Background Although posterior capsule tightness is believed to cause abnormal contact in the subacromial space, it is not clear whether this tightness changes the contact between the acromion and ...humeral head. Materials and methods Nine fresh, frozen cadaveric shoulders were used to measure contact pressure on the coracoacromial arch during passive flexion, abduction, and internal and external rotation at 90° of elevation in the scapular plane, as well as horizontal adduction and abduction. The site where the peak contact pressure occurred was also observed. The posterior capsule in the region from 8 to 10 o’clock in the right shoulder was plicated to simulate posterior capsule tightness. Results Peak contact pressure significantly increased with the tightened posterior capsule during flexion. Although peak contact pressure on the coracoacromial ligament during internal rotation significantly increased after capsule tightening, there was no significant increase in pressure when considering the entire coracoacromial arch. The angle where the peak contact pressure occurred during flexion was not significantly far from the end range. The site of the peak contact pressure in 7 of 9 shoulders was on the lesser tuberosity during flexion, regardless of the posterior capsule tightness. Conclusions Posterior capsule tightness increased contact pressure mainly on the lesser tuberosity during flexion. The peak contact pressure occurred close to the end range of flexion, mainly on the lesser tuberosity. These findings are useful to understand the contribution of posterior capsule tightness to subacromial contact.
Background Repair of proximal humeral fractures with locking plates has greatly improved outcomes. However, an alarming rate of complications including screw cutout and impingement under the acromion ...has recently been reported. A novel locking plate with smooth pegs was developed to reduce these risks. The purpose of this study was to compare these 2 fixation methods with a cadaveric biomechanical study. Materials and methods Fourteen pairs of cadaveric proximal humeri (mean age, 77 years) were harvested, and bone density was measured. Osteosynthesis was performed on each pair using either a locking plate with threaded screws (TS group) or smooth pegs (SP group) on the contralateral side. Seven pairs of humeri were tested for cyclic bending, and 7 pairs for cyclic torsional evaluation: TS bending, SP bending, TS torsion, and SP torsion. The bending protocol consisted of cyclically loading to a maximum of 7.5 Nm bending moment for 10,000 cycles. The torsion protocol consisted of ±2 Nm of axial torque for 10,000 cycles. Surgical neck fractures were simulated by excising a 10-mm wedge of bone. Results No implant failure or screw cutout was observed in any of the groups tested. Under bending loads, mean displacement of the distal fragment was significantly less for the SP group than that for the TS group over 5,000 cycles. In torsion tests, no significant differences were observed between the 2 fixation methods. Discussion The SP group demonstrated superior biomechanical characteristics to the TS group in regards to cyclic bending.
Abstract Background Theoretically, patients with only one functional arm secondary to contralateral amputation or paralysis will subject their only functional upper extremity to increased loads. This ...could become an issue after reverse shoulder arthroplasty (RSA). However, there are no reported data on the implant survival or function for patients with a nonfunctional contralateral upper extremity. Objective To report the outcomes of RSA in patients with contralateral upper extremity amputation or paralysis. Design Retrospective case series. Setting Tertiary university hospital. Patients All patients who underwent RSA between January 2004 and December 2013. Methods Of 1335 RSA procedures performed, 5 patients had a minimum 2-year follow-up and nonfunctional contralateral upper extremity. There were 3 men and 2 women, with a mean (standard deviation) age and length of follow-up of 72.4 (7.5) years and 56.4 (24-132) months. Two of the patients had a contralateral upper extremity amputation, and the other 3 had contralateral upper extremity paralysis as a result of stroke, traumatic brain injury, and traumatic brachial plexus injury at birth. Main Outcomes Pain, range of motion, functional scores (Simple Shoulder Test, American Shoulder and Elbow Society and Quick-Disability of the Arm, Shoulder and Hand), satisfaction, complications/reoperations, and radiographic loosening. Results RSA resulted in substantial improvement in pain ( P = .008), forward flexion ( P = .02), and external range of motion ( P = .01). The mean (standard deviation) Simple Shoulder Test, American Shoulder and Elbow Society, and Quick-Disability of the Arm, Shoulder, and Hand scores were 9.8 (1.3), 82 (13), and 17.8 (13.4), respectively. The results were excellent in 3, satisfactory in 1, and unsatisfactory in 1 patient (due only to external rotation limited to 10°). Subjectively, all 5 patients felt greatly improved and stated they would undergo RSA again. There were no complications or reoperations. There were no shoulders with component loosening. Conclusions RSA seems to be a safe, effective, and successful surgical procedure for patients with a nonfunctional contralateral upper extremity. Studies with larger sample sizes and longer follow-up will hopefully validate the present findings. Level of Evidence IV (case series).
