Arthroscopic extra-articular Bankart procedure

The arthroscopic extraarticular Bankart procedure tries to imitate the open Bankart procedure. An anterior-inferior transmuscular approach through the subscapular muscle permits to implant self-locking tacks into the anterior inferior third of the glenoid rim. The extraarticular location of the implants makes a superomedial capsular shift possible, if required. A total of 257 arthroscopic repairs following traumatic recurrent anterior shoulder dislocation have been carried out between 1992 and 1996. 177 patients were treated only with bioabsorbable Suretac device. Clinical and radiological follow up was possible in 165 patients. According to the Rowe score 69.7% were classified as excellent, 10.9% as good, 9.7% fair and 9.7% poor. Postoperative complications: the recurrence rate was 9.7%, allergic reactions representing a foreign body reaction to the synthetic material were seen in 5 cases (3%) and a frozen shoulder in 6 cases 3.6%). 61% of the patients involved in overhead or contact sports returned to their preoperative sport activities.     

Capsulorrhaphy through an anterior approach for the treatment of atraumatic posterior glenohumeral instability with multidirectional laxity of the shoulder

Between June 1983 and March 1992, we performed a capsular reconstruction procedure through an anterior approach in ten patients (ten shoulders) who had multidirectional laxity of the shoulder and symptomatic atraumatic posterior glenohumeral instability. The procedure included closure of the capsule in the rotator interval and imbrication of the anterior, inferior, and posteroinferior aspects of the capsule by a double-breasting technique that decreases the overall capsular volume. The mean duration of follow-up was sixty months (range, twenty-four to 103 months). According to the system of Rowe and Zarins, the result was graded as excellent for five shoulders, good for four, and poor for one. On the basis of our results, we recommend capsular reconstruction through an anterior approach only in patients who have persistent multidirectional laxity and symptomatic atraumatic posterior instability of the shoulder despite participation in an intensive rehabilitation program.     

Cytotoxicity of tocopherols and their quinones in drug-sensitive and multidrug-resistant leukemia cells

Eighty-two patients with traumatic anterior shoulder instability were treated with an arthroscopic transglenoid multiple suture technique (Caspari's method) and followed-up for more than 2 years. A retrospective analysis of the clinical outcome was performed to determine the factors related to poor results. The mean age at operation was 21 years (range, 13 to 50 years) and the mean follow-up period was 40 months (range, 24 to 70 months). According to the status of the ligament-labrum complex and the glenoid bone defect, the Bankart lesions were classified into five types arthroscopically. There were 21 shoulders of type 1, 33 shoulders of type 2, 22 shoulders of type 3, and 6 shoulders of type 5. Twenty-four of the patients played contact sports before the operation. The clinical outcome was assessed by Rowe's criteria (1978). To analyze the factors related to a poor outcome, a multivariate analysis was done to assess the influence of 12 clinical factors (age at operation, age at first dislocation, sex, dominant side, disease duration, number of dislocations, sporting activity before operation, inferior joint laxity, thickness of the ligament-labrum complex, type of Bankart lesion, number of sutures, and method of suture fixation). Fifty-five of 82 patients had an excellent outcome, 14 had a good result, and 13 had a poor result. According to postoperative instability, redislocation was seen in 13 patients (16%), resubluxation in 2 patients (2%), with a recurrence rate of 18%. The mean limitation of external rotation at 90 degrees abduction was 6.0 degrees (range, 0 degrees to 30 degrees), and there was a 10 degrees loss of external rotation in 10 patients. The factors significantly related to recurrence were a type 3 Bankart lesion, playing contact sports preoperatively, a thin ligament-labrum complex, and repair with less than four sutures. In conclusion, a 18% rate of recurrence is not acceptable. To obtain a better clinical outcome, very careful selection of patients for this technique is necessary. Our analysis of the factors related to a poor outcome may help to decide what the proper indications are for this technique.     

