Cofield, Robert H.

Purpose: To compare the outcomes of total shoulder arthroplasty (TSA) with posterior capsule plication (PCP) and reverse shoulder arthroplasty (RSA) in patients with primary osteoarthritis, posterior subluxation, and bone loss (Walch B2). Patients and methods: All shoulders undergoing anatomic TSA with PCP were retrospectively identified (group 1, G1) and compared to shoulders undergoing RSA (group 2, G2) for Walch B2 osteoarthritis. There were 15 patients in G1 (mean (SD) age and follow-up of 70.5 (7.5) years and 42.8 (18.4) months, respectively) and 16 patients in G2 (mean (SD) age and follow-up of 72.6 (5.4) years and 35.1 (14.2) months, respectively). Results: Both groups had substantial improvements in pain and function. In G1, results were excellent in 80% and satisfactory in 20%, compared to 81% and 6% in G2, respectively ( p = 0.2). The mean (SD) American Shoulder and Elbow Surgeons score was 91.2 (6.7) and 80.3 (14.3) in G1 and G2, respectively ( p = 0.08). The mean Simple Shoulder Test score was 10.6 in G1 and 8.5 in G2 ( p = 0.01). There were no reoperations in either group, but G1 had seven postoperative complications. Conclusions: The outcomes of TSA with PCP are comparable to RSA in patients with osteoarthritis and biconcave glenoids. However, TSA leads to more complications while RSA leads to lower functional outcomes.

Background: Glenohumeral arthrodesis is associated with a high rate of complications. Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. The purpose of this study was to examine the clinical outcomes of glenohumeral arthrodesis. Methods: Twenty-nine patients with 29 affected shoulders underwent primary glenohumeral arthrodesis between 1992 and 2009. Surgical indications included rotator cuff arthropathy and pseudoparalysis (n = 7), neurologic injuries (n = 12), chronic infection (n = 3), recurrent dislocations (n = 3), and proximal humeral or shoulder girdle tumors (n = 4). Surgical fixation techniques included plates and screws in 18 patients and screws only in 11 patients. Results: All patients were examined, with a mean follow-up of 12 years (range, 2 to 22 years). Twelve patients (41%) had postoperative complications, including 6 periprosthetic fractures, 7 nonunions, and 3 infections. Eleven patients (38%) required additional surgical procedures after arthrodesis, including revision internal fixation to achieve glenohumeral fusion after nonunions (n = 7), irrigation and debridement with antibiotic treatment for deep infections (n = 2), open reduction and internal fixation to treat fracture (n = 2), and implant removal to treat symptomatic patients (n = 3). Patients experienced reasonable overall pain relief. The mean postoperative scores were 35 points for the Subjective Shoulder Value, 58 points for the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and 54 points for the Short Form-36. Eighty-seven percent of patients reported postoperative limitations. Patients with neurologic injuries had worse functional outcomes, and an arthrodesis position of ≥25° yielded better functional outcomes. Conclusions: Glenohumeral arthrodesis is associated with a high rate of patients with complications (41%). Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Thirty patients with unilateral, traumatic recurrent anterior instability were assessed by examination under anesthesia of both shoulders in the anterior, anteroinferior, inferior, posterior, and posteroinferior directions while the examiner controlled the patients' arm rotation. There were significant side-to-side differences in humeral head translation, depending on arm rotation. Humeral head translation was significantly greater in the abnormal shoulder only in the anteroinferior direction with 40° and 80° of external rotation of the arm. Defining an “abnormal” examination as grade 3 translation (translation of the humeral head up onto the glenoid rim) or grade 4 translation (translation of the humeral head over the glenoid rim, that is, dislocated) and translation two grades greater than the contralateral uninjured side, the test sensitivity was 83%, and the test specificity was 100%. Assessing humeral head translation by examination under anesthesia is a useful adjunct to the diagnostic tools for shoulder instability, but the number of tests should be expanded to include the anteroinferior and posteroinferior directions, and the tests should be done with the arm in varying degrees of rotation.

