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.     

Blood selenium in healthy persons and individuals with malignant diseases

INTRODUCTION: Dislocation of the long head of biceps tendon, including subluxation to displacement out of the bicipital groove, is an uncommon cause of shoulder pain. We investigated the role of US in the diagnosis of this condition. MATERIAL AND METHODS: We examined eight patients with dislocation of the long head of biceps tendon: seven had a displaced, and one a subluxated tendon. All patients had early radiographic and US studies of the shoulder; then, three (37%) were submitted to CT-arthrography and two (25%) to MRI. US was performed at 7.5-13 MHz frequency, CT-arthrography with a volumetric acquisition technique and MRI with a surface coil at 1.5 T. Three patients with tendon dislocation had surgical confirmation of the diagnosis. RESULTS: Dislocation of the long head of biceps tendon was always diagnosed with US in all our eight patients; CT-arthrography and MRI confirmed the US findings. In the patient with subluxation of the long head of biceps tendon, US showed the tendon displaced over the lesser tuberosity whereas, in the 7 cases of complete luxations, the groove was empty and the tendon displaced medially. At CT-arthrography, the tendon was well outlined by contrast medium within its sheath. In dislocations, it was close to the anterior aspect of the humeral head. In two cases of dislocation, MRI showed both the empty bicipital sulcus and the medial tendon displacement. The subscapularis tendon tear was always associated with tendon dislocation; a supraspinatus tendon tear was observed in 6 cases. CONCLUSIONS: When imaging a painful shoulder, we should investigate the integrity and course of the long head of biceps tendon. In clinical practice, dislocation of this tendon can be reliably diagnosed with US. CT-arthrography and MRI should be used only to supplement inconclusive US studies.     

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.     

Magnetic resonance imaging of bone destruction in rheumatoid arthritis: comparison with radiography

Bony changes in forty-four knees of patients with clinically established rheumatoid arthritis (RA) were examined using magnetic resonance imaging (MRI) and plain film radiography. In all cases MRI was clearly superior to radiographs, demonstrating 25 marginal erosions and 42 subchondral cysts, while the number seen on radiographs was 3 and 8, respectively. These results emphasize the problems in visualizing bone erosions in large joints using plain films. MRI is the method of choice for detecting early changes in RA, not only because of its high sensitivity, but also because of the ability of contrast-enhanced MRI to provide physiological characterization of these lesions.     

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.     

Posture in patients with shoulder overuse injuries and healthy individuals

Assessment of posture is an integral component of patient evaluation with shoulder overuse injuries. However, the professional literature contains relatively few studies that have assessed the relationship between posture, function, and injury. The purpose of this study was to determine the relationship and differences in postural variables within and between subjects with overuse injuries to the shoulder of healthy subjects. Thirty patient subjects and 30 healthy subjects matched for age and gender were recruited. Scapular protraction and rotation, forward head position, midthoracic curvature, and passive humeral elevation in the plane of the scapula were measured randomly in standing. All measurement techniques were standardized and validated. Intrarater and interrater reliability for all clinical measures were established before data collection. Forward head position was significantly greater (p < .001) in the patient group than the healthy group; humeral elevation was significantly greater (p < .001) in the healthy group than in the patient group and in the uninvolved shoulders (p < .01) than the involved shoulders within the patient group. Scapular protraction, rotation, midthoracic curvature, and scapular symmetry were not significantly different between groups. Scapula protraction and rotation were significantly related (p < .05) in the patient group. No other postural variables were related. Conclusions regarding the influence of posture to shoulder injury are inconclusive based on several confounding variables that may have affected the outcome.     

Cerebellar deficient folia (cdf): a new mutation on mouse chromosome 6

OBJECTIVE: To discuss the case of an 8-yr-old boy with an aneurysmal bone cyst of the right proximal humerus, including the features imaged on plain film radiography, computed tomography (CT), magnetic resonance imaging (MRI), including spin echo and fast field echo imaging. CLINICAL FEATURES: The patient suffered for 1 yr from intermittent but progressive pain in his right upper arm and shoulder area. There was no history of trauma or known systemic disease. There was decreased range of motion in abduction of the glenohumeral joint and pain on focal pressure along the deltoid muscle. A complete imaging evaluation consisting of plain film radiography, CT and MRI was performed, which revealed the classical imaging features of an aneurysmal bone cyst. An additional cystic lesion was detected by the MRI that was not appreciated on the plain films or CT. INTERVENTION AND OUTCOME: The patient was referred for biopsy to confirm the preliminary diagnosis of aneurysmal bone cyst. No treatment was instituted. CONCLUSION: Evaluation of aneurysmal bone cyst may be completed with CT scanning and more specifically with MRI MRI coronal T2, weighted images are advantageous for visualization of the main cystic lesion and any additional cysts. Fast field echo images show a better contrast between the cyst and bone marrow with extension of the cyst into the epiphysis as evident in this case. Follow-up studies revealed complete healing of the cyst with only residual densities in the humeral metaphyseal area.     

