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PubMed2000

Posterior-inferior capsular shift for the treatment of recurrent, voluntary posterior subluxation of the shoulder.

BACKGROUND: The treatment of recurrent posterior instability of the shoulder, especially when it is associated with voluntary subluxation, remains controversial, and operative correction generally is not advised. METHODS: The results of operative correction of recurrent posterior subluxation in a consecutive series of twenty-six shoulders in twenty-four patients were reviewed. Eighteen shoulders were on the dominant side. The average age of the patients was twenty-four years (range, fifteen to thirty-three years). All of the patients had involuntary as well as voluntary posterior instability, but none had a psychiatric disorder. Only five patients had sustained a definite injury that had initiated the instability. Seven shoulders had had previous operations. A program of nonoperative treatment for a duration of at least three months had failed to control the symptoms in all patients. The twenty-six shoulders were treated with a posterior-inferior capsular shift procedure, which included repair of a so-called posterior Bankart lesion in seven shoulders. In addition, one of the shoulders had a posterior bone block and three shoulders (in two patients) had an osteotomy of the posterior part of the glenoid because of excessive glenoid retroversion. The outcome was assessed by means of a personal interview and a clinical examination, which included calculations of a score according to the system of Constant and Murley and the performance of the Simple Shoulder Test, and by means of a radiographic examination, with standardized radiographs and computerized tomography scanning. RESULTS: At an average of 7.6 years (range, 1.8 to 14.6 years) after the operation, the patients estimated that the function of the shoulder was an average of 86 percent of that of a normal shoulder. The average relative score according to the system of Constant and Murley was 91 percent. The subjective result was excellent for sixteen shoulders, good for eight, and fair for two. More than half of all of the patients were able to perform all activities of the Simple Shoulder Test, but eight patients (eight shoulders; 31 percent) still had discomfort at night. Five patients (21 percent) changed their profession because of the shoulder. All but one shoulder had a nearly normal active range of motion. The instability recurred in six (23 percent) of the twenty-six shoulders; three recurrences were in shoulders that had had a primary operation, and three were in shoulders that had had an operation on the posterior aspect of the shoulder before the index procedure. The instability did not recur in four shoulders that had had previous operations on the anterior aspect of the shoulder. The subjective shoulder value, which was the patient's estimation of the value of the affected shoulder as a percentage of that of an entirely normal shoulder, was significantly higher for the stable shoulders (91 percent) than for the unstable shoulders (72 percent) (p<0.05). The relative score according to the system of Constant and Murley was also higher for the stable shoulders (93 percent) than for the unstable shoulders (87 percent), but the difference was not found to be significant, with the numbers available. The joints were found to be well centered radiographically, and only six shoulders showed minimum signs of osteoarthritis. Computerized tomography scanning revealed an average glenoid retroversion of 3.2 degrees (range, 17 degrees of retroversion to 22 degrees of anteversion). When only the shoulders that had not had a posterior bone block or an osteotomy of the posterior aspect of the glenoid were considered, the average glenoid retroversion of those that had recurrent instability was 12.5 degrees, whereas it was only 6.2 degrees for those that remained stable (p<0.05). CONCLUSIONS: Overall, operative correction of voluntary posterior instability of the shoulder yielded very satisfactory intermediate-term clinical results. (ABSTRACT TRUNCATED)

Adolescent↗
PubMed1998

Prospective evaluation of shoulder-related problems in patients with pectoral cardioverter-defibrillator implantation.

