Short Stems and Stemless Shoulder Arthroplasty: Current Concepts Review.

Historically, the shoulder arthroplasty humeral component has been designed for the management of infections, tumours and fractures. In all these cases the stem was needed as a scaffold. Original humeral components were not developed for use in shoulder arthritis, so these designs and derivates had a long stem. The newest humeral implants innovations consist in shortening of the implant, or even removing the whole stem, to rely on stemless fixation at the level of the metaphysis. This implies the advantages of preserved bone stock, less stress shielding, eliminating the diaphyseal stress riser, easier implant removal at revision, and humeral component placement independent from the humeral diaphyseal axis. Nowadays, surgeons try to balance the need for a stable fixation of the humeral component with the potential need for revision surgery. Complications of revision shoulder arthroplasty are related to the need for removing a well-fixed humeral stem, the length of the procedure, and the need to treat severe bone loss.

Accelerated rehabilitation following reverse total shoulder arthroplasty.

BACKGROUND: Postoperative rehabilitation is considered essential and indeed routine practice following rTSA. However, the optimal approach to postoperative rehabilitation is unknown, based on protocols for anatomic TSA, and published literature is sparse, as is the quantity and quality of research evidence. The aim of this study is to outline the accelerated rehabilitation protocol (with immediate activity and no immobilization at all) following reverse total shoulder arthroplasty (rTSA) and assess its safety and effectiveness compared to the more conservative rehabilitation protocols of immobilization in a sling for 6 weeks and for 3 weeks. MATERIALS AND METHODS: Between July 2005 and October 2017, a total of 357 consecutive rTSA in 320 patients underwent a primary rTSA and were included in the study. Patients were divided into 3 groups depending on rehabilitation protocol (6 and 3 weeks' postoperative immobilization, respectively, for groups 1 and 2, and no immobilization for group 3). Patients were assessed preoperatively and reviewed at 3 weeks, 3, 6, and 12 months, and yearly thereafter postoperatively. Constant score (CS), Subjective Shoulder Value (SSV), patient satisfaction, and pain scores were used at each appointment and patients assessed both clinically and radiographically. RESULTS: Mean age at surgery was 76 years (range 40-93). At 1-year follow-up, the CS improved from 16.6 (adjusted 23.9) to 63.2 (adjusted 91.5) in group 1 (n = 114), from 21.5 (adjusted 30.7) to 67.7 (adjusted 98.4) in group 2 (n = 125), and from 22.6 (adjusted 31.3) to 66.6 (adjusted 94.9) in group 3 (n = 118). Pain score improved from 3.1/15 preoperatively to 12.5/15 postoperatively in group 1, from 3.5/15 to 13/15 in group 2, and from 3.7/15 to 12.5/15 in group 3. SSV improved to 8.5/10, 8.6/10, and 8.1/10 for groups 1, 2, and 3, respectively. Mean range of motion (ROM) improved to 142° elevation and 131° abduction in group 1, 153° elevation and 144° abduction in group 2, and 149° elevation and 146° abduction in group 3. No statistically significance differences were observed in CS, SSV, patient satisfaction, pain, and ROM between the 3 groups. Less postoperative complications were observed in group 3 (No immobilization). CONCLUSION: Accelerated rehabilitation regime post rTSA without immobilization is safe and lead to reliable good clinical results and quick return to function. This study confirms noninferiority of the accelerated rehabilitation regime with fewer postoperative complications related to falls. Accelerated rehabilitation regime post rTSA have further psychological and emotional advantage to the patient, with earlier return to normal function and regaining independence. We recommend the accelerated rehabilitation regime without immobilization following rTSA.

Software simulations of changing offsets and thus soft tissue tension when revising anatomic to reverse total shoulder arthroplasty in convertible platform systems.

