Estabilização de ombro em um gato ­ Relato de caso / Shoulder estabilization in a cat ­ Case report

A estabilidade da articulação do ombro é garantida por ligamentos, cápsula articular, tendões e músculos, contudo traumas podem causar falência dos mecanismos estabilizadores, com consequente luxação ou instabilidade articular. Objetivou-se relatar o caso de instabilidade medial e lateral de ombro direito em felino sem raça definida, atendido com queixa de claudicação aguda de membro torácico secundária a trauma por confronto com outro animal. Inicialmente foi realizado tratamento clínico por meio de imobilização articular. Contudo, devido ao insucesso da técnica, procedeu-se para o tratamento cirúrgico de estabilização articular com prótese ligamentar sintética. No pós-operatório imediato, evidenciou-se ausência de crepitações e instabilidade articular. Após oito dias da cirurgia, o paciente apresentou retorno total às funções de apoio do membro e sem sinais de dor ou redução de movimentos. Concluiu-se que, embora de reduzida ocorrência, a instabilidade de origem traumática do ombro configura-se como um diferencial para claudicação aguda de membro torácico e que o tratamento cirúrgico pode ser necessário, mostrando-se eficiente na resolução de tais casos com o acesso e técnica de estabilização propostos.

The stability of the shoulder joint is granted by ligaments, joint capsule, tendons and muscles. However, traumatic injuries can cause failure of the stabilization mechanisms, which leads to articular luxation or instability. The aim of the paper is to report a case of medial and lateral right shoulder joint instability in a mixed-breed cat, presenting acute forelimb lameness after a fight trauma with another cat. Initially, it was recommended a conservative treatment through articular immobilization. However, the technique was unsuccessful, and the surgery treatment was performed, to stabilize the joint with synthetic ligament prosthetic. In the postoperative period, no crepitation or instability were identified. After eight days of surgery, the patient returned totally to the normal function of the forelimb, without movement restriction or pain. It was concluded that, although rare, the traumatic shoulder joint instability is a differential diagnosis for acute forelimb lameness and the surgical treatment can be necessary, showing a good result in the resolution of these injuries with the surgical approach and stabilization method proposed.

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.

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

Prótesis reversa de hombro en necrosis avascular de cabeza húmero / Reverse shoulder prosthesis in avascular necrosis of the humerus head

Paciente de sexo femenino, de 39 años y de ocupación modista, con antecedentes mórbidos de importancia de artritis reumatoide en tratamiento con corticoides desde los 31 años, presenta sintomatología en la articulación glenohumeral derecha de forma insidiosa con dolor leve y limitación funcional que va aumentando por ocho meses hasta hacerse invalidante, siendo controlada únicamente por consultorio de reumatología; acude a consultorio de traumatología en diciembre de 2018, al examen físico pre quirúrgico limitación completa de todos los arcos de movimiento de articulación glenohumeral derecha que se encontraba asociado a dolor intenso a la realización de movimientos forzados presentando los siguientes arcos de movimiento: flexión 50°, abducción 15°, rotación interna 20°, rotación externa 15°, extensión 10°y dolor a la movilización pasiva y activa. Por exámenes complementarios radiológicos, tomográficos y de resonancia magnética se llega al diagnóstico de necrosis de cabeza humeral derecha con ruptura completa de supraespinoso, infra espinoso y subescapular. Se realiza procedimiento en el complejo hospitalario de Miraflores; se decide la artroplastia reversa de hombro por el compromiso articular y afectación del componente musculo tendinoso del manguito rotador. Teniendo un post quirúrgico con excelentes resultados funcionales que le devuelven los arcos de movilidad para desempeñar una vida cotidiana normal sin dolor.(AU)

