Journal Scan: Journal of Shoulder and Elbow Surgery
Year: 2010
Type: article
Abstract: Shoulder Arthroplasty Subscapularis function after total shoulder replacement: results with lesser tuberosity osteotomy. Qureshi S, Hsiao A, Klug RA, Lee E, Braman J, Flatow EL. J Shoulder Elbow Surg. 2008;17:68-72. Context: Traditionally, the subscapularis tendon is incised when performing total shoulder arthroplasties. Yet some authors have reported significant rates of subscapularis dysfunction after TSA as measured by the belly press and lift-off tests when a tenotomy is used. Therefore a lesser tuberosity osteotomy technique was developed in an attempt to mitigate this dysfunction. Study Design and Results: Twenty-eight patients (30 shoulders) were retrospectively reviewed clinically and radiographically at a minimum of 1 year postoperatively after having a TSA performed via a lesser tuberosity osteotomy. Standard releases were performed. All patients were reported to have normal subscapularis function before surgery. All the osteotomies were reported to be healed by the 6-week postoperative visit. The belly press test was normal in 18 of 30 (60%), and 25 of 30 patients (83%) were able to tuck in a shirt behind the back without difficulty. This was compared with a previous cohort of patients who had tenotomy and in whom the belly press test was normal in only 33% and the ability to tuck in a shirt was normal in only 32%. Conclusions: Lesser tuberosity osteotomies suggest good rates of healing with favorable subscapularis function. Comments: The premise of the lesser tuberosity osteotomy approach is that healing is more predictable in a bone-to-bone fashion as compared with a tendon-to-tendon fashion with a tenotomy. Yet studies have reported low correlation between subscapularis integrity and function as measured by the above tests. The current work suggests that the tissue must not only be in continuity (as seen on imaging studies) but firmly adherent to the humerus. Pearls: Delicate management of the subscapularis by either approach is necessary, as subscapularis rupture after TSA has been correlated with instability and weakness and could lead to early glenoid component failure via an AP “rocking horse” effect. The belly press and lift off tests are frequently positive even when the subscapularis is intact. This might have more to do with preoperative dysfunction (which can be difficult to assess secondary to contractures) and the amount and types of releases with possibly neurapraxias. A biomechanical evaluation of three surgical techniques for subscapularis repair. Van den Berghe GR, Nguyen B, Patil S, D'Lima DD, Mahar A, Pedowitz R, Hoenecke HR. J Shoulder Elbow Surg. 2008;17:156-161. Context: Subscapularis dysfunction after TSA has been reported by many authors. Reasons for the dysfunction include failure of the repair, change in length of the tendon, and denervation. There are several methods to manage the subscapularis tendon which include tenotomy, releasing the tendon from the lesser tuberosity, and lesser tuberosity osteotomy. Study Design and Results: Nineteen unmatched human cadaveric shoulders were used to compare three methods of repair. Six shoulders had a tendon-to-tendon repair (Group 1) using four #2 FiberWires placed in a horizontal mattress fashion. Six had a tendon-to-bone repair (Group 2) in which the subscapularis was repaired with #2 FiberWires through drill holes at the anatomic neck in a horizontal mattress fashion. Seven others had a lesser tuberosity osteotomy (Group 3) repaired with #2 FiberWires in a mattress fashion through transosseous tunnels and tied over a buttress plate. The repairs were loaded initially to 150 N and cycled 500 times at 1 Hz and those that remained intact subsequently were loaded to 300 N and run for 1500 cycles or until failure. The rate of complete failure for the 150 N load was statistically higher for tendon-to-bone repair compared with the other groups; there was no significant difference between Groups 1 (tendon-to-tendon) and 3 (lesser tuberosity osteotomy). At the 300 N load there was no significant difference between any of the three groups. The change in length of the repaired tendon imposed by the method of repair also was recorded. The tendon-to-tendon repair shortened the tendon by 5.3 mm, whereas the tendon-to-bone repair shortened the repair by 2.6 mm. The bone-to-bone construct did not change in length once it was loaded. Conclusions: Tendon-to-bone repair of the subscapularis is not as strong as either tendon-to-tendon or lesser tuberosity osteotomy repairs in this fatigue testing model. When the tendon-to-tendon repair is performed in a horizontal mattress fashion the tendon is shortened. Lesser tuberosity osteotomy repairs seem to have a minimal affect on tendon length. Comments: This study is meaningful only regarding initial changes in length and strength: because it was a cadaver study, no healing could be assessed. In this