Background Proper soft tissue balance is paramount to maintaining stability and a functional arc of motion in shoulder arthroplasty but is impaired in patients with prior glenohumeral (GH) dislocations. The purpose of this study was to determine the clinical outcomes, revisions, and complications of reverse shoulder arthroplasty (RSA) in patients with a history of glenohumeral dislocation. Methods Twenty-four patients with a history of GH dislocations that developed arthropathy underwent primary RSA from 2007 to 2013 were retrospectively reviewed. Mean follow-up was 3.3 years (2–7 years). Mean age was 70 years. Eight patients (33%) and 7 patients (29%) had complete or partial subscapularis deficiency, respectively. Results Twenty-two patients (92%) had little to no pain at final follow-up. Mean shoulder elevation improved from 48° to 120° ( P < .001) and mean external rotation increased from 13.2° to 48° ( P < .001). There were trends toward less complete pain relief and poorer motion in those with complete subscapularis deficiency. None of the patients experienced a postoperative dislocation or evidence of glenoid loosening at final radiographic follow-up, but 1 patient (4.2%) underwent early revision to a hemiarthroplasty for glenoid loosening. Conclusion RSA provides patients with prior glenohumeral dislocations a stable, pain-free arc of motion. Postoperative instability was not identified as a major failure mode at short-term follow-up. Complete subscapularis deficiency is a risk factor for poorer clinical outcome.

Background: Although obesity is associated with increased complication rates after lower-extremity arthroplasty, there is a relative paucity of studies examining the effect of body mass index (BMI) on shoulder arthroplasty. The purpose of this investigation was to evaluate the effect of BMI on implant survival and the rate of complications after shoulder arthroplasty. Methods: Using an institutional total joint registry, 4,567 consecutive shoulder arthroplasty cases from 1970 to 2013 were studied. The mean BMI was 29.7 kg/m 2 (range, 14 to 66 kg/m 2 ), with 1,622 patients (36%) with a BMI of 30 to 40 kg/m 2 and 297 patients (7%) with a BMI of >40 kg/m 2 . There were 2,493 female patients (55%). BMI was dichotomized after examination of the smoothing spline curve. The associations of factors and complications were assessed using Cox proportional hazard regression analysis. Results: Increasing BMI was associated with an increased risk of a revision surgical procedure, reoperation, revision for mechanical failure, and superficial infection, and it was negatively associated with risk of a periprosthetic fracture. The risk of a revision surgical procedure increased in a linear fashion with increasing BMI (hazard ratio [HR], 1.05, or a 5% increased risk per 1 unit of BMI; p = 0.03). Increased BMI was also associated with an increased risk of revision for mechanical failure (HR, 1.05; p = 0.004). In a multivariate model, the association of BMI and risk of a revision for any reason, revision for mechanical failure, and reoperation maintained significance (p ≤ 0.02). The most marked association between increasing BMI and any complication in shoulder arthroplasty was its association with superficial wound infection (HR, 1.09; p = 0.03). Conclusions: Increasing BMI is strongly associated with increased rates of revision surgical procedures and postoperative complications after shoulder arthroplasty. It is important to consider these findings when counseling patients, estimating risks, and estimating complication risks in policy decisions. Level of Evidence: Prognostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Aims In the initial development of total shoulder arthroplasty (TSA), the humeral component was usually fixed with cement. Cementless components were subsequently introduced. The aim of this study was to compare the long-term outcome of cemented and cementless humeral components in arthroplasty of the shoulder. Patients and Methods All patients who underwent primary arthroplasty of the shoulder at our institution between 1970 and 2012 were included in the study. There were 4636 patients with 1167 cemented humeral components and 3469 cementless components. Patients with the two types of fixation were matched for nine different covariates using a propensity score analysis. A total of 551 well-balanced pairs of patients with cemented and cementless components were available after matching for comparison of the outcomes. The clinical outcomes which were analysed included loosening of the humeral component determined at revision surgery, periprosthetic fractures, post-operative infection and operating time. Results The overall five-, ten-, 15- and 20-year rates of survival were 98.9%, 97.2%, 95.5%, and 94.4%, respectively. Survival without loosening at 20 years was 98% for cemented components and 92.4% for cementless components. After propensity score matching including fixation as determined by the design of the component, humeral loosening was also found to be significantly higher in the cementless group. Survival without humeral loosening at 20 years was 98.7% for cemented components and 91.0% for cementless components. There was no significant difference in the risk of intra- or post-operative fracture. The rate of survival without deep infection and the mean operating time were significantly higher in the cemented group. Conclusion Both types of fixation give rates of long-term survival of > 90%. Cemented components have better rates of survival without loosening but this should be weighed against increased operating time and the risk of bony destruction of the proximal humerus at the time of revision of a cemented humeral component. Cite this article: Bone Joint J 2017;99-B:666–73.