Stabilising function of the biceps in stable and unstable shoulders

We studied the contributions of the long and short heads of the biceps (LHB, SHB) to anterior stability in 13 cadaver shoulders. The LHB and SHB were replaced by spring devices and translation tests at 90 degrees abduction of the arm were performed by applying a 1.5 kg anterior force. The position of the humeral head was monitored by an electromagnetic tracking device with or without an anterior translational force; with 0 kg, 1.5 kg or 3 kg loads applied on either LHB or SHB tendons in 60 degrees, 90 degrees or 120 degrees of external rotation; and with the capsule intact, vented, or damaged by a Bankart lesion. The anterior displacement of the humeral head under 1.5 kg force was significantly decreased by both the LHB and SHB loading in all capsular conditions when the arm was in 60 degrees or 90 degrees of external rotation. At 120 degrees of external rotation, anterior displacement was significantly decreased by LHB and SHB loading only when there was a Bankart lesion. We conclude that LHB and SHB have similar functions as anterior stabilizers of the glenohumeral joint with the arm in abduction and external rotation, and that their role increases as shoulder stability decreases. Both heads of the biceps have been shown to have a stabilising function in resisting anterior head displacement, and consideration should therefore be given to strengthening the biceps during rehabilitation programmes for chronic anterior instability of the shoulder.     

How much does inferior capsular shift reduce shoulder volume?

The purpose of this study was to quantitate the effect of inferior capsular shift on shoulder volume. Four fresh frozen cadaveric shoulders were analyzed. Volume before and after shift was determined using 3 techniques: (1) Magnetic resonance imaging sequences were digitized to computer and analyzed for volume via a 35-mm camera using Cue 2 software. The capsule was delineated by contrast between light and dark regions. Volume was calculated by summing the total area of respective slices. (2) Ultrasound images, obtained after surgical exposure of the capsule, were digitized. Volume was calculated using the formula for a prolate ellipsoid. (3) An 18-gauge needle was used to inject and evacuate saline via an anterior approach. Quantity of aspirated fluid provided a direct measure of volume. Inferior capsular shift was performed. After the operation, measurements were repeated. Inferior capsular shift reduced volume in all shoulders with each technique. On average, inferior capsular shift reduced joint volume by 57 %). A measurable reduction in shoulder joint volume is an effect of capsular shift. This measurement may have clinical application if volume is an indicator of instability or laxity.     

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Although conservative management with or without manipulation performed with the patient under anesthesia is the generally accepted treatment strategy for adhesive capsulitis, considerable interest is being shown in arthroscopic surgical procedures for this disorder. This study reviews the outcome of patients who underwent an arthroscopic release of the inferior capsule, reproducing in a controlled fashion the traumatic disruption of the inferior capsule commonly caused by manipulation with the patient under anesthesia. The outcome of 24 patients (26 shoulders) was assessed with an average follow-up of 13.5 months. A total of 88% of patients were very satisfied with the procedure, and no operative complications occurred. A return to normal or near normal shoulder function in 76% or more of the study group for forward flexion, abduction, and external rotation was demonstrated. A total of 50% of patients still had some restriction in internal rotation. The Constant Scoring system, also used to assess clinical shoulder function, revealed 87% of patients had achieved an excellent or good result when compared with the contralateral normal shoulder score. Our results suggest that arthroscopic capsular release is a safe and effective treatment for adhesive capsulitis, with patterns of recovery that compare favorably to other treatment modalities.     

Gleno-humeral arthroscopic arthrolysis for shoulder stiffness. Apropos of 26 cases. Société Fran?aise d'Arthroscopie