A 39 year old female patient with a dressmaker occupation, with a significant morbid history of rheumatoid arthritis under treatment with corticosteroids since the age of 31, presents insidious symptoms in the right glenohumeral joint with mild pain and functional limitation that increases due to eight months until it became invalidating, being controlled only by the rheumatology office; he attended the trauma clinic in December 2018, for the pre-surgical physical examination, complete limitation of all the arches of motion of the right glenohumeral joint, which was associated with severe pain when performing forced movements, presenting the following arches of movement: 50° flexion, abduction 15°, internal rotation 20°, external rotation 15°, extension 10° and pain on passive and active mobilization. By complementary radiological, tomographic and magnetic resonance examinations, the diagnosis of necrosis of the right humeral head with complete rupture of the supraspinatus, infraspinous and subscapularis was reached. Procedure is performed at the Miraflores hospital complex; Reverse shoulder arthroplasty was decided due to joint involvement and involvement of the muscletendon component of the rotator cuff. Having a surgical post with excellent functional results that return the mobility arches to carry out a normal daily life without pain.(AU)

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

Shoulder Arthroplasty: Tenotomy of the Subscapularis Tendon versus the Lesser Tuberosity Osteotomy / Artroplastia de ombro: tenotomia do subescapular versus osteotomia do tubérculo menor

Abstract Objective To evaluate and compare subscapular muscle function among patients undergoing subscapular tenotomy (Group A) and lesser tuberosity osteotomy (Group B), in patients treated with total and partial anatomic shoulder arthroplasty for primary osteoarthrosis. Methods Retrospective study of patients with primary glenohumeral osteoarthrosis surgically undergoing total or partial anatomic shoulder prosthesis implant, evaluated by clinical examination, imaging exams, analogue pain scale and Constant and Murley functional score. A total of 28 patients were evaluated, totalizing a sample of 32 operated shoulders. The minimum follow-up was of 12 months (mean 47.45 months). Results Among patients submitted to subscapularis tendon tenotomy, 10 had an ultrasound with total rupture of its thickness (56%). All of the patients of the group B showed lesser tuberosity healing. There was no difference between groups comparing strength evaluated by Belly press and Bear hug tests as well as clinical outcome, through the Constant and Murley score. Conclusions We did not find differences between Groups A and B evidenciated by comparing strength in the Lift-off test, in the Belly press and Bear hug tests and through he Constant and Murley score.

Resumo Objetivo Avaliar e comparar a função do músculo subescapular entre os grupos submetidos a tenotomia do subescapular (Grupo A) e osteotomia do tubérculo menor (Grupo B), em pacientes tratados por artroplastia anatômica total e parcial de ombros apresentando osteoartrose primária. Métodos Estudo retrospectivo de pacientes portadores de osteoartrose primária glenoumeral tratados cirurgicamente com prótese anatômica total ou parcial de ombro, avaliados por exame clínico, exames de imagens, escala visual analógica de dor e escore funcional de Constant e Murley. Foram avaliados 28 pacientes, totalizando uma amostra de 32 ombros operados. O seguimento mínimo foi de 12 meses (média 47,45 meses). Resultados Nos pacientes submetidos à tenotomia do tendão subescapular, dez obtiveram resultado ultrassonográfico com ruptura de sua espessura total (56%). A consolidação ocorreu em todos pacientes submetidos a osteotomia do tubérculo menor. Não houve diferença entre os grupos na comparação do teste Lift Off, da força nos testes Belly Press e Bear hug, e no escore de Constant e Murley. Conclusões Não encontramos diferença entre os grupos A e B na comparação do teste Lift Off, da força nos testes Belly Press e Bear hug, e no escore de Constant e Murley.

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

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.

Resultados a corto plazo de la prótesis invertida de hombro según la patología / Short-term results of reverse shoulder prosthesis according to pathology

