Management of complications after reverse shoulder arthroplasty

Reverse total shoulder arthroplasty (RTSA) has become the treatment of choice for patients with rotator cuff arthropathy. Complication rate after RTSA has been reported to be three to five times that of conventional total shoulder arthroplasty. Intraoperative and postoperative complications include neurological injury, infection, dislocation or instability, acromial or scapular spine fracture, hematoma, and scapular notching. Knowledge of optimal component placement along with preoperative planning and recognition of risk factors are essential in optimizing patient outcome. The purpose of this review article is to identify the most common and serious complications associated with the RTSA and discuss the current methods of management. Complications after RTSA pose a significant challenge for healthcare providers and economic burden to society. Therefore, it is essential to make the proper diagnosis and develop and implement early management plans to improve patient outcome and satisfaction.     

Fracture of the scapular neck combined with rotator cuff tear: A case report

BACKGROUNDScapular fracture has a low incidence rate, accounting for 0.4%-0.9% of all fractures, and scapular neck fractures are extremely rare, comprising approximately 7%-25% of all scapular fractures. Scapular neck fractures are often studied as case reports mostly accompanied by other injuries, thus leading to confusion. All previous cases of scapular neck fractures are not associated with rotator cuff injuries.CASE SUMMARYA 62-year-old man was admitted to our emergency department 6 h after his right shoulder and back were impacted by heavy objects. The patient presented chest tightness and shortness of breath. Chest computed tomography (CT) showed pneumohemothorax, multiple rib fractures, and right scapula fractures. Three-dimensional CT reconstruction of the right shoulder joint showed a trans-spinous scapular neck fracture with a glenohumeral joint dislocation. Rotator cuff injury was suspected because the patient had a glenohumeral joint dislocation and was then confirmed by shoulder magnetic resonance imaging. A staged surgery was performed, including open reduction and internal fixation of the right scapula fracture and repairing of rotator cuff by right shoulder arthroscopy. At the 5-mo follow-up, the fracture line was blurred and the shoulder joint function was good.CONCLUSIONFracture of the scapular neck combined with rotator cuff tear is rare and the rotator cuff injury should not be ignored in clinical work. Stable internal fixation combined with secondary arthroscopic repair of rotator cuff tear can achieve good results.     

Expanding roles for reverse shoulder arthroplasty

Since its introduction in the USA in 2003, reverse total shoulder arthroplasty (RTSA) has been used with increasingly frequency as surgeons have observed the remarkable improvement in pain, range of motion, and function associated with this implant. RTSA was initially used exclusively for elderly, low demand individuals with end-stage rotator cuff tear arthropathy. However, RTSA is now being increasingly successfully employed for the management of irreparable rotator cuff tears, glenohumeral osteoarthritis with an intact rotator cuff, acute proximal humerus fractures, the sequelae of proximal humerus fractures, neoplasms of the proximal humerus, inflammatory arthropathy, young patients and failed anatomic total shoulder arthroplasty and hemiarthroplasty. While long-term outcomes are pending, short- and mid-term follow-up results suggest that in experienced hands, RTSA may be a reasonable treatment for many previously difficult to treat pathologies within the shoulder.     

Open vs. closed reduction combined with minimally invasive plate osteosynthesis in humeral fractures

Aim To explore a more effective surgical procedure, the outcomes of closed manipulative reduction (CMR) combined with minimally invasive plate osteosynthesis (MIPO) and conventional open reduction and internal fixation (ORIF) for treating proximal humeral fractures were compared. Material and methods In a retrospective study of patients operated for humerus shaft fractures from April 2008 to July 2011, the outcomes of 33 patients treated with CMR/MIPO were compared with the outcomes of 42 patients treated with ORIF. The fractures were classified, and the incision length, blood transfusion, operating time, as well as the VAS (Visual Analog Scale) pain scores were analyzed. The neck–shaft angles of the proximal humerus were detected, and the postoperative function of the shoulder was evaluated. Results The mean values of incision length, blood transfusion, and VAS pain scores at the 1st and 3rd day after CMR/MIPO and operation time were lower than that of ORIF. The postoperative radiographs verified good position of all screws and satisfactory bone fracture reduction in both groups. Meanwhile, in the ORIF group, nonunion (three cases) and humeral head necrosis (four cases) were detected. Conclusions The MR/MIPO technique showed smaller incisions, easier operation, less blood transfusion and more effective recovery of shoulder joint function for treating proximal humeral fractures than ORIF.     

