Do the humeral radiographic changes at 5-year follow-up affect the clinical outcomes of press-fit humeral stems in primary reverse shoulder arthroplasties?

INTRODUCTION: The purposes of this study were to analyze and compare the functional outcomes and radiological changes around the press-fit humeral components in two contemporary medialized reverse total shoulder arthroplasty (RTSA) systems at a minimum of 5-year follow-up. MATERIALS AND METHODS: Between December 2003 and December 2015, 249 consecutive RTSAs were performed at our hospital. Of these, 68 primary uncemented RTSA met our inclusion criteria. The Constant-Murley score (CMS), the modified Constant score, a visual analog scale (VAS) and active shoulder range of motion (ROM) were measured pre- and postoperatively. Radiological assessment was performed by plain radiographs at a minimum of 5 years postoperatively. RESULTS: At a mean follow-up of 80.2 months, there was no significant difference (p = .59) between the postoperative functional scores and range of motion of the two groups (Delta Xtend and Lima SMR). Radiological data of stress-shielding were observed in 38 patients (55.9%) being slightly more frequent in the Lima SMR group (21 patients) than in the Delta Xtend group (17 patients) (p = .62). CONCLUSIONS: Our study shows that the good functional results are similar between the two uncemented RTSA systems used and that they do not depend on the presence of radiological changes (stress-shielding) in the humeral stem at a minimum 5-year follow-up.

Adjuvant Arthroscopy Does Not Improve the Functional Outcome of Volar Locking Plate for Distal Radius Fractures: A Randomized Clinical Trial.

PURPOSE: To evaluate the outcomes of adding arthroscopy to osteosynthesis of distal radius fractures (DRF) with volar locking plate (VLP), by Patient-Rated Wrist Evaluation (PRWE) 1 year after surgery. METHODS: In total, 186 functionally independent adult patients who met the inclusion criteria (DRF and a clinical decision for surgery with a VLP) were randomized to arthroscopic assistance or not. Primary outcome was PRWE questionnaire results 1 year after surgery. For the main variable, PRWE, we obtained the minimal clinically important difference based on a distribution-based method. Secondary outcomes included Disabilities of the Arm, Shoulder and Hand and 12-Item Short Form Health Survey questionnaires, range of motion, strength, radiographic measures, and presence of joint step-offs by computed tomography. Data were collected preoperatively and at +1 and +4 weeks, +3 and +6 months, and +1 year after surgery. Complications were recorded throughout the study. RESULTS: In total, 180 patients (mean age: 59.0 ± 14.9 years; 76% women) were analyzed by modified intention to treat. A total of 82% of the fractures were intra-articular (AO type C). No significant difference between arthroscopic (AG) and control (CG) groups in median PRWE was found at +1 year (median AG: 5.0, median CG: 7.5, difference in medians 2.5; 95% confidence interval [CI] -2.0, 7.0, P = .328). The proportion of patients who exceeded the minimal clinically important difference of 12.81 points in the AG and CG was 86.4% vs 85.1%, P = .819, respectively. Percentage of associated injuries and step-offs reduction maneuvers was greater with arthroscopy (mean differences: 17.1 95% CI -0.1, 26.1, P < .001) and 17.4 (95% CI 5.0, 29.7, P = .007). The difference in percentage of residual joint step-offs at the postsurgical computed tomography in radioulnar, radioscaphoid, and radiolunate joints was not significant (P = .990, P = .538, and P = .063). Complications were similar between groups (16.9% vs 20.9%, P = .842). CONCLUSIONS: Adjuvant arthroscopy did not significantly improve PRWE score +1 year after surgery for DRF with VLP, although the statistical power of the study is below the initially estimated to detect the expected difference. LEVEL OF EVIDENCE: Level I, randomized controlled trial.

The Spanish version of the Constant-Murley Shoulder Score: translation, cultural adaptation, and validity.

