothesized that there would be clear morphometric discriminators between the various glenoid types and that specific numeric threshold values would allow identification of each glenoid type., Methods: The computed tomography scans of 707 shoulders were analyzed: 585 obtained from shoulders with PGHOA and 122 from shoulders without glenohumeral pathology. Glenoid morphology was classified according to the Walch classification. All computed tomography scans were imported in a dedicated automatic 3D-software program that referenced measurements to the scapular body plane. Glenoid and humeral modeling was performed using the best-fit sphere method, and the root-mean-square error was calculated. The direction and orientation of the glenoid and humerus described glenohumeral relationships., Results: Among shoulders with PGHOA, 90% of the glenoids and 85% of the humeral heads were directed posteriorly in reference to the scapular body plane. Several discriminatory pathoanatomic parameters were identified: GHJ narrowing < 3 mm was a discriminatory metric for type A glenoids. Posterior humeral subluxation > 70% discriminated type B1 from normal GHJs. The root-mean-square error was a discriminatory metric to distinguish type B2 from type A, type B3, and normal GHJs. Type B3 glenoids differed from type A2 by greater retroversion (>13°) and subluxation (>71%). The type C glenoid retroversion inferior limit was 21°, whereas normal glenoids never presented with retroversion > 16°., Conclusion: Pathoanatomic metrics with the identified threshold values can be used to discriminate glenoid types in shoulders with PGHOA., (Copyright © 2021 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Three-dimensional (3D) geometry of the normal glenohumeral bone anatomy and relations is poorly documented. Our aims were (1) to determine the 3D geometry of the normal glenohumeral joint (GHJ) with reference to the scapular body plane and (2) to identify spatial correlations between the orientation and direction of the humeral head and the glenoid., Methods: Computed tomographies (CTs) of the normal, noninjured GHJ were collected from patients who had undergone CTs in the setting of (1) polytrauma, (2) traumatic head injury, (3) chronic acromioclavicular joint dislocations, and (4) unilateral trauma with a contralateral normal shoulder. We performed 3D segmentation and measurements with a fully automatic software (Glenosys; Imascap). Measurements were made in reference to the scapular body plane and its transverse axis. Geometric measurements included version, inclination, direction, orientation, best-fit sphere radius (BFSR), humeral subluxation, critical shoulder angle, reverse shoulder angle, glenoid area, and glenohumeral distance. Statistical correlations were sought between glenoid and humeral 3D measurements (Pearson correlation)., Results: A total of 122 normal GHJs (64 men, 58 women, age: 52 ± 17 years) were studied. The glenoid BFSR was always larger than the humerus BFSR (constant factor of 1.5, standard deviation = 0.2). The mean glenoid version and inclination were -6° ± 4° and 7° ± 5°, respectively. Men and women were found to have significantly different values for inclination (6° vs. 9°, P = .02), but not for version. Humeral subluxation was 59% ± 7%, with a linear correlation with glenoid retroversion (r = -0.70, P < .001) regardless of age. There was a significant and linear correlation between glenoid and humeral orientation and direction (r = 0.72 and r = 0.70, P < .001)., Conclusion: The 3D geometry of the glenoid and humeral head present distinct limits in normal shoulders that can be set as references in daily practice: version and inclination are -6° and 7°, respectively, and humeral posterior subluxation is 59%; interindividual variations, regardless of the size, are relative to the scapular plane. There exists a strong correlation between the position of the humeral head and the glenoid orientation and direction., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Glenoid lateralization has been shown to be the most imortant factor in maximizing passive range of motion and shoulder stability while preventing scapular impingement and notching. We aimed to evaluate mid- to long-term functional and radiologic