Management of proximal humerus fractures utilizing reverse total shoulder arthroplasty

The increased incidence of proximal humerus fractures has resulted in a thoughtful evolution of treatment options in order to optimize clinical outcomes. Complex three- and four-part fractures present a treatment challenge, particularly in elderly patients with significant medial comorbidities and poor bone quality. While open reduction and internal fixation is a reasonable surgical option in some patients with acceptable bone quality and simple fracture patterns that are not susceptible to avascular necrosis, shoulder hemiarthroplasty is a well-established procedure for many elderly patients (i.e., >70 years). Historically, hemiarthroplasty has provided reliable pain relief, but outcomes with regard to function, motion, and strength have varied. Ultimately, successful outcomes are dependent upon tuberosity healing, since an intact rotator cuff is required to restore function. With the advent of reverse total shoulder arthroplasty (RTSA) and increased familiarity with the surgical technique, successful outcomes have been achieved in older patients with poor potential for tuberosity healing. In this review, we discuss the recent role of RTSA in the setting of proximal humerus fractures, including surgical indications, preferred operative technique, and recent literature that supports its use.     

Treatment Options for Massive Irreparable Rotator Cuff Tears

Purpose of ReviewMassive irreparable rotator cuff tears present a significant challenge to the orthopedic surgeon. No single treatment, particularly among joint-preserving options, has been shown to be superior. The purpose of this review is to discuss recent advances in the treatment of massive irreparable rotator cuff tears, including partial repair with and without graft augmentation, interposition grafts, superior capsule reconstruction, subacromial balloon spacers, tendon transfer, and reverse total shoulder arthroplasty. We will also offer guidance on surgical indications based on our clinical experience.Recent FindingsPartial repair may offer reasonable clinical improvement for patients with lower preoperative function despite high re-tear rates. Additionally, several types of interposition grafts have shown promising short-term results and may outperform repair alone. Subacromial balloon spacers may lead to clinical improvement, especially in patients without glenohumeral osteoarthritis or pseudoparalysis, and recently received FDA approval for use in the USA. Superior capsule reconstruction is a technically demanding procedure that appears to produce excellent short-term results particularly when performed at high volume, but long-term studies in heterogeneous study groups are needed. Tendon transfers improve function by restoring force coupling in the shoulder, offering a promising option for younger patients. Reverse total shoulder arthroplasty (RTSA) is a reliable option for treatment of irreparable cuff tears in elderly patients with lower functional demands.SummaryIrreparable cuff tears remain a difficult condition to treat. Recommended treatment for younger patients without glenohumeral osteoarthritis is particularly controversial. For older patients with low-demand lifestyles and glenohumeral osteoarthritis, RTSA is an effective treatment option. For all discussed procedures, patient selection appears to play a critical role in clinical outcomes.     

Treatment of lower part of glenoid fractures through a novel axillary approach: A case report

BACKGROUNDBased on the location and size of the fracture block, open reduction and internal fixation can be employed or assisted for shoulder arthroscopy in the treatment of glenoid fractures. However, the treatment of lower part of glenoid fractures through a novel axillary approach has not been reported so far. CASE SUMMARYA 22-year-old right-handed man was transferred to our outpatient clinic because of right shoulder injury during a traffic accident. X-ray examination after admission suggested the fracture of the lower part of the right glenoid and an ipiselial proximal humeral fracture. Three-dimensional (3D) computed tomography (CT) further suggested that the size of the fracture block of the lower part of the right glenoid was 3.4 mm × 16.2 mm. The patient was diagnosed as the fracture of the lower part of the glenoid, also known as bony Bankart lesion without shoulder dislocation. After general anesthesia, the patient was surgically treated with the open reduction internal fixation through a novel axillary approach. 3D CT and shoulder joint function were reexamined at 12 mo of follow-up, showing acceptable recovery.CONCLUSIONThis case report describes a novel axillary approach adopted in an open reduction with cannulated screw and wire anchor internal fixation. After a follow-up for more than 12 mo, 3D CT and shoulder joint function examinations display a good recovery.     

