Two-year clinical outcomes and complication rates in anatomic and reverse shoulder arthroplasty implanted with Exactech GPS intraoperative navigation.

INTRODUCTION: We compared the 2-year clinical outcomes of both anatomic and reverse total shoulder arthroplasty (ATSA and RTSA) using intraoperative navigation compared to traditional positioning techniques. We also examined the effect of glenoid implant retroversion on clinical outcomes. HYPOTHESIS: In both ATSA and RTSA, computer navigation would be associated with equal or better outcomes with fewer complications. Final glenoid version and degree of correction would not show outcome differences. MATERIAL AND METHODS: A total of 216 ATSAs and 533 RTSAs were performed using preoperative planning and intraoperative navigation with a minimum of 2-year follow-up. Matched cohorts (2:1) for age, gender, and follow-up for cases without intraoperative navigation were compared using all standard shoulder arthroplasty clinical outcome metrics. Two subanalyses were performed on navigated cases comparing glenoids positioned greater or less than 10° of retroversion and glenoids corrected more or less than 15°. RESULTS: For ASTA, no statistical differences were found between the navigated and non-navigated cohorts for postoperative complications, glenoid implant loosening, or revision rate. No significant differences were seen in any of the ATSA outcome metrics besides higher internal and external rotation in the navigated cohort. For RTSA, the navigated cohort showed an ARR of 1.7% (95% CI 0%, 3.4%) for postoperative complications and 0.7% (95% CI 0.1%, 1.2%) for dislocations. No difference was found in the revision rate, glenoid implant loosening, acromial stress fracture rates, or scapular notching. Navigated RTSA patients demonstrated significant improvements over non-navigated patients in internal rotation, external rotation, maximum lifting weight, the Simple Shoulder Test (SST), Constant, and Shoulder Arthroplasty Smart (SAS) scores. For the navigated subcohorts, ATSA cases with a higher degree of final retroversion showed significant improvement in pain, Constant, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), SST, University of California-Los Angeles shoulder score (UCLA), and Shoulder Pain and Disability Index (SPADI) scores. No significant differences were found in the RTSA subcohort. Higher degrees of version correction showed improvement in external rotation, SST, and Constant scores for ATSA and forward elevation, internal rotation, pain, SST, Constant, ASES, UCLA, SPADI, and SAS scores for RTSA. CONCLUSION: The use of intraoperative navigation shoulder arthroplasty is safe, produces at least equally good outcomes at 2 years as standard instrumentation does without any increased risk of complications. The effect of final implant position above or below 10° of glenoid retroversion and correction more or less than 15° does not negatively impact outcomes.

Factors associated with improvement or loss of internal rotation after reverse shoulder arthroplasty.

BACKGROUND: Internal rotation (IR) with reverse total shoulder arthroplasty (rTSA) can be unpredictable. Identifying the factors associated with loss of or improved IR could aid preoperative patient counseling. This study quantifies the change in IR experienced by rTSA patients with nonfracture indications and identifies the patient, implant, and operative factors associated with IR loss or gain at 2-year minimum follow-up. METHODS: A total of 1978 primary rTSA patients were analyzed from an international database of a single rTSA prosthesis to quantify IR at 2 years' minimum follow-up. rTSA patients were divided into 2 cohorts based on their preoperative IR score, with group 1 patients having less active IR as defined by a preoperative IR score ≤3 and group 2 patients having greater active IR as defined by a preoperative IR score ≥4 (ie, L5 or higher). For both group 1 and 2 patients, univariate and multivariate analyses were performed to quantify the risk factors associated with IR loss after rTSA. RESULTS: Overall, 58.9% of rTSA patients experienced IR improvement and 17.0% lost IR after rTSA. The occurrence of IR loss or gain was dependent on preoperative IR score, as 73.2% of group 1 patients improved IR and only 40.1% of group 2 patients improved IR, whereas 31.0% of group 2 patients lost IR and only 6.3% of group 1 patients lost IR after rTSA. Numerous risk factors for IR loss were identified. For group 1 patients, male sex (P = .004, odds ratio [OR] = 2.056), tobacco usage (P = .004, OR = 0.348), larger humeral stem diameter (P = .008, OR = 0.852), and not having subscapularis repaired (P = .002, OR = 2.654) were significant risk factors for IR loss. For group 2 patients, male sex (P = .005, OR = 1.656), higher body mass index (P = .002, OR = 0.946), a diagnosis other than osteoarthritis (P < .001, OR = 2.189), nonaugmented baseplate usage (P < .001, OR = 2.116), and not having subscapularis repaired (P < .001, OR = 3.052) were significant risk factors for IR loss. CONCLUSION: The majority of patients improve IR after rTSA in the nonfracture setting. rTSA patients with substantial IR prior to surgery had a greater probability for losing IR compared to patients with poor preoperative IR. Numerous risk factors for IR loss were identified; these risk factors are useful for counseling patients considering rTSA, as some patients are more likely to lose IR than others.