Shoulder stiffness is a problem which covers many different conditions. In fact there is still a semantic and pathogenetic confusion. The words: capsulite retractile, frozen shoulder, adhesive capsulitis, stiff shoulder contracture have been successively used and this ambiguity renders the literature difficult to interpret. Moreover the cause of the stiffness which depends on the aetiology, is not always clearly known: capsular contraction, capsular adhesion, capsular scarring following trauma or surgery, extra capsular phenomenons in the subacromial bursa, muscles or tendons. MATERIALS AND METHODS: 26 shoulders (25 patients) were reviewed with a follow up of 21 months using the Constant's scoring system. Patients had an average duration of symptoms for 13 months (1 to 27). Pre op passive motion was: abduction: 74 degrees, external rotation: 6 degrees, forward flexion: 84 degrees. The average motion core was 12.9/40. We distinguished three groups: primary frozen shoulder (13 cases) ; bipolar stiffness (3 cases) due to rotator cuff disease ; acquired "surgical" stiffness, (10 cases). The capsular release was performed, at the anterior rim of the glenoid fossa, purely anterior or anterior and inferior, followed by gentle manipulation. If external rotation was not improved the coraco-humeral ligament was detached from its coracoid attachment. Additional procedures were performed:acromioplasty (5 cases), bursectomy (3 cases), SLAP lesion debridement (1 case). Only 2 out 13 primary shoulders required an additional procedure. RESULTS: 1-There were no intra-operative complications (vascular or neural). 2-Range of Motion: the average gain under anesthesia was: abduction: 72 degrees, external rotation: 34 degrees, forward flexion: 86 degrees. Final result was obtained with a mean duration of seven months. There was no difference according to the aetiology. Gain was more important in the primary group (9.69 to 34.9 vs 15.8 to 30.6). 3-Subjective results were better in the primary group. 4-Objective results demonstrated an absolute Constant's score of 70.3, that is to say 83.4 per cent of the contralateral supposed healthy shoulder. There were 3 excellent, 5 very good, 7 good, but 11 fair or poor results. The relative Constant's score was 91 per cent in the primary group and only 76 per cent in the acquired group. The difference was due to the pain and strength which were greatly improved in the primary group. DISCUSSION: Arthroscopic release of shoulder contracture is feasible, safe and effective. For primary frozen shoulder, there is usually spontaneous recovery. Indications for surgery are very few. There is no evidence that arthroscopic release shortens spontaneous evolution. Therefore, we propose it in very selected cases of dramatically limited motion. One year of evolution is an acceptable time. For bipolar stiffnesses, arthroscopy allows one to recognize the exact cause of the stiffness and to treat it, especially the subacromial pathology. In this occurrence, buroscopy must be performed and cuff pathology treated. For acquired surgical stiffnesses, gain of motion is significant. Subjective and objective results are less satisfactory than those of primary frozen shoulder, due to persistance of pain and lack of strength. The alternative is open release, but arthroscopic release has less morbidity. It can be proposed early as soon as capsular tissue has healed (for instance 6 months).     

Arthroscopic shoulder stabilization. Differentiated treatment strategy with Suretac, Fastak, Holmium: YAG-laser and electrosurgery

The goal for arthroscopic stabilization of anterior glenohumeral instability is to achieve an outcome equivalent to or better than open procedures. A number of arthroscopic procedures have been advocated to reestablish continuity of the inferior glenohumeral ligament complex (IGHLC) with the glenoid. Implantable suture anchors were developed to avoid the problems associated with arthroscopic staple capsulorrhaphy like iatrogenic injury of the glenoid or humeral surface, loosening and migration of the staple. Several transosseous techniques include the need for an accessory posterior incision, the possibility of neurovascular injury (Suprascapular or axillary nerve), and the loosening of the repair after typing over the fascia of the infraspinatus posteriorly. The preferred techniques are cannulated, absorbable fixation device (Suretac) and easy implantable suture anchors made of titanium (Fastak). Even in the hands of experienced arthroscopists, unacceptably high recurrence rates for arthroscopic shoulder stabilization have been reported, due to the steep learning curve for both technical performance and patient selection. Our experience suggests, that if proper selection criteria are employed, normal patients and overhead-athletes may benefit from the advantages of an arthroscopic repair without accepting an increased risk for recurrence. We performed a prospective analysis of 105 shoulders, who underwent arthroscopic stabilization with Suretac or Fastak between 4/96 and 7/98. 48 shoulders were available for followup at least one year. The redislocation rate was 6.25% (3 shoulders) and the rate of subluxation without dislocation also was 6.25%, but none of the shoulders required a second open stabilization. The reason for redislocation or subluxation were 5/6 traumatic injuries, participating in contact sports or in one case a generalized ligamentous laxity. In combination with the LACS-Procedure or the Electro thermally assisted capsular shift (ETACS) not only the capsular detachment but also the capsular redundancy may be adressed and a lower failure rate can be expected.     

Ab initio quantum mechanical and X-ray crystallographic studies of gemcitabine and 2''-deoxy cytosine

Thirty-seven of 41 consecutive patients with recurrent anterior instability of the shoulder were retrospectively observed for a mean of 5.6 years (range, 4 to 10) after an arthroscopic stabilization procedure had been performed. The operative technique involved the use of transglenoid sutures to repair the capsule and labrum. According to the criteria established by Rowe, 27 patients (74%) had good or excellent results, and 3 patients (7%) were graded as fair. Seven patients (19%) developed recurrent instability after the procedure and had failed results. Failure rates were equal in patients with a history of recurrent dislocation and those with recurrent subluxation. Absence of a Bankart lesion at operation was associated with postoperative instability (P = 0.03). The presence or size of humeral head defects did not influence the result. Eight of 12 athletes who engaged in sports requiring repetitive overhead shoulder motion returned to full activity, and none of the 12 developed instability after operation. Four of the 13 patients who participated in contact sports or recreational skiing developed postoperative instability (P = 0.21). All failures occurred within 2 years of the procedure.     