Three-dimensional in vivo comparative analysis of the kinematics of normal shoulders and shoulders with massive rotator cuff tears with successful conservative treatment

BackgroundThis study used in vivo three-dimensional to two-dimensional image registration techniques to compare the glenohumeral kinematics of shoulders with massive rotator cuff tears that were successfully treated conservatively and those of normal shoulders.MethodsTen patients (age, 67.4 ± 3.63 years) with massive rotator cuff tears on one side and without contralateral tears were enrolled. We performed computed tomography and fluoroscopy on both shoulder joints and created three-dimensional bone models of the humerus and scapula using image registration techniques. We measured the humeral superoinferior translation, angle of humeral external rotation, scapular upward rotation, scapular anteroposterior tilt, and scapular external rotation of the torn shoulders with good range of motion after effective conservative treatment and compared these measurements to those of the contralateral normal shoulders.FindingsThere was a significant difference in the initial position of the humeral head relative to the glenoid in the tear group; it was 2.0 mm higher than that in the normal group (p < .05). This difference disappeared in the range from 40° to full elevation. The scapular motion of the tear group was significantly more upwardly rotated than that of the normal group: by 9.9° at rest (p < .05) and by 11.6° at terminal elevation (p < .05). No significant differences were detected for humeral head external rotation, scapular anteroposterior tilt, and scapular external rotation between the two groups.InterpretationKinematics of shoulders with massive cuff tears could not be recovered completely even though the patients had no significant symptoms after successful conservative treatment.     

Scapulohumeral rhythm and associated spinal motion

BACKGROUND: To investigate the coordination of humeral, scapular and thoracolumbar spine motions during a number of unilateral and bilateral upper limb movements in a range of movement conditions. METHODS: Thirty-two healthy women performed unilateral and bilateral arm elevations in three planes-sagittal, coronal and scapular. Scapular, humeral and spinal orientations were measured at 100 Hz using a multi-sensor, 6-degree-of-freedom electromagnetic tracking system. Segmental displacements were computed following International Society of Biomechanics recommendations. FINDINGS: Humeral, scapular and thoracic segments demonstrate consistent, synchronous interactions. Scapular upward rotation is significantly greater on the non-dominant side than the dominant in all planes of movement and in both unilateral and bilateral arm movement. Unilateral and bilateral arm movements produce significantly different ranges and patterns of spinal motion and ranges of scapular external rotation. There does not appear to be any effect of age, height or weight on the ranges or patterns of motion of the shoulder girdle and spine during arm elevation. INTERPRETATION: Movement of the arm into elevation, irrespective of the plane of motion, has significant implications for the shoulder girdle and the thoracic spine. Clinical assessment of the shoulder should include the thoracic spine.     

A Novel Rehabilitation Program Using Neuromuscular Electrical Stimulation (NMES) and Taping for Shoulder Pain in Swimmers: A Protocol and Case Example

In-pool return to swim protocols have been described for swimmers returning from being deactivated from swimming due to a shoulder injury who have full shoulder strength. Many swimmers actively participate in swim practice and competition with shoulder pain and experience deficits in performance. There are multiple reported risk factors associated with shoulder pain among swimmers, including training errors and physical impairments. These include pool and dry-land training errors, weakness in the scapular stabilizers and rotator cuff, and muscle tightness. A need exists for dry-land rehabilitation programs for impairments common to swimmers that can be performed in a traditional outpatient physical therapy setting. The purpose of this clinical commentary is to present a protocol using neuromuscular electrical stimulation (NMES), taping, strengthening, and stretching to address impairments that are common among swimmers while allowing continued active participation in practice and competition.Level of EvidenceLevel 5     

Scapular bone grafting with allograft pin fixation for repair of bony Bankart lesions: A biomechanical study

