3D image-based morphometric analysis of the scapular neck length in subjects undergoing reverse shoulder arthroplasty.

Scapular notching after RSA may, in part, be related to a patient's scapular morphology. The purpose of this study was to develop a novel 3 D measurement technique to describe infraglenoid tubercle morphometry. We hypothesize that the parameters describing infraglenoid tubercle would be normally distributed and would correlate with individual's demographics and glenoid morphometry. A group of 110 subjects treated with RSA were evaluated. Scapular geometry was obtained from pre-operative CT scans. The scapular neck length was defined in anterior and posterior view as the orthogonal distance between the glenoid surface and (a) the point of most significant change of curvature on lateral pillar; (b) the most lateral portion of the infraglenoid tubercle. Scapular neck angle, maximum anatomical adduction angle, glenoid width, height and version were also measured. Scapular neck length measured in the anterior and posterior view were normally distributed with mean values of 17.6 ± 2.8 mm and 7.9 ± 2.5 mm, respectively. Scapular neck angle was on average 112.4 ± 10.6° and maximal adduction angle was 17.6 ± 2.8°. No significant associations between infraglenoid tubercle morphometric parameters, demographic, glenoid size or version were identified. Improved understanding of the patient-specific risk factors for scapular notching will help surgeons with pre-surgical planning and implant selection. Parametrization of the infraglenoid tubercle presented in this study showed normal distribution in the population unrelated to gender, side or demographics. The size of the infraglenoid tubercle is a unique trait, pre-operative evaluation of the scapular neck should be always warranted to decrease the incidence of post-operative notching. Clin. Anat. 31:43-55, 2018. © 2017 Wiley Periodicals, Inc.

Large diaphyseal-incorporating allograft prosthetic composites: when, how, and why : Treatment of advanced proximal humeral bone loss.

BACKGROUND: Proximal humeral bone loss in shoulder arthroplasty is a complex problem with a heterogeneous presentation. Different etiologies may contribute to varying degrees of severity in bone loss that dictate different treatment approaches. OBJECTIVES: The purpose of this is article is to describe our technique for treatment of proximal humeral bone loss with proximal humeral allograft prosthetic composites (APC) and identify factors that may predict when larger allografts may be necessary. MATERIALS AND METHODS: Ninety-nine patients were identified that had undergone reverse total shoulder arthroplasty with use of a proximal humeral allograft. Thirty-nine of these had large allografts that involved a significant portion of the diaphysis. Preoperative characteristics were examined to identify factors that may be associated with use of a larger diaphyseal-incorporating allograft. RESULTS: Well-fixed humeral stems could be treated with short metaphyseal allografts in 55 of 65 (85%) cases. Loose stems required longer diaphyseal-incorporating allografts in 28 of 31 (90%) cases, and these were commonly associated with periprosthetic fractures (n = 10), failed prior APC (n = 6), and infection (n = 5). Noncemented stems required diaphyseal grafts in 75% of cases, compared to cemented stems which required larger grafts in 34% of cases. CONCLUSIONS: Proximal humeral bone loss in the setting of revision shoulder arthroplasty can be successfully managed with a reverse total shoulder and proximal humeral allograft. Larger allografts are frequently required for loose humeral stems, and noncemented stems appear more likely to require larger allografts than cemented stems.

The treatment of deep shoulder infection and glenohumeral instability with debridement, reverse shoulder arthroplasty and postoperative antibiotics.

