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Total Shoulder Arthroplasty: clinical and radiological studies on the implant positioning and fixation
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Orthopaedics.ORCID iD: 0000-0003-4698-8627
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Shoulder arthroplasty surgery has shown remarkable progress during the last few decades. A number of factors affect postoperative range of motion, pain and prosthetic durability. Among these factors, the length of the lever arm and joint stability is the ones that can be altered by the selected prosthetic component. It is uncertain how much of the normal anatomy needs to be re-established. Stemless prostheses with total reliance on metaphyseal fixation were introduced in France in 2004 (TESS, Zimmer Biomet). The goals were to avoid stem-related complications. Stemless implants have other potential benefits, including the ability to restore shoulder anatomy.

Study I: This is a prospective cohort study of 49 patients with one of two versions of the TESS prosthesis (anatomical or reverse) with clinical and radiological follow-up ranging from 9–24 months. The TESS prosthesis showed short-term results that were comparable with other shoulder prosthetic systems.

Study II: This is a prospective comparative non-randomised study of 37 patients (40 shoulders) who underwent TESS reverse shoulder arthroplasty (RSA) with a follow-up ranging from 15–66 months. We found a significant improvement in functional outcome and reduction of pain in both stemmed and stemless groups. Glenoid overhang influenced the occurrence of scapular notching (SN).

Study III: This is a radiological study showing that CT had a good reliability and reproducibility in estimating LHO.

Study IV: This is a prospective radiological study of 69 patients (70 shoulders) with primary osteoarthritis (OA) who had undergone stemless total anatomical shoulder arthroplasty (TSA). This study showed that stemless anatomical TSA could be useful in restoring shoulder anatomy.

Study V: This is a prospective study of 44 patients with OA who had undergone stemless anatomical TSA with a clinical and radiological follow up ranging from 12 – 50 months. Our study showed that LHO reconstruction close to the anatomy of a healthy contralateral shoulder improved shoulder function. Stemless anatomical TSA help to restore LHO. Increasing LHO may have a negative effect on shoulder function at three months but had no effect at 12 months. The main conclusions of this thesis are:

1. TSA (anatomic and reverse) using stemless humeral components is reliable if bone quality is adequate. The complication rate is comparable with other shoulder prosthetic systems.

2. Glenoid overhang decreased complications in RSA.

3. LHO measurement on AP radiographs is less reliable and underestimates the distance when compared with CT.

4. Stemless TSA could be of help in reconstructing shoulder anatomy.

5. Shoulder reconstruction close to the anatomy of a healthy contralateral shoulder improves shoulder function.

 

Abstract [sv]

Axelprotes kirurgi har visat avsevärd utveckling under de senaste decennierna. Ett antal faktorer påverkar postoperativt rörelseomfång, smärta och proteshållbarhet. Bland dessa faktorer utgör längden av hävarmen och ledstabilitet de faktorer som kan ändras genom val av proteskomponent. Det är osäkert om den normala anatomin måste återupprättas. Oskaftad protes med eliminering av humerusstamm och tillit till metafysär fixering introducerades i Frankrike år 2004 (TESS, Zimmer Biomet). Målen var att undvika stam relaterade komplikationer. Oskaftat implantat har andra potentiella fördelar, inklusive möjligheten att återställa axelnsanatomi.

Syftet med denna avhandling var:

(1) Att undersök radiologisk stabilitet av oskaftade axelproteser. (2) Att studera effekten av protes placering vid omvänd axelartroplastik både radiologiska och kliniskt utfall. (3) Att studera tillförlitlighet av mätningen av den laterala humeral offset (LHO), avståndet mellan processus coracoideus till laterala kanten av tuberkulum majus, med användning av CT eller röntgen. (4) Att studera oskaftad axelprotes förmåga att återställa axelnsanatomi. (5) Att studera den kliniska betydelsen av LHO återställning i för det funktionella resultatet efter axelartroplastik.

Studie I: Detta är en prospektiv kohortstudie av 49 patienter med en av de två versionerna av TESS (anatomisk eller omvänd) med klinisk och radiologisk uppföljning från 9-24 månader. TESS protes visade lovande resultat på kort sikt med komplikationer som var jämförbar med andra axelprotessystem.

Studie II: Detta är en prospektiv jämförande icke-randomiserad studie av 37 patienter (40 skuldror) som opererades med TESS omvänd axelartroplastik med en uppföljning från 15-66 månader. Vi fann en signifikant förbättring av funktion och minskning av smärta i både skaftad och oskaftad grupper. Glenoid overhang bedöms påverka risken för scapular notching (SN).