Background Dislocation is a challenging complication after reverse shoulder arthroplasty (RSA). We sought to evaluate the outcome of nonoperative and operative management of the dislocation after primary and revision RSA. Methods Between 2006 and 2013, dislocation occurred in 12/1081 primary RSAs (1.1%) and 15/342 revision RSAs (4.4%). Seventeen (69%) shoulders dislocated within 3 months of surgery. Ten (68%) patients underwent revision RSA for prosthetic instability. Mean age was 69 years, and mean follow-up after index RSA was 4 years. Results Closed reduction and bracing achieved a stable shoulder in 60% (3/5 patients) after primary and 20% (1/5 patients) after revision RSA dislocation. Operative management achieved a stable shoulder in 88% (7/8 patients) of primary and 64% (7/11 patients) of revision RSAs ( P = .40). Overall, 9 shoulders (33%) had persistent instability at the final follow-up: 2/12 (17%) primaries versus 7/15 (47%) revisions ( P = .08). Preoperative prosthetic instability was the main risk factor for chronic instability in the revision cohort ( P = .02). Worse functional outcomes were associated with the dislocation of a revision RSA ( P = .02). Conclusion After primary RSA dislocations, closed reduction is successful in half, while revision surgery is successful in 85% of cases. Conversely, closed reduction of a dislocated revision RSA is rarely successful, while revision surgery is successful 65% of the time. Every attempt should be made to achieve stability at the time of primary and revision RSA, since reduction or revision surgery does not guarantee the restoring stability.

Abstract The reported rate of complications of reverse shoulder arthroplasty (RSA) seems to be higher than the complication rate of anatomical total shoulder arthroplasty. The reported overall complication rate of primary RSA is approximately 15%; when RSA is used in the revision setting, the complication rate may approach 40%. The most common complications of RSA include instability, infection, notching, loosening, nerve injury, acromial and scapular spine fractures, intra-operative fractures and component disengagement. Careful attention to implant design and surgical technique, including implantation of components in the correct version and height, selection of the best glenosphere-humeral bearing match, avoidance of impingement, and adequate management of the soft tissues will hopefully translate in a decreasing number of complications in the future. Cite this article: Barco R, Savvidou OD, Sperling JW, Sanchez-Sotelo J, Cofield RH. Complications in reverse shoulder arthroplasty. EFORT Open Rev 2016;1:72-80. DOI: 10.1302/2058-5241.1.160003.

Abstract In rheumatoid arthritis (RA), tissue-infiltrating lymphocytes can be arranged in sophisticated organizations that resemble microstructures usually formed in secondary lymphoid organs. Molecular pathways and host risk factors involved in this process of lymphoid neogenesis remain to be defined. In a series of 64 synovial tissue biopsies, lymphoid follicles with germinal centers (GCs) were found in 23.4% of the patients. Follicular dendritic cells (FDCs) were exclusively present in tissues with GCs, suggesting that the recruitment or in situ maturation of FDCs is a critical factor for GC formation in the synovial membrane. Primary follicles were absent, emphasizing the role of Ag recognition in the generation of inflammation-associated lymphoid organogenesis. Multivariate logistic regression analysis of tissue cytokines and chemokines identified two parameters, in situ transcription of lymphotoxin (LT)-β and of B lymphocyte chemoattractant (BLC; BLC/CXCL13), that were predictors for FDC recruitment and synovial GC formation. LT-β and BLC/CXCL13 were found to be independent variables that could, in part, compensate for each other to facilitate GC formation. Prediction models incorporating in situ transcription of LT-β and BLC/CXCL13 had high negative yet moderate positive predictive values, suggesting that LT-β and BLC/CXCL13 are necessary but not sufficient. LT-β protein was detected on a subset of mantle zone and GC B cells, but also on T cells in follicular structures. BLC/CXCL13 was produced by FDCs in follicular centers, but was predominantly found in endothelial cells and synovial fibroblasts, suggesting heterotypic signaling between cells of the synovial membrane and infiltrating lymphocytes in regulating extranodal lymphoid neogenesis.