Background: Revision reverse shoulder arthroplasty (RSA) poses considerable surgical challenges. We hypothesized that a newly developed press-fit stem, which is modeled on the medullary canal of the supracondylar region of the distal humerus by a slight distal bend, achieve both correct fit and sufficient primary stability and that additional distal fixation by interlocking screws is favorable in case of advanced humeral bone loss. Methods: A modular tapered press-fit stem was implanted in 16 Sawbone humeri in three consecutively created defect situations (200 mm (experimental group type 31, 160 mm (type 4 degrees) and 120 mm (type 5 degrees) bone length above the epicondylar line. In experimental groups type 4 degrees and 5 degrees, additional distal interlocking screw fixation with one to three screws was tested. Primary stability was investigated by measuring micromotions with a high-precision rotational setup. Findings: Highest relative micromotions were noted at the proximal end in experimental groups type 3 degrees and type 4 degrees, whereas in type 5 degrees highest micromotions could be seen at the distal end. Overall micmmotions were significantly lower in type 3 degrees and increased with extended defect size. In experimental group type 5 degrees, micro-motions increased with reduced additional distal screw fixation. Interpretation: The examined press-fit stem did not provide sufficient primary rotational stability in all constructs without additional support. Advanced distal humeral bone loss had a strong impact on primary fixation. In experimental group type 5 degrees with 120 mm bone remaining, it might be beneficial to use three distal interlocking screws in the supracondylar region in order to neutralize torque and to avoid early loosening.

Background The success of shoulder arthroplasty, both reverse and anatomical, depends on correcting the underlying glenoid deformity especially in patients with an osteoarthritis. We hypothesized that the distribution of glenoid version and especially inclination are underestimated in the shoulder arthritis population, and also that superior glenoid inclination can be detected through 3-dimensional (3D) software program of computed tomography (CT) to a greater proportion in patients with rotator cuff insufficiency, but also in patients with osteoarthritis with an intact rotator cuff. Because of the influence of rotator cuff imbalance on secondary glenoid wear the values of the critical shoulder angle (CSA) and the fatty infiltration of the rotator cuff are further analyzed. The aim of our study is to determine; 1) the distribution of glenoid inclination and version; 2) the relationship between glenoid inclination, version, the critical shoulder angle (CSA) to the status of the rotator cuff; 3) the proportion of patients with both an intact rotator cuff and a superior inclination greater than 10°. Methods A total of 231 shoulders were evaluated with X-ray images, 3-dimentional (3D) software program of computed tomography (CT), and magnetic resonance imaging. The cohort was divided into 3 groups according to their inclination angles and also grouped as intact-rotator cuff and torn-cuff group. Results The median (min/max) values for the 231 shoulders were 8° (− 23°/56°) for the inclination angle, − 11°(− 55°/23°) for the version angle, and 31.5°(17.6°/61.6°) for the CSA. The majority of the glenoids were found to show posterior-superior erosion. Glenoid inclination angle and CSA were significantly higher in torn-cuff group when compared with intact-cuff group ( P < 0.001, both). The rotator cuff tears were statistically significant in high inclination group than low inclination group and no inclination group ( p < 0.001). In the high inclination group, 41 of 105 (39%) shoulders had an intact rotator cuff, in about 18% of all shoulders. Conclusion Our findings show that 3D evaluation of glenoid inclination is mandatory for preoperative planning of shoulder replacement in order to properly assess superior inclination and that reverse shoulder arthroplasty may be considered more frequently than as previously expected, even when the rotator cuff is intact. Level of evidence Level III.