Studie III: Detta är en radiologisk studie som visade att CT hade god tillförlitlighet och reproducerbarhet att mäta LHO.

Studie IV: Detta är en prospektiv radiologisk studie av 69 patienter (70 skuldror) med primär artros som hade genomgått oskaftad total anatomisk axelprotes. Denna studie visade att oskaftad axelprotes kan vara till hjälp att återställa axelnsanatomi.

Studie V: Detta är en prospektiv studie av 44 patienter med unilateral primär artros som hade genomgått oskaftad total axelprotes med en klinisk och radiologisk uppföljning från 12 - 50 månader. Vår studie visade att LHO rekonstruktion till den friska axeln förbättrar axelfunktion. Oskaftat implantat kan vara av hjälp till att återställa LHO. Ökad LHO kan ha en negativ effekt på axelnsfunktion vid tre månader, men denna effekt påvisade ej vid 12 månader.

De viktigaste slutsatserna i denna avhandling är: 1. Oskaftad total axel artroplastik (anatomisk och omvänd) är tillförlitlig om benkvalitén är god med komplikationer som var jämförbar med andra axelprotessystem. 2. Glenoid overhang minskar komplikationer vid omvänd axelartroplastik. 3. LHO mätningen på röntgen är mindre tillförlitlig och underskattar avståndet jämfört med CT. 4. Oskaftad axelprotes skulle kunna vara till hjälp för att rekonstruera axelnsanatomi. 5. Axel rekonstruktion inom anatomi till att efterlikna anatomi på den friska kontralaterala axeln förbättrar axelfunktion.

Place, publisher, year, edition, pages
Umeå: Umeå university , 2015. , 75 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1753
Keyword [en]
Total shoulder arthroplasty, reverse shoulder arthroplasty, stemless shoulder arthroplasty, TESS shoulder prosthesis, comprehensive shoulder prosthesis, scapular notching, arm lengthening, Quick DASH, lateral humeral offset, glenohumeral offset, shoulder anatomy, CT shoulder, shoulder anatomy reconstruction.
National Category
Orthopedics
Research subject
Orthopaedics
Identifiers
URN: urn:nbn:se:umu:diva-110794ISBN: 978-91-7601-327-4 (print)OAI: oai:DiVA.org:umu-110794DiVA: diva2:865501
Public defence
2015-11-20, Aulan, Länssjukhuset Sundsvall-Härnösand, Sundsvall, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2015-10-30 Created: 2015-10-28 Last updated: 2015-10-30Bibliographically approved
List of papers
1. Results of the Total Evolutive Shoulder System (TESSA(A (R))): a single-centre study of 56 consecutive patients
Open this publication in new window or tab >>Results of the Total Evolutive Shoulder System (TESSA(A (R))): a single-centre study of 56 consecutive patients
2011 (English)In: Archives of Orthopaedic and Trauma Surgery, ISSN 0936-8051, E-ISSN 1434-3916, Vol. 131, no 12, 1623-1629 p.Article in journal (Refereed) Published
Abstract [en]

Shoulder arthroplasty surgery has undergone remarkable progress. New concepts like reverse and stemless shoulder prostheses have been widely used. The Total Evolutive Shoulder System (TESSA (R)) is a new innovative system that provides the surgeon with different prosthetic versions. The purpose of the present study was to evaluate our short-term results and complications of the TESS. 56 consecutive patients were operated with one of the two versions of TESS (anatomical or reverse) between October 2007 and December 2009. Preoperative and postoperative evaluation of the function and life quality was achieved by the Quick Disability of the Arm, Shoulder and Hand (DASH) index and EQ-5D self-report questionnaire, respectively. Radiographic follow-up by anteroposterior, axillary and lateral views was done. The anterosuperior approach was used in all cases. We compared the outcome in fracture patients with other categories. 49 patients were available for 9-24 months (mean 14) clinical and radiographic postoperative follow-up. The mean of quick DASH improved from 56 preoperatively to 34 postoperatively (p < 0.001) and EQ-5D from 0.36 preoperatively to 0.73 postoperatively (p < 0.001). The complications were few and we had no radiolucencies or scapular notching during the study period. Fracture patients did worse compared to other categories. TESS prosthesis showed promising short-term results with few complications. The reverse version could be implanted without stem if initial stability was adequate. Long-term follow-up is required to confirm the results of this innovative system in the long run.

