Effect of COVID-19 on Shoulder Arthroplasty at a Tertiary Care Medical Center in New York City / Efeito da COVID-19 na artroplastia de ombro em um centro médico terciário na cidade de Nova York

Abstract Objective The COVID-19 pandemic led to an unprecedented pause in elective surgeries, including shoulder arthroplasty. We sought to determine whether clinical and/or demographic differences would be seen between patients who presented for shoulder arthroplasty during the pandemic compared with the previous year (2019). Methods Institutional records were queried for patients who underwent shoulder replacement between March 1 and July 1 of 2019 and 2020. Demographics, range of motion, surgical duration, hospitalization time, discharge disposition, and postoperative management were analyzed. Results The mean duration of surgery was 160 ± 50 minutes in 2020 and 179 ± 54 minutes in 2019 (p= 0.13). The mean hospitalization time was 36 ± 13 hours in 2020 and 51 ± 40 hours in 2019 (p= 0.04). In 2019, 96% of the patients participated in physical therapy, while 71% did it in 2020 (p= 0.003). A total of 100% of the 2019 patients and 86% of the 2020 patients participated in an in-person postoperative follow-up (p= 0.006). The 2019 patients reported for an office visit on average 14 ± 11 days after surgery; the 2020 patients waited 25 ± 25 days to return for a follow-up (p= 0.10). Range of motion, age, American Society of Anesthesiologists (ASA) scores, and complication rates did not differ between the cohorts. Conclusion Patients presenting for surgery during the initial phase of the pandemic were demographically and clinically similar to 2019 patients. However, the length of stay was significantly reduced during the COVID-19 pandemic. Postoperative follow-up and physical therapy were delayed in 2020, but this did not lead to differences in complication or readmission rates compared with those of the 2019 cohort. Level of EvidenceIII.

Resumo Objetivo A pandemia de COVID-19 causou uma pausa sem precedentes em cirurgias eletivas, inclusive artroplastia de ombro. Procuramos determinar as possíveis diferenças clínicas e/ou demográficas entre os pacientes que realizaram artroplastia de ombro durante a pandemia em comparação com o ano anterior (2019). Métodos Os registros institucionais foram consultados para obtenção de informações sobre pacientes submetidos a artroplastia de ombro entre 1° de março a 1° de julho de 2019 e 2020. Dados demográficos, amplitude de movimento, duração da cirurgia, tempo de hospitalização, condições à alta e manejo pós-operatório foram analisados. Resultados O tempo médio de cirurgia foi de 160 ± 50 minutos em 2020 e de 179 ± 54 minutos em 2019 (p= 0,13). O tempo médio de internação foi de 36 ± 13 horas em 2020 e de 51 ± 40 horas em 2019 (p= 0,04). Em 2019, 96% dos pacientes fizeram fisioterapia, enquanto 71% o fizeram em 2020 (p= 0,003). Todos os pacientes de 2019 e 86% dos pacientes de 2020 participaram do acompanhamento pós-operatório presencial (p= 0,006). Os pacientes de 2019 retornaram para a consulta médica em média 14 ± 11 dias após a cirurgia; os pacientes de 2020 retornaram para o acompanhamento em 25 ± 25 dias (p= 0,10). A amplitude de movimento, a idade, a pontuação da American Society of Anesthesiologists (ASA, na sigla em inglês) e as taxas de complicações não diferiram entre as coortes. Conclusão Os pacientes submetidos a cirurgia na fase inicial da pandemia eram demográfica e clinicamente semelhantes aos pacientes de 2019. No entanto, o tempo de internação diminuiu de forma significativa durante a pandemia de COVID-19. O acompanhamento pós-operatório e a fisioterapia foram adiados em 2020, mas isso não levou a diferenças nas taxas de complicações ou de reinternações em comparação às da coorte de 2019. Nível de EvidênciaIII.

Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures / 中华创伤杂志(英文版)

PURPOSE@#Unsatisfactory results of hemiarthroplasty in Neer's 3- and 4-part proximal humerus fractures in elderly, have led to the shift towards reverse shoulder arthroplasty (RSA). The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores.@*METHODS@#We include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head. Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded. According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month, the patients were divided into 2 groups, as the group with successful tuberosity repair and the other with failed tuberosity repair. Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independent t-test for normally distributed parameters and Mann-Whitney test for the parameters, where data was not normally distributed.@*RESULTS@#Of 41 patients, tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases. Lysis of the tuberosity occurred in 5 patients, tuberosity displacement in 2, and nonunion in 2. Mean age was 70.4 years (range 65 - 79 years) and mean follow-up was 58.7 months (range 18 - 93 months). There were no major complications. Group with successful tuberosity repair showed improvement in mean active range of movements, like anterior elevation (165.1° ± 4.9° vs. 144.6° ± 9.4°, p < 0.000), lateral elevation (158.9° ± 7.2° vs. 138.4° ± 9.6°, p < 0.000), external rotation (30.5° ± 6.9° vs. 35.0° ± 6.3°, p = 0.367), internal rotation (33.7° ± 7.5° vs. 32.6° ± 6.9°, p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1 vs. 55.5 ± 5.7, p < 0.000), American shoulder and elbow surgeons score (90.3 ± 2.4 vs. 69.0 ± 5.7, p < 0.000), disability of arm shoulder and hand score (22.1 ± 2.3 vs. 37.6 ± 2.6, p < 0.000).@*CONCLUSION@#Successful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion, strength and shoulder scores. Standardized repair technique and interposition of cancellous bone grafts, harvested from the humeral head can improve the rate of tuberosity healing.

Clinical outcomes of reverse shoulder arthroplasty for the treatment of failed fixation of proximal humeral fracrtures in the elderly patients / 中国骨伤

OBJECTIVE@#To evaluate the clinical outcomes of reverse total shoulder arthroplasty as a revision procedure for the failed fixation of proximal humeral fractures in the elderly patients.@*METHODS@#A retrospective analysis was performed on 8 patients with failed internal fixation of proximal humeral fractures from May 2014 to March 2020, including 3 males and 5 females, aged from 65 to 75 years old. All 8 patients underwent reverse total shoulder arthroplasty, and the mean time between initial fixation and reverse total shoulder arthroplasty ranged from 8 to 16 months. Range of motion(ROM), University of California at Los Angeles(UCLA) shoulder score, visual analogue scale (VAS), self-rating anxiety scale(SAS), and Constant-Murley score of shoulder function were assessed pre-operatively and at the last follow-up. Complications relating to the surgery were recorded.@*RESULTS@#All 8 patients successfully followed up. The mean follow-up after reverse total shoulder arhroplasty ranged from 16 to 28 months. The range of motion (forward flexion, external rotation, abduction and internal rotation) of the affected shoulder was significantly improved after surgery, and the post-operative VAS, SAS and UCLA scores were also significantly improved. For the Constant-Murley score of shoulder joint function, the total scores and the subscores of pain, daily activities, range of motion and strength test at the last follow-up were all significantly improved. Scapular glenoid notch was observed in patient, which was evaluated as grade 1 on imaging. All the other patients did not develop specific or non-specific complications.@*CONCLUSION@#Reverse total shoulder arhroplasty is an appropriate treatment as a revision surgery for failed fixation of proximal humeral fractures. It has shown satisfactory clinical outcomes, accelerating the rehabilitation of shoulder function and improving the quality of life.

