Revising Failed Reverse Total Shoulder Arthroplasty: Comprehensive Techniques for Precise Explantation of Well-Fixed Implants.

Background: With the increased utilization of reverse total shoulder arthroplasty (RTSA), there has been a corresponding increase in the incidence of and demand for revision RTSA3. In cases in which the patient has undergone multiple previous surgeries and presents with well-fixed shoulder implants, even the most experienced shoulder surgeon can be overwhelmed and frustrated. Having a simple and reproducible treatment algorithm to plan and execute a successful revision surgery will ease the anxiety of a revision operation and avoid future additional revisions. The extraction techniques described here strive to preserve the humeral and glenoid anatomy, hopefully facilitating the reimplantation steps to follow. Description: The main principles of implant removal include several consistent, simple steps. In order to revise a well-fixed humeral implant, (1) identify the old implants; (2) create a preoperative plan that systematically evaluates the glenoid and humeral deficiencies; (3) prepare consistent surgical tools, such as an oscillating saw, osteotomes, and/or a tamp; (4) follow the deltoid; (5) dissect the soft tissue with a sponge; (6) dissect the bone with use of an osteotome; and (7) remove the humeral stem in rotation. In cases in which there is also a well-fixed glenoid implant, the surgical procedure will require additional steps, including (8) exposure of the anteroinferior glenoid, (9) disengagement of the glenosphere, and (10) removal of the glenoid baseplate in rotation. Alternatives: Alternatives to revision RTSA include nonoperative treatment, implant retention with conversion of modular components, extensile revision surgical techniques, and/or mechanical implant removal. With the advent of modular humeral and glenoid components, surgeons may choose to change the implant components instead of removing the entire humeral and glenoid implants; however, repeat complications may occur if the previous implant or implant position was not completely revised. When confronted with a tough humeral explantation, an extensile surgical approach involves creating a cortical window or humeral osteotomy to expose the humeral implant. This approach can compromise the humeral shaft integrity, leading to alternative and less ideal reconstruction implant choices, the use of cerclage wires, and/or the use of a strut graft, all of which may complicate postoperative mobilization. If glenoid implant removal is necessary, the glenosphere is removed first, followed by the underlying baseplate component(s). If the glenosphere is stuck or if screws are cold-welded, the use of a conventional mechanical extraction technique with a burr or diamond saw may be required; however, this may lead to additional metal debris and intraoperative sparks. Rationale: Revision RTSA can lead to high complication rates, ranging from 12% to 70%2, which will often require additional revision surgeries4. The first steps to all revision RTSA procedures include careful surgical exposure and component explantation. A simplified approach to expose the humerus and glenoid, coupled with a systematic and atraumatic approach to remove the implants without inadvertent injuries, will prevent surgical complications and the need for re-revision. The proposed comprehensive technique hopefully will allow precise removal of the humeral and glenoid implants while also preserving the remnant humerus or glenoid for future reconstruction. Expected Outcomes: Few studies have evaluated postoperative patient outcomes in revision RTSA. Chalmers et al. performed a meta-analysis and found that patients were able to achieve a mean elevation of 106°, a mean American Shoulder and Elbow Surgeons score of 63, and a mean Single Assessment Numeric Evaluation score of 522. Boileau showed very similar outcomes, with a mean elevation of 107° and a mean adjusted Constant score of 621. These outcomes are slightly inferior to those of primary RTSA, but patients remain satisfied with their improvement from their preoperative function. Important Tips: Preoperative preparation will reduce intraoperative reparation. Know the existing implant and the unique features of its design, understand the patient anatomy including bone defects, and anticipate all of the potential tools that may be needed.Know your anatomy. The anteromedial deltoid edge will help you identify the scarred-in humeral shaft.Da Vinci said that simplicity is the ultimate sophistication. Some of the most common surgical tools and instruments can be more effective than custom-designed ones.The implant should be removed in rotation.There are some company-specific explantation instruments that can be very helpful. Give the appropriate ones a try, but be prepared to consider alternative solutions. Acronyms and Abbreviations: RTSA = reverse total shoulder arthroplastyCT = computed tomographyFE = forward elevation.

