Comparison of modified Hackethal bundle nailing versus anterograde nailing for fixation of surgical neck fractures of the humerus: Retrospective study of 105 cases

AbstractIntroductionIntramedullary fixation of displaced surgical neck fractures of the humerus can be performed either by retrograde pinning or anterograde nailing. The goal of the current study was to compare the postoperative reduction and stability obtained with these two techniques.HypothesisIntramedullary nailing will provide the best reduction and stabilization of these fractures.Patients and methodsThis was a multicenter retrospective study that included patients with sub-tuberosity fractures with or without greater tuberosity fragment. These patients were treated either by retrograde Hackethal type pinning (group 1) or Telegraph anterograde nailing (group 2). To be included, patients needed to have A/P and lateral X-rays that had been taken before the surgery, immediately post-operative, between four and six weeks post-operative, and at the last follow-up. The outcomes were head angulation, translation and greater tuberosity position.ResultsOne hundred and five patients (40 retrograde pinning and 65 anterograde nailing) with an average age of 69 years (18–97 years) were included. The pre-operative fracture displacement was similar between the two groups. After the surgery, the A/P head angulation had been corrected in 72.5% of patients in group 1 and 84% in group 2 (no significant difference). Translation was still present in 17.5% of patients in group 1 and 1.5% in group 2 (P<0.05). At the last follow-up, union was achieved without residual angulation on lateral X-rays in 71% of patients in group 1 and 88% in group 2 (P<0.05). The fractures had healed with residual translation is 19.5% of patients in group 1 and 3% in group 2 (P<0.05).Discussion and conclusionIn cases of displaced surgical neck fractures with or without a greater tuberosity fragment, anterograde nailing provides better reduction and stability than retrograde pinning. However, fixation of the greater tuberosity fragment must be improved.Level of evidenceIV (retrospective comparative study)

Influence of surgical approach on functional outcome in reverse shoulder arthroplasty

SummaryIntroductionReverse shoulder arthroplasties (RSA) can be performed using a Deltopectoral (DP) or alternatively a Transdeltoid (TD) approach.HypothesisAlthough the humeral cut is lower by TD approach, this should not affect postoperative functional results.Material and methodsThis retrospective multicentric study evaluated the complete medical records of RSA implanted between October 2003 and December 2008. Inclusion criteria were: follow-up of at least 1year, a complete file including a comparative radiological work-up making it possible to analyze eventual arm and humeral lengthening. Evaluation of postoperative function was based on Active Anterior Elevation (AAE).ResultsWe studied 144 RSA in 142 patients. One hundred and nine RSA were implanted by the DP approach and 35 by the TD approach. Mean lengthening of the humerus compared to the controlateral side by DP approach was 0.5±1.3cm while there was a mean shortening of −0.5±1.0cm by TD approach (P<0.001). The difference in cut was partially compensated by using thicker polyethylene inserts with the TD approach. Mean arm lengthening compared to the controlateral side was 1.7±1.7cm by DP approach and 1.2±1.4cm by TD approach (mean difference 0.5cm; (95% CI −0.1; 1.2). AAE for RSA by DP approach was 145±22° and 135±29° by TD approach (mean difference 10°, 95% CI −1; 21).DiscussionRSA results in improved AAE because of restored deltoid tension and an increase in the deltoid lever arm. The humeral cut by TD is lower, but this was partially corrected in this study by the use of thicker polyethylene inserts. Nevertheless there is no significant clinical difference in postoperative function between the two approaches.Level of EvidenceLevel IV. Retrospective therapeutic study

Hemiarthroplasty versus reverse shoulder arthroplasty in 4-part displaced fractures of the proximal humerus: Multicenter retrospective study

Introduction: Complex 4-part fractures of the proximal humerus are one of the most difficult fractures to manage. For several years, reverse total arthroplasty (RSA) has been proposed as an alternative to hemiarthroplasty (HA) when internal fixation is insufficient. The goal of this study was to compare the short and intermediate term results of these 2 different types of arthroplasty. Materials and methods: In a retrospective, multicenter study, 57HA and 41 RSA were reviewed after a follow-up of at least 2 years. The clinical evaluation was based on the absolute and adjusted Constant scores, Simple shoulder value (SSV) and the quick-DASH scores. The radiological assessment included standard radiological tests. Results: After a mean follow-up of 39 months, the RSA group had a significantly higher adjusted Constant score than the HA group (83% vs 73%, respectively P = 0.02). However, there was no significant difference in the absolute Constant score, the quick-DASH or the SSV scores. Active anterior elevation was better in the RSA group, while internal rotation was better in the HA group (130◦ vs 112◦, P = 0.01; sacrum vs L3, P = 0.03). There was no significant difference in external rotation (28◦ vs 23◦, P = 0.31). The rate of complications was higher in the HA group than in the RSA group (24% vs 10%, P = 0.01). The radiological rate of union of the greater tuberosity was similar in both groups (70%) and scapular notching was found in 23% of the RSA group. Conclusion: The short and intermediate term clinical outcomes are better with RSA than with HA. The complication rate is higher with HA. Nevertheless, scapular notching occurred in more than 20% of patients with RSA, suggesting that care should be taken when using this prosthesis in young, active patients

