Faculty Bibliography

UNLABELLED:Worldwide, the usage of both anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthro- plasty (rTSA) has increased significantly due, in part, to the predictability of acceptable outcomes achieved with each prosthesis type. This study quantifies outcomes using five different metrics and compares results using one platform total shoulder arthroplasty system that utilizes the same humeral component and instrumentation to perform both aTSA or rTSA. METHODS:200 patients were treated by two orthopaedic surgeons using either aTSA or rTSA. 73 patients received aTSA for treatment of osteoarthritis (OA), and 127 patients received rTSA for treatment of rotator cuff tear arthro- plasty (CTA). Each was scored preoperatively, and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI metrics, motion was also quantified. The average follow-up for all patients was 31.4 ± 9.7 months. RESULTS:All patients demonstrated significant improvements in pain and function following treatment of OA with aTSA and treatment of CTA with rTSA. No instances of instability or glenoid loosening were reported in either cohort; one instance of infection occurred in the rTSA cohort. aTSA was associated with significantly higher pre- and postoperative outcome scores and significantly larger pre- and postoperative range of motion than rTSA. However, rTSA was demonstrated to be significantly more effective at improving outcome scores, active forward flexion, and strength than was aTSA. DISCUSSION AND CONCLUSIONS/CONCLUSIONS:Significant improvements in outcome scores were observed for both aTSA and rTSA using one platform shoulder system at a mean follow-up of 31.4 months. Significant differences were observed between prosthesis type and between scoring metrics, particularly between the Constant and ASES scoring metrics. Additional and longer term follow-up is required to confirm these observed differences.

The education of orthopaedic residents is an important responsibility shared by all those involved in residency training. The education of orthopaedic residents begins with the selection process, which recognizes the importance of choosing qualified individuals who can successfully complete the training program. Education during the 5 years of required training entails the acquisition of a body of knowledge, the development of surgical skills, and the exhibition of a level of professionalism consistent with being a physician and surgeon. Residency training also requires an evaluation of performance and, when necessary, measures to improve performance or correct inappropriate behaviors. The goal at the end of the 5-year training period is to have well-qualified, skilled, and knowledgeable orthopaedic surgeons who can enter practice and provide the highest level of patient care.

PURPOSE: This study quantifies the ability of humeral retroversion, glenoid tilt, bone graft, and varying prosthesis design parameters to restore anatomic muscle length and deltoid wrapping with reverse shoulder arthroplasty. METHODS: A computer model simulated abduction and internal and external rotation for a normal shoulder, the RSP reverse shoulder, the Equinoxe reverse shoulder, and the Grammont reverse shoulder when implanted using various implantation methods. The length of eight different muscles and the deltoid wrapping angle were quantified to evaluate the ability of each implantation method and design to restore anatomic muscle tensioning. RESULTS: Each reverse shoulder shifted the center of rotation medially and inferiorly relative to the normal shoulder and caused a corresponding shift in the position of the humerus. Each reverse shoulder elongated each head of the deltoid and shortened the internal and external rotators relative to the normal shoulder. The surgical techniques and prosthesis designs, which resulted in a more lateral humeral position, were associated with more deltoid wrapping and better tensioning of the anterior and posterior shoulder muscles. CONCLUSIONS: Muscle tensioning and deltoid wrapping can be substantially altered by surgical implantation meth- ods using the Grammont reverse shoulder. However, the results of this study demonstrate that more anatomic muscle tensioning and improved deltoid wrapping are achieved using alternative prosthesis designs that better restore the lateral position of the humerus.

PURPOSE: The purpose of this study is to validate a reverse shoulder computer impingement model and quantify the impact of implant position on scapular impingement by comparing it to that of a radiographic analysis of 256 patients who received the same prosthesis and were followed postoperatively for an average of 22.2 months. METHODS: A geometric computer analysis quantified anterior and posterior scapular impingement as the humerus was internally and externally rotated at varying levels of abduction and adduction relative to a fixed scapula at defined glenoid implant positions. These impingement results were compared to radiographic study of 256 patients who were analyzed for notching, glenoid baseplate position, and glenosphere overhang. RESULTS: The computer model predicted no impingement at 0 degrees humeral abduction in the scapular plane for the 38 mm, 42 mm, and 46 mm devices when the glenoid baseplate cage peg is positioned 18.6 mm, 20.4 mm, and 22.7 mm from the inferior glenoid rim (of the reamed glenoid) or when glenosphere overhang of 4.6 mm, 4.7 mm, and 4.5 mm was obtained with each size glenosphere, respectively. When compared to the radiographic analysis, the computer model correctly predicted impingement based upon glenoid base- plate position in 18 of 26 patients with scapular notching and based upon glenosphere overhang in 15 of 26 patients with scapular notching. CONCLUSIONS: Reverse shoulder implant positioning plays an important role in scapular notching. The results of this study demonstrate that the computer impingement model can effectively predict impingement based upon implant positioning in a majority of patients who developed scapular notching clinically. This computer analysis provides guidance to surgeons on implant positions that reduce scapular notching, a well-documented complication of reverse shoulder arthroplasty.

