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Replacement Surgery and Rehabilitation of the Shoulder

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (31 July 2021) | Viewed by 31042

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Prof. Dr. Patric Raiss

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OCM–Orthopädische Chirurgie München, Steinerstrass 6, 81369 München, Germany
Interests: osteoarthritis of the shoulder; shoulder arthroplasty; shoulder instability; stabilization procedures of the shoulder; rotator cuff diseases; rotator cuff repair; fractures of the proximal humerus; fracture treatment

Special Issue Information

Dear Colleagues,

Replacement surgery of the shoulder and the elbow has become a viable treatment option for multiple degenerative diseases with satisfying clinical and radiographic results. Due to new clinical and biomechanical investigations, our understanding of arthroplasty surgery increases, and we are able to differentiate more and more which patient needs what kind of replacement. Next to the continuous improvement of the hardware (implants), especially shoulder arthroplasty has entered a “virtual” world as new softwares, namely, 3D planning tools, is available on the market, allowing us to understand the pathology better and to make our decisions based on standardized measuring methods. Patient-specific instruments and implants are partially available today and will most definitely be the future of this field. Artificial Intelligence will enter into the “shoulder world”, giving us new insights, and may have an impact on our decision-making processes. I look forward to following this process as shoulder arthroplasty is entering a three-dimensional and virtual world. I hope you enjoy reading this Special Issue with very interesting studies from well-known specialists all over the world.

Prof. Dr. Patric Raiss
Guest Editor

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Keywords

Shoulder
arthroplasty
shoulder arthroplasty
reverse arthroplasty
shoulder replacement
shoulder prosthesis
replacement surgery

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Published Papers (9 papers)

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Research

10 pages, 492 KiB

Open AccessArticle

Periprosthetic Stress Shielding of the Humerus after Reconstruction with Modular Shoulder Megaprostheses in Patients with Sarcoma

by Sebastian Klingebiel, Kristian Nikolaus Schneider, Georg Gosheger, Thomas Ackmann, Maximilian Timme, Carolin Rickert, Niklas Deventer and Christoph Theil

J. Clin. Med. 2021, 10(15), 3424; https://doi.org/10.3390/jcm10153424 - 31 Jul 2021

Cited by 11 | Viewed by 3184

Abstract

(1) Background: Modular megaprosthetic reconstruction using a proximal humerus replacement has emerged as a commonly chosen approach after bone tumor resection. However, the long-term risk for revision surgery is relatively high. One factor that might be associated with mechanical failures is periprosthetic osteolysis around the stem, also known as stress shielding. The frequency, potential risk factors, and the effect on implant survival are unknown. (2) Methods: A retrospective single-center study of 65 patients with sarcoma who underwent resection of the proximal humerus and subsequent reconstruction with a modular endoprosthesis. Stress shielding was defined as the development of bone resorption around the prosthesis stem beginning at the bone/prosthesis interface. The extent of stress shielding was measured with a new method quantifying bone resorption in relation to the intramedullary stem length. All patients had a minimum follow-up of 12 months with conventional radiographs available and the median follow-up amounted to 36 months. (3) Results: Stress shielding was observed in 92% of patients (60/65). The median longitudinal extent of stress shielding amounted to 14% at last follow-up. Fifteen percent (10/65) showed bone resorption of greater than 50%. The median time to the first radiographic signs of stress shielding was 6 months (IQR 3–9). Patients who underwent chemotherapy (43/65) showed a greater extent of stress shielding compared to those without chemotherapy. Three percent (2/65) of patients were revised for aseptic loosening, and one patient had a periprosthetic fracture (1/65, 1.5%). All these cases had >20% extent of stress shielding (23–57%). (4) Conclusions: Stress shielding of the proximal humerus after shoulder reconstruction with modular megaprosthesis is common. It occurs within the first year of follow-up and might be self-limiting in many patients; however, about one third of patients shows progression beyond the first year. Still, mechanical complications were rare, but stress shielding might be clinically relevant in individual cases. The extent of stress shielding was increased in patients who underwent perioperative chemotherapy. Stress shielding can be quantified with an easy method using the stem length as a reference. Full article

(This article belongs to the Special Issue Replacement Surgery and Rehabilitation of the Shoulder)

