The posterior ridge of the greater tuberosity of the humerus: a suitable landmark for the posterior approach to the shoulder joint?

The purpose of this study was to evaluate the posterior ridge of the greater tuberosity, a palpable prominence during surgery, as a landmark for the posterior approach to the glenohumeral joint.Methods: Twenty-five human cadaveric shoulders were dissected. In 5 cases, a full-thickness rotator cuff tear was present. The posterior surgical anatomy was defined, and the distance from the ridge to the interval between the infraspinatus (IS) and teres minor (TM) muscle, the distance from the ridge to the inferior border of the glenoid (IBG), and the distance between the IS-TM interval and the IBG were determined.Results: In all specimens, a prominent ridge on the posterior greater tuberosity lateral to the articular margin could be identified. The IS-TM interval was located, on average, 3 mm proximal to this ridge. The IS-TM interval corresponded to a point 5 mm proximal to the IBG. In all shoulders, the ridge was located, on average, 8 mm proximal to the IBG. The plane of the IS-TM interval showed a vertically oblique direction.Conclusion: The posterior ridge of the greater tuberosity is a suitable landmark to locate the internervous plane between the IS and TM and should not be crossed distally. Unlike other landmarks, the ridge moves with the humeral head, making it is less dependent on the patient's size, sex, and arm position and the quality of the rotator cuff. The ridge is always located proximal to the insertion of the TM and IBG

Unnecessary operations in shoulder surgery: "table of confusion" applied to "field of confusion"

Eine Operation oder Behandlung als „nötig“ oder „unnötig“ zu deklarieren kann als binomialer Klassifikator betrachtet werden und in einer Konfusionsmatrix („Table of Confusion“) analysiert werden. Ambroise Parré (1510–1590) hat die Wundbehandlung mit heissem Öl dank wissenschaftlicher Reflexion über eigener Arbeit als „Standard of Care“ ablösen können. Immer noch ist die Frage: „Was ist die aktuelle Standardbehandlung?“ entscheidend darüber, ob eine Operation nötig oder unnötig sei. Die Erwartungen des Patienten können die Entscheidung operative versus konservative Behandlung beeinflussen. Am Beispiel der proximalen Humerusfraktur können zwei unterschiedliche operative Strategien (primäre versus sekundäre Schulterprothese) zu einer unnötigen Operation führen, was allerdings erst im Nachhinein beurteilbar wird. Weitere Faktoren, welche analysiert werden, sind Zeit („Test of Time“) und finanzielle Aspekte. Zusammenfassend kann uns nur die objektive wissenschaftliche Analyse richtige Leitlinien für unser Handeln geben und damit sowohl den Patienten wie auch den Orthopädischen Chirurgen vor unnötigen Operationen schützen. </jats:p

Osteolytic changes around biodegradable cement restrictors in hip surgery

Background and purpose — Biodegradable cement restrictors are widely used in hip arthroplasty. Like others, we observed osteolytic reactions associated with a specific cement restrictor (SynPlug; made of PolyActive) and reviewed our patients. Patients and methods — We identified 703 patients with suitable radiographs from our database (2007 to 2012) who underwent cemented hip arthroplasty and received a SynPlug biodegradable cement restrictor. We reviewed all available radiographs to determine the incidence, severity, and progression of osteolysis. Mean postoperative follow-up was 1.8 (1–7) years Results — 1 year after implantation, the femoral cortex showed thinning by 12% in the anterior-posterior view and by 8% in the axial view. This had increased to 14% and 12%, respectively, at the latest available follow-up postoperatively (at a mean of 4 years). Cortical thinning of less than 10% was found in 37% of patients, but cortical thinning of 10–30% was found in 56% of patients. In the remaining 7%, a reduction of more than 30% of the original cortical thickness was observed. Interpretation — Osteolytic changes associated with the SynPlug biodegradable bone restrictors are inconsistent and highly variable. While some patients showed increased weakening of the femoral cortex with the potential risk of periprosthetic fracture, in others the degree of osteolysis only increased slightly or stabilized after 2 or more years. Any cortical bone loss after total hip replacement should be avoided, so the use of PolyActive biodegradable cement restrictors should be discontinued. Patients with a PolyActive cement restrictor in place should be followed up closely after surgery