Nonunion of distal humeral fractures: Current concepts.

The incidence of complex articular fractures of the distal humeral in adults has increased and will be growing in the future due to the greater incidence of high energy trauma and to the higher percentage of elderly population. Successful treatment is challenging for the needed balance between a stability of often comminuted fracture and early motion. Nonunion is a common complication after distal humerus fractures that is influenced by a variety of factors such as biology, in particular the blood supply of the metaphysis, the non-anatomical reduction of the fracture, the methods of fixation, and mechanical failure. These can involve the intra-articular or extra-articular areas. Clinical presentation may be mainly with a flail elbow in extra-articular nonunion or mainly with disfunction and stiffness for an intra-articular nonunion. However, the symptoms will depend on the degree of articular surfaces damage and the main localization of nonunion in the intra- and extra-articular region. The surgical treatment is usually required, being the non-operative treatment with a brace a reasonable option just for low-demand patients and with a high risk of complications. Despite a limited range of motion regained, the union rate achieved with internal fixation and bone grafting is substantially high.

Return to sport after arthroscopic xenograft bone block associated with Bankart repair and subscapularis augmentation in competitive contact athletes with recurrent anterior shoulder instability.

BACKGROUND: Open Bankart repair and Latarjet stabilization are two of surgical procedures used in the treatment of shoulder instability in contact athletes. The aim of this study is to evaluate the outcomes of bone block arthroscopic procedure, performed with xenograft, in combination with Bankart repair and selective subscapularis augmentation (ASA) for contact athletes with recurrent anterior shoulder instability. METHODS: We retrospectively assessed contact athletes who underwent arthroscopic bone block with xenograft and Bankart repair with selective augmentation of subscapularis for recurrent anterior shoulder instability between January 2017 and December 2021. Shoulders with posterior instability or multidirectional instability were excluded. Recurrence, complications, return to sport, and functional scores (Rowe score, WOSI score, ASES score) were assessed. A CT scan at 2-year follow-up was performed to assess the status of Bone block integration, its displacement and restoration of glenoid surface. RESULTS: 16 patients were included in the study with a mean age of 24. None of the patients treated with arthroscopic bone block and ASA presented new dislocation episodes. An increase in preoperative scores was observed at the last follow-up, in particular the ASES, Rowe, and WOSI scores increased from 69±7, 31±9 , 1235±46 respectively to 96.1±3.2, 94±6, 119±51. All athletes returned to sporting activity at or near the same level as pre-surgery. The glenoid bone surface increase from 83% to 116% at last follow-up. CONCLUSION: Bone block treatment with Xenograft combined with Bankart repair and ASA procedures has been shown to be effective in treating instability in contact athletes with significant glenoid deficit. All athletes returned to athletic activity at a level similar to the pre-intervention period.

Comparison Of Early And Late Aseptic Baseplate Failure In Primary Reverse Shoulder Arthroplasty With And Without Structural Glenoid Autograft.

