Reverse total shoulder replacement for patients with "weight-bearing" shoulders.

Reverse total shoulder arthroplasty (rTSA) has gained popularity in recent years and is indicated for a wide variety of shoulder pathologies. However, use of rTSA in patients with "weight-bearing" shoulders that support wheelchair use or crutches has higher risk. The aim of this study was to assess the results of rTSA in such patients. Between 2005 and 2014, 24 patients (30 shoulders) with weight-bearing shoulders were treated with rTSA at our unit. Patients had cuff arthropathy (n=21), rheumatoid arthritis (n=3), osteoarthritis (n=1), acute fracture (n=3), or fracture sequela (n=2). Postoperatively, patients were advised not to push themselves up and out of their wheelchair for 6 weeks. The study surgeries were performed in 2016, and 21 patients (27 shoulders) who were available for a mean follow-up of 5.6 years (range, 2-10 years). The mean age on surgery day was 78 years (range, 54-90 years). Constant-Murley score improved from 9.4 (range, 2-26) preoperatively to 59.8 (range, 29-80) at the final follow-up (P=0.001). Pain improved from 2/15 (range, 0-8) to 13.8/15 (range, 9-15) (P=0.001). Patient satisfaction (Subjective Shoulder Value) improved from 0.6/10 to 8.7/10 (P=0.001) at final follow-up. Significant improvement in mean range of motion from 46° to 130° of elevation, 13° to 35° of external rotation, and 29° to 78° internal rotation was recorded (P=0.001). Final mean Activities of Daily Living External and Internal Rotation was 32.4/36 (range, 16-36). There were three patients with Sirveaux-Nerot grade-1 (10%) glenoid notching and three with grade 2 (10%). rTSA can be used for treatment of patients with weight-bearing shoulders. Such patients reported pain free movement, resumed daily activities, and high satisfaction rates

Does surgical site infection influence neurological outcome and survival in patients undergoing surgery for metastatic spinal cord compression?

Purpose: Most of the literature on infection after surgery for spinal metastases focuses on incidence and risk factors for surgical site infection (SSI). To the best of our knowledge, there is no report on the influence of infection on neurological outcome and survival in patients undergoing emergent surgery for metastatic spinal cord compression (MSCC).Methods: Our aim was to establish if SSIs adversely affected the neurological outcome and survival in patients with MSCC. We reviewed 318 consecutive patients admitted for surgical intervention for MSCC from October 2005 to October 2012. Morbidity (neurological outcome, length of hospital stay and additional procedures) and survival rates were analysed.Results: During this study period, the incidence of infection was 29/318 (9.1%). The median length of stay in hospital in the infected group was 25 days compared to 13 days in the non-infected group (p = 0.001). Twenty out of the 29 (69%) infected patients underwent an additional procedure (29 procedures in total) compared to 9/289 (3%) non-infected patients (p = 0.001). There was no statistical difference between the two groups with regard to neurological outcome (p = 0.37) but the survival rate was statistically different between the two groups [infected group: median survival 131 days (19–1558) vs. non-infected group: 258 days (5–2696; p = 0.03)].Conclusion: Surgical site infection increased the morbidity with considerably longer hospital stay and requirement for additionalprocedures. Although there was no difference in neurological outcome, the infected group of patients had a significantlyshorter survival

Prospective analysis of health-related quality of life after surgery for spinal metastases

Purpose Most spinal metastases are detected late and thus the impact of treatment on the health related quality of life (HRQOL) is an important consideration. This study investigated the HRQOL following surgery for spinal metastases. Methods Prospective study of patients operated for symptomatic spinal metastases, at a single tertiary referral spine centre (2011-2013). Data was collected pre-operatively and up to 2 years following surgery (if alive). The HRQOL assessment was performed using recognised systems including the Frankel Score (neurological status), EQ-5D and the Oswestry Disability Index. Results 199 patients were studied (median age 65yrs, 43% (86) F; 57% (113) M). The Frankel score improved significantly after surgery in 69 patients (35%), worsened in 17 (8%), with 20/39 patients regaining the ability to walk (51%). All the HRQOL scores improved significantly following surgery. The complication rate was 27%; median survival 270 days, and 44 patients (22%) survived at 2 years. Conclusions This large prospective study showed that surgical treatment for spinal metastases significantly improved the HRQOL

Bone printing: New frontiers in the treatment of bone defects

Bone defects can be congenital or acquired resulting from trauma, infection, neoplasm and failed arthroplasty. The osseous reconstruction of these defects is challenging. Unfortunately, none of the current techniques for the repair of bone defects has proven to be fully satisfactory. Bone tissue engineering (BTE) is the field of regenerative medicine (RM) that focuses on alternative treatment options for bone defects that will ideally address all the issues of the traditional techniques in treating large bone defects. However, current techniques of BTE is laborious and have their own shortcomings. More recently, 2D and 3D bone printing has been introduced to overcome most of the limitations of bone grafts and BTE. So far, results are extremely promising, setting new frontiers in the management of bone defects. © 2015 Elsevier Ltd. All rights reserved

