Robert H Cofield

Mayo Clinic - Rochester, Rochester, Minnesota, United States

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Publications (175)385.3 Total impact

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    ABSTRACT: Background Little information is available on the long-term outcome of shoulder arthroplasty in young patients. The purpose of this study was to report the results, complications, and revision rate of total shoulder arthroplasties (TSAs) in patients younger than 50 years at a minimum 20-year follow-up. Materials and methods Between 1976 and 1985, a single surgeon performed 78 Neer hemiarthroplasties (HAs) and 36 Neer TSAs in patients < 50 years. Fifty-six HAs and 19 TSAs with a minimum 20-year follow-up, or follow-up until reoperation, were analyzed for clinical, radiographic and survivorship outcomes. Results Both HA and TSA showed significant improvements in pain scores (P < .001), abduction (P < .01), and external rotation (P = .02). Eighty-one percent of shoulders were rated much better or better than preoperatively. Modified Neer ratings were similar between groups (P = .41). Unsatisfactory ratings in HA were due to reoperations in 25 (glenoid arthrosis in 16) and limited motion, pain, or dissatisfaction in 11. Unsatisfactory ratings in TSA were due to reoperations in 6 (component loosening in 4) and limited motion in 5. Estimated 20-year survival was 75.6% (confidence interval, 65.9-86.5) for HAs and 83.2% (confidence interval, 70.5-97.8) for TSAs. Discussion At long-term follow-up, both HA and TSA continue to provide lasting pain relief and improved range of motion. However, there are a large number of unsatisfactory Neer ratings. Whereas both groups have survivorship in excess of 75% at 20 years, surgeons should remain cautious in performing shoulder arthroplasty in the young patient.
    Journal of Shoulder and Elbow Surgery. 10/2014;
  • Shawn Sahota, John W Sperling, Robert H Cofield
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    ABSTRACT: Removal of a humeral component during revision shoulder arthroplasty can be difficult. If the component cannot be extracted from above, an alternative approach may compromise bone integrity. Two potential solutions are a humeral window and a longitudinal split. This review was performed to determine complications and outcomes associated with these osteotomies during revision arthroplasty. We reviewed records of 427 patients undergoing revision shoulder arthroplasty, identifying those requiring a window or longitudinal split. Outcomes were intraoperative and postoperative complications, rate of healing, and security of implant fixation. Twenty-six patients underwent creation of a window. Six intraoperative fractures were documented: 5 in greater tuberosity and 1 in humeral shaft. At radiographic follow-up, 23 of 26 windows healed; 2 patients had limited follow-up, and 1 did not have follow-up at our institution. Nineteen patients underwent longitudinal osteotomy. One had intraoperative fracture in greater tuberosity. At radiographic follow-up, 17 of 19 longitudinal splits healed; 1 had limited radiographic follow-up, and 1 did not have follow-up at our institution. Three patients underwent formation of both window and longitudinal osteotomy. At radiographic follow-up, all shoulders healed, and there were no intraoperative or postoperative fractures or malunions. In both groups, there were no cases of malunion or clinical loosening. These data suggest that windows and longitudinal splits facilitate controlled removal of well-fixed components with high rate of union and low rate of intraoperative or postoperative sequelae.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 04/2014; · 1.93 Impact Factor
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    ABSTRACT: Long-stemmed humeral components are often associated with revision shoulder arthroplasty. However, long-stemmed humeral components will likely prove useful in selected patients with extra large shoulders and in those with bone loss from nonarthroplasty causes and in humeral fractures. This study was developed to examine the frequency of use of longer humeral stems, identify the indications for their use, define the results, and enumerate the complications encountered. Thirty-five primary shoulder arthroplasties were followed up clinically and radiographically for at least 2 years or until revision surgery. The primary indications for use of an intermediate or long stem were a large humeral canal in 18 shoulders and severe preoperative metaphyseal or diaphyseal bone loss in 17. Average clinical follow-up was 6.5 years. Excellent or satisfactory results were achieved in 21 of 35 shoulders. No components met criteria to be considered radiographically at risk for clinical loosening. Intraoperative complications included an unrecognized nondisplaced diaphyseal fracture that later displaced in 1 shoulder. Late complications included deep infection in 1 and fracture nonunion in 1. Intermediate or long-stemmed humeral components proved useful in obtaining a secure distal fit in patients with a large humeral canal or in those with significant proximal bone loss. Worse clinical results were achieved in those with bone loss. Radiographic follow-up shows these components are at a low risk for loosening.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 04/2014; · 1.93 Impact Factor
