Obesity and Reverse Total Shoulder Arthroplasty

Purpose of ReviewRates of obesity and reverse total shoulder arthroplasty (rTSA) in the USA have both escalated with time. Obese patients experience arthritis at higher rates than normal weight patients; therefore, these numbers go hand in hand. Obesity has been correlated with health comorbidities such as anxiety, cardiovascular disease, diabetes, and metabolic syndrome as well as poorer outcomes and higher complication rates following lower extremity arthroplasty. The current review investigates these comorbidities as they relate to obese patients undergoing rTSA.Recent FindingsFunctional outcomes are similar to normal weight counterparts. Although longer operative times and a large soft tissue envelope would intuitively predispose these patients to higher risk for infection or other complications, this has not been reliably demonstrated. Technical considerations and awareness of potential risks in the obese patient demographic may aid the surgeon in preoperative planning and counseling of their patient.SummaryObese patients undergoing rTSA have been shown to have higher risks specifically for infection, revision, and medical complications; however, this has not been consistently demonstrated in the single surgeon series where, more often, no difference in these metrics has been found. Outcomes measures and satisfaction are reliably improved, even when considering superobese patients, and majority of studies find their improvements and absolute values to be in line with their normal weight counterparts. Thus, rTSA does not seem to carry the same level of adverse risk associated with lower joint arthroplasty but potential for higher risk still bears consideration when counseling obese patients. Attention to factors that may negatively affect prosthesis positioning may optimize retention rates and limit early failure.     

The Influence of Reverse Total Shoulder Arthroplasty Implant Design on Biomechanics

Purpose of ReviewAs reverse total shoulder arthroplasty indications have expanded and the incidence of its use has increased, developments in implant design have been a critical component of its success. The purpose of this review is to highlight the recent literature regarding the effect of implant design on reverse total shoulder arthroplasty biomechanics.Recent FindingsImplant design for reverse total shoulder arthroplasty has evolved considerably from the modern design developed by Paul Grammont. The Grammont design had a medialized center of rotation and distalized humerus resulting from a 155° humeral neck shaft angle. These changes intended to decrease the forces on the glenoid component, thereby decreasing the risk for implant loosening and improving the deltoid moment arm. However, these features also led to scapular notching. The Grammont design has been modified over the last 20 years to increase the lateral offset of the glenosphere and decrease the prosthetic humeral neck shaft angle to 135°. These changes were made to optimize functional range of motion while minimizing scapular notching and improving active external rotation strength. Lastly, the introduction of preoperative planning and patient-specific instrumentation has improved surgeon ability to accurately place implants and optimize impingement-free range of motion.SummarySuccess and durability of the reverse total shoulder arthroplasty has been contingent upon changes in implant design, starting with the Grammont-style prosthesis. Current humeral and glenoid implant designs vary in parameters such as humeral and glenoid offset, humeral tray design, liner thickness, and neck-shaft angle. A better understanding of the biomechanical implications of these design parameters will allow us to optimize shoulder function and minimize implant-related complications after reverse total shoulder arthroplasty.     

Reverse Total Shoulder Arthroplasty with Concurrent Latissimus Dorsi Tendon Transfer

Purpose of ReviewReverse total shoulder arthroplasty (rTSA) has emerged as an effective treatment option for patients with rotator cuff arthropathy resulting from irreparable rotator cuff tears. However, patients with combined loss of abduction and external rotation may still experience functional deficits after rTSA. One option to address this has been the latissimus dorsi tendon transfer (LDTT), or modified L’Episcopo procedure. The purpose of this review is to describe the role of LDTT with rTSA and to critically evaluate the evidence on whether a supplemental LDTT ultimately improves patient function.Recent FindingsPatients with an intact rotator cuff demonstrated a significant increase in active external rotation following rTSA compared to those with a deficient rotator cuff following rTSA. Compared to their pre-operative baseline assessments, patients who undergo rTSA with LDTT report significant improvements in active external rotation. However, a randomized trial comparing rTSA patients with and without LDTT failed to demonstrate a significant difference in active external rotation or patient-reported outcomes between groups.SummaryObservational studies have shown that patients experience significant improvements in active range of motion and various patient-reported outcome measures following rTSA with latissimus dorsi tendon transfer. When directly comparing rTSA with LDTT to rTSA alone, the current literature fails to demonstrate a statistically significant difference in active external rotation or patient-reported outcomes at short-term follow-up. Further randomized controlled trials are required to fully understand the potential benefits of added tendon transfer in the rTSA patient population.     