outcomes after bony increased-offset-reverse shoulder arthroplasty (BIO-RSA) using a Grammont-style (medialized) humeral implant., Methods: The study included 143 consecutive shoulders (140 patients; mean age, 72 years) treated with a BIO-RSA for rotator cuff deficiency. A cylinder of autologous cancellous bone graft, harvested from the humeral head, was placed between the reamed glenoid surface and baseplate; fixation was achieved using a long central peg (25 mm) and 4 screws. A large baseplate (29 mm) with a small baseplate sphere (36 mm) was used in 77% of cases, and a Grammont-style (medialized) humeral implant with 155° of inclination was used in all cases. All patients underwent clinical and radiographic assessment at a minimum of 5 years after surgery; in addition, 86 cases (60%) underwent computed tomography scan assessment., Results: At a mean follow-up of 75 months (range, 60-126 months), the survivorship of the BIO-RSA using revision as an endpoint was 96%. No cases of dislocation or humeral loosening were observed. Overall, 118 patients (83%) were either very satisfied (61%) or satisfied (22%). The adjusted Constant score improved from 40% ± 18% to 93% ± 23%, and the Subjective Shoulder Value improved from 31% ± 15% to 77% ± 18% (P < .001). The humeral bone graft incorporated completely in 96% of cases (137 of 143). Severe inferior scapular notching (grade 3 or 4) occurred in 18% (24 of 136). The risk of postoperative notching correlated to a lower body mass index (P < .05), superior glenosphere inclination (P = .02), and high or flush glenosphere positioning (P = .035)., Conclusions: BIO-RSA is a safe and effective technique to lateralize the glenoid, providing consistent bone graft healing, excellent functional outcomes, a low revision rate, and a high rate of patient satisfaction. Thin patients (with a low body mass index) and glenosphere malposition (with persistent superior inclination and/or insufficient lowering of the baseplate and sphere) are associated with higher risk of scapular notching.Our data confirm the importance of implanting the baseplate with a neutral inclination (reverse shoulder arthroplasty angle < 5°) and with sufficient glenosphere inferior overhang (>5 mm) in preventing scapular notching. The use of a less medialized humeral implant (135° or 145° inclined) and smaller (25-mm) baseplate (when using a small, 36-mm sphere) should allow reduction in the incidence of scapular notching., (Copyright © 2020. Published by Elsevier Inc.)

Background: Scapulothoracic arthrodesis (STA) has been proposed for the treatment of painful scapular winging in patients with facioscapulohumeral muscular dystrophy (FSHD). However, the rate of osseous fusion is variable, and there is a theoretical risk of reduced respiratory function after bilateral STA., Methods: This was a retrospective study of 10 STAs, performed sequentially, in 5 FSHD patients. The surgical technique involved use of a semitubular plate and wire construct with autograft (iliac crest) interposed between the scapula and rib cage. Osseous fusion, respiratory function, and shoulder function were evaluated. The mean follow-up period was 141 ± 67 months (range, 24-225 months)., Results: Early complications included 1 pneumothorax and 1 pleural effusion. No late complications occurred, and no patients underwent reoperation. On postoperative computed tomography images, complete bony union of the scapula to the ribs was observed in 90% of shoulders (9 of 10). Comparison of preoperative and postoperative pulmonary function test results showed no significant difference in vital capacity (from 87% ± 14% to 85% ± 12%) and forced vital capacity (from 86% ± 16% to 77% ± 15%). Patients gained on average 40° of active forward elevation (from 62° ± 20° to 102° ± 4°) and 22° of abduction (from 58° ± 21° to 89° ± 7°) (P < .001). The mean Subjective Shoulder Value increased from 25% ± 8% to 72% ± 18% (P < .001). All patients were pleased with the results and would recommend the procedure to other persons., Conclusion: In patients with FSHD, bilateral STA provides satisfactory shoulder function with a high rate of scapulothoracic fusion and few or no significant respiratory repercussions., (Copyright © 2019. Published by Elsevier Inc.)