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    ABSTRACT: Chronic locked shoulder dislocations account for 2% to 5% of all shoulder dislocations. There is little information regarding the mid-term to long-term results of anatomic shoulder arthroplasty for treatment of this problem. Thirty-two shoulder arthroplasties were performed in thirty-two patients who had chronic locked posterior dislocation of the shoulder. Eighteen patients were treated with a hemiarthroplasty and fourteen, with a total shoulder arthroplasty. Inclusion criteria included moderate or severe pain and functional limitations. Structural indications included an impression fracture involving ≥45% of the humeral head, fibrosis of the articular cartilage, and/or severe osteopenia of the humeral head. When one-third or more of the glenoid was devoid of articular cartilage, a glenoid component was placed. All patients were followed for a minimum of two years (mean, 8.2 years) or until a reoperation. The operations led to pain relief, with the median pain score decreasing from 4 (on a 5-point scale) preoperatively to 3 postoperatively (p < 0.01), and improvement in shoulder external rotation, from a preoperative median of -15° to a postoperative median of 50° (p < 0.001). Instability recurred in three patients in the early postoperative period. Nine patients underwent a reoperation for various reasons. According to a modified Neer rating system, there were four excellent, fifteen satisfactory, and thirteen unsatisfactory outcomes. Although shoulder arthroplasty for locked posterior dislocation can provide pain relief, improved shoulder external rotation, and a low risk of recurrent instability, the overall rate of satisfaction is inferior to that following anatomic arthroplasty for treatment of glenohumeral osteoarthritis. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. PEER REVIEW This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
    The Journal of Bone and Joint Surgery 02/2014; 96(3):e19. · 3.23 Impact Factor
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    ABSTRACT: The purpose of the present study was to assess thirty and ninety-day reoperation rates after shoulder arthroplasty from 2000 to 2010. Our institution's joint registry was queried to identify shoulder arthroplasties performed from January 2000 to December 2010. Data regarding patient demographics and the type of procedure were reviewed. Reoperations within thirty and ninety days after the index procedure were analyzed. During the eleven-year study period, 2305 primary arthroplasties (502 hemiarthroplasties, 1440 anatomic total shoulder arthroplasties, and 363 reverse total shoulder arthroplasties) and 518 revision arthroplasties (twenty-one hemiarthroplasties, 356 anatomic total arthroplasties, and 141 reverse arthroplasties) were performed. Fifty-four percent of patients were female; mean age was sixty-eight years (range, eighteen to ninety-seven years) and body mass index was 30.3 kg/m2 (range, 14.7 to 65.9 kg/m2). Reoperation was required within thirty days after fourteen primary arthroplasties (0.6%) and eight revision arthroplasties (1.5%); it was required within ninety days after thirty-two primary arthroplasties (1.4%) and thirteen revision arthroplasties (2.5%). The most frequent causes for reoperation after primary and revision arthroplasty were instability (n = 14 and 6) and infection (n = 13 and 3). The mean number of additional procedures required was 1.3 (range, one to four) for primary arthroplasties and 1.8 (range, one to three) for revision arthroplasties; 20% of patients undergoing reoperation required two or more additional procedures. Reoperations led to readmission in 82% of cases. Short-term reoperation after shoulder arthroplasty was infrequent. Wound complications and shoulder instability were the most frequent causes for reoperation. Reoperation was twice as frequent after revision surgery as after primary shoulder arthroplasty. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. PEER REVIEW This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
    The Journal of Bone and Joint Surgery 02/2014; 96(3):e17. · 3.23 Impact Factor
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    ABSTRACT: We assessed the clinical results, radiographic outcomes and complications of patients undergoing total shoulder replacement (TSR) for osteoarthritis with concurrent repair of a full-thickness rotator cuff tear. Between 1996 and 2010, 45 of 932 patients (4.8%) undergoing TSR for osteoarthritis underwent rotator cuff repair. The final study group comprised 33 patients with a mean follow-up of 4.7 years (3 months to 13 years). Tears were classified into small (10), medium (14), large (9) or massive (0). On a scale of 1 to 5, pain decreased from a mean of 4.7 to 1.7 (p = < 0.0001), the mean forward elevation improved from 99° to 139° (p = < 0.0001), and the mean external rotation improved from 20° (0° to 75°) to 49° (20° to 80°) (p = < 0.0001). The improvement in elevation was greater in those with a small tear (p = 0.03). Radiographic evidence of instability developed in six patients with medium or large tears, indicating lack of rotator cuff healing. In all, six glenoid components, including one with instability, were radiologically at risk of loosening. Complications were noted in five patients, all with medium or large tears; four of these had symptomatic instability and one sustained a late peri-prosthetic fracture. Four patients (12%) required further surgery, three with instability and one with a peri-prosthetic humeral fracture. Consideration should be given to performing rotator cuff repair for stable shoulders during anatomical TSR, but reverse replacement should be considered for older, less active patients with larger tears. Cite this article: Bone Joint J 2014;96-B:224-8.