BACKGROUND: The Constant-Murley Score (CMS) is one of the most employed tools for assessing shoulder function. It was first devised in 1987 for the English population and is now widely used internationally. However, it had yet to be cross-culturally adapted and validated to Spanish, which is the world's second-most native language. Formal adaptation and validation of clinical scores is paramount for them to be used with rigorous scientific methodology. METHODS: Following international recommendations for the cross-cultural adaptation of self-report measures, the CMS was first adapted into Spanish in six stages: translation, synthesis, back-translation, a review by expert committee, pretesting, and final appraisal by expert committee. After conducting a pretest with 30 individuals, the Spanish version of the CMS was tested on 104 patients with various shoulder pathologies to assess content, construct, criterion validity, and reliability. RESULTS: No major conflicts were encountered in the process of cross-cultural adaptation, with 96.7% of pretested patients having a full understanding of every item in the test. The validation showed excellent content validity (content validity index = .90), construct validity (strong correlation between items within the same subsection of the test), and criterion validity (CMS - Simple Shoulder Test, Pearson r = .587, P = .01; CMS - American Shoulder and Elbow Surgeons, Pearson r = .690, P = .01). Reliability of the test was also excellent, with high internal consistency (Cronbach's α = .819), interrater reliability (intraclass correlation coefficient = .982), and intrarater reliability (intraclass correlation coefficient = .937), without showing ceiling or floor effects. CONCLUSION: Spanish version of the CMS has been proved to accurately reproduce the original score and to be easily comprehensible by native Spanish speakers with acceptable intrarater-interrater reliability and construct validity. INTRODUCCIóN: La escala de Constant-Murley (CMS) es una de las más empleadas para evaluar la función del hombro. Se ideó por primera vez para la población inglesa en 1987 y actualmente es ampliamente empleada a nivel internacional. Sin embargo, su validación y adaptación transcultural no se han realizado al español, la segunda lengua nativa más hablada en el mundo. Actualmente no puede resultar admisible el empleo de escalas en las que no tengamos la seguridad de que existe una equivalencia conceptual, cultural y lingüística entre la versión original y la empleada. MATERIAL Y MéTODO: La versión traducida al español de la CMS se realizó siguiendo las recomendaciones internacionales: traducción, síntesis de la traducción, retrotraducción, revisión por comité de expertos, pretest y validación. Tras la realización del pretest en 30 individuos, la versión española de la escala de CMS se probó en 104 pacientes con diferentes patologías de hombro para evaluar las propiedades psicométricas de la escala: contenido, constructo, validez de criterio y fiabilidad. RESULTADOS: No se encontraron problemas importantes durante el proceso de adaptación transultural con un entendimiento completo de todos los ítems del pretest por el 96.7% de los pacientes. La escala adaptada demostró una excelente validez de contenido (índice de validez de contenido = .90), de constructo (fuerte correlación entre ítems de la misma subsección del test), y de criterio (CMS-SST Pearson's r = .587, p = .01; CMS-ASES Pearson's r = .690, p = .01). La Fiabilidad del test resultó excelente, con una elevada consistencia interna (Cronbach's α = .819), fiabilidad interobservador (ICC = .982) e intraobservador (ICC = .937), sin efectos techo y suelo. CONCLUSIóN: La versión Española de la CMS garantiza la equivalencia con respecto al cuestionario original. Los presentes resultados, sugieren que esta versión es válida, fiable y reproducible para la evaluación de la patología de hombro en nuestro entorno.

Dislocation after reverse total shoulder arthroplasty using contemporary medialized modular systems. Can we still consider it such a frequent complication?