Background: Our aim was to analyze the epidemiology, etiologies, and revision options for failed shoulder arthroplasty from 2 tertiary centers., Methods: From 1993 to 2013, 542 failed arthroplasties were revised in 540 patients (65% women): 224 hemiarthroplasties (HAs, 41%), 237 anatomic total shoulder arthroplasties (TSAs, 44%) and 81 reverse total arthroplasties (RSAs, 15%). Data about patients, pathology, and reintervention procedures, as well as intraoperative data, were analyzed from our 2 local registries that prospectively captured all the revision procedures. Patients had an average follow-up period of 8.7 years., Results: The revision rate was 12.7% for HAs, 6.7% for TSAs, and 3.9% for RSAs. HAs were revised earlier (33 ± 40 months) than RSAs (47 ± 150 months) and TSAs (69 ± 61 months). Glenoid failure was a major cause of reintervention: erosion in HAs (29%) or loosening in TSAs (37%) and RSAs (24%). Instability was another major cause of reintervention: 32% in RSAs, 20% in TSAs, and 13% in HAs. Humeral implant loosening led to revision in 10% of RSAs, 6% of HAs, and 6% of TSAs. Multiple reinterventions were required in 21% of patients, mainly for instability (26%) and/or infection (25%). The final implant was an RSA in 48%, especially when associated with cuff insufficiency, instability, and/or bone loss. Final reimplantation was possible in 90% of cases, with the remaining 10% treated with a resection or spacer., Conclusion: Glenoid failure and instability are the most common causes of revision. Soft-tissue insufficiency and/or infection results in multiple revisions. Surgeons must recognize all complications so that they can be addressed at the first revision operation and avoid further reinterventions. RSA was the most common final revision implant., (Copyright © 2019. Published by Elsevier Inc.)

Background: We evaluated survival and midterm results of pyrocarbon interposition shoulder arthroplasty (PISA) in arthritic patients younger than 65 years., Methods: Fifty-eight PISAs (InSpyre; Tornier-Wright, Bloomington, MN, USA), implanted in 56 patients between 2010 and 2015, were prospectively observed. The mean age at surgery was 52 ± 13 years. The cause was primary osteoarthritis (18), fracture sequelae (16), post-instability arthritis (15), aseptic necrosis (3), inflammatory disease (2), and failed hemiarthroplasty (4); 34 shoulders (61%) had previously undergone surgery. Glenoid erosion was assessed in 4 grades according to the Sperling classification. Humeral erosion was also assessed in 4 grades. Multivariate analysis was used to determine predisposing risk factors for both humeral and glenoid erosion., Results: At a mean follow-up of 47 ± 15 months, survival rate was 90%. Six patients (10%) required conversion to reverse total shoulder prosthesis for painful glenoid erosion (n = 2) and humeral erosion with greater tuberosity stress fractures (n = 4). The mean Constant score and subjective shoulder value significantly increased from 36 ± 14 points to 70 ± 15 points and 32% ± 14% to 75% ± 19%, respectively (P < .001). Humeral medialization was observed in 78% of the cases with increased pain score. Uncorrected anteroposterior implant subluxation (12 cases) was associated with lower Constant score (50 points vs. 72 points; P = .02) and lower subjective shoulder value (53% vs. 78%; P = .002). On multivariate analysis, no risk factors for glenoid or humeral erosion were found., Conclusion: At midterm follow-up, PISA does not protect from progressive glenoid erosion and can lead to greater tuberosity erosion and stress fractures. Longer follow-up is required to see whether PISA survival will be superior to that of hemiarthroplasty., (Copyright © 2019. Published by Elsevier Inc.)

