Cofield, Robert H.

Purpose Our purpose was to evaluate the distance from the bony edge of the glenoid to the visible (or macroscopic) demarcation at the junction of the labrum and the articular cartilage. Methods Ten fresh‐frozen cadaveric upper extremity specimens were dissected. The shoulder was disarticulated and periarticular structures were removed, leaving the glenoid with the labrum attached. The macroscopic edge of the glenoid was then marked with a drill at the 3‐, 4‐, 5‐, 6‐, 7, 8‐, and 9‐o'clock positions, as defined by a clock face (right) and a reverse clock face (left). Soft tissue and cartilage were then removed, and the distance from the outer edge of the drill hole to the bony rim was measured. Results The mean distance from the bony edge in hourly intervals starting at the 3‐o'clock position anteriorly and extending to the 9‐o'clock position posteriorly was 4.03 mm (range, 2.1 to 5.21 mm; SD, 0.96 mm), 4.2 mm (range, 2.1 to 5.31 mm; SD, 0.97 mm), 4.51 mm (range, 3.1 to 5.2 mm; SD, 0.91 mm), 5.14 mm (range, 3.1 to 7 mm; SD, 1.38 mm), 3.24 mm (range, 1.1 to 5.2 mm; SD, 1.4 mm), 3.78 mm (range, 1 to 6 mm; SD, 1.6 mm), and 4.28 mm (range, 2.1 to 7.3 mm; SD, 1.51 mm), respectively. A trend was noted for significant differences between locations, but this did not reach statistical significance (analysis of variance, P = .086). Conclusions The macroscopic edge of the labrum on the glenoid face does not correspond to the bony edge of the glenoid. The labrum overlaps onto the bony surface of the glenoid from a minimum of 1.6 mm to a maximum of 7.3 mm. Clinical Relevance Our findings provide anatomic data that enhances the arthroscopist's ability to anatomically reconstruct the glenoid labrum.

ABSTRACT We recently described a sonication technique for the diagnosis of prosthetic knee and hip infections. We compared periprosthetic tissue culture to implant sonication followed by sonicate fluid culture for the diagnosis of prosthetic shoulder infection. One hundred thirty-six patients undergoing arthroplasty revision or resection were studied; 33 had definite prosthetic shoulder infections and 2 had probable prosthetic shoulder infections. Sonicate fluid culture was more sensitive than periprosthetic tissue culture for the detection of definite prosthetic shoulder infection (66.7 and 54.5%, respectively; P = 0.046). The specificities were similar (98.0% and 95.1%, respectively; P = 0.26). Propionibacterium acnes was the commonest species detected among culture-positive definite prosthetic shoulder infection cases by periprosthetic tissue culture (38.9%) and sonicate fluid culture (40.9%). All subjects from whom P. acnes was isolated from sonicate fluid were male. We conclude that sonicate fluid culture is useful for the diagnosis of prosthetic shoulder infection.

Between 1976 and 2004, 38 revision arthroplasties (35 patients) were performed for aseptic loosening of the humeral component. The mean interval from primary arthroplasty to revision was 7.1 years (0.4 to 16.6). A total of 35 shoulders (32 patients) were available for review at a mean follow-up of seven years (2 to 19.3). Pre-operatively, 34 patients (97%) had moderate or severe pain; at final follow-up, 29 (83%) had no or only mild pain (p < 0.0001). The mean active abduction improved from 88° to 107° (p < 0.01); and the mean external rotation from 37° to 46° (p = 0.27). Excellent or satisfactory results were achieved in 25 patients (71%) according to the modified Neer rating system. Humeral components were cemented in 29, with ingrowth implants used in nine cases. There were 19 of standard length and 17 were longer (two were custom replacements and are not included). Bone grafting was required for defects in 11 humeri. Only two glenoid components were left unrevised. Intra-operative complications included cement extrusion in eight cases, fracture of the shaft of the humerus is two and of the tuberosity in four. There were four re-operations, one for recurrent humeral loosening, with 89% survival free of re-operations at ten years. Revision surgery for aseptic loosening of the humeral component provides reliable pain relief and modest improvement of movement, although there is a substantial risk of intra-operative complications. Revision to a total shoulder replacement gives better results than to a hemiarthroplasty.