Uso de artroplastia reversa de hombro más aloinjerto estructural en paciente con defecto glenoideo anteroinferior: reporte de caso y revisión de la literatura / Use of reverse shoulder arthroplasty plus structural allograft in a patient with an anterior inferior glenoid defect: case report and review of the literature

Los defectos glenoideos en una prótesis primaria o de revisión son un reto para el cirujano ortopedista; la toma adecuada de decisiones y la planificación preoperatoria son dos herramientas fundamentales para que el acto quirúrgico presente los mejores resultados. Existen diversos métodos de imágenes para determinar el tipo de defecto que la glena pueda presentar, ya sea aumento de la retroversión o, peor aún, una glena anteversa acompañada de una subluxación o luxación como tal. Se presenta a continuación un caso de un paciente masculino, de cuarenta y siete años, con artrosis glenohumeral Hamada tipo IV, lesión de manguito rotador Patte tipo 3, con marcada limitación funcional y hallazgos imagenológicos de alteración de su estructura ósea a nivel de glena y cabeza humeral, con dos años de evolución. Se propone como tratamiento una prótesis reversa de hombro con uso de aloinjerto estructural de pilón tibial. Se expone el caso con seguimiento a seis meses de rangos de movilidad y escala de dolor

Glenoid defects in a primary or revision prosthesis are a challenge for an orthopedic surgeon. Appropriate decision-making and preoperative planning are two fundamental tools for the surgical act to present the best results. There are various imaging methods to determine the type of defect that the glenoid may present, whether it is increased retroversion or, worse still, an anteverted glenoid accompanied by a subluxation or dislocation as such.The following is a case of a 47-year-old male patient with Hamada type IV glenohumeral osteoarthritis, Patte type 3 rotator cuff injury, with marked functional limitation and imaging achievements of alterations in his bone structure at the level of the glenoid and humeral head, with two years of evolution. A reverse shoulder prosthesis with the use of a structural allograft of the distal tibia is proposed as treatment, and the case is presented with a 6-month follow-up of ranges of motion and pain scale

Reverse Shoulder Arthroplasty: Evaluation of the Clinical and Functional Outcomes per Etiology / Artroplastia reversa de ombro: Avaliação dos resultados clínicos e funcionais de acordo com a etiologia

Abstract Objective The present study aimed to evaluate the clinical outcomes of reverse shoulder arthroplasty to treat several conditions. Methods Retrospective, longitudinal study analyzing the Constant and University of California at Los Angeles (UCLA) scores and range of motion of patients undergoing reverse shoulder arthroplasty. Results In total, 28 patients were analyzed, with a mean age of 75.6 years old. The mean duration of follow-up was 45 months. Overall, there was a significant variation (p< 0.0001) between the preoperative (10.2 points) and the postoperative UCLA scores (29.6 points), corresponding to a relative increase of approximately 200%. In addition, the mean Constant score was 67.8, and the complication rate was 17.8%. As for functional outcomes per etiology, fracture sequelae cases presented the best mean elevation (165°), Constant score (79 points), postoperative UCLA score (32.5 points), and absolute delta UCLA score increase (22 points), but with no statistical significance. However, cases operated for fracture sequelae showed significantly higher elevation (p= 0.027) and Constant score (p= 0.047) compared to rotator cuff arthropathy cases. In addition, the lowest mean postoperative Constant and UCLA scores were observed for the following etiologies: primary arthrosis, acute fracture, and arthroplasty revision. Conclusion Reverse shoulder arthroplasty showed satisfactory functional outcomes and may be a treatment option not only for rotator cuff arthropathy but for several other conditions.

Resumo Objetivo Avaliar os resultados clínicos da artroplastia reversa do ombro no tratamento de suas diversas indicações. Métodos Estudo longitudinal retrospectivo que analisou os resultados dos escores Constant, UCLA e amplitudes de movimentos dos pacientes submetidos à artroplastia reversa do ombro. Resultados Foram analisados 28 pacientes, a média de idade foi de 75.6 anos, com seguimento médio de 45 meses. No geral, obtivemos uma variação significativa (p< 0,0001) entre o escore UCLA pré-operatório (10,2 pontos) e o escore UCLA pós-operatório (29,6 pontos), o que corresponde a um aumento relativo de aproximadamente 200%. Além disso, obtivemos pontuação média do escore Constant de 67,8 e uma taxa de complicações de 17,8%. Quanto aos resultados funcionais segundo as indicações, os casos de sequela de fratura apresentaram as melhores médias de elevação (165°), escore Constant (79 pontos), escore UCLA pós-operatório (32,5 pontos) e aumento absoluto na variação do escore UCLA (22 pontos), sem significância estatística. Porém, identificou-se que os casos operados por sequela de fratura apresentaram elevação (p= 0,027) e pontuação no escore Constant (p= 0,047) significativamente maiores em relação aos casos de artropatia do manguito rotador. Além disso, observamos que as menores médias dos escores Constant e UCLA pós-operatórios foram obtidos nas seguintes etiologias: artrose primária, fratura aguda e revisão de artroplastia. Conclusão A artroplastia reversa de ombro apresentou resultados funcionais satisfatórios, podendo ser uma opção de tratamento não somente nos casos de artropatia do manguito rotador, mas também em várias outras patologias.

Navigation in Shoulder Arthroplasty Surgery / Navegação em cirurgia de artroplastia de ombro

Abstract The indication of shoulder arthroplasties has increased progressively. Accurate positioning of the components may have significant implications for clinical results. The navigation used to aid in the performance of anatomical and reverse total arthroplasties has provided greater precision in implant placement, especially on the glenoid. The development of the technique, material, and prosthesis design have shown encouraging results and led to a trend toward its expansion. In this way, we estimate a higher survival of the arthroplasties resulting from lower rates of dislocation and early loosening. We aim to describe the current technique and to present the results of the literature with navigation. However, comparative clinical studies with long term follow-up are necessary to prove the efficacy in the final results of total shoulder arthroplasties.

Resumo A indicação de artroplastias do ombro aumentou progressivamente. O posicionamento preciso dos componentes pode ter implicações significativas para os resultados clínicos. A navegação utilizada para auxiliar no desempenho de artroplastias totais anatômicas e reversas tem proporcionado maior precisão na colocação do implante, especialmente do componente glenoidal. O desenvolvimento da técnica, do material e do desenho da prótese têm mostrado resultados encorajadores e levado a uma tendência de expansão da sua utilização. Dessa forma, estimamos uma maior sobrevida das artroplastias resultantes de menores taxas de instabilidade e soltura precoce. Nosso objetivo é descrever a técnica atual e apresentar os resultados da literatura com navegação. No entanto, estudos clínicos comparativos com acompanhamento de longo prazo são necessários para comprovar a eficácia nos resultados finais das artroplastias totais do ombro.

