Background Locking plates for open reduction–internal fixation (ORIF) of proximal humeral fractures are widely used. We observed an unusually high number of patients with complications referred to ...our institution. It was the purpose of this study to report these complications, as well as their treatment and outcome. Materials and methods From 2003 to 2010, all patients treated for complications after ORIF with locking plates for proximal humeral fractures were prospectively collected and retrospectively analyzed. Patients were followed up clinically and radiographically. Results In total, 121 patients (67 women and 54 men; mean age, 59 years) were referred after primary locking plate ORIF; 80% had a 3- or 4-part fracture. A mean of 3 complications occurred per patient, including malreduction, primary screw cutout, malunion, nonunion, avascular necrosis, and infection. Secondary screw cutout was found in 57% of patients, causing glenoid destruction in 33% of patients. A mean of 1.5 revision surgeries were needed. Hemiarthroplasty, total shoulder arthroplasty, and reverse shoulder arthroplasty improved the mean Constant score (24 to 55 points, P < .05; 29 to 54 points, P = .3; and 25 to 48 points, P < .05, respectively) after a mean of 24 months. In 6 patients, glenoid implantation was no longer possible because of the destruction by perforated head screws. Conclusion In this negatively selected series, complications resulted in secondary arthroplasties in over 50% of the patients. Shoulder function, though improved, remained substantially restricted even after revision surgery. Glenoid destruction by locking screws was the most devastating and previously almost unseen complication, which limited the options of treatment.
Background Accurate assessment of glenoid inclination is of interest for a variety of conditions and procedures. The purpose of this study was to develop an accurate and reproducible measurement for ...glenoid inclination on standardized anterior-posterior (AP) radiographs and on computed tomography (CT) images. Materials and methods Three consistently identifiable angles were defined: Angle α by line AB connecting the superior and inferior glenoid tubercle (glenoid fossa) and the line identifying the scapular spine; angle β by line AB and the floor of the supraspinatus fossa; angle γ by line AB and the lateral margin of the scapula. Experimental study: these 3 angles were measured in function of the scapular position to test their resistance to rotation. Conventional AP radiographs and CT scans were acquired in extension/flexion and internal/external rotation in a range up to ±40°. Clinical study: the inter-rater reliability of all angles was assessed on AP radiographs and CT scans of 60 patients (30 with proximal humeral fractures, 30 with osteoarthritis) by 2 independent observers. Results The experimental study showed that angle α and β have a resistance to rotation of up to ±20°. The deviation from neutral position was not more than ±10°. The results for the inter-rater reliability analyzed by Bland-Altman plots for the angle β fracture group were (mean ± standard deviation) −0.1 ± 4.2 for radiographs and −0.3 ± 3.3 for CT scans; and for the osteoarthritis group were −1.2 ± 3.8 for radiographs and −3.0 ± 3.6 for CT scans. Conclusion Angle β is the most reproducible measurement for glenoid inclination on conventional AP radiographs, providing a resistance to positional variability of the scapula and a good inter-rater reliability.
Background The etiology of rotator cuff disease is age related, as documented by prevalence data. Despite conflicting results, growing evidence suggests that distinct scapular morphologies may ...accelerate the underlying degenerative process. The purpose of the present study was to evaluate the predictive power of 5 commonly used radiologic parameters of scapular morphology to discriminate between patients with intact rotator cuff tendons and those with torn rotator cuff tendons. Methods A pre hoc power analysis was performed to determine the sample size. Two independent readers measured the acromion index, lateral acromion angle, and critical shoulder angle on standardized anteroposterior radiographs. In addition, the acromial morphology according to Bigliani and the acromial slope were determined on true outlet views. Measurements were performed in 51 consecutive patients with documented degenerative rotator cuff tears and in an age- and sex-matched control group of 51 patients with intact rotator cuff tendons. Receiver operating characteristic analyses were performed to determine cutoff values and to assess the sensitivity and specificity of each parameter. Results Patients with degenerative rotator cuff tears demonstrated significantly higher acromion indices, smaller lateral acromion angles, and larger critical shoulder angles than patients with intact rotator cuffs. However, no difference was found between the acromial morphology according to Bigliani and the acromial slope. With an area under the receiver operating characteristic curve of 0.855 and an odds ratio of 10.8, the critical shoulder angle represented the strongest predictor for the presence of a rotator cuff tear. Conclusion The acromion index, lateral acromion angle, and critical shoulder angle accurately predict the presence of degenerative rotator cuff tears.
Background The role of reverse shoulder arthroplasty (RTSA) in the relatively young individual is currently unclear. Our study evaluates the midterm to long-term results of RTSA for patients aged ...younger than 65 years with pseudoparalysis secondary to massive irreparable rotator cuff tears, with or without arthritis. Methods Between 1997 and 2006, 46 RTSAs (41 patients) were performed. Mean age was 60 years (range, 46-64 years). At the latest follow-up, 5 patients had died and 1 was lost, leaving 35 patients (40 shoulders) with a mean follow-up of 93 months (range, 60-171 months). Results The mean relative Constant score increased from 34% to 74% ( P < .0001) and the subjective shoulder value improved from 23% to 66% ( P < .0001). Significant improvements were seen in active forward elevation (72° to 119°), pain scores, and strength ( P < .001). One or more complications occurred in 15 shoulders (37.5%), with 6 failures (15%) resulting in removal or conversion to hemiarthroplasty (3 with infection, 3 with glenoid loosening). Ten shoulders (25%) underwent partial or total component exchange, conversion to hemiarthroplasty, or removal. Of the 15 patients who developed complications, 9 did not require prosthesis removal or conversion and functional outcome and subjective shoulder value were similar to those with no complications ( P > .4). Conclusion RTSA in younger patients provides significant subjective improvement and substantial gain in overall function, which is maintained up to 10 years. Although the complication rate is high, most can be treated successfully without compromise to clinical outcome. However, it is imperative that the high complication rate is explained to patients, with the risks and benefits carefully considered.
