Improved outcomes of older patients with acute and displaced proximal humerus fractures treated with window bone ingrowth fracture-specific stem reverse shoulder arthroplasty.

BACKGROUND: The optimal treatment of displaced proximal humerus fractures (PHFs) in the older people population remains controversial. Reverse shoulder arthroplasty (RSA) is a popular surgical treatment option that provides improved and reproducible results. However, the relevance of fracture-specific stem designs for RSA to improve tuberosity consolidation and shoulder function remains debatable. METHODS: This study included all patients 70 years or older with acute and displaced PHFs primarily treated with RSA at a single institution in Portugal, between January 2010 and December 2019 who participated in a minimum follow-up of 2 years. RESULTS: A total of 112 patients (15 men and 97 women) with a median clinical follow-up of 52 months were included. The mean age at the time of fracture was 78.6 years. All fractures were classified as Neer types 3 and 4 (n = 50 and n = 62, respectively). A window bone ingrowth fracture-specific stem was used for 86 patients, and a conventional humeral stem was used for 26 patients. Regarding the tuberosity fixation technique, 76 tuberosities were attached using technique A (according to Boileau's principles), 36 tuberosities were attached using technique B (not following Boileau's principles) and 11cases were classified as technique C (if fixation was not possible). The overall survival rate during the 2-year follow-up was 88.2%; however, this decreased to 79% at 5 years. Only three patients had complications (two infections and one dislocation) requiring revision surgery. In the multivariable analysis, the tuberosity fixation technique (P = 0.012) and tuberosity anatomical consolidation (P < 0.001) were associated with improved Constant scores (median Constant Score 62.67 (technique A), 55.32 (technique B), 49.70 (technique C). Fracture-specific humeral implants (P = 0.051), the tuberosity fixation technique (P = 0.041), tuberosity anatomical consolidation (P < 0.001), and dementia influenced the achievement of functional mobility (P = 0.014). Tuberosity anatomic consolidation was positively associated with bone ingrowth fracture-specific humeral implants (P < 0.01) and a strong tuberosity fixation technique (P < 0.01). CONCLUSION: RSA is used for complex and displaced fractures of the proximal humerus in older patients. Dementia was negatively correlated with functional outcomes. A window bone ingrowth fracture-specific stem combined with strong tuberosity fixation can yield better clinical and radiological results. LEVEL OF EVIDENCE: Level II; prospective comparative study; treatment study.

Superior capsular reconstruction: current evidence and limits.

The treatment of rotator cuff tears (RCTs) has evolved. Nonsurgical treatment is adequate for many patients; however, for those for whom surgical treatment is indicated, rotator cuff repair provides reliable pain relief and good functional results. However, massive and irreparable RCTs are a significant challenge for both patients and surgeons. Superior capsular reconstruction (SCR) has become increasingly popular in recent years. It works by passively restoring the superior restriction of the humeral head, thus restoring the pair of forces and improving the kinematics of the glenohumeral joint. Early clinical results using fascia lata (FL) autograft were promising in terms of pain relief and function. The procedure has evolved, and some authors have suggested that FL autografts could be replaced by other methods. However, surgical techniques for SCR are highly variable, and patient indications remain undefined. There are concerns that the available scientific evidence does not support the popularity of the procedure. This review aimed to critically evaluate the biomechanics, indications, procedural considerations, and clinical outcomes associated with the SCR procedure.

Comparative clinical and radiologic evaluation between patients undergoing standard reversed shoulder arthroplasty or bony increased offset.