study, tendon-to-tendon repair seemed better than tendon-to-bone (although the latter may have a higher healing rate. This study seems to support lesser tuberosity osteotomy, in that this technique seems to offer stable length and the healing potential of bone-to-bone repair. Additionally failures of the tendon-to-bone and lesser tuberosity osteotomies were via suture cutting through the bone despite using a cortical augmentation plate. Pearls: The bone and tendons in elderly patients can be poor. This can be made worse with vigorous posterior retraction of the humeral head to expose the glenoid. Care should be taken when exposing the glenoid to avoid crushing the anterior humeral surface and the stump of the subscapularis (if a tenotomy is used). Quantitative analysis of glenoid bone loss in osteoarthritis using three-dimensional computed tomography scans. Scalise JJ, Bryan J, Polster J, Brems JJ, Iannotti JP. J Shoulder Elbow Surg. 2008;17:328-335. Context: Osteoarthritis of the shoulder is commonly associated with posterior glenoid bone loss with accompanying alterations in version. Determination of the amount of bone loss and version is difficult on plain radiographs and two-dimensional (2-D) CT scans owing to patient position and gantry position, respectively. Study Design and Results: Twelve consecutive patients with clinical and radiographic unilateral arthritis had 3-D CT scans performed of both shoulders. Glenoid bone loss was determined using two methods and these were compared. The nonarthritic glenoid was used as a subject-specific template for glenoid volume. The first method used a custom-designed software package in which a vault implant (a virtual glenoid vault) was scaled to fit the endosteal surfaces of the normal glenoid. A best-fit vault model was implanted into the normal glenoid so as to have as few, if any, voxels (similar to pixels in 2-D images) outside the native glenoid. The same was performed with the arthritic glenoid and the number of voxels outside each glenoid was compared and this difference represented the glenoid bone loss. The second method calculated the 3-D volume of right and left glenoids in each subject, and the arthritic and nonarthritic volumes were compared. It was found that the average glenoid bone loss in the arthritic shoulder as determined using the vault implant model was 15.6%. The amount of bone loss determined by comparing the measured volumes was 14.8% with a correlation coefficient of .99 (p < .0001). Conclusions: The vault model (implanting a virtual glenoid vault into a glenoid cavity) can accurately measure the total the amount of glenoid. Comment: Determining how much glenoid bone loss and version to correct is difficult. That the vault model accurately measures the total amount of glenoid bone loss suggests that the virtual glenoid accurately depicts the geometry of the bone loss as well. This virtual glenoid then could serve as a template for reconstruction/augmentation. Pearls: Reaming the high side to balance bone loss can significantly narrow the AP dimension of the glenoid and necessitate a smaller glenoid component and compromise fixation. Also, one must remember that there are compensatory soft tissue adaptations to acquired glenoid bone loss. Thus, giving the patient a “normal” glenoid will not function well, unless the soft tissues are balanced as well Treating the subluxation which often occurs with the bone loss requires not only correcting the osseous problem but the soft tissue must be balanced. Revision shoulder arthroplasty for glenoid component loosening. Cheung EV, Sperling JW, Cofield RH. J Shoulder Elbow Surg. 2008;17:371-375. Context: Glenoid component loosening is the most frequent long-term mode of failure of total shoulder arthroplasty. There have been few studies dedicated to the clinical outcomes of operative treatment in patients with painful glenoid loosening after total shoulder arthroplasty. Furthermore, little is known regarding risk factors for an unsatisfactory result and the rate of failure in this cohort of patients. Study Design and Results: The authors report a retrospective review of a group of 68 patients (mean age, 65 years) with symptomatic loosening of the glenoid component after total shoulder arthroplasty. The patients were divided into two treatment groups based on intraoperative bone loss and the ability to have a stable glenoid component implanted. Treatment consisted of either revision glenoid placement or allograft cancellous bone grafting of the glenoid defect without glenoid placement. Thirty-three patients glenoid revision placement and were for a of whereas patients were with glenoid bone grafting and were for a of of the patients also repair of a There was significant in in both of patients with a glenoid and of patients after glenoid bone grafting had to in of shoulders with glenoids and of shoulders after bone in was seen only with compared with preoperative and there were no in