Background: Avoiding superior inclination of the glenoid component in reverse shoulder arthroplasty (RSA) is crucial. We hypothesized that superior inclination was underestimated in RSA. Our purpose was to describe and assess a new measurement of inclination for the inferior portion of the glenoid (where the baseplate rests)., Methods: The study included 47 shoulders with rotator cuff tear arthropathy (mean age, 76 years). The reverse shoulder arthroplasty angle (RSA angle), defined as the angle between the inferior part of the glenoid fossa and the perpendicular to the floor of the supraspinatus, was compared with the global glenoid inclination (β angle or total shoulder arthroplasty [TSA] angle). Measurements were made on plain anteroposterior radiographs and reformatted 2-dimensional (2D) computed tomography (CT) scans by 3 independent observers and compared with 3-dimensional (3D) software (Glenosys) measurements., Results: The mean RSA angle was 25° ± 8° on plain radiographs, 20° ± 6° on reformatted 2D CT scans, and 21° ± 5° via 3D reconstruction software. The mean TSA angle was on average 10° ± 5° lower than the mean RSA angle (P < .001); this difference was observed regardless of the method of measurement (radiographs, 2D CT, or 3D CT) and type of glenoid erosion according to Favard. In Favard type E1 glenoids with central concentric erosion, the difference between the 2 angles was 12° ± 4° (P < .001)., Conclusion: The same angle cannot be used to measure glenoid inclination in anatomic and reverse prostheses. The TSA (or β) angle underestimates the superior orientation of the reverse baseplate in RSA. The RSA angle (20° ± 5°) needs to be corrected to achieve neutral inclination of the baseplate (RSA angle = 0°). Surgeons should be aware that E1 glenoids (with central erosion) are at risk for baseplate superior tilt if the RSA angle is not corrected., (Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The Walch classification describes glenoid morphology in primary arthritis. As knowledge grows, several modifications to the classification have been proposed. The type D, a recent modification, was defined as an anteverted glenoid with or without anterior subluxation. Literature on the anteverted glenoid in primary osteoarthritis is limited. The purpose of this study, therefore, was to analyze the anatomic characteristics of the type D glenoid on radiographs and computed tomography (CT)., Methods: The shoulder arthroplasty databases from 3 institutions were examined to identify patients with primary glenohumeral osteoarthritis and glenoid anteversion (≥5°), with or without anterior subluxation. The type D study cohort consisted of 18 patients (3% of the osteoarthritis cohort) and was a mean of 70 years old, with 11 women and 7 men. All radiographs were reviewed, and computed tomography Digital Imaging and Communications in Medicine (National Electrical Manufacturers Association, Rosslyn, VA, USA) data were analyzed on validated 3-dimensional imaging software. Rotator cuff fatty infiltration, glenoid measurements (anteversion and inclination), and humeral head subluxation according to the scapular plane were determined., Results: In the study cohort, the mean glenoid anteversion was 12° (range, 5°-24°), the mean inclination was 0°, and the mean anterior subluxation was 38% (range, 6%-56%). Eight patients (44%) had a biconcave glenoid with a posterosuperiorly positioned paleoglenoid and an anteroinferiorly positioned neoglenoid, and 10 patients had a monoconcave glenoid. Fatty infiltration of the rotator cuff muscles never exceeded Goutallier stage 2., Conclusion: The type D glenoid is an addition to the original Walch classification and is characterized by glenoid anteversion (≥5°), anteroinferior humeral head subluxation, and absence of severe subscapularis fatty infiltration., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

Background: Glenoid deficiency and erosion (excessive retroversion/inclination) must be corrected in reverse shoulder arthroplasty (RSA) to avoid prosthetic notching or instability and to maximize function, range of motion, and prosthesis longevity. This study reports the results of RSA with an angled, autologous glenoid graft harvested from the humerus (angled BIO-RSA)., Methods: A trapezoidal bone graft, harvested from the humeral head and fixed with a long-post baseplate and screws, was used to compensate for residual glenoid bone loss/erosion. For simple to moderate (<25°) glenoid defects, standardized instrumentation combined with some eccentric reaming (<15°) was used to reconstruct the glenoid and obtain neutral implant