Vacular injuries associated with traumatic knee dislocation: retrospective and cadaveric study

This is a retrospective -clinical and an experimental- cadaveric study of the traumatic knee dislocation and the possibility of a resulting injury to the popliteal artery. Clinical study: From 1994 to 2010, 45 patients, 43 (95.6%) male (17- 65 years old). Of them 11 (24.4%) had an injury to the popliteal artery. The dislocation was treated using external fixation in 28 (62.2%), open repair in 15 (33.3%), combined external fixation and open repair in 1 (2.2%) and closed reduction and casting in 1 (2.2%). All the patients with popliteal artery injuries were treated with femoropopliteal by pass with reverse saphenous vein graft from the contralateral limb. The average Lysholm score was 70.57 and the IKDC 72.17. The patients were divided in 2 groups one with and one without injury to the popliteal artery but the results in both groups were similar. In order to study the surgical repair the patients were again divided in 2 groups, one treated with external fixation and one with open repair and no statistically significant difference was found. Long term complications were noted in 12 patients. No statistically significant correlation between long term complications and the treatment method was noted. No statistically significant correlation between the long term results and vascular injury was found. The patients treated with external fixation had the tendency to have more stiffness and instability. Experimental study: The experiments were performed in the Athens City Morgue. Overall 31 cadavers were used. The experimental method was: Ι. popliteal artery cannulation, ΙΙ. removal of knee stabilizers, ΙΙΙ. angiography under fluoroscopy of the popliteal artery with the knee reduced and dislocated, using gastrographin. Four types of dislocations were studied: 1, hyperextension-anterior, 2, varus-valgus, 3, posterior and 4, rotatory-posterior. In the posterior and the rotatory-posterior dislocation the angle at the P2 segment of the popliteal artery was measured. In both types the angle was significantly different between the dislocated and the reduced position. In the hyperextension- anterior and in the varus-valgus dislocation the fraction of the mean tibial condyle diameter to the mean popliteal artery diameter was measured. In the anterior-hyperextension dislocation the fraction was significantly different between the reduced and the dislocated position. In contrast in the varus-valgus dislocation this was not noted. Therefore in hyperextension the injury is caused by the stretching of the artery. In the posterior and the rotatory dislocation the injury is caused by the acute bending of the popliteal artery at the P2 segment. This is in a new concept and it is different to the mechanism that is reported in the literature. In conclusion and after combining the experimental and the clinical data we can deduce that the posterior type KD-IV dislocations of the knee, have the greatest possibility of popliteal artery injury. Those are dislocations resulting from posterior force and with complete rupture of all the ligaments of the knee joint.H παρούσα διατριβή αφορά την αναδρομική- κλινική και την πειραματική-νεκροτομική μελέτη του τραυματικού εξαρθρήματος του γόνατος και της πιθανότητας βλάβης της ιγνυακής αρτηρίας συνεπεία αυτού. Κλινική μελέτη: Από το 1994 μέχρι το 2010, 45 ασθενείς, 43 (95,6%) άνδρες (17- 65 ετών). Βλάβη στην ιγνυακή αρτηρία είχαν 11 (24,4%). Η αντιμετώπιση του εξαρθρήματος του γόνατος έγινε με εξωτερική οστεοσύνθεση (28/45, 62,2%), ανοικτή αποκατάσταση (15/45, 33,3%), συνδυασμένη εξωτερική και εσωτερική (1/45, 2,2%) και κλειστή ανάταξη και τοποθέτηση γυψονάρθηκα (1/45, 2,2%). Σε όλους τους ασθενείς με αγγειακή βλάβη στην ιγνυακή αρτηρία έγινε μηροϊγνυακή παράκαμψη με ανάστροφο φλεβικό μόσχευμα. Η μέση βαθμολογία της κλινικής έκβασης ήταν κατά το σύστημα Lysholm 70,57 και κατά το σύστημα IKDC 72,17. Στη συνέχεια οι