BACKGROUNDSevere bony Bankart lesions are a difficult challenge in clinical treatment and research. The current treatment methods consist mostly of Latarjet-Bristow surgery and its modified procedures. While good results have been achieved, there are also complications such as coracoid fracture, bone graft displacement, and vascular and nerve injury.AIMTo analyze the techniques and biomechanical properties of transversely fixing a bone block from the scapular spine using bone allograft pins with suture threads to repair bony Bankart lesions.METHODSFresh human shoulder joint specimens and a cadaver specimen model for scapular bone grafting with allograft pin fixation for repair of bony Bankart lesions were used. When the humeral rotation angles were 0°, 30°, 60° and 90°, and the axial loads were 30 N, 40 N, and 50 N, the humerus displacement was studied by biomechanical experiments.RESULTSWhen the angle of external rotation of the humerus was 0°, 30°, 60°, and 90°, with axial loads of 30 N, 40 N, and 50 N, the data of the normal control group, allograft pin repair group, and titanium alloy hollow screw repair group were compared with each other by the q-test, which showed that there were no statistically differences among the three groups (P > 0.05).CONCLUSIONThe joints repaired with bone block from the scapular spine transversely fixed with allograft bony pins to repair bony Bankart lesions show good mechanical stability. The bone block has similar properties to normal glenohumeral joints in terms of biomechanical stability.     

肩胛骨骨折的分类及微创手术人路的应用疗效分析

目的：探讨微创切口治疗肩胛骨骨折的适应证及疗效。方法：2004-02-2012本院17例肩胛骨骨折的病例纳入本研究。17例患者中,男性15例．女忡2例．年龄范围为19～75岁,平均年龄为39岁。其中,肩胛孟骨折9例,肩胛骨突起部位骨折3例,肩胛骨体部骨折5例;车祸伤8例,高处坠落伤5例,直接暴力伤2例,刀砍伤2例;闭合性骨折14例,开放性骨折3例。卡艮据Hardegger的分型方法．体部骨折6处．肩胛骨骨折5例,肩胛颈骨折2处．盂缘骨折2处．盂窝骨折2处。其中混合型骨折10例,合并全身发伤5例。通过微创切口入路手术,对不同类型的肩胛骨骨折使用重建钢板或拉力螺钉和钢丝等固定。结果：17例患者获得随访,随访时间6月～3年,平均18个月。根据Rowe疗效评价标准。优11例,良2例,可2例,优良率83．7％。术后并发肩关节创伤性芙仃炎2例。结论：经微创切口入路内固定肩胛骨骨折操作简单,暴露较充分．效果可靠。除了肩胛骨体部粉粹性山脚折外及漂浮肩外．几乎各类犁的肩胛骨骨折均可通过微创切口入路完成,尤其通用于肩胛骨的体部骨折及肩胛骨骨折以及肩胛颈骨折盂缘骨折盂窝骨折。这是向胛骨骨折手术治疗的一种案例有效方法。     

Biomechanical analysis of the humeral head coverage,glenoid inclination and acromio-glenoidal height as isolated components of the critical shoulder angle in a dynamic cadaveric shoulder model

BackgroundThe Critical Shoulder Angle was introduced as a combined radiographic surrogate parameter reflecting the influence of the morphological characteristics of the scapula on the development of degenerative shoulder disease such as rotator cuff tears and osteoarthritis. Although, glenoid inclination and lateral extension of the acromion were studied in biomechanical models separately, no investigation included all three individual parameters that determine the Critical Shoulder Angle: glenoid inclination, acromial coverage and acromial height in one cadaveric study protocol.MethodsThree proximal humerus cadavers were attached to a robotic shoulder simulator which allowed for independent change of either lateral acromial coverage, glenoid inclination or acromial height. Combined dynamic scapula-thoracic and glenohumeral abduction up to 60° with different Critical Shoulder Angle configurations was performed and muscle forces as well as joint reaction forces were recorded.FindingsAll three components had an effect on either muscle forces and or joint reaction forces. While glenoid inclination showed the highest impact on joint stability with increasing upward-tilting causing cranial subluxation, changing of the lateral acromial coverage or acromial height had less influence on stability but showed significant alteration of joint reaction forces.InterpretationAll three components of the Critical Shoulder Angle, glenoid inclination, lateral acromial extension and acromial height showed independent biomechanical effects when changed isolated. However, glenoid inclination seems to have the largest impact regarding joint stability.     

Occipital condyle fracture in a victim of a motor vehicle collision

Occipital condyle fractures are rarely reported in the Emergency Medicine literature. It is unclear whether these fractures are rare or under-diagnosed. Occipital condyle fractures are associated with high-energy blunt trauma with significant cranial-cervical torque or axial loading. We report a case of a female patient with an occipital condyle fracture. The patient only complained of shoulder pain, but was found to have high cervical spine tenderness, after a moderate-speed front-end motor vehicle collision. Initial cervical spine radiographs were non-diagnostic. Computed tomography of the cervical spine demonstrated a non-displaced occipital condyle fracture. Conservative management with a semi-rigid cervical collar was successful in treating this patient's fracture. A review of the literature covers the diagnosis, radiographic findings, and management of this fracture.     