alignment. For severe (>25°) and complex (multiplanar) glenoid bone defects, patient-specific grafts and guides were used after 3-dimensional planning. Patients were reviewed with minimum 2 years of follow-up. Mean follow-up was 36 months (range, 24-81 months). Preoperative and postoperative measurements of inclination and version were performed in the plane of the scapula on computed tomography images., Results: The study included 54 patients (41 women, 13 men; mean 73 years old). Fifteen patients had combined vertical and horizontal glenoid bone deficiency. Among E2/E3 glenoids, inclination improved from 37° (range, 14° to 84°) to 10.2° (range -28° to 36°, P < .001). Among B2/C glenoids, retroversion improved from -21° (range, -49° to 0°) to -10.6° (-32° to 4°, P = .06). Complete radiographic incorporation of the graft occurred in 94% (51 of 54). Complications included infection in 1 and clinical aseptic baseplate loosening in 2. Mild notching occurred in 25% (13 of 51) of patients. Constant-Murley and Subjective Shoulder Value assessments increased from 31 to 68 and from 30% to 83%, respectively (P < .001)., Conclusion: Angled BIO-RSA predictably corrects glenoid deficiency, including severe (>25°) multiplanar deformity. Graft incorporation is predictable. Advantages of using an autograftharvested in situ include bone stock augmentation, lateralization, low donor-site morbidity, low relative cost, and flexibility needed to simultaneously correct posterior and superior glenoid defects., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The concept of free interposition arthroplasty proved successful for small joints of the hand, wrist, and foot, particularly after the use of implants coated with pyrocarbon, which enhanced their tribologic and elastic properties. The present study reports preliminary outcomes of a pyrocarbon-coated interposition shoulder arthroplasty (PISA) implant., Methods: This was a prospective study of 67 consecutive patients who underwent shoulder PISA at 9 centers. The mean age at surgery was 51 years, with only 12 patients older than 60 years. The indications for surgery were primary glenohumeral arthritis in 42, avascular necrosis in 13, and secondary arthritis in 12 patients., Results: Revision surgery was performed in 7 patients (10.4%), 2 (3.0%) were lost to follow-up, and the outcome assessments were incomplete in 3 (4.4%). This left 55 patients, aged 49.3 ± 12.0 years, with complete outcomes assessments at a mean follow-up of 26.8 ± 3.4 months. The Constant score improved from 34.1 ± 15.1 preoperatively to 66.1 ± 19.7 postoperatively. The radiographic findings revealed erosion in 6 glenoids and thinning of 3 humeral tuberosities., Conclusion: In a cohort of young arthritic patients, PISA renders clinical scores and implant survival comparable to those of hemishoulder arthroplasty but remain inferior to those results reported for total shoulder arthroplasty. The study enabled identification of contraindications and potential causes of failure that wererelated to the concept of free interposition and smaller radius of curvature of the sphere. Until long-term results are available, this type of innovative implant should remain to be tested in a few specialized shoulder centers., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Posterior humeral subluxation is the main cause of failure of total shoulder arthroplasty. We aimed to compare humeral head subluxation in various reference planes and to search for a correlation with retroversion, inclination, and glenoid wear., Materials and Methods: We included 109 computed tomography scans of primary glenohumeral osteoarthritis and 97 of shoulder problems unrelated to shoulder osteoarthritis (controls); all computed tomography scans were reconstructed in the anatomic scapular plane and the glenoid hull plane that we defined. In both planes, we measured retroversion, inclination, glenohumeral offset (Walch index), and scapulohumeral offset., Results: Retroversion in the scapular plane (Friedman method) was lower than that in the glenoid hull plane for controls and for arthritic shoulders. The threshold of scapulohumeral subluxation was 60% and 65% in the scapular plane and glenoid hull plane, respectively. The mean upward inclination was lower in the scapular plane (Churchill method) than in the glenoid hull plane (Maurer method). In the glenoid hull plane, 35% of type A2 glenoids showed glenohumeral offset greater than 75%, with mean retroversion of 25.6° ± 6° as compared with 7.5° ± 7.2° for the "centered" type A2 glenoids (P < .0001) and an upward inclination of -1.4° ± 8° and 6.3° ± 