BACKGROUND:The etiology of degenerative rotator cuff tears is multifactorial but chronic inflammation plays an important role in the pathogenesis. Some polyunsaturated fatty acids (PUFA) can modulate inflammation and marine n-3 (Omega-3) PUFA have anti-inflammatory effects. We hypothesized that the Omega-3 Index is lower in patients with degenerative rotator cuff tears when compared to controls without rotator cuff tendinopathy. METHODS:From 684 consecutive patients with full thickness rotator cuff tears 655 were excluded because of possible bias. In the remaining 29 patients (22 m, 7 f; 53,9 y) with degenerative full thickness rotator-cuff tears, erythrocyte fatty acids were analyzed using the HS-Omega-3 Index® methodology. 15 healthy volunteers (10 m, 5 f; 52.5y) served as a control. RESULTS:The Omega-3 Index (% EPA + DHA) was 5.01% (95% CI: 3.81-4.66) in patients and 6.01% (95% CI: 4.48-5.72) in controls (p = 0.028) CONCLUSIONS: Patients with full thickness degenerative rotator cuff tears had a significantly lower Omega-3 Index than controls without rotator cuff tendinopathy. Whether a lower Omega-3 Index represents an independent risk factor for degenerative rotator cuff tears should be further investigated, e.g. in a longitudinal study.

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). Results Glenosphere size was most predictive of increased extension and external rotation, whereas lateralization of the centre of rotation was the most predictive factor for internal rotation. A larger diameter of glenosphere combined with a 10° tilted configuration demonstrated superior values for extension and external rotation, whereas the eccentric component improved internal rotation by a mean 8.9° (standard deviation 2.7°) compared with a standard concentric glenosphere. Conclusion Glenosphere configuration can be modified to increase range of movement in RSA. Friction-type scapular notching was most effectively reduced by use of a large-diameter glenosphere with 10° inferior tilt. Cite this article: Bone Joint J 2018;100-B:1182–6.

Background Glenoid morphology, glenoid version and humeral head subluxation represent important parameters for the treating physician. The most common method of assessing glenoid morphology is the Walch classification which has only been validated with computed tomography (CT). Methods CT images and magnetic resonance imaging (MRI) images of 25 patients were de-identified and randomized. Three reviewers assessed the images for each parameter twice. The Walch classification was assessed with a weighted kappa value. Glenoid version and humeral head subluxation were comparted with a reproducibility coefficient. Results The Walch classification demonstrated almost perfect intraobserver agreement for MRI and CT images (k = 0.87). Weighted interobserver agreement values for the Walch classification were fair for CT and MRI (k = 0.34). The weighted reproducibility coefficient for glenoid version measured 9.13 (CI 7.16–12.60) degrees for CT and 13.44 (CI 10.54–18.55) degrees for MRI images. The weighted reproducibility coefficient for percentage of humeral head subluxation was 17.43% (CI 13.67–24.06) for CT and 18.49% (CI 14.5–25.52) for MRI images. Discussion CT and MRI images demonstrated similar efficacy in classifying glenoid morphology, measuring glenoid version and measuring posterior humeral head subluxation. MRI can be used as an alternative to CT for measuring these parameters.

Pyrocarbon (PyC) interposition shoulder arthroplasty can be used to treat advanced collapse of the humeral head after avascular necrosis.

Introduction: Shoulder hemi arthroplasty has several limitations in fracture sequelae with humeral head avascular necrosis like reduced lateral offset, shortening and contracture of the rotator cuff (for stemmed humeral implants), limited fixation (stemless implants) and glenoid erosion. The novel pyrocarbon ball implant may better address these problems by using a different way of fixation in the humeral metaphysis. Objectives: We aimed to assess the clinical and radiological results of this implant in a series of patients after failed treatment of a proximal humerus fracture. Methods: In 11 consecutive patients with a humeral head necrosis (4 males, 7 females, age 57 ± 13 years) a pyrocarbon hemiprosthesis (Inspyre, Tornier) was implanted. The rotator cuff and the tuberosities were mostly intact or attached to the humerus (MRI). The glenoid was intact without gross bone loss or erosion. The DASH, the Constant-Murley and the Euroquol 5D score were assessed after a mean follow up (FU) of 24 months. The postoperative radiographs were compared to those at FU. Migration of the implant, the joint space, the width of the lateral metaphysis and radiolucency were assessed. Results: The mean passive abduction at FU was 77° (SD ± 19°), anteversion 121° (SD ± 33°), ER in adduction 24° (SD ± 8°). The abduction strength was 55% compared to the healthy side. The DASH score at FU was 36, the constant score 53. The Euroquol was 72. The implant migrated 3,6 mm (±2,5) to cranial, the joint space reduced by 1,1 mm (±1,1), the lateral metaphyseal bone reduced by 3,3 mm (±3,7) and a 1,7 mm (±0,3) radiolucent line was detectable around the implant. Conclusions: The pyrocarbon ball implant has shown excellent results after 2 years when implanted in cases of humeral head necrosis after failed fracture treatment. Superior migration of the implant, a joint line reduction and lateral metaphyseal erosion occurred only to a slight extend. Keywords: Pyrocarbon, Hemiprosthesis, Proximal Humerus Fracture Sequelae.