BACKGROUND: Revision shoulder arthroplasty may involve the need to remove a well-fixed humeral stem. To avoid this, convertible platform systems have been introduced. The biomechanics of reverse total shoulder arthroplasty (rTSA) differs from anatomic shoulder arthroplasty (aTSA). The different humeral osteotomy and soft tissue tension may jeopardize the optimal results of the converted rTSA. The aim was to evaluate the radiographic parameters of soft tissue distraction when converting an aTSA to rTSA in a platform system and assess the capability of conversion without "over-stuffing" the shoulder in the "best-case scenario". METHODS: Radiographic analysis of soft tissue distraction parameters: difference in acromio-humeral distance, difference in lateral humeral offset and difference in latero-inferior displacement were evaluated in aTSA and in the converted rTSA in six different implants. Image analysing software was used on 10 non-deformed osteoarthritic shoulder X-rays to simulate conversion. RESULTS: The greatest increase in arm length was found for Tornier Ascend Flex (26.8 ± 3.6 mm) while the smallest increase was observed with Lima SMR (19.3 ± 4 mm). The humerus remained most lateralized with the Zimmer Anatomical/Inverse ( - 1.4 ± 2.9 mm) while Lima SMR ( - 15.8 ± 2.7 mm) was more medialized. The greatest increase in latero-inferior distance was found in the onlay systems. A group analysis of onlay rTSA showed an increase of 46% in arm length (p < 0.0001), 83% larger humeral offset (p < 0.0001) and 144% increase in latero-inferior distraction (p < 0.0001) when compared to inlay rTSA. CONCLUSION: The conversion of aTSA to rTSA using a convertible platform system may lead to significant increase in radiographic parameters corresponding to soft tissue tension. This may alter the biomechanics, restrict the convertibility or jeopardize the optimal clinical outcome of rTSA even in the best-case scenario.

Focal inlay resurfacing for full-thickness chondral defects of the femoral medial condyle may delay the progression to varus deformity.

INTRODUCTION: Full-thickness chondral defects at the knee joint predispose to the beginning of a degenerative process which final consequence is the compartment collapse and finally the deviation to varus, because the cartilage of the medial femoral condyle is the most frequently affected area. Likewise, people with these chondral defects are more likely to develop tricompartmental osteoarthritis, reason why early surgical management should be the treatment of choice. The aim of this study was to compare the pre- and post-operative lower limb alignment (mechanical axis), in cases of full-thickness chondral defects of the femoral medial condyle that have been managed by means of a prosthetic focal inlay resurfacing, at a minimum follow-up of five years. METHODS: A retrospective study of patients treated for chondral defects in the medial femoral condyle was performed. The inclusion criteria were patients who had undergone a focal inlay resurfacing and minimum follow-up of 5 years. Patients that required a concomitant valguizing tibial osteotomy were finally excluded. The follow-up analysis was performed by means of radiological examinations performed prior to surgery and at the last follow-up visit. The mean limb mechanical axis of the operated knees was calculated both pre- and post-operatively, and comparisons between these two settings were performed. RESULTS: Ten patients were included: eight men and two women. The mean age at the time of surgery was 55 (40-65) years. The mean follow-up was 9 years (range 5-15). The mean limb mechanical axis was 1.33 ± 4.16 in the pre-operative setting and 2.40 ± 5.50 in the post-operative setting (p = 0.441). CONCLUSION: In the setting of small to moderate size, unique femoral medial condyle full-thickness chondral lesions, filling the defect with an inlay prosthetic resurfacing may protect against the progression to varus deformity. LEVEL OF EVIDENCE: Therapeutic case series, Level IV.

Is there a significant decrease in the femoral cortical bone around Furlong® stems after 18 years of follow-up?

INTRODUCTION: In the context of total hip arthroplasty (THA), there are several reasons that have motivated the development of short stems. It has been postulated that short stems allow a better conservation of the bone stock if compared to conventional stems. As far as we have knowledge, the quantitative loss of diaphyseal bone stock in patients with standard femoral stems has not been fully described. The aim of this study was to provide evidences about the thickness of the cortical bone at the diaphysis in patients who have undergone unilateral THA with Furlong® stems with a minimum follow-up of 18 years. PATIENTS AND METHODS: A retrospective study of patients who underwent THA in a single hospital was performed. The inclusion criteria were patients who had undergone a non-cemented elective THA with a Furlong® stem, minimum follow-up of 18 years, and contralateral femur and hip without history of previous surgical procedures. The follow-up analysis was performed by means of radiological examinations performed at the last follow-up visit. Data related to the sex, age at surgery and adverse events registered during the follow-up were gathered. The cortical thickness index (CTI) and cortical thickness (CT) assessed at the last follow-up visit in anteroposterior pelvic X-rays were analyzed, both in the operated hip and in the non-operated hip (which was used as control). Calibration of the measurements was done by means of using the circumference of the head of the THA. RESULTS: The total number of patients who met the inclusion criteria was 22. There were 14 women and eight men. There were 12 left hips. The mean age at the time of surgery was 59.32 ± 6.83 (range 50-70) years. The mean follow-up was 20.86 ± 1.90 (range 18-24) years. The CTI was found to be 11.93% greater in the non-operated hips. The CT measured at 3 cm and 6 cm from lesser trochanter, and at 9 cm from the greater trochanter, was found to be 21.64%, 15.33% and 18.73% greater in the non-operated hips, respectively. CONCLUSION: After a minimum of 18 years from the implantation of a Furlong® stem, the bone density that surrounds the implant seems to involve a cortical bone ten percent less thick than the cortical bone of the non-operated contralateral side. With this stem, the cortical zones with less CT seem to be the lateral cortex at 9 cm from the greater trochanter, and the medial cortex at 3 and 6 cm from the lesser trochanter. LEVEL OF EVIDENCE: III, retrospective case-control study.

