Elongation of the brachial plexus after reverse shoulder arthroplasty: an anatomical study.

INTRODUCTION: The use of reverse shoulder arthroplasty (RSA) is becoming more extended and its clinical results are good or excellent according to the literature. The main biomechanical characteristic of RSA is that it lowers and medializes the centre of rotation of the shoulder causing an arm lengthening. Although the number of neurological complications is low (5%), there are more neurophysiological changes in the brachial plexus with RSA than with the anatomic shoulder arthroplasty. The main goal of this study was to quantify the lengthening of the terminal branches of the brachial plexus suffered after RSA implantation. MATERIALS AND METHODS: 20 Embalmed cadavers were analysed. Four distances using bone references were employed to measure the lengthening of the arm and subacromial space. The brachial plexus and its terminal branches (radial, axillary, ulnar, musculocutaneous and median nerves) and the axillary artery, were identified and marked. Measurements were made to determine the change of position of the neurovascular structures, the arm lengthening and the lengthening of each nerve before and after the implantation of RSA. Two models of RSA were used: SMR®(Lima) and Delta Xtend®(DePuy-Synthes). RESULTS: The mean arm elongation was 10.5 mm. The subacromial space suffers an elongation of 20.5-29.8%. All the neurovascular structures suffered elongation: median nerve 23.1%, musculocutaneous nerve 22.1%, ulnar nerve 19%, radial nerve 17%, axillary nerve 12-14.5%, axillary artery 24.8%. There were no differences in the results between the types of prosthesis. CONCLUSIONS: Due to its design, the RSA causes an arm lengthening which is reflected by the elongation of the neurovascular structures of the arm.

Acute Carpal Tunnel Syndrome After Radial Artery Cannulation: A Case Report.

CASE: A 20-year-old postpartum woman developed paresthesias and intolerable pain over the volar aspect of the first through fourth fingers, after radial artery cannulation (RAC) during cesarean section. Ultrasonography did not show any hematoma in the forearm. Urgent carpal tunnel release and median nerve decompression were performed, resulting in complete disappearance of symptoms. CONCLUSION: Acute median nerve compression is a rare injury in its own, but it is even rarer as a complication of RAC. Urgent decompression should be performed as soon as possible to avoid future neurological deficits.

Reverse total shoulder arhroplasty for the treatment of failed fixation in proximal humeral fractures.

BACKGROUND: This study evaluates the clinical outcomes in patients with proximal humerus fractures (PHF) treated with reverse total shoulder arthroplasty (RTSA) as a revision procedure for failed fixation that have more than 5 years of follow-up. MATERIALS AND METHODS: This is a retrospective study of 270 RTSA. The inclusion criteria for this study consisted of patients initially treated with either open reduction and plate fixation (ORIF) or fixation using an intramedullary nail (IMN), who were managed with a single-stage revision to a RTSA, and had a minimum of 24 months clinical and radiological follow-up. Six patients with failed fixation of displaced PHF were revised with RTSA. One patient was excluded from the study because she died. Five shoulders were reviewed for the purpose of this study. The patients were evaluated using Constant score, relative Constant score and visual analogue scale for pain. RESULTS: The mean follow-up was 89 months (65-108). The mean absolute Constant score improved from 31, 81 to 44, 2 and the relative Constant score improved from 31,81% to 67,2%. Mean VAS improved from 6, 8 to 2. One patient rated their outcome excellent, 1good, 1 satisfied and 2 poor. CONCLUSION: RTSA is an appropriate treatment as a revision surgery for failed fixation of PHF. Patients should be adequately warned that they will improve their function but may have complications following this salvage procedure.

Topical Tranexamic Acid May Improve Early Functional Outcomes of Primary Total Knee Arthroplasty.

INTRODUCTION: The use of tranexamic acid (TXA) reduces postoperative anemia and blood transfusion requirements. We investigated if these beneficial effects improve the early outcomes of primary total knee arthroplasty (TKA). METHODS: We retrospectively studied 166 consecutive patients (179 TKAs) who received topical TXA (3 g before tourniquet deflation). This "study group" was compared with a "control group" of 197 consecutive patients (209 TKAs) in whom no TXA was used. We captured outcomes during the first 4 postoperative months. Knee Society score (KSS) was determined preoperatively, 6 weeks, and 4 months postoperatively. The outcomes were compared using univariate analysis. Multiple logistic regressions were calculated to assess differences between groups in KSS at 6 weeks and 4 months, controlling for age, sex, body mass index, and preoperative KSS. RESULTS: Postoperative hemoglobin was significantly higher in the study than that in the control group on day 1, day 2, and at discharge (P < .0001). Blood transfusions were required in 5% and 22% of patients (P < .001), respectively. Six weeks postoperatively, the functional KSS and its 5 categories (ability to walk, negotiate stairs up and down, stand up from a chair, and the use of support) were significantly higher in the study than those in the control group (P ≤ .001). Four months postoperatively, there was no difference in the KSS between the groups. DISCUSSION: Our study suggests that the clinical benefit of topical TXA administration extends beyond the hospitalization period. Its use may improve knee function during the first 6 postoperative weeks. This beneficial clinical effect seems to be negligible afterward.

Reverse shoulder arthroplasty for acute proximal humeral fractures in the geriatric patient: results, health-related quality of life and complication rates.

PURPOSE: Reverse shoulder arthroplasty (RSA) in fractures is especially indicated in patients of advanced age, although the influence of age on functional outcomes, health-related quality of life (HRQoL) and complication rate is unknown. We hypothesized that complication rate would decrease in the geriatric population because of their reduced activity, improving the perceived HRQoL. METHODS: Retrospective study of 42 patients with proximal humeral fractures treated with RSA, divided into two groups: <80 years (<80y)(n = 16) and ≥80 years (≥80y)(n = 26). The assessment tools used were radiological images (functional outcome) with the Constant-Murley score(CMS); disabilities of the arm, shoulder and hand (DASH) score; and HRQoL with the EQ-5D index. Mean follow-up time was 32.6 months. RESULTS: Mean CMS adjusted for age and sex (R-CMS) was 68 % ± 29 %. Patients in the ≥80y group had a lower total CMS, 33 vs 64 (p = 0.027). Mean active range of motion at 24 months <80y/≥80y was: forward flexion: 126°/110°; abduction: 117°/105°; external rotation: 22°/20°; and internal rotation: L3/sacrum. Mean EQ-VAS was 74 ± 16 in the <80y group, and 63 ± 12.6 in the ≥80y group. Mean DASH was 29.5 ± 9.2. The EQ-5D "self-care" item in the >80y group was the most affected. The "pain/discomfort" item was lower for the two age groups than for the reference population. There were 9.5 % complications: one prosthesis dislocation, one periprosthetic fracture and two surgical wound haematoma. CONCLUSIONS: Our results indicate that age is a critical factor for RSA success. Lower functional outcomes have been obtained in patients older than 80y, although the EQ-5D results in our sample were similar or even better than the referred population. LEVEL OF EVIDENCE: Level III.