Primary shoulder reverse arthroplasty: Surgical technique

AbstractTotal reverse shoulder replacement is now a very common surgical procedure that has been shown to be effective in the treatment of rotator cuff tear arthropathies or massive rotator cuff tears with pseudo paralysis, even without arthritis. However, the survival curves of the oldest series decrease between 8 and 10 years after arthroplasty (events: implant survival, or worsening of clinical outcome) which explains why the indication for this type of arthroplasty is usually limited to patients over seventy. Moreover, details and technical modifications have been suggested to improve the surgical technique, the quality of fixation and the mechanical conditions of this non-anatomical prosthesis to improve clinical outcome and implant survival. Within the framework of primary surgery, excluding traumatic or revision surgery, the primary indications for this option are massive rotator cuff tears with (or without) osteoarthritis and primary osteoarthritis with rotator cuff tears and/or with severe glenoid wear and finally, rheumatoid arthritis. The purpose of this conference was to assess and describe the most important preoperative criteria and surgical conditions necessary for this procedure as well as specific technical details about the surgical procedure itself based on available options and options under evaluation such as the positioning of the glenoid component (lateralization, bone graft, orientation) and the association of muscle transfers

Reverse prostheses in arthropathies with cuff tear: are survivorship and function maintained over time?

BACKGROUND: The use of reverse shoulder arthroplasty has considerably increased since first introduced in 1985. Despite demonstrating early improvement of function and pain, there is limited information regarding the durability and longer-term outcomes of this prosthesis. QUESTIONS/PURPOSES: We determined complication rates, functional scores over time, survivorship, and whether radiographs would develop signs of loosening. PATIENTS AND METHODS: We retrospectively reviewed 527 reverse shoulder arthroplasties performed in 506 patients between 1985 and 2003. Clinical and radiographic assessment was performed in 464 patients with a minimum followup of 2 years and 148 patients with a minimum followup of 5 years (mean, 7.5 years; range, 5-17 years). Cumulative survival curves were established with end points being prosthesis revision and Constant-Murley score of less than 30 points. RESULTS: Eighty-nine of 489 had at least one complication for a total of 107 complications. Survivorship free of revision was 89% at 10 years with a marked break occurring at 2 and 9 years. Survivorship to a Constant-Murley score of less than 30 was 72% at 10 years with a marked break observed at 8 years. We observed progressive radiographic changes after 5 years and an increasing frequency of large notches with long-term followup. CONCLUSIONS: Although the need for revision of reverse shoulder arthroplasty was relatively low at 10 years, Constant-Murley score and radiographic changes deteriorated with time. These findings are concerning regarding the longevity of the reverse shoulder arthroplasty, and therefore caution must be exercised when recommending reverse shoulder arthroplasty, especially in younger patients. LEVEL OF EVIDENCE: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence

Spatial analysis of the trophic interactions between two juvenile fish species and their preys along a coastal-estuarine gradient

International audienceCoastal and estuarine systems provide nursery grounds for many marine fish species. Their productivity has been correlated with terrigeneous inputs entering the coastal-estuarine benthic food web, thereby favouring the establishment of fish juveniles. Studies in these ecosystems often describe the nursery as a single large habitat without verifying nor considering the presence of contiguous habitats. Our study aimed at identifying different habitats based on macrozoobenthic communities and morpho-sedimentary characteristics and assessing the trophic interactions between fish juveniles and their benthic preys within these habitats. It included 43 sampling sites covering 5 habitats in which we described taxonomically and quantitatively the invertebrates and fish communities with stable isotopes and gut contents. It suggested that the benthic common sole Solea solea displayed feeding plasticity at the population level, separating the juveniles (G0) from the older fish (G1) into different "feeding sub-populations". Size-based feeding plasticity was also observable in the spatial occupancy of that species in the studied bay. The demersal pouting, Trisopterus luscus, equally used the different habitats but displayed low feeding plasticity across and inside each habitat. Stable isotopes proved to be powerful tools to study the spatial distribution of trophic interactions in complex ecosystems like the bay of Vilaine and to define optimal habitats for fish that use the coastal-estuarine ecosystem as nursery ground

Spatial changes in fatty acids signatures of the great scallop Pecten maximus across the Bay of Biscay continental shelf