between groups. to the only of shoulders with a glenoid and three of shoulders with grafting had good or Seven patients in each group revision for The for the of revision at were between and respectively. when was as for to glenoid revision failure at the rate of was in the glenoid group compared with the bone grafting group Conclusions: The outcomes of revision for glenoid component loosening in the in and patient but and a high for revision surgery. There is a to a glenoid component when in the revision in of risk for glenoid revision failure and patient Comments: the from this study are the results and are by several study It that the of glenoid bone loss in the groups were which to the to or the may have clinical and radiographic Furthermore, the to or bone was not but based on the of the defect at the of surgery. There were glenoid used in this study a significant of and have of owing to the reported higher rates of loosening. In the of between groups was which may measured Pearls: The results of this study the of patients with a glenoid after total shoulder arthroplasty. it seems that and patient can be with either revision glenoid placement or bone grafting of the glenoid in this which is in patients before surgery. studies are using glenoid and to the clinical and radiographic of revision glenoid placement. patients with shoulder shoulder with total shoulder arthroplasty. J Shoulder Elbow Surg. Context: is a types of shoulder This results in arthritic and Treatment of these patients is by the of the Study Design and Results: The authors retrospectively report on patients with with total shoulder arthroplasty. The of the patients was years) and was performed at a of after of the were for the of patients. of patients had performed for a or repair. In at of the patients had placement of an and of At the of shoulder loss of and changes were was on and results in three shoulders. were positive for in one shoulder significant in to to and were of patients had good or glenoid were seen in three patients and no patient had a shoulder arthroplasty for treatment of clinical results in these patients in the glenoid may Comment: The of be determined from this study the of known risk factors in this The glenoid changes and seen in these patients of glenoid The of in these patients from intraoperative is Pearls: regarding the outcomes for surgical management of are and this clinical outcomes after total shoulder arthroplasty in this study of this cohort is the of glenoid seen with early The results of this study can serve as a other methods of treatment as arthroplasty with or without glenoid as shoulder for or repair, can lead to of and glenoid EV, J Shoulder Elbow Surg. Context: The in long-term total shoulder is glenoid Glenoid in and these regarding may to long-term glenoid Study Design and Results: glenoids were for and the of The study was performed between to and the was only glenoid patient review and a radiographic analysis was performed. of glenoid was performed in to the of and of for surface and was for each of four patient age, arthritis and intraoperative The was significantly for glenoid glenoid had significantly and was in both the with in the group and surface in the no significant difference was on the AP on the the group had more in three glenoid had loosening and on both Conclusions: The of the glenoid component on to in radiographic and were and may to glenoid loosening. Comments: This study, with to has many A with is the low of glenoid in This has to be as well as and glenoid are used in current Furthermore, the of glenoid is often All of the glenoid by the authors for one or and unless one the rate of of each one which is This study only as a of Pearls: A implant has a between the of of the humeral head and glenoid. the of are this is for performing total shoulder The on the are in or and the glenoid implant to the is and seems to be a for long-term and total shoulder arthroplasty for of the humeral S, J Shoulder Elbow Surg. Context: of the shoulder often is with arthroplasty. This study to or total shoulder better and outcomes were Study Design and Results: This was a retrospective cohort study of the patients of four shoulders were for a of There were and with a of The most for was by patients and were with total shoulder arthroplasty The same was used in patient with a in the TSA group Glenoid were and used in of glenoid and were and respectively. was and to of patients were with and patients had compared with patients in the other groups. The average were not significantly between and TSA shoulders. TSA shoulders had but and In the based on and were higher in the group with for There were two in the groups for glenoid whereas there were more in the TSA groups four were for glenoid Conclusions: and TSA good results for patients by humeral head with had the Glenoid was the for total shoulder Comments: Shoulder arthroplasty for to outcomes for of humeral A significant weakness