Objetivo: Analizar los resultados funcionales y las complicaciones a corto plazo de la prótesis invertida de hombro según diferentes patologías. Materiales y Métodos: Entre 2009 y 2013, se colocaron 85 prótesis invertidas de hombro. Las indicaciones fueron: artropatía por ruptura del manguito rotador, artrosis glenohumeral, fracturas de húmero proximal y artroplastias de revisión. Se evaluó a los pacientes clínica y radiológicamente, y fueron analizados según los diferentes grupos. Resultados: El seguimiento promedio fue de 42 meses (rango 26-60) y la media de la edad, de 74.5 años (rango 56-90). El puntaje de Constant mejoró de 16,7 a 62,1 en promedio (p <0,001) y el de ASES, de 12,7 a 68,8 en promedio (p <0,001). La elevación aumentó de 80,5° a 111,5° (p <0,001). No hubo mejoría significativa en las rotaciones interna ni externa. Sesenta pacientes (78,9%) refirieron estar muy satisfechos/satisfechos. En 22 pacientes (27,8%), se hallaron muescas en el borde inferior de la glena. La tasa de complicaciones fue del 20%, y estas fueron más frecuentes en el grupo de fracturas y artroplastias de revisión. Conclusiones: La prótesis invertida de hombro mejora significativamente los puntajes funcionales, la flexión anterior y la abducción, independientemente de la indicación quirúrgica. Presenta limitaciones con respecto a las rotaciones externa e interna en el posoperatorio. Es una alternativa válida en múltiples patologías de hombro; sin embargo, la tasa de complicaciones es elevada, por lo que su indicación debe ser precisa, especialmente en pacientes tratados por fracturas o en cirugías de revisión. Nivel de Evidencia: IV

Objective: The purpose of this study is to analyze the short-term functional results and complications of the reverse shoulder prosthesis according to different etiologies. Methods: Between 2009 and 2013, 85 reverse shoulder arthroplasties were performed. Surgical indications included: rotator cuff tear artropathy, glenohumeral osteoarthritis, proximal humeral fractures and revision arthroplasty. Patients were clinically and radiologically evaluated and analyzed in different groups. Results: The mean follow-up was 42 months (range 26-60) and the mean age was 74.5 years (range 56-90). Constant score improved from 16.7 to 62.1 on average (p<.001) while ASES score improved from 12.7 to 68.8 on average (p<.001). Elevation increased from 80.5° to 111.5° (p<.001). There was no significant improvement in internal and external rotation. Sixty patients (78.9%) were very satisfied/satisfied. A total of 22 patients (27.8%) had notches in the inferior rim of the glenoid. Complication rate was 20%, being more frequent in the group of fractures and revision arthroplasties. Conclusions: The reverse shoulder arthroplasty significantly improved functional scores, anterior flexion and abduction, regardless of surgical indication. It has limitations with respect to the external and internal rotation postoperatively. It is a valid alternative in multiple shoulder conditions; however, complication rate is high, so the indication should be accurate, especially in patients treated for fractures or in revision surgeries. Level of Evidence: IV

Factores determinantes en la indicación de la prótesis invertida de hombro / Facteurs déterminant l'indication de prothèse d'épaule inversée / Determining Factors in Inverted Shoulder Prosthesis Indication

Objetivo: Desarrollar criterios para determinar las indicaciones apropiadas de la prótesis invertida de hombro en artropatías por lesión del manguito rotador y las variables determinantes de este proceso. Método: Se utilizó un panel de expertos mediante metodología RAND/UCLA con 9 expertos en Traumatología, 2 en Rehabilitación y 1 en Reumatología, que evaluaron 192 casos hipotéticos. Cada experto puntuó mediante una escala del 1 (extremadamente inadecuado) al 9 (extremadamente apropiado). Resultados: 22 casos hipotéticos fueron considerados adecuados. El dolor, limitación funcional, necesidad funcional, defecto glenoideo, edad, artrosis y posibilidad de reparación del manguito rotador son variables determinantes para indicar la implantación de una prótesis invertida de hombro. Conclusiones: El método RAND/UCLA es útil para el estudio de las indicaciones de procedimientos como la prótesis invertida de hombro, y proporciona una lista de las indicaciones adecuadas. Las variables requieren ser validadas mediante estudios prospectivos o revisión de historias clínicas(AU)

Objective: Develop criteria to determine the appropriate indications of inverted shoulder prosthesis in arthropathies due to rotator cuff injury and the variables that determine this process. Method: A panel of experts assessed 192 hypothetical cases using RAND/UCLA methodology. Nine Traumatology experts, two Rehabilitation experts and one Rheumatology expert comprised this panel. Each expert scored on a scale from 1 (extremely unsuitable) to 9 (extremely appropriate). Results: 22 hypothetical cases were considered adequate. Pain, functional limitation, functional need, glenoid defect, age, osteoarthritis and possibility of rotator cuff repair are determining as variables to indicate the implantation of an inverted shoulder prosthesis. Conclusions: The RAND/UCLA method is useful for the study of procedure indications such as the inverted shoulder prosthesis, and it provides a list of suitable indications. Prospective studies or medical record reviews should validate these variables(AU)

