Reverse shoulder prosthesis in patients with rheumatoid arthritis: a systematic review

PURPOSE: To obtain detailed information on the outcomes of patients with rheumatoid arthritis (RA) undergoing reverse shoulder arthroplasty (RSA) METHODS: A literature search was conducted for studies reporting on the use of RSA in RA patients from 1990 to 2014. The inclusion criteria were a report of sufficient information on pre-operative status and surgical outcome allowing evaluation of the therapeutic potential of RSA in RA. The literature search resulted in 586 hits, but only five studies that met the inclusion criteria were assessed. RESULTS: There were 100 shoulders that had been operated on, of which 87 were followed for a mean of 55.4 months, the longest follow-up being 11.9 years Most patients had glenohumeral erosive lesions of Larsen Grade III or IV. The Delta III prosthesis was implanted in most cases and in three studies bone graft was used for severe glenoid lesions. The main outcome measures employed were the Constant score (Cs) and ASES questionnaire. The mean increase in Cs and ASES score after surgery was 42.4 and 54 points, respectively. The mean post-operative forward elevation was 120.6°, the average increment being 51° and the mean increase of abduction was 58.5°. The mean prevalence of scapular notching was 35.4 %. The rate of adverse events was 31 %, but the vast majority were of minor severity. Eight prostheses underwent revision, due to infection in four. CONCLUSIONS: RSA implanted in RA patients would appear to give similar results to those obtained in massive cuff tears with or without arthropathy

Kinematic analysis of reaching movements of the upper limb after total or reverse shoulder arthroplasty

Studies have analyzed three-dimensional complex motion of the shoulder in healthy subjects or patients undergoing total shoulder arthroplasty (TSA) or reverse shoulder arthroplasty (RSA). No study to date has assessed the reaching movements in patients with TSA or RSA. Twelve patients with TSA (Group A) and 12 with RSA (Group B) underwent kinematic analysis of reaching movements directed at four targets. The results were compared to those of 12 healthy subjects (Group C). The assessed parameters were hand-to-target distance, target-approaching velocity, humeral-elevation angular velocity, normalized jerk (indicating motion fluidity), elbow extension and humeral elevation angles. Mean Constant score increased by 38 points in Group A and 47 in Group B after surgery. In three of the tasks, there were no significant differences between healthy subjects and patients in the study groups. Mean target-approaching velocity and humeral-elevation angular velocity were significantly greater in the control group than in study groups and, overall, greater in Group A than Group B. Movement fluidity was significantly greater in the controls, with patients in Group B showing greater fluidity than those in Group A. Reaching movements in the study groups were comparable, in three of the tasks, to those in the control group. However, the latter performed significantly better with regard to target-approaching velocity, humeral-elevation angular velocity and movement fluidity, which are the most representative characteristics of reaching motion. These differences, that may be related to deterioration of shoulder proprioception after prosthetic implant, might possibly be decreased with appropriate rehabilitation

Lumbar interspinous process fixation and fusion with stand-alone interlaminar lumbar instrumented fusion implant in patients with degenerative spondylolisthesis undergoing decompression for spinal stenosis

Abstract STUDY DESIGN: Prospective cohort study. PURPOSE: To assess the ability of a stand-alone lumbar interspinous implant (interspinous/interlaminar lumbar instrumented fusion, ILIF) associated with bone grafting to promote posterior spine fusion in degenerative spondylolisthesis (DS) with vertebral instability. OVERVIEW OF LITERATURE: A few studies, using bilateral laminotomy (BL) or bilateral decompression by unilateral laminotomy (BDUL), found satisfactory results in stenotic patients with decompression alone, but others reported increased olisthesis, or subsequent need for fusion in DS with or without dynamic instability. METHODS: Twenty-five patients with Grade I DS, leg pain and chronic low back pain underwent BL or BDUL and ILIF implant. Olisthesis was 13% to 21%. Follow-up evaluations were performed at 4 to 12 months up to 25 to 44 months (mean, 34.4). Outcome measures were numerical rating scale (NRS) for back and leg pain, Oswestry disability index (ODI) and short-form 36 health survey (SF-36) of body pain and function. RESULTS: Fusion occurred in 21 patients (84%). None had increased olisthesis or instability postoperatively. Four types of fusion were identified. In Type I, the posterior part of the spinous processes were fused. In Type II, fusion extended to the base of the processes. In Type III, bone was present also around the polyetheretherketone plate of ILIF. In Type IV, even the facet joints were fused. The mean NRS score for back and leg pain decreased by 64% and 80%, respectively. The mean ODI score was decreased by 52%. SF-36 bodily pain and physical function mean scores increased by 53% and 58%, respectively. Computed tomography revealed failed fusion in four patients, all of whom still had vertebral instability postoperatively. CONCLUSIONS: Stand-alone ILIF with interspinous bone grafting promotes vertebral fusion in most patients with lumbar stenosis and unstable Grade I DS undergoing BL or BDUL