BACKGROUND: The pectoral approach to implantation of cardioverter defibrillators (ICDs) has become a standard in defibrillator therapy because of reduced generator size, weight, and volume. But the size of these devices is still comparable to the size of the early conventional antibradycardia pacemakers that were associated with a number of significant pocket- and shoulder-related problems after implantation in the pectoral region. In a prospective, single-center study of 50 patients with subpectoral implantation of a fourth-generation ICD, the ipsilateral shoulder joint was evaluated regarding active shoulder motility, shoulder-related pain, shoulder function, shoulder elevation, insertion tendinitis, and morphologic alterations of the shoulder. METHODS AND RESULTS: The shoulder was evaluated before implantation and at 3, 6, and 12 months after implantation. Shoulder motility was documented by evaluating active abduction, forward flexion, and external rotation. Shoulder-related pain and function were documented by the "Basic Shoulder Evaluation Form," insertion tendinitis was diagnosed by standardized palpation and the impingement test, and morphologic alterations were documented by ultrasound and radiograph of the shoulder. Three months after implantation, 20 (40%) patients had a reduced active abduction, 30 (60%) patients had an impaired active forward flexion, and eight (16%) patients had a reduced external rotation. Thirty-one (62%) patients reported shoulder-related pain or impaired shoulder function according to the "Basic Shoulder Evaluation Form." Twenty-four (48%) patients showed a shoulder elevation and 21 (42%) patients demonstrated clinical signs of insertion tendinitis. After 12 months the number of patients with reduced active abduction, forward flexion, and external rotation dropped to four (8%). Shoulder-related pain and reduced function were documented in seven (13%) patients, four (8%) patients still had shoulder elevation, and five (10%) patients still had signs of insertion tendinitis. None of the postoperatively performed ultrasounds or radiographs showed any pathologic shoulder alterations. No predictors for the occurrence of shoulder-associated problems could be found. CONCLUSIONS: (1) Decreased active shoulder motility, shoulder-related pain, reduced function, shoulder elevation, and insertion tendinitis of the ipsilateral shoulder joint are diagnosed in many patients 3 months after subpectoral ICD implantation. (2) After 12 months the number of patients with impaired shoulder motility, function, shoulder-related pain, shoulder elevation, and insertion tendinitis decreased significantly. (3) Ultrasound and radiographs of the ipsilateral shoulder showed no evidence of pathologic morphologic alterations after subpectoral ICD implantation. (4) No shoulder-associated problems required an operative revision of the subpectoral generator pocket.

Defibrillators, Implantable↗
PubMed2003

Arthrographic and clinical findings in patients with hemiplegic shoulder pain.

OBJECTIVES: To identify the etiology of hemiplegic shoulder pain by arthrographic and clinical examinations and to determine the correlation between arthrographic measurements and clinical findings in patients with hemiplegic shoulder pain. DESIGN: Case series. SETTING: Medical center of a 1582-bed teaching institution in Taiwan. PARTICIPANTS: Thirty-two consecutive patients with hemiplegic shoulder pain within a 1-year period after first stroke were recruited. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical examinations included Brunnstrom stage, muscle spasticity distribution, presence or absence of subluxation and shoulder-hand syndrome, and passive range of motion (PROM) of the shoulder joint. Arthrographic measurements included shoulder joint volume and capsular morphology. RESULTS: Most patients had onset of hemiplegic shoulder pain less than 2 months after stroke. Adhesive capsulitis was the main cause of shoulder pain, with 50% of patients having adhesive capsulitis, 44% having shoulder subluxation, 22% having rotator cuff tears, and 16% having shoulder-hand syndrome. Patients with adhesive capsulitis showed significant restriction of passive shoulder external rotation and abduction and a higher incidence of shoulder-hand syndrome (P=.017). Those with irregular capsular margins had significantly longer shoulder pain duration and more restricted passive shoulder flexion (P=.017) and abduction (P=.020). Patients with shoulder subluxation had significantly larger PROM (flexion, P=.007; external rotation, P<.001; abduction, P=.001; internal rotation, P=.027), lower muscle tone (P=.001), and lower Brunnstrom stages of the proximal upper extremity (P=.025) and of the distal upper extremity (P=.001). Muscle spasticity of the upper extremity was slightly negatively correlated with shoulder PROM. Shoulder joint volume was moderately positively correlated with shoulder PROM. CONCLUSIONS: After investigating the hemiplegic shoulder joint through clinical and arthrographic examinations, we found that the causes of hemiplegic shoulder pain are complicated. Adhesive capsulitis was the leading cause of shoulder pain, followed by shoulder subluxation. Greater PROM of the shoulder joint, associated with larger joint volume, decreased the occurrence of adhesive capsulitis. Proper physical therapy and cautious handling of stroke patients to preserve shoulder mobility and function during early rehabilitation are important for a good outcome.

