Cofield, Robert H.

We assessed the clinical results, radiographic outcomes and complications of patients undergoing total shoulder replacement (TSR) for osteoarthritis with concurrent repair of a full-thickness rotator cuff tear. Between 1996 and 2010, 45 of 932 patients (4.8%) undergoing TSR for osteoarthritis underwent rotator cuff repair. The final study group comprised 33 patients with a mean follow-up of 4.7 years (3 months to 13 years). Tears were classified into small (10), medium (14), large (9) or massive (0). On a scale of 1 to 5, pain decreased from a mean of 4.7 to 1.7 (p = < 0.0001), the mean forward elevation improved from 99° to 139° (p = < 0.0001), and the mean external rotation improved from 20° (0° to 75°) to 49° (20° to 80°) (p = < 0.0001). The improvement in elevation was greater in those with a small tear (p = 0.03). Radiographic evidence of instability developed in six patients with medium or large tears, indicating lack of rotator cuff healing. In all, six glenoid components, including one with instability, were radiologically at risk of loosening. Complications were noted in five patients, all with medium or large tears; four of these had symptomatic instability and one sustained a late peri-prosthetic fracture. Four patients (12%) required further surgery, three with instability and one with a peri-prosthetic humeral fracture.Consideration should be given to performing rotator cuff repair for stable shoulders during anatomical TSR, but reverse replacement should be considered for older, less active patients with larger tears.Cite this article: Bone Joint J 2014;96-B:224–8.

Instability after arthroplasty of the shoulder is difficult to correct surgically. Soft-tissue procedures and revision surgery using unconstrained anatomical components are associated with a high rate of failure. The purpose of this study was to determine the results of revision of an unstable anatomical shoulder arthroplasty to a reverse design prosthesis. Between 2004 and 2007, 33 unstable anatomical shoulder arthroplasties were revised to a reverse design. The mean age of the patients was 71 years (53 to 86) and their mean follow-up was 42 months (25 to 71). The mean time to revision was 26 months (4 to 164). Pain scores improved significantly (pre-operative visual analogue scale (VAS) of 7.2 (sd 1.6); most recent VAS 2.2 (sd 1.9); p = 0.001). There was a statistically significant increase in mean active forward elevation from 40.2° (sd 27.3) to 97.0° (sd 36.2) (p = 0.001). There was no significant difference in internal (p = 0.93) or external rotation (p = 0.40). Radiological findings included notching in five shoulders (15%) and heterotopic ossification of the inferior capsular region in three (9%). At the last follow-up 31 shoulders (94%) were stable. The remaining two shoulders dislocated at 2.5 weeks and three months post-operatively, respectively. According to the Neer rating system, there were 13 excellent (40%), ten satisfactory (30%) and ten unsatisfactory results (30%). Revision of hemiarthroplasty or anatomical total shoulder replacement for instability using a reverse design prosthesis gives good short-term results. Cite this article: Bone Joint J 2013;95-B:668–72.

When an ingrown toenail is unresponsive to simple treatment methods, surgical treatment options are available. At our institution, 100 patients with 142 affected toes were surgically treated by one of five techniques and observed for a mean of 9.7 years (range, 7.8 to 10.0 years). Plastic nail wall reduction was effective (four of four nail edges) for mild disease. After marginal nail excision with chemical matrix ablation, the recurrence rate was 20% (12 of 61 nail edges); eight required further surgical treatment. Marginal nail excision combined with surgical excision of the associated nail matrix (Heifetz procedure) was more successful: recurrence occurred in only 6% (6 of 95 nail edges), and only one toe required further surgical treatment. For severe nail deformity, nail ablation with matrix excision (Zadik procedure) was followed by recurrence in 33% (three of nine toes); all three required additional surgical treatment. After terminal amputation (Lapidus/Thompson-Terwilliger procedure), the recurrence rate was 12% (2 of 17 toes); only one nail required additional surgical treatment.

