Status of total shoulder arthroplasty

Some patients with degenerative, rheumatoid, and traumatic diseases of the glenohumeral joint require treatment primarily to relieve pain. In the absence of complete knowledge of basic mechanical requirements, clinical trials with both constrained and resurfacing prosthesis were initiated. Three types of constrained prostheses were placed in 23 patients. Pain relief was satisfactory, but six reoperations were necessary and motion greater than 90 degrees was rarely achieved. Twenty-five prostheses that were used to replace the glenohumeral articulation, but were not stable by virtue of design, were implanted. Again, pain relief was excellent; mechanical problems were not present, and motion was almost always greater than 90 degrees. Achieving stability by capsular-muscle cuff repair has not been as great a problem as anticipated. These results suggest that more emphasis should be placed on repair of the glenohumeral stabilizing structures than on their replacement.     

Assessment of outcome in shoulder arthroplasty

This article discusses outcome measures for the patient requiring shoulder arthroplasty and the weakness and strengths of various assessment tools in current use. The optimal method to measure the outcome of patients with shoulder arthroplasty is yet to be defined; however, the ideal assessment should include measures of general health, a shoulder-specific assessment, and an assessment that is specific to the disease state for which shoulder arthroplasty is indicated. The authors also provide appendices with their recommended calculations for the elevation of the shoulder arthroplasty patient.     

Postoperative rehabilitation following total shoulder arthroplasty

It is essential that patients receive proper rehabilitation following a total shoulder arthroplasty. This should ideally include a preoperative visit that includes the specified therapist, patient, and primary caregiver. The rehabilitative process is an individual program, and the protocol described is suggested as a guide for the therapist. The order of the exercises listed is more important than the time at which they are started, with an emphasis on maximizing motion prior to aggressive strengthening.     

Uncemented total shoulder arthroplasty. A review

Clinicians have had much experience with uncemented humeral components. A press-fitted humeral component will usually remain stable in the absence of a glenoid component. From the information available, surgeons should not continue to use press-fitted humeral components for total shoulder arthroplasty. Tissue ingrowth humeral components offer promise; however, the reports to date have short or intermediate length followup, and radiographic results do not equal those of cemented components. Early clinical results with tissue ingrowth glenoid components are excellent; radiographically evident changes occur much less frequently than they do following cement fixation. However, their disadvantage is the possibility of accelerated polyethylene wear and subsequent metal-induced synovitis. As such, there are no clear cut indications for cement fixation versus tissue ingrowth fixation for the glenoid component other than those intuitively based on bone quality and quantity in the glenoid fossa. Accruing experience will help to define the indications better, but given the similarity of clinical outcomes to date, distinction between the options may be difficult.     

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.     

Impingement syndrome following total shoulder arthroplasty and humeral hemiarthroplasty: treatment with arthroscopic acromioplasty

In this pilot study, 99Tcm-labelled human immunoglobulin G (99Tcm-HIG) was evaluated as a lymphoscintigraphic agent in five rabbits. It was injected intradermally into the web space of the hind legs of the rabbits (37 MBq/0.1 ml). Sequential scintigrams were obtained using a gamma camera for 120 min. The injection site and the hind legs were massaged post-injection. Blood samples were obtained at 5, 15, 30, 60, 90 and 120 min. Two of the rabbits were killed after 2 h. Their organs were weighed and tissue specimens were obtained, weighed and counted against a standard using a gamma counter. The lymph channels and the lymph nodes were well visualized on the scintigrams. The background activity was very low, making interpretation easier. About 30% of the injected dose migrated from the injection site by 2 h. The mean popliteal lymph node uptake was 5.71 +/- 4.62% per gram of tissue. The lymph node to other tissue concentration ratios were very high, ranging from 63:1 for the kidneys to 1099:1 for the heart. We conclude that 99Tcm-HIG is a promising new agent for the visualization of the lymphatic system due to its easy labelling procedure, the stability of the label, its widespread availability and good image quality. It may potentially be useful in detecting and evaluating inflammatory lymph nodes.     

Isolation and characterization of polyethylene wear debris associated with osteolysis following total shoulder arthroplasty

OBJECTIVE: As anorectic and bulimic patients present similar clinical and neurobiological symptoms, the purpose of this study was to compare brain glucose metabolism at rest in these patients. METHODS: Positron emission tomography with (18-F)-fluorodeoxyglucose was used to evaluate cerebral glucose metabolism (CMRglu) in 10 normal-weight bulimic women, in 10 underweight anorectic patients, and in 10 age- and sex-matched healthy volunteers. RESULTS: Absolute global cortical glucose activity was significantly lower in anorectic patients compared with bulimic and control subjects. Anorectic patients compared with normal control subjects also showed higher relative CMRglu in the inferior frontal cortex and in the basal ganglia, and putamen and caudate relative hypermetabolism when compared with bulimic patients. Thus, both eating disorder groups differed from control subjects in low relative parietal values of glucose. DISCUSSION: While absolute global metabolism seems to be related to weight loss, we can hypothesize either a common parietal cortex dysfunction in eating disorders or a particular sensitivity of this cortex to consequences of eating disturbances.     