Shoulder Arthroplasty for the Treatment of Proximal Humeral Fractures: Current Concepts / Artroplastia do ombro no tratamento das fraturas da extremidade proximal do úmero: Conceitos atuais

Abstract Complex proximal humeral fractures, especially in elderly patients, often require arthroplastic surgical treatment. Traditionally, shoulder hemiarthroplasty (HA) is the method of choice, resulting in long implant survival and a painless shoulder; however, shoulder HA has heterogeneous clinical outcomes related to the correct position of the implant, both in terms of height and version, and the anatomical consolidation of tuberosities. Today, reverse shoulder arthroplasties are increasingly used to treat such fractures. These techniques result in better functional outcomes compared to HAs, especially regarding anterior flexion, but implant longevity has not been established. The development of specific prosthetic humeral components for the treatment of fractures, which were recently introduced in the clinical practice, led to better clinical outcomes.

Resumo Fraturas complexas da extremidade proximal do úmero, especialmente em idosos, frequentemente necessitam de tratamento cirúrgico artroplástico. Tradicionalmente, a hemiartroplastia (HA) do ombro é o método de escolha, com longa sobrevida do implante, e oferece um ombro indolor, mas com resultados clínicos heterogêneos, relacionados ao correto posicionamento do implante quanto à altura e à versão, além da consolidação anatômica dos tubérculos. Atualmente, a utilização de artroplastias reversas do ombro para o tratamento dessas fraturas vêm aumentando exponencialmente, com melhores resultados funcionais do que as HAs, principalmente quanto à flexão anterior, apesar de a longevidade do implante ainda não ter sido estabelecida. O desenvolvimento de componentes umerais protéticos específicos para o tratamento de fraturas, introduzidos na prática clínica nos últimos anos, levou a resultados clínicos melhores.

Correlation Between Implant Positioning and Functional Outcomes in Partial Shoulder Resurfacing / Correlação entre posicionamento do implante das artroplastias parciais de recobrimento do ombro e os resultados funcionais

Abstract Objective The present study aimed to correlate functional outcomes and implant positioning in a case series of partial shoulder resurfacing arthroplasties. Methods A total of 25 patients were assessed for range of motion, functional outcome per the University of California at Los Angeles (UCLA) score and radiographic findings. Preand postoperative data were compared. In addition, patients were grouped according to the cervical-diaphyseal angle (CDA) determined by an anteroposterior radiography and to the retroversion angle (RVA) determined by an axillary radiography. A CDA from 130° to 140° and a RVA from 20° to 40° consisted in ideal positioning (anatomical standard). Data were analyzed using the Wilcoxon signed-rank test, analysis of variance (ANOVA) followed by the Kruskal-Wallis test or the Mann-Whitney test as appropriate. Results The mean follow-up time was 48.3 months (12 to 67 months). The postoperative functional score (31.5) was higher than the preoperative score (15.5) (p < 0.001). In 6 patients, the implant was in anatomical positioning, while implant positioning was considered "nonstandard" in 19 subjects. Seven patients had a CDA < 130°, and 14 patients had a CDA ranging from 130° to 140°; in addition, the CDA was > 140° in 4 subjects. The RVA was up to 20° in 15 patients and ranged from 20° to 40° in 10 subjects. Using these criteria to group patients, the postoperative clinical-functional parameters were not statistically different from the preoperative findings (p > 0.05). Conclusion Partial shoulder resurfacing results in significant postoperative functional recovery in patients with degenerative joint diseases. However, implant positioning assessed by CDA and RVA does not correlate with clinical-functional outcomes and, therefore, it is an inaccurate indicator of surgical success. Level of Evidence IV; Case Series.

Resumo Objetivo O objetivo do presente estudo é correlacionar os resultados funcionais de uma série de casos de artroplastias parciais de recobrimento do ombro com o posicionamento do implante. Métodos Um total de 25 pacientes foram avaliados em relação à amplitude de movimentos, à avaliação funcional pelo escore de Universidade da Califórnia Los Angeles (UCLA) e por análise radiográfica. Os dados pré- e pós-operatórios foram comparados. Adicionalmente, os pacientes foram agrupados quanto ao ângulo cérvico-diafisário (ACD) avaliado na radiografia em anteroposterior e quanto ao ângulo de retroversão (ARV) avaliado na radiografia em posição axilar. Foi considerado como posicionamento ideal (padrão anatômico) um ACD entre 130° e 140° e um ARV entre 20° e 40°. Os dados foram analisados pelo teste pareado de Wilcoxon, pela análise de variância (ANOVA, na sigla em inglês) seguida pelo pós-teste de Kruskal-Wallis ou pelo teste de Mann-Whitney, quando apropriado. Resultados O seguimento médio foi de 48,3 meses (12 a 67 meses). A avaliação funcional pós-operatória (31,5) foi melhor do que a pré-operatória (15,5) (p < 0,001). Seis pacientes apresentaram posicionamento anatômico do implante, enquanto 19 pacientes foram considerados "fora do padrão." Sete pacientes apresentaram um ACD < 130°, quatorze apresentaram um ACD entre 130° e 140°, e quatro apresentaram um ACD >140°. Quinze pacientes apresentaram um ARV ≤ 20°, e 10 entre 20° e 40°. Utilizando esses critérios para agrupar os pacientes, a comparação dos parâmetros da avaliação clínico-funcional pós-operatória não foi estatisticamente diferente (p > 0,05). Conclusão A artroplastia parcial de recobrimento do ombro oferece significativa recuperação funcional pós-operatória em pacientes com doenças degenerativas articulares. Entretanto, o posicionamento do implante avaliado pelos ACD e ARV não se correlaciona com o resultado clínico-funcional, sendo, portanto, uma medida imprecisa de sucesso da cirurgia. Nível de Evidência IV, Série de Casos.

Influencia de la consolidación de las tuberosidades en los resultados clínicos de la prótesis invertida para fracturas de húmero proximal / Influence of the consolidation of the tuberosities on the clinical outcomes of the reverse arthroplasty in proximal humerus fractures

Objetivo: Comparar los resultados clínicos y las complicaciones de una serie consecutiva de pacientes con fracturas de húmero proximal tratados con prótesis invertida de hombro y con consolidación anatómica de las tuberosidades o sin ella. Materiales y Métodos: Se evaluó a 113 pacientes >65 años con fractura de húmero proximal tratados con prótesis invertida de hombro. Setenta presentaron consolidación anatómica de las tuberosidades y 43, ausencia de consolidación. Se evaluó el rango de movilidad, y se utilizaron los puntajes de Constant-Murley, ASES, SANE y la escala analógica visual. Se documentaron todas las complicaciones y las reoperaciones. Resultados: El seguimiento promedio fue de 56 meses (rango 24-96) y la edad media era de 73 años (rango 65-83). La elevación activa y la rotación interna medias posoperatorias fueron de 131° (± 14) y 27° (± 5), respectivamente. La rotación externa posoperatoria media en abducción y aducción fue de 27° (± 1) y 15° (± 6), respectivamente. La escala analógica visual promedio posoperatoria fue de 1,7 (± 0,8). Los puntajes ASES, de Constant-Murley y SANE promedio fueron de 76 (± 6), 62 (± 11) y 74% (± 7), respectivamente. La elevación anterior, la rotación externa y los puntajes funcionales promedio finales ASES y de Constant-Murley fueron significativamente mejores en el grupo con consolidación de las tuberosidades. Conclusiones: En pacientes >65 años con fractura de húmero proximal tratados con prótesis invertida de hombro tanto la movilidad posoperatoria, como los puntajes funcionales fueron significativamente mejores en los pacientes con consolidación anatómica de las tuberosidades. Nivel de Evidencia: III