Reverse shoulder arthroplasty

The reverse shoulder arthroplasty emerged as a potential solution for those patients who could not be managed effectively with a conventional total shoulder arthroplasty. Grammont revolutionized the design by medializing and distalizing the center of rotation and utilizing a large convex glenoid surface and concave humeral component with a neck-shaft angle of 155°. This design has been highly successful in cuff deficient shoulders, and indications continue to broaden. Many mid-term studies have improved upon the early encouraging results. Long-term studies are starting to emerge, demonstrating good survivorship, but progressive functional and radiographic deterioration continue to be concerning. Careful patient selection and attention to appropriate technique are required to reduce the current high rate of complications. New prosthesis designs are continuing to develop to address some of these limitations.     

Platform systems in shoulder arthroplasty

A platform system for shoulder arthroplasty can include a convertible modular humeral stem and/or a metal-backed glenoid component to facilitate straightforward conversion from either a hemiarthroplasty or anatomic total shoulder arthroplasty to a subsequent anatomic total shoulder arthroplasty, or more frequently, reverse total shoulder arthroplasty without any revision to the stem and/or glenoid baseplate. Recent studies have demonstrated a decreased rate of intraoperative humeral fracture, complications, and blood loss when a platform system is used and the humeral stem is not exchanged during revision arthroplasty. Future studies with larger patient cohorts are necessary to truly evaluate the potential value and limitations of this technology.     

The Perioperative Nurse's Role in Table-Enhanced Anterior Total Hip Arthroplasty

The anterior approach to total hip arthroplasty (THA), when performed with the patient in the supine position, is enhanced by the use of a radiolucent, orthopedic table.This technique has numerous advantages: enhanced intraoperative fluoroscopy because of the patient's supine position on a radiolucent table, improved femoral exposure, and reduced soft tissue trauma. Criteria for patient selection is not limited as it may be for other arthroplasty techniques.The role of the perioperative nurse during an anterior THA is to ensure optimal function of the orthopedic table and provide safe patient care. A clear understanding of the surgical techniques used and the functions of the table are imperative. AORN J 90 (July 2009) 53-68. © AORN, Inc, 2009.     

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.     

全髋关节置换术患者的延续性护理

目的探讨全髋关节置换术患者延续性护理的方法和效果。方法便利抽样法选择2014年1月至2015年6月解放军第101医院收治的行全髋关节置换术的104例患者为研究对象,按入院先后将其分为观察组和对照组各52例,两组患者住院期间均给予常规护理,观察组患者出院后给予6个月的延续性护理,评价并比较两组患者出院后第1、3、6月的Harris髋关节功能评分和Barthel指数评分及术后6个月内患者并发症的发生情况、对护理服务的满意度。结果出院后第1、3、6个月,观察组患者的Harris髋关节功能评分和Barthel指数评分均高于对照组(均P0.05),并发症的发生率低于对照组,护理服务满意率高于对照组(均P0.05)。结论延续性护理的实施有助于促进全髋关节置换术患者术后髋关节功能的恢复和生活自理能力的提高。     

人工全膝关节置换前后的康复治疗

目的：探讨人工全膝关节置换（TKA）术后的康复治疗效果。方法：90例110膝行TKA的患者，在术前后均给予康复指导和训练，并采用美国特种外科医院（HSS）膝关节评分标准进行疗效评定。结果：术后21d独立行走68例（75．6％），扶拐行走22例（24．4％），其中内翻畸形1例（1．1％），无膝过伸；膝关节屈膝90。有75膝（68．2％），100。19膝（17．3％），〉110。12膝（10．9％），510。屈曲畸形4膝（3．6％）；术后疼痛消失86膝（78．2％），明显改善22膝（20％），无改善2膝（8．2％）。临床疗效评定，达优88膝（80％），良15膝（13％），优良率93％。结论：加强患者术前后的康复治疗，有利于减少膝关节疼痛和增加膝关节活动度和肌力。     

