Reverse Shoulder Arthroplasty for Proximal Humeral Fractures: Is the Bigliani-Flatow Stem Suitable for Tuberosity Fixation and Healing?

Background/Objectives: The aim of the study was to investigate the clinical, functional, and radiographic results of patients affected by three- or four-part proximal humeral fractures treated with reverse total shoulder arthroplasty, to investigate whether a prosthetic stem nonspecifically designed for fractures (i.e., the Bigliani-Flatow stem) promotes tuberosities' healing, and to evaluate the impact of tuberosity fixation and healing on the outcomes. Methods: Patients' data such as gender, age, side and dominancy, comorbidities, complications during or after surgery, and time lapse between trauma and surgery were prospectively collected. The type of fixation of the stem, the thickness and type of liner, and whether the tuberosities were fixed or not were also recorded. The Constant score weighted on the contralateral limb, QuickDASH, Oxford Shoulder Score, and Subjective Shoulder Value were collected. Tuberosities' healing was assessed with X-rays (anteroposterior, Grashey, and axillary views). Results: Overall, 34 patients were included, with an average follow-up of 42 months. Tuberosities were reinserted in 24 cases and their healing rate was 83%. The mean values were the following: a Constant score of 64, Oxford Shoulder Score of 39, Subjective Shoulder Value of 71, and QuickDASH score of 27. There were no significant differences in the scores or range of motion between patients with tuberosities healed, reabsorbed, or not reattached. There was a better external rotation in the group with healed tuberosities and a longer duration of surgery to reattach tuberosities. Conclusions: The treatment of proximal humerus fractures with the Bigliani-Flatow stem is associated with good clinical and functional results. The healing rate of the tuberosities was high and comparable, if not even better, than the mean rates reported for the stems dedicated to fractures of the proximal humerus and was, therefore, also appropriate for this indication.

Os Acromiale in Professional Tennis Players.

BACKGROUND: Os acromiale is a rare condition mostly reported in the literature through case reports, imaging studies, or reports of surgical treatment. This condition is the result of nonunion of growth plates of the acromion during the natural developmental process that occurs between 15 and 25 years of age. Its incidence is low, and few studies are available in the literature on athletes with high functional demands, and particularly on athletes within a specific sport. PURPOSE: To collect epidemiological data and to report the amount of time out of play as well as the type of treatment and its efficiency in professional tennis players. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: We performed a retrospective study using the medical data of athletes within our national tennis league who complained about their shoulder between 2011 and 2016. Nine professional tennis players (mean age, 20 years) with painful shoulders were diagnosed with os acromiale; 3 of them played at an international level, with the other 6 playing at a national level. The diagnosis was confirmed using radiography, including the axillary view, and magnetic resonance imaging (MRI). One female player had associated subacromial bursitis. RESULTS: All cases of os acromiale were classified as involving the mesoacromion, following the Lieberson classification. No patient underwent surgery, and no patient was treated with local or subacromial infiltration. Patients stopped competition and training throughout the rehabilitation period. All patients received medical treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), ice, and physical therapy with a specific rehabilitation program. All athletes returned to their former level of play after a mean of 37 days. No patient suffered from recurrent pain. One patient underwent MRI after 2 years, showing a normal bone signal and complete healing of the acromion. CONCLUSION: Conservative treatment including NSAIDs, rest, ice, and physical therapy allowed for good recovery and return to the former level of play. Surgical treatment is usually not indicated for os acromiale in the professional tennis player.

Bipolar Acromioclavicular Joint Resection.

Acromioclavicular (AC) joint arthropathy remains one of the most common causes of shoulder pain. In the case of AC joint arthropathy resistant to conservative treatment, most authors have recognized distal clavicle resection as the gold-standard treatment. However, some challenges remain to be solved. One is the difficulty in visualization of the superior and posterior part of the distal clavicle from the midlateral portal, causing an incomplete resection of the distal clavicle. This could potentially lead to unresolved pain and therefore surgical failure. We propose a technique for arthroscopic resection of the distal clavicle and the medial portion of the acromion, without any added portal: bipolar AC joint resection. The term "bipolar" is used because both the acromion and the clavicle are resected, without injuring the superior capsule.

Subclinical hypothyroidism and diabetes as risk factors for postoperative stiff shoulder.