BACKGROUND: Shoulder arthroplasty provides predictable pain relief and functional improvement of the shoulder for glenohumeral disease. With recent emphasis on health economic planning and rising patient expectation, physicians are encouraged to adopt more evidence-based strategies for decision-making. In the context of shoulder arthroplasty, surgeon preference and bias may play a large role in the choice of the procedure performed. The purpose of this study is to objectively examine the perceived differences and similarities, from the surgeon's perspective, between total shoulder arthroplasty (TSA) and hemiarthroplasty anticipated outcomes. METHODS: We conducted a web-based survey that asked surgeons to weigh the relative values of these procedures in relation to one another. Within the survey, there were numerous variables in which the surgeon was asked to choose the preferred surgical outcome. Ninety-eight surgeons responded to the survey. The average age was 51.7 years. RESULTS: Surgeons in our study chose pain relief and improved ROM as a more likely outcome in TSA than any level of complication and as a more likely out-come than improved strength compared to hemiarthroplasty. These results emphasized the perception amongst the polled surgeons that TSA is a preferred treatment option for patients who expect a high level of pain relief and ROM even at the expense of a decreased strength. CONCLUSION: This study is a first step in the construction of a patient oriented model for treatment decisions. With this information, we may be better able to tailor our patients' needs and wishes to the procedures that most predictably result in the outcomes they desire.

Subscapularis tenotomy for total shoulder arthroplasty has been the standard approach for shoulder surgeons that utilize the deltopectoral approach. The risk of subscapularis insufficiency after this approach has been well documented. In order to avoid subscapularis complications, Lafosse reported a technique for total shoulder arthroplasty that utilizes a trans-deltoid approach through the rotator interval that yielded satisfactory clinical outcomes. However, he also reported concerns about humeral head undersizing and inadequate osteophyte resection. We present an alternative subscapularis preserving technique that is performed through the deltopectoral interval and allows complete osteophyte excision and accurate humeral head sizing. This technique requires modified instrumentation and is facilitated by the use of an adaptable prosthesis with dual eccentricity. Case examples using this technique are presented.

INTRODUCTION: Shoulder arthroplasty provides excellent outcomes for most patients; however, a subset of these patients with a failed arthroplasty will require revision. Recently, the reverse total shoulder arthroplasty (rTSA) has been used in these difficult clinical situations. Therefore, we sought to examine our initial experience using rTSA as a treatment for failed shoulder arthroplasty. METHODS: During a 5-year period, 31 patients (mean age, 68.7 years) underwent rTSA for treatment of a failed shoulder arthroplasty and their presurgical and operative data were analyzed. Of the 31 patients, 28 were available for an average follow-up of 40.7 months. Their outcomes were assessed with American Shoulder and Elbow Surgeons (ASES), University of California-Los Angeles (UCLA), and Simple Shoulder Test (SST) scores, and the visual analog scale (VAS) for pain. RESULTS: Compared with preoperative status, there were statistically significant improvements in all outcome measurements, including the ASES (24.0 to 66.2), UCLA (7.4 to 23.5), SST (1.5 to 7.6), and VAS (7.0 to 2.6). Active forward elevation improved from 44 degrees preoperatively to 108 degrees postoperatively (P < .001). Results were rated as good or excellent by 19 patients (67.9%), satisfactory by 4 (14.3%), and unsatisfactory by 5 (17.8%). Among the types of failed arthroplasty, patients with failed TSA noted the greatest improvement in their outcome, but this improvement was not statistically significant. CONCLUSIONS: The data suggest that patients can expect improved functional outcome and decreased pain after revision of previous arthroplasty to rTSA and that this procedure can provide a reliable salvage option for a challenging clinical problem.

We conducted a study to evaluate the outcomes and complications of open reduction and internal fixation (ORIF) of 2-, 3-, and 4-part proximal humerus fractures using a standard management protocol with locking plates. Of 72 patients with acute proximal humerus fractures managed with ORIF and locking plates, 63 were available at the minimum follow-up of 1 year and met the inclusion criteria. At each follow-up, radiographs were reviewed for healing, hardware failure, osteonecrosis, shoulder range of motion, and DASH (Disabilities of the Arm, Shoulder, and Hand) scores; any complications were recorded. Mean age was 62 years and mean follow-up was 19 months. There were 12 two-part fractures, 42 three-part fractures, and 9 four-part fractures. Thirteen patients had complications. Mean shoulder forward elevation was 135; patients with complications had a significantly lower mean forward elevation (P=.002). DASH scores were significantly lower in patients without complications than in those with complications (P=.01). Although excellent outcomes can be achieved when locking plates are used to manage proximal humerus fractures, complications are possible. Physicians must weigh the functional outcome data when considering management options for these types of injuries.