Objective: The objective of this study was to compare the clinical outcomes and complications of a consecutive series of patients with proximal humerus fractures (PHF) treated with reverse shoulder arthroplasty (RSA), with and without anatomical healing of the tuberosities. Materials and Methods: We evaluated 113 patients >65 years old with PHF treated with RSA. Seventy patients presented anatomical healing of the tuberosities and 43 presented absence of healing. Range of motion (ROM), Constant score, ASES score, visual analog scale (VAS) and the score of the numerical evaluation of single evaluation (SANE) were evaluated. Results: The mean follow-up was 56 months (range, 24-96 months) and the mean age was 73 years (range, 65-83 years). Mean postoperative active elevation and internal rotation were 131° (±14) and 27° (±5), respectively. The mean postoperative external rotation in abduction and adduction was 27° (±1) and 15° (±6) respectively. The mean postoperative VAS was 1.7 (±0.8). The mean ASES, Constant and SANE scores were 76 (±6), 62 (±11) and 74% (±7), respectively. Anterior elevation, external rotation, and final mean ASES and Constant functional scores were significantly better in the group with tuberosity healing than in the group without healing. Conclusions: In patients >65 years old with PHF treated with RSA, both postoperative ranges of motion and functional scores were significantly better in patients where anatomic tuberosity healing was achieved than in those where it was not achieved. Level of Evidence: III

Lateralización y distalización objetiva en prótesis reversa de lateralización glenoidea / Lateralization and distalization in reverse shoulder arthroplasty

Introducción: la artroplastia reversa de hombro (RSA, por su nombre en inglés) con un centro de rotación lateralizado ha demostrado reducir las tasas de notching, restaurar el contorno del hombro y mejorar la rotación externa. La lateralización puede lograrse desde el componente glenoideo o desde el vástago humeral. Boutsadis et al. describieron dos mediciones angulares en radiografías postoperatorias para determinar objetivamente la lateralización y la distalización en la RSA: el ángulo de lateralización del hombro (LSA, por su nombre en inglés) y el ángulo de distalización del hombro (DSA, por su nombre en inglés). Estas mediciones son reproducibles y se correlacionan con los resultados funcionales y la amplitud de movimiento. La prótesis DJO (DJO Surgical, Austin, TX, EE. UU.) presenta una glenosfera con centro de rotación lateralizado, con un ángulo cuello-eje de 135°. Este implante ha dado resultados clínicos satisfactorios en los estudios de seguimiento a medio y largo plazo. Hasta la fecha, no se ha descripto la medición objetiva de los índices de lateralización y su asociación con la amplitud de movimiento postoperatorio mediante LSA y DSA en este tipo de implante. Materiales y métodos: se realizó una revisión retrospectiva de las artroplastias inversas de hombro efectuadas en una única institución por un único cirujano de hombro formado en la especialidad (autor principal) entre enero de 2014 y abril de 2021. Se incluyeron los pacientes que se sometieron a una RSA por artropatía del manguito rotador o por osteoartritis glenohumeral primaria con un implante lateralizado en el lado de la glenoides y un ángulo cuello-eje de 135°. En todos los pacientes se obtuvo una radiografía postoperatoria para evaluar las medidas radiográficas de la LSA y la DSA. Las radiografías fueron revisadas de manera independiente por tres autores y se evaluó la concordancia entre los examinadores. Resultados: un total de treinta y nueve pacientes cumplieron los criterios de inclusión. Su edad media fue de 77.5 años, y la distribución por sexos fue de un 74.3% de mujeres. La mediana final de rotación externa activa fue de 26° y la mediana final de flexión activa hacia adelante fue de 125°. El análisis radiográfico realizado por los tres revisores dio como resultado un ángulo de lateralización con un punto de corte de 93° (73° ­ 118°) y un ángulo de distalización con un punto de corte de 40° (15° ­ 65°). El coeficiente de correlación entre los tres evaluadores para el ángulo de lateralización fue de 0.59 y para el ángulo de distalización fue de 0.79.Discusión: el principal hallazgo de esta investigación es que un implante RSA con lateralización glenoidea proporciona una lateralización objetiva con LSA de 93° y una distalización con DSA de 40°. Estos resultados cumplen el rango ideal para la restauración óptima del movimiento. Las mediciones radiográficas postoperatorias de la lateralización y la distalización para este tipo de implante son reproducibles entre diferentes observadores. Nivel de Evidencia: IV

Introduction: reverse shoulder arthroplasty (RSA) with a lateralized center of rotation has proven to reduce notching rates, restore shoulder contour and improve external rotation. Lateralization can be achieved from the glenoid component or from the humeral stem. Boutsadis et al. described two angular measurements on postoperative radiographs to objectively determine lateralization and distalization in RSA: the lateralization shoulder angle (LSA) and the distalization shoulder angle (DSA). These measurements are reproducible, and they correlate with functional outcomes and range of motion. The DJO prosthesis (DJO Surgical, Austin, TX, USA) features a lateralized center of rotation glenosphere, with a neck-shaft angle of 135°. This implant has yielded satisfactory clinical outcomes in the medium, and long term follow-up studies. To date, objective measurement of lateralization rates and their association postoperative range of motion using LSA and DSA has not been described in this type of implant.Materials and methods: a retrospective review was performed of reverse shoulder arthroplasties performed in a single institution by a single fellowship trained shoulder surgeon (senior author) between January 2014 and April 2021. Patients were included if they underwent a RSA for rotator cuff arthropathy or primary glenohumeral osteoarthritis with a glenoid-side lateralized implant and a 135° neck-shaft angle. In all patients, a postoperative X-ray was obtained in order to evaluate the radiographic measurements of LSA and DSA. Radiographs were independently reviewed by three authors and the agreement between the examiners was assessed.Results: a total of thirty-nine patients met the inclusion criteria. Their average age was 77.5 years, the sex distribution was 74.3% female patients. Final median active external rotation was 26° and final median active forward flexion was 125°. The radiographic analysis performed by the three reviewers resulted in a lateralization angle with a cut-off point of 93° (73° ­ 118°) and a distalization angle with a cut-off point of 40° (15° ­ 65°). The correlation coefficient between the three evaluators for the lateralization angle was 0.59and for the distalization angle was 0.79.Discussion: the main finding of this research is that an RSA implant with glenoid-side lateralization provides an objective lateralization with LSA of 93° and a distalization with DSA of 40°. These results met the ideal range for optimal restoration of motion. Postoperative radiographic lateralization and distalization measurements for this type of implant are reproducible between different observers. Level of Evidence: IV

Artroplastia invertida lateralizada para artropatía del manguito rotador en pacientes >60 años. Resultados y complicaciones a corto plazo / Reverse total shoulder arthroplasty in patients >60 years of age with rotator cuff tear arthropathy. Short-term outcomes and complications