MRI in the diagnosis of osteoid osteoma

INTRODUCTION: Osteoid osteoma (OO) is a frequently encountered benign bone tumor, seen in young adults with male predominance. MATERIALS AND METHODS: Nine patients complaining of nonspecific extremity pain underwent MRI examination. The sequences obtained were T1 and T2 weighted spin-echo and T2 weighted gradient echo. A CT scan examination followed in all cases, exploring the region of the abnormal signal seen on MRI. The results of both examinations were compared. RESULTS: In six of the nine patients (66.6%) MRI showed evidence suggestive of osteoid osteoma, comparable that seen on CT scan. In three patients (33.3%), MRI showed a nonspecific and ill-defined bone marrow signal abnormality. CT cuts focused on those areas of signal abnormality showed the nidus. DISCUSSION: MRI is more sensitive than CT scan in detecting soft tissue and bone marrow abnormalities adjacent to an osteoid osteoma. This may produce a misleading aggressive appearance on MR images. CT scanning is more specific than MRI, by showing the nidus. In three patients studied, the nidus was only seen by CT, the other six osteoid osteomas were equally seen by CT and by MRI. In our study, MRI revealed abnormalities in all the cases. It was also highly specific for osteoid osteoma in 66.6%. CONCLUSION: MRI is very sensitive in detecting bone marrow and soft tissue abnormalities, and can suggest the diagnosis of OO in a good number of patients. In the remainder cases MRI guides the CT-scan. CT is more accurate and remains the definite examination for the diagnosis of OO, by showing the nidus.     

Arthrography and computed arthrotomography study of seventy patients with primary glenohumeral osteoarthritis

Seventy patients with primary glenohumeral osteoarthritis underwent roentgenographic and computed tomography studies. Glenohumeral joint space loss and a normal acromiohumeral space were the roentgenographic inclusion criteria. Women made up 61% of the sample. The dominant shoulder was affected in 95% of cases and both shoulders in 41%. Mean age at first evaluation was 65 years. Arthrography showed a tear confined to the supraspinatus tendon in 16 cases (23%); no patients had tears involving more than one tendon. Computed tomography demonstrated glenoid retroversion (mean 16 degrees) but was unable to differentiate primary glenoid dysplasia from wear due to osteoarthritis. Posterior subluxation of the humeral head was found in 28 cases (40%) but was not consistently correlated with the presence of glenoid retroversion.     

Osteonecrosis of the humeral head treated by core decompression

Core decompression is one treatment used for symptomatic osteonecrosis of the humeral head. The purpose of this report was to examine the long term outcome of this procedure. Sixty-three shoulders in 43 patients who underwent a core decompression for humeral head osteonecrosis were followed up from 2 to 20 years (mean, 10 years). None of these patients had responded to nonoperative treatment before core decompression. Results of core decompression according to preoperative Ficat and Arlet stage revealed Stage I disease had 15 of 16 (94%) successful outcomes and Stage II had 15 of 17 (88%) successful outcomes. Stage III had 16 of 23 (70%) successful results and Stage IV had one of seven (14%) successful result. Core decompression of the shoulder is a safe procedure with few recognized complications and can be performed on an outpatient basis. The procedure has been successful for Stages I, II, and III osteonecrosis in terms of early relief of pain and increased function.     

Evaluation of the effects of bioadhesive substances as addition to oral contrast media: an experimental study

The primary restraint preventing humeral head translation is the capsuloligamentous system. Muscle forces can also decrease translation; however, the timing and magnitude of muscle response has not been previously reported. Fine wire electromyographic analysis of the biceps long head, anterior deltoid, pectoralis major, latissimus dorsi, and rotator cuff muscles was performed after an anterior translation force was applied to 15 normal shoulders. The reflex response time (time to 5% maximal muscle test), the protection response time (time to 20% maximal muscle test), the duration of the protection response, and the magnitude of the protection response were calculated. The shoulder reaction data showed 2 consistent patterns. Activation of the anteriorly located muscles preceded the posteriorly located muscles, and the rotator cuff muscles fired with greater magnitude than the more peripherally located muscles.     