Failed Reverse Total Shoulder Arthroplasty: What Are Our Bailouts?

Purpose of ReviewAs the population continues to age and indications continue to expand, the number of reverse total shoulder arthroplasty (RSTA) procedures has increased significantly. While RTSA is an effective solution to many shoulder problems, it is not without complications. Furthermore, as the number of RTSA procedures increases, so will the number of complications following this procedure. While some complications can be managed with revision RTSA, there are some complications that, unfortunately, cannot. The purpose of this review is to discuss the revision options for failed RTSA.Recent FindingsWhile there has been a significant amount of recent literature surrounding RTSA, much of this literature has been aimed at improving outcomes for primary RTSA by improving glenoid placement, maximizing range of motion, etc., or improving outcomes following conversion of another surgery to RTSA [1••, 2, 3]. There has been little evidence surrounding options for failed RTSA that cannot be salvaged to a revision RTSA. These options are limited and often involve resection arthroplasty and hemiarthroplasty, although neither option provides patients with significant function of the shoulder [4, 5•].SummaryComplications following RTSA are becoming more common as the number of RTSA continues to increase. Furthermore, as the indications for RTSA expand, the complications will continue to increase as this implant is used to tackle more difficult problems about the shoulder. When possible, the etiology of the problem with the RTSA should be addressed and may involve component revision, bone grafting, etc. When the problem cannot be solved with revision RTSA, then the patient can be converted to a hemiarthroplasty, or have a resection arthroplasty, with the understanding that their shoulder function will be limited.     

锁定钢板与肩关节置换术治疗肱骨近端骨折的临床分析

目的：探讨肱骨近端锁定钢板与肩关节置换术治疗肱骨近端骨折的临床疗效及适应证。方法2006年5月至2011年9月62例肱骨近端骨折患者,其中49例获得随访。男17例,女32例;平均年龄66.5岁（24-83岁）,根据Neer分型：二部分骨折23例、三部分骨折16例、四部分骨折10例。49例患者采用肱骨近端锁定钢板治疗36例（内固定组）,其中二部分骨折23例、三部分骨折13例。采用肩关节置换治疗13例（关节置换组）,其中三部分骨折3例、四部分骨折10例。术后参照Neer肩关节功能评定标准评定疗效。结果内固定组手术时间平均为94min（70-150min）,49例患者获得手术后平均18.6个月（12-32个月）随访,无一例出现并发症。按Neer评分系统评价临床结果内固定组优13例、良18例、可4例、差1例,优良率86%;关节置换组优3例、良8例、可1例、差1例,优良率85%。结论年龄〈60岁,Neer分型属于二、三部分骨折患者,可以考虑选择肱骨近端锁定钢板治疗,年龄〉60岁的四部分骨折可考虑选择肩关节置换术,疗效满意。     

Effect of the Spacing of Backpack Shoulder Straps on Cervical Muscle Activity,Acromion and Scapular Position,and Upper Trapezius Pain

[Purpose] This study investigated the effect of the spacing of backpack shoulder straps on cervical muscle activity, acromion and scapular position, and upper trapezius (UT) pain. [Subjects] Fourteen males aged 20–32 years, were recruited. [Methods] We measured the MPS (midcervical paraspinal) activity, acromial angle, scapular distance, and UT pain after gait carrying a backpack with different shoulder strap spacings. [Results] The MPS, scapular inferior distance, and UT pressure pain threshold was significantly decreased and the acromion angle was significantly increased when carrying a backpack with wide shoulder straps compared to narrow shoulder straps. [Conclusion] A backpack with wide shoulder straps may cause scapular depression syndrome and chronic UT pain.Key words: Backpack, Scapular position, Shoulder straps     

Comparison of scapular upward rotation during arm elevation in the scapular plane in healthy volunteers and patients with rotator cuff tears pre- and post-surgery