    The bone & joint journal. 02/2014; 96-B(2):224-8.
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    ABSTRACT: Malunion of proximal humeral fractures complicated by damage to the glenohumeral cartilage and injury to the joint capsule and rotator cuff can include treatment requiring anatomic shoulder arthroplasty. This study defines results and complications of this procedure and identifies factors associated with success or failure. From 1976 to 2007, 109 patients underwent shoulder arthroplasty for proximal humerus malunions. Ninety-five met the criteria for analysis with a mean follow-up period of 9.2 years. Fracture types according to the Neer classification were two part in 20, three part in 37, four part in 31, and head splitting in 2, with 16 fracture-dislocations. Hemiarthroplasty was performed in 45 patients, with 50 undergoing total arthroplasty. Pain scores improved from 7.8 to 3.1 (P < .001). The mean active elevation and external rotation improved from 69° to 109° and from 8° and 39°, respectively (P = .001). Of 31 patients with available radiographs, 20 had healed tuberosity osteotomies. Sixteen complications required 10 reoperations, including 6 of 9 patients with severe postoperative instability. There were 57 excellent or satisfactory results by use of the Neer rating. No patient, injury pattern, previous treatment, surgical, or radiologic variation was significantly associated with an increased risk of an unsatisfactory result, except for severe postoperative instability. Kaplan-Meier survivorship for reoperation, in 109 shoulders, was 94.8% (95% confidence interval, 90.5%-99.4%) at 5 years and 90.1% (95% confidence interval, 83.6%-97.1%) at 10 and 15 years. Anatomic shoulder arthroplasty improves pain and motion. Surgery is complex. Tuberosity osteotomies often heal. Postoperative instability is the most common complication leading to reoperation and is usually associated with rotator cuff and shoulder capsule injury.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 01/2014; · 1.93 Impact Factor
  • Shawn Sahota, John W. Sperling, Robert H. Cofield
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    ABSTRACT: Background Removal of a humeral component during revision shoulder arthroplasty can be difficult. If the component cannot be extracted from above, an alternative approach may compromise bone integrity. Two potential solutions are a humeral window and a longitudinal split. This review was performed to determine complications and outcomes associated with these osteotomies during revision arthroplasty. Methods We reviewed records of 427 patients undergoing revision shoulder arthroplasty, identifying those requiring a window or longitudinal split. Outcomes were intraoperative and postoperative complications, rate of healing, and security of implant fixation. Results Twenty-six patients underwent creation of a window. Six intraoperative fractures were documented: 5 in greater tuberosity and 1 in humeral shaft. At radiographic follow-up, 23 of 26 windows healed; 2 patients had limited follow-up, and 1 did not have follow-up at our institution. Nineteen patients underwent longitudinal osteotomy. One had intraoperative fracture in greater tuberosity. At radiographic follow-up, 17 of 19 longitudinal splits healed; 1 had limited radiographic follow-up, and 1 did not have follow-up at our institution. Three patients underwent formation of both window and longitudinal osteotomy. At radiographic follow-up, all shoulders healed, and there were no intraoperative or postoperative fractures or malunions. Conclusions In both groups, there were no cases of malunion or clinical loosening. These data suggest that windows and longitudinal splits facilitate controlled removal of well-fixed components with high rate of union and low rate of intraoperative or postoperative sequelae.