Adult↗
PubMed2001

Infection after shoulder arthroplasty.

Between 1972 and 1994, 2279 patients underwent primary shoulder arthroplasty (2512 shoulders) and 194 patients underwent revision shoulder arthroplasty (222 shoulders) at the authors' institution. Of these, 18 patients with primary shoulder arthroplasties (19 shoulders) and seven patients with revision shoulder arthroplasties (seven shoulders) were diagnosed with deep periprosthetic infection. Additionally, during this period, seven patients (seven shoulders) with primary shoulder arthroplasties and one patient (one shoulder) with a previously revised shoulder arthroplasty were referred to the authors' institution for treatment of deep periprosthetic infection. Two patients (two shoulders) were excluded because of incomplete medical records and with component removal performed elsewhere. The average time from arthroplasty to the diagnosis of infection was 3.5 years (range, 0-14.8 years). The patients were divided into four groups on the basis of treatment. Group I comprised 20 patients (21 shoulders) who underwent resection arthroplasty. Six of the 21 shoulders had additional episodes of infection. Group II comprised six patients (six shoulders) who underwent debridement and prosthetic retention. Three of the six shoulders failed this treatment with subsequent reinfection and underwent a resection arthroplasty. Group III comprised two patients (two shoulders) who had removal of the prosthesis, debridement, and immediate reimplantation. One patient underwent resection arthroplasty 9 months after direct exchange because of reinfection. Group IV comprised three patients (three shoulders) who had removal of the prosthesis, debridement, and delayed reimplantation. Reinfection has not occurred in any of these patients. At final followup, patients with a prosthesis in situ had better pain relief and shoulder function than patients treated with resection arthroplasty. Delayed reimplantation may offer the best hope for pain relief, eradication of infection, and maintenance of shoulder function.

Adult↗
PubMed2001

Long-term results of total shoulder arthroplasty following bone-grafting of the glenoid.

BACKGROUND: The marked loss of glenoid bone volume or alteration of glenoid version can affect glenoid component fixation in patients undergoing total shoulder arthroplasty. The purpose of this study was to evaluate the long-term results associated with the use of bone-grafting for restoration of glenoid volume and version at the time of total shoulder arthroplasty. METHODS: Twenty-one shoulders received an internally fixed, corticocancellous bone graft for the restoration of peripheral glenoid bone stock at the time of total shoulder arthroplasty between 1980 and 1989. Grafting was indicated when glenoid bone stock was insufficient to maintain adequate version or fixation of the prosthesis. Seventeen shoulders were available for follow-up; the average duration of follow-up for the thirteen shoulders that did not have prosthetic failure within the first two years was seventy months. Total shoulder arthroplasty was performed because of osteoarthritis in five shoulders, chronic anterior fracture-dislocation in five, capsulorrhaphy arthropathy in three, inflammatory arthritis in two, recurrent dislocation in one, and failure of a previous arthroplasty in one. All patients had some form of anterior or posterior instability preoperatively. There were five anterior and twelve posterior glenoid defects. Bone from the resected humeral head was used for grafting in fifteen shoulders, and bicortical iliac-crest bone was used in two. RESULTS: The average glenoid version after grafting was 4 degrees of retroversion, with an average correction of 33 degrees. The graft failed to maintain the original correction in three shoulders due to nonunion, dissolution, or shift. Five total shoulder replacements failed, necessitating glenoid revision at two to ninety-one months postoperatively. The failures were associated with recurrent massive cuff tears (one shoulder), persistent instability (two shoulders), improper component placement (one shoulder), and loss of graft fixation (one shoulder). There were no humeral component failures. According to the criteria of Neer et al., the functional result was rated as excellent in three shoulders, satisfactory in six, and unsatisfactory in eight. CONCLUSIONS: Despite the finding that eight shoulders had an unsatisfactory functional result at the time of longterm follow-up, corticocancellous grafting of the glenoid successfully restored glenoid version and volume in fourteen of the seventeen shoulders in the present study. Patients with glenoid deficiency often have associated glenohumeral instability, which may affect the results of total shoulder arthroplasty. Bone-grafting of the glenoid is a technically demanding procedure that can restore bone stock in patients with structural defects.