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11 pages, 4132 KiB

Open AccessArticle

Impact of Sports Activity on Medium-Term Clinical and Radiological Outcome after Reverse Shoulder Arthroplasty in Cuff Deficient Arthropathy; An Institutional Register-Based Analysis

by David Endell, Laurent Audigé, Alexandra Grob, Hans-Kaspar Schwyzer, Michael Glanzmann, Alex Marzel and Markus Scheibel

J. Clin. Med. 2021, 10(4), 828; https://doi.org/10.3390/jcm10040828 - 18 Feb 2021

Cited by 3 | Viewed by 2161

Abstract

There is a lack of consensus on what physicians can recommend and what patients can expect concerning sports activity after reverse shoulder arthroplasty (RSA). The purpose of this retrospective register-based observational study was to investigate the association between participation in sports or physical activity involving the upper extremity and 5-year clinical and radiological outcomes for primary RSA patients. We screened the institutional arthroplasty registry for patients reporting the type and level of sports postoperatively after primary, unilateral RSA due to rotator cuff deficiency. One hundred thirty-eight patients with clinical and radiological outcomes documented at a minimum 5-year follow-up were divided into three groups comprising those who participated regularly in: sports mainly involving the upper extremity (sports upper extremities, SUE, n = 49), sports mainly involving the lower extremities (sports lower extremities, SLE, n = 21), and those who did not participate in sports at all (no sports, NS, n = 68). The participants had a mean age of 72 years (standard deviation (SD) 8) and were overall predominantly female patients (62%). Primary clinical outcomes included the Constant Score (CS) and Shoulder Pain and Disability Index (SPADI). Secondary radiographs were analyzed for radiolucent lines (RLL), signs of glenoid or humeral prosthesis loosening, bone resorption, bone formation, and scapular notching. A total number of 8 senior surgeons were involved in treatment of patients, and two types of prosthesis were used. The SUE group had non-significantly higher mean scores for CS (75 points) and SPADI (88 points) compared to SLE (71 and 78 points, respectively) and NS patients (66 and 78 points, respectively) (p ≥ 0.286). The incidence of RLL around the humeral diaphysis was higher in NS compared to SUE patients (32% versus 12%, respectively) (p = 0.025); all other radiological parameters were similar between the groups. There were no cases of loosening in the SUE group that led to revision surgery. Patients engaging in sports activities involving the upper extremity show similarly good functional scores 5 years post-RSA as the other groups, without additional signs of implant loosening as a result of increased shoulder use. Full article

(This article belongs to the Special Issue Replacement Surgery and Rehabilitation of the Shoulder)

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10 pages, 6612 KiB

Open AccessArticle

3D-Analysis of the Proximal Humeral Anatomy before and after Stemless Shoulder Arthroplasty—A Prospective Case Series Study

by Matthias Koch, Borys Frankewycz, Andreas Voss, Max Kaeaeb, Sebastian Herrmann, Volker Alt and Stefan Greiner

J. Clin. Med. 2021, 10(2), 259; https://doi.org/10.3390/jcm10020259 - 12 Jan 2021

Cited by 3 | Viewed by 2353

Abstract

Background: Stemless shoulder arthroplasty (SSA) is used to anatomically reconstruct proximal humerus geometry and preserve proximal humerus bone stock. The current literature lacks 3D-analysis of pre- and postoperative proximal humeral anatomy after SSA. The aim of this study was to prospectively analyze the humeral head anatomy using a computer-assisted topography mapping technique after SSA in relation to the preoperative status and the contralateral (not affected) side. Methods: Twenty-nine patients (mean age: 63.5 ± 11.7 years) affected by primary shoulder osteoarthritis and treated with SSA were included. Preoperative and postoperative CT scans of the affected and contralateral sites were analyzed regarding joint geometry. Clinical outcome was assessed by Constant and Disabilities of the Arm, Shoulder and Hand (DASH) score shortly before and one year after surgery. Results: Clinical outcome improved significantly. No correlation between clinical outcome and the evaluated anatomical parameters was found. There was a significant decrease of the humeral head height (p < 0.01) and radius (p = 0.03) in the preoperative versus the postoperative joint geometry. The comparison to the contralateral site showed also a significant decrease of the humeral head height (p < 0.01). All other parameters showed no significant differences. Conclusion: Proximal humeral anatomy can be almost anatomically reconstructed by SSA. Solely the humeral head height differs significantly to the preoperative as well as contralateral morphology. Full article