of this study is the of of glenoid for patients compared with with should have a which of the patients with of should have Also, without preoperative be radiographs at the glenoid with and without glenoid be these the of function and is with either Pearls: of the humeral by initially the but with of the head will the glenoid patients with should be clinically and radiographically for glenoid TSA should be for patients with Shoulder Arthroplasty of the glenoid component of a total shoulder J, A, J Shoulder Elbow Surg. Context: of the glenoid component in total shoulder is one of the most with this This has been to several factors and of but few studies have placement. Study Design and Results: Glenoid component was by a that two and two The were to of to normal cancellous bone and were through the humeral component in that the of the humeral component did not the to the were loaded to failure at 30 All failures with with the to the of the load to the from an in failure at N N which by in to the in failure at N N for of each the load was by if the was if either of the were and if the was Conclusions: to failure in bone of the of The load to failure was when loaded to the The seems to be the most when loaded to the Comments: of the patients are which the for good fixation. The of the can it difficult to the in may with the placement. Pearls: placement is and can be difficult in revision There are of the regarding neck the glenoid has a one might to the a little higher to good using an can in the position for the and good placement. in shoulder arthroplasty. J Shoulder Elbow Surg. Context: a of the behind the glenoid has the potential to lead to failure in shoulder arthroplasty. The of the humeral may the neck in This has regarding of the Study Design and Results: and consecutive shoulder were performed in four shoulder were shoulders in patients were retrospectively with clinical and radiographic were for All were performed by a shoulder of the were placed via a approach and the other through a a or was used. also were The postoperative was for patients. AP and were at and at and 3 was to were for on and intraoperative was in of shoulders at had 1 had had and had was in at and at 1 The was seen in patients with and the was in patients with shoulders patients had more than and did not with surgical approach was 3 and initially were most to with was not by the There was no correlation between and There was an correlation with the glenoid implant with higher of Conclusions: In a study, was in a significant number of postoperative shoulders. Yet had no on clinical outcomes to Comments: This study on and that may and clinical The of patients from to as the results are This to in studies regarding to patients at to early but not and with Also, the approach was associated with a of by more placement of the glenoid Pearls: The has as the of and glenoid failure more Design as in and higher more neck may in rates and the of the glenoid seems to be with over must be balanced with the other of the as and that might not have any other surgical The between tuberosity and the of JW, J Shoulder Elbow Surg. Context: rates for more repairs are well in many have that there is an osseous component to this rate. It was in a model that bone loss occurs in a repair model. Study Design and Results: tuberosity were retrospectively calculated for shoulders with using AP were as or to a to the and were or to the of the patients were not statistically The tuberosity (as determined by imaging were significantly more in the more compared with the In of the were than of and of the were than of The had significantly more compared with the group Conclusions: There was significantly tuberosity in the more Comments: results are with the loss of load from the the tuberosity bone and The of tuberosity in the can affect the of bone and bone In this bone may have a ability to Pearls: of the and healing from the the bone is this might significantly affect There might be a for the of in these The of tuberosity in can affect the of bone and bone A of the by and J, R, J Shoulder Elbow Surg. Context: The authors a of shoulder associated with an rupture of the associated with and retraction which to of the Study Design and Results: This is a retrospective review of patients (mean age, years) for evaluation of shoulder who had an to the patients were The authors report a of the clinical and clinical and radiographic for these patients. two patients had a of whereas the patients had in the of whom had a on with of A previous in two patients and of a in three patients in an of of was seen in patients. All patients had on which of the at the of the tendon or the In had in the were on and the tendons were analysis was performed on patients and was normal in patients were with and and surgical repair of the All patients were for a of The from to patients had outcomes as patients the patients had worse an average of There were at compared with