Four-part fractures treated with a reversed total shoulder prosthesis: Prospective and retrospective multicenter study. Results and complications

Introduction: The reversed shoulder prosthesis is becoming the gold standard for cases of complex fracture of the proximal humerus after 70 years of age. Material and methods: The French Society of Orthopaedic and Traumatology Surgery (SOFCOT) conducted a prospective and retrospective multicenter study to evaluate the results of the reversed shoulder prosthesis implanted in patients with a four-part fracture in nine centers. In the retrospective study (n = 41 patients, 78 years of age, 14% ASA grade 3, 21% associated fractures) and in the prospective study (n = 32 patients, 79 years of age, 37% ASA grade 3, 21% associated fractures) evaluation by independent surgeons was conducted to measure the QuickDASH score, the Constant score, the SSV (subjective shoulder value), and complications to correlate these measurements with radiological results. Results: In both studies, use of an autograft (75%) to perform an osteosuture of tuberosities (90%) and no postoperative immobilization (75%) were similar. In the retrospective study at 39 months (range: 24–62 months) of follow-up, the QuickDASH reached 28 (range: 0–59), the Constant scores (raw Constant = 57, weighted Constant = 83.4%), and SSV 75 (range: 35–100). Complications after the 1st month (7%) were nonunion or ossifications. In the prospective study at 11 months (range: 5–16.5 months) of follow-up, the QuickDASH reached 40 (range: 1–75), the Constant scores 50 (raw Constant) and 74.6% (weighted Constant), and SSV 69 (range: 10–100). Complications after the 1st month (21%) were stiffness and dislocation, with two patients who underwent revision surgery. In both studies, early complications reached 6% (palsy, dislocation). Conclusion: This double (retrospective and prospective) study confirms the good results with a low level of complications of the reversed implant in cases of fracture but with osteosuture of tuberosities

Infraglenoidal scapular notching in reverse total shoulder replacement: a prospective series of 60 cases and systematic review of the literature

<p>Abstract</p> <p>Background</p> <p>The impact of infraglenoidal scapular notching in reversed total shoulder arthroplasty (RTSA) is still controversially discussed. Our goal was to evaluate its potential influence on subjective shoulder stability and clinical outcome. We hypothesized that subjective instability and clinical outcome after implantation of RTSA correlates with objective scapular notching.</p> <p>Methods</p> <p>Sixty shoulders were assessed preoperatively and at minimum 2-year follow-up for active range of motion and by use of the Oxford instability score, Rowe score for instability, Constant score for pain, Constant shoulder score, DASH score. All shoulders were evaluated on anterior-posterior and axillary lateral radiographic views. These X-ray scans were classified twice by two orthopaedic surgeons with respect to infraglenoidal scapular notching according to the classification of Nerot. Notching was tested for correlation with clinical outcome scores to the evaluated notching.</p> <p>Results</p> <p>We found no significant correlation between infraglenoidal scapular notching and clinical outcomes after a mid-term follow-up from 24 to 60 months, but at the final follow-up of 60 months and more, we did see statistically significant, positive correlations between infraglenoidal scapular notching and the Constant pain score as well as active range of motion. At mean follow-up of 42 months (range from 24 to 96 months) we found no significant correlation between subjective instability and infraglenoidal scapular notching.</p> <p>Conclusions</p> <p>We conclude that patients' subjective impression on their shoulders' stability is not correlating with radiological signs of infraglenoidal scapular notching. Nevertheless clinical parameters are affected by infraglenoidal scapular notching, at least in the long term</p

Distal humerus fractures in patients over 65: Complications

SummaryIntroductionFractures of the distal humerus in patients over the age of 65 remain a therapeutic challenge. Treatment options include conservative treatment, internal fixation or total elbow arthroplasty. The complications of these different treatment options were evaluated in a multicentre study.Materials and methodsFour hundred and ninety-seven medical records were evaluated. A retrospective study was performed in 410 cases: 34 received conservative treatment, 289 internal fixation and 87 underwent total elbow arthroplasty. A prospective study was performed in 87 cases: 22 received conservative treatment, 53 internal fixation, and 12 underwent total elbow arthroplasty. Patients were evaluated after at least 6 months follow-up.ResultsThe rate of complications was 30% in the retrospective study and 29% in the prospective study. The rate of complications in the conservative treatment group was 60%, and the main complication was essentially malunion. The rate of complications was 44% in the internal fixation group and included neuropathies, mechanical failure or wound dehiscence. Although complications only developed in 23% of total elbow arthroplasties, they were often more severe than those following other treatments.DiscussionComplications develop in one out of three patients over 65 with distal humerus fractures. Three main types of complications were identified. Neuropathies especially of the ulnar nerve, especially during arthroplasty, must always be identified, the nerve requiring isolation and transposition. Bone complications, due principally to mechanical failure, were found following internal fixation. Despite technical progress, care must be taken not to favor excessive utilization of this treatment option in complex fractures on fragile bone. Although there were relatively fewer complications with total elbow arthroplasty they were more difficult to treat. Ossifications were frequent whatever the surgical option and can jeopardize the functional outcome.Level of evidenceLevel IV