We retrospectively reviewed 21 patients (22 shoulders) who presented with deep infection after surgery to the shoulder, 17 having previously undergone hemiarthroplasty and five open repair of the rotator cuff. Nine shoulders had undergone previous surgical attempts to eradicate their infection. The diagnosis of infection was based on a combination of clinical suspicion (16 shoulders), positive frozen sections (> 5 polymorphonuclear leukocytes per high-power field) at the time of revision (15 shoulders), positive intra-operative cultures (18 shoulders) or the pre-operative radiological appearances. The patients were treated by an extensive debridement, intravenous antibiotics, and conversion to a reverse shoulder prosthesis in either a single- (10 shoulders) or a two-stage (12 shoulders) procedure. At a mean follow-up of 43 months (25 to 66) there was no evidence of recurrent infection. All outcome measures showed statistically significant improvements. Mean abduction improved from 36.1 degrees (sd 27.8) pre-operatively to 75.7 degrees (sd 36.0) (p < 0.0001), the mean forward flexion from 43.1 degrees (sd 33.5) to 79.5 degrees (sd 43.2) (p = 0.0003), and mean external rotation from 10.2 degrees (sd 18.7) to 25.4 degrees (sd 23.5) (p = 0.0037). There was no statistically significant difference in any outcome between the single-stage and the two-stage group.

Use of the reverse shoulder prosthesis for the treatment of failed hemiarthroplasty in patients with glenohumeral arthritis and rotator cuff deficiency.

We report the use of the reverse shoulder prosthesis in the revision of a failed shoulder hemiarthroplasty in 19 shoulders in 18 patients (7 men, 11 women) with severe pain and loss of function. The primary procedure had been undertaken for glenohumeral arthritis associated with severe rotator cuff deficiency. Statistically significant improvements were seen in pain and functional outcome. After a mean follow-up of 44 months (24 to 89), mean forward flexion improved by 26.4 degrees and mean abduction improved by 35 degrees . There were six prosthesis-related complications in six shoulders (32%), five of which had severe bone loss of the glenoid, proximal humerus or both. Three shoulders (16%) had non-prosthesis related complications. The use of the reverse shoulder prosthesis provides improvement in pain and function for patients with failure of a hemiarthroplasty for glenohumeral arthritis and rotator cuff deficiency. However, high rates of complications were associated with glenoid and proximal humeral bone loss.

Primary semi-constrained arthroplasty for chronic fracture-dislocations of the elbow.

We present six patients with chronic dislocation of the elbow who were treated by primary semiconstrained total elbow arthroplasty. All were women with a mean age of 65 years (51 to 76), the mean interval between dislocation and surgery was 17 weeks (5 to 52) and the mean follow-up 58 months (24 to 123). The most dramatic improvement was in function. The mean American Shoulder and Elbow Surgeon score was 5.2 times better (p < 0.001) and the mean total range of movement increased from 33 degrees to 121 degrees (p < 0.001) after operation. Three patients developed wear of polyethylene. One required revision for a periprosthetic fracture, and another required a bushing exchange. Primary semiconstrained elbow arthroplasty provides significant, predictable functional improvement. Potential solutions for wear of polyethylene include a different operative technique or design of implant. Despite the high incidence of such wear, total elbow arthroplasty should be considered as a viable treatment option for chronic dislocation of the elbow in elderly patients.

Biomechanical effects of malposition of tuberosity fragments on the humeral prosthetic reconstruction for four-part proximal humerus fractures.

Variable outcomes in the prosthetic reconstruction of 4-part humerus fractures often can be attributed to inconsistent and nonanatomic tuberosity placement. To compare the effects of anatomic (anterior fin) versus nonanatomic (lateral fin) tuberosity placement, we developed a dynamic cadaver model for shoulder motion. With the use of a robotically driven, computer-controlled articulator, we tested external rotation torque in 5 fresh human shoulders. After evaluation of the intact shoulders, we experimentally induced 4-part humerus fractures in the specimens. These were then repaired by hemiarthroplasty, with the use of standard techniques to secure the greater and lesser tuberosities in either anatomic or nonanatomic positions; order was randomized. Nonanatomic tuberosity reconstruction led to significant impairment in external rotation kinematics and an 8-fold increase in torque requirements (P =.001). In contrast, anatomic reconstruction produced results indistinguishable from normal shoulder controls. This study underscores the importance of rotational alignment of tuberosities during reconstruction. Failure to properly position tuberosity fragments in the horizontal plane may result in insurmountable postoperative motion restriction.