Background: Long-term results and complication rates in shoulder arthroplasty are related to implant positioning. Current literature reports increased precision in glenoid component positioning using 3-dimensional (3D) computed tomography (CT) planning tools. This study evaluated the accuracy of glenoid version and inclination measurements using 2D CT scans compared with a validated 3D software program and its influence on decision making on implant selection.Methods: Preoperative CT scans were obtained from 50 patients undergoing total shoulder arthroplasty. Glenoid version and inclination measurements were performed in random order by 3 independent qualified orthopedic surgeons on reformatted 2D CT scans. Indication for anatomic or reverse shoulder arthroplasty was based on glenoid deformity and on rotator cuff conditions. Results were compared with those from a validated 3D computer software program, and the final decision was made according to the 3D planning.Results: Mean preoperative glenoid retroversion on reformatted 2D CT scans was 11.9 degrees +/- 9.6 degrees and mean superior inclination was 10.7 degrees +/- 8.6 degrees. When the 3D software was used, glenoid retroversion averaged 15.1 degrees +/- 10.6 degrees and superior inclination averaged 8.9 degrees +/- 9.9 degrees. The 2D CT demonstrated good interobserver and intraobserver reliability for glenoid version and inclination. Decision on the choice of implant was adjusted in 7 patients after the 3D planning.Conclusions: Our findings show that measurements of glenoid version and inclination on reformatted 2D CT scans are less accurate compared with 3D measurements. A preoperative 3D planning software allows for improvement of virtual glenoid positioning and influences the decision making process. (C) 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Cementless surface replacement of the shoulder represents an alternative to conventional stemmed anatomic prostheses. Glenoid erosion is a well-known complication in hemiarthroplasty. However, there is limited data concerning radiographic evaluation and prognostic factors for this phenomenon.

