Two-year follow-up of the SMR stemless platform shoulder system: a multicenter, prospective clinical study.

Background: The use of stemless shoulder arthroplasty for osteoarthritis has grown substantially over the past decades. The goal of this study is to evaluate the clinical and radiological outcomes of the Lima SMR stemless anatomic and reverse total shoulder arthroplasty. Methods: Seventy-three implants in 73 patients (61 anatomic total shoulder arthroplasties [aTSAs] and 12 reverse shoulder arthroplasties [RSAs]) were analyzed with a minimum follow-up of 2 years. The average age in the aTSA group was 65.8 ± 8.7 and 78.3 ± 4.8 in the RSA group. Primary osteoarthritis was the indication in most cases (aTSA 93.7%, RSA 67%). Patients were evaluated preoperatively, at 4, 12, and 24 months postoperatively using the Constant score, the ASES, Oxford Shoulder Score, EuroQol 5 Dimensions 5 Levels questionnaire, range of motion scores, and radiographically. Statistical significance was evaluated using the paired t-test (P < .5). Results: At 2-year follow-up, the overall average Constant score significantly improved from 40.0 ± 16.7 to 80.9 ± 21.4 (P < .001). Improvement of the ASES (from 31.7 ± 15.6 to 82.5 ± 19.4) and Oxford Shoulder Score (from 19.1 ± 7.4 to 41.9 ± 7.9) was also significant (P < .001). In the aTSA group, all range of motion scores improved significantly (P < .001). In the RSA group, all range of motion scores improved but only active forward flexion and external rotation in abduction improved significantly (P < .05). Most patients were satisfied or completely satisfied at 24 months (aTSA 93.9%, RSA 100%). Two humeral implants in the RSA configuration showed loosening on the first postoperative day related to excessive forces exerted on the shoulder, both requiring revision to a stemmed implant. In the aTSA group, no signs of radiolucencies, osteolysis, gradual loosening, or migration of the components were seen at the final follow-up. In the RSA group, one case had radiolucent lines with subsidence of the humeral core at 12 months, which had not progressed at 24 months and was asymptomatic. All other RSA cases showed no radiolucent lines, migration, scapular notching, or osteolysis. Three anatomic implants were converted with retention of the glenoid baseplate and humeral core to a reverse arthroplasty due to atraumatic cuff failure (N = 2) and traumatic cuff failure (N = 1). After these procedures, patients were satisfied with their results. There were no other complications. Conclusion: The 2-year results presented in this study show good functional and radiological outcomes using the SMR stemless system.

Satisfactory Short-Term Outcomes of Reverse Shoulder Arthroplasty for Complex Three- and Four-Part Fractures of the Humeral Head in Octogenarians.

BACKGROUND: Proximal humeral fractures with severe comminution and poor bone quality are among the most common injuries in the elderly population. Reverse shoulder arthroplasty (RSA) has been widely used to manage complex three- and four-part humeral head fractures. The purpose of the present study was to report the result of this technique in the demanding population of octogenarians. MATERIALS AND METHODS:  Twenty-six patients above the age of 80 years were included in the study and followed for a minimum of one-year follow-up. To assess the functional outcomes the postoperative range of motion (ROM), the Constant score, the visual analog scale for pain, and the disability of the arm and shoulder score (DASH) were measured at 6 and 12 months. Radiological assessment and potential complications were also recorded. RESULTS: The mean age of the study population was 81.9 years (81-86) at the time of surgery. There was a statistically significant improvement in all outcomes over the follow-up intervals. Shoulder ROM was 125.7o for flexion, 98.2o for abduction, 42.2o for internal rotation, and 43.2o for external rotation at 12 months. The mean Constant, DASH, and VAS scores at the last follow-up were 61.3, 31.9, and 0.5, respectively. Reported complications include one superficial surgical site infection. CONCLUSION: RSA is a safe and reliable surgical option with satisfactory outcomes to manage complex three- and four-part fractures of the humeral head as it can provide prompt pain relief and function in octogenarians.

Reverse Shoulder Arthroplasty for the Treatment of 3 and 4- Part Fractures of the Humeral Head in the Elderly.

BACKGROUND: Proximal humeral fractures in elderly patients present with severe comminution and osteoporotic bone quality. Reverse shoulder arthroplasty has lately been proven beneficial in treating patients with complex proximal humeral fractures. The above technique is recommended and has better results in elderly than in younger individuals. METHODS: We performed a literature search in the databases Pubmed, Medline, EMBASE and Cochrane Library for published articles between 1970 and 2016 using the terms: proximal humerus fractures and reverse shoulder arthroplasty. RESULTS: Significant benefits with the use of reverse prosthesis, especially in patients older than 70 years with a proximal humeral fracture, include reduced rehabilitation time as well as conservation of a fixed fulcrum for deltoid action in case of rotator cuff failure. Compared with hemiarthroplasty and internal fixation, reverse prosthesis may be particularly useful and give superior outcomes in older patients, due to comminuted fractures in osteopenic bones. However, significant disadvantages of this technique are potential complications and a demanding learning curve.Therefore, trained surgeons should follow specific indications when applying the particular treatment of proximal humeral fractures and be familiar with the surgical technique. CONCLUSION: Although long-term results and randomized studies for reverse prosthesis are lacking, short and mid- term outcomes have given promising results encouraging more shoulder surgeons to use this type of prosthesis in proximal humeral fractures.