Planning software and patient-specific instruments in shoulder arthroplasty

Computer planning software and patient-specific instrumentation have been investigated in multiple subspecialties of orthopedics with mixed results. Shoulder arthroplasty has evolved over the last decade with improvements in implant design and surgical instrumentation. Despite these advances, glenoid positioning in shoulder arthroplasty continues to be a difficult problem. Recent advances in three-dimensional imaging techniques and the use of computer planning software may potentially address some of the common difficulties encountered by surgeons. The addition of patient-specific instrumentation and guides provide an option for patients with significant glenoid deformity that may allow improved accuracy of glenoid component implantation compared to using standard instrumentation. Studies have reported improved positioning of the glenoid component in both anatomic and reverse total shoulder arthroplasty with patient-specific instrumentation and guides. More research is needed to determine whether these improvements lead to better patient-reported outcomes or implant survival. In addition, further studies will be needed to address whether this technology is cost effective for large-scale implementation in the orthopedic community.     

人工全髋关节置换翻修术后的康复

目的探讨人工全髋关节置换翻修术后康复训练的有效方法。方法对24例不同病因行各类人工全髋关节置换翻修术后患者,给予有异于初次人工全髋关节置换术后患者的特殊康复治疗,于手术前和手术后1、3个月进行Harris评分并判定疗效。结果全髋关节翻修手术后1、3个月患者疼痛、活动度、步行能力、日常生活能力比术前均有所提高（P〈0.05或P〈0.001）。术后3个月疗效评定：优4例,良13例,中6例,差1例,优良率70.83%。结论 1）全髋关节翻修术后的早期康复对髋关节功能的恢复有重要的作用;2）由于人工全髋关节置换翻修手术的复杂性,其术后的康复训练需从髋关节骨骼的完整性（是否骨质疏松、骨缺损的程度）、内植物相对的稳定性（选择何种类型的假体固定）、关节周围的软组织条件3个方面进行评定;3）术后康复训练遵循个体化、渐进性、全面性的原则,重点是增加肌力,尤其是髋外展肌肌力的训练。     

Simultaneous bilateral acromial base fractures after staged reverse total shoulder arthroplasty: A case report

BACKGROUNDAcromial and scapular spine fractures after reverse total shoulder arthroplasty (RTSA) are a well-known complication that may negatively impact the effects of long-term outcomes. However, to the best of our knowledge, there has been no report of simultaneous bilateral fractures of the acromion or scapular spine that occurred following staged RTSA.CASE SUMMARYA 79-year-old right-handed male visited our outpatient clinic with a chief complaint of pain and limited motion of both shoulder joints for a one-year duration. Based on plain radiographs and magnetic resonance images, the preoperative diagnosis was bilateral cuff tear arthropathy with failed rotator cuff repair. This patient was treated with staged bilateral RTSA at a two-month interval. At 5 and 3 mo after right and left side surgery, the patient returned to the outpatient clinic with severe pain and limited motion of both shoulder joints for 2 wk without a traumatic event. A computed tomography scan revealed non-displaced acromial base fractures of both shoulders. Considering bilateral involvement, fracture location, and patient’s demand, open reduction and internal fixation (ORIF) using plate for bilateral acromial base fractures were performed. At 2 years after ORIF, the fracture was completely healed, and the patient was satisfied with shoulder status.CONCLUSIONThis report describes an extremely rare case of simultaneous bilateral acromial base fractures after staged RTSA managed successfully by ORIF with a pre-contoured plate designed for distal clavicle fractures. Although acromial fracture after RTSA can be treated conservatively, simultaneous bilateral fractures may warrant surgical intervention as a means of addressing difficulties in activities of daily living.     

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.     