Forty-one patients with 42 involved feet received local care for neuropathic foot disease. Thirty-one patients had ulcers (nine with associated fractures), and 10 did not (eight with fracture and two with severe ligamentous injury). Patients were examined at least 1 year after initiation of treatment, and follow-up averaged 3 years (range, 1 to 9). Treatment included ulcer cleansing, debridement, local bone excision, molded plaster casts, and antibiotics for patients with significant infection. Most patients used special shoes. Of the 42 involved extremities, 39 (93%) healed with treatment, 21 extremities (50%) remained healed at follow-up examination, and 16 patients (39%) continue to have difficulty with recurrent foot ulceration or osteoarthropathy. Thirty-nine patients (95%) have avoided the need for a major amputation.

The diagnosis of diabetic neuroarthropathy of the foot can be difficult. A series of 96 patients (116 extremities) who had diabetes and peripheral neuropathy with bone and joint changes was reviewed. Typically, the patients were middle-aged or older, were taking insulin, and had had diabetes for more than 10 years. Retinopathy, nephropathy, and peripheral vascular disease were often present. There were abnormalities of vibratory sensation (94%) and of the gastrosoleus reflex (88%). The finding of specific radiographic abnormalities assisted but did not reliably differentiate neuropathy from infection. Three patterns of radiographic changes were noted: (1) at the metatarsophalangeal and interphalangeal joints, usually with underlying ulceration; (2) at the tarsometatarsal joints; and (3) in the anterior pillar-medial column of the foot, with talus, talonavicular, navicular, or naviculocuneiform destruction. Ulceration and infection in patients with patterns (2) and (3) were rare. When correlated, the demographic features, mode of presentation, physical signs, specific radiographic abnormalities, and patterns of change were distinctive and allowed the diagnosis of this complication of diabetes to be readily made.

Our objective was to examine the rate of revision and its predictive factors in patients undergoing total shoulder arthroplasty (TSA). We used prospectively collected data from the Mayo Clinic Total Joint Registry to examine five-, ten- and 20-year revision-free survival following TSA and the predictive factors. We examined patient characteristics (age, gender, body mass index, comorbidity), implant fixation (cemented versus uncemented), American Society of Anesthesiologists class and underlying diagnosis. Univariate and multivariable adjusted hazard rates were calculated using Cox regression analysis. A total of 2207 patients underwent 2588 TSAs. Their mean age was 65.0 years (19 to 91) and 1163 (53%) were women; osteoarthritis was the underlying diagnosis in 1640 shoulders (63%). In all, 212 TSAs (8.2%) were revised during the follow-up period. At five, ten and 20 years, survival rates were 94.2% (95% confidence interval (CI) 93.2 to 95.3), 90.2% (95% CI 88.7 to 91.7) and 81.4% (95% CI 78.4 to 84.5), respectively. In multivariable analyses men had a higher hazard ratio of revision of 1.72 (95% CI 1.28 to 2.31) (p < 0.01) compared with women, and those with rotator cuff disease had a hazard ratio of 4.71 (95% CI 2.09 to 10.59) (p < 0.001) compared with patients with rheumatoid arthritis. We concluded that male gender and rotator cuff disease are independent risk factors for revision after TSA. Future studies are needed to understand the biological rationale for these differences.