the shoulder and was significantly was performed for patients with of the Conclusions: The authors a the with an and the of are risk of in the seen on should the to this clinical outcomes can be with management despite the of with Comments: This study an of the clinical and results of a of a of the The of this problem Pearls: The function with the humeral an is to on be to this integrity and clinical after repair using a study of and A, J, J Shoulder Elbow Surg. Context: This study to the results of Determining healing rates and outcomes are Study Design and Results: This was a study of and repairs performed by one patients the and were for and to patients had and 18 had the and were to and of the also were All patients had with and with a of was A of management in patients. were measured using the with measured using a integrity was measured at 1 year using to was after repair. for a on were repairs were performed in fashion with the patient in the position and Standard releases were performed with repairs when repair with suture was performed to the tuberosity with the at the side and no of repair. The tuberosity was with and placed to the All patients an had a had had and one had a tenotomy. patients a and a from to and at 3 for and for groups had of and of intact in the group of 18 (83%) in the were commonly associated with four of had an and suture repair. Conclusions: repairs lead to outcomes in and to surgical technique and are to had the most healing at Comments: This study for the regarding the of and The of this study are surgical and weakness is the of patients. Pearls: healing suggest an correlation between healing and function. It is to have a good despite tendon failure seen on postoperative imaging and for a J Shoulder Elbow Surg. Context: of the posterior can be difficult to tendon has been for management of in patients with clinical Study Design and Results: The authors report a of patients (mean age, years) with of the posterior with tendon were seen at three times after and and the results were to several revision and of the subscapularis tendon A of patients for as by posterior no normal and no was The clinical results measures of and patient outcomes of arthritis and the from to 68 from to from to from to and from to were seen in revision and the results were seen in patients were as having unsatisfactory results with of to shoulders were was by than of patients at three arthritis and the by 1 as a Conclusions: tendon can be used to manage patients with of the posterior clinical The clinical results and of are more predictable for patients with an posterior an intact no normal and no previous tendon not the of arthritis or humeral Comment: patient patients in the revision and subscapularis groups than in both The authors that the patients for from these groups at and were and had good clinical This significantly the a better clinical Furthermore, the clinical were not performed by which the for Pearls: who more than one of the of a good posterior an intact no normal and no previous should be for shoulder arthroplasty. The of anterior in patients with S, J Shoulder Elbow Surg. Context: The patient with the an at and the anterior may some patients in function. Study Design and Results: elderly patients with an average of were with All patients had and before were with and to changes of in patients. the subscapularis in patients. All patients had which to surgical were before and after the consisted of with through a of the are with the of the to are performed 3 to times for the first The is to the and to a and then The were for and the patients were at and was from to did not from to patients did not significantly a shoulder and the other had an who were good and did not Conclusions: can in the treatment of Comments: This study is The of a in which a shoulder can and be This should a in not only the shoulder but should be an initial for patients with painful associated with a Pearls: patients with intact anterior without or compromise is for an with an Shoulder between and in J Shoulder Elbow Surg. Context: on the are A better of the of may to more regarding and of the shoulder and and may lead to a in to these and subsequently Study Design and Results: The authors used 3-D to are in in the were on from were for each at Hz by for a at to a analysis was used to and for and and to as shoulder or to for of the difference in for a group of can be via changes and to affect The results of the study can be used to on the and can be developed based on these Conclusions: This study that and and that may be for of the difference in in this and may have the ability to changes in to and and the on Comments: This study a to study and to and it may be difficult to changes in position, and without the of a and Pearls: is but is one of many that affect may not or should lead to better
Institution: Tennessee Orthopaedic Clinics
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W4250558412