The purpose of this study was to evaluate the subjective shoulder value (SSV) and to compare it with the Constant score (CS). The SSV is defined as a patient’s subjective shoulder assessment ...expressed as a percentage of an entirely normal shoulder, which would score 100%. Patients who underwent operative treatment for rotator cuff repair (n = 247), arthroplasty (n = 83), or stabilization for recurrent anterior instability (n = 111) were included in this study. Correlation between the SSV and CS was highest postoperatively and was higher in the rotator cuff group (0.80) than in the osteoarthritis (0.69) and instability (0.61) groups. The relative CS could reliably predict the variance in the SSV in patients with rotator cuff tears (54%) and osteoarthritis (41%) and, to a lesser extent, in instability patients (23%). The SSV is an easily administered, responsive, and valid measure of shoulder function. The SSV may offer an improvement over the CS in assessing shoulder instability patients, as the CS may overestimate the results of these patients.
Background Anatomic reduction and stable internal fixation of complex proximal humeral fractures in the elderly is challenging. Secondary displacement, screw perforation, and humeral head necrosis ...are common complications. The outcome of hemiarthroplasty is unpredictable and strongly dependent on the uncertain healing of the greater tuberosity. This multicenter study retrospectively analyzes the midterm results of primary reverse total shoulder arthroplasty for the treatment of acute, complex fractures of the humerus in an elderly population. Methods Fifty-two shoulders in 51 patients with a mean age of 77 years treated with reverse total shoulder arthroplasty for an acute, complex fracture of the proximal humerus were clinically and radiographically analyzed after a mean follow-up period of 35 months (range, 12-90 months). Results There were no intraoperative complications. Revision surgery was performed in 4 shoulders. At final follow-up, the absolute and relative Constant scores averaged 62 points (range, 21-83 points) and 86% (range, 30%-100%), respectively, with a mean Subjective Shoulder Value of 83% (range, 30%-100%). Of the patients, 92% rated the treatment outcome as excellent or good. Patients with a resected or secondarily displaced greater tuberosity had an inferior clinical outcome to those with a healed greater tuberosity. Conclusion The midterm clinical results are predictably good, with low complication rates and a rapid postoperative recovery of painfree everyday function. If secondary displacement of the greater tuberosity occurs, revision surgery may warrant consideration in view of potential improvement of ultimate outcome.
Background Corrective osteotomies of malunited fractures of the proximal and distal humerus are among the most demanding orthopedic procedures. Whereas the restoration of the normal humeral anatomy ...is the ultimate goal, the quantification of the deformity as well as the transfer of the preoperative plan is challenging. The purpose of this study was to provide a guideline for 3-dimensional (3D) corrective osteotomies of malunited intra-articular fractures of the humerus and a detailed overview of existing and novel instruments to enlarge the toolkit for 3D preoperative planning and intraoperative realization using patient-specific guides. Methods We describe the preoperative 3D deformity analysis, relevant considerations for the preoperative plan, design of the patient-specific guides, and surgical technique of corrective osteotomies of the humerus. Results The presented technique demonstrates the benefit of computer-assisted surgery for complex osteotomies of the humerus from a preoperative deformity analysis to the creation of feasible surgical procedures and the generation of patient-specific guides. Conclusions A 3D analysis of a post-traumatic deformity of the humerus, 3D preoperative planning, and use of patient-specific guides facilitate corrective osteotomies of complex malunited humeral fractures.
In this study, we show the use of three-dimensional printing models for preoperative planning of transcatheter valve replacement in a patient with an extreme porcelain aorta. A 70-year-old man with ...severe aortic stenosis and a porcelain aorta was referred to our center for transcatheter aortic valve replacement. Unfortunately, the patient died after the procedure because of a potential ischemic event. Therefore, we decided to fabricate three-dimensional models to evaluate the potential effects of these constructs for previous surgical planning and simulation of the transcatheter valve replacement.
Background Open reduction and internal fixation (ORIF) of complex fractures of the proximal humerus may yield unsatisfactory results. This study analyzed the results obtained after revision of failed ...ORIF of proximal humeral fractures using reverse total shoulder arthroplasty (RTSA). Methods Fifty-four shoulders of 53 patients with a subjectively unacceptable outcome after ORIF of a complex fracture of the proximal humerus were revised with RTSA. At a minimum follow-up of 2 years (mean follow-up, 46 months; range, 24-108 months), 44 shoulders were clinically and radiographically reviewed for the purpose of this study. Six patients had been lost to follow-up, and 4 patients (7%) were excluded from functional analysis because of revision surgeries. Results The mean absolute Constant score improved from 26 (range, 4-54) to 55 (range, 19-80) points; the mean relative Constant score improved from 32% (range, 4%-85%) to 67% (range, 27%-94%) of an age- and gender-matched, normal shoulder. The mean subjective shoulder value improved from 29% (range, 0%-90%) preoperatively to 67% (range, 5%-95%) at final follow-up. Nineteen patients rated their outcome excellent, 16 good, and 7 fair; 2 patients were dissatisfied. Conclusion RTSA is a valuable salvage procedure after failed ORIF of a proximal humeral fracture with relatively low revision rates. Shoulder function, patient satisfaction, and pain levels can be reliably improved.
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