Adult↗
PubMed1996

Measuring function of the shoulder. A cross-sectional comparison of five questionnaires.

Measures of both generic and disease-specific health status are being developed and used with increasing frequency for the appraisal of musculoskeletal conditions. The purpose of this study was to compare prospectively the validity of five questionnaires in the assessment of function of the shoulder. Ninety subjects who had various problems related to the shoulder agreed to enter the study. All of the subjects completed a questionnaire package that included the Shoulder Pain and Disability Index, the Simple Shoulder Test, the Subjective Shoulder Rating Scale, the Modified American Shoulder and Elbow Surgeons Shoulder Patient Self-Evaluation Form, and the Shoulder Severity Index as well as a measure of generic health status (the acute version of the Short Form 36 [SF-36]) and two questions that asked the patient to rate the severity of the problem and his or her over-all health. Frequency distributions were created and compared among questionnaires. Spearman rank correlations were calculated to compare the questionnaires with each other and with other assessments. One-way analysis of variance was used to determine the ability of the questionnaires to discriminate between self-rated severity of the problem and over-all health. The frequency distributions were similar among the five shoulder questionnaires, but those of the five shoulder questionnaires differed from that of the SF-36. The correlations were good (0.73 < or = r < or = 0.80) among all of the five shoulder questionnaires except the Subjective Shoulder Rating Scale; they were lower with the Subjective Shoulder Rating Scale and the physical function dimension of the SF-36 (0.12 < or = r < or = 0.60). The shoulder questionnaires discriminated between levels of severity (p < 0.0001) but not between levels of over-all health (0.10 < or = p < or = 0.86). In this concurrent comparison of measures of shoulder-specific outcome in the same subjects, the shoulder questionnaires performed similarly, both in describing function of the shoulder and in discriminating between levels of severity. The shoulder questionnaires performed differently than the SF-36, which confirms the need to use both disease-specific and generic health-status measures to evaluate patients who have a problem related to the shoulder.

Adult↗
PubMed2002

Characterizing the functional improvement after total shoulder arthroplasty for osteoarthritis.

BACKGROUND: Both shoulder surgeons and patients who are considering total shoulder arthroplasty are interested in the anticipated improvement in shoulder comfort and function after the procedure. The purpose of the present study was to characterize shoulder-specific functional gains in relation to preoperative shoulder function and to present this information in a way that can be easily communicated to patients who are considering this surgery. METHODS: We analyzed the preoperative and follow-up shoulder function in patients managed with total shoulder arthroplasty for the treatment of primary glenohumeral osteoarthritis. Functional self-assessments were available for 102 (80%) of 128 shoulders after thirty to sixty months of follow-up. Outcome was assessed with respect to the change in the number of shoulder functions that were performable, the change in shoulder function as a percentage of the preoperative functional deficit, and the change in the ability to perform specific shoulder functions. RESULTS: The average number of shoulder functions that were performable improved from four of twelve preoperatively to nine of twelve postoperatively (p < 0.01). Function improved in ninety-six shoulders (94%). The number of functions that were performable at the time of follow-up was positively associated with preoperative shoulder function (p < 0.05): the better the preoperative function, the better the follow-up function. The improvement in function was greatest for shoulders with less preoperative function (p < 0.01). On the average, patients regained approximately two-thirds of the functions that had been absent preoperatively. Significant improvement was noted in eleven of the twelve shoulder functions that were examined (p < 0.01). The chance of regaining a function that had been absent before surgery was 73%, whereas the chance of losing a function that had been present before surgery was 6%. Older men tended to have greater functional improvement than younger men. CONCLUSION: Total shoulder arthroplasty for the treatment of primary glenohumeral osteoarthritis significantly improves shoulder function. Postoperative function is related to preoperative function. The improvement that was observed in this clinical series can be conveyed to patients most simply by stating that, after surgery, shoulders typically regained approximately two-thirds of the functions that had been absent preoperatively.

Adult↗
PubMed1998

Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results.