    Journal of Shoulder and Elbow Surgery. 01/2014;
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    ABSTRACT: Background Long-stemmed humeral components are often associated with revision shoulder arthroplasty. However, long-stemmed humeral components will likely prove useful in selected patients with extra large shoulders and in those with bone loss from nonarthroplasty causes and in humeral fractures. This study was developed to examine the frequency of use of longer humeral stems, identify the indications for their use, define the results, and enumerate the complications encountered. Materials and methods Thirty-five primary shoulder arthroplasties were followed up clinically and radiographically for at least 2 years or until revision surgery. The primary indications for use of an intermediate or long stem were a large humeral canal in 18 shoulders and severe preoperative metaphyseal or diaphyseal bone loss in 17. Average clinical follow-up was 6.5 years. Results Excellent or satisfactory results were achieved in 21 of 35 shoulders. No components met criteria to be considered radiographically at risk for clinical loosening. Intraoperative complications included an unrecognized nondisplaced diaphyseal fracture that later displaced in 1 shoulder. Late complications included deep infection in 1 and fracture nonunion in 1. Conclusions Intermediate or long-stemmed humeral components proved useful in obtaining a secure distal fit in patients with a large humeral canal or in those with significant proximal bone loss. Worse clinical results were achieved in those with bone loss. Radiographic follow-up shows these components are at a low risk for loosening.
    Journal of Shoulder and Elbow Surgery. 01/2014;
  • Akin Cil, John W Sperling, Robert H Cofield
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    ABSTRACT: Glenoid bone deficiencies may be addressed by specialized components. The purpose of this study is to evaluate the clinical and radiographic outcomes of 3 different types of nonstandard glenoid components. Thirty-eight patients with a mean age of 65 years (range, 34-84 years) underwent a primary or revision anatomic shoulder arthroplasty with one of 3 nonstandard glenoid components: a polyethylene component with an angled keel for posterior glenoid wear without posterior subluxation; a polyethylene component with 2 mm of extra thickness for central glenoid erosion; or a posteriorly augmented metal-backed glenoid component for posterior glenoid wear and posterior subluxation. Average clinical follow-up was 7.3 years (range, 2-19 years) or until revision surgery. At the most recent follow-up, 24 patients had no, mild, or occasionally moderate pain. Mean elevation improved from 91° to 126°, and mean external rotation improved from 24° to 53°. Thirteen patients had moderate or severe subluxation preoperatively, and 11 had subluxation at follow-up. On radiographic evaluation, 3 glenoid components had loosened and 3 were at risk for loosening at an average 5.5 years of follow-up. Seven patients had revision surgery: 4 for instability, 1 for osteolysis, 1 for component loosening with osteolysis, and 1 for a periprosthetic fracture. Three additional patients had removal of glenoid components, 2 for infection and 1 for loosening. Ten-year survival rate free of revision or removal of the angled keel component was 73% (95% CI: 75.3-70.7); of the extra thick (+2 mm) component, 69% (95% CI: 65-73); and of the posteriorly augmented metal-backed glenoid component, 31% (95% CI: 35.6-26.4). The effectiveness of nonstandard glenoid components in addressing glenoid bone deficiencies is compromised by an increased rate of component loosening and by only partial success in eliminating subluxation.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 12/2013; · 1.93 Impact Factor
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    ABSTRACT: Glenoid bone grafting can be useful to restore an asymmetrically eroded glenoid to better support the glenoid component and improve positioning. The purpose of this study was to evaluate the clinical and radiographic results of patients undergoing structural bone grafting for glenoid deficiency with placement of a cemented glenoid component during primary total shoulder arthroplasty. Between January 1, 1976, and December 31, 2008, 24 patients (25 shoulders) of 2607 shoulders undergoing primary total shoulder arthroplasty (0.96%) had structural bone grafting with a humeral head autograft and screw fixation. The mean clinical follow-up was 8.7 years, and the mean radiographic follow-up was 7.6 years. Twenty-three shoulders experienced pain relief, and patients expressed satisfaction with the operation in these