ασθενείς χωρίστηκαν σε 2 ομάδες ανάλογα με την ύπαρξη ή όχι βλάβης στη ιγνυακή αρτηρία και δεν βρέθηκε στατιστικά σημαντική διαφορά μεταξύ τους. Για να μελετηθεί η χειρουργική αποκατάσταση του εξαρθρήματος του γόνατος οι ασθενείς χωρίστηκαν σε 2 ομάδες και δεν βρέθηκε στατιστικά σημαντική διαφορά μεταξύ τους. Οι απώτερες επιπλοκές στην τελική επανεξέταση ήταν 12 (30,77%). Δεν βρέθηκε στατιστικά σημαντική συσχέτιση της εμφάνισης απώτερων επιπλοκών με το είδος της αποκατάστασης. Αναζητήθηκε συσχέτιση μεταξύ των αποτελεσμάτων και της ύπαρξης αρτηριακής βλάβης, αλλά δεν βρέθηκε στατιστικά σημαντική διαφορά για καμία παράμετρο. Νεκροτομική μελέτη: Το πειραματικό μέρος έγινε στο Νεκροτομείο Αθηνών. Διενεργήθηκαν αγγειογραφίες στην ιγνυακή αρτηρία πτωματικών γονάτων. Συνολικά χρησιμοποιήθηκαν 31 πτώματα. Η πειραματική μέθοδος, περιελάμβανε: Ι. καθετηριασμό της ιγνυακής αρτηρίας, ΙΙ. διατομή των σταθεροποιητικών στοιχείων του γόνατος, ΙΙΙ. αγγειογραφία, υπό ακτινοσκοπικό έλεγχο, της ιγνυακής αρτηρίας με το γόνατο σε θέση ανάταξης και σε εξάρθρημα. Ως σκιαγραφικό χρησιμοποιήθηκε γαστρογραφίνη. Μελετήθηκαν 4 ομάδες εξαρθρημάτων: 1, υπερέκτασης- πρόσθιο, 2, βλαισότητας-ραιβότητας, 3, οπίσθιο και 4, στροφικό με οπίσθια παρεκτόπιση. Μετά το τέλος έγιναν μετρήσεις στις αγγειογραφικές εικόνες. Στο οπίσθιο και στο στροφικό με οπίσθια παρεκτόπιση εξάρθρημα έγινε μέτρηση της γωνίωσης στο τμήμα P2 ιγνυακής αρτηρίας. Βρέθηκε ότι υπάρχει στατιστικά σημαντική διαφορά (p=,005) της γωνίας, στο οπίσθιο εξάρθρημα προκαλείται στατιστικά σημαντικά μεγαλύτερη γωνίωση της ιγνυακής αρτηρίας σε σύγκριση με το στροφικό εξάρθρημα γόνατος. Στο εξάρθρημα υπερέκτασης και στο βλαισότητας-ραιβότητας έγινε μέτρηση λόγου της διαμέτρου του κνημιαίου κονδύλου προς τη μέση διάμετρο της ιγνυακής. Βρέθηκε ότι στο πρόσθιο-υπερέκτασης υπάρχει στατιστικά σημαντική διαφορά αντίθετα με το βλαισότητας-ραιβότητας. Σε υπερέκταση ο μηχανισμός βλάβης είναι η διελκυσμός του αγγείου. Σε οπίσθιο και λιγότερο σε στροφικό εξάρθρημα η βλάβη προκαλείται από μεγάλη γωνίωση της αρτηρίας. Το τελευταίο δε συμφωνεί με τον αναφερόμενο στη βιβλιογραφία μηχανισμό, δηλαδή άμεση πλήξη από το οπίσθιο τμήμα του κνημιαίου κονδύλου επί της αρτηρίας. Συμπερασματικά, συνδυάζοντας τα πειραματικά και τα κλινικά δεδομένα βρίσκουμε ότι τα οπίσθια εξαρθρήματα τύπου KD-IV, δηλαδή αυτά στα οποία έχουν υποστεί ρήξη όλα τα συνδεσμικά στοιχεία του γόνατος και που έχουν μηχανισμό οπίσθιας παρεκτόπισης, έχουν την μεγαλύτερη πιθανότητα ύπαρξης αρτηριακής βλάβης. Σε αυτά ο μηχανισμός πρόκλησης της βλάβης είναι η μεγάλη γωνίωση της ιγνυακής αρτηρίας κατά τη διέλευσή της από τον μηρό, γωνίωση που αντιστοιχεί στον χαλινό της κατάφυσης του μέγα προσαγωγού προς τη λευκή γραμμή

The role of reverse shoulder arthroplasty in management of proximal humerus fractures with fracture sequelae: a systematic review of the literature

Fracture sequelae of the proximal humerus poses a complex management decision due to the frequent deformity and its consequences on the peri-articular soft tissues. These patients are frequently elderly with significant medical comorbidities. Due to the age of the patient there is frequently rotator cuff deficiency and therefore the reverse shoulder arthroplasty (RSA) becomes the arthroplasty of choice. We have performed a systematic review of the literature and report nine studies presenting RSA for the treatment of fracture sequelae of the proximal humerus. It is clear that RSA can improve the range of movement and function following proximal humerus fracture sequelae. However, there is a risk of significant complications including dislocation (16.7%), infection (6.7%), intra-operative fracture (3%) and neurological injury (2.6%). There is a need to invest in future prospective comparative studies and randomised trials to further test RSA in fracture sequelae patients. This will provide us with information regarding the longevity of different prosthesis, outcomes and costeffectiveness of treatment