The spatial variability of food resources along continental margins can strongly influence the physiology and ecology of benthic bivalves. We explored the variability of food sources of the great scallop Pecten maximus, by determining their fatty acid (FA) composition along an inshore-offshore gradient in the Bay of Biscay (from 15 to 190 m depth). The FA composition of the digestive gland showed strong differences between shallow and deep-water habitats. This trend was mainly driven by their content in diatom-characteristic fatty acids, which are abundant near the coast. Scallops collected from the middle of the continental shelf were characterized by higher contents of flagellate markers than scallops from shallow habitats. This could be related to a permanent vertical stratification in the water column, which reduced vertical mixing of waters, thereby enhancing organic matter recycling through the microbial loop. In the deeper water station (190 m), FA compositions were close to the compositions found in scallops from shallow areas, which suggest that scallops could have access to the same resources (i.e. diatoms). Muscle FA composition was more indicative of the physiological state of scallops over this depth range, revealing contrasting reproductive strategies among the two coastal sites and metabolic or physiological adaptation at greater depth (e.g. structural and functional adjustments of membrane composition). This study therefore revealed contrasted patterns between shallow and deeper habitats for both P. maximus muscle and digestive gland tissues. This emphasizes the variability in the diet of this species along its distribution range, and stresses the importance of analyzing different tissues for their FA composition in order to better understand their physiology and ecology

Spatial variability of stable isotope ratios in oysters (Crassostrea gigas) and primary producers along an estuarine gradient (Bay of Brest, France)

This study aimed at characterizing the diet of the oyster Crassostrea gigas along an estuarine gradient in the Bay of Brest (France), through stable isotope (delta C-13 and delta N-15) measurements in primary producers and wild oysters. The contribution of different potential food sources to the diet of C. gigas was estimated at high spatial resolution (over a gradient of 40 km with samplings every 2 km) to identify ecological transition zones and highlighted the dominance of resuspended biofilm in oysters diet. Although the different primary producers did not display any obvious pattern along the estuarine gradient, the stable isotope signatures of C. gigas differed among estuarine, inner Bay, and open sea sites. In particular, a striking N-15 depletion pattern was found along the gradient which allowed to identify seven homogeneous groups. Moreover, some unexpected values found at two stations within the estuary revealed localized anthropogenic disturbances. Overall, our results suggest that suspension feeders might be better indicators of ecosystem functioning than primary producers and reflect the different ecological processes occurring along estuarine gradients, including localized anthropogenic inputs. We suggest that the usefulness of suspension feeders as indicators of ecosystem functional typology lies in the dominance of benthic material in their diet, which results in locally occurring processes being reflected in oysters' stable isotope ratios

Comparative study of isotopic trends in two coastal ecosystems of North Biscay: A multitrophic spatial gradient approach

In coastal estuarine embayments, retention of water masses due to coastal topography may result in an increased contribution of continental organic matter in food webs. However, in megatidal embayments, the effect of topography can be counterbalanced by the process of tidal mixing. Large amounts of continental organic matter are exported each year by rivers to the oceans. The fate of terrestrial organic matter in food webs of coastal areas and on neighboring coastal benthic communities was therefore evaluated, at multi-trophic levels, from primary producers to primary consumers and predators. Two coastal areas of the French Atlantic coast, differing in the contributions from their watershed, tidal range and aperture degree, were compared using carbon and nitrogen stable isotopes (delta C-13 and delta N-15) during two contrasted periods. The Bay of Vilaine receives large inputs of freshwater from the Vilaine River, displaying N-15 enriched and C-13 depleted benthic communities, emphasizing the important role played by allochtonous inputs and anthropogenic impact on terrestrial organic matter in the food web. In contrast, the Bay of Brest which is largely affected by tidal mixing, showed a lack of agreement between isotopic gradients displayed by suspended particulate organic matter (SPOM) and suspension-feeders. Discrepancy between SPOM and suspension-feeders is not surprising due to differences in isotopes integration times. We suggest further that such a discrepancy may result from water replenishment due to coastal inputs, nutrient depletion by phytoplankton production, as well as efficient selection of highly nutritive phytoplanktonic particles by primary consumers. (C) 2013 Elsevier Ltd. All rights reserved