Local arthroscopic bone grafting of a juxta-articular glenoid bone cyst

This report describes a rare, juxta-articular bone cyst of the posterior glenoid that developed after a fracture of the glenoid in a 38-year-old male. The patient had persistent pain, popping and stiffness of his right shoulder for 3 years, and failed to improve after a nonoperative rehabilitation program. At arthroscopy, the senior author transported an autogenous bone graft from the bare area of the humeral head to fill the glenoid cyst arthroscopically. At second-look arthroscopy approximately 1 year after the index procedure, the bone graft had consolidated within the original cystic defect and the surface was covered with fibrocartilage. The graft harvest site posteriorly on the humeral head had healed with a small amount of scar tissue at the articular margin. Comfortable motion and function were restored.     

CT and MRI evaluation of musculoskeletal infection

While the plain film and nuclear medicine bone scan are still the traditional imaging modalities used in the evaluation of musculoskeletal infection, the cross-sectional imaging modalities, computed tomography (CT) and magnetic resonance imaging (MRI), have become critical in the delineation of many types of musculoskeletal infection. In particular, the evaluation of soft tissue infections, including cellulitus, myositis, fasciitis, abscess, and septic arthritis are often best evaluated by MRI or CT due to their excellent anatomic resolution and soft tissue contrast. Even in osseous infection, CT and MRI can give better anatomic delineation of the extent of infection. In cases where the plain film and nuclear medicine bone scan findings are complicated due to previous surgery, trauma, or underlying illness, the anatomic resolution and soft tissue contrast provided by MRI and CT are often necessary to determine if underlying infection exists. MRI's visualization of the bone marrow allows for the sensitive detection of osteomyelitis, although specificity for the diagnosis of osteomyelitis is aided by other findings, including cortical destruction. The CT and MRI findings in the spectrum of musculoskeletal infections are discussed and contrasted, and pitfalls in their evaluation of musculoskeletal infection are described.     

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.     

Glenohumeral deformity secondary to brachial plexus birth palsy

Ninety-four patients who had brachial plexus birth palsy were entered into a prospective study to evaluate the association between persistent palsy, age-related musculoskeletal deformity, and functional limitations. Of these patients, forty-two had either computerized tomography or magnetic resonance imaging to assess the presence and degree of incongruity of the glenohumeral joint, deformity of the humeral head, and hypoplasia of the glenoid as part of the preoperative planning for a reconstructive operation. Functional ability was rated with use of the classification of Mallet, on a scale of 1 to 5. The mean glenoscapular angle (the degree of retroversion of the glenoid) on the affected side was -25.7 degrees compared with -5.5 degrees on the unaffected side. Twenty-six (62 per cent) of the forty-two shoulders had evidence of posterior subluxation of the humeral head, with a mean of only 25 per cent (range, 0 to 50 per cent) of the head being intersected by the scapular line. Progressive deformity was found with increasing age (p < 0.001). The natural history of untreated brachial plexus birth palsy with residual weakness is progressive glenohumeral deformity due to persistent muscle imbalance. The status of the glenohumeral joint must be addressed when the choice between tendon transfer and humeral derotation osteotomy for reconstruction of the shoulder is considered for these patients.     

The rotator cuff opposes superior translation of the humeral head

To determine the influence of rotator cuff muscle activity on humeral head migration relative to the glenoid during active arm elevation we studied five fresh cadaveric shoulders. The shoulder girdles were mounted in an apparatus that simulated contraction of the deltoid and rotator cuff muscles while maintaining the normal scapulothoracic relationship. The arms were abducted using four different configurations of simulated muscle activity: deltoid alone; deltoid and supraspinatus; deltoid, infraspinatus, teres minor, and subscapularis; and deltoid, supraspinatus, infraspinatus, teres minor, and subscapularis. For each simulated muscle configuration the vertical position of the humeral head in relation to the glenoid was determined at 30 degrees, 60 degrees, 90 degrees, and 120 degrees of abduction using digitized anteroposterior radiographs. Both muscle activity and abduction angle significantly influenced the glenohumeral relationship. With simulated activity of the entire rotator cuff, the geometric center of the humeral head was centered in the glenoid at 30 degrees but had moved 1.5 mm superiorly by 120 degrees. Abduction without the subscapularis, infraspinatus, and teres minor muscles caused significant superiorly directed shifts in humeral head position as did abduction using only the deltoid muscle. These results support the possible use of selective strengthening exercises for the infraspinatus, teres minor, and subscapularis muscles in treatment of the impingement syndrome.     

