To The Editor:
The Current Concepts Review "Shoulder Arthrodesis" (2001;83:593-600),
by Clare et al., is an excellent review dealing with all important
points of discussion for shoulder arthrodesis. However, we cannot
agree with their statement that failure of union is rare when current
fixation techniques are used. Pseudarthrosis is still one of the
most frequent complications after shoulder fusion. In this context,
Table I
shows an overview of the literature (papers, published since 1970,
involving ten or more shoulder arthrodeses) and the rate of pseudarthroses
1-33
. Of 691 arthrodeses performed with different fixation techniques,
sixty-one (8.8%) were followed by pseudarthrosis. Recently, we reviewed
our series of thirty fused shoulders (technique: acromiohumeral
and glenohumeral; fixation: pelvic reconstruction plate in twenty-six
and dynamic compression plate in four) since 1987. At a mean of
twenty-nine months (range, six to ninety-seven months), three (10%)
nonunions occurred.
-Oliver R�hmann, MD
Oliver R�hmann, MD
Department of Orthopaedics
Hannover Medical School
Anna-von-Borries-Str.
30625 Hannover
Germany
E-mail address: ruehmann@annastift.de
D.J. Clare, M.A. Wirth, G.I. Groh, and C.A. Rockwood
Jr. reply:
Dr. R�hmann's comments concerning rates of pseudarthrosis after
shoulder arthrodesis are points certainly well taken. In the Complications
section of our report, we made the statement: "Failure of union
. . . is rare when current fixation techniques are used." Our thoughts
are not any different in reaction to Dr. R�hmann's response. The
current fixation methods specifically referred to are well-followed
AO techniques utilizing either single or double plating and combining glenohumeral
and acromiohumeral surfaces. In our Current Concepts Review, the
studies that utilized these techniques had successful fusion rates.
In a series of seventeen shoulder fusions, Kostuik and Schatzker
15
reported no pseudoarthroses. Richards et al.
27
reported on fifty-seven patients who underwent shoulder arthrodesis
with use of the AO technique. Three nonunions resulted, requiring
secondary bone-grafting. In their series of seventeen patients,
Hawkins and Neer
13
reported a pseudarthrosis in four patients. Several types of fixation
methods were used in that study, and it was not mentioned which
particular method was used in the patients who had pseudarthrosis.
The next issue is how one defines a successful fusion rate after
shoulder arthrodesis. A pseudarthrosis rate between 5% and 10% should
not be considered a poor or unacceptable result. Pseudarthrosis
is a complication that can be managed successfully with secondary
bone-grafting. Malposition of the arthrodesis continues to be a
much more serious and prevalent complication. It is easier to address
a pseudarthrosis than a malpositioned arthrodesis. The bottom line
is that this is an end-stage salvage procedure to be performed when
no other options exist.
-David J. Clare, MD
Michael A. Wirth, MD
Gordon I. Groh, MD
Charles A. Rockwood Jr., MD
Corresponding author: David J. Clare, MD
Nebraska Orthopaedic and Sports Medicine
6940 Van Dorn Street, Suite 201
Lincoln, NE 68506
E-mail address: clare@cornhusker.net