Purpose The purposes of this study was to better understand the utilization of anterior acromioplasty over time, in the absence of rotator cuff repair; to examine the relation to patient characteristics (age, sex) and types of rotator cuff pathology (inflammation or fibrosis, partial‐thickness tearing, full‐thickness tearing undergoing debridement); and to assess the utilization of arthroscopy in this procedure. Methods Using the resources of the Rochester Epidemiology Project, cataloging medical records of residents in Olmsted County, Minnesota, we identified 246 patients who underwent anterior acromioplasty between 1980 and 2005. It has previously been shown that rarely does a resident of Olmsted County undergo an orthopaedic procedure at a facility outside the county. Results The incidence of anterior acromioplasty increased over time ( P < .001), with crude rates of 3.3 per 100,000 persons in 1980 to 1985 and 19.0 per 100,000 persons in 2000 to 2005. Sex, age, and types of rotator cuff pathology did not significantly change over the 26‐year period. There was a dramatic shift from use of the open approach to the arthroscopic approach over this time period ( P < .001) and a decrease in the concomitant performance of distal clavicle resection ( P < .001). Conclusions The frequency of anterior acromioplasty has dramatically increased over time. Increasing knowledge about this syndrome, including better imaging, has facilitated patient treatment for a stable spectrum of rotator cuff pathology (inflammation or fibrosis, partial‐thickness tearing, full‐thickness tearing undergoing debridement), as has the application of endoscopic surgery. Level of Evidence Level III, epidemiologic study.

This study was performed to review the safety and outcome of total shoulder replacements in patients who are ≥ 80 years of age. A total of 50 total shoulder replacements in 44 patients at a mean age of 82 years (80 to 89) were studied. Their health and shoulder status, the operation and post-operative course were analysed, including pain, movement, patient satisfaction, medical and surgical complications, radiographs, the need for revision surgery, and implant and patient survival. A total of 27 patients had an ASA classification of III or IV and medical abnormalities were common. Of the 13 shoulders with bony deficiency of the glenoid, nine required grafting. The duration of hospital stay was prolonged and blood transfusions were common. There were no peri-operative deaths. The mean follow-up was for 5.5 years (2 to 12). Pain was significantly reduced (p < 0.001) and movement improved in active elevation and both external and internal rotation (p < 0.001). Using the Neer scale for assessing outcome, 40 (80%) shoulders had an excellent or satisfactory result. There were medical or surgical complications in 17 cases. Four shoulders developed radiological evidence of loosened glenoid components, and three of these had a poor outcome. Three other shoulders required revision, two for instability. By the time of this review 39 of the patients had died from unrelated causes at a mean of 7.5 years (0.8 to 16.4) after surgery. Total shoulder replacement is a relatively effective treatment in this elderly group of patients. However, there is a requirement for more intense patient care in the peri-operative period, and non-fatal medical or surgical complications are common. Most of these elderly patients will have a comfortable functional shoulder for the rest of their lives.

Background Tightness of the posteroinferior capsule is assumed to be the cause of internal rotation loss in baseball pitchers. Although the relationship between posterior capsule and subacromial impingement has been recognized, this relationship during the baseball-pitching motion is unclear. Hypothesis Contact pressure during baseball-pitching motion increases with posterior capsule tightness. Study Design Controlled laboratory study. Methods Eight fresh-frozen shoulders were used. The peak contact pressure and area on the coracoacromial arch were measured on a custom-designed shoulder experimental device capable of 6 degrees of freedom motion. Simultaneously, the sites of peak pressure on the coracoacromial arch and humerus were observed from various angles. The posteroinferior capsule tightness was simulated by plicating the capsule in the region from 6 to 8 o'clock. The static testing positions correlated to the early cocking, late cocking, acceleration, deceleration, and follow-through phases of the pitching motion. Results The peak contact pressure during the follow-through phase (0.63 ± 0.50 MPa) significantly increased with posteroinferior capsule tightness (1.00 ± 0.65 MPa) (P = .014). Additionally, the contact area on the coracoacromial ligament during the follow-through phase (0.98 ± 0.67 cm2) significantly increased with posteroinferior capsule tightness (1.47 ± 0.91 cm 2) (P < .001). The site of the peak contact pressure did not change between the 2 conditions. Conclusion Our findings demonstrate that posteroinferior capsule tightness leads to higher contact pressure under the subacromial arch and increased contact area, particularly on the coracoacromial ligament during the follow-through phase. Clinical Relevance This tightness may affect risk of injury of the rotator cuff and its surrounding tissues by increasing subacromial contact during pitching.