Seventy-eight Neer hemiarthroplasties and thirty-six Neer total shoulder arthroplasties were performed at our institution, between January 1, 1976, and December 31, 1985, in ninety-eight patients who were fifty years old or less. Two patients (two shoulders) died, and four patients (four shoulders) were lost to follow-up. The remaining seventy-four hemiarthroplasties (95 per cent) in sixty-four patients and thirty-four total shoulder arthroplasties (94 per cent) in thirty-one patients were included in the clinical analysis as the preoperative and operative records were complete and the patients had been followed for at least five years (mean, 12.3 years) or until revision. All 114 shoulders were included in the survivorship analysis. Both total shoulder arthroplasty and hemiarthroplasty resulted in significant long-term relief of pain (p < 0.0001) as well as improvement in active abduction (p < 0.0001) and external rotation (p < 0.0001). However, with the numbers available, we could not detect a significant difference between the two procedures with respect to these variables. A complete set of radiographs was available for sixty-eight (92 per cent) of the seventy-four shoulders that had a hemiarthroplasty and for thirty-two (94 per cent) of the thirty-four shoulders that had a total shoulder arthroplasty. A radiolucent line around the humeral component was noted after sixteen (24 per cent) of the hemiarthroplasties and after seventeen (53 per cent) of the total shoulder arthroplasties. A radiolucent line around the glenoid component was seen after nineteen (59 per cent) of the total shoulder arthroplasties. Erosion of the glenoid was found after forty-six (68 per cent) of the hemiarthroplasties. The results were graded according to a modification of the system of Neer et al. and of Cofield. Fifteen hemiarthroplasties led to an excellent result; twenty-four, a satisfactory result; and thirty-five, an unsatisfactory or unsuccessful result. Four total shoulder arthroplasties were followed by an excellent result; thirteen, a satisfactory result; and seventeen, an unsatisfactory or unsuccessful result. The estimated survival of the hemiarthroplasty prostheses (with 95 per cent confidence intervals) was 92 per cent (86 to 98 per cent) at five years, 83 per cent (75 to 93 per cent) at ten years, and 73 per cent (59 to 88 per cent) at fifteen years. Analysis of the results in association with the two major diagnoses revealed that the risk of revision was higher for the thirty shoulders that had the hemiarthroplasty for the treatment of the sequelae of trauma than for the twenty-eight that had the procedure for the treatment of rheumatoid arthritis (p = 0.017). The estimated survival of the total shoulder prostheses (with 95 per cent confidence intervals) was 97 per cent (92 to 100 per cent) at five years, 97 per cent (91 to 100 per cent) at ten years, and 84 per cent (70 to 100 per cent) at fifteen years. The risk of revision was higher for the seven shoulders that had had a tear of the rotator cuff at the time of the operation than for the twenty-seven that had not had one (p = 0.029). The data from the present study indicate that a shoulder arthroplasty provides marked long-term relief of pain and improvement in motion; however, nearly half of all young patients who have a shoulder arthroplasty have an unsatisfactory result according to a rating system. Care should be exercised when either a hemiarthroplasty or a total shoulder arthroplasty is offered to patients who are fifty years old or less.

Adult↗
PubMed2002

[Differential therapy for the rheumatoid shoulder].