shoulders. Postoperative active elevation averaged 148°, and external rotation with the arm at the side averaged 60°. On radiographic evaluation, 10 shoulders had glenoids at risk for component loosening. Two of these shoulders were symptomatic and underwent revision surgery to address glenoid component loosening. The Neer result rating was excellent in 18 shoulders, satisfactory in 5, and unsatisfactory in the 2 shoulders undergoing revision. Structural bone grafting in primary total shoulder arthroplasty is uncommonly necessary. When it is performed, the clinical outcomes are favorable; however, radiographic analysis shows a moderate rate of failure of glenoid component fixation. It seems likely that alternative treatment methods may prove to be more effective in addressing glenoid wear.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 12/2013; · 1.93 Impact Factor
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    ABSTRACT: This is an update on a previously documented cohort of patients who underwent shoulder arthroplasty for rheumatoid arthritis, with a minimum 5-year clinical follow-up. The survivorship of 303 consecutive shoulder arthroplasties (108 hemiarthroplasties, 195 total shoulder arthroplasties) for rheumatoid arthritis at one institution was assessed. There were 255 arthroplasties in the clinical analysis and 188 in the radiographic analysis. Kaplan-Meier survivorship free of revision at 5 years and 10 years was 96.1% and 92.9% for total shoulder arthroplasty (TSA) and 89.2% and 87.9% for hemiarthroplasty (HA). The most common indications were glenoid loosening (5%) and infection (2%) for TSA revision and glenoid arthrosis (7%) for HA revision. Pain relief was greater with TSA than with HA. In patients with an intact rotator cuff, in comparing TSA with HA, those with a TSA had greater improvements in pain scores (-2.7 vs -1.8 on a 5-point scale) and degrees of elevation (45 versus 24) (P = .08). Approximately 30% of humeral components and 73% of glenoid components had periprosthetic lucencies. There was a shift in position of the glenoid in 33% of TSAs, and 36% were "at risk." Eighty-one percent of HAs had moderate or severe glenoid erosion. Both HA and TSA provide pain relief and improved motion in patients with rheumatoid arthritis. In patients with an intact rotator cuff, pain relief and range of motion are more improved with TSA compared with HA. There is a high rate of component lucency, but component revision is uncommon.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 12/2013; · 1.93 Impact Factor
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    ABSTRACT: The Latarjet procedure has been used commonly for extra-articular treatment of anterior glenohumeral joint instability. Recently, the technique also has been used as a bone-grafting procedure to repair large glenoid defects. The "sling effect" and the "bone-block effect" have been proposed as the stabilizing mechanisms of this procedure. The aim of this study was to determine the stabilizing mechanisms of this procedure. Eight fresh-frozen shoulders were prepared and tested with use of a custom testing machine instrumented with a load cell. With a 50-N axial force applied to the humerus, the humeral head was translated anteriorly. Translational force was measured at both the end-range and the mid-range arm positions, with the capsule intact, after creation of a Bankart lesion, after creation of a large glenoid defect, and after the Latarjet procedure with no load and then three different sets of loads applied to the subscapularis and conjoint tendons. Then, these two tendons were removed to observe the contribution of the sling effect to the stability. Finally, the sutures attaching the coracoacromial ligament to the capsular flap were removed in order to observe the effect of that attachment. The translational force, which decreased significantly after creation of a Bankart lesion or a large glenoid defect, returned to the intact-condition level after the Latarjet procedure was performed. At the end-range arm position, the contribution of the sling effect by the subscapularis and conjoint tendons was 76% to 77% as the load changed, and the remaining 23% to 24% was contributed by the suturing of the capsular flap. At the mid-range position, the contribution of the sling effect was 51% to 62%, and the remaining 38% to 49% was contributed by the reconstruction of the glenoid. The main stabilizing mechanism of the Latarjet procedure was the sling effect at both the end-range and the mid-range arm positions. The Latarjet procedure remains an effective procedure for restoring stability to an unstable glenohumeral joint, particularly when there is glenoid bone deficiency.
