Total shoulder arthroplasty: Factors influencing prosthetic sizing

Prosthetic sizing of the glenohumeral articulation influences postoperative shoulder strength stability and range of motion through its influence on the lateral humeral offset. Prosthetic sizing along with proper prosthetic orientation, soft tissue balancing, capsular release, and rotator cuff repair when necessary, are inter-related factors that significantly influence the function of the prosthetic shoulder. Intraoperative assessment of prosthetic size is determined by the lateral humeral offset rotator cuff tissue tension, intraoperative range of motion, and stability of the shoulder.     

Biomechanical benefits of anterior offsetting of humeral head component in posteriorly unstable total shoulder arthroplasty: A cadaveric study

Restoration of joint stability during total shoulder arthroplasty can be challenging in the face of severe glenoid retroversion. A novel technique of humeral head component anterior‐offsetting has been proposed to address posterior instability. We evaluated the biomechanical benefits of this technique in cadaveric specimens. Total shoulder arthroplasty was performed in 14 cadaveric shoulders from 7 donors. Complementary shoulders were assigned to either 10° or 20° glenoid retroversion, with retroversion created by eccentric reaming. Two humeral head component offset positions were tested in each specimen: The anatomic (posterior) and anterior (reverse). With loads applied to the rotator cuff and deltoid, joint contact pressures and the force and energy required for posterior humeral head translation were measured. The force and energy required to displace the humeral head posteriorly increased significantly with the anterior offset position compared to the anatomic offset position. The joint contact pressures were significantly shifted anteriorly, and the joint contact area significantly increased with the anterior offset position. Anterior offsetting of the humeral head component increased the resistance to posterior humeral head translation, shifted joint contact pressures anteriorly, and increased joint contact area, thus, potentially increasing the joint stability in total shoulder arthroplasty with simulated glenoid retroversion. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:666–674, 2016.     

Analgesia for day-case shoulder surgery

Background. Single-shot nerve blocks provide excellent postoperativeanalgesia for a limited period and are increasingly used inday-case units. They allow early patient discharge followingpainful operative procedures that would otherwise require overnighthospitalization. We investigated the adequacy of analgesia athome after the block had worn off. Methods. A prospective audit by telephone 1 week after surgeryof 50 consecutive patients who had had a single-shot interscaleneblock for day-case shoulder arthroscopic surgery. Results. The mean length of adequate sensory block was 22.5h (9–48 h) after which 20% of patients had a maximum visualanalogue scale (VAS) score of 5/5. Most patients did not takeanalgesics as prescribed and two patients (5.4%) required additionalanalgesia from their family doctor or accident and emergencydepartment. Conclusions. We conclude that analgesia at home is often inadequateafter painful day-case surgical procedures if single-shot localanaesthetic blockade is used. Br J Anaesth 2004; 92: 414–15     

液压扩张结合小针刀疗法治疗肩周炎的临床观察

2000年2月-2006年1月采用液压扩张配合小针刀疗法治疗肩周炎187例,疗效满意,现报告如下.     

液压扩张结合小针刀疗法治疗肩周炎的临床观察

2000年2月-2006年1月采用液压扩张配合小针刀疗法治疗肩周炎187例,疗效满意,现报告如下。1资料与方法1·1一般资料本组187例（197肩）,男81例,女106例;年龄34⁷8岁,平均46·7岁。左肩79例,右肩98例,双肩10例。病程2周³年,平均7·4个月。1·2诊断标准①肩部疼痛,夜间尤甚,甚则痛醒;②肩关节活动受限,以外展、旋转、后伸为著,被动增大活动范围则有剧痛;③肩关节周围有广泛压痛点;④X线片多为正常,部分患者可见肩部骨质疏松、囊性变或肩峰下钙化影。     

Low side-to-side sigmorectal anastomosis with intestinal staplers

The radiologic appearance of a side-to-side stapled sigmoid to rectal anastomosis is described. Barium which collects in the stump of the sigmoid may give the false appearance of an anastomotic leak and unnecessarily delay colostomy closure. Oblique views and observation in the radiologic suite for emptying of the distal stump will confirm this condition.     