PURPOSE: Postoperative stiffness can be a disabling condition after arthroscopic shoulder surgery. The purpose of this study was to analyse the potential contribution of subclinical forms of hypothyroidism and diabetes in the development of postoperative shoulder stiffness. METHODS: A prospective study was conducted on 65 consecutive patients scheduled for arthroscopic subacromial decompression or rotator cuff tear repair. Patients with preoperative stiffness were excluded. Preoperative measurements of free thyroxine, free triiodothyronine, thyroid-stimulating hormone and fasting glycaemia were taken in all patients to detect subclinical forms of diabetes and hypothyroidism. A follow-up was planned at 30, 60, 90 and 180 days after surgery. According to range of motion measurements, postoperative stiffness was classified as severe or moderate at follow-up. Univariate and logistic regression analyses were performed for the assessment of risk factors for stiffness. RESULTS: The overall incidence of postoperative stiffness was 29 % (19/65) in our cohort. Considering only the arthroscopic rotator cuff repairs, this incidence was 23 % (7/31). A new diagnosis of subclinical forms of diabetes or hypothyroidism was made in five cases. All five of these cases developed postoperative stiffness. The logistic regression analysis demonstrated that hypothyroidism was a risk factor for severe stiffness (RR = 25; p = 0.001) and that diabetes was a risk factor for moderate stiffness (RR = 5.7; p = 0.03). CONCLUSION: The postoperative stiffness in the majority of patients can be predicted by a careful analysis of past medical history and by detecting subclinical forms of hypothyroidism and diabetes. LEVEL OF EVIDENCE: Prognostic study, Level II.

Resection arthroplasty after failure of a radial head prosthesis: a case report.

Radial head represents a secondary elbow stabilizer for varus-valgus and postero-lateral stress. In complex fractures, that cannot be synthesized, the presence of associated ligament injuries makes radial head replacement necessary to restore elbow stability. This study evaluates how the elbow responds to a prosthetic removal after a complex injury repair.

Patient specific instrumentation in total knee arthroplasty: a state of the art.

Patient specific instrumentation (PSI) is a modern technique in total knee arthroplasty (TKA) aiming to facilitate the implant of the prosthesis. The customized cutting blocks of the PSI are generated from pre-operative three-dimensional model, using computed tomography (CT) or magnetic resonance imaging (MRI). A correct surgical plan is mandatory for a good surgical implant. The PSI guide takes into account any slight deformities or osteophytes and applies preoperative planning for bone resection, using the pre-determined implant size, position, and rotation. The apparent benefits of this technology are that neutral postoperative alignment is more reproducible, surgical time is decreased, and the entire procedure results more efficient and cost-effective. The use of PSI is indicated when advanced osteoarthritis, severe pain, and limited function/walking ability are present, such as in a standard instrumentation TKA. In addition to that, PSI finds its indication when intra-medullary guides cannot be used. For example, when there is a post-traumatic femoral deformity. Large debates have taken place about this topic during the last years and, at the moment, there is no consensus in literature regarding the accuracy and reliability of PSI as many studies have shown controversial and inconsistent results. Literature does not suggest PSI techniques as a gold standard in TKA, and therefore it cannot be recommended as a standard technique in standard, not complicated primary TKA. Moreover, literature does not underline any improvement in components alignment, surgical time, blood loss or functional outcomes. Nevertheless, many patients who underwent TKA suffered a previous trauma. In case of deformities, like femoral or tibial fractures healed with a malalignment, preoperative planning may result difficult, and some intra-operative technical difficulties can occur, such as the use of intra-medullar rod. In these selected cases, PSIs may be very useful to avoid errors in alignment and planning.

Predominance of the critical shoulder angle in the pathogenesis of degenerative diseases of the shoulder.

HYPOTHESIS: The critical shoulder angle (CSA) could be responsible for cuff tears and concentric osteoarthritis. We aimed to assess this association when potential confounding factors were excluded and to test the hypothesis that more extreme CSAs are associated with larger tears and more severe osteoarthritis. METHODS: The study cohort was composed of 200 patients with primary concentric osteoarthritis (40 patients), isolated supraspinatus tears (40 patients), cuff tears involving at least the supraspinatus and infraspinatus (40 patients), and no history of shoulder problems (control group, 80 patients). Data pertaining to CSA, age, gender, dominant arm, smoking, hypertension, body mass index, and type of work were collected. RESULTS: The average CSA angle was 34° ± 3° in the control group, 36° ± 3° with supraspinatus tears, 40° ± 3.5° with supraspinatus and infraspinatus tears, and 28° ± 2° with concentric osteoarthritis. Patients with large cuff tears had a significantly greater CSA compared with those with isolated supraspinatus tears (P = .03). The CSA (odds, 1.7; confidence interval [CI], 1.4-2.0) was the most relevant risk factor for cuff tears. The Spearman coefficient between CSA and grade of eccentric osteoarthritis was 0.4 (P = .01). The 2 significant risk factors for concentric osteoarthritis were the CSA (odds, 0.5; CI 0.4-0.6) and age (odds, 1.1; CI, 1.0-1.2). CONCLUSION: Larger CSAs are associated with increased risk of symptomatic cuff tears, larger cuff tears, and the severity of eccentric osteoarthritis. Smaller angles increased the risk and severity of concentric symptomatic osteoarthritis. These associations remained significant even after removal of some of the potentially confounding variables.