BACKGROUND: Modifications of the medialized design of Grammont-type reverse shoulder arthroplasty (RSA) using a bony increased offset (BIO-RSA) has shown better clinical results and fewer complications. The aim of this study is to compare the clinical results, complications, and radiological outcomes between patients undergoing standard RSA and BIO-RSA. METHODS: A retrospective review was performed of 42 RSA procedures (22 standard RSA and 20 BIO-RSA). With a minimum of 1 year of follow-up, range of motion (ROM), Constant shoulder score (CSS), visual analog scale (VAS), and subjective shoulder score (SSS) were compared. Radiographs and computed tomography (CT) scan were examined for scapular notching, glenoid and humeral fixation, and graft healing. RESULTS: At a mean follow-up of 27.6 months (range, 12-48 months), a significant difference was found for active-internal rotation (P=0.038) and for passive-external rotation (P=0.013), with better results in BIO-RSA. No other differences were found in ROM, CSS (P=0.884), VAS score, and SSS. Graft healing and viability were verified in all patients with CT scan (n=34). The notching rate was 28% in the standard RSA group and 33% in the BIO-RSA group, but the standard RSA had more severe notching (grade 2) than BIO-RSA (P=0.039). No other significative differences were found in glenoid and humeral fixation. CONCLUSIONS: Bone-graft lateralization is associated with better internal and external rotation and with less severe scapular notching compared to the standard RSA. Integration of the bone graft occurs effectively, with no relevant changes observed on radiographic evaluation.

Shoulder Arthroplasty Options for Glenohumeral Osteoarthritis in Young and Active Patients (<60 Years Old): A Systematic Review.

Aim: This study aims to describe the shoulder arthroplasty options for young and active patients (<60 years old) with glenohumeral osteoarthritis. Methods: A systematic review of the literature was conducted by searching on Pubmed database. Studies that reported outcomes of patients with glenohumeral arthritis, younger than 60 years, that underwent shoulder arthroplasty [(Hemiarthroplasty (HA), Hemiarthroplasty with biological resurfacing (HABR), Total shoulder arthroplasty (TSA), Reversed total shoulder arthroplasty (RSA)] were included. Data include patient characteristics, surgical technique, range of motion, pain relief, outcome scores, functional improvement, complications, need for and time to revision. Results: A total of 1591 shoulders met the inclusion criteria. Shoulder arthroplasty provided improvements in terms of ROM on the 3 plains, forward flexion (FF), abduction (Abd) and external rotation (ER), in different proportions for each type of implant. Patients submitted to RSA had lower preoperative FF (p = 0.011), and the highest improvement (Δ) in Abd, but the worst in terms of ER (vsTSA, p = 0.05). HA had better ER postoperative values (vsRSA p = 0.049). Pain scores improved in all groups but no difference between them (p = 0.642). TSA and RSA groups had the best CS Δ (p = 0.012). HA group had higher complication rates (21.7%), RSA (19.4%, p = 0.034) and TSA (19.4%, p = 0.629) groups the lowest, and HABR had the highest rate of revisions (34.5%). Conclusions: HA had the highest rate of complications and HABR unacceptable rates of revision. These implants have been replaced by modern TSAs, with RSA reserved for complex cases. Surgeons should be aware of the common pitfalls of each option.

Knee Meniscus Posterior Root Repair with FiberTak.

Repair of medial meniscal root tear is nowadays a validated procedure in order to restore knee biomechanics and to prevent early development of arthritis. There are various techniques described, without any being considered superior. This article describes a technique with a knotless suture anchor design, using a high posteromedial portal to insert the anchor and a meniscal suture passer device from the anteromedial portal. The technique eliminates the need for transtibial drilling and knot tying, and it certifies a strong reproducible tension.

Asymmetric Bilateral Chronic Shoulder Dislocation in a Young Patient - A Rare Case Report.