7° (P = .03), respectively. The correlation between retroversion and scapulohumeral offset was r = 0.64 in the glenoid hull plane and r = 0.59 in the scapular plane (P < .05)., Conclusion: Measurement in the glenoid hull plane may be more accurate than in the scapular plane. Thus, the glenoid hull method allows for better understanding type B3 of the modified Walch classification., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The type B3 glenoid is an addition to the Walch classification. A potential etiologic theory is that it is a progression of the B2. It is characterized by uniconcavity, absent paleoglenoid, medialization, retroversion, and subluxation. The purpose of this study was to describe the morphology of B3 glenoids., Methods: Fifty-two patients with B3 glenoids underwent 3-dimensional analysis of computed tomography data. Glenoid measurements (retroversion, inclination, medialization) and humeral head subluxation according to the scapular and glenoid planes were determined. The measured variables were compared between male and female patients., Results: The mean B3 retroversion, inclination, and medialization were 24° ± 7°, 8° ± 6° superior, and 14 ± 4 mm, respectively. The mean posterior subluxation was 80% ± 8% and 54% ± 6% according to the scapular and glenoid planes, respectively. There were no differences in B3 characteristics between sexes (P > .05). A significant correlation existed between glenoid retroversion and humeral head subluxation relative to the scapular plane, with every 1° increase in retroversion translating to a 1% increase in subluxation (P < .001). In contrast, when referencing the glenoid plane, the humeral head remained concentric to the erosion., Conclusions: The B3 is uniconcave and retroverted. As glenoid retroversion increases, posterior humeral head subluxation significantly increases as referenced to the scapular plane; however, when referenced to the glenoid plane, the head remains concentric to the erosion. This appearance of "concentricity" is acquired secondary to the wear pattern, creating a uniconcave glenoid. Therefore, surgeons should be aware that the visualized concentricity is a product of the erosion pattern and thus may conceal a greater amount of subluxation potential., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Since Walch and colleagues originally classified glenoid morphology in the setting of glenohumeral osteoarthritis, several authors have reported varying levels of interobserver and intraobserver reliability. We propose several modifications to the Walch classification that we hypothesize will increase interobserver and intraobserver reliability., Methods: We propose the addition of the B3 and D glenoids and a more precise definition of the A2 glenoid. The B3 glenoid is monoconcave and worn preferentially in its posterior aspect, leading to pathologic retroversion of at least 15° or subluxation of 70%, or both. The D glenoid is defined by glenoid anteversion or anterior humeral head subluxation. The A2 glenoid has a line connecting the anterior and posterior native glenoid rims that transects the humeral head. Using 3-dimensional computed tomography glenoid reconstructions, 3 evaluators used the original Walch classification and the modified Walch classification to classify 129 nonconsecutive glenoids on 4 separate occasions. Reliabilities were assessed by calculating κ coefficients., Results: Interobserver reliabilities improved from an average of 0.391 (indicating fair agreement) using the original classification to an average of 0.703 (substantial agreement) using the modified classification. Intraobserver reliabilities improved from an average of 0.605 (moderate agreement) to an average of 0.882 (nearly perfect agreement)., Conclusion: When 3-dimensional glenoid reconstructions and the modified Walch classification described herein are used, improved interobserver and intraobserver reliabilities are obtained., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The β-angle, formed by the intersection of a line on the floor of the supraspinatus fossa and glenoid fossa line, has been described as a reliable measurement tool in the clinical setting to analyze glenoid inclination on the anteroposterior (AP) view of the shoulder. The purpose of this study was to compare the accuracy of the β-angle measurement using different imaging modalities with a validated 3-dimensional (3D) software tool., Materials and Methods: The β-angle was measured on AP radiographs, unformatted 2-dimensional (2D) computed tomography (CT) scan, and reformatted 2D CT scan in the scapular plane for 51 shoulders