Labral reconstruction with tendon allograft: histological findings show revascularization at 8 weeks from implantation.

This description shows the histological findings of a peroneus brevis tendon allograft used for labral reconstruction, implanted 8 weeks before being retrieved due to a postoperative complication unrelated to the graft. As far as we have knowledge this is the first description about revascularization of an allograft used for hip labral reconstruction. The histological report of the removed peroneus brevis tendon allograft shows evidence of vascular ingrowth represented by small vessels with a thin muscular wall in all layers of the graft and cellular migration mainly represented by mature fibroblasts.

Survival of hydroxyapatite-coated cups: acetabular screws involve a lower rate of revision surgery due to aseptic loosening.

BACKGROUND: It is believed that the path of acetabular screws may represent a shuttle between hydroxyapatite (HA) particles and the liner. The aim was to assess the relationship between acetabular screws and revision surgery for aseptic loosening in total hip arthroplasties (THAs). MATERIAL AND METHODS: A retrospective multicentric study was performed. Patients older than 18 years and patients who underwent THA with both the stem and cup HA-coated were included. The rate of revision-surgery considering only aseptic loosening was calculated. The proportion of cases in which acetabular screws were used was registered, as well as the proportion of cups that showed osteolysis. The statistical relationship between acetabular screws and osteolysis, as well as acetabular screws and revision-surgery for aseptic loosening were assessed. RESULTS: There were 749 cases. Mean age 62.1 (45-84) years. Mean follow-up 14.19 (8.9-16.7) years. Revision surgery was performed in 12.8% (96/749) of the cups. 73.95% (71/96) of the revised cups showed aseptic loosening. The overall 15-year survival of the cups considering only aseptic loosening was 84.4%. Acetabular screws were used in 47.5% (356/749) of the cups. Acetabular screws were used in 40.44% (55/136) of the cups that showed osteolysis. The use of acetabular screws was associated with less osteolysis (p = 0.006). Acetabular screws were used in 35.21% (25/71) of the cups that were revised for aseptic loosening. The use of acetabular screws was associated with a lower rate of revision surgery (p = 0.020). CONCLUSIONS: In THA with the stem and cup HA-coated, the use of acetabular screws is associated with a lower rate of revision surgery.

The "Purse String" Procedure for Recurrent Anterior Glenohumeral Instability: A Simple Technique to Achieve Bankart Repair, Capsular Shift, and a Good Labral Bumper.

Failure of arthroscopic techniques in cases of recurrent anterior glenohumeral instability may result from inadequate treatment of capsular injury. The use of few anchors has been cited as a cause of failure in arthroscopic stabilization techniques. This applies to the use of the suture anchors as spot-welding points in conventional techniques. It has been shown that horizontal mattress suture techniques restore better labral height and anatomy than simple suture techniques in the repair of acute Bankart lesions. Horizontal mattress repairs, like the one achieved with the "purse-string" technique, pushes the labrum toward the humeral side of the joint, thus providing a buttress to the glenohumeral joint. We present the purse-string technique, which involves the use of only 1 suture anchor located at the 4-o'clock position. Sutures are passed through the labrum and capsule from south to north, thus allowing the incorporation of more capsular tissue involved in the raising of the anterior labral bumper. One suture anchor at the 4-o'clock position is used to ensure a purse-string effect, with tightening of the capsule in the inferosuperior plane and repair of the Bankart lesion. The repair achieved is 3-fold: Bankart repair, south-to-north capsular shift, and creation of an anterior bumper.

The "Parachute" Technique: A Simple and Effective Single-Row Procedure to Achieve an Increased Contact Area Between the Cuff-Tendon and Its Footprint.