INTRODUCTION: Improvement in reverse total shoulder arthroplasty (RTSA) prosthesis and technique has reduced the initially high complication and revision rates associated with this implant. However, instability continues to be a leading cause of reoperation after RTSA, being related in previous studies with medialized designs. The aim of this study was to determine the dislocation rate with the employment of two medialized modular systems of RTSA in our institution. MATERIALS AND METHODS: A retrospective review of two different modular systems of RTSA (SMR Modular Shoulder System and Delta XTEND Reverse Shoulder) was performed between 2009 and 2017 with a minimum 3-year follow-up. Baseline demographic, clinical (Constant, ASES and ROM), and radiographic data were collected. Characteristics of postoperative instability cases were also evaluated. RESULTS: 237 primary RTSA (41% SMR/59% Delta) and 34 revision RTSA (44% SMR/56% Delta) with a mean follow-up of 75.6 ± 5.2 months (79.2 SMR/86.3 Delta, p = .586) were included in the present study. Indications for primary RTSA were osteoarthritis, rotator cuff tear arthropathy and massive irreparable rotator cuff tear (64%), acute fracture (32%), and fracture sequelae (4%). Subscapularis tendon was always repaired in degenerative pathology and tuberosities reattached in traumatic cases. The mean age of the global series was 76.5 ± 5.3 years (75.8 SMR/78.6 Delta, p = .104) with a mean Constant/ASES score at final follow-up of 68.5 ± 4.3/72.9 ± 20.3 (71/68 SMR and 69/74 Delta, p = .653 and .642). Only 2 patients (one acute fracture and one fracture sequelae) suffered an early postoperative anterior dislocation (before 3 months) which represents a rate of .84% in primary cases and .73% including revision surgery. Closed reduction manoeuvres were not successful, and both patients required revision surgery. At the end follow-up, both were stable and had no further dislocations. CONCLUSION: The dislocation rate after RTSA with the employment of two contemporary modular systems with a medialized centre of rotation is extremely low, especially when compared with the previously published series with the original Grammont design. Acute fracture and fracture sequelae were the main diagnoses associated with this instability. The reasons for the low dislocation rate are multifactorial, but the improvement in the baseplate position according to the more recent standards of "ideal position" and technical aspects such as subscapularis repair or tuberosity reattachment in fractures probably play an important role in this aspect.

Does the Addition of a Vascularized Fibula Improve the Results of a Massive Bone Allograft Alone for Intercalary Femur Reconstruction of Malignant Bone Tumors in Children?