Objetivo: Comunicar los resultados y las complicaciones a corto plazo de la artropatía del manguito rotador tratada con artroplastia invertida lateralizada en pacientes >60 años. Materiales y Métodos: Se identificaron retrospectivamente las artropatías del manguito rotador tratadas con prótesis invertida lateralizada entre 2015 y 2019. Criterios de inclusión: edad >60 años, adecuada función deltoidea y seguimiento mínimo de 24 meses. Antes de la cirugía y después, se registraron el rango de movilidad activa, y los puntajes de Constant-Murley y de la escala analógica visual para dolor. En las radiografías, se determinaron los grados de artrosis glenohumeral, de muescas escapulares y de aflojamiento de la prótesis. Se documentaron las complicaciones, la satisfacción con el procedimiento y la supervivencia del implante. Resultados: La serie incluyó 40 hombros operados en 38 pacientes (edad promedio 72 años, rango 61-91), con un seguimiento promedio de 25 meses. La elevación anterior aumentó de 82,63° a 136,71° (p <0,001); la rotación externa, de 16,59° a 32,11° (p <0,001) y la rotación interna, de L5 a L3 (p <0,001). El puntaje de Constant-Murley ascendió de 28,25 a 69,97 (p <0,001) y el de dolor disminuyó de 8,34 precirugía a 1,26 poscirugía (p <0,001). La tasa de complicaciones fue del 12,5% y la supervivencia del implante, del 97,4%. Conclusiones: La artroplastia invertida lateralizada es una excelente alternativa quirúrgica para la artropatía del manguito rotador en pacientes >60 años, los resultados son satisfactorios, la tasa de complicaciones es aceptable y la supervivencia del implante es del 97,4%. Nivel de Evidencia: IV

Background: The purpose of this study is to show the short-term results and complications in a series of patients >60 who underwent a reverse arthroplasty for the treatment of rotator cuff arthropathy in a high complexity hospital. Materials and Methods: We retrospectively analyzed our Service's database to identify patients with rotator cuff arthropathy who had undergone a reverse shoulder arthroplasty between 2015 and 2019. Inclusion criteria: 60 years of age or older, functional deltoid, at least one year of follow-up. The range of motion was measured pre and postoperatively in flexion, external rotation, and internal rotation, as well as Constant score and visual analog scale for pain. The grade of arthritis, scapular notching, and prosthetic loosening was radiographically assessed. We identified complications, satisfaction, and prosthesis survivorship. Results: Forty shoulders in 38 patients of 72 years of age on average (61-91) underwent reverse shoulder arthroplasty, with 25 months of follow-up. Flexion increased from 82.86° to 136.71° (p<0.001), external rotation went from 16.59° to 32.11° (p<0.001), and internal rotation from L5 to L3 (p<0.001). Constant score rose from 28.25 to 69.97 (p<0.001) and visual analog scale for pain decreased from 8.34 to 1.26 (p<0.001). The complication rate was 12.5% and a 97.4% prosthesis survivorship was registered. Conclusions: We believe that reverse shoulder arthroplasty represents an excellent option in the treatment of rotator cuff arthropathy in patients older than 60 in view of the satisfactory functional outcomes with an acceptable complication rate. Level of Evidence: IV

Reemplazo de hombro ambulatorio: Presentación de protocolo perioperatorio y resultados iniciales / Same-day discharge shoulder arthroplasty: Perioperative protocol and initial results

Introducción El reemplazo de hombro es efectivo para mejorar el dolor y la funcionalidad en patologías crónicas del hombro. Considerando los riesgos y costos asociados a la estancia hospitalaria, realizar este procedimiento de forma ambulatoria surge como una opción para optimizar esta estrategia terapéutica. Materiales & Métodos Estudio observacional descriptivo prospective de pacientes operados por un mismo cirujano con artroplastia de hombro ambulatoria (RHA) utilizando analgesia regional con bomba de infusión elastomérica. Se registraron las escalas de ASES y SANE, el dolor, la satisfacción del paciente, las complicaciones y reingresos a 90 días. Resultados Se intervinieron 10 pacientes de un promedio de edad de 59.6 (±3.9) años, siendo el 40% prótesis anatómicas, 50% reversas y 10% hemiartroplastia. Al cuarto día postoperatorio el dolor por EVA fue 1,3 (±0,62) y al décimo día 2,7 (±1,1). La puntuación SANE antes del procedimiento fue de 31 (±9,7), y 90 días después fue de 76,1 (±6,8). Todos los pacientes refirieron una alta satisfacción. Un paciente al 3er día presentó un episodio de broncoespasmo leve, tratado de forma ambulatoria. Un paciente presentó una infección superficial que mejoró completamente con el antibiótico oral. No se presentaron reingresos o consultas a urgencias a 90 días. Discusión Se presentan los desenlaces a corto plazo de la primera serie de casos en nuestro medio de RH ambulatorio. Este procedimiento puede ser realizado de forma segura, siguiendo un protocolo estandarizado y realizando una juiciosa selección de los pacientes.

Background Shoulder arthoplasty is an effective procedure to improve pain and function in chronic shoulder pathologies. Considering the risks and costs associated with hospital stay, performing joint replacements on an outpatient setting emerges as an option to optimize this therapeutic strategy. Methods A prospective analysis was performed in 10 patients undergoing same-day discharge total shoulder arthroplasty with anatomic and reverse prostheses. Pain was managed with a continuous peripheral interscalene block using an elastomeric infusion pump. ASES and SANE scores, pain, patient satisfaction, complications, and readmissions after 90 days were recorded. Results 10 patients (average age 59.6 (±3.9) years) underwent outpatient shoulder arthroplasty (50% reverse shoulder arthroplasty, 40% total shoulder arthroplasty and 10% hemiarthroplasty). On post-operative day 4, mean visual analogue scale (VAS) for pain assessment was 1.3 (±0.62) and day 10, 2.7 (±1.1). Pre-operative SANE score was 31 (±9.7), and 90 days after the procedure was 76.1 (±6.8). All patients were satisfied with the procedure. One patient had a mild bronchospasm on day 3 that resolved with bronchodilators on an outpatient basis. One patient had a superficial surgical site infection that resolved completely with oral antibiotics administration. There were no re-admissions or major complications.

Tuberosity Healing after Reverse Shoulder Arthroplasty for Proximal Humerus Fractures: Is there Clinical Improvement? / Consolidação dos tubérculos na artroplastia reversa do ombro após fratura proximal do úmero: Existe melhoria nos resultados funcionais?

Abstract Objective To compare the functional results of patients with complex proximal humerus fracture submitted to total shoulder reverse arthroplasty with and without tuberosity healing. The secondary goal was to know the tuberosity healing rate after reverse shoulder arthroplasty with our surgical technique. Methods A retrospective, cohort type study, with a prospective database collection. In total, 28 patients fulfilled the inclusion criteria: age ≥ 65 years, reverse shoulder arthroplasty for complex proximal humerus fracture (type-3 or -4, according to Neer), and a minimum of 24 months of follow-up. At six months of follow-up, all of the patients were evaluated radiographically for tuberosity, and then they were divided into 2 groups: those with healed tuberosities and those with non-healed tuberosities. A clinical evaluation using the Constant score, active range of motion and the Visual Analog Scale (VAS) at the last follow-up was also performed. Results Tuberosity healing occurred in 21 patients (76.3%). There were statistically significant differences in the Constant scoring system (p < 0.001), forward elevation (p = 0.020), internal rotation (p = 0.001) and external rotation (p = 0.003) when comparing the group of healed tuberosities with the group of non-healed tuberosities. No differences were found regarding the VAS score. Conclusion Tuberosity healing results in an improvement of the functional outcomes of patients submitted to reverse shoulder arthroplasty as a treatment for complex proximal humeral fractures in the elderly.