Background The purpose of this study was to evaluate the effectiveness of existing technologies implemented in a novel manner to objectively capture upper extremity function. Materials and methods ...Patients scheduled to undergo reverse shoulder arthroplasty were recruited for the study. Functional limb use was measured with triaxial accelerometers worn in the subjects' natural living environment. Functional reach area was captured by 3-dimensional motion analysis testing as subjects were asked to circumduct their limb, reaching as far as possible in a circular manner. Statistical testing (α ≤ .05) was performed by paired t tests to identify differences between limbs. Results There was no difference in functional limb activity between sides for the lower ( P = .497) or upper arm ( P = .918) for inactivity time. Mean activity was greater for the uninvolved limb compared with the involved limb (lower arm, P = .045; upper arm, P = .005). Low-intensity activity was greater for the involved arm compared with the uninvolved arm (lower arm, P = .007; upper arm, P = .015), whereas high-intensity activity was greater for the uninvolved arm (lower arm, P = .013; upper arm, P = .005). Radius of the functional reach area was greater for the uninvolved limb compared with the involved limb ( P = .006). Conclusions Novel methods of capturing function were effective in discerning differences in side-to-side abilities among patients scheduled to undergo reverse shoulder arthroplasty. These testing procedures may be used to capture function across a spectrum of shoulder diseases. These objective data are invaluable in assessing the impact of disease and recovery after intervention and obtaining reimbursement from third-party payers.
Currently, there is little information on the outcome of humeral head replacement for steroid-associated osteonecrosis of the humeral head. The purpose of this study was to evaluate the outcome of ...patients who underwent humeral head replacement for steroid-associated osteonecrosis to determine the results, risk factors for an unsatisfactory outcome, and rates of revision surgery. Between 1980 and 2000, 32 shoulder hemiarthroplasties were performed for steroid-associated osteonecrosis. We included 31 hemiarthroplasties in 25 patients with a minimum 2-year follow-up (mean, 12.0 years) in the study. The mean age of the 23 female and 9 male patients was 49.4 years at the time of surgery (range, 25-86 years). Overall, mean pain scores decreased from 4.6 to 2.6 ( P < .0001). However, moderate or severe pain was reported in 12 shoulders (38%) at the most recent follow-up, 2 of them requiring implant revision. The mean preoperative to postoperative active elevation increased from 92° to 139° ( P < .0001), and external rotation increased from 36° to 65° ( P < .0001). According to a modified Neer result rating system, there were 13 excellent results (42%), 4 satisfactory results (13%), and 14 unsatisfactory results (45%). Improvement in pain and function most often occurred after hemiarthroplasty as a treatment for steroid-associated osteonecrosis of the humeral head. However, there are a large number of unsatisfactory results related to glenoid cartilage wear over time.
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.