Arthroscopic shoulder stabilization using transglenoid sutures

The results of arthroscopic stabilization using multiple transglenoid sutures in 24 patients with posttraumatic recurrent anterior shoulder instability are presented with a minimum follow-up of 2 years. No serious complications were recorded. There were 2 recurrences. The remaining 22 patients had good or excellent results according to the modified Rowe score, with a median score of 89. The median value for loss of external rotation was 5 degrees. Seventeen patients were active in sports and 11 returned to the same sports at the same competitive level.     

Detection of avian leukosis virus subgroup J using the polymerase chain reaction

PURPOSE: To compare neutral, external rotation, and abduction external rotation positions of the glenohumeral joint during magnetic resonance (MR) arthrography in the assessment of the joint capsule, biceps-labral complex, and glenohumeral ligaments. MATERIALS AND METHODS: MR imaging with intraarticular administration of gadopentetate dimeglumine was performed in 10 adult cadaveric glenohumeral joints. Fat-suppressed oblique coronal, oblique sagittal, and axial. T1-weighted spin-echo imaging and axial three-dimensional spoiled gradient-recalled imaging were performed with each shoulder in the neutral, external rotation, and abduction external rotation positions. Shoulders were sectioned in the planes that yielded optimal MR images. Anatomic and MR imaging findings were correlated. RESULTS: The biceps-labral complex was best visualized on oblique coronal and axial images obtained in external rotation. Oblique axial abduction external rotation imaging best delineated the inferior glenohumeral ligament but did not improve assessment of the superior and middle glenohumeral ligaments in comparison with findings in neutral and external rotation. CONCLUSION: Although MR arthrography of the glenohumeral joint clearly delineates the biceps-labral complex and glenohumeral ligaments, external rotation of the shoulder optimizes visualization of the former structures. Abduction external rotation is the best position for evaluation of the inferior glenohumeral ligament and anterior capsular attachment.     

First trimester prenatal diagnosis using transcervical cells: an evaluation

In view of potential problems with metallic implants around the shoulder a bioabsorbable tact has been used in arthroscopic repair of labral lesions in the shoulder joint. We report on a consecutive series of 70 patients (71 shoulders) who had arthroscopic stabilization of Bankart lesions, SLAP lesions, and other labral detachments with the Suretac device. Minimum follow-up time was 12 months (range 12 to 27 months). Clinical outcome was assessed with the Constant score. The recurrence of dislocation or subluxation in the 42 unstable shoulders was 12% (5 of 42), and in 78% (33 of 42) the Constant score was rated good or excellent. The recurrence of dislocation in true anteroinferior dislocators was 3.2% (1 of 31). A total of 82.3% (14 of 17) of patients with SLAP repairs were rated good or excellent, and 53% (9 of 17) returned to their preinjury level of sporting activities. Eight (67%) of 12 patients with labral detachments other than Bankart and SLAP lesions were rated good or excellent, and 64% (7 of 11) returned fully to sports.     

Indirect MR arthrography of anterior shoulder instability in the ABER and the apprehension test positions: a prospective comparative study of two different shoulder positions during MRI using intravenous gadodiamide contrast for enhancement of the joint fluid

OBJECTIVE: The value of MRI for the evaluation of anterior shoulder instability can be enhanced by shoulder positions that stress the stabilising structures. The ABER position is one that has been described in combination with intra-articular gadopentetate dimeglumine arthrography. We believe that MRI in the Apprehension test position with 90 degrees abduction and maximal tolerable external rotation provides maximum tension on the anterior stabilising structures and with this technique it is sufficient to use indirect gadodiamide arthrography following intravenous injection of the contrast medium. The purpose of this study was to make a prospective comparative evaluation of the ABER and Apprehension test positions when using indirect arthrography with intravenous gadodiamide administration in shoulders with anterior instability. DESIGN AND PATIENTS: Sixteen patients with persistent anterior instability after recurrent shoulder dislocations were examined in an open MRI unit (0.2 T) following 0.1 mmol/kg of intravenous gadodiamide. Oblique axial T1-weighted imaging was used for analysis. Operative findings were used for correlation. RESULTS: Both the ABER and the Apprehension test position were useful techniques in detecting capsulolabral pathology and Hill-Sachs lesions. The Apprehension test position produced significantly better gadodiamide-enhanced joint fluid in the region of pathology in both the capsulolabral lesion and the Hill-Sachs lesion. It also visualised the size of the Hill-Sachs lesion significantly better than did the ABER position. CONCLUSION: MRI examination of anterior shoulder instability in the Apprehension test position was more beneficial than examination in the ABER position in visualising capsulolabral and Hill-Sachs lesions when using indirect arthrography.     