Place, publisher, year, edition, pages
Springer, 2011
Keyword
Shoulder arthroplasty, Outcome, Quick DASH, EQ-5D, Complications
National Category
Orthopedics Surgery
Research subject
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-110332 (URN)10.1007/s00402-011-1368-4 (DOI)000297115200003 ()
Available from: 2015-10-20 Created: 2015-10-20 Last updated: 2017-12-01Bibliographically approved
2. Clinical and radiological outcome of the Total Evolutive Shoulder System (TESSA (R)) reverse shoulder arthroplasty: a prospective comparative non-randomised study
Open this publication in new window or tab >>Clinical and radiological outcome of the Total Evolutive Shoulder System (TESSA (R)) reverse shoulder arthroplasty: a prospective comparative non-randomised study
Show others...
2014 (English)In: International Orthopaedics, ISSN 0341-2695, E-ISSN 1432-5195, Vol. 38, no 5, 1001-1006 p.Article in journal (Refereed) Published
Abstract [en]

Purpose The aims of this study were to assess the function and quality of life after the Total Evolutive Shoulder System (TESS) reverse shoulder arthroplasty (RSA), to evaluate the radiological stability of the stemless version and to address the effect of arm lengthening and scapular notching (SN) on the outcome. Methods This was a prospective comparative non-randomised study. A total of 37 consecutive patients (40 shoulders) underwent TESS RSA between October 2007 and January 2012; 16 were stemless and 26 were stemmed. At a mean follow-up of 39 months (15-66), we evaluated range of motion (ROM), pain and functional outcome with QuickDASH and quality of life with EQ-5D score. Radiologically, component positioning, signs of loosening, SN and arm length difference were documented. Results We found a significant improvement in functional outcome and reduction of pain in both stemmed and stemless groups. No humeral loosening was evident, but there were four glenoid loosenings. In 12 shoulders that developed SN, seven already had scapular bone impression (SBI) evident on initial post-operative radiographs. Glenoid overhang seemed to decrease the risk of SN. Arm lengthening was associated with better EQ-5D but did not influence ROM or functional outcome. Conclusions Reverse shoulder arthroplasty markedly improved shoulder function. SN is of concern in RSA, but proper positioning of the glenoid component may prevent its development.

Keyword
Reverse shoulder arthroplasty, Scapular notching, Stemless shoulder, Arm lengthening
National Category
Orthopedics
Identifiers
urn:nbn:se:umu:diva-102893 (URN)10.1007/s00264-013-2277-7 (DOI)000335147900013 ()24458592 (PubMedID)
Available from: 2015-05-09 Created: 2015-05-09 Last updated: 2017-12-04Bibliographically approved
3. Radiologic assessment of glenohumeral relationship: reliability and reproducibility of lateral humeral offset
Open this publication in new window or tab >>Radiologic assessment of glenohumeral relationship: reliability and reproducibility of lateral humeral offset
Show others...
2015 (English)In: Surgical and Radiologic Anatomy, ISSN 0930-1038, E-ISSN 1279-8517, Vol. 37, no 4, 363-368 p.Article in journal (Refereed) Published
Abstract [en]

It has been shown that anatomical reconstruction is an important step in achieving good function after shoulder arthroplasty. It is essential to reconstruct the distance between the coracoid process and greater tubercle as this relates to the moment arm of the deltoid and rotator cuff muscles. This study evaluated the reliability of measurement of the lateral humeral offset (LHO) on plain radiographs and on computed tomography (CT). Four independent observers performed measurements of LHO on radiographs and CT from 26 patients awaiting shoulder reconstruction. The interobserver reliability and intraobserver reproducibility were assessed. Interobserver reliability and intraobserver reproducibility of LHO in axial CT scans were excellent. Plain radiography showed fair to excellent interobserver reliability and variable intraobserver reproducibility. CT is a reliable tool to measure LHO supporting its use in preoperative planning. When AP radiography is used for preoperative planning the examiner should be aware of its limitations and standardisation protocols should be considered.

Keyword
Shoulder radiology, Shoulder arthroplasty, Lateral humeral offset, Shoulder reconstruction, teoarthritis
National Category
Surgery
Identifiers
urn:nbn:se:umu:diva-103207 (URN)10.1007/s00276-015-1424-9 (DOI)000353359100007 ()25588981 (PubMedID)
Available from: 2015-05-26 Created: 2015-05-18 Last updated: 2017-12-04Bibliographically approved
4. Geometrical analysis of stemless shoulder arthroplasty: a radiological study of seventy TESS total shoulder prostheses
Open this publication in new window or tab >>Geometrical analysis of stemless shoulder arthroplasty: a radiological study of seventy TESS total shoulder prostheses
Show others...
2016 (English)In: International Orthopaedics, ISSN 0341-2695, E-ISSN 1432-5195, Vol. 40, no 4, 751-758 p.Article in journal (Refereed) Published
Abstract [en]