A New Electromagnetic Navigation System for Pedicle Screws Placement: A Human Cadaver Study at the Lumbar Spine.

INTRODUCTION: Technical developments for improving the safety and accuracy of pedicle screw placement play an increasingly important role in spine surgery. In addition to the standard techniques of free-hand placement and fluoroscopic navigation, the rate of complications is reduced by 3D fluoroscopy, cone-beam CT, intraoperative CT/MRI, and various other navigation techniques. Another important aspect that should be emphasized is the reduction of intraoperative radiation exposure for personnel and patient. The aim of this study was to investigate the accuracy of a new navigation system for the spine based on an electromagnetic field. MATERIAL AND METHOD: Twenty pedicle screws were placed in the lumbar spine of human cadavers using EMF navigation. Navigation was based on data from a preoperative thin-slice CT scan. The cadavers were positioned on a special field generator and the system was matched using a patient tracker on the spinous process. Navigation was conducted using especially developed instruments that can be tracked in the electromagnetic field. Another thin-slice CT scan was made postoperatively to assess the result. The evaluation included the position of the screws in the direction of trajectory and any injury to the surrounding cortical bone. The results were classified in 5 groups: grade 1: ideal screw position in the center of the pedicle with no cortical bone injury; grade 2: acceptable screw position, cortical bone injury with cortical penetration ≤ 2 mm; grade 3: cortical bone injury with cortical penetration 2,1-4 mm, grad 4: cortical bone injury with cortical penetration 4,1-6 mm, grade 5: cortical bone injury with cortical penetration >6 mm. RESULTS: The initial evaluation of the system showed good accuracy for the lumbar spine (65% grade 1, 20% grade 2, 15% grade 3, 0% grade 4, 0% grade 5). A comparison of the initial results with other navigation techniques in literature (CT navigation, 2D fluoroscopic navigation) shows that the accuracy of this system is comparable. CONCLUSION: EMF navigation offers a high accuracy in Pedicle screw placement with additional advantages compared to other techniques. The short set-up time and easy handling of EMF navigation should be emphasized. Additional advantages are the absence of intraoperative radiation exposure for the operator and surgical team in the current set-up and the operator's free mobility without interfering with navigation. Further studies with navigation at higher levels of the spine, larger numbers of cases and studies with control group are planned.

Bilateral spinal decompression of lumbar central stenosis with the full-endoscopic interlaminar versus microsurgical laminotomy technique: a prospective, randomized, controlled study.

BACKGROUND: Extensive decompression with laminectomy, where appropriate, is often still described as the method of choice when operating on degenerative lumbar spinal stenosis. Nonetheless, tissue-sparing procedures are becoming more common. Endoscopic techniques have become the standard in many areas because of the surgical advantages they offer and the benefits for rehabilitation. One key issue when operating on the spine was the development of instruments to provide sufficient bone resection under continuous visual control. This was achieved by using endoscopes for operations carried out in cases of spinal canal stenosis. OBJECTIVE: This study of patients with degenerative lumbar central spinal stenosis compares the results of spinal decompression using the full-endoscopic interlaminar technique (FI) with a conventional microsurgical laminotomy technique (MI). STUDY DESIGN: Prospective, randomized, controlled study. SETTINGS: 135 patients with microsurgical or full-endoscopic decompression were followed up for 2 years. Alongside general and specific parameters, the following measuring instruments were also used for the investigation: Visual Analog Scale (VAS), German version of the North American Spine Society Instrument (NASS), Oswestry Low-Back-Pain-Disability Questionnaire (ODI). RESULTS: Postoperatively 72 % of the patients no longer had leg pain or the pain was almost completely reduced and 21.2 % experienced occasional pain. The clinical results were the same in both groups. The rate of complications and revisions was significantly reduced in the FI Group. The full-endoscopic techniques brought advantages in the following areas: operation, complications, traumatization, rehabilitation. LIMITATIONS: Lack of placebo control group. CONCLUSIONS: The recorded results demonstrate that the full-endoscopic interlaminar bilateral decompression adopting a unilateral approach provides an adequate and safe supplement and alternative to the conventional microsurgical bilateral laminotomy technique when the indication criteria are fulfilled. At the same time, it offers the advantages of a minimally invasive intervention.