Introduction: Chronic shoulder dislocations are infrequent and can be easily overlooked unless a carefully clinical history, physical examination, and radiographic evaluation are undertaken. Bilateral simultaneous instability is almost pathognomonic for a convulsive disorder. To the best of our knowledge, we describe the first case of asymmetric bilateral chronic dislocation. Case Report: A 34-year-old male patient with a history of epilepsy and schizophrenia and multiple seizure episodes, suffered a bilateral asymmetric shoulder dislocation. Radiological examination revealed a posterior shoulder dislocation of the right shoulder with a severe reverse Hill-Sachs lesion comprising more than 50% of the humeral head surface, while on the left shoulder, a chronic anterior shoulder dislocation with a Hill-Sachs lesion of moderate dimension. On the right shoulder, a hemiarthroplasty was performed, and on the left, a stabilization with Remplissage Technique, subscapularis plication, and temporary trans-articular Steinmann pin fixation was done. After bilateral rehabilitation, the patient showed residual pain in the left shoulder and slight range of motion limitation. There were no new episodes of shoulder instability. Conclusion: Our aim is to emphasize the importance of being alert to flag patients and make a prompt and accurate diagnosis of acute shoulder instability episodes, to avoid unnecessary morbidity, as well as of a high index of suspicion when a history of seizures is present. Despite the uncertain prognosis of a bilateral chronic shoulder dislocation functional results, the surgeon must take into consideration the patient's age, functional demand, and expectations to define the best treatment strategy.

Subacromial resurfacing with fascia lata autograft for irreparable cuff tears : JEO 2021 expert opinion short report & surgical technique with video.

Massive and irreparable rotator cuff tears remain a major challenge for orthopaedic surgeons and several surgical options have been accepted for different patterns of irreparable cuff tears. However, the high-cost and technical complexity of some surgeries and the inconsistent clinical results of others, leave room for the search for surgical options that can offer a good balance between technical simplicity, a lower cost and an acceptable clinical result.The rationale behind some available techniques includes lowering the humeral head, which enables a more efficient balance of the force couples around the shoulder during rehabilitation. The interpositional arthroplasty with a biodegradable balloon, the Superior Capsule Reconstruction and, more recently, subacromial resurfacing with a dermal allograft have been presented as valid options to address that purpose.This technical note presents Subacromial Resurfacing with fascia lata as an option for the treatment of irreparable rotator cuff tears in the elderly population. Its low-cost and reasonable technical demand, along with the need for further elucidation of the ideal indications and technical optimization of other available techniques may open up room for the success of this option.

Extensive skin necrosis after periprosthetic knee infection: a case that highlights the possibility of complications induced by low-molecular-weight heparin.

We describe a case of a patient with atrial fibrillation, anticoagulated with dabigatran, that developed severe knee skin necrosis in the setting of an acute periprosthetic knee infection, after initiating low-molecular-weight heparin. A wide range of etiology hypotheses was discussed within a multidisciplinary team. The complex approach consisted of treating the underlying infection, multiple types of soft-tissue management, and stopping enoxaparin.

Isolated traumatic posterior dislocation of the radial head in an adult, a rare injury: New case report.

Isolated radial head dislocations are rare in adults with only 23 cases published in 45 years. The diagnosis may be easily missed on radiographs and a CT-scan is often required. If managed promptly patient can restore normal range of motion and elbow function. Authors report a new case of a 67-year-old female presenting a posttraumatic isolated posterior dislocation of the radial head. Treatment consisted of closed reduction followed by immobilization for four weeks in a plaster cast with the elbow flexed at 90°, followed by active mobilization and physiotherapy. At 18 months of follow-up, functional outcome is excellent with no differences between both sides.

Femoral neck stress fracture in a young female recruit: case report.

INTRODUCTION: Femoral neck stress fractures are uncommon and depending on their location, can be at high risk for non-union and significant morbidity.  Their prevalence is higher among runners and military recruits, and women seem to be at higher risk. METHODS: A 27-year-old female, who was enrolled in military recruit, reported left side groin pain after a strenuous running exercise. Due to persistent pain an X-Ray was ordered, which revealed no signs of acute lesions. Further imaging studies with CT scan and MRI identified a compression-type femoral neck stress fracture. RESULTS: The patient was submitted to conservative treatment consisting of restricting from full weight-bearing. Six weeks after she initiated partial weight-bearing, becoming asymptomatic at seven months. Follow-up imaging studies revealed union of the fracture. DISCUSSION: This diagnosis should be considered when evaluating military and athlete populations. Early recognition of these injuries is crucial because complication and morbidity rates are high.