A dynamic shoulder model for biomechanical measurements of shoulder specimen

The article discusses a dynamic shoulder model capable of simulating the forces generated by the rotator cuff and the deltoid muscle, and elevation movements of the glenohumeral joint using, a computer-aided servohydraulic unit. In 10 cadaver shoulder specimen, the effects of the loss of function of the supraspinatus muscle on maximum elevation was determined with an ultrasound system. Changes in the so-called impingement pressure below the coracoacromial arch were determined with the aid of capacitive pressure sensors. With the supraspinatus muscle inactive/ absent, the maximum elevation of the humerus showed a decrease of 6% (p < 0.05), which, however, was overcome by an increase in deltoid power of only one-third of the supraspinatus muscle power loss. For a simulated isolated supraspinatus defect, the subacromial pressure below the coracoacromial arch decreased by 8% (p > 0.05). These results confirm clinical investigations showing that isolated lesions affecting the supraspinatus tendon often fail to produce symptoms and thus require no surgical reconstruction.     

The weightbearing shoulder

To determine the effect of the swing-through crutch-walking gait on shoulder degeneration, 20 shoulders were examined in ten patients who had used the swing-through gait for a mean of 8.7 years. No degenerative changes were found in the 20 examined shoulders either clinically or radiographically. A special X-ray view was determined to assess potential degenerative changes. The patients showed a mean increase in the forearm bone density as a result of their crutch-walking gait.     

Total wrist arthroplasty

Although arthroplasty is a well-established procedure for many joints, its use in the wrist is less common, and the indications are less well defined. The standard procedure for the painful arthritic wrist remains radiocarpal arthrodesis. However, as technology and surgical procedures improve, wrist arthroplasty is being used more frequently. The authors provide a brief history of total wrist arthroplasty and review the arthroplasties most commonly used in the United States. Results with total wrist implants, the complications related to arthroplasty, technical aspects of the procedure, and salvage options are also discussed.     

Total hip arthroplasty

Total hip arthroplasty, or surgical replacement of the hip joint with an artificial prosthesis, is a reconstructive procedure that has improved the management of those diseases of the hip joint that have responded poorly to conventional medical therapy. In this review we briefly summarize the evolution of total hip arthroplasty, the design and development of prosthetic hip components, and the current clinical indications for this procedure. The possible complications of total hip arthroplasty, its clinical performance over time, and future directions in hip replacement surgery are also discussed.     

Neuropathic arthropathy of the shoulder

We retrospectively reviewed the records of six men (seven shoulders) with neuropathic arthropathy of the shoulder who were referred to our shoulder service during a twenty-eight-year period (from 1969 through 1997). The etiology of the neuropathic condition was syringomyelia in five patients (six shoulders) and chronic alcoholism in one patient. Five patients (six shoulders) were initially misdiagnosed, and seven operative procedures that were unrelated to the etiology of the neuropathic condition were performed in four of these patients. Radiographs revealed destruction of the shoulder joint and marked resorption of the humeral head in all patients. Magnetic resonance images revealed a syrinx of the central cord in all of the patients except for the one who had chronic alcoholism.     

Complications of shoulder instability surgery

Complications of shoulder instability surgery may results from errors made during the preoperative, intraoperative, or postoperative periods. Some complications are preventable whereas the risk of others can be reduced. A few complications remain unpreventable. Two sources of error in the preoperative period that can lead to complications are an incorrect diagnosis and failure to address a patient's expectations of treatment. These errors and their subsequent complications are preventable. Preventing complications during the intraoperative period begins with proper patient positioning and a thorough knowledge of shoulder anatomy. Understanding the indications and limitations of the various stabilization procedures, as well as applying proper surgical technique, is essential to avoid a surgical misadventure. Complications recognized in the postoperative period include recurrent instability, limitation of motion, inability to return to the previous level of sport, problems related to hardware, pain, development of osteoarthritis, and neurovascular injuries. Infection and hematoma formation may also occur; both need to be recognized and treated early to maximize outcome. A protocol for treating each complication that may occur often is helpful. Knowledge of the complications that can arise is paramount to preventing their occurrence. This knowledge comes through experience, study, and continued research.