Many techniques of arthroscopic rotator cuff repair have been described. No significant differences in clinical outcomes or rerupture rates have been observed when comparing single-row with double-row methods. Not all single- and double-row repairs are the same. The details of the technique used are crucial. It has been shown that the suture-tendon interface is the weakest point of the reconstruction. Therefore, the biomechanical properties of rotator cuff repairs might be influenced more by the suture configuration than by the number of anchors or by the number of rows involved. Techniques that secure less amount of tendon over a smaller area of the healing zone might be expected to have higher failure rates. The way the sutures of the "parachute technique" are configured represents a quadruple mattress that increases the contact and pressure between the tendon and its footprint and increases the primary load to failure of the repair. We present a simple and effective single-row technique that involves the biomechanical and biological advantages related to the increased contact area and pressure between the cuff and its footprint.

Reconstruction of Massive Posterior Nonrepairable Acetabular Labral Tears With Peroneus Brevis Tendon Allograft: Arthroscopy-Assisted Mini-Open Approach.

Many of the described labral-reconstruction procedures are purely arthroscopic. This approach only allows segmentary reconstructions. For more extensive reconstructions, surgical dislocation of the hip still represents the more suitable approach. We present an arthroscopy-assisted procedure combined with an anterior mini-open approach, which could be considered for reconstruction of nonrepairable labral lesions located in the posterior aspect of the acetabulum and massive reconstructions in cases of global-pincer femoroacetabular impingement and protrusio acetabuli. Our technique saves the morbidity that might be related to the surgical dislocation of the hip and incorporates a peroneus brevis tendon allograft. This option may restore the anatomy and labral function without morbidity at the donor site, as well as remove graft length restrictions during massive reconstructions.

Reconstruction of nonrepairable acetabular labral tears with allografts: mid-term results.

BACKGROUND: Many labral tears are nonrepairable. For these cases, labral reconstruction procedures may be considered in order to restore the joint fluid seal and prolong hip longevity. AIMS: The aim of this study was to describe the clinical and functional outcomes of a series of cases with nonrepairable labral tears that underwent labral reconstruction with tendon allografts. The hypothesis was that labral reconstruction would provide good clinical outcomes. METHOD: A cohort of 20 patients with nonrepairable labral tears, which underwent to labral grafting mainly by means of arthroscopic assisted anterior mini-open approach, were included in this study. The study period was comprised between July 2008 and September 2013. RESULTS: DCS-score resulted in 17 satisfactory results, whereas Nonarthritic Hip Score (NAHS) resulted in mean improvement of 39 points. 1 retrieved allograft demonstrated 8 weeks after implantation new whole revascularisation. CONCLUSIONS: We concluded that labral reconstruction with tendon allograft provides relief of painful symptoms, and represents a reliable alternative for patients with nonrepairable labral tears that are not yet candidates for a joint replacement procedure.

Biomechanical analysis of acromioclavicular joint dislocation repair using coracoclavicular suspension devices in two different configurations.

BACKGROUND: The best treatment option for some acromioclavicular (AC) joint dislocations is controversial. For this reason, the aim of this study was to evaluate the vertical biomechanical behavior of two techniques for the anatomic repair of coracoclavicular (CC) ligaments after an AC injury. MATERIALS AND METHODS: Eighteen human cadaveric shoulders in which repair using a coracoclavicular suspension device was initiated after injury to the acromioclavicular joint were included in the study. Three groups were formed; group I (n = 6): control; group II (n = 6): repair with a double tunnel in the clavicle and in the coracoid (with two CC suspension devices); group III (n = 6): repair in a "V" configuration with two tunnels in the clavicle and one in the coracoid (with one CC suspension device). The biomechanical study was performed with a universal testing machine (Electro Puls 3000, Instron, Boulder, MA, USA), with the clamping jaws set in a vertical position. The force required for acromioclavicular reconstruction system failure was analyzed for each cadaveric piece. RESULTS: Group I reached a maximum force to failure of 635.59 N (mean 444.0 N). The corresponding force was 939.37 N (mean 495.6 N) for group II and 533.11 N (mean 343.9 N) for group III. A comparison of the three groups did not find any significant difference despite the loss of resistance presented by group III. CONCLUSION: Anatomic repair of coracoclavicular ligaments with a double system (double tunnel in the clavicle and in the coracoid) permits vertical translation that is more like that of the acromioclavicular joint. Acromioclavicular repair in a "V" configuration does not seem to be biomechanically sufficient.

Delayed rupture of all finger flexor tendons (excluding thumb) following nonoperative treatment of Colles' fracture: A case report and literature review.

