Faculty Bibliography

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.

BACKGROUND: Reverse total shoulder arthroplasty (rTSA) has been used to treat patients with irreparable rotator cuff dysfunction. Despite the proven clinical efficacy, there is minimal information regarding the underlying changes to the shoulder kinematics associated with this construct. Therefore, we sought to examine the kinematics of dynamic shoulder motion in patients with well-functioning rTSA. METHODS: We tested 12 healthy subjects and 17 patients with rTSA. All rTSA patients were able to elevate their arms to at least 90 degrees and received the implant as the primary arthroplasty at least 6 months before testing. On average, the rTSA patients elevated their arms to 112 degrees +/- 12 degrees (mean +/- SD) and reported an American Shoulder and Elbow Surgeons outcome score of 90.6 +/- 6.3. A 3-dimensional electromagnetic motion capture device was used to detect the dynamic motion of the trunk, scapula, and humerus during bilateral active shoulder elevation along the sagittal, scapular, and coronal planes. RESULTS: In both healthy and rTSA shoulders, the majority of the humeral-thoracic motion was provided by the glenohumeral motion. Therefore, the ratio of glenohumeral to scapulothoracic (ST) motion was always greater than 1.62 during elevation along the scapular plane. In comparison to healthy subjects, however, the contribution of ST motion to overall shoulder motion was significantly increased in the rTSA shoulders. This increased contribution was noted in all planes of shoulder elevation and was maintained when weights were attached to the arm. CONCLUSION: Kinematics of the rTSA shoulders are significantly altered, and more ST motion is used to achieve shoulder elevation.

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.

BACKGROUND: Superior labrum anterior-posterior (SLAP) lesions of the shoulder that require surgical repair are relatively uncommon. However, recent observations suggest that there may be a rise in the incidence of SLAP lesion repair. MATERIALS AND METHODS: The Statewide Planning and Research Cooperative Systems (SPARCS) database from the New York State Department of Health was used to acquire data for all outpatient ambulatory surgery procedures that were performed in New York State from 2002 to 2010. The data were reviewed and analyzed to compare the incidence of arthroscopic SLAP lesion repairs relative to other outpatient surgical procedures. RESULTS: Within New York State, from 2002 to 2010, the number of all ambulatory surgical procedures increased 55%, from 1,411,633 to 2,189,991. Correspondingly, the number of ambulatory orthopedic procedures increased 135%, from 118,126 to 278,136. In comparison, the number of arthroscopic SLAP repairs increased 464%, from 765 to 4,313 (P < .0001). This represented a population-based incidence of 4.0/100,000 in 2002 and 22.3/100,000 in 2010. The mean age of patients undergoing arthroscopic SLAP repair in 2002 was 37 +/- 14 years. The mean age in 2010 was 40 +/- 14 years (P < .0001). CONCLUSIONS: The data suggest a substantial increase in the number of arthroscopic SLAP repairs that is significantly more rapid than the rising rate of outpatient orthopedic surgical procedures. In addition, there is a significant increase in the age of patients who are being treated with arthroscopic SLAP repairs.

BACKGROUND: Shoulder arthroplasty has become more prevalent, and patients undergoing shoulder arthroplasty are becoming more active. Recommendations for return to athletic activity have not recently been updated and do not consider the newest arthroplasty options. METHODS: A survey was distributed to 310 members of the American Shoulder and Elbow Surgeons, inquiring about allowed participation in 28 different athletic activities after 5 types of shoulder arthroplasty options (total shoulder arthroplasty, hemiarthroplasty, humeral resurfacing, total shoulder resurfacing, and reverse shoulder arthroplasty). RESULTS: The response rate to the survey was 30.3%, with 74.1% of respondents allowing some return to athletic activity after shoulder arthroplasty. The 28 athletic activities were grouped into 4 categories based on the load and possible impact to the shoulder. Only 51% of respondents allowed any participation in contact sports, whereas 90% allowed some participation in noncontact low-load sports. Return to sports after humeral resurfacing was highest, at 92.0% of the respondents, whereas the least percentage of surgeons allowed sports after reverse total shoulder arthroplasty, at 45.2%. CONCLUSION: The majority of surveyed surgeons allowed some return to sports after shoulder arthroplasty. Surgeons were more likely to recommend return to sports if the activities did not involve significant contact, risk of fall or collision, or application of high loads to the shoulder joint. Surgeons were also more likely to recommend return to sports if the arthroplasty did not involve the glenoid. CLINICAL RELEVANCE: The results of this survey may help surgeons counsel patients regarding return to specific athletic activities after various types of shoulder arthroplasty.