(This article belongs to the Special Issue Replacement Surgery and Rehabilitation of the Shoulder)

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13 pages, 1718 KiB

Open AccessArticle

Glenoid Component Loosening in Anatomic Total Shoulder Arthroplasty: Association between Radiological Predictors and Clinical Parameters—An Observational Study

by Alexandra Grob, Florian Freislederer, Alex Marzel, Laurent Audigé, Hans-Kaspar Schwyzer and Markus Scheibel

J. Clin. Med. 2021, 10(2), 234; https://doi.org/10.3390/jcm10020234 - 11 Jan 2021

Cited by 13 | Viewed by 3338

Abstract

The mechanisms of glenoid component loosening in anatomic total shoulder arthroplasty (aTSA) are still unclear, and it remains undetermined which specific radiographic features are associated with clinical outcomes. Patients with primary osteoarthritis who underwent aTSA with a stemless implant and a pegged glenoid between January 2011 and December 2016 were extracted from a local registry. Anteroposterior radiographs were evaluated at six, 12, 24 months, and five years post-TSA for lateral humeral offset (LHO), joint gap (JG), acromiohumeral distance (AHD), and radiolucency (modified Franklin score); 147 patients were included. Mixed-model linear regression was used. Both constant score (CS) and subjective shoulder value (SSV) markedly decreased at five years follow-up compared to one year (p < 0.001 for both). AHD, LHO, and JG all showed a consistent and statistically significant decline over time, with the joint gap decreasing by half. Consistently, smaller JG and AHD were correlated with lower SSV (p = 0.03 and p = 0.07, respectively). Massive loosening was associated with a 14.5 points lower SSV (p < 0.01). Finally, narrowing of the JG was significantly correlated with increased radiolucency (p < 0.001) and tended toward worse SSV (p = 0.06). In summary, radiographic parameters displaying medialization and cranialization after aTSA with a cemented pegged glenoid are useful predictors of impaired shoulder function. Full article

(This article belongs to the Special Issue Replacement Surgery and Rehabilitation of the Shoulder)

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14 pages, 3193 KiB

Open AccessArticle

Clinical Outcome of Two-Stage Revision after Periprosthetic Shoulder Infection

by Sebastian Klingebiel, Christoph Theil, Georg Gosheger, Kristian Nikolaus Schneider, Thomas Ackmann, Maximilian Timme, Dominik Schorn, Dennis Liem and Carolin Rickert

J. Clin. Med. 2021, 10(2), 218; https://doi.org/10.3390/jcm10020218 - 9 Jan 2021

Cited by 12 | Viewed by 2946

Abstract

Background: Periprosthetic shoulder infections are devastating complications after shoulder arthroplasty. A potential treatment concept is a two-stage prosthesis exchange. Data are sparse in terms of clinical outcome, including infection-free survival and patient satisfaction after this procedure. In the present study, we investigated recurrence of infection, revision-free survivorship and clinical outcome following two-stage revision due to periprosthetic shoulder infection. Furthermore, reasons for poor outcome were analyzed. Methods: Sixteen patients undergoing two-stage revision after shoulder joint infection were retrospectively identified. Recurrence of infection was analyzed by Kaplan–Meier survival curve. Clinical outcome was quantified with subjective shoulder value (SSV), “quick” Disabilities of the Arm, Shoulder and Hand (qDASH) and Rowe score. Range of motion (ROM) was measured pre- and postoperatively. Postoperative scores and ROM were compared in a subgroup analysis according to different reimplanted prosthesis types. Results: The reinfection-free implant survival was 81% after one year and at final follow-up (FU; mean of 33.2 months). The overall revision-free survival amounted to 56% after one year and at final FU. Patients who received reverse shoulder arthroplasty (RSA) as part of reimplantation had less disability and long-term complications. This group demonstrated better subjective stability and function compared to patients revised to megaprostheses or large-head hemiarthroplasties. Conclusions: Two-stage revision following periprosthetic joint infection of the shoulder allows appropriate infection control in the majority of patients. However, the overall complications and revision rates due to mechanical failure or reinfection are high. Reimplantation of RSA seem superior to alternative prosthesis models in terms of function and patient satisfaction. Therefore, bone-saving surgery and reconstruction of the glenoid may increase the likelihood of reimplantation of RSA and potentially improve outcome in the case of infection-related two-stage revision of the shoulder. Full article