The Clinical Outcome of Patellofemoral Arthroplasty vs Total Knee Arthroplasty in Patients Younger Than 55 Years

BackgroundPatellofemoral osteoarthritis affects 10% of patients older than 40 years and is commonly treated by patellofemoral joint arthroplasty (PFA) or a total knee arthroplasty (TKA). PFA is a more conservative approach with documented faster recovery. No study to date has compared both approaches with respect to patient-reported outcome measures in patients younger than 60 years.MethodsA retrospective case-matched cohort based on age, sex, body mass index, and side of 23 PFAs (in 19 patients) operated on by 2 surgeons and of 23 TKAs (23 patients) operated on by 6 surgeons was included in the study. All patients were younger than 55 years and operated on between March 2010 and September 2015. The Western Ontario and McMaster Osteoarthritic Index, Knee injury and Osteoarthritis Outcome scores, Tegner, and University of California, Los Angeles activity scores were compared between preoperative and minimum 2-year postoperative timepoints between groups.ResultsTKA and PFA were comparable on all patient-reported outcome measures at minimum 2-year follow-up; however, PFA patients exhibited statistically significantly larger improvement between 1 year postoperative and 2 years postoperative timepoints (P < .05). All patients improved between preoperative and postoperative timepoints (P < .05).ConclusionAlthough TKA performed better with respect to functional outcomes at the 1-year mark, at 2-year follow-up, PFA and TKA performed equally well. Our results allow us to conclude that in younger patients with isolated patellofemoral osteoarthritis who desire a more conservative, kinematic-preserving approach, PFA continues to be a practical treatment option yielding early outcomes that compare favorably with TKA.     

盂肱关节注射治疗压痛点不明确的冻结肩

冻结肩好发于40～60岁,女性多发,有较多患者局部压痛点广泛或不明确。2003年5月～2010年9月,笔者对79例冻结肩门诊患者行盂肱关节注射治疗,取得较好的疗效,报道如下。     

Ambulatory latissimus dorsi flap breast reconstruction: A prospective cohort study of an enhanced recovery after surgery (ERAS) protocol

PurposeEnhanced recovery after surgery (ERAS) protocols improve quality of recovery and decrease length of stay for patients undergoing both alloplastic and autologous breast reconstruction. Their use in latissimus dorsi (LD) flap reconstruction has not been well established. The purpose of this study was to compare postoperative outcomes, length of stay, and total costs in a prospectively enrolled group of patients who underwent LD flap breast reconstruction using an ERAS protocol to those of a retrospective cohort of patients who were treated with a traditional recovery after surgery (TRAS) protocol.MethodsIn a prospective cohort study conducted from 2016 to 2019, an ERAS protocol was implemented for patients undergoing LD flap breast reconstruction. The primary outcome was 24-h discharge, and secondary outcomes were readmission rate, complications, and quality of recovery. Outcomes of patients who underwent LD flap reconstruction with the ERAS protocol were compared with those of a retrospective cohort of patients who underwent LD flap reconstruction with TRAS protocols.ResultsTwenty patients enrolled in the ERAS group were compared with 58 patients in the TRAS group. Postoperatively, 100% of ERAS patients were discharged within 24 h (60% on the same day) as compared to 21% (9% on the same day) in the TRAS group (p<0.0001). Minor and major complication rates were similar (30% ERAS vs. 33% TRAS and 20% ERAS vs. 10% TRAS, respectively, p > 0.05). There was significant reduction in length of stay and total cost between the two groups (6.4 h vs. 58.5 h (p = 0.003) and $5,666.80 vs. $8890.25 (p = 0.0003), respectively).ConclusionsBreast reconstruction with the LD flap can be performed safely and effectively in the ambulatory setting. The implementation of an ERAS protocol was successful in discharging all patients home within 24 h, and the expedited discharge was associated with an acceptable complication rate, reduced length of stay, and excellent quality of recovery. Conversion from TRAS to ERAS protocols was associated with $3,223.45 cost savings per patient.     