Over the last decade, reverse total shoulder arthroplasty has gained significant popularity due to its ability to address difficult reconstructive shoulder problems that could not be adequately treated in the past. The concept of the reverse shoulder prosthesis was introduced in the 1970s, but the initial attempts were associated with high complication and implant failure rates. The pioneering work of Paul Grammont (shifting the center of rotation medially and distally) and the development of the DELTA prosthesis have been fundamental to all subsequent reverse shoulder arthroplasty systems. These semiconstrained prostheses utilize the deltoid to improve function and stability of the shoulder joint by coupling a convex glenoid with a concave humeral component. Modern generations of reverse shoulder prosthesis continue to evolve on the fundamentals of Grammont. Though results of these new prosthesis demonstrate promising outcomes, many controversies and challenges continue to be refined. An historical review of the evolution of reverse shoulder arthroplasty is presented, as well as the currently expanding indications for its application

OBJECTIVE: The purpose of this article is to review imaging of the rotator interval, an anatomically complex region in the shoulder that plays an important role in the normal function of the shoulder joint. The rotator interval can be difficult to evaluate by imaging, and it is not routinely evaluated arthroscopically unless the clinical examination or imaging findings suggest an abnormality of the rotator interval. Rotator interval pathology is implicated in glenohumeral instability, biceps instability and adhesive capsulitis-entities which remain a challenge to diagnose and treat. CONCLUSION: Imaging can play an important role in increasing suspicion for injury to the rotator interval so that this region can be evaluated and appropriate treatment can be initiated

BACKGROUND: We reviewed all revision operations performed by a single surgeon on previous hemi- and total shoulder arthroplasties from November 1987 to March 2005. METHOD: Thirty-five patients' charts were reviewed to determine the causes of failures. In addition, their outcomes after the revision surgery were analyzed. RESULTS: Overall, results were satisfactory in 71% by Neer criteria at a mean follow-up of 27.6 months. Outcomes were related to reason for failure. When failure was because of glenoid erosion, loosening, or humeral loosening, the mean improvement in forward elevation (FE) (28.9 degrees ) and external rotation (ER) (16.1 degrees ) was significantly better (P=.024 FE; P=.000 ER) than when the failure was because of infection, soft-tissue problems, or pain of undetermined origin (FE=-5.6 degrees ; ER=-6.8 degrees ).Likewise, UCLA scores in the first group were significantly better than in the second group (P=.003). In the first group, 16/18 patients were satisfied, while in the second group only 4/17 were satisfied. CONCLUSION: Our data suggest that patients whose revisions are because of glenoid erosion or component loosening can expect to have better outcomes than those whose revisions are performed for infection, instability, or other soft-tissue problems

HYPOTHESIS: Our initial hypothesis was that the medial row of double-row rotator cuff repair techniques would bear most of the load on the repaired cuff. MATERIALS AND METHODS: Six cadaver shoulders underwent simulated rotator cuff repairs using sequential single row, double-row, and suture-bridge repair techniques. Suture tensions at each anchor were measured for several static, simulated shoulder positions by specially designed, instrumented anchors. RESULTS: Significantly greater suture tensions were measured in the anchors in a single row repair construct than either the double row repair or suture bridge repair construct (P < .001). In the double-row and suture bridge techniques, there was no apparent difference in the loads born by the medial and lateral row anchors. Shoulder abduction from 45 degrees to 60 degrees had little effect on anchor tensions; 45 degrees internal and external rotation significantly (P = .032) increased loads on the anterior and posterior anchors by at least 125%. DISCUSSION: Forces are transmitted through the entire portion of the tendon at its humeral fixation, loading the lateral anchors as well as the medial row for the techniques studied. This 'load sharing' can explain the higher fixation strengths of double row techniques seen experimentally. CONCLUSION: The magnitude and distribution of anchor suture tensions could have important implications for lateral row fixation devices and post-operative positioning and activity. LEVEL OF EVIDENCE: Basic Science