Radial head fractures associated with elbow dislocations treated by immediate stabilization and early motion.

Twenty-one elbow dislocations with an associated radial head fracture were treated with immediate joint reduction, stabilization, and early range-of-motion exercises. In all cases initial treatment involved closed reduction of the ulnohumeral joint. For those cases involving minimally displaced and a few moderately displaced radial head fractures, treatment consisted of benign neglect (4 of 21). Of the more severely displaced fractures (17 of 21), 9 were treated with open-reduction internal fixation and 8 with immediate silicone head replacement. Despite radial head treatment, 6 of these cases remained unstable, prompting primary repair of collateral ligaments; 3 eventually required application of a hinged fixator as a salvage option. Results confirmed that initial radial head displacement predicts functional outcome. Our study demonstrates that fracture dislocations of the elbow demand a broad consideration of treatment options and that reconstruction of elbow stability requires either primary repair of collateral ligaments or the possible use of a hinged fixator device.

Loading model for the human femur taking the tension band effect of the ilio-tibial tract into account.

A loading model permitting the application of relevant loads to the diaphysis and constructed on the basis of current knowledge of the biomechanics of the femur will be presented. This model takes into account the force acting through the ilio-tibial tract in the frontal plane and the forces acting on the condyles in the sagittal plane. There is compression on the femoral head and on the condyles and tension on the greater trochanter. Experimental verification using human cadaveric femora instrumented with strain gauges has shown that the adequate loading condition is: a line of force tangential to the femoral head a line of force tangential to the dorsal aspect of the distal junction of the diaphysis and metaphysis. Under these conditions, the calculated forces will accord well with values assessed in vivo. The model described here represents a simple procedure for experimental load application, producing realistic strain values. The proximal part of the bone is placed under tension on the dorsal aspect; the medial aspect is under compression. The strain pattern develops such that the tensile forces affect the anterior aspect distally and compression the dorsal aspect.

A biomechanical comparison of the antegrade inserted universal femoral nail with the retrograde inserted universal tibial nail for use in femoral shaft fractures.

Femoral shaft fractures with and without bony contact were simulated in cadaver specimens fixed with one of two different types of intramedullary locked nail systems; conventional antegrade nail fixation of the femur with the universal AO femoral nail or retrograde insertion in the femur with the universal tibial nail (a smaller diameter slotted nail) were utilized. Mechanical testing simulated one leg stance, and resultant deformation was measured in bending, torsion, and shortening. In stable fractures, fracture stability was similar to both devices, while in unstable fractures, the larger femoral nail was more stable. Furthermore, the simulation of single leg stance led to a coupled deformation of varus bending, axial shortening, and external rotation, which was dependent on bone geometry.

Humeral head replacement for glenohumeral arthritis.

From July 1977 through March of 1983, humeral head replacement was performed on 35 shoulders with osteoarthritis and 32 shoulders with rheumatoid arthritis and followed-up for an average of 9.3 years. Satisfactory pain relief was achieved in 44 (66%) and 52 of the shoulders (78%) were described by patients as being much better or better. Active elevation was improved from an average of 84 degrees to an average of 110 degrees with external rotation improving from 20 degrees to 44 degrees. Strength improvement also occurred. Only three complications developed, and these did not affect the final outcome. Because of moderate or severe pain, 12 shoulders (18%) required revision to total shoulder arthroplasty, and all patients were relieved of their pain. The result ratings were excellent in 10 shoulders, satisfactory in 23, and unsatisfactory in 34 (51%). With longer follow-up, a satisfactory level of pain relief may not continue for those patients with osteoarthritis and rheumatoid arthritis who have had humeral head replacement alone. Whereas this form of treatment should certainly be considered in those patients who have inadequate glenoid bone to support a glenoid implant and probably be considered in younger patients or patients who wish to remain more active, these latter patients must be fully appraised that the probability of continuing pain relief is less than has often been appreciated.

A review of corrective osteotomies for deformity in Paget's disease.