Sprengel's deformity of the shoulder: Current perspectives in management

Sprengel's deformity or congenital elevation of scapula is a complex deformity of the pectoral girdle, and results in symptomatic cosmetic and functional disability. Several studies have attempted to analyze the three-dimensional aspects of this deformity; optimal methodologies of quantification and surgical correction techniques have been debated since the condition was first described. This article presents a concise review of the exact pathoanatomy, clinical presentation, imaging techniques, and surgical procedures described in the management of this condition.     

Femoral head�Cneck offset in the Indian population: A CT based study

Background:

Femoroacetabular impingement has been postulated as the important cause of primary osteoarthritis in non dysplastic hips. We postulated that the rarity of primary osteoarthritis of hip in Indian population could be attributable to morphological differences, specifically to a lower prevalence of abnormal head–neck morphology. We conducted an anthropometric study to evaluate the prevalence of abnormal head–neck offset in Indian population and to correlate it with the low prevalence of primary osteoarthrosis in the Indian population.

Materials and Methods:

The computed tomography (CT) images of 85 apparently normal hips were analysed. An axial image was created parallel to the central axis of the femoral neck and passing through the center of the femoral head using coronal scout view. This image was then used to calculate alpha and beta angles and the head–neck offset ratio. The measurements were made by two independent observers on two different occasions.

Results:

The prevalence of abnormal head–neck offset ratio was 11.7% and the mean alpha and beta angles were 45.6° and 40.6°, respectively. Pearson correlation coefficients for intra-observer and inter-observer agreement were, respectively, 0.84 and 0.80 for alpha angle, 0.80 and 0.77 for beta angle and 0.78 and 0.75 for head–neck offset ratio. The values were similar to those reported in the western population.

Conclusion:

The differences in the prevalence of hip osteoarthritis in Indian and western populations are not attributable to variation in the prevalence of abnormal head–neck offset.     

Sprengel’s shoulder treated by the Woodward procedure: analysis of factors affecting functional and cosmetic outcome

Purpose

To report the functional and cosmetic results of cases with Sprengel’s shoulder who underwent the Woodward procedure.

Materials and methods

Twelve children were operated at a mean age of 5.58 years and reviewed at an average follow up of 31.83 months.

Results

The mean preoperative Cavendish grade for cosmetic evaluation was 3.17, which decreased to 1.25 postoperatively (statistically significant, p < 0.0005, Wilcoxon signed-rank test). Similarly, the range of abduction at the shoulder increased from a mean of 115.83° preoperatively to 153.33° at final review (p < 0.0005). Age had a negative correlation with both functional improvement (r = −0.55, Spearman correlation coefficient) and cosmetic improvement (r = −0.11), although the latter suggested a very weak association, if any. Cavendish grade improvement and increase in abduction had a strong positive association (r = 0.713). However, there was no correlation between the increase in abduction and lowering of the scapula achieved (r = 0.131). The presence of an omovertebral bar did not affect the final functional outcome, nor did the presence of associated congenital anomalies.

Conclusion

The Woodward procedure is a reliable method for obtaining uniformly predictable results in Sprengel’s shoulder. The surgery should be performed at a younger age in order to optimise the functional outcome.     

肱骨远端C型骨折手术治疗的研究进展

肱骨远端C型骨折是一少见而又复杂的关节内损伤,非手术治疗难以准确复位骨折和重建关节面,切开复位内固定则是目前最理想的治疗选择。尺骨鹰嘴截骨入路可以提供充足的术野显露,是最常用的手术入路,但存在截骨处不愈合、内固定失败等并发症。为避免牺牲鹰嘴的完整性,肱三头肌内外侧入路、肱三头肌翻转入路、肱三头肌-肘肌瓣翻转入路、肱三头肌劈开入路及肱三头肌腱膜舌形瓣入路等则应用到骨折的显露中,但不同入路的局限性,使得入路选择在术野暴露与伸肘功能受影响之间存在一定矛盾性。随着"双柱"理论的推广,双钢板固定C型骨折比单钢板具有显著力学优势。在体外生物力学试验中,即便平行双钢板较垂直双钢板更有优势,但目前尚不清楚两者在临床运用中是否存在差异。对于关节面无法重建的C型骨折,肘关节置换术可能是最终的选择,由于技术水平限制,其长期疗效还有待观察。     