Hypothesis This study was conducted to test the hypothesis that patients would have improved pain and range of motion after conversion total shoulder arthroscopy but that overall outcome would be ...substantially affected by the need for removal of the humeral component and associated alterations of bony anatomy or soft tissue deficiencies. Materials and methods Thirty-four patients (34 shoulders) with HHR after a proximal humeral fracture underwent revision total shoulder arthroplasty for painful glenoid arthrosis, with mean follow-up of 9.4 years (range, 2.3-20.4 years). After initial review, repeat analysis was performed based on the complexity of osseous (humeral stem revision) and soft tissue management, including rotator cuff tear, greater tuberosity resorption, malunion or nonunion, or instability. Results Overall, patients had reduction in pain ( P = .0001), and improved active abduction ( P = .05) and external rotation ( P = .0005). Less improvement in active abduction was documented in patients who required soft tissue management ( P = .03). Results of the modified Neer rating documented 3 excellent, 9 satisfactory, and 22 unsatisfactory results (motion deficiencies in 14). Kaplan-Meier survival analysis free of repeat revision was 100% at 1 year, 96.8% at 5 years (95% confidence interval, 90%-100%), and 92.2% at 10 years (95% confidence interval, 82% to 100%). Discussion Conversion total shoulder arthroplasty is effective for addressing painful glenoid arthrosis after primary HHR for a proximal humeral fracture, with or without the need to change the humeral component. However, active motion may not improve in patients with rotator cuff tearing, a greater tuberosity nonunion, malunion, or resorption.
Acute deep infection after open reduction–internal fixation of proximal humeral fractures is uncommon. Currently, there are no reported series on the outcomes of patients treated for infection after ...surgery for proximal humeral fractures. The purpose of this study was to review the frequency, clinical presentation, bacteriology, treatment, and outcomes of patients with such fractures complicated by acute deep infection. Between 1993 and 2003, 5 patients with acute deep infection after open reduction–internal fixation of proximal humeral fractures were identified. The medical records, laboratory data, and radiographs were examined retrospectively. The mean age at the time of infection diagnosis was 50 years (range, 33-82 years), and the mean interval from proximal humeral fracture fixation to the time of infection diagnosis was 27 days (range, 14-40 days). All patients were available for final follow-up evaluation at a mean of 6.4 years (range, 32 months to 8.3 years). Of the 5 patients, 4 (80%) went on to nonunion requiring revision surgery. Coagulase-negative Staphylococcus species and Propionibacterium acnes were the most common organisms isolated. A mean of 3.3 surgical debridements were necessary for the eradication of infection. At a mean final follow-up of 6.4 years, the American Shoulder and Elbow Surgeons score averaged 53 points (range, 33-75 points) and the Simple Shoulder Test score averaged 6.2 points (range, 1-10 points). Acute deep infection after open reduction–internal fixation of proximal humeral fractures is a devastating complication. Patients should be counseled that the results of treatment of deep infection are plagued with high complication rates, poor functional outcome, and a notably high nonunion rate.
Subscapularis tenotomy is a simple, reproducible, and time-efficient method to provide secure repair of the subscapularis in shoulder arthroplasty. Comparing lesser tuberosity osteotomy with ...tenotomy, biomechanical research has shown no difference in maximum load, stiffness, elongation amplitude, or cyclic elongation. Clinical research has shown satisfactory results of subscapularis healing with tendon-to-tendon repair. In addition, research on the outcome of lesser tuberosity osteotomy shows concerning rates of progressive fatty infiltration of the subscapularis. Therefore, the complexity of lesser tuberosity osteotomy, in conjunction with concerns about possible nonunion and fragmentation, does not seem to warrant changing from the safe, reliable, and simple approach of subscapularis tenotomy.
There have been multiple studies on the prevalence of pulmonary embolism, the probability of death from a pulmonary embolism, and the risk factors for the development of pulmonary embolism after ...lower extremity and pelvic trauma. However, there is no information on the risk of pulmonary embolism after the surgical management of proximal humeral fractures. A review of 137 consecutive patients who underwent operative treatment for acute, isolated proximal humeral fractures at our institution between January 1, 1998, and December 31, 2003, was performed to identify all who sustained a pulmonary embolism. Postoperatively, 7 patients sustained a pulmonary embolism that was confirmed by computed tomography. Of these, 4 had been treated with a hemiarthroplasty and 3 had undergone open reduction–internal fixation. The overall incidence of pulmonary embolism in this series was 5.1%. None of the patients sustained a fatal pulmonary embolus. These data suggest that the rate of pulmonary embolism after operative treatment of proximal humeral fractures is not low. This study raises the question of whether prophylactic anticoagulation is needed after routine proximal humeral repair.
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