BackgroundFunction loss caused by rotator cuff tears alters the scapular orientation, however, few prior studies have reported on scapular movements after rotator cuff repair. The purpose was to determine the scapular orientations before and after rotator cuff repair.MethodsWe recruited 14 healthy controls, 10 small and six massive rotator cuff tear in patients. The scapular upward rotation during arm elevation was analyzed using fluoroscopic imaging.FindingsBefore surgery, both rotator cuff groups demonstrated greater scapular upward rotation compared to healthy controls. Two months postoperation, the analyses showed significant differences between the patients with small rotator cuff tears and healthy controls at arm elevations of 90°, and between patients with both rotator cuff tear groups and healthy controls at arm elevations of 120°. At five months post-operation, significant differences still existed between the healthy controls and both rotator cuff groups. In regard to the temporal effects in the patients with small rotator cuff tears, the scapular upward rotation decreased significantly over time (2–5 months postoperation) at arm elevations of 120°. We did not identify a main effect owing to time in the patients with massive rotator cuff tears.InterpretationIn patients with small rotator cuff tears, scapular upward rotation was reduced over the period of 2–5 months postoperation, however, the patients with massive rotator cuff tears showed greater scapular upward rotation throughout the experimental period. The results suggested that the execution of the rehabilitation program should consider that the tear size could affect scapular motion.     

Biomechanical analysis of scapular neck malunion--a simulation study

OBJECTIVE: To explain loss of shoulder function following scapular neck malunion in terms of biomechanical changes around the gleno-humeral joint. DESIGN: Biomechanical modelling study. BACKGROUND: Residual rotation of the scapular neck after fracture can lead to pain and loss of function, and the indications for surgical intervention are contested. METHODS: A 3D, large-scale, musculo-skeletal model of the upper limb was used to compare shoulder biomechanics in the case of scapular neck malunion with normal anatomy. Abduction of the humerus was simulated with three models: normal anatomy, 24 degrees and 40 degrees inferior scapular neck rotation. RESULTS: Predicted muscle activation differed greatly between the control and the fracture cases. The motion required additional muscle effort for the maintenance of gleno-humeral stability in the fracture cases. Higher moments in the plane of abduction were generated by the teres major, pectoralis major and biceps brachii muscles with high humeral elevation angles. The rotator cuff muscles were severely shortened in the post-fracture cases and the forces in these muscles were greatly reduced in a test of loaded abduction with the humerus at 90 degrees. CONCLUSIONS: Given the function of the rotator cuff muscles as stabilisers of the gleno-humeral joint, it is concluded that the loss of force in these muscles, together with other changes in muscle activation, will lead to loss of arm function in patients with scapular neck malunion. RELEVANCE:These findings will contribute to the improved treatment of patients with scapular neck malunion by identifying important factors in the consideration of surgical intervention.     

Three-dimensional scapular morphology is associated with rotator cuff tears and alters the abduction moment arm of the supraspinatus

BackgroundNumerous studies have reported an association between rotator cuff injury and two-dimensional measures of scapular morphology. However, the mechanical underpinnings explaining how these shape features affect glenohumeral joint function and lead to injury are poorly understood. We hypothesized that three-dimensional features of scapular morphology differentiate asymptomatic shoulders from those with rotator cuff tears, and that these features would alter the mechanical advantage of the supraspinatus.MethodsTwenty-four individuals with supraspinatus tears and twenty-seven age-matched controls were recruited. A statistical shape analysis identified scapular features distinguishing symptomatic patients from asymptomatic controls. We examined the effect of injury-associated morphology on mechanics by developing a morphable model driven by six degree-of-freedom biplanar videoradiography data. We used the model to simulate abduction for a range of shapes and computed the supraspinatus moment arm.FindingsRotator cuff injury was associated with a cranial orientation of the glenoid and scapular spine (P = .011, d = 0.75) and/or decreased subacromial space (P = .001, d = 0.94). The shape analysis also identified previously undocumented features associated with superior inclination and subacromial narrowing. In our computational model, warping the scapula from a cranial to a lateral orientation increased the supraspinatus moment arm at 20° of abduction and decreased the moment arm at 160° of abduction.InterpretationsThree-dimensional analysis of scapular morphology indicates a stronger relationship between morphology and cuff tears than two-dimensional measures. Insight into how morphological features affect rotator cuff mechanics may improve patient-specific strategies for prevention and treatment of cuff tears.