Total shoulder endoprosthesis design St. Georg

Experiences with shoulder replacement in 40 cases since 1966 and the development of a nonblocked total prosthesis are described. The replacement of both joint surfaces according to the principles of low friction arthroplasty ist needed to obtain relief of pain. The nonblocked system corresponds in a high degree to physiologic conditions. The shape of the implant and the meticulous reconstruction of the inner and outer rotator cuffs reduce the danger of dislocation considerably. Only small bone resection is necessary. In cases of dislocated compound fractures and of painful posttraumatic and rheumatic arthrosis, total replacement could be an alternative to resection of the humeral head as well as to shoulder arthrodesis.     

Bulk effect of rotator cuff on inferior glenohumeral stability as function of scapular inclination angle: a cadaver study

Eleven fresh cadaver shoulders were studied to determine the static contribution (bulk effect) of the rotator cuff on inferior glenohumeral stability provided by scapular inclination. All musculature, including the rotator cuff, was removed. The position of the humerus relative to the scapula was recorded using an electromagnetic tracking device under conditions of no force and 1.5 kg of inferior translation force applied to the humerus, with the arm in the hanging position (sulcus test) and then in 90 degrees abduction (Abduction-Inferior Stability test = ABIS test), with the scapula inclined referable to the vertical line at -15 degrees, 0 degrees, 15 degrees and 30 degrees in the sulcus test and at 15 degrees, 30 degrees, 45 degrees and 60 degrees in the ABIS test. In the sulcus test without load, all shoulders dislocated at scapular inclination angles of -15 degrees and 0 degrees, whereas no shoulders dislocated at 30 degrees. The angle of scapular inclination had a significant effect on humeral head positions (p < 0.0001), with the head position at -15 degrees and 0 degree being lower than at 15 degrees, which was lower than at 30 degrees. In the ABIS test, none of the shoulders dislocated, although the effect of the angle of scapular inclination was significant (p < 0.0001), with the position of the humeral head being higher at 15 degrees than at other angles of inclination. Comparison of these data and previously reported data with the cuff intact showed no significant effect of rotator cuff removal on humeral head position and displacement in both tests. Therefore, we conclude that the static condition of the rotator cuff has no significant effect on the stabilizing function of scapular inclination. The stabilizing mechanism of scapular inclination seems to be associated with the bony configuration and/or anatomy and biomechanical properties of the superior capsuloligamentous structures.     

Retrograde nailing of humerus shaft fractures with the unreamed humerus nail. An international multicenter study

Combined with the new unreamed humeral nail (UHN) (Synthes), the retrograde approach to the endomedullary canal of the humeral shaft promises careful reduction and fixation of humeral shaft fractures. This prospective multicenter study reports and analyses 102 retrograde nailings with the UHN and their operative procedures. Seven patients with pathological fractures have died meanwhile, but 75 patients could be followed up until bone healing. Seventy-three fresh humeral shaft fractures, 12 pseudarthrosis, 3 refractures and 14 pathological fractures have been treated with the UHN. In 98 cases (96.1%) the surgeon estimated fracture stability well enough to initiate immediate postoperative elbow and shoulder mobilization. The difficulties involved with free-hand interlocking proximally at the nail tip in 5.9%, fissure or avulsion at the insertion point in 3.9% and radial nerve palsy also in 3.9% of the cases were the most important intraoperative complications. In all 75 patients followed up, bone healing occurred, but five fractures (6.7%) needed more than 8 months connected with a second operative procedure. In one case spongious bone transplantation and new locking bolts had been performed. In three cases a special compression device has been used, whereas in one case also a new nail and in the second spongious bone transplantation had been added. In the fifth case plate osteosynthesis had been performed. At the end of treatment 89.4% of the patients had excellent shoulder function and 88.0% excellent elbow function. Once the indication for surgery is established, the UHN can be considered a reliable and safe implant for stabilizing humeral shaft fractures.     

Primary management of comminuted humeral head fracture in the elderly patient with a humerus head prosthesis

The purpose of this prospective study was to determine the early subjective and functional result and outcome after primary implantation of humeral endoprosthesis in severely comminuted humeral head fractures in elderly patients. From 1993 to 1995, 27 humeral head fractures (27 patients) were treated by primary implantation of a Neer II modular shoulder prosthesis. Of these, 23 patients were women, 4 patients were men. The average age of patients was 76 (48-91) years. Postoperatively, one shoulder had to be mobilized under general anesthesia. Of the 27 patients 21 could be clinically examined after 16 (3-29) months postoperatively; 4 patients had died in the meantime, 2 did not come to the control examination because of a great distance and because they were happy. The average Constant Score was 48 (25-76) points; the difference to the other shoulder was 30 (18-69) points. Of the 21 patients 19 were satisfied by the result and 20 would reaccept the same procedure. These preliminary results suggest that primary shoulder prosthesis in humeral head fractures in the elderly patient is a valuable alternative option.