    The Journal of Bone and Joint Surgery 08/2013; 95(15):1390-7. · 3.23 Impact Factor
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    ABSTRACT: HYPOTHESIS: The purposes of this study were to determine the incidence of blood transfusion after revision shoulder arthroplasty and to assess risk factors associated with an increased risk of transfusion. MATERIALS AND METHODS: Between 1994 and 2008, 566 consecutive revision shoulder procedures were performed at our institution, which formed the basis of this study. The patient's age, sex, body mass index, comorbidities, preoperative and postoperative hemoglobin level, details of the surgery, operative time, and transfusion details were documented retrospectively from medical records. RESULTS: Overall, 11.3% of patients (64 of 566) required a transfusion. An increased transfusion rate was associated with age (odds ratio [OR] per 10 years, 1.5 [95% confidence interval (CI), 1.2 to 2.0]; P = .002), operative time (≤5 hours vs >5 hours) (OR, 3.3 [95% CI, 1.9 to 5.8]; P < .001), diabetes (OR, 2.3 [95% CI, 1.2 to 4.4]; P = .01), and cardiac disease (OR, 2.7 [95% CI, 1.5 to 5.0]; P < .001). There were significant associations between preoperative hemoglobin level (OR, 0.4 per 1 point [95% CI, 0.3 to 0.5]; P < .001) and a decreased odds of transfusion. The type of surgery (surgery on humeral component) also had an impact on the need for transfusion (P < .001). CONCLUSIONS: Older age, low preoperative hemoglobin level, increased operative time, diabetes, presence of cardiac disease, and type of revision surgery are associated with higher postoperative transfusion rates. These factors should be taken into consideration to more accurately predict the need for transfusion and modify preoperative blood-ordering protocols.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 05/2013; · 1.93 Impact Factor
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    ABSTRACT: Instability after arthroplasty of the shoulder is difficult to correct surgically. Soft-tissue procedures and revision surgery using unconstrained anatomical components are associated with a high rate of failure. The purpose of this study was to determine the results of revision of an unstable anatomical shoulder arthroplasty to a reverse design prosthesis. Between 2004 and 2007, 33 unstable anatomical shoulder arthroplasties were revised to a reverse design. The mean age of the patients was 71 years (53 to 86) and their mean follow-up was 42 months (25 to 71). The mean time to revision was 26 months (4 to 164). Pain scores improved significantly (pre-operative visual analogue scale (VAS) of 7.2 (sd 1.6); most recent VAS 2.2 (sd 1.9); p = 0.001). There was a statistically significant increase in mean active forward elevation from 40.2° (sd 27.3) to 97.0° (sd 36.2) (p = 0.001). There was no significant difference in internal (p = 0.93) or external rotation (p = 0.40). Radiological findings included notching in five shoulders (15%) and heterotopic ossification of the inferior capsular region in three (9%). At the last follow-up 31 shoulders (94%) were stable. The remaining two shoulders dislocated at 2.5 weeks and three months post-operatively, respectively. According to the Neer rating system, there were 13 excellent (40%), ten satisfactory (30%) and ten unsatisfactory results (30%). Revision of hemiarthroplasty or anatomical total shoulder replacement for instability using a reverse design prosthesis gives good short-term results. Cite this article: Bone Joint J 2013;95-B:668-72.
    The bone & joint journal. 05/2013; 95-B(5):668-72.
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    ABSTRACT: Historically, results of open revision of rotator cuff repair have been mixed and often poor. We reviewed the outcomes of revision rotator cuff repair with a detailed analysis of clinical and radiographic risk factors in order to improve patient selection for this type of surgery. Thirty-six patients (37 shoulders) underwent first-time, open revision rotator cuff repair between 1995 and 2005. Average follow-up was 7.0 years (range 1-14.9 years). The tear size was small in 1 shoulder, medium in 8, large in 22 and massive in 6. Associations of 29 clinical and radiographic factors with the outcomes of pain, motion, and function were assessed. Satisfactory outcome occurred in 22 shoulders (59%): An excellent result in 2, a good result in 7, and a fair result in 13. Unsatisfactory, poor results occurred in 15. Pain was substantially reduced in 25 (68%). Median pain scores decreased to five from a pre-operative eight (P = 0.002). Median motion did not change from pre-operative to post-operative. The chance of a satisfactory outcome and improved post-operative motion were associated with males, greater pre-operative motion, increased acromial humeral distance, the absence of glenohumeral arthritis, or a degenerative re-tear. Revision rotator cuff repair, although a safe operation, with a low re-operative rate, has very mixed overall results. By knowing the factors associated with success, surgeons can better counsel patients and with this increased knowledge, consider alternative treatment choices.
    International Journal of Shoulder Surgery 04/2013; 7(2):41-5.