Despite frequent involvement, the rheumatoid shoulder is neglected in operative treatment of the upper extremities. The slow course of omarthritis, the compensation mechanism of scapulothoracic motion and neighbouring joints as well as dominating disabilities of the lower extremities and the rheumatoid hand are possible explanations. The pattern of destruction of the rheumatoid shoulder is characterized by progressive joint and soft tissue deterioration. Soft tissue involvement determines the course of the shoulder joint. The subacromial space is a common and early site for rheumatoid involvement, often leading to bursitis, tenosynovitis of the biceps tendon and rotator cuff rupture. Sonography and MRI enable the early detection of subacromial and glenohumeral pathology before deterioration is visible radiologically. Surgical intervention in patients with rheumatoid arthritis of the shoulder is based on the degree of radiological destruction according to Larsen, the natural course of the shoulder joint and the soft-tissue condition. The goals of surgery are to relieve pain, increase motion and restore shoulder function. Surgery should be carried out early in the course of the disease, thus determining the long-term prognosis and the remaining surgical options. Depending on the pattern of destruction of the rheumatoid shoulder, the options for treatment can be divided into early and late procedures.Joint-preserving surgery is indicated in the early stages of radiological destruction according to Larsen classification O-III, whereas the late stages of destruction (Larsen IV-V) require reconstructive surgery. The introduction of arthroscopic and semiarthroscopic techniques has improved the acceptance of early synovectomy for the rheumatoid shoulder, but there is still a place for open synovectomy in patients with extensive soft-tissue repair and bone-remodelling procedures. Arthroscopic and open synovectomy are supplementary and noncompetitive surgical procedures for the rheumatoid shoulder. With proceeding bone and soft-tissue destruction corresponding to Larsen stage IV and V, synovectomy is not successful and reconstructive surgery is necessary. Resection-interposition-arthroplasty (RAIP) remains a controversial alternative to arthroplasty in young patients with sufficient bone stock and a reconstructable rotator cuff. The success of cup-replacement will additionally restrict the indications for RAIP. RIAP remains a possible salvage procedure after aseptic and septic loosening of shoulder arthroplasty. Glenohumeral replacement arthroplasty has become the procedure of choice in reconstructive surgery of the shoulder. The severity of soft-tissue and bone destruction determines the choice of shoulder prosthesis. Current modular shoulder systems with increased numbers of humeral-head stem combinations are calculated to achieve a better adjustment of the soft-tissue tension and to optimize the adaptation between head geometry and the natural shape of the glenoid.The surrounding soft-tissue structure, especially the condition of the rotator cuff, is very important for the functional recovery after shoulder arthroplasty. We prefer a hemiarthroplasty of the rheumatoid shoulder joint to avoid critical glenoid fixation. Patients with irreparable rotator cuff tears and severe glenohumeral arthritis remain a difficult challenge in shoulder surgery and the ideal procedure has not yet been found.Pain relief and a modest increase in active motion are the main goals in operative treatment. Bipolar shoulder arthroplasty represents an adequate alternative to currently favoured hemiarthroplasty in patients with cuff-deficient shoulders.

Arthritis, Rheumatoid↗
PubMed1999

Newborn shoulder width: a prospective study of 2222 consecutive measurements.

OBJECTIVES: To relate maternal and infant characteristics to newborn shoulder width and to evaluate the predictive value of newborn shoulder width measurement in cases of shoulder dystocia. DESIGN: Newborn shoulder width was systematically measured at birth during a period of 18 months. SETTING: Department of Obstetrics and Gynaecology of Saint-Antoine University Hospital, Paris, France. POPULATION: A total of 2222 newborn shoulder width measurements were performed and 22 cases of true shoulder dystocia occurred during the study period. METHODS: Newborn shoulder width measurements were reviewed and correlated with maternal age, parity, nonpregnant weight, weight gain during pregnancy, height, race, fasting glucose and one hour glucose levels, gestational age, birthweight and sex of the neonate. A receiver-operating characteristics curve was constructed to evaluate newborn shoulder width as a test for predicting shoulder dystocia. RESULTS: The mean newborn shoulder width was 122.06 mm (10.50 SD). Stepwise multiple regression showed that newborn shoulder width was significantly associated with birthweight (P < 0.001), parity (P = 0.04), and nonpregnant weight (P = 0.04). We estimated that the best cut off for shoulder dystocia prediction was a newborn shoulder width measurement with a low false positive rate (< 10%) in association with a high sensitivity rate. Therefore, newborn shoulder width measurement > or = 140 mm was selected. This measurement should have a low sensitivity of 27.27%, a specificity of 91.82%, a positive predictive value of 4.02%, and a negative predictive value of 99.01% for shoulder dystocia prediction. Nevertheless, birthweight > or = 4000 g should have a better predictive value retrospectively for shoulder dystocia. CONCLUSIONS: Newborn shoulder width measurement, which is strongly correlated with birthweight, still remains a poor predictor for shoulder dystocia, even when this evaluation is correct antenatally.

Adult↗