While frequently discussed as a standard treatment for the management of an infected shoulder replacement, there is little information on the outcome of two-stage re-implantation. We examined the outcome of 17 consecutive patients (19 shoulders) who were treated between 1995 and 2004 with a two-stage re-implantation for the treatment of a deep-infection after shoulder replacement. All 19 shoulders were followed for a minimum of two years or until the time of further revision surgery. The mean clinical follow-up was for 35 months (24 to 80). The mean radiological follow-up was 27 months (7 to 80). There were two excellent results, four satisfactory and 13 unsatisfactory. In 12 of the 19 shoulders (63%) infection was considered to be eradicated. The mean pain score improved from 4.2 (3 to 5 (out of 5)) to 1.8 (1 to 4). The mean elevation improved from 42° (0° to 140°) to 89° (0° to 165°), mean external rotation from 30° (0° to 90°) to 43° (0° to 90°), and mean internal rotation from the sacrum to L5. There were 14 complications. Our study suggests that two-stage re-implantation for an infected shoulder replacement is associated with a high rate of unsatisfactory results, marginal success at eradicating infection and a high complication rate.

We have examined the relief from pain and the functional outcome in 18 patients who underwent resection arthroplasty of the shoulder as a salvage operation between 1988 and 2002. The indications included failed shoulder replacement in 17, with infection in 13, and chronic septic arthritis in one. The mean follow-up was 8.3 years (2.5 to 16.6). Two intra-operative fractures of the humerus occurred, both of which healed. The level of pain was significantly decreased (t-test, p < 0.001) but five patients continued to have moderate to severe pain. The mean active elevation was 70° (0° to 150°) postoperatively and represented an improvement from 39° (0° to 140°) (t-test, p = 0.003), but internal and external rotation were hardly changed. The mean number of positive answers on the 12-question Simple Shoulder Test was 3.1 (0 to 12) but the shoulder was generally comfortable when the arm was positioned at rest by the side. The mean post-operative American Shoulder and Elbow Surgeon’s score was 36 (8 to 73). Despite applying this procedure principally to failed shoulder replacements, the results were similar to those reported in the literature for patients after severe fracture-dislocation. Reduction of pain is possible in one half to two-thirds of patients. The outcome of this operation in providing relief from pain cannot be guaranteed, but the shoulder is usually comfortable at rest, albeit with profound functional limitations.

All patients treated for a first-time anterior glenohumeral dislocation in Olmsted County, Minnesota, from 1970 through 1979 were identified. Of these 124 patients, 116 were available for study at a mean followup of 4.63 years (range 2 to 11). Of the 116 patients, 38 (33%) had recurrence of dislocation: 21 of the 32 (66%) pa tients less than 20 years old,17 of the 43 (40%) patients 20 through 40 years old, and none of the 41 patients older than 40 years. Symptomatic instability remained a problem in 24 patients. Twenty-seven of 33 (82%) young athletes had recurrence of dislocation as com pared with only 8 of 27 (30%) nonathletes of similar ages. Patients restricted from resuming sports partici pation for 6 weeks or more had significantly better results than those restricted for less than 6 weeks. The recurrence rate of dislocation is not as high as previously reported. However, the rate in athletes is much higher than that in nonathletes. Many patients continue to complain of symptomatic instability without actual redislocation. In our younger patients, we now advise immobilization for from 3 to 6 weeks, followed by extensive rehabilitation before return to athletic ac tivity.