(This article belongs to the Special Issue Replacement Surgery and Rehabilitation of the Shoulder)

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13 pages, 3199 KiB

Open AccessArticle

Fracture-Specific and Conventional Stem Designs in Reverse Shoulder Arthroplasty for Acute Proximal Humerus Fractures—A Retrospective, Observational Study

by Jan-Philipp Imiolczyk, Philipp Moroder and Markus Scheibel

J. Clin. Med. 2021, 10(2), 175; https://doi.org/10.3390/jcm10020175 - 6 Jan 2021

Cited by 17 | Viewed by 4000

Abstract

Tuberosity healing and stem design can be outcome-dependent parameters in hemiarthroplasty for proximal humerus fractures (PHF). The relevance of fracture-specific stem design in reverse shoulder arthroplasty (RSA) is still a matter of debate. This retrospective study evaluates tuberosity healing and function for fracture specific stems (A) compared to conventional stems (B) in RSA for complex PHF in 26 patients (w = 21, mean age 73.5 years). Clinically, range of motion (ROM), Constant-Murley-Score (CS), Subjective Shoulder Value (SSV), and external rotation lag signs (ERLS) were evaluated. Healing of greater tuberosity (GT) and lesser tuberosity (LT), scapular notching, and loosening were examined radiologically. There were no statistical significant differences with regards to CS (A: 73 ± 11; B: 77 ± 9 points), SSV (A: 78% ± 11%; B: 84% ± 11%), external rotation (A: 18° ± 20°; B: 24° ± 19°), or internal rotation (A: 5.7 ± 2.2; B: 6.7 ± 2.8 CS-points) (p > 0.05). Mean forward flexion was superior for group A (p = 0.036). Consolidation of GT (82%) and LT (73%) was similar in both groups. Anatomical healing was slightly higher in group B (p > 0.05). Scapular notching was found in 27% (A) and 55% (B) (p > 0.05). RSA for PHF provides good to excellent clinical results. The quantitative and qualitative union rate for both cohorts was similar, indicating that fracture stems with open metaphyseal designs to allow for bone ingrowth do not improve tuberosity healing. ERLS correlates with a worse function in CS and ROM in all planes. Full article

(This article belongs to the Special Issue Replacement Surgery and Rehabilitation of the Shoulder)

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12 pages, 2592 KiB

Open AccessArticle

Postoperative Trends of Serum C-Reactive Protein Levels after Primary Shoulder Arthroplasty—Normal Trajectory and Influencing Factors

by Sebastian Klingebiel, Jan Christoph Theil, Georg Gosheger, Kristian Nikolaus Schneider, Maximilian Timme, Dominik Schorn, Dennis Liem and Carolin Rickert

J. Clin. Med. 2020, 9(12), 3893; https://doi.org/10.3390/jcm9123893 - 30 Nov 2020

Cited by 1 | Viewed by 3084

Abstract

Background—Postoperative serum C-reactive protein (CRP) is an important diagnostic parameter for systemic inflammation and reflects surgical trauma. While trends and normal trajectories after total knee (TKA) or hip arthroplasty (THA) are established, there is no reference standard for shoulder arthroplasty (SA). Therefore, the aim of this study was to research CRP trends and influencing factors following SA. Methods—This retrospective study analyzed postoperative serum CRP levels and trajectories in 280 patients following SA. Influence of prosthesis design, sex, operating time, BMI, and humeral augmentation with bone cement were analyzed using descriptive statistics and (non-) parametric testing. Results—There is a CRP trend with a peak on day two or three, with a subsequent decrease until day seven. Reverse and stemmed prostheses show a statistically higher CRP peak than stemless prostheses or hemiarthroplasties (HA). There was no influence of gender, body mass index (BMI), operating time, or bone cement. Conclusion—The presented findings may contribute to a better understanding of the postoperative CRP course after SA. The results of this retrospective study should be validated by a prospective study design in the future. Full article

(This article belongs to the Special Issue Replacement Surgery and Rehabilitation of the Shoulder)