BONE REGROWTH AFTER SURGICAL DECOMPRESSION FOR LUMBAR SPINAL STENOSIS

Abstract: We reviewed 40 patients treated surgically for lumbar stenosis at an average time of 8.6 years after operation. In 32, total laminectomy had been performed and in eight bilateral laminotomy, both at one or more levels. Of the 16 patients with degenerative spondylolisthesis, ten had had a concomitant spinal fusion. Patients were assigned to one of four groups according to the amount of bone regrowth: group 0 had no regrowth and groups I, II, and III, had mild, moderate or marked regrowth, respectively. Only 12% of the patients showed no bone regrowth; 48% were assigned to group I, 28% to group II and 12% to group III. Imaging studies showed varying degrees of recurrent stenosis in patients with moderate or marked bone regrowth. All patients with degenerative spondylolisthesis showed bone regrowth, which was more severe in those who had not had a fusion. The clinical results were satisfactory in most of the patients with mild or no bone regrowth and significantly less good in those with moderate or marked regrowth. In the group with degenerative spondylolisthesis, the proportion of satisfactory results was significantly higher in patients who had had spinal fusion. The long-term results of surgery for lumbar stenosis depend both upon the amount of bone regrowth and the degree of postoperative vertebral stability

Subacromial space in adult patients with thoracic hyperkyphosis and in healthy volunteers.

The assumption that subacromial space decreases in patients with thoracic hyperkyphosis arises from sporadic and personal observations. The purpose of this study was to compare width of subacromial space calculated on radiographs and CT scans of a high number of patients with thoracic hyperkyphosis that registered on exams of healthy volunteers. We measured the subacromial space, using Petersson's method, on radiographs of 47 patients with idiopathic or acquired thoracic hyperkyphosis and of 175 healthy shoulder volunteers. Both groups were further distinguished considering gender and age. Females with hyperkyphosis were also divided in two subgroups: those with a kyphotic curve of less (24 patients) or more (19 patients) than 50 degrees , respectively. Subacromial space of all patients and of 21 volunteers was also evaluated using CT. Acromio-humeral space was less wide in patients with hyperkyphosis with respect to coeval volunteers of the same gender; in females and in subjects older than 60. Subacromial width of females with hyperkyphosis whose curve was more than 50 degrees was significantly narrower (p<0.05) than that measured on radiograms or CT scans of females with a less severe spinal deformity. Decrease of subacromial space may be attributed to less posterior tilting of the scapula and to dyskinesis of the scapular movement. Scapular malposition causes an anomalous orientation of the acromion that may contribute to subacromial impingement. Patients with thoracic hyperkyphosis greater than 50 degrees had a subacromial space narrower than that measured in patients with a less severe kyphosis. This suggests that subacromial width is directly related to severity of thoracic kyphosis. Because hyperkyphosis of patients with osteoporotic vertebral fractures may worsen over the time, subacromial decompression could give only temporary shoulder pain relief

LUMBAR SPINAL STENOSIS AND DIABETES. OUTCOMES OF SURGICAL DECOMPRESSION

Abstract: We reviewed 25 diabetic (mean age 68 years) and 25 non-diabetic patients (mean age 71 years) who had undergone decompression for lumbar spinal stenosis at a mean of 3.4 years after operation to determine whether diabetes affected the outcome of surgery. The preoperative symptoms were similar in the two groups except that an abrupt onset of symptoms, the presence of night pain and the absence of any posture-related pain relief were recorded only by diabetic patients. Nerve-conduction velocity was slowed in 80% of the diabetic and in 25% of the nondiabetic patients. Peripheral vascular deficiency was diagnosed in 20% of patients with diabetes and in 4% of non-diabetics. The outcome of surgery was similarly successful in the two groups. Mistaken preoperative diagnosis was the cause of failure in three diabetic patients, two with diabetic neuropathy and one with diabetic angiopathy

Morphometric anatomical and CT study of the human adult sacroiliac region.