Background: Revision of failed shoulder arthroplasty is often associated with poor results and a high rate of complications. Significant humeral bone loss after removal of long stems poses a considerable surgical challenge. Therefore, the aim of our study was the evaluation of the clinical and radiologic outcome of cemented long-stem humeral components in revision reverse shoulder arthroplasty with a minimum 5 years' follow-up.Methods: Between June 2001 and June 2009, revision reverse shoulder arthroplasty using long-stem cemented humeral components was performed in 124 patients. Mean age at time of surgery was 69.6 years (range, 42-87 years). Complete clinical and radiographic data were available in 50 patients at a mean of 7 years (range, 5-11.6 years). Postoperative radiographs were evaluated for radiolucent lines, implant migration, fracture, and glenoid notching.Results: The mean Constant score improved from 11.1 points (range, 0-27 points) to 39.5 points (range, 14-73 points) at the latest follow-up. Progressive humeral radiolucency was present in 24 patients, including 6 patients demonstrating complete loosening or progressive distal migration of the humeral stem. We noted an overall of 12 additional complications in 8 patients, necessitating revision surgery in 16.Conclusion: The use of long-stem humeral components is a beneficial treatment in revision reverse shoulder arthroplasty. Nevertheless, the high percentage of patients with humeral loosening is concerning. Modular cementless revision stems that are adapted to the distal humeral medullary canal and additional distal screw and cable fixation might enhance durable distal fixation in case of advanced bone loss. (C) 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Stemless humeral implants show comparable midterm clinical results compared to stemmed components. Recently, radiolucencies around the metaphyseal seating of humeral stemless implants were reported on postoperative radiographs. It is controversial whether they are attributable to bone resorption. We hypothesized these radiolucencies result from imaging artifacts. Seven cadaveric specimens (three male and four female) were first radiographed and then scanned with CT. A stemless humeral component of current design was implanted in each specimen. After implantation, all specimens were radiographed with different exposure settings. The implant was removed, and the specimens were scanned with CT again. Pre- and post-implantation radiographs and CT scans were compared. The mean Hounsfield units (HU) at the humeral resection plane from the pre-implantation CT were correlated with the diameter of the radiolucent halo on the post-implantation radiographs. A symmetric radiolucent halo of variable diameters occurred on all radiographs after implantation when an automatic exposure control was used. The halo disappeared in all specimens when the tube voltage was reduced. Lower CT-values (HU) before the implantation resulted in greater halos on the radiograph after implantation. Symmetric radiolucent halos can result from imaging artifacts, which is most likely due to radiation scatter. The halos can be minimized by reducing the tube voltage. The halo effect appears to be pronounced in bones with decreased density. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2040-2050, 2017.

Background: Recent developments in reverse shoulder arthroplasty (RSA) have focused on changes in several design-related parameters, including humeral component design, to allow for easier convertibility. Alterations in humeral inclination and offset on shoulder kinematics may have a relevant influence on postoperative outcome. This study used a virtual computer simulation to evaluate the influence of humeral neck shaft angle and glenoid lateralization on range of motion in onlay design RSA.Methods: Three-dimensional RSA computer templating was created from computed tomography (CT) scans in 20 patients undergoing primary total shoulder arthroplasty for concentric osteoarthritis (Walch A1). Two concurrent factors were tested for impingement-free range of motion: humeral inclination (135 degrees vs. 145 degrees) and glenoid lateralization (0 mm vs. 5 mm).Results: Decreasing the humeral neck shaft angle demonstrated a significant increase in impingementfree range of motion. Compared to the 145 degrees configuration, extension was increased by 42.3 degrees (-8.5 degrees to 73.5 degrees), adduction by 15 degrees (10 degrees to 23 degrees), and external rotation with the arm at side by 15.1 degrees (8.5 degrees to 26.5 degrees); however, abduction was decreased by 6.5 degrees (-1 degrees to 12.5 degrees). Glenoid lateralization led to comparable results, but an additional increase in abduction of 7.6 degrees (-1 degrees to 16.5 degrees) and forward flexion of 26.6 degrees (6.5 degrees to 62 degrees) was observed.Conclusion: Lower humeral neck shaft angle and glenoid lateralization are effective for improvement in range of motion after RSA. The use of the 135 degrees model with 5 mm of glenoid lateralization provided the best results in impingement-free range of motion, except for abduction.