INTRODUCTION: Early reverse total shoulder arthroplasty (RTSA) designs demonstrated high glenoid baseplate complication and revision rates. While contemporary designs have reduced the incidence of glenoid baseplate failures, there are reports of elevated failure risks in RTSA with glenoid bone grafting within the first 2 years. This study aims to evaluate the incidence and etiology of aseptic glenoid baseplate failure with a contemporary central screw baseplate. The null hypothesis is that majority of the baseplate failure occurs within the first 2 years and use of glenoid bone grafting does not lead to higher risk of baseplate failure. METHODS: In 2014 - 2019, 753 consecutive patients who underwent primary RSA using the same inlay press-fit humeral stem and monoblock central screw baseplate were retrospectively reviewed. Fracture and septic arthropathy cases were excluded. All patients underwent preoperative radiographic and computed tomography evaluation. If there was significant glenoid erosion (Walch A2, B2, B3, C1, C2, E2, E3, and/or E4 variants), patient-specific structural glenoid bone grafting was performed. All patients underwent standardized radiographic follow-up and failure was strictly defined as any hardware breakage and/or shift in glenoid baseplate position. Failures were defined as "early" if occurring within 2 years and "late" if occurring greater than 2 years after surgery. Comparative analysis was performed to evaluate demographics, glenoid graft use, and graft union rates between the cohorts. RESULTS: There were 23 patients with baseplate failures (23/753, 3.0%) at mean of 23 months. Twenty-two failures (96%) occurred in patients who received structural glenoid bone grafting. Only 1 failure (0.2%) occurred when bone grafting was not indicated (p<0.001). The most common failure pattern was associated with B2 glenoid (16/23, 70%). There were 5 (22%) early failures and 18 (78%) late failures. There were no differences in any patient demographic characteristics between cohorts. All 5 early failures had graft nonunion and 4/5 occurred without trauma. In the 18 late failures , 9/18 (50%) occurred without trauma (p=0.135). Seventeen of these patients had glenoid grafting, of which 9/17 (53%) had graft nonunion. CONCLUSIONS: Contemporary RTSA glenoid baseplate designs have an acceptably low incidence of failure. However, the addition of structural bone graft to correct glenoid wear leads to higher aseptic baseplate failure rate. The majority of these patients suffer failure after the 2-year postoperative mark, highlighting the necessity of longer follow-up. Further analysis is necessary to quantify glenoid characteristics (severity of glenoid erosion, critical size of graft) associated with failure.

Unexpected positive cultures of humeral head detected with dithiothreitol in primary shoulder arthroplasty.

BACKGROUND: Unexpected positive cultures (UPCs) are frequently observed in primary shoulder arthroplasty, and its clinical significance has not yet been well defined. This study aimed to evaluate the UPCs in humeral head in primary shoulder replacement and to understand if UPCs increase in patients with risk factors for contamination (previous surgery or infiltrations). METHODS: Patients undergoing total shoulder replacement were enrolled in this prospective observational study. To reduce the risk of humeral head contamination, all known procedures to reduce Cutibacterium acnes burden of the skin were implemented. Patients were divided into 2 groups, namely, patients who had undergone previous rotator cuff repair or infiltration and patients with no risk factors for contamination. All the humeral heads harvested were treated with dl-dithiothreitol, in a specific device (MicroDTTect), to increase the sensitivity of the cultures for bacterial identification. The cultures were analyzed for aerobic and anaerobic bacteria for up to 14 days. RESULTS: The UPCs' positivity rate of the 80 patients in the study was 19% (15 patients). The positivity rates for UPCs in the group with and without risk factors were 30% (12 patients) and 7.5% (3 patients), respectively. The rate of positive culture was higher in men (87%) than in women (13%). The observed positivity was due to C acnes and Peptoniphilus asaccharolyticus, both slow-growing anaerobes. CONCLUSIONS: Patients with previous surgery or infiltrations had a 4-fold higher rate of positivity for UPCs compared with patients without previous risk factors. The higher percentage of positivity in patients with risk factors could be related to changes in the joint microenvironment after shoulder procedures. We do not know whether the presence of UPCs could be associated with the development of periprosthetic infections at longer follow-up.

Malunion of distal humeral fractures: Current concepts.

The incidence of complex articular fractures of the distal humeral in adults has increased and will be growing in the future due to the greater incidence of high-energy trauma and to the higher percentage of the elderly population. Successful treatment is challenging for the needed balance between the stability of often comminuted fractures and early motion. Malunion is a common complication after distal humerus fractures that is influenced by a variety of factors, such as biology, particularly the blood supply of the metaphysis, the nonanatomical reduction of the fracture, the methods of fixation, and mechanical failure. These can involve the intra-articular or extra-articular areas. The clinical presentation may be mainly with pain and instability as for the cubitus varus, or with disfunction and stiffness as for an intra-articular malunion. However, the symptoms will depend on the degree of articular surfaces damage and the degree of deformities in specific planes. The surgical treatment can be challenging, varying from supracondylar osteotomies and re-contouring arthroplasty for extra-articular deformities to interposition arthroplasty, and elbow replacement for intra-articular deformities.

Anatomical total shoulder arthroplasty revision to reverse shoulder arthroplasty using convertible glenoid: a systematic review of clinical and radiological outcomes.