Corrective diaphyseal osteotomies for pagetic deformities may require a long time for union. However, metaphyseal osteotomies healed uneventfully. The use of plate fixation was associated with a lower rate of complications in diaphyseal osteotomies in Paget's disease. External fixation was associated with the highest rate of complications. Medical treatment did not seem to minimize blood loss or expedite union rate or time to union.

A retrospective analysis of plate contouring in the tibia using the conventional 4.5 (narrow) dynamic compression plate.

Plate contouring is an essential part of plate osteosynthesis. Its safety and technical ease is dependent on plate factors (material and design) and the complexity of the contouring. Our purpose was to determine the range of plate contouring; estimate the strain on the plate from the radius of curvature in the area of contouring; and determine whether shaped plates had a reduction in their load carrying capacity. A retrospective analysis of 500 radiographed tibias that had undergone osteosynthesis with the conventional dynamic compression plate was conducted to evaluate the radius of curvature and degree of bend in the plates, and to determine whether plates were bent at screw holes. Contouring of the plate to fit the bone was done by the surgeon at the time of application. Postoperative radiographs were evaluated. We found that (a) the shorter the length of plate contoured, the greater the strain; (b) plates were bent at screw holes, and these tended to be the areas of highest strain; (c) the range of plate strain was 0.6-16% (average 1.6%); and (d) plates were bent from 10 to 90 degrees (average 20 degrees).

Retrograde reamed femoral nailing.

Closed, reamed, antegrade nailing remains the standard of care for femoral shaft fractures. This technique however, may be less attractive in the management of femoral shaft fractures associated with (a) ipsilateral acetabular, pelvis, or femoral neck fractures; (b) polytrauma requiring multiple simultaneous surgical procedures; and (c) pregnancy. We now report on our experience with the retrograde femoral nailing as a treatment option in these situations. Between 4/88 and 10/90, 29 retrograde femoral nailing in 24 patients were attempted. Average age was 29.3 (16-74) years. Five fractures were open. Fracture location was isthmal in 14 and infraisthmal in 15. The comminution was classified according to Winquist and Hansen: I(10), II(7), III(7), and IV(5). Nailing was possible in 28/29 cases. Insertion was made through an extraarticular medial condylar portal. Nail diameter ranged from 10 to 13 mm. An AO Universal Femoral Nail was used in the first 11 cases; all subsequent fractures were stabilized using an AO Universal Tibial Nail because its design appeared better suited to this technique. Follow-up was possible for 25 fractures in 21 patients and averaged 16.0 (range, 11-27); months 23/25 (92%) fractures healed within 12 weeks. No case was associated with an infection, loss of reduction, or nail failure. Knee flexion averaged 122 degrees; only two knees had an extensor lag of > 5 degrees. Intraoperative complications included three cases of crack propagation at the insertion site, and four infraisthmal malreductions (two valgus, two flexion). Based on these results, we feel that retrograde reamed femoral nailing is a suitable alternative to antegrade nailing and should be considered in situations where proximal access is neither possible nor desirable.

Athletes on Anabolic-Androgenic Steroids.

In brief We performed a retrospective review to determine the efficacy of the clinic we established to diminish health problems among athletes who used or were considering using anabolic-androgenic steroids. The clinic evaluated 18 patients by standard questionnaire, history, physical exam, and laboratory tests. Intervention included counseling, explaining any evident steroid-health connections to the patient, medical referral, and treatment of detectable problems. The patients who had considered steroid use remained steroid-free, and the patients who had follow-up visits minimized their steroid use and exhibited fewer health problems.

Tuberculous osteomyelitis masked by concomitant staphylococcal infection.