Endoscopic repair of tears of the superficial layer of the distal triceps tendon.

PURPOSE: The purpose of this study was to evaluate the results after endoscopic repair of partial superficial layer triceps tendon tears. METHODS: Fourteen patients treated surgically between July 2005 and December 2012 were studied prospectively for 12 months. Indication for surgery was a partial detachment of the triceps tendon from the olecranon that was proved by magnetic resonance imaging (MRI) in all cases. Ten of these patients had chronic olecranon bursitis. All patients were treated with endoscopic surgery including bursectomy and repair of the distal triceps tendon with double-loaded suture anchors. Clinical examination of the patients as well as functional and subjective scores (Mayo Elbow Performance Index [MEPI], Disabilities of the Arm, Shoulder and Hand Score [Quick DASH]) were obtained preoperatively and postoperatively at 6 and 12 months. An isokinetic strength measurement and MRI were performed preoperatively and 12 months after surgery. RESULTS: All 14 patients were completely evaluated. The MEPI and Quick DASH Score improved significantly after the repair at all postoperative examinations. The MEPI gained 29 points, up to 96 points at last follow-up (P < .05), and the Quick DASH Score went down 15.6 points after 12 months to 4.5 points (P < .05). Maximum extension power improved 55.8%, up to 94.7% at last follow-up compared with the contralateral side. Using MRI, we found one reruptured partial tear of the triceps tendon that did not require revision surgery. DISCUSSION: Although triceps tendon ruptures are generally uncommon, partial superficial tears might be more common than previously described. Once the diagnosis is made, endoscopic repair is a method leading to good clinical results with improved function of the affected elbow. CONCLUSIONS: Endoscopic repair of superficial tears of the triceps tendon is able to restore function and strength and leads to excellent clinical results after 1 year. Strength recovers to nearly that of the contralateral side, and serious complications appear to be infrequent. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Arthroscopic versus conservative treatment of first anterior dislocation of the shoulder in adolescents.

BACKGROUND: Conservative treatment of posttraumatic antero-inferior shoulder instability leads to a high failure rate in a young and active population. However, treatment in an adolescent age group is not well documented. METHODS: We conducted a prospective study with adolescent patients (age 15 to 18 y) who suffered a first traumatic anterior dislocation of the shoulder. Two groups of patients were formed. The first group was treated with early arthroscopic stabilization and the second was treated conservatively. There were 43 shoulders in the operative group and 29 shoulders in the conservative group. The rehabilitation protocol was the same for both groups. All patients were followed up prospectively after 12, 24, and 36 months using Rowe Score. RESULTS: A total of 38 shoulders in the surgical group and 27 shoulders in the conservative group could be completely evaluated. From the conservative group, 19 patients (70.3%) suffered a recurrence of the instability. From the arthroscopic group, 5 patients (13.1%) suffered a recurrence of the instability. CONCLUSIONS: In an adolescent population (15 to 18 y), conservative treatment after first traumatic shoulder dislocation including immobilization in internal rotation leads to a significantly higher and unacceptable high failure rate compared with early arthroscopic stabilization. LEVEL OF EVIDENCE: Level II-prospective comparative study.

Arthroscopic reconstruction of isolated subscapularis tears: clinical results and structural integrity after 24 months.

PURPOSE: The purpose of this study was to evaluate the magnetic resonance imaging (MRI) and clinical results of arthroscopic repair of isolated subscapularis tears at 24 months' follow-up. METHODS: We prospectively followed up 20 patients with isolated subscapularis tears treated with arthroscopic repair with suture anchors in a 3-year period (January 2006 to December 2008) at our institution. Clinical examination of the patients and functional scores (Constant and University of California, Los Angeles [UCLA] scores) were obtained preoperatively and at 6 months, 12 months, and 24 months postoperatively. MRI and routine radiographs were obtained to evaluate the repair at the last follow-up. RESULTS: Of the patients (mean age, 42 years; age range, 31 to 56 years), 19 (95%) had complete follow-up. Constant and UCLA scores improved significantly after the repair at all postoperative examinations. The Constant score gained 39.7 points to a mean of 81 points (range, 61 to 95 points) at last follow-up, and the UCLA score improved from 16 points to 32 points (range, 25 to 35 points). Of the shoulders, 13 had a concomitant lesion of the long head of the biceps; 12 were treated with biceps tenodesis. At last follow-up, there were 2 retears detected by both MRI and examinations (positive belly-press and liftoff tests). Seventeen patients were satisfied with their results at 24 months postoperatively. CONCLUSIONS: Arthroscopic repair of isolated subscapularis tendon tears is an effective technique with good-to-excellent clinical and functional results. LEVEL OF EVIDENCE: Level IV, therapeutic case series.