Purpose The aim of this study was to investigate the ability of a stemless shoulder prosthesis to restore shoulder anatomy in relation to premorbid anatomy. Methods This prospective study was performed between May 2007 and December 2013. The inclusion criteria were patients with primary osteoarthritis (OA) who had undergone stemless total anatomic shoulder arthroplasty. Radiographic measurements were done on anteroposterior X-ray views of the glenohumeral joint. Results Sixty-nine patients (70 shoulders) were included in the study. The mean difference between premorbid centre of rotation (COR) and post-operative COR was 1 ± 2 mm (range −3 to 5.8 mm). The mean difference between premorbid humeral head height (HH) and post-operative HH was −1 ± 3 mm (range −9.7 to 8.5 mm). The mean difference between premorbid neck-shaft angle (NSA) and post-operative NSA was −3 ± 12° (range −26 to 20°). Conclusions Stemless implants could be of help to reconstruct the shoulder anatomy. This study shows that there are some challenges to be addressed when attempting to ensure optimal implant positioning. The critical step is to determine the correct level of bone cut to avoid varus or valgus humeral head inclination and ensure correct head size.

Place, publisher, year, edition, pages
Springer, 2016
Keyword
Stemless shoulder arthroplasty, TESS stemless prosthesis, Total shoulder arthroplasty, Shoulder anatomy, Shoulder radiology
National Category
Orthopedics
Research subject
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-110786 (URN)10.1007/s00264-015-2935-z (DOI)000373145500016 ()26257276 (PubMedID)
Projects
avhandling
Available from: 2015-10-28 Created: 2015-10-28 Last updated: 2017-12-01Bibliographically approved
5. Association of lateral humeral offset with functional outcome and geometric restoration in stemless total shoulder arthroplasty
Open this publication in new window or tab >>Association of lateral humeral offset with functional outcome and geometric restoration in stemless total shoulder arthroplasty
Show others...
2016 (English)In: Journal of shoulder and elbow surgery, ISSN 1058-2746, E-ISSN 1532-6500, Vol. 25, no 10, E285-E294 p.Article in journal (Other academic) Published
Abstract [en]

Background: Restoration of shoulder geometry is desirable in total shoulder arthroplasty (TSA) and thought to influence the postoperative clinical outcome. We aimed to study the association of postoperative lateral humeral offset (LHO) changes and clinical outcome, as well as to investigate the ability of stemless anatomic TSA to restore shoulder geometry. Methods: In patients with primary shoulder osteoarthritis who underwent stemless anatomic TSA, the preoperative and postoperative clinical outcome was measured. Shoulder geometry was measured on preoperative computed tomography for the osteoarthritic shoulder and contralateral healthy shoulder and on postoperative computed tomography for the operated shoulder. Results: Forty-four patients with a minimum follow-up of 12 months (range, 12-50 months) were available for the study. Postoperatively, the clinical outcome measures improved. The postoperative difference in LHO between the operated shoulder and contralateral healthy shoulder was 1.3 +/- 4.6 mm and was correlated with scores on the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire at 3 months (Pearson correlation = 0.36, P =.01) and visual analog scale for pain at rest (Pearson correlation = 0.30, P =.03) and with exertion (Pearson correlation = 0.34, P =.01) at 3 months. Lengthening of LHO was associated with worsening shoulder function at 3 months but not at 12 months. The postoperative shoulder geometric parameters were restored postoperatively to acceptable ranges. Conclusion: The stemless anatomic TSA could restore shoulder geometry in an acceptable manner. At 3 months but not at 12 months, increased LHO had a negative effect on shoulder function and resulted in more shoulder pain at rest and with exertion but did not affect quality of life, health status, or range of motion.

Place, publisher, year, edition, pages
Elsevier, 2016
Keyword
Stemless shoulder prosthesis, TESS shoulder prosthesis, shoulder anatomy restoration, shoulder offset, lateral humeral offset, total shoulder arthroplasty
National Category
Orthopedics Sport and Fitness Sciences
Research subject
Orthopaedics
Identifiers
urn:nbn:se:umu:diva-110793 (URN)10.1016/j.jse.2016.02.021 (DOI)000389697800001 ()27083578 (PubMedID)
Projects
Avhandling
Note

First published in thesis in manuscript form with the title: Association of lateral humeral offset with functional outcome in total shoulder arthroplasty : a study of 44 stemless implants

Available from: 2015-10-28 Created: 2015-10-28 Last updated: 2017-12-01Bibliographically approved

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