Treatment of recurrent anterior dislocation of the shoulder with pectoralis minor muscle-bone flap]

We treated 10 patients with recurrent anterior dislocation of the shoulder by transplantation of pectoralis minor muscle-bone flap transplanted to the upper part of the humerus. All patients were followed-up for an average 31 months and no recurrent was found. We consider that the muscle beily exerts a protective effect like a barrier on the weak anterio inferior region of the shoulder and increases the force for extending the shoulder and lifting the arm. The operation is based on biomechanics. Meanwhile, suturing the laxative joint capsule and repairing the weak anteroinfeior region of the shoulder is more beneficial to prevent from redislocation of the humerus head.     

Management of haemophilia in the developing world

We used a dynamic shoulder-testing apparatus and nine fresh-frozen, entire upper extremities from cadavera to evaluate the effects of varying degrees of capsulolabral injury on the kinematics of the glenohumeral joint during abduction in the scapular plane and external rotation. Joint kinematics were recorded with use of a six-degrees-of-freedom magnetic tracking device before and after the creation of each capsulolabral lesion in a progressive manner. Dislocation did not occur after simulation of a large Bankart lesion or even after sectioning of the anterior aspect of the joint capsule. However, division of the entire joint capsule (that is, both the anterior aspect and the posterior aspect) resulted in a significant increase (p < 0.05) in posterior translation during abduction in the scapular plane, and two of the nine shoulders dislocated posteriorly. External rotation of the abducted extremity produced no increase in anterior or posterior translation.     

Long-term results of the Latarjet procedure for the treatment of anterior instability of the shoulder

We performed ninety-five consecutive Latarjet procedures for the treatment of recurrent anterior instability of the shoulder between 1969 and 1983. In 1993, we retrospectively reviewed the clinical and radiographic results that were available for fifty-six patients (fifty-eight shoulders) who had been followed for an average of 143 years (range, ten to twenty-three years). The purpose of the study was to determine the prevalence of glenohumeral osteoarthrosis and the factors related to its development after the Latarjet procedure. The procedure was performed for the treatment of recurrent anterior dislocation in fifty shoulders and painful recurrent anterior subluxation in eight. All patients had a radiographic evaluation (three anteroposterior radiographs, with the humerus in external, neutral, and internal rotation, and one lateral radiograph) before the operation and at the latest follow-up examination. At the time of the latest follow-up, none of the patients had recurrent dislocation, six patients had apprehension with regard to possible dislocation, and one had occasional subluxation. According to the system of Rowe et al., fifty-one (88 per cent) of the fifty-eight shoulders had an excellent or good result; five (9 per cent), a fair result; and two (3 per cent), a poor result. Twenty-two shoulders had no glenohumeral osteoarthrosis. Thirty-four shoulders had centered glenohumeral osteoarthrosis (the humeral head remained in front of the center of the glenoid cavity), which was grade 1 in twenty-five shoulders, grade 2 in four, grade 3 in three, and grade 4 in two, and two shoulders had grade-4 eccentric glenohumeral osteoarthrosis (the humeral head was more proximal than normal in relation to the center of the glenoid cavity). Postoperative grade-1 glenohumeral osteoarthrosis, unlike the higher grades, had no effect on the function of the shoulder.     

Corneal endothelial cell loss caused by detached opacified anterior lens capsule in the anterior chamber

From 1984 to 1986, we performed cataract surgery through a 1.5 mm anterior capsule hole in 77 eyes. The hole was enlarged to 6.0 mm by a slit incision, and an intraocular lens was implanted into an almost completely intact capsular bag. Twelve (16%) eyes developed severe postoperative anterior capsule opacification. The opacified central anterior capsule, approximately 5 mm in diameter, was detached by can-opener anterior capsulotomy using a neodymium:YAG laser and fell into the inferior anterior chamber. Inferior corneal endothelial cell loss occurred in nine of the 12 eyes within 20 months after detachment; in six of the nine, inferior corneal endothelial cell density decreased 50% more than central cornea cell density. This method will be unsuitable for treating the extensive anterior capsule opacification that will occur when endocapsular cataract surgery that retains most of the lens capsule is widely performed in the future.     