Resumo Objetivo Comparar os resultados funcionais entre pacientes com fratura complexa do úmero proximal submetidos a artroplastia reversa com tubérculos consolidados e tubérculos não consolidados. O objetivo secundário foi determinar a taxa de consolidação dos tubérculos com este tipo de prótese. Métodos Estudo de tipo coorte, retrospectivo, com coleta prospectiva de dados. No total, 28 pacientes cumpriram os critérios de inclusão: idade superior a 65 anos, prótese reversa do ombro por fratura complexa do úmero proximal (3 ou 4 partes, segundo Neer), e tempo de seguimento mínimo de 24 meses. Aos seis meses, todos os pacientes foram avaliados radiograficamente quanto à consolidação dos tubérculos e divididos em dois grupos: grupo com tubérculos consolidados e grupo com tubérculos não consolidados. A avaliação funcional realizou-se segundo o sistema de pontuação de Constant, da amplitude de movimento ativo, e da Escala Visual Analógica (EVA) à data da última consulta. Registaram-se todas as complicações. Resultados A consolidação dos tubérculos ocorreu em 21 pacientes (76,3%). Verificou-se diferenças estatisticamente significativas no sistema de pontuação de Constant (p < 0.001), elevação anterior (p = 0.020), rotação interna (p = 0.001) e externa (p = 0.003), quando se comparou o grupo dos tubérculos consolidados com o grupo dos tubérculos não consolidados. Não houve diferenças significativas na EVA entre os 2 grupos. Conclusão A consolidação dos tubérculos traduz uma melhoria dos resultados funcionais em pacientes submetidos a artroplastia reversa do ombro como tratamento de fraturas complexas do úmero proximal em idosos.

Eficácia, segurança e custo-efetividade comparada de tratamentos cirúrgicos e conservadores de fratura de úmero proximal: revisão rápida de evidências / Comparative effectiveness, safety and cost-effectiveness between surgical and conservator treatments for proximal humeral fracture: a rapid review of evidence

Tecnologia: Hemiprótese de ombro ajustável. Próteses de cabeça excêntrica reproduzem a anatomia da extremidade proximal do úmero. Indicação: Reconstrução da extremidade proximal do úmero no tratamento de fraturas complexas de úmero. Pergunta: o tratamento cirúrgico é superior ao tratamento conservador, para tratamento de fratura proximal de úmero, com melhores desfechos funcionais, menos complicações, menor mortalidade? Os efeitos terapêuticos da prótese de ombro excêntrica são superiores aos da prótese de ombro Neer II em pacientes com fratura proximal de úmero submetidos a hemiartroplastia de ombro nos desfechos de resultados funcionais e complicações cirúrgicas? Métodos: Levantamento bibliográfico foi realizado em bases de dados Pubmed, BVS e Google com estratégias estruturadas de busca. Foi feita avaliação da qualidade metodológica das revisões sistemáticas com a ferramenta AMSTAR e para os estudos econômicos, foi utilizado o QHES checklist. Resultados: Foram identificados 485 registros nas bases de dados internacionais e nacionais. Após a remoção de duplicatas e exclusão dos não elegíveis, pela análise de título e resumo, foram selecionadas quatro revisões sistemáticas e um estudo econômico. Conclusão: Não há evidências suficientes de ensaios clínicos para informar qual a melhor escolha entre as intervenções (não cirúrgicas, cirúrgicas ou de reabilitação) para essas fraturas. Não foram encontrados estudos brasileiros sobre eficácia e custo-efetividade das diferentes abordagens cirúrgicas bem como os tipos e marcas de próteses entre si

Technology: Adjustable shoulder hemi prosthesis. Eccentric head prostheses reproduce the anatomy of the proximal extremity of the humerus. Indication: Reconstruction of the proximal extremity of the humerus in the treatment of complex humerus fractures. Question: Is surgical treatment superior to conservative treatment, for the treatment of proximal humerus fractures, with better functional outcomes, less complications, less mortality? Are the therapeutic effects of the eccentric shoulder prosthesis superior to those of the Neer II shoulder prosthesis in patients with proximal humerus fractures who underwent shoulder hemiarthroplasty in the outcomes of functional results and surgical complications? Methods: Bibliographic survey was carried out in Pubmed, BVS and Google databases with structured search strategies. The methodological quality of systematic reviews was assessed using the AMSTAR tool and for economic studies, the QHES checklist was used. Results: Were they identified 485 records in international and national databases. After removing duplicates and excluding the ineligible ones, by analyzing the title and summary, four systematic reviews and one economic study were selected. Conclusion: There is not enough evidence of clinical trials to inform which is the best choice between interventions (nonsurgical, surgical or rehabilitation) for these fractures. No brazilian studies were found about the efficacy and cost-effectiveness of the different surgical approaches, as well as the types and brands of prostheses between them

Resultados funcionales y radiográficos de la prótesis reversa y la reinserción del troquíter en pacientes con fracturas de húmero proximal / Functional and radiologic outcomes of reverse shoulder arthroplasty and greater tuberosity reattachment in proximal humerus fractures

Objetivo: Comunicar los resultados funcionales y radiográficos de pacientes tratados con prótesis reversa por fracturas complejas. El objetivo secundario fue determinar la relación entre rangos de movilidad y puntaje ASES con la evolución radiográfica del troquíter. Materiales y Métodos: Se incluyeron 16 pacientes >65 años, tratados con prótesis reversa y reinserción del troquíter, entre 2013 y 2017, operados antes de las 4 semanas del trauma y con un seguimiento mínimo de 2 años. Se consignaron el puntaje ASES y el rango de movilidad activa. En las radiografías, se evaluaron la posición y la consolidación del troquíter, y se registraron las complicaciones y su tratamiento. Resultados: La media de la edad fue 74.5 años (RIC 66-78.5), 11 (69%) eran mujeres. Once fracturas (69%) eran a 4 fragmentos y 5, luxofracturas a 4 fragmentos. La media entre el trauma y la cirugía fue 9.4 días y el seguimiento, 29.5 meses. En 9 casos (56%), el troquíter presentó consolidación. Rotación interna: 5 pacientes alcanzaron la región glútea con el pulgar; 4, la vértebra T12; 4, la vértebra L3; 3, la T7. Las medianas de rotación externa y flexión anterior fueron 30° (RIC 17,5-40) y 100° (RIC 87,5-160). El puntaje ASES promedio fue 78,3 (RIC 63,3-87,4). No hubo una asociación estadísticamente significativa entre la evolución del troquíter y la flexión anterior y el puntaje (p = 0,24 y 0,52, respectivamente). Conclusión: La prótesis reversa en fracturas agudas con reinserción de las tuberosidades puede llevar a buenos resultados funcionales. No se encontró relación entre la consolidación del troquíter y el puntaje ASES. Nivel de Evidencia: IV