Background: The concept of onlay design reverse shoulder arthroplasty has been introduced to overcome complications observed with the traditional Grammont-type prosthesis. The aim of this study was to determine the influence of arm lengthening on the short-term clinical outcome in onlay reverse shoulder arthroplasty and investigate the effect of humeral tray offset positioning on arm lengthening and range of motion. Methods: We retrospectively evaluated 56 patients undergoing reverse shoulder arthroplasty with the Aequalis Ascend Flex prosthesis (Tornier, Bloomington, MN, USA) at a minimum 2 years' follow-up. Arm lengthening was determined using bilateral scaled radiographs of the entire humerus. The Constant score and active range of motion were documented preoperatively and postoperatively. The relationship between arm lengthening, humeral tray offset position, and functional outcome was analyzed. Results: The Constant score improved from 25.5 +/- 9.5 points to 71.5 +/- 13.8 points at a mean follow-up of 30.1 +/- 5.2 months. Mean postoperative anterior elevation was 145.2 degrees +/- 21.1, and external rotation was 30.7 degrees +/- 20.3 degrees. Arm lengthening exceeding 2.5 cm was related to a decrease in anterior elevation. We found a relationship between arm lengthening averaging 2.2 +/- 1.7 cm and increased Constant score values. Humeral tray positioning demonstrated no influence on the functional outcome. There was a trend toward increased arm lengthening in lateral offset positioning. Conclusions: Onlay reverse shoulder arthroplasty yields good short-term clinical results. In our population, arm lengthening averaging 1 to 2.5 cm was found to be the best compromise on postoperative range of motion. (C) 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Die Behandlung von Knochendefekten bei der primären Schulterendoprothetik hat in den letzten Jahren durch verfeinerte Methoden der Computertomographie(CT)-Diagnostik und 3‑D-Planung sowie die Ausweitung der Indikation für inverse Totalendoprothesen große Fortschritte gemacht. Wegen der häufig begleitenden chronischen Dezentrierung des Humeruskopfes werden selbst bei erhaltener Rotatorenmanschette zunehmend inverse Implantate in Kombination mit einem Glenoidaufbau bevorzugt. Parallel dazu hat die Behandlung der Glenoidlockerung mit fortgeschrittenem Knochenverlust durch die zementfreie Fixation der Basisplatte und Transfixationstechnik nach Norris eine grundlegende Veränderung erfahren. Die Operationstechnik erfordert sowohl bei der primären Endoprothetik als auch bei Revisionen eine detaillierte präoperative Planung mittels reformatierter Röntgen-CT und spezieller Instrumentation.

In elbow arthroplasty, a special attention is attributed to postsurgical infections because many patients have predispositions like rheumatoid arthritis and consecutive immunosuppression. In cases of revision arthroplasty different strategies to eradicate the bacteria and to restore joint function are discussed. We aimed to expose detection methods of postsurgical infections including low-grade infections, therapy approaches and surgical procedures for the treatment of an infected elbow arthroplasty.

Obecność zakażenia miejsca operowanego może być katastrofalnym powikłaniem w chirurgii barku i łokcia i należy jemu zapobiegać za pomocą wszelkich środków

STRESZCZENIE Obecność zakażenia miejsca operowanego może być katastrofalnym powikłaniem w chirurgii barku i łokcia i należy jemu zapobiegać za pomocą wszelkich środków. Istnieje kilka czynników predysponujących występowanie zakażenia, w tym przygotowanie przedoperacyjne, sprzętu, dojścia operacyjne, dawkowanie i czas stosowanie antybiotyków, jak i predyspozycje samego pacjenta oraz występowanie wcześniejszych chorób. Celem tej pracy było scharakteryzowanie częstości występowania i predyspozycji do występowania zakażeń w okolicach barku i łokcia w trakcie i po zabiegach chirurgicznych, jak i strategii zapobiegania zakażeniom w operowanym miejscu.

Background: Reverse shoulder arthroplasty leads to arm lengthening. Different techniques have been described to determine postoperative lengthening. The purpose of this study was to evaluate the reliability of the acromiohumeral distance (AHD) in determining arm lengthening after reverse shoulder arthroplasty.Methods: At 2 centers, 44 patients who had received an onlay design reverse shoulder arthroplasty were observed for a minimum of 6 months. Examination followed a standardized protocol including preoperative and postoperative radiographs on anteroposterior view in neutral rotation. Two orthopedic surgeons independently performed the measurements in random order.Results: Mean arm lengthening averaged 2.5 cm (range, 0.3-3.9 cm) according to AHD measurement. Significant differences in interobserver and intraobserver variability for postoperative AHD measurements were found (P < .01). The mean intrapatient difference was 0.5 cm (range, 0.02-1.5 cm).Conclusion: According to our study, the AHD is not a reliable measurement technique to determine arm lengthening after reverse shoulder arthroplasty. (C) 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.