PURPOSE: The aim of the present systematic review is to collect all the available evidence regarding the clinical and radiological results of revision to reverse shoulder arthroplasty (RSA) of modular anatomic shoulder prostheses (TSA) using a convertible metal-backed glenoid (MBG). METHODS: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies investigating revision of TSA to RSA utilizing a convertible MBG and reporting clinical and radiological outcomes were identified. RESULTS: A total of five studies on the use of convertible modular glenoid component in the setting of TSA revision to RSA were finally included in the present systematic review. A total of 60 procedures were reported. Mean operative times was 65 min. Intraoperative complications included 3 cases of glenoid loosening. Only one case of dislocation was reported as postoperative complication. At mean follow-up of 32.3 months post-revision, no glenoid loosening was reported, VAS score decreased from 7.7 to 1.5, Constant Score increased from 24.8 to 57.6. CONCLUSIONS: Revision to RSA after failed TSA using a convertible modular glenoid component was associated with a low rate of intraoperative and postoperative complications, low surgical time and led to good results in term of pain relieve and functional outcomes. Given the complexity and risk associated with revision of anatomic shoulder prosthesis having a convertible glenoid may help to simplify the procedure and improve clinical results.

The internal joint stabilizer for elbow instability: current concepts.

The management of residual elbow instability is challenging in both acute and chronic injuries. Among the available devices, the hinged external fixator provides an additional joint stabilization while allowing an early motion, but it is clumsy and associated to high rate of pin track complications. To address these issues, an internal joint stabilizer (IJS) has been recently developed. An easier recreation of the axis of rotation coupled to the reduced lever arm of the hinge is the root of the consistent and satisfactory results thus far observed. In addition, the device is more comfortable for the patients being an internal stabilizer. Nonetheless, a second surgery for the device removal is necessary, of which the timing is still not standardized. This current concepts paper describes literature regarding outcomes of the IJS focusing on the rate of maintained radiographic joint reduction, the resultant range of motion, and the associated complication profile.

Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy.

INTRODUCTION: Rotator cuff tear (RCT) is a painful, progressive condition resulting from damage to the rotator cuff tendons and is the leading cause of shoulder-related disability. Surgical repair of rotator cuff is an established standard of care (SOC); however, failure of the procedure can occur. In this context, the use of collagen-based bioinductive implant REGENETEN showed long-term improvements in clinical scores. The aim of the study was to assess the cost-effectiveness of REGENETEN combined with SOC (SOC + REGENETEN) compared to SOC alone from both National Healthcare Service (NHS) and societal perspectives in Italy. METHODS: A decision analytic model was developed to estimate the number of tears healed and costs for the two considered treatment strategies over 1 year. Clinical data were retrieved from the literature, and the clinical pathways for the management of patients with RCTs were retrieved from four key opinion leaders in Italy. RESULTS: Over a 1-year time horizon, healed lesions were 90.70% and 72.90% for surgical repair of RCTs with and without REGENETEN, respectively. Considering the NHS perspective, mean costs per patient were €7828 and €4650 for the two strategies, respectively, leading to an incremental cost-effectiveness ratio (ICER) of €17,857 per healed tear. From the societal perspective, the mean costs per patient were €12,659 for SOC and €11,784 for REGENETEN, thus showing savings of €4918 per healed tear when the bioinductive implant is used. The sensitivity analyses confirmed the robustness of the model results. CONCLUSION: In the context of paucity of cost-effectiveness studies, our findings provide additional evidence for clinicians and payers regarding the value of a new treatment option that supports a tailored approach for the management of patients with RCTs.

The rotator cuff refers to a group of four muscles, with tendons connected to the upper arm bone, which act together to allow lifting and rotating the shoulder. A tear of the rotator cuff can affect either a single tendon or multiple tendons. Typical first-line treatment includes conservative therapies, which aim to alleviate pain and reduce functional impairment, but are often ineffective. Persisting disease is usually managed through conventional surgical repair. Recently, REGENETEN, a collagen-based bioinductive implant derived from purified bovine Achilles tendon, positioned over the site of the damaged rotator cuff, achieved successful rotator cuff tendon repair with an increase in healed tears of 17.80% at 1 year compared to conventional surgery. Considering the National Healthcare Service perspective in Italy, the cost needed to achieve one additional healed tear using REGENETEN compared to conventional surgery is €17,857. From the societal perspective, which includes patients' productivity losses from hospital admission to return to work, the use of REGENETEN may be cost-saving compared to conventional surgery. The findings of our study provide evidence for clinicians and payers to support the value of a new treatment option for patients with rotator cuff lesions.