A systematic and easily reproduced bone protocol was used over a 14-month period to evaluate bone histologically and by mycobacterial culture in patients with chronic osteomyelitis. On examination of 140 bone specimens, we found four patients with unsuspected tuberculous osteomyelitis whose diagnosis was obscured by a concomitant staphylococcal osteomyelitis. Three of the patients had axial skeleton involvement, and one had disease of the femur. No patient had a history of a positive skin test or of tuberculous disease, and none had coexistent pulmonary disease. The underlying granulomatous infection was initially revealed in one patient by histologic examination of bone and in three others only by mycobacterial culture of bone. Concomitant osseous tuberculosis should be excluded in patients with staphylococcal osteomyelitis. Evaluation using a bone protocol with histologic study and culture on Löwenstein-Jensen medium is effective in diagnosing occult osseous tuberculosis.

The effects of testosterone propionate and methenolone enanthate on the healing of humeral osteotomies in the Wistar rat.

A randomized blind prospective study was carried out to determine if an anabolic androgenic steroid with a high anabolic/androgenic ratio, Group A, (1/0.05) methenolone enanthate (me), compared to an anabolic/androgenic agent with a low anabolic/androgenic ratio, Group B, (1.0/1.0) testosterone propionate (tp), compared to a control, Group C, cottonseed oil (co), affected midhumeral osteotomy healing in 100 two-month-old female Wistar rats. The rats received 4 mg/kg me, 4 mg/kg te, and equal volumes of co weekly. The rats were sacrificed at 2, 4, and 6 weeks. The entire humerus with the healing osteotomy was carefully dissected until all soft tissue attachments were stripped. The healing callus was then subjected to (1) biochemical analysis (hexosamine, hydroxyproline, and calcium), (2) biomechanical testing (progressive distraction of the callus at 1 mm/min on an electrohydraulic materials test system, model 1331, Instron Corp, Canton, MA, and (3) histology. Results of the biochemical testing demonstrated that the percentage of calcium in the healing callus at 2 weeks in group B (tp) was 7.3 +/- 1.0, and this value was greater than that in group C (co), 4.8 +/- 1.6 (p greater than .01), and greater than that in group A (me), 5.6 +/- 0.6 (p greater than .01). At 4 weeks, the percentage of calcium in the callus in group B (tp) was 6.8 +/- 1.9, in group A (me) 7.3 +/- 3.7, and these values were both greater than that in group C (co), 3.9 +/- 2.2 (p greater than .02 and .01, respectively). At 6 weeks the percentage of calcium in the callus in group B (tp) was 11.7 +/- 3.9 and in group A (me) 12.7 +/- 3.9, and again these values were both greater than that in group C (co), 6.7 +/- 2.6 (p greater than .02 and .01, respectively). The remainder of the biochemical analysis, hexosamine and hydroxyproline content, did not show a statistical difference in groups A, B, and C at 2, 4, and 6 weeks. The biomechanical studies and histology also failed to show statistical differences between the three groups at 2, 4, and 6 weeks. The conclusion of this study is that an agent with a low androgenic activity does not increase calcium callus concentrations early in the course of fracture healing compared to an agent with higher androgenic activity. As healing progresses, both agents increase the concentration of calcium in osteotomy healing. The clinical significance of this study is that agents with low androgenic activities favorably influence osteotomy healing and may be clinically useful because they lack unwanted virilizing activity.

Anabolic androgenic steroids and a stroke in an athlete: case report.

Use of anabolic androgenic steroids among athletes has grown at an alarming rate in recent years, despite the knowledge that their use has resulted in such side effects as severe depression of high-density lipoprotein levels, increased low-density lipoprotein/cholesterol levels, and hepatocellular carcinoma. We report here the case of a 34-year-old man whose hobby was body building, in the course of which he had been taking various anabolic androgenic agents for four years. Seventeen days before a scheduled body physique contest, he developed an acute right hemiparesis and experienced difficulty in speaking. In the emergency room he developed a simple partial seizure activity; an electroencephalogram showed abnormal slowing suggestive of left hemispheric structural lesion. After rehabilitation, he was able to ambulate independently; he had mild motor weakness in the right upper extremity with no sensory changes at discharge. Physicians working with athletes who use anabolic androgenic steroids should warn them of the risk of stroke.