Distal Humeral Hemiarthroplasty Versus Total Elbow Arthroplasty for Acute Distal Humeral Fractures.

For acute distal humeral fractures not amenable to open reduction and internal fixation, total elbow arthroplasty has become an established alternative. However, lifelong activity restrictions designed to prevent early mechanical failure make this a poor option for some patients. This has led to a renewed interest in distal humeral hemiarthroplasty. Using modern implants and techniques, distal humeral hemiarthroplasty has shown outcomes comparable to those of total elbow arthroplasty at short- to mid-term follow-up, with an overall higher but different complication rate. Long-term data are needed, but the available literature suggests that distal humeral hemiarthroplasty be considered as another option on the treatment spectrum in select patient populations. [Orthopedics. 2017; 40(1):13-23.].

Multicenter trial of an internal joint stabilizer for the elbow.

BACKGROUND: Our primary efficacy objective was to evaluate the effectiveness of the internal joint stabilizer of the elbow (IJS-E) in maintaining concentric location of the elbow during and after removal of the device in the treatment of persistent or recurrent instability after elbow fracture or dislocations, or both. The secondary study objectives were to assess range of motion, Broberg-Morrey functional score, Broberg-Morrey categorical rating, the Disabilities of the Arm, Shoulder and Hand score, and the rate of complications and adverse events after the use of IJS-E. METHODS: Twenty-four patients were studied in a multicenter, nonrandomized, prospective, single-arm study. The IJS-E was used to provide temporary stabilization of the elbow joint and allow a functional range of motion while ligaments and fractures healed. RESULTS: The elbow remained concentrically aligned in 23 of 24 patients. One coronoid-deficient elbow did not maintain concentric reduction. At the last evaluation a minimum of 6 months after device removal, the mean arc of elbow flexion was 119° (range, 80°-150°; standard deviation [SD], 18°), and the mean arc of forearm rotation was 151° (range, 90°-190°; SD, 24°). The mean and median Broberg-Morrey scores were 93 and 97, respectively. Categorically the results were excellent in 14, good in 8, fair in 1, and poor in 1. The mean Disabilities of the Arm, Shoulder and Hand score was 16 (range, 0-68; SD, 18). CONCLUSION: The IJS-E maintains concentric reduction, allows elbow motion, and avoids the inconveniences and pin problems of percutaneous fixation.

A mini external fixator for hand and finger fractures constructed from readily available materials.

Phalangeal and metacarpal fractures with severe comminution and/or soft tissue compromise can present a challenge for the orthopedic surgeon. Maintaining viability of the soft tissues while providing rigid fixation of bony injuries is the goal when treating these injuries. Commercially available mini external fixators can help to achieve these goals. However, these devices are costly and are not always available when the surgeon needs them. In this technique study, we discuss the implementation of a mini external fixator using readily available implements in the operating room that is efficient, cost effective, and easy to apply.

Reconstruction for persistent instability of the elbow after coronoid fracture-dislocation.

The results of reconstruction for chronic instability after coronoid fracture have not been previously described. Patients with persistent instability after coronoid fracture-dislocation were assessed after reconstruction. A satisfactory outcome was considered to be present based on the Mayo Elbow Performance Score and on the patient's willingness to repeat the operation. The length of follow-up was a minimum of 2 years, averaging over 5 years. Overall, 13 of 21 patients (62%) were classified as having a successful outcome objectively, and 17 of 21 (81%) were classified as having a successful outcome subjectively. The duration of the delay to definitive treatment was closely associated with the ultimate outcome (P < .01), as the outcome of only 1 of 7 elbows with a delay greater than 7 weeks was classified as an objective success. Of the patients, 19 had a fractured radial head, 11 of which were initially treated with a radial head excision; none was subsequently reconstructed. Sixteen patients were treated with a hinged external fixator. Of the elbows, 13 remained reduced whereas 8 had variable amounts of anterior or posterior instability. Two failures were ultimately reconstructed with a total elbow arthroplasty. Instability that persists after the initial unsuccessful management of a coronoid fracture and an elbow dislocation is a difficult problem to salvage with subsequent reconstruction. This experience emphasizes the need for better reconstructive options and especially underscores the need for appropriate initial management of this difficult injury.