Arthroplasty as Primary Treatment for Metadiaphyseal Proximal Humerus Fractures: A Viable Alternative to Osteosynthesis for the Elderly.

Introduction: in the elderly patient population, where fracture comminution, osteoporotic fractures, and associated arthritis or rotator cuff pathologies dominate, metadiaphyseal proximal humeral fracture is a challenging subset of fractures to treat. This study reports on cementless long-stem reverse total shoulder arthroplasty (RTSA) as primary treatment of metadiaphyseal proximal humeral fractures in elderly patients. Materials & Methods: Between January 2018 and October 2021, 22 consecutive patients sustained proximal humerus fractures with metadiaphyseal extension and underwent surgery with cementless long-stem RTSA. Patients older than 60 years with minimum 1 year of clinical and radiographic follow-up were included. Patient demographics, range of motion, and patient reported outcomes [Visual Analog Scale (VAS) pain scale, Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), and American Shoulder Elbow Surgeon (ASES) scores] were retrospectively collected. Postoperative X-rays were evaluated for fracture and tuberosity union. Results: There were 14 eligible patients with a median age of 71 years (range 61-91 years) and a median 13 months follow-up. At final follow-up, the median active elevation was 120° (range 80°-150°), external rotation was 40° (range 0°-50°), and internal rotation was 40° (range 0°-80°). Median VAS was 2 (range 0-8), SST was 71% (range 33%-92%), SSV was 78% (range 20-90%), and ASES was 73 (range 17-90). All patients exhibited radiographic union. There were five minor complications in three patients: postoperative neuropathy, tuberosity nonunion, scapula notching, and proximal humeral stress shielding. Conclusion: Cementless long-stem RTSA is a viable alternative to primary fracture fixation in the elderly patient population with metadiaphyseal proximal humerus fractures.

Can We Completely Trust in Automated Software for Preoperative Planning of Shoulder Arthroplasty? Software Update May Modify Glenoid Version, Glenoid Inclination and Humeral Head Subluxation Values.

BACKGROUND: The purpose of this study was to evaluate the impact of software updating on measurements of the glenoid inclination and version, along with humeral head subluxation performed by an automated 3D planning program. The hypothesis was that the software update could significantly modify the values of the glenoid inclination and version, as well as of the humeral head subluxation. METHODS: A comprehensive pool of 76 shoulder computed tomography (CT) scans of patients who underwent total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) were analyzed with the automated program Blueprint in 2018 and again in 2020 after a software update. RESULTS: A statistically significant difference of 8.1 ± 8.2 and 5.4 ± 7.8 (mean difference of -2.8 ± 5.0, p < 0.001) was indeed reached when comparing the mean glenoid inclination achieved with Blueprint 2018 and Blueprint 2020, respectively. The glenoid version, as well as the humeral head subluxation evaluations, were not significantly different between the two software versions, with mean values being -9.4 ± 8.9 and -9.0 ± 7.4 and 60.1 ± 12.6 and 61.8 ± 12.0, respectively (p = 0.708 and p = 0.115, respectively). In 22% of CT scans, the software update determined a variation of the glenoid inclination of more than 5° or 10°. CONCLUSION: The present study shows the software update of an automated preoperative planning program may significantly modify the values of glenoid inclination. Even though without a significant difference, variations were also found for the glenoid version and humeral head subluxation. Accordingly, these results should further advise surgeons to carefully and critically evaluate data acquired with automated software.

Vancomycin powder embedded in collagen sponge decreases the rate of prosthetic shoulder infection.