of 49 patients undergoing primary total shoulder arthroplasty. Comparison to the glenoid inclination angle calculated by the 3D software was performed., Results: The β-angle measured on reformatted CT scan was found to be the most accurate measurement method, with a mean difference of 1° (standard deviation [SD], 0.5°) with respect to 3D measurement. On AP radiographs, the β-angle was not as accurate, with a mean difference of 3° (SD, 0.7°; P < .006). The β-angle on unformatted 2D CT scan was not a reliable method to measure glenoid inclination, with a mean difference of 10° (SD, 0.9°; P < .0001)., Conclusion: The β-angle measured with 2D CT scan formatted in the scapular plane was the most accurate method for measuring glenoid inclination. The β-angle on the AP radiograph is less accurate and reliable. Measurement of the β-angle on an unformatted 2D CT scan is not an acceptable method to determine glenoid inclination., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The modular pyrocarbon (MoPyC) radial head prosthesis (Tornier, Saint-Ismier, France) is a monoblock modular radial head prosthesis. This study assessed midterm outcomes after implantation of the prosthesis., Materials: A retrospective study was conducted of a consecutive cohort of 65 patients who underwent radial head replacement with the MoPyC prosthesis from January 2006 to April 2013. Indications were fractures, early or late failures from orthopedic or fixation treatments, and revisions after another implant. Patients were observed for >2 years for range of motion, pain, and stability; function by the Mayo Elbow Performance Score (total score, 100) and grip strength were assessed. Quality of stem implantation, bone resorption around the neck, and periprosthetic lucency were noted and quantified on radiographs. Capitellum shape and density as well as humeroulnar aspect (river delta sign) were evaluated. Complications and revision procedures were noted., Results: We evaluated 52 of 65 patients (mean follow-up, 46 ± 20 months; range, 24-108). The Mayo Elbow Performance Score was 96 ± 7; pain score, 42 ± 7/45; and motion score, 18 ± 2/20. Function and stability were excellent. Radiology revealed 92% of patients with cortical resorption around the neck without mechanical failure. Bone resorption was mostly anterior and lateral; it resolved within the first year and thereafter was stable. Eight patients underwent revision surgery for stiffness. No implant failures were noted., Conclusion: Results of the MoPyC radial head prosthesis appear to be satisfactory. Bone resorption around the neck (stress shielding) is frequent and stable after 1 year and does not impair stem fixation. The MoPyC prosthesis appears to be a reliable solution for replacing the radial head., (Copyright © 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Increased critical shoulder angles consist of both the acromial cover and glenoid inclination and have been found in patients with rotator cuff pathology. The purpose of this study was to determine the correlation of the critical shoulder angle and glenoid inclination and to determine the difference in glenoid inclination between patients with osteoarthritis and massive rotator cuff tears., Methods: The critical shoulder angle and glenoid inclination were measured on anteroposterior radiographs, and glenoid inclination was also measured on a validated 3-dimensional computer software program of 50 shoulders undergoing primary total shoulder arthroplasty. Twenty-five shoulders had osteoarthritis and A1 glenoids, as defined by the Walch classification, and were undergoing anatomic shoulder arthroplasty. The other 25 shoulders had massive rotator cuff tears and E0 glenoids, as defined by the Favard classification. The 2 groups were compared., Results: Critical shoulder angle and glenoid inclination were significantly correlated (R(2) = 0.7426, P < .001). Shoulders with massive rotator cuff tears (E0) demonstrated increased glenoid inclination measurements than shoulders with osteoarthritis (A1). As measured by the 3-dimensional software, the massive rotator cuff group had a glenoid inclination of 13.6° ± 4.3° and the osteoarthritis group had a glenoid inclination of 4.7° ± 5.6°. When measured by anteroposterior radiographs, the average glenoid inclination was 13.6° ± 4.6° in the massive rotator cuff group and was 7.6° ± 5.01° in the osteoarthritic group ., Conclusion: Glenoid inclination is linearly correlated with the critical shoulder angle and is significantly increased in patients with massive rotator cuff tears., (Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)