Rotator Cuff Deficient Arthritis of the Glenohumeral Joint

Rotator cuff deficient arthritis of the glenohumeral joint, especially cuff tear arthropathy, has proved a challenging clinical entity for orthopaedic surgeons ever since Charles Neer originally detailed the problem in 1983. Understanding has improved regarding the pathophysiology and pathomechanics underlying cuff tear arthropathy. Surgical reconstruction options can lead to excellent outcomes for patients afflicted with these painful and functionally limited shoulders. Humeral hemiarthroplasty and reverse total shoulder arthroplasty have jumped to the forefront in the treatment of cuff tear arthropathy. As studies continue to look at the results of these procedures in cuff tear arthropathy, existing indications and treatment algorithms will be further refined. In this article the history and pathophysiology of cuff tear arthropathy are reviewed. Additionally, the clinical findings and results of surgical reconstruction are discussed

Posterior shoulder instability managed by arthroscopic acromial pediculated bone-block. Technique

In posterior shoulder instability (recurrent dislocation, involuntary posterior subluxation or voluntary subluxation that has become involuntary), surgery may be considered in case of failure of functional treatment if there are no psychological contraindications. Acromial bone-block with pediculated deltoid flap, as described by Kouvalchouk, is an alternative to iliac bone-block, enabling triple shoulder locking by the blocking effect, the retention hammock provided by the deltoid flap and posterior capsule repair. Arthroscopy allows shoulder joint exploration and diagnosis of associated lesions, with opening and conservation of the posterior capsule; it greatly facilitates bone-block positioning and capsule reinsertion. The present report describes the procedure in detail

Malignant fibrous histiocytoma of the distal femur after an arthroscopic anterior cruciate ligament reconstruction: A case report and a review of the literature

<p>Abstract</p> <p>Background</p> <p>Malignant degeneration in association with orthopaedic implants is a known but rare complication. To our knowledge, no case of osseous malignant fibrous histiocytoma after anterior cruciate ligament reconstruction is reported in the literature.</p> <p>Case presentation</p> <p><b>We report a </b>29-year-old male Turkish patient who presented with severe pain in the operated knee joint 40 months after arthroscopic anterior cruciate ligament reconstruction. X-ray and MR imaging showed a large destructive tumor <b>in </b>the medial femoral condyle. Biopsy determined a malignant fibrous histiocytoma. After neoadjuvant chemotherapy, wide tumor resection and distal femur reconstruction with a silver-coated non-cemented tumor knee joint prosthesis was performed. Adjuvant chemotherapy was continued according to the EURAMOS 1 protocol.</p> <p>Conclusions</p> <p>Though secondary malignant degeneration after orthopaedic implants or prostheses is not very likely, the attending physician should take this into consideration, especially if symptoms worsen severely over a short period of time.</p

Prosthetic overhang is the most effective way to prevent scapular conflict in a reverse total shoulder prosthesis

Methods An average and a "worst case scenario" shape in A-P view in a 2-D computer model of a scapula was created, using data from 200 "normal" scapulae, so that the position of the glenoid and humeral component could be changed as well as design features such as depth of the polyethylene insert, the size of glenosphere, the position of the center of rotation, and downward glenoid inclination. The model calculated the maximum adduction (notch angle) in the scapular plane when the cup of the humeral component was in conflict with the scapula. Results A change in humeral neck shaft inclination from 155 degrees to 145 degrees gave a 10 degrees gain in notch angle. A change in cup depth from 8 mm to 5 mm gave a gain of 12 degrees. With no inferior prosthetic overhang, a lateralization of the center of rotation from 0 mm to 5 mm gained 16 degrees. With an inferior overhang of only 1 mm, no effect of lateralizing the center of rotation was noted. Downward glenoid inclination of 0 boolean OR to 10 boolean OR gained 10 degrees. A change in glenosphere radius from 18 mm to 21 mm gained 31 degrees due to the inferior overhang created by the increase in glenosphere. A prosthetic overhang to the bone from 0 mm to 5 mm gained 39 degrees. Interpretation Of all 6 solutions tested, the prosthetic overhang created the biggest gain in notch angle and this should be considered when designing the reverse arthroplasty and defining optimal surgical technique