BACKGROUND: Massive bone allograft with or without a vascularized fibula is a potentially useful approach for femoral intercalary reconstruction after resection of bone sarcomas in children. However, inadequate data exist regarding whether it is preferable to use a massive bone allograft alone or a massive bone allograft combined with a vascularized free fibula for intercalary reconstructions of the femur after intercalary femur resections in children. Because the addition of a vascularized fibula adds to the time and complexity of the procedure, understanding more about whether it reduces complications and improves the function of patients who undergo these resections and reconstructions would be valuable for patients and treating physicians. QUESTIONS/PURPOSES: In an analysis of children with bone sarcomas of the femur who underwent an intercalary resection and reconstruction with massive bone allograft with or without a vascularized free fibula, we asked: (1) What was the difference in the surgical time of these two different surgical techniques? (2) What are the complications and number of reoperations associated with each procedure? (3) What were the Musculoskeletal Tumor Society scores after these reconstructions? (4) What was the survival rate of these two different reconstructions? METHODS: Between 1994 and 2016, we treated 285 patients younger than 16 years with a diagnosis of osteosarcoma or Ewing sarcoma of the femur. In all, 179 underwent resection and reconstruction of the distal femur and 36 patients underwent resection and reconstruction of the proximal femur. Additionally, in 70 patients with diaphyseal tumors, we performed total femur reconstruction in four patients, amputation in five, and a rotationplasty in one. The remaining 60 patients with diaphyseal tumors underwent intercalary resection and reconstruction with massive bone allograft with or without vascularized free fibula. The decision to use a massive bone allograft with or without a vascularized free fibula was probably influenced by tumor size, with the indication to use the vascularized free fibula in longer reconstructions. Twenty-seven patients underwent a femur reconstruction with massive bone allograft and vascularized free fibula, and 33 patients received massive bone allograft alone. In the group with massive bone allograft and vascularized fibula, two patients were excluded because they did not have the minimum data for the analysis. In the group with massive bone allograft alone, 12 patients were excluded: one patient was lost to follow-up before 2 years, five patients died before 2 years of follow-up, and six patients did not have the minimum data for the analysis. We analyzed the remaining 46 children with sarcoma of the femur treated with intercalary resection and biological reconstruction. Twenty-five patients underwent femur reconstruction with a massive bone allograft and vascularized free fibula, and 21 patients had reconstruction with a massive bone allograft alone. In the group of children treated with massive bone allograft and vascularized free fibula, there were 17 boys and eight girls, with a mean ± SD age of 11 ± 3 years. The diagnosis was osteosarcoma in 14 patients and Ewing sarcoma in 11. The mean length of resection was 18 ± 5 cm. The mean follow-up was 117 ± 61 months. In the group of children treated with massive bone allograft alone, there were 13 boys and eight girls, with a mean ± SD age of 12 ± 2 years. The diagnosis was osteosarcoma in 17 patients and Ewing sarcoma in four. The mean length of resection was 15 ± 4 cm. The mean follow-up was 130 ± 56 months. Some patients finished clinical and radiological checks as the follow-up exceeded 10 years. In the group with massive bone allograft and vascularized free fibula, four patients had a follow-up of 10, 12, 13, and 18 years, respectively, while in the group with massive bone allograft alone, five patients had a follow-up of 10 years, one patient had a follow-up of 11 years, and another had 13 years of follow-up. In general, there were no important differences between the groups in terms of age (mean difference 0.88 [95% CI -0.6 to 2.3]; p = 0.26), gender (p = 0.66), diagnosis (p = 0.11), and follow up (mean difference 12.9 [95% CI-22.7 to 48.62]; p = 0.46). There was a difference between groups regarding the length of the resection, which was greater in patients treated with a massive bone allograft and vascularized free fibula (18 ± 5 cm) than in those treated with a massive bone allograft alone (15 ± 4 cm) (mean difference -3.09 [95% CI -5.7 to -0.4]; p = 0.02). Complications related to the procedure like infection, neurovascular compromise, and graft-related complication, such as fracture and nonunion of massive bone allograft or vascularized free fibula and implant breakage, were analyzed by chart review of these patients by an orthopaedic surgeon with experience in musculoskeletal oncology. Survival of the reconstructions that had no graft or implant replacement was the endpoint. The Kaplan-Meier test was performed for a survival analysis of the reconstruction. A p value less than 0.05 was considered significant. RESULTS: The surgery was longer in patients treated with a massive bone allograft and vascularized free fibula than in patients treated with a massive bone allograft alone (10 ± 0.09 and 4 ± 0.77 hours, respectively; mean difference -6.8 [95% CI -7.1 to -6.4]; p = 0.001). Twelve of 25 patients treated with massive bone allograft and vascularized free fibula had one or more complication: allograft fracture (seven), nonunion (four), and infection (four). Twelve of 21 patients treated with massive bone allograft alone had the following complications: allograft fracture (five), nonunion (six), and infection (one). The mean functional results were 26 ± 4 in patients with a massive bone allograft and vascularized free fibula and 27 ± 2 in patients with a massive bone allograft alone (mean difference 0.75 [95% CI -10.6 to 2.57]; p = 0.39). With the numbers we had, we could not detect a difference in survival of the reconstruction between patients with a massive bone allograft and free vascularized fibula and those with a massive bone allograft alone (84% [95% CI 75% to 93%] and 87% [95% CI 80% to 94%], respectively; p = 0.89). CONCLUSION: We found no difference in the survival of reconstructions between patients treated with a massive bone allograft and vascularized free fibula and patients who underwent reconstruction with a massive bone allograft alone. Based on this experience, our belief is that we should reconstruct these femoral intercalary defects with an allograft alone and use a vascularized fibula to salvage the allograft only if a fracture or nonunion occurs. This approach would have resulted in about half of the patients we treated not undergoing the more invasive, difficult, and risky vascularized procedure.Level of Evidence Level III, therapeutic study.