To identify and describe the morphometry and CT features of the articular and extra-articular portions of the sacroiliac region. The resulting knowledge might help to avoid complications in sacroiliac joint (SIJ) fusion. We analyzed 102 dry hemi-sacra, 80 ilia, and 10 intact pelves and assessed the pelvic computerized tomography (CT) scans of 90 patients, who underwent the examination for conditions not involving the pelvis. We assessed both the posterior aspect of sacrum with regard to the depressions located externally to the lateral sacral crest at the level of the proximal three sacral vertebrae and the posteroinferior aspect of ilium. Coronal and axial CT scans of the SIJ of patients were obtained and the joint space was measured. On each side, the sacrum exhibits three bone depressions, not described in anatomic textbooks or studies, facing the medial aspect of the posteroinferior ilium, not yet described in detail. Both structures are extra-articular portions situated posteriorly to the SIJ. Coronal CT scans of patients showing the first three sacral foramens and the interval between sacrum and ilium as a continuous space display only the S1 and S3 portions of SIJ, the intermediate portion being extra-articular. The S2 portion is visible on the most anterior coronal scan. Axial scans show articular and extra-articular portions and features improperly described as anatomic variations. Extra-articular portions of the sacroiliac region, not yet described exhaustively, have often been confused with SIJ. Coronal CT scans through the middle part of sacrum, the most used to evaluate degenerative and inflammatory conditions of SIJ, show articular and extra-articular portions of the region

THE MORPHOMETRY OF THE CORACOID PROCESS - ITS AETHIOLOGIC ROLE IN THE SUBCORACOID IMPINGEMENT SYNDROME

Abstract: Anatomical morphometric studies of the coracoid process and coraco-glenoid space were carried out on 204 dry scapulae. No statistically significant correlations were found between length, or thickness of the coracoid process, prominence of the coracoid tip, coracoid slope, coraco-glenoid distance, or position of the coracoid tip with respect to the uppermost point of the glenoid. These anatomical characteristics were independent. of the dimensions of the scapulae. Three configurations of the coraco-glenoid space were identified. Type I configuration was found in 45% of scapulae and Type II and Type III, in 34% and 21% of specimens, respectively. The lowest value of the coraco-glenoid distance were seen in Type I scapulae. Morphometric characteristics which might predispose to subcoracoid impingement were found in 4% of Type I scapulae. A total of 27 scapulae, nine with each type of configuration were submitted to CT scanning. Scapulae with a Type I configuration were found to have low values for the coraco-glenoid angle and coracoid overlap, which are known to be associated with a short coraco-humeral distance. Subjects with a Type I configuration, and severe narrowing of the coraco-glenoid space, appear to be predisposed to coraco-humeral impingement. These morphometric characteristics may be easily evaluated on CT scans

RELATIONSHIP BETWEEN OS ACROMIALE AND ACROMIOCLAVICOLAR JOINT ANATOMIC POSITION

Most of the orthopaedic literature on os acromiale is focused on the clinical implications, such as impingement and rotator cuff tears; although os acromiale is present in 8% of subjects, scarce information is reported on the causes that may predispose patients to it. Our aim is to investigate whether the origin of os acromiale is related to the position of the acromioclavicular (AC) joint. The acromions of 211 volunteers (control group) and 33 subjects without or with os acromiale were radiographically (axillary view) classified by the Edelson and Taitz method. The method distinguishes the acromion into three types on the basis of the distance between the anterior aspect of the acromion and the AC joint. Of 33 subjects with os acromiale, 11 were without pain. We have compared the frequency of the three types of acromion observed in the two investigated cohorts. Half of the acromions of the control group (52.1%) had the articular facet of the AC joint on the acromion tip, whereas in 45.4% the facet tip was located distally. On the other hand, of 33 subjects with os acromiale, 18.1% and 81.1%, respectively, had the AC joint lying on or distal to the acromion tip. Our data suggest that the greater the distance of the AC joint from the anterior edge of the acromion, the higher the likelihood of an os acromiale

A new test of resistance in the diagnosis of postero-superior rotator cuff tears.

The aim of this study was to assess the diagnostic accuracy of a new clinical test for the diagnosis of subacromial impingement and full thickness postero-superior rotator cuff tears. One hundred and twenty patients who underwent arthroscopic treatment for acromioplasty or cuff repair were previously submitted to a new test of resistance. The test is performed in the standing position with the involved arm in 90 degrees abduction, 20 degrees -30 degrees anteposition and in external rotation (as for full-can test). Thus, the patient was invited to follow the way of a spiral drawn on a drawing sheet for 20 turns; 1 turn = from the centre to the end of the spiral and vice versa (spiral width = 20 cm). The test was considered positive when the patient was not able to conclude it due to strength decrease or to shoulder pain. Sensitivity, specificity, positive and negative predictive values as well as diagnostic accuracy were calculated for our test of resistance. The test resulted scarcely reliable as detector of subacromial impingement and not very reliable as detector of small tear. When the test is positive there is a high probability that a subacromial disease exists; instead, when it is negative there is a high probability that the patient has not a large or massive cuff tear. The resistance test (Gum-Turn test) adds to our armamentarium of physical examination signs in patients with painful shoulder and furnishes further information on possible dimensions of tendinous tear