Objective: To report functional and radiologic outcomes of reverse shoulder arthroplasty (RSA) in patients with complex proximal humeral fractures. A second objective was to assess the relation between the greater tuberosity healing and the range of motion (ROM) and the American Shoulder and Elbow Surgeons (ASES) score. Materials and Methods: Sixteen patients treated between 2013 and 2017, older than 65 years old, operated before 4 weeks after the trauma, and with a minimum of 2-year follow-up were included. ASES scores and active ROMs were recorded. Greater tuberosity and the prosthesis position and healing were radiologically evaluated, and the complications and treatment were recorded. Results: The median age was of 74.5 years (IQR 66-78.5), 11 patients were females (69%). According to Neer classification, 11 cases were four-part fractures and 5 were four-part fracture-dislocations. The average time between trauma and surgery was 9.4 days, and the average follow-up was of 29.5 months. The greater tuberosity was healed in 9 cases (56%). Internal rotation: 5 patients (31.25%) were able to reach up with their thumbs to gluteal level, 4 (25%) to T12, 3 (18.75%) to T7, and 4 (25%) to L3. The medians for external rotation and forward flexion were 30° (IQR 17.5°-40°) and 100° (IQR 87.5°-160°). The average ASES score was of 78.3 (IQR 63.3-87.4). There was no significant statistical relation between greater tuberosity healing and forward flexion or ASES score (P=0.24 and P=0.52, respectively). Conclusion: The use of reverse prostheses for complex fractures with greater tuberosity reattachment could lead to good functional outcomes, low complication rates and reoperations. There was no significant statistical relation between ASES score and greater tuberosity healing or failure to heal. Level of Evidence: IV

Reverse shoulder arthroplasty: Functional results in rotator cuff arthropathy / Artroplastia reversa de ombro: Resultados funcionais na artropatia do manguito

Abstract Objective To evaluate the functional results of patients submitted to reverse shoulder arthroplasty for the treatment of rotator cuff arthropathy refractory to conservative treatment. Methods A retrospective study of 20 patients (21 shoulders), 17 women (81%) and 3 men (19%), underwent a reverse shoulder arthroplasty between October 2012 and September 2017, for a rotator cuff arthropathy treatment, operated by a single surgeon in a single center. The patients were assessed using the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Short-Form (36) Health Survey (SF-36), the visual analogue scale (VAS) of pain rating, and the University of California - Los Angeles (UCLA) score. The mean age at surgery was of 66 years old (range: 55 to 83 years old). The duration of symptoms before surgery was of ∼ 2.5 years (range: 12 months to 6 years). The mean follow-up was of 42.4 months (range: 19 to 56.7 months). Results The mean postoperative scores were 18.2 points in DASH; 2 points in EVA, of which 16 (77%) corresponded to mild pain, 4 (18%) to moderate pain, and 1 (5%) to severe pain; 29 points in UCLA, of which 6 patients presented a regular result (28%), 10 patients a good result (48%), and 5 patients an excellent result (24%); and 63 points in the SF-36. The complications were four cases of notching, one case of acromial fracture due to stress, and one case of postoperative infection. Conclusions Reverse arthroplasty of the shoulder presents good functional results in the evaluated scores, providing a significant improvement in the quality of life of the patients.

Resumo Objetivo Avaliar os resultados funcionais dos pacientes submetidos a artroplastia reversa de ombro, para tratamento da artropatia do manguito refratária a tratamento conservador. Métodos Estudo retrospectivo de 20 pacientes (21 ombros), 17 mulheres (81%) e 3 homens (19%), submetidos a artroplastia reversa de ombro no período de outubro de 2012 a setembro de 2017, para tratamento de artropatia de manguito rotador, operados por um único cirurgião em um único centro. Os pacientes foram avaliados pelo escore de disfunções do braço, ombro e mão (DASH, na sigla em inglês), pelo questionário genérico de avaliação de qualidade de vida SF-36 (SF-36), pela escala visual analógica de dor (EVA) e pelo escore da Universidade de Los Angeles - Califórnia (UCLA, na sigla em inglês). A média de idade na cirurgia foi de 66 anos (variação de 55 a 83 anos). O tempo de sintomas antes da realização da cirurgia foi de ∼ 2,5 anos (variação de 12 meses a 6 anos). O seguimento médio foi de 42,4 meses (variação de 19 a 56,7 meses). Resultados A média dos escores pós-operatórios foi de 18,2 pontos no DASH; de 2 pontos na EVA, sendo 16 (77%) de dores leves, 4 (18%) de dores moderadas e 1 (5%) de dor intensa; de 29 pontos no UCLA, sendo 6 pacientes com resultado regular (28%), 10 pacientes com resultado bom (48%), e 5 pacientes com resultado excelente (24%); e de 63 pontos no SF-36. Tivemos como complicações quatro casos de notching, um caso de fratura de acrômio por estresse, e um caso de infecção pós-operatória. Conclusões A artroplastia reversa do ombro apresenta bons resultados funcionais nos escores avaliados, propiciando melhora significativa na qualidade de vida dos pacientes.

Artroplastia de resección de hombro como salvamento para infecciones recalcitrantes: estado actual de la técnica a propósito de dos casos / Shoulder resection arthroplasty as a salvage procedure for recalcitrant infections: current state of the art regarding two cases

INTRODUCCIÓN Y OBJETIVOS La artroplastia de resección de hombro (ARH) se presenta como una técnica obsoleta y una opción no válida en la actualidad, debido a la evolución de las técnicas quirúrgicas y de los implantes. Pero, como consecuencia del aumento exponencial del uso de artroplastias de hombro, están aumentando en paralelo el número de fracasos e infecciones, con necesidad de revisión y rescate. Es por ello que, en determinadas situaciones y pacientes, esa técnica vuelve a ser una opción necesaria como salvataje, aunque tiene un alto coste funcional. El objetivo de nuestro trabajo, es presentar dos casos de artroplastia de resección de hombro como una opción válida de tratamiento en la actualidad y la revisión de la literatura. CASOS Se presentan dos casos de ARH como tratamiento de rescate, en un caso de osteomielitis crónica de cabeza humeral y un caso de infección de hemiartroplastia de hombro. Ambos pacientes se encontraban sin dolor y libres de infección con un seguimiento de más de 30 meses. En un caso la funcionalidad fue limitada con un Constant de 45 pero el otro caso la funcionalidad fue aceptable con un Constant de 67. CONCLUSIONES La ARH sigue siendo una técnica útil tras el fracaso de procedimientos de revisión, para resolver infecciones protésicas recalcitrantes u osteomielitis. Los resultados funcionales son pobres, por lo que debe reservarse para pacientes con baja demanda funcional y como salvataje, tras agotar otras opciones.

INTRODUCTION AND OBJECTIVES shoulder resection arthroplasty (SRA) is currently considered as an outdated technique, due to the advances in surgical techniques and new prosthesis designs. However, with the exponential increase in the use of shoulder arthroplasties, the number of failures and infections is equally increasing, as well as the revisions and salvage procedures. In certain situations, SRA is therefore a necessary solution, although it grossly compromise shoulder function. The aim of our study is to present two cases who underwent SRA as a valid treatment option nowadays and a literature review. CASES We present two cases of SRA as salvatage treatment. First case in a chronic humeral head osteomyelitis and second in a partial shoulder prosthesis recalcitrant infection. Both patients had complete pain relief and infection was solved with a follow-up over 30 months. In the first case, postoperative shoulder function was limited with a Constant­Murley score of 45. In the second case, function was fairly good with a Constant of 67. CONCLUSIONS SRA remains a valuable technique after the failure of revision procedures, as a salvage for recalcitrant prosthetic infections or osteomyelitis. The functional results are poor, so it should be reserved for patients with low functional demand and as salvatage procedure, after assess other options.