人工肱骨头置换治疗肱骨近端粉碎性骨折

目的探讨人工肱骨头置换治疗肱骨近端粉碎性骨折的疗效。方法对8例肱骨近端粉碎性骨折(NeerⅣ型)患者行人工肱骨头置换术,术中同时修复受损的肩袖和关节囊,术后患肩早期进行功能锻炼。结果术后随访6～34个月,病人主观满意度为86.5%,肩关节疼痛评分4.6分,主动活动度:平均外展91°、前屈95°、外旋35°、内旋至L2水平,术后三角肌、肩内旋肌、外旋肌力平均为4.5、4.1、4.2分,肩关节功能评分为3.5分。X线片示肱骨头位置良好,无假体松动或断裂。结论对肱骨近端粉碎性骨折,人工肱骨头置换是一种有效的治疗方法,能明显减少术后肩关节疼痛,最大限度恢复其运动功能。     

OffsetRuler结合可调颈假体柄在全髋关节置换术中的应用

目的 探讨Offset Ruler结合可调颈假体柄在全髋关节置换术（THA）中的应用价值.方法 2009年4月至2010年3月所有THA的患者中,共有67例患者（67髋）采用了Offset Ruler结合Wright公司的Profemur Z可调颈假体柄.其中DDH 31例（Crowe Ⅰ型 9例,Ⅱ型18例,Ⅲ型4例）,股骨头坏死11例,髋关节骨关节炎6例,股骨颈骨折19例;男31例（31髋）,女36例（36髋）,年龄平均64.3岁（42～81岁）.术前测量患者双下肢长度,并通过X线（标准骨盆平片）测量股骨偏心距（femoral offset,FO）及双下肢长度,计算术中需调整的患侧FO及长度.术中利用Offset Ruler,确定最后的假体型号.手术由同一组医生完成,评估由未参加手术的同一位医生完成.结果 67例患者均获得随访,随访时间为12～26个月,平均随访20.3个月.所有患者术中测试人工关节稳定性好,无脱位倾向,无撞击;术后均未出现神经损伤、感染、假体脱位等并发症.术前患肢较健侧平均短缩1.8 cm（0～3.3 cm）,术后患者双下肢平均长度差0.2 cm（0～1.3 cm）.所有患者行走均无跛行感,均感满意.结论 Offset Ruler操作方便,在THA术中使用Offset Ruler,结合可调颈假体柄,可以有效恢复股骨偏心距,减少或消除术后双下肢不等长的发生,增加患者满意度.     

肱骨头置换治疗肱骨近端粉碎性骨折中期疗效分折

目的探讨肱骨头置换治疗肱骨近端粉碎性骨折的临床疗效。方法对2001年7月～2006年12月采用肱骨头置换治疗的55例肱骨近端粉碎性骨折患者临床资料进行回顾性分析，根据Neer分类：三部分骨折39例，四部分骨折16例，均为新鲜骨折，所有假体均采用单极骨水泥型假体。结果55例关节活动度：外展平均100°（90°～110°），前屈95°（80°～100°），外旋35°（30°～40°），内旋L2水平（L1-～L3）。采用半关节成形改良评分系统（SSMH）对患肩进行综合评分，本组评定结果平均26.2分（23～28分），优（27分以上）41例，良（24-27分）7例，优良率达87．3％。无假体松动、下沉或断柄，无肩袖功能不全、关节不稳、异位骨化、脱位等并发症。结论肱骨头置换对于肱骨近端粉碎性骨折是一种行之有效的治疗方法，慎重选择适应证和假体、精细的手术操作和完善的术后功能锻炼是治疗成功与否的关键。