Omarthrose ecentrée : symposium

Cuff tear arthropathy is defined as the combination of a gleno-humeral arthritis and a massive rotators cuff tear. It is generally admitted that the cuff tear, or its deficiency jeopardises the results of anatomic prosthesis. Grammont imagined and grew the concept of the reverse prosthesis whose aim was to remedy the insufficiency of the rotator cuff and whose use has dramatically modified the therapeutic approach in these complicated situations. The aim of this symposium is to analyse the results of shoulder arthroplasty (anatomic prosthesis, bipolar or reverse) in cuff tear arthropathy, in massive and isolated cuff tears which justify the use of prosthetic surgery, and in centered osteoarthritis with deficient cuff also justifying this use. Massive cuff tears and cuff tear arthropathy have been considered as the stages of a same pathology by Hamada whose classification has been used for the purposes of this study. Out of the 738 initial prosthesis, 111 have been eliminated because of death, incomplete files or lost of sight, without any known complication. Out of the remaining 627 who were used as a basis for this symposium (representing 85% of initial cases), 570 who still had their prosthesis were reviewed and their functional results analysed after 2 years or more. The population was mainly female (72%) who were injured on the dominant side (75%) with a mean age of 72 years. The preoperative Constant score was in average 24 and 24% of the patients had already been operated on their shoulder. For those who had an acetabulization of the acromion, the strength in external rotation was significantly less satisfying and the lesion of the infraspinatus and the teres minor were more frequent. 48 hemiarthroplasties, 52 bipolar and 527 reverse prosthesis were studied. At revision, with an average follow up of 52 months, the revision rate was 23% for hemiarthroplasties, 14% for reversed prosthesis and only 8% for bipolar prosthesis. The prosthesis was removed in 21% of hemiarthroplasties, 5% of reverse and 2% of bipolar. No infection to report in the hemi group or the bipolar group, whereas there was an infection rate of 5% in the reverse group. Nevertheless, the Constant score was significantly better with reverse (62) than with bipolar (45) or hemi (44). The active elevation was also better with the reverse whereas the external rotation was not as good as with anatomic prosthesis. The analytic study of the results of the reverse prosthesis shows a negative influence of the lesion of the sub-scapularis and the teres minor. The results are disappointing with young patients and those who had surgical precedents. On X-ray, we can notice 0.5% of humeral loosening withouth any correlation to the fact that the implant is cemented or not, 3.6% of glenoid loosening and 68% of scapular notches without any significant change on the Constant score. Their occurrence is correlated to a preoperative rising of the humeral head and a superior glenoid lesion. It is observed more frequently with the supero-lateral approach compared to the delto-pectoral one. The frequency of these notches grows with the follow up and their occurrence is often associated to humeral radiolucent lines. On the long term, the survival rate of these prosthesis is 89% at 10 years. The Constant score deteriorates gradually after 7 years; this seems to be linked to the occurrence of x-ray modifications in the years that followed. The main complications observed with reverse prosthesis were the infections (5.1%), the glenoid problems (5.1%), the instabilities (3.6%), the acromion fractures (3.0%). Infections can be treated by a wash out and antibiotics in the first 3 months, then the removal of the prosthesis becomes necessary. The instabilities occur more often for males, with delto-pectoral approach and with 36mm diameter glenoids. The glenoid problems are frequent in the first years and often due to technical errors or material defects (unscrewing of the glenosphere). Acromion fractures have an important clinical impact when they concern the spine and there healing is difficult to obtain, whichever method is used. In conclusion, the use of a prosthesis for cuff tear arthropathies must be thought about, especially in massive cuff tear without osteoarthritis, in patients with previous surgery, and in patients younger than 70. If the active elevation is conserved and the patient is young, the use of an hemi or a bipolar prosthesis can be debated. In other cases, the indication of a reverse prosthesis is preferable given that the clinical results are better. In these cases, the surgical technique must be accurate, bearing in mind the advantages and disadvantages of the two possible approaches, the type of implant (36 vs 42), the position and orientation of the glenoid baseplate according to the pre-operative bone wear, the orientation of the humeral implant, the need for reinsertion of the subscapularis and, maybe, the possibility of an associated transfer of the latissimus dorsi