Purpose There has been a significant increase in surgeon as well as patient interest in arthroscopic treatment of shoulder pathology. We hypothesize that patients have a strong preference for arthroscopic shoulder surgery. Currently, there are no data in the literature reporting on how people perceive open versus arthroscopic shoulder surgery. Methods Prospectively, a total of 202 patients were administered a questionnaire at the offices of 2 fellowship‐trained shoulder surgeons, 1 located at a tertiary referral center (center A) and 1 in private practice (center B). The questionnaire asked a series of questions about specific factors when choosing an orthopaedic surgeon and the preference for arthroscopic or open surgery. In addition, 7 short‐term and long‐term outcomes were listed, and the patient was asked to choose whether open or arthroscopic surgery would provide the best outcome or whether he or she felt that there was no difference. Results Among patients at center A, 88% would prefer arthroscopy if they were to have shoulder surgery, as would 96% of patients at center B. Among patients at center A, 14% would avoid shoulder surgery if the only option was open surgery, as would 25% at center B. The reputation of the surgeon and institution were the primary factors in choosing a surgeon. Recommendation of a former patient and years of surgeon experience were less important factors for patient selection of a shoulder surgeon. Conclusions The study shows that the vast majority of patients perceive multiple advantages of arthroscopic shoulder surgery despite a lack of published data to support many of these assumptions, particularly with regard to expected functional outcome of arthroscopic versus open shoulder surgery. Clinical Relevance Shoulder surgeons should be aware of these perceptions when discussing treatment options with patients. A continued effort should be made to emphasize known scientific data when considering the relative risks and benefits of arthroscopic and open shoulder surgery.

Purpose Currently, there is little information available concerning the results of shoulder synovectomy in patients with rheumatoid arthritis. Furthermore, it remains difficult to assess the success of shoulder synovectomy because of a high association of rotator cuff tears in rheumatoid patients. We hypothesized that synovectomy in patients with a functionally intact rotator cuff would provide durable pain relief. Type of Study Case series. Methods Sixteen shoulders in 13 patients with rheumatoid arthritis were treated with arthroscopic shoulder synovectomy from 1988 to 2002 with a mean follow‐up of 5.5 years. Patients with full‐thickness rotator cuff tears or partial tears that required repair were excluded. Two of the 13 patients had been diagnosed with juvenile rheumatoid arthritis and 11 had adult‐onset disease. The medical records of the patients were reviewed and patients were assessed clinically and by questionnaire to assess pain, satisfaction, range of motion, radiographic outcomes, and occurrence of complications. Results There was an improvement in pain at long‐term follow‐up in 13 of 16 patients ( P < .001). Active shoulder elevation improved from a median of 145° to 160° but was not significant ( P = .14). External rotation improved significantly ( P = .01) from a median of 45° (range, 0° to 90°) to 60° (range, 0° to 100°). According to the Neer rating system, there were 5 excellent, 8 satisfactory, and 3 unsatisfactory results. Seven of 8 shoulders followed‐up radiographically for more than 1 year showed radiographic progression of disease. All 3 patients reporting pain that was no better or worse than before surgery had radiographic arthrosis at last follow‐up with advancing periarticular erosions and reduction of glenoid articular space. Conclusions Arthroscopic synovectomy of the shoulder in patients with rheumatoid arthritis with an intact rotator cuff offers a reliable decrease in pain with less predictable improvements in range of motion. Limitations in predicting final results based on preoperative radiographs should be discussed with patients; those with more advanced radiographic changes may not benefit from the procedure. Level of Evidence Level IV, therapeutic study, case series, no control group.

There are theoretical and practical advantages to modular rather than monoblock designs of prostheses for shoulder arthroplasty, but there are no reported studies which specifically compare the clinical and radiological results of their use. We have compared the results of unconstrained total shoulder arthroplasty for osteoarthritis using both types of implant. The monoblock design was used between 1992 and 1995 and the modular design after 1995. Both had cemented all-polyethylene glenoids, the monoblock with matched and the modular with mismatched radii of curvature. There were 34 consecutive shoulders in each group with a mean follow-up of 6.1 years in the first and 5.2 years in the second. There were no significant differences in improvement of pain scores, active elevation, external rotation, internal rotation, patient satisfaction, or the Neer ratings between the two groups. Two of 28 glenoid components in the first group and six of 30 in the second met the criteria for being radiologically at risk for loosening (p = 0.25). There were no significant differences in clinical outcome or radiological changes between the first- and second-generation designs of implant for shoulder arthroplasty.