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11 pages, 2047 KiB

Open AccessArticle

The Characteristics of the Favard E4 Glenoid Morphology in Cuff Tear Arthropathy: A CT Study

by Gilles Walch, Philippe Collotte, Patric Raiss, George S. Athwal and Marc Olivier Gauci

J. Clin. Med. 2020, 9(11), 3704; https://doi.org/10.3390/jcm9113704 - 18 Nov 2020

Cited by 6 | Viewed by 5388

Abstract

Background: Cuff tear arthropathy (CTA) is characterized by superior migration of the humeral head with superior erosion of the glenoid. Rarely, humeral head migration can be anteroinferior with associated anterior erosion of the glenoid, a pattern described by Favard as the type E4 glenoid. The purpose of this retrospective imaging study was to analyze the 2D and 3D characteristics of the E4 glenoid. Methods: A shoulder arthroplasty database of 258 cuff tear arthropathies was examined to identify patients with an E4 type deformity. This resulted in a study cohort of 15 females and 2 males with an average age of 75 years. All patients had radiographs and CT scans available for analysis. CT-scan DICOM (Digital Imaging and Communications in Medicine) data were uploaded to a validated three-dimensional (3D) imaging software. Muscle fatty infiltration, glenoid measurements (anteversion, inclination), and humeral head subluxation according to the scapular plane were determined. Results: The mean anteversion and inclination of the E4 cohort were 32° ± 14° and −5° ± 2, respectively. The mean anterior subluxation was 19% ± 16%. All cases had severe grade 3 or 4 fatty infiltration of the infraspinatus, whereas only 65% had grade 3 or 4 subscapularis fatty infiltration. A significant correlation existed between glenoid anteversion and humeral head subluxation (p < 0.001), but no correlation was found with muscle fatty infiltration. The CT analysis demonstrated an acquired erosive biconcave morphology in 11 patients (65%) and monoconcavity in 6 patients (35%). Conclusion: The E4 type glenoid deformity in cuff tear arthropathy is characterized by an anterior erosion and anteversion associated with anterior subluxation of the humeral head. Full article

(This article belongs to the Special Issue Replacement Surgery and Rehabilitation of the Shoulder)

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13 pages, 1528 KiB

Open AccessArticle

Subsidence of Uncemented Short Stems in Reverse Shoulder Arthroplasty—A Multicenter Study

by Anna-K. Tross, Alexandre Lädermann, Thomas Wittmann, Marc Schnetzke, Philip-C. Nolte, Philippe Collin and Patric Raiss

J. Clin. Med. 2020, 9(10), 3362; https://doi.org/10.3390/jcm9103362 - 20 Oct 2020

Cited by 15 | Viewed by 3613

Abstract

Background: The radiological phenomenon of subsidence following the implantation of uncemented short-stem reverse prostheses (USSP) has not yet been described. The purpose of this study was to describe the rate and potential risk factors for subsidence. We hypothesized that subsidence may be a frequent finding and that a subsidence of >5 mm (mm) is associated with an inferior clinical outcome. Methods: A total of 139 patients with an average age of 73 ± 9 years were included. The clinical and radiological outcome was evaluated at a minimum follow-up (FU) of 12 months. Results: No humeral component loosening was present at a mean FU of 18 (range, 12–51) months. Mean Constant Score (CS) and Subjective Shoulder Value (SSV) improved significantly from 34.3 ± 18.0 points and 37.0 ± 19.5% preoperatively to 72.2 ± 13.4 points and 80.3 ± 16.5% at final FU (p < 0.001). The average subsidence of the USSP was 1.4 ± 3.7 mm. Subsidence of >5 mm was present in 15 patients (11%). No association between a subsidence >5 mm and CS or SSV was found (p = 0.456, p = 0.527). However, a subsidence of >5 mm resulted in lower strength at final FU (p = 0.022). Complications occurred in six cases (4.2%), and the revision rate was 3.5% (five cases). Conclusions: Although subsidence of USSP is a frequent radiographic finding it is not associated with loosening of the component or a decrease in the clinical outcome at short term FU. Level of evidence: Level 4, retrospective study. Full article

(This article belongs to the Special Issue Replacement Surgery and Rehabilitation of the Shoulder)

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