Objectif: Proposer les critères définissant l'indication appropriée de prothèse d'épaule inversée dans les arthropathies pour lésion de la coiffe des rotateurs, et les variables déterminant ce processus. Méthodes: Un panel d'experts, compris par 9 traumatologues, 2 kinésithérapeutes et 1 rhumatologue, a été utilisé pour évaluer 192 cas hypothétiques par la méthode RAND/UCLA. Chaque expert a fait son évaluation sur une échelle de 1 (extrêmement inapproprié) à 9 (extrêmement approprié). Résultats: Vingt-deux cas hypothétiques ont été considérés comme appropriés. Des variables telles que la douleur, la limitation fonctionnelle, la nécessité fonctionnelle, le défaut glénoïdien, l'âge, l'arthrose et la possibilité de correction de la coiffe des rotateurs, ont déterminé l'indication de prothèse d'épaule inversée. Conclusions: La méthode RAND-UCLA est utile pour l'étude des indications de procédés, tels que la prothèse d'épaule inversée, et procure une liste des indications appropriées. Il faut valider les variables avec des études prospectives ou une révision des dossiers médicaux(AU)

Morphologic Variability of the Shoulder between the Populations of North American and East Asian

BACKGROUND: The aim of this study was to determine if there were significant differences in glenohumeral joint morphology between North American and East Asian populations that may influence sizing and selection of shoulder arthroplasty systems. METHODS: Computed tomography reconstructions of 92 North American and 58 East Asian patients were used to perform 3-dimensional measurements. The proximal humeral position was normalized in all patients by aligning it with the scapular plane utilizing anatomic landmarks. Measurements were performed on the humerus and scapula and included coronal and axial humeral head radius, humeral neck shaft and articular arc angles, glenoid height and width, and critical shoulder angle. Glenohumeral relationships were also measured and included lateral distance to the greater tuberosity and acromion, abduction lever arm, and acromial index. Parametric and nonparametric statistical analyses were used to compare population metrics. RESULTS: East Asian glenohumeral measurements were significantly smaller for all linear metrics (p < 0.05), with the exception of acromial length, which was greater than in the North American cohort (p < 0.001). The increase in acromial length affected all measurements involving the acromion including abduction lever arms. No difference was found between the neck shaft and articular angular measurements. CONCLUSIONS: The East Asian population exhibited smaller shoulder morphometrics than their North American cohort, with the exception of an extended acromial overhang. The morphologic data can provide some additional factors to consider when choosing an optimal shoulder implant for the East Asian population, in addition to creating future designs that may better accommodate this population.

Influence of Glenosphere Design on Outcomes and Complications of Reverse Arthroplasty: A Systematic Review

BACKGROUND: Different implant designs are utilized in reverse shoulder arthroplasty. The purpose of this systematic review was to evaluate the results of reverse shoulder arthroplasty using a traditional (Grammont) prosthesis and a lateralized prosthesis for the treatment of cuff tear arthropathy and massive irreparable rotator cuff tears. METHODS: A systematic review of the literature was performed via a search of two electronic databases. Two reviewers evaluated the quality of methodology and retrieved data from each included study. In cases where the outcomes data were similar between studies, the data were pooled using frequency-weighted mean values to generate summary outcomes. RESULTS: Thirteen studies met the inclusion and exclusion criteria. Demographics were similar between treatment groups. The frequency-weighted mean active external rotation was 24° in the traditional group and 46° in the lateralized group (p = 0.0001). Scapular notching was noted in 44.9% of patients in the traditional group compared to 5.4% of patients in the lateralized group (p = 0.0001). The rate of clinically significant glenoid loosening was 1.8% in the traditional group and 8.8% in the lateralized group (p = 0.003). CONCLUSIONS: Both the traditional Grammont and the lateralized offset reverse arthroplasty designs can improve pain and function in patients with diagnoses of cuff tear arthropathy and irreparable rotator cuff tear. While a lateralized design can result in increased active external rotation and decreased rates of scapular notching, there may be a higher rate of glenoid baseplate loosening.