AIMS: We report a case of delayed all digital flexor tendon ruptures after nonoperative management of distal radius fracture. METHODS: An 84-year-old woman, noted loss of flexion of your fingers. She had a history of Colles' fracture 40 years before, which had been left untreated. Darrach procedure were carried and a tendon transfers for the flexor tendon ruptures. RESULTS: Despite attempts of early active mobilisation, a poor operative outcome was observed. CONCLUSION: Tendon rupture can occur several months or years after the injury, and prompt recognition and treatment can minimize disability.

Primary lipoma arborescens of the knee may involve the development of early osteoarthritis if prompt synovectomy is not performed.

BACKGROUND: Primary lipoma arborescens (LA) is a rare, benign intra-articular hyperplastic tumor that has been associated with osteoarthritis (OA). The aim of this study was to determine whether prompt synovectomy could avoid progressive joint degeneration in cases of primary LA of the knee. MATERIALS AND METHODS: A review of currently available literature about the disease was carried out. The clinical, histological and radiological records of a series of nine knees with primary LA diagnosed and treated between 2002 and 2012 were retrospectively reviewed. Eight of the knees had histological confirmation of LA and none had evidence of condropathy on the initial magnetic resonance image or degenerative changes at the initial radiographic examination. RESULTS: At the final follow-up no evidence of OA was found in the three knees that underwent synovectomy when symptoms did not last more than 1 year. The five knees in which synovectomy was delayed developed progressive joint degeneration. CONCLUSION: In this series, primary LA of the knee involved the development of early osteoarthritis when prompt synovectomy was not performed. Timely synovectomy is strongly recommended, if not mandatory. LEVEL OF EVIDENCE: IV.

Anatomic reconstruction of chronic coracoclavicular ligament tears: arthroscopic-assisted approach with nonrigid mechanical fixation and graft augmentation.

It has recently been suggested that all coracoclavicular ligament tears could be considered for surgery because nonoperative management might result in irreversible changes in the scapular position that could lead to muscle kinematic alterations that would perturb the shoulder girdle function and result in pain. In this technical note we describe an anatomic technique for the treatment of chronic coracoclavicular ligament tears that overcomes the issues related to open surgery, metal hardware, the inferior resistance to secondary displacement of only grafting and nonanatomic techniques, and the saw effect and anterior loop translation that can be seen in systems that surround the base of the coracoid. Our technique incorporates the use of a tendon graft and a nonrigid mechanical stabilizer that protects the graft from stretching during the process of healing and integration into bone, guaranteeing the maintenance of a reduced acromioclavicular joint.

Silicone proximal interphalangeal joint arthroplasty for primary osteoarthritis using a volar approach.

PURPOSE: To evaluate the short-term clinical and radiographic outcome of a silicone proximal interphalangeal (PIP) joint implant using a volar approach in patients with primary osteoarthritis. METHODS: We retrospectively reviewed 36 proximal PIP joints that were replaced with Avanta silicone implants in 26 patients. Inclusion criteria were diagnosis of primary osteoarthrtitis of the PIP joint and failure to respond to conservative treatment. Clinical asessment included range of motion, patient satisfaction, and pain scores. The Quick-Disabilities of the Arm, Shoulder, and Hand questionnaire was administered at final follow-up. Radiographs were reviewed for alignment and implant fracture. Complications were also recorded. RESULTS: After an average follow-up of 18 months (range, 12-60 mo), pain relief was markedly reduced in all patients, decreasing from a mean score of 7.2 preoperatively to 0.4 postoperatively. The arc of active motion of the PIP joint improved from 33° to 72°. Satisfaction averaged 4.8 on a 5-point Likert scale, and all patients stated they would repeat the surgery. The median final average Quick-Disabilities of the Arm, Shoulder, and Hand score was 7 (range, 4-12). Radiograph review showed 2 implant fractures at 1 and 2 years after surgery, respectively, but without clinical changes. The average deformity in the coronal plane changed from 12° (range, 8° to 18°) preoperatively to 4° (range, 3° to 8°) postoperatively, whereas the average flexion contracture changed from 18° (range, 10° to 30°) to 0° (all patients achieved full active extension). No other complications were observed. No revision surgery has been needed to date. CONCLUSIONS: The volar approach to PIP joint silicone arthroplasty offers the advantages of maintaining the integrity of the extensor mechanism, providing pain relief, and improving postoperative range of motion with minimal complications. However, further research is needed to determine the long-term efficacy of this implant. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.