A new parallel closing mechanism for the laminectomy rongeur makes it significantly more precise: a biomechanical and mechanical comparison study

Purpose To prove that a modified closing mechanism of the rongeur gives better precision compared to the old Kerrison rongeur. Methods Forty persons from the departments of orthopaedic surgery, urology and neurosurgery (35 orthopaedic, 2 urology and 3 neurosurgery) took part in the study. All participants were asked to punch ten times in a first step with either the old Kerrison rongeur with the scissors-like handle or the modified punch with a new parallel closing mechanism. In a second step, they punched 10 times with the other instrument. Shaft movement in three dimensions was measured with a stereoscopic, contactless, full-field digital image correlation system. Results The new rongeur is significantly more precise with less movement in all three dimensions. The mechanical model of the new rongeur shows that the momentum needed to keep the tip at the initial position changes only minimally during the closing act on the new model. Conclusion The new rongeur is more precise compared to the old Kerrison model. It is more robust against changes in the direction of the finger forces and may reduce soreness, fatigue and CTS in spine surgeons. Level of evidence Not applicable: technical study.ISSN:0940-6719ISSN:1432-0932ISSN:00199115

Schlafverhalten von Personen nach Implantation einer inversen Schulterprothese im Vergleich zu einer gesunden Kontrollgruppe

Background Individuals with shoulder pathologies frequently report sleep problems. Improving sleep quality is a treatment focus of shoulder arthroplasty. So far, it is unclear whether altered anatomy and biomechanics in reversed total shoulder arthroplasty affect sleep quality in the long term. In addition to a subjective evaluation, a reliable assessment can be obtained by recording objective sleep parameters. With the help of actigraphy, body movements are registered and divided into active and inactive phases by means of threshold values. Thanks to the valid correspondence with waking and sleeping phases, the calculation of objective sleep parameters is successful. Objectives The aims of the study were to investigate whether objective sleep parameters differ in persons with reversed total shoulder arthroplasty (RTSA) 1 year postoperatively compared to a healthy control group and to explore what the reasons are. Material and methods The present work is an exploratory cross-sectional study with one measurement time point. 29 study participants (15 in the RTSA-group, 14 in the control group) collected objective sleep parameters and body position data during seven nights using actigraphy. The Mann–Whitney–U test was used for the mean comparison of sleep parameters. In addition, reasons for wakefulness were explored. Results and conclusions The groups showed no significant differences in all objective sleep parameters with nearly identical sleep efficiency (p = 0.978). In the RTSA-group, 11% lay on the operated side and 65% on the back. This is just above the significance level compared to the control group with 45% in the supine position (p = 0.056). The increased use of the supine position could promote sleep-related medical conditions such as sleep apnoea and requires further research.Hintergrund Personen mit Schulterpathologien berichten häufig über Schlafprobleme. Die Verbesserung der Schlafqualität ist ein Behandlungsziel der Schulterendoprothetik. Bisher ist unklar, ob veränderte Anatomie und Biomechanik bei inversen Schultertotalprothesen die Schlafqualität längerfristig beeinflussen. Zu einer zuverlässigen Einschätzung führt nebst subjektiver Bewertung die Erhebung von objektiven Schlafparametern. Mithilfe der Aktigraphie werden Körperbewegungen registriert und in aktive und inaktive Phasen eingeteilt. Dank der validen Übereinstimmung mit Wach- und Schlafphasen gelingt die Berechnung der objektiven Schlafparameter. Ziel der Arbeit Ziele der Studie waren zu untersuchen, ob sich objektive Schlafparameter bei Personen mit inverser Schultertotalprothese („reverse total shoulder arthroplasty“ [RTSA]) ab einem Jahr postoperativ im Vergleich zu einer gesunden Kontrollgruppe unterscheiden und was die Gründe dafür sind. Material und Methoden Die vorliegende Arbeit ist eine explorative Querschnittsstudie mit einem Messzeitpunkt. 29 Studienteilnehmende (15 RTSA-Gruppe, 14 Kontrollgruppe) erhoben während 7 Nächten mithilfe der Aktigraphie objektive Schlafparameter und Daten zur Körperlage. Der Mann-Whitney-U-Test wurde für den Mittelwertvergleich der Schlafparameter verwendet. Gründe für die Wachphasen wurden explorativ untersucht. Ergebnisse und Diskussion Die Gruppen zeigten bei allen objektiven Schlafparametern keine signifikanten Unterschiede mit einer nahezu identischen Schlafeffizienz (p = 0,978). Die RTSA-Gruppe lag zu 11 % auf der operierten Seite und zu 65 % auf dem Rücken. Dies ist im Vergleich zur Kontrollgruppe mit 45 % Rückenlage knapp über dem Signifikanzniveau (p = 0,056). Das vermehrte Einnehmen der Rückenlage könnte atembezogene Schlafstörungen fördern und bedarf weiterer Forschung