Omarthrose ecentrée : symposium

Cuff tear arthropathy is defined as the combination of a gleno-humeral arthritis and a massive rotators cuff tear. It is generally admitted that the cuff tear, or its deficiency jeopardises the results of anatomic prosthesis. Grammont imagined and grew the concept of the reverse prosthesis whose aim was to remedy the insufficiency of the rotator cuff and whose use has dramatically modified the therapeutic approach in these complicated situations. The aim of this symposium is to analyse the results of shoulder arthroplasty (anatomic prosthesis, bipolar or reverse) in cuff tear arthropathy, in massive and isolated cuff tears which justify the use of prosthetic surgery, and in centered osteoarthritis with deficient cuff also justifying this use. Massive cuff tears and cuff tear arthropathy have been considered as the stages of a same pathology by Hamada whose classification has been used for the purposes of this study. Out of the 738 initial prosthesis, 111 have been eliminated because of death, incomplete files or lost of sight, without any known complication. Out of the remaining 627 who were used as a basis for this symposium (representing 85% of initial cases), 570 who still had their prosthesis were reviewed and their functional results analysed after 2 years or more. The population was mainly female (72%) who were injured on the dominant side (75%) with a mean age of 72 years. The preoperative Constant score was in average 24 and 24% of the patients had already been operated on their shoulder. For those who had an acetabulization of the acromion, the strength in external rotation was significantly less satisfying and the lesion of the infraspinatus and the teres minor were more frequent. 48 hemiarthroplasties, 52 bipolar and 527 reverse prosthesis were studied. At revision, with an average follow up of 52 months, the revision rate was 23% for hemiarthroplasties, 14% for reversed prosthesis and only 8% for bipolar prosthesis. The prosthesis was removed in 21% of hemiarthroplasties, 5% of reverse and 2% of bipolar. No infection to report in the hemi group or the bipolar group, whereas there was an infection rate of 5% in the reverse group. Nevertheless, the Constant score was significantly better with reverse (62) than with bipolar (45) or hemi (44). The active elevation was also better with the reverse whereas the external rotation was not as good as with anatomic prosthesis. The analytic study of the results of the reverse prosthesis shows a negative influence of the lesion of the sub-scapularis and the teres minor. The results are disappointing with young patients and those who had surgical precedents. On X-ray, we can notice 0.5% of humeral loosening withouth any correlation to the fact that the implant is cemented or not, 3.6% of glenoid loosening and 68% of scapular notches without any significant change on the Constant score. Their occurrence is correlated to a preoperative rising of the humeral head and a superior glenoid lesion. It is observed more frequently with the supero-lateral approach compared to the delto-pectoral one. The frequency of these notches grows with the follow up and their occurrence is often associated to humeral radiolucent lines. On the long term, the survival rate of these prosthesis is 89% at 10 years. The Constant score deteriorates gradually after 7 years; this seems to be linked to the occurrence of x-ray modifications in the years that followed. The main complications observed with reverse prosthesis were the infections (5.1%), the glenoid problems (5.1%), the instabilities (3.6%), the acromion fractures (3.0%). Infections can be treated by a wash out and antibiotics in the first 3 months, then the removal of the prosthesis becomes necessary. The instabilities occur more often for males, with delto-pectoral approach and with 36mm diameter glenoids. The glenoid problems are frequent in the first years and often due to technical errors or material defects (unscrewing of the glenosphere). Acromion fractures have an important clinical impact when they concern the spine and there healing is difficult to obtain, whichever method is used. In conclusion, the use of a prosthesis for cuff tear arthropathies must be thought about, especially in massive cuff tear without osteoarthritis, in patients with previous surgery, and in patients younger than 70. If the active elevation is conserved and the patient is young, the use of an hemi or a bipolar prosthesis can be debated. In other cases, the indication of a reverse prosthesis is preferable given that the clinical results are better. In these cases, the surgical technique must be accurate, bearing in mind the advantages and disadvantages of the two possible approaches, the type of implant (36 vs 42), the position and orientation of the glenoid baseplate according to the pre-operative bone wear, the orientation of the humeral implant, the need for reinsertion of the subscapularis and, maybe, the possibility of an associated transfer of the latissimus dorsi