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    ABSTRACT: BACKGROUND: Glenoid component loosening is thought to be a major cause of failure. This study assesses radiographic and clinical failure in shoulder arthroplasty, identifying factors predictive of loosening. METHODS: Three-hundred two shoulder arthroplasties were implanted utilizing a cemented, keeled glenoid component, mean clinical follow-up 8.6 years. One-hundred fifty one shoulders had preoperative, early postoperative, and most recent radiographs, mean radiographic follow-up 8.0 years, minimum 4 years or less if revision was performed (2 cases). RESULTS: Fifty-two of 151 glenoid components (34%) showed a shift in position or a complete lucent line ≥1.5 mm. Four humeral components (3%) shifted or showed a 2-mm lucency in 3 zones. Component survival (Kaplan-Meier) free from radiographic failure at 5 and 10 years were 99% (95% CI) (98-100%) and 67% (95% CI) (58-78%). Glenoid components with lines at the keel on initial radiographs were at risk for radiographic failure, hazard ratio 4.6 95% CI 1.2-17.2, P = .02. No associations were found between radiographic survival and age, gender, diagnosis, glenoid erosion, and preoperative or early subluxation. Late subluxation superiorly was associated with the glenoid at risk for radiographic failure (P = .006). Glenoid component survivals free from revision at 5 and 10 years for the 302 shoulders were 99% (95% CI) (97-100%) and 93% (95% CI) (90-97%). CONCLUSION: Glenoid radiolucencies are seldom seen early, except beneath the faceplate. Glenoid radiolucencies develop, with notable changes 5 or more years following surgery. Humeral components seldom loosen. Revision rates remain low. The high frequency of late radiographic changes dictates the need for innovation.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 03/2013; · 1.93 Impact Factor
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    ABSTRACT: BACKGROUND: Currently, there is little information on the benefits and problems associated with long-stem humeral components in shoulder arthroplasty. This study examined the frequency of use, indications, complications, and security of fixation using a long-stem humeral component in revision shoulder arthroplasty. MATERIALS AND METHODS: Eighty revision shoulder arthroplasties were monitored clinically for at least 2 years or until repeat revision surgery. The primary indications for use of an intermediate or long stem were proximal bone loss in 40, nonunion in 14, a malpositioned previous stem with bone loss in 10, an acute intraoperative fracture in 7, an acute preoperative periprosthetic fracture in 5, diaphyseal bone loss in 2, and a box-shaped osteotomy to remove a well-fixed stem in 2. Clinical follow-up was an average of 5.9 years, and radiographic follow-up was an average of 4.7 years. RESULTS: Intraoperative complications included fracture removing the previous stem in 5, a cortical perforation in 6, and cement extrusion in 7. Late complications included fracture nonunion in 5, deep infection in 2, and component loosening in 1. One component met criteria to be considered radiographically "at risk" for clinical loosening. CONCLUSIONS: Long-stem humeral components are useful to obtain secure fixation in healthy bone in revision shoulder arthroplasty in patients with proximal bone loss, diaphyseal fracture, or a previously malpositioned stem. Complications are frequent, and caution should be taken to avoid intraoperative fractures, distal cortical perforation, or cement extrusion. These components are at low risk for loosening.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 01/2013; · 1.93 Impact Factor
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    ABSTRACT: BACKGROUND: Humeral head variations were developed based on anatomic and biomechanical advantages; however, the effect of this expanded prosthetic inventory has yet to be investigated clinically. This study seeks to determine whether prosthetic variety has led to better outcomes, has led to similar outcomes facilitating joint reconstruction, or created any unanticipated complications. METHODS: One hundred sixty primary total shoulder arthroplasties were performed for osteoarthritis. Patients received 52 standard, 60 eccentric, and 48 offset humeral heads. Head geometry was selected intraoperatively during trialing based on a complementing relationship to the glenoid throughout a near-normal range of motion. Patients had 2 years of follow-up or follow-up until reoperation (mean, 4.7 years; range, 0.8-8.3 years). RESULTS: Mean pain scores decreased from 4.5 to 1.9 on a 5-point scale (P < .001), mean elevation increased from 94° to 150°, mean external rotation increased from 22° to 57° (P < .001), larger lucent lines (≥1.5 mm) or change in glenoid position occurred around 19 components, and survivorship was 98% (95% confidence interval, 97%-100%) at 1 year and 98% (95% confidence interval, 95%-100%) at 5 years. No difference among head configurations was found for any of these outcomes. CONCLUSIONS: Evolution of designs has provided options to more accurately re-create anatomy including changes caused by osteoarthritis. At the length of follow-up in this study, clinical outcomes, radiographic performance, and survivorship are equivalent when applying these humeral head variations, and no special complications have developed.
    Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.] 01/2013; · 1.93 Impact Factor
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    ABSTRACT: The objective of this study was to assess the frequency of, and risk factors for, periprosthetic fractures during and after shoulder arthroplasty. All adults treated with a primary total shoulder arthroplasty or humeral head replacement at the Mayo Clinic Medical Center from 1976 to 2008 were identified. Periprosthetic fractures were validated by medical record review. Univariate and multivariable-adjusted logistic regression analyses were used to assess the association of demographic factors (age, sex, and body mass index [BMI]), underlying diagnosis, implant fixation (cemented or uncemented), American Society of Anesthesiologists (ASA) class, and comorbidity as assessed with the Deyo-Charlson index. The cohort consisted of 2207 patients treated with a total of 2588 primary total shoulder arthroplasties and 1349 patients treated with 1431 humeral head replacements. Seventy-two medical-record-confirmed periprosthetic fractures occurred in association with the total shoulder arthroplasties. These consisted of forty-seven intraoperative fractures (forty humeral fractures, five glenoid fractures, and two fractures for which the site was unclear) and twenty-five postoperative fractures (twenty humeral fractures, three glenoid fractures, and two fractures for which the site was unclear). There were thirty-three fractures associated with the humeral head replacements. Fifteen were intraoperative (eight humeral fractures and seven glenoid fractures), and eighteen were postoperative (sixteen humeral fractures and two glenoid fractures). In the multivariable regression analysis of the total shoulder arthroplasties, female sex (odds ratio [OR], 4.19; 95% confidence interval [CI], 1.82 to 9.62; p < 0.001; a 2.4% rate for women versus 0.6% for men) and the underlying diagnosis (p = 0.04; posttraumatic arthritis: OR, 2.55; 95% CI, 0.92 to 7.12) were associated with a significantly higher risk of intraoperative humeral fracture in general, and female sex was associated with the risk of intraoperative humeral shaft fracture (OR, infinity; p < 0.001). In combined analyses of all patients (treated with either total shoulder arthroplasty or humeral head replacement), a higher Deyo-Charlson index was significantly associated with an increased risk of postoperative periprosthetic humeral shaft fracture (OR, 1.27; 95% CI, 1.11 to 1.45); p < 0.001), after adjusting for the type of surgery (total shoulder arthroplasty or humeral head replacement). The overall risk of periprosthetic fractures after total shoulder arthroplasty or humeral head replacement was low. Women had a significantly higher risk of intraoperative humeral shaft fracture. The underlying diagnosis (especially posttraumatic arthritis) was significantly associated with the risk of intraoperative humeral fracture, and comorbidity was significantly associated with the risk of postoperative humeral shaft fracture. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
    The Journal of Bone and Joint Surgery 10/2012; 94(19):1777-85. · 3.23 Impact Factor

Publication Stats

3k Citations
385.30 Total Impact Points

Institutions

  • 1990–2014
    • Mayo Clinic - Rochester
      • • Division of Orthopaedic Surgery
      • • Department of Orthopedics
      Rochester, Minnesota, United States
  • 1993–2013
    • Mayo Foundation for Medical Education and Research
      • • Department of Orthopaedic Surgery
      • • Department of Orthopedics
      Rochester, MI, United States
  • 2011–2012
    • University of Alabama at Birmingham
      Birmingham, Alabama, United States
  • 2010
    • Fundación Jiménez Díaz
      Madrid, Madrid, Spain
  • 2008–2010
    • Wilford Hall Ambulatory Surgery Center
      Lackland Air Force Base, Texas, United States
    • Stanford University
      • Department of Orthopaedic Surgery
      Stanford, CA, United States
  • 2002–2008
    • Hospital Valle Del Nalon
      Galicia, Spain
    • Hospital Vital Álvarez Buylla
      Asturias, Spain
  • 2007
    • St. Joseph's Health Care London
      London, Ontario, Canada
    • The University of Western Ontario
      • The Hand and Upper Limb Centre
      London, Ontario, Canada
  • 2006
    • Lexington Equine Surgery and Sports Medicine
      Lexington, Kentucky, United States
  • 2004
    • Virginia Commonwealth University
      Richmond, Virginia, United States
  • 2000
    • North Dakota State University
      • Department of Mechanical Engineering
      Fargo, ND, United States
  • 1999–2000
    • Mayo Clinic - Scottsdale
      Scottsdale, Arizona, United States