Reverse shoulder arthroplasty as a salvage procedure after failed internal fixation of fractures of the proximal humerus: outcomes and complications.

Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory. An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure.

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.

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.

Optimal position for plate fixation of complex fractures of the proximal radius: a cadaver study.

OBJECTIVE: To determine the optimal postion for plate fixation in complex fractures of the proximal radius in which head and neck dissociation occurs. DESIGN: Technical study. SETTING: Tertiary referral center, teaching hospital, U.S. military. SUBJECTS: Five preserved cadavers. MAIN OUTCOME MEASURE: Radioulnar impingement and proximity to neurovascular structures were directly measured in elbows plated in each of three positions: neutral, full pronation, and full supination. RESULTS: Application of the 2.0-millimeter T-plate to the lateral aspect of the radial head and neck with the forearm in neutral position had no impingement, whereas application in full pronation resulted in loss of the last 30 degrees of supination. Plate application in full supination resulted in the loss of the last 10 degrees of pronation. In addition, there was no impingement when the 2.7-millimeter plate was applied similarily in the neutral position. None of these positions resulted in increased risk to neurovascular structures. CONCLUSIONS: The optimal position for plate fixation of complex proximal radius fractures is with the forearm in neutral position, with the plate applied directly lateral. A larger implant, 2.7 millimeters, may be used if this technique is followed without further risk of impingement and loss of motion.