Background Although the safety of the beach-chair position (BCP) is widely accepted, rare devastating neurologic complications have been reported and attributed to cerebral hypoperfusion. Cerebral ...oxygenation (regional oxygen saturation rSO2 ) can be monitored noninvasively using near-infrared spectroscopy. The purpose of this study was to determine the effect of BCP angle on cerebral oxygenation in patients undergoing shoulder surgery in the BCP. Methods Fifty patients undergoing shoulder arthroscopy were prospectively enrolled to participate. Following induction of general anesthesia, each patient's rSO2 was recorded at 0° of elevation and again at 30°, 45°, 60°, and 80° of elevation. Mean rSO2 values and mean differences in rSO2 were reported. Results An average total decrease of 5% in rSO2 was seen when comparing 0° with 80° ( P < .001). There were statistically significant differences in rSO2 values at beach-chair angles of 0° versus 30° ( P < .001), 30° versus 45° ( P = .007), and 45° versus 60° ( P < .001) but not between 60° and 80° ( P = .12). The decrease in rSO2 was similar between each progressive increase in the beach-chair angle, leading to a linear decline in rSO2 as the BCP increased (regression slope of −0.060%/°, P < .001). No patient's cerebral oxygenation dropped greater than 20% from baseline. Neither body mass index nor American Society of Anesthesiologists score had a significant impact on the relation of rSO2 to BCP angle. Conclusions The average drop in rSO2 is significantly less than the threshold of 20% used as an identifier for a cerebral deoxygenation event. This study illustrates the direct effect the BCP angle has on cerebral oxygenation.
Background This study set out to accurately determine the incidence of wound complications after distal humerus fracture fixation, to assess risk factors, and to determine their implications on ...outcome. Methods Eighty-nine distal humerus fractures (mean patient age, 58 years) were treated with internal fixation at an average of 4 days after injury. Mean follow-up time was 15 months (range, 6-72 months). Twenty-nine (33%) fractures were open. Medical records and radiographs were reviewed to determine wound complications. Logistic regression analysis was carried out to determine associated risk factors. Results Fourteen patients (15.7%) developed a major wound complication requiring on average 2.5 (range, 1-6) additional surgical procedures. Six patients required plastic surgical soft tissue coverage. All 14 fractures complicated by wound problems united. The final mean range of motion in the major wound complication group was 100° (range, 65°-130°), compared with 100° (range, 10°-140°) in those with no or minor wound problems. Grade III open fractures and the use of a plate to stabilize the olecranon osteotomy were identified as significant risk factors for development of major wound complications. Conclusions The incidence of major wound complications after fixation of distal humerus fractures is substantial. The presence of a grade III open fracture and the use of an olecranon osteotomy stabilized with a plate are significant risk factors for major wound complications. Fracture healing rates and functional elbow range of motion do not appear to be affected by major wound complications when they are handled with proper soft tissue coverage techniques.
Background Reverse shoulder arthroplasty (RSA) is becoming a commonly performed procedure. Surgeons are advised to select older patients with lower demands. This study defines patient reported ...activities following RSA. Materials and methods Seventy-eight patients with 81 treated shoulders (average age 73 years; 49 women, 32 men) completed a survey asking about clinical parameters: pain, motion, strength, and 72 different activities. Diagnoses were rotator cuff tear arthropathy in 70 shoulders, massive rotator cuff tears with psuedoparalysis in 6, and failed treatment for proximal humeral fractures in 5. Average time from surgery to survey was 3.6 years (range, 3-5). Results All clinical parameters were favorable. The 3 most commonly reported activities were low demand (cooking, baking, and driving), medium demand (gardening, leaf raking, and lawn mowing), and high demand (snow shoveling, wheelbarrow use, and dirt shoveling). These were comparable to the activities reported for total shoulder arthroplasty and hemiarthroplasty. There was no clinical or activity difference between those components with a lateral or a medial center of rotation. Conclusion A significant proportion of patients continue medium or high demand activities following RSA. These are similar to other types of shoulder arthroplasties. Future studies to determine the safety level of different activities would be helpful to counsel patients accordingly.