Arthroscopic release for chronic, refractory adhesive capsulitis of the shoulder

Idiopathic adhesive capsulitis usually responds to gentle physical therapy or, if that fails, to closed manipulation with the patient under anesthesia. In some patients, however, loss of motion may be refractory to either of these treatments and an operative release may be indicated. We are reporting on the technique and results of arthroscopic capsular release as a new alternative for the management of such patients. During a three-year period, we managed twenty-three patients who had idiopathic adhesive capsulitis that had failed to respond to physical therapy or closed manipulation. These patients had an arthroscopic anterior capsular release and received forty-eight hours of intensive physical therapy as inpatients. During the physical therapy, the patients received an interscalene regional analgesic with use of repeated nerve blocks or with a continuous infusion through an interscalene catheter. This was followed by a supervised outpatient physical-therapy program. Six patients also had an arthroscopic acromioplasty for the treatment of impingement. There were no complications related to any of the procedures. At a mean of thirty-nine months (range, twenty-four to sixty-four months) after the arthroscopic procedure, the improvement in the score of Constant and Murley averaged 48 points (range, 13 to 77 points). The mean improvement in motion was 49 degrees (range, 0 to 105 degrees) for flexion; 42 degrees (range, 10 to 80 degrees) and 53 degrees (range, 0 to 100 degrees) for external rotation in adduction and abduction, respectively; and eight spinous-process levels (range, three to fourteen levels) and 33 degrees (range, 30 to 60 degrees) for internal rotation in adduction and abduction, respectively. These gains in motion were all significant (p < 0.01) compared with the preoperative values and were within a mean of 7 degrees of the values for the contralateral, normal shoulder. We concluded that, in patients who have loss of motion that is refractory to closed manipulation, arthroscopic capsular release improves motion reliably with little operative morbidity.     

Static functional study with magnetic resonance of anterior shoulder instability

We studied the glenohumeral joint, in its different components, with cine MRI. Ten asymptomatic volunteers and 6 patients with recurrent shoulder instability were examined with T2-weighted GE MR sequences on the axial plane with the subjects' arms rotated in different positions. The sections corresponding to the subcoracoid space and bicipital groove were recorded in closed-loop video format for cine display. Normal morphological glenoid labrum changes were demonstrated in different degrees of humerus rotation. The subscapularis tendon and the capsule were redundant and infolded toward the joint on internal rotation in 4/6 patients. We found capsular detachment in 2 patients, humeral head subluxation in 3 and subcoracoid impingement in 2 patients. Cine MRI permitted the accurate study of the changes in the glenoid labrum, capsule and subscapularis tendon in all patients and it also showed narrowed coracohumeral distance (< 11 mm) on internal rotation.     

Revision total shoulder arthroplasty for the treatment of glenoid arthrosis

The development of painful glenoid arthrosis is the most common reason for reoperation after replacement of the humeral head. We performed twenty-two revision total shoulder arthroplasties, between 1983 and 1992, for the treatment of painful glenoid arthrosis in shoulders that had a prosthetic replacement of the humeral head. Eighteen shoulders (seventeen patients) were included in the study as their preoperative and operative records were complete and they had been followed for at least two years (mean, 5.5 years; range, 2.3 to 10.0 years). The indications for the hemiarthroplasty were trauma (ten shoulders), osteoarthrosis (four), rheumatoid arthritis (two), and osteonecrosis secondary to the use of steroids (two). The mean interval between the hemiarthroplasty and the total shoulder replacement was 4.4 years (range, 0.8 to 12.7 years). The mean score for pain in the shoulder decreased from 4.3 points before the revision to 2.2 points after it (p = 0.0001). The mean active abduction increased from 94 degrees before the revision to 124 degrees after it (p = 0.01), and the mean external rotation increased from 32 to 58 degrees (p = 0.007). Two shoulders needed another operation after the revision because of a late infection in one and particulate synovitis associated with instability in the other. With the numbers available for study, we did not detect a significant difference in pain relief and range of motion with respect to gender, diagnosis, subluxation, or the presence of periprosthetic radiolucency. Our findings indicate that most patients with painful glenoid arthrosis after a hemiarthroplasty have marked pain relief and improvement in motion after revision to a total shoulder replacement. However, seven of the eighteen shoulders that had this procedure had an unsatisfactory result due to a limited range of motion or the need for a subsequent operation. Therefore, long-term studies are necessary to evaluate the durability of total shoulder replacement in this group of patients.