Background: Component selection and placement in reverse total shoulder arthroplasty (RTSA) is still being debated. Recently, scapulothoracic orientation and posture have emerged as relevant factors when planning an RTSA. However, the degree to which those parameters may influence ROM and whether modifiable elements of implant configuration may be helpful in improving ROM among patients with different postures have not been thoroughly studied, and modeling them may be instructive. Questions/purposes: Using a dedicated expansion of a conventional preoperative planning software, we asked: (1) How is patient posture likely to influence simulated ROM after virtual RTSA implantation? (2) Do changes in implant configuration, such as humeral component inclination and retrotorsion, or glenoid component size and centricity improve the simulated ROM after virtual RTSA implantation in patients with different posture types? Methods: In a computer laboratory study, available whole-torso CT scans of 30 patients (20 males and 10 females with a mean age of 65 ± 17 years) were analyzed to determine the posture type (Type A, upright posture, retracted scapulae; Type B, intermediate; Type C, kyphotic posture with protracted scapulae) based on the measured scapula internal rotation as previously described. The measurement of scapular internal rotation, which defines these posture types, was found to have a high intraclass correlation coefficient (0.87) in a previous study, suggesting reliability of the employed classification. Three shoulder surgeons each independently virtually implanted a short, curved, metaphyseal impaction stem RTSA in each patient using three-dimensional (3D) preoperative surgical planning software. Modifications based on the original component positioning were automatically generated, including different humeral component retrotorsion (0°, 20°, and 40° of anatomic and scapular internal rotation) and neck-shaft angle (135°, 145°, and 155°) as well as glenoid component configuration (36-mm concentric, 36-mm eccentric, and 42-mm concentric), resulting in 3720 different RTSA configurations. For each configuration, the maximum potential ROM in different planes was determined by the software, and the effect of different posture types was analyzed by comparing subgroups. Results: Irrespective of the RTSA implant configuration, the posture types had a strong effect on the calculated ROM in all planes of motion, except for flexion. In particular, simulated ROM in patients with Type C compared with Type A posture demonstrated inferior adduction (median 5° [interquartile range -7° to 20°] versus 15° [IQR 7° to 22°]; p < 0.01), abduction (63° [IQR 48° to 78°] versus 72° [IQR 63° to 82°]; p < 0.01), extension (4° [IQR -8° to 12°] versus 19° [IQR 8° to 27°]; p < 0.01), and external rotation (7° [IQR -5° to 22°] versus 28° [IQR 13° to 39°]; p < 0.01). Lower retrotorsion and a higher neck-shaft angle of the humeral component as well as a small concentric glenosphere resulted in worse overall ROM in patients with Type C posture, with severe restriction of motion in adduction, extension, and external rotation to below 0°. Conclusion: Different posture types affect the ROM after simulated RTSA implantation, regardless of implant configuration. An individualized choice of component configuration based on scapulothoracic orientation seems to attenuate the negative effects of posture Type B and C. Future studies on ROM after RTSA should consider patient posture and scapulothoracic orientation. Clinical Relevance: In patients with Type C posture, higher retrotorsion, a lower neck-shaft angle, and a larger or inferior eccentric glenosphere seem to be advantageous.

Background and purpose — There is a lack of information on any associations between the functional outcome and age and diagnosis in patients who have undergone shoulder arthroplasty. We therefore evaluated the functional outcome in “young” and “old” patients treated with either hemiarthroplasty (HA) or total shoulder arthroplasty (TSA) with diverse diagnoses. Patients and methods — The functional results of 496 primary shoulder arthroplasties were analyzed using the Constant score (age- and sex-adjusted) and subjective satisfaction. Patients ≤55 years of age at surgery were defined as “young. Diagnoses were primary osteoarthritis (n = 339), posttraumatic osteoarthritis (n = 78), cuff tear arthropathy (n = 36), avascular necrosis (n = 30), and rheumatoid arthritis (n = 13). Mean length of follow-up was 4 (2–14) years. Results — 70% of the TSA patients were very satisfied with the postoperative result, as compared to 39% after HA. The Constant score and patient satisfaction were similar in the “young” and “old” groups. Pain relief was better in the “old” group. The mean improvement in the Constant score after cuff tear arthropathy (22 points) was inferior to that for primary osteoarthritis (36 points), avascular necrosis (34 points), and rheumatoid arthritis (37 points). Inferior mean Constant scores were also seen for posttraumatic osteoarthritis (29 points) compared to primary osteoarthritis (36 points). 63% of patients with primary osteoarthritis were very satisfied, as compared to only 36% of the patients with posttraumatic osteoarthritis. Interpretation — Shoulder arthroplasty is successful in the medium term for different glenohumeral diseases, irrespective of patient age at surgery. However, the appropriate treatment method for cuff tear and posttraumatic conditions of the shoulder remains to be found, particularly in young patients.

Background In patients with myelomeningocele (MMC), a high number of fractures occur in the paralyzed extremities, affecting mobility and independence. The aims of this retrospective cross-sectional study are to determine the frequency of fractures in our patient cohort and to identify trends and risk factors relevant for such fractures. Materials and methods Between March 1988 and June 2005, 862 patients with MMC were treated at our hospital. The medical records, surgery reports, and X-rays from these patients were evaluated. Results During the study period, 11% of the patients (n = 92) suffered one or more fractures. Risk analysis showed that patients with MMC and thoracic-level paralysis had a sixfold higher risk of fracture compared with those with sacral-level paralysis. Femoral-neck z-scores measured by dual-energy X-ray absorptiometry (DEXA) differed significantly according to the level of neurological impairment, with lower z-scores in children with a higher level of lesion. Furthermore, the rate of epiphyseal separation increased noticeably after cast immobilization. Mainly patients who could walk relatively well were affected. Conclusions Patients with thoracic-level paralysis represent a group with high fracture risk. According to these results, fracture and epiphyseal injury in patients with MMC should be treated by plaster immobilization. The duration of immobilization should be kept to a minimum (<4 weeks) because of increased risk of secondary fractures. Alternatively, patients with refractures can be treated by surgery, when nonoperative treatment has failed.