Cemented vs. uncemented reverse total shoulder arthroplasty for the primary treatment of proximal humerus fractures in the elderly—a retrospective case–control study

Abstract Background Uncemented reverse total shoulder arthroplasty (RTSA) for the primary treatment of proximal humerus fractures (PHF) in elderly patients was introduced at our institution in 2017. Recent reports have raised concerns about increased rates of early bone resorption at the proximal humerus with uncemented fracture stems. The aim of this study was to find out whether there was any difference in functional or radiographic outcomes between cemented and uncemented RTSA for PHF. Methods Seventeen consecutive patients who underwent uncemented RTSA (group nC) in 2017 and 2018 were age and sex matched (propensity score matching 1:2) to 34 patients with cemented RTSA implanted between 2011 and 2016 (group C) for the primary treatment of PHF. These two groups were compared in terms of clinical and radiographic outcomes at 2 years after the index surgery. Results The mean bone quality was low in both groups: in group nC the deltoid tuberosity index (DTI) was 1.43 (1.22–1.72) and in group C 1.42 (1.22–1.67). At the final 2 year follow-up, the relative CS was 98.3% (71–118) in group nC and 97.9% (36–125) in group C (p = 0.927); the absolute CS was 70.2 (49–89) in group nC and 68.0 (30–94) in group C (p = 0.509). Lucent lines at the humeral site were seen in 8 cases (47%) in group nC and in 13 cases (38%) in group C (p = 0.056). Compared to 3% in group C, all patients in group nC showed at least grade 1 and 65% showed grade 3 bone resorption at the proximal humerus (p < 0.001). Conclusion Compared to cemented RTSA bone resorption at the proximal humerus was significantly more frequent in patients with uncemented RTSA for PHF. So far, this is rather a radiographic than a clinical finding, because both groups showed very satisfying functional outcomes and low revision rates at the 2 year follow-up. Level of Evidence III. A retrospective case–control study

Outcomes of management of proximal humeral fractures with patient-specific, evidence-based treatment algorithms

Background: Previous studies have identified risk factors for different types of treatment of proximal humeral fracture (PHF) and allowed the development of a patient-specific, evidence-based treatment algorithm with the potential of improving overall outcomes and reducing complications. The purpose of this study was to evaluate the results and complications of treating PHF using this algorithmic approach. Methods: All patients with isolated PHF between 2014 and 2017 were included and prospectively followed. The initial treatment algorithm (Version 1 [V1]) based on patients' functional needs, bone quality, and type of fracture was refined after 2 years (Version 2 [V2]). Adherence to protocol, clinical outcomes, and complications were analyzed at a 1-year follow-up. Results: The study included 334 patients (mean age, 66 years; 68% female): 226 were treated nonoperatively; 65, with open reduction and internal fixation (ORIF); 39, with reverse total shoulder arthroplasty (RTSA); and 4, with hemiarthroplasty. At 1 year, the preinjury EuroQol 5-Dimension (EQ-5D) values were regained (0.88 and 0.89, respectively) and the mean relative Constant Score (CS) and Subjective Shoulder Value (SSV) (and standard deviation [SD]) were 96% +/- 21% and 85% +/- 16%. Overall complications and revision rates were 19% and 13%. Treatment conforming to the algorithm outperformed non-conforming treatment with respect to relative CS (97% versus 88%, p = 0.016), complication rates (16.3% versus 30.8%, p = 0.014), and revision rates (10.6% versus 26.9%, p < 0.001). Conclusions: Treating PHF using a patient-specific, evidence-based algorithm restored preinjury quality of life as measured with the EQ-5D and approximately 90% normal shoulders as measured with the relative CS and the SSV. Adherence to the treatment algorithm was associated with significantly better clinical outcomes and substantially reduced complication and revision rates