Reconstrucción anatómica del Acromion en casos de fracturas traumáticas y posterior a artroplastia reversa del Hombro. Reporte de Casos / Anatomic reconstruction of the acromion in cases of traumatic fractures after reverse shoulder arthroplasty. Report of a series of cases

Introducción Tanto las fracturas traumáticas del acromion, así como las fracturas acromiales por insuficiencia posterior a artroplastia reversa del hombro, son entidades poco frecuentes. Con la ampliación des los criterios operativos para la artroplastia reversa del hombro, es de suponer un aumento en el caso des las fracturas acromiales por insuficiencia posteriores a dicho procedimiento quirúrgico. Al ser estas entidades poco frecuentes hacen falta en la literatura recomendaciones basadas en la evidencia para el manejo de estas, las cuales representan un reto para el especialista tratante. Materiales y Métodos Reporte de seis casos entre 2013 y 2016 en el hospital cantonal de Frauenfeld (Suiza) de dos grupos de pacientes con fracturas del Acromion. En el grupo A se clasificaron tres pacientes que presentaron fractura por insuficiencia del acromion posterior a artroplastia reversa del Hombro. En el grupo B clasificaron tres pacientes con fracturas traumáticas del acromion en las cuales el manejo conservador no fue exitoso. Los dos grupos de pacientes fueron sometidos al mismo método quirúrgico con reducción abierta y reconstrucción anatómica del Acromion por medio de fijación con placa y tornillos interfragmentarios. Resultados Posterior a la intervención quirúrgica, la función del hombro se recuperó en todos los pacientes del Grupo A. La flexión anterior aumentó en promedio de 53° a 127°, y la abducción mejoró de 52° a 125°. Las mediciones posteriores al año de la intervención mostraron puntajes constantes entre 55-71, así como un valor subjetivo de hombro (SSV) de 50-90. En el Grupo B, el rango de movimiento preoperatorio se mantuvo constante. La flexión hacia delante mejoró de 133° a 157° y la abducción aumentó de 147° a 153°. Un año después de la cirugía, los puntajes de Constant en el grupo B variaron de 70 a 86 y el SSV se encontró entre 80 a 100. Los tres pacientes del Grupo B consiguieron retomar sus actividades diarias sin dolor y pudieron regresar al trabajo. La extracción de la placa fue necesaria en la mitad de los pacientes de la cohorte (Grupo A n=1, Grupo B n=2). Discusión La fractura del acromion es una condición seria que puede causar daño significativo al funcionamiento del hombro. Tanto en pacientes con ARH así como en pacientes sin ARH previa, nuestra técnica operativa abierta de reconstrucción anatómica del acromion mostró buenos resultados. Recomendamos el manejo quirúrgico por medio de reconstrucción con placa y clavos de fijación. Nivel de evidencia: IV

Aim To propose a surgical technique to treat the traumatic acromion fractures, as well as acromion fractures before reverse total Shoulder Replacement (TSR). Methods Six patients were treated with the same fixation technique between December 2013 and December 2016. Three patients had acromial insufficiency fractures (type II) following TSR (Group A). The other three patients, who had traumatic acromion fractures, underwent unsuccessful conservative treatment (Group B). Surgical treatment involved reconstruction of the acromion using an open technique with plate and interfragmentary screw fixation. Results Following reconstruction, shoulder function was regained in all patients in Group A. Forward flexion increased, on average, from 53° to 127°, and abduction improved from 52° to 125°. Measurements at one-year follow-up were Constant scores from 55-71, and subjective shoulder value (SSV) from 50-90. In Group B, preoperative range of motion was not substantially diminished. Forward flexion improved from 133° to 157°, and abduction increased from 147° to 153°. One year following surgery, the Constant scores in Group B ranged from 70-86, and SSV was 80-100. All three patients performed daily activities without pain, and were able to return to work. Plate removal was necessary in half the patients in the cohort (Group A n=1; Group B n=2). Conclusion An acromion fracture is a serious condition that can cause significant damage to shoulder functioning. In patients with or without previous TSR, this fixation technique was used successfully to reconstruct the anatomic lateral and basal acromion. Evidence Level: IV

Reverse total shoulder arthroplasty for the treatment of old fracture of proximal humerus in elderly patients / 中国骨伤

OBJECTIVE@#To investigate clinical results of reverse total shoulder arthroplasty in treating old fracture of proximal humerus in elderly patients.@*METHODS@#From January 2012 to December 2017, 12 elderly patients with old proximal humeral fractures were treated with reverse total shoulder arthroplasty. There were 5 males and 7 females with an average age of 70.2 years old (ranged from 63 to 81 years old) and an average course of 12.3 months (ranged from 9 to 18 months). VAS score was used to evaluate the degree of pain relief of shoulder joint, Constant-Murley score was used to evaluate the improvement of shoulder joint function and observe the complications during and after operation.@*RESULTS@#All the 12 patients were followed up with an average duration of 22.3 months (ranged from 15 to 56 months). At the latest follow-up, the VAS score was 1.9±1.4, and Constant-Murley score was 83.4±8.4. Among them, shoulder joint flexion was (92.5±7.7)°, abduction was (90.4±14.3)°, external rotation was(31.9±10.0)°, and internal rotation was(58.9±13.1)°. There was statistical significance before and after treatment(<0.05). There were 2 cases with glenoid notch. The imaging findings were grade I and grade II respectively. No loosening was found during follow-up. No infection, acromial fracture, prosthesis loosening, axillary nerve injury and other complications occurred.@*CONCLUSIONS@#Reverse total shoulder arthroplasty in treating old proximal humeral fractures in elderly patients can achieve satisfactory results, however, indications and complications should be noted.

Reverse total shoulder arthroplasty for the treatment of comminuted fracture of proximal humerus in elderly patients with rotator cuff injury / 中国骨伤

OBJECTIVE@#To investigate clinical results of reverse total shoulder arthroplasty in treating comminuted fracture of proximal humerus in elderly patients with rotator cuff injury.@*METHODS@#From January 2017 to December 12, 12 comminuted fracture or dislocation of proximal humerus elderly patients were diagnosed as rotator cuff injury by preoperative MRI and operative exploration, and treated by reverse total shoulder arthroplasty. Among them, including 7 males and 5 females aged from 65 to 86 years old; 5 patients injured on the left side and 7 patients injured on the right side. Range of motion, postoperative complication were observed, VAS score was used to evaluate pain release and UCLA score was used to assess recovery of shoulder joint.@*RESULTS@#All patients were followed up from 8 to 18 months. At the latest follow-up, shoulder range of motion conditions were as following:forward bend and lifts ranged from 90° to 150°, external rotation ranged from 10°to 30°, internal rotation could reached L₃ level(S₁-L₁), VAS was for 0 to 6 points, UCLA score ranged from 18 to 32 points, 5 patients were good and 7 patients were poor. No infection, prothesis loosening, shoulder stress fracture, injury of vessel and nerve occurred.@*CONCLUSIONS@#Reverse total shoulder arthroplasty in treating comminuted fracture of proximal humerus in elderly patients with rotator cuff injury has advantages of early recovery of shoulder joint range of motion, less pain and high patients' satisfactory.