Hypothesis The purposes of this study were to determine the incidence of blood transfusion after revision shoulder arthroplasty and to assess risk factors associated with an increased risk of ...transfusion. Materials and methods Between 1994 and 2008, 566 consecutive revision shoulder procedures were performed at our institution, which formed the basis of this study. The patient's age, sex, body mass index, comorbidities, preoperative and postoperative hemoglobin level, details of the surgery, operative time, and transfusion details were documented retrospectively from medical records. Results Overall, 11.3% of patients (64 of 566) required a transfusion. An increased transfusion rate was associated with age (odds ratio OR per 10 years, 1.5 95% confidence interval (CI), 1.2 to 2.0; P = .002), operative time (≤5 hours vs >5 hours) (OR, 3.3 95% CI, 1.9 to 5.8; P < .001), diabetes (OR, 2.3 95% CI, 1.2 to 4.4; P = .01), and cardiac disease (OR, 2.7 95% CI, 1.5 to 5.0; P < .001). There were significant associations between preoperative hemoglobin level (OR, 0.4 per 1 point 95% CI, 0.3 to 0.5; P < .001) and a decreased odds of transfusion. The type of surgery (surgery on humeral component) also had an impact on the need for transfusion ( P < .001). Conclusions Older age, low preoperative hemoglobin level, increased operative time, diabetes, presence of cardiac disease, and type of revision surgery are associated with higher postoperative transfusion rates. These factors should be taken into consideration to more accurately predict the need for transfusion and modify preoperative blood-ordering protocols.
High-energy proximal humerus fractures in elderly patients can occur through a variety of mechanisms, with falls and MVCs being common mechanisms of injury in this age group. Even classically ...low-energy mechanisms can result in elevated ISS scores, which are associated with higher mortality in both falls and MVCs. These injuries result in proximal humerus fractures which are commonly communicated via Neer’s classification scheme. There are many treatment options in the armamentarium of the treating surgeon. Nonoperative management is widely supported by systematic review as compared to almost all other treatment methods. ORIF is particularly useful for complex patterns and fracture dislocations in healthy patients. Hemiarthroplasty can be of utility in patients with fracture patterns with high risk of AVN and poor bone quality risking screw cut-out. Reverse total shoulder arthroplasty is a popular method of treatment for geriatric patients also, with literature now showing that even late conversion from nonoperative management or ORIF to rTSA can lead to good clinical outcomes. Prevention is possible and important for geriatric patients. Optimizing medical care including hearing, vision, strength, and bone quality, in coordination with primary care and geriatricians, is of great importance in preventing fractures and decreasing injury when falls do occur. Involving geriatricians on dedicated trauma teams will also likely be of benefit.
Background Deficient glenoid bone is a reconstructive challenge in shoulder arthroplasty. One solution is an ingrowth anatomic glenoid with column and screw fixation, with or without supplemental ...bone graft. This study examines the outcome of patients managed in this manner. Materials and methods This type of glenoid component was used in 21 shoulder arthroplasties with central or peripheral glenoid bone deficiencies: 13 for bone loss due to arthritic wear and 8 for revision arthroplasty. Patients were monitored clinically for a mean of 11.1 years (range, 7.6-15.1 years) and by x-ray imaging for a mean of 9.1 years (range, 2.2-14.2 years). Results Revision procedures were needed for 7 shoulders at a mean of 10.4 years (range 5.5-14.3 years), 6 for polyethylene or metal wear leading to glenoid loosening in 4. In the 14 nonrevised shoulders, pain ratings (1 to 5 scale) decreased from a mean of 4.5 to 1.9 ( P < .001). Mean active elevation increased from 100° to 125° ( P = .02). Mean external rotation increased from 28° to 43° ( P = .06). Results assessed by the Neer rating were excellent in 3, satisfactory in 10, and unsatisfactory in 1. In radiographic assessment of the unrevised shoulders, 4 were at risk for glenoid loosening, and 1 was at risk for humeral loosening. Conclusions This method of reconstruction can offer pain relief and improved motion. However, the large number of revision procedures and additional adverse changes on x-ray imaging suggest other reconstructive options may be more successful and durable.
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