快速康复外科理念在老年全髋关节置换术患者围术期中的应用

目的探讨快速康复外科(fast track surgery,FTS)理念在老年全髋关节置换术(total hip arthroplasty,THA)患者围术期护理中的应用效果。方法按随机数字表法将2009年10月至2011年12月浙江省杭州市第一人民医院骨科收治的拟行THA的69例患者分为对照组36例和观察组33例,对照组采取常规围术期护理,观察组在对照组基础上将FST理念融入围术期护理,采用汉密尔顿焦虑量表(hamilton anxiety scale,HAMA)及疼痛视觉模拟评分法(visual analog scale,VAS)于术前1d及术后7d分别对患者进行测评,同时记录相关的生理指标。结果两组患者术前的HAMA评分、VAS评分、收缩压、舒张压和心率的差异均无统计学意义(均P>0.05);术后的HAMA评分、VAS评分、收缩压、舒张压和心率等均较术前有所下降(P<0.05或P<0.01);术后观察组的HAMA评分、VAS评分及心率较对照组下降更明显(P<0.05或P<0.01),但两组患者收缩压和舒张压的差异无统计学意义(P>0.05)。结论将FST理念应用于老年髋关节置换患者的围术期护理,有助于减轻患者围术期的焦虑程度,缓解其术后疼痛,同时能改善患者的血压和心率等生理指标,值得在临床推广应用。     

人工全髋关节置换术后伤口有效引流方法的研究

目的探究人工全髋关节置换术后伤口有效的引流方法，以提高手术的疗效。方法将80例人工全髋关节置换术患者术后随机分成自然引流组、夹管2h组、间断夹管组和常规负压引流组等4组，对术后伤口引流量、有无伤口感染或异常渗出、血红蛋白值变化、术后输血量等进行观察，并作统计学分析比较。结果各组引流方法对血红蛋白值变化和输血量无明显影响，但间断夹管组在有效引流的同时引流量最少，且该组中需输血的患者数明显少于其他各组。结论人工全髋关节置换术后伤口采用间断夹管法引流可减少失血量和需输血概率，且不增加感染率，是一种较为理想、值得推广的伤口引流方法。     

全膝关节置换术前本体感觉训练对术后的影响

目的：探讨全膝关节置换术前本体感觉训练对术后功能恢复的影响。方法：选取48例严重膝关节骨关节炎且拟行全膝关节置换术的患者,随机分为2组。训练组26例在行全膝关节置换术前6周进行本体感觉训练,包括膝屈曲位、双单腿、睁闭眼等的平板训练,固定自行车练习等。对照组22例未进行本体感觉训练。2组分别在行全膝关节置换术前后6周进行膝关节本体感觉测试（即膝关节主动复位误差角度值）;术后6周进行膝关节功能评分（Hospital for Special Surgery,HSS）;以Biodex 3等速系统测量2组患者双膝关节主动复位误差角度,以作为个体本体感觉能力优劣的代表。结果：术后6周训练组患膝关节主动复位误差角度值明显小于术前及对照组（P〈0.05）。HSS项目中的疼痛、行走功能、肌力及稳定性评分,训练组均明显高于对照组（P〈0.05）。结论：全膝关节置换术前进行本体感觉训练,可以提高患者术后本体感觉及肢体功能。     

全髋置换患者术后康复训练恢复关节功能的效果观察

目的探讨全髋置换患者术后康复训练恢复关节功能的效果。方法30例全髋置换患者,根据髋关节假体类型不同分为骨水泥组和生物型组,分别进行相应的康复治疗程序,比较每位患者术前、术后髋关节功能改善程度。结果30例全髋置换患者经过系统的康复训练后,Harris髋关节功能评分与术前比较经t检验,具有显著性差异,P<0.01,训练后髋关节功能比训练前明显改善;骨水泥组与生物型组经康复训练后,髋关节功能评分分别与训练前比较,均具有显著性差异,P<0.01,两组髋关节功能训练后均比训练前明显改善;训练前、后两组间髋关节功能评分均无显著性差异,P>0.05,说明全髋置换术患者采用不同人工关节不影响康复训练后髋关节功能评分。结论根据髋关节假体类型不同,采用相应的康复训练程序,能明显改善患者髋关节功能。