BACKGROUND: Shoulder arthroplasty is a successful procedure to treat degenerative and traumatic diseases of the glenohumeral joint. Periprosthetic infection represents an infrequent but dreaded complication (2%-4%). Application of intrawound vancomycin powder seems to reduce periprosthetic infections, but limited information is available on its efficiency in shoulder arthroplasty. The purpose of this study was to evaluate if the vancomycin powder embedded in a collagen sponge could decrease the rate of prosthetic shoulder infection. METHODS: A retrospective analysis of 827 patients undergoing total shoulder arthroplasty was performed. The study involved a control group of 405 patients and a group of 422 with the intraoperative insertion of intrawound vancomycin powder. Incidence of periprosthetic infection was evaluated comparing the 2 groups at a minimum follow-up of 12 months. Patient demographics, comorbidities, and perioperative information were compared between the 2 groups. RESULTS: No infection was observed in the group treated with intrawound vancomycin, and 13 cases of infection were observed in the control group (3.2%) (P value <.001) without subacromial vancomycin application. No wound complications requiring revision were observed as a result of intrawound vancomycin application. DISCUSSION AND CONCLUSION: Intrawound vancomycin powder significantly reduces the rate of periprosthetic shoulder infections without any increase in local and systemic aseptic complications at a minimum follow-up of 12 months. Our results support the use of intrawound local vancomycin for prophylaxis of shoulder periprosthetic infections.

Reverse Total Shoulder Arthroplasty with a Cementless and Metaphyseal Stem Fixation Is a Viable Option for the Treatment of Proximal Humeral Fractures with Calcar Involvement.

BACKGROUND: The purpose of the study was to evaluate the suitability of reverse total shoulder arthroplasty (RTSA) with a cementless and metaphyseal stem fixation as a treatment for complex proximal humeral fractures (PHFs) with a calcar fragment when this may be fixed with a steel wire cerclage. Clinical and radiographic outcomes were compared with the same RTSA for PHFs without a calcar fragment at a minimum of five-year follow-up. METHODS: A retrospective analysis was performed on acute PHFs "with a medial calcar fragment" (group A) and "without a calcar fragment" (group B) treated with a RTSA and cementless metaphyseal stem fixation. RESULTS: At an average follow-up of 6.7 years (5-7.8 years), no statistical difference was observed comparing group A (18 patients) to group B (50 patients) for active anterior elevation (141 ± 15° vs. 145 ± 10°, p = 0.67), active external rotation ER1 (49 ± 15° vs. 53 ± 13°, p = 0.55), and active internal rotation (5 ± 2 vs. 6 ± 2, p = 0.97). Similarly, a comparison of ASES score (89.2 ± 10 vs. 91.6 ± 9, p = 0.23) and Simple Shoulder Test score (91.1 ± 11 vs. 90.4 ± 10, p = 0.49) revealed no significant difference. CONCLUSION: RTSA with a cementless and metaphyseal stem fixation represents a safe and feasible treatment for complex PHFs with a medial calcar fragment when this may be fixed with a steel wire cerclage.

Does arthroscopic superior capsule reconstruction using porcine dermal xenograft represent a viable option in case of massive irreparable posterosuperior rotator cuff tear?

INTRODUCTION: The aim of the present study was to evaluate clinical and structural outcomes of patients with a massive irreparable rotator cuff tear treated with arthroscopic superior capsule reconstruction using an acellular porcine dermal xenograft. We hypothesized that this procedure would lead to improvement in clinical and functional results and that structural failure would not influence the final clinical results. MATERIALS AND METHODS: A retrospective analysis on arthroscopic superior capsule reconstruction performed from October 2016 to January 2019 was conducted. The procedure was performed in patients with a massive irreparable posterosuperior rotator cuff tear without a severe glenohumeral arthropathy (Hamada I and II) and complaining a painful pseudoparalysis. Clinical evaluation and MRI study were performed before surgery and after at least 14 months. RESULTS: A comprehensive group of 21 patients with 11 females and 10 males and a mean age of 57 ± 8.5 years underwent arthroscopic superior capsule reconstruction. The graft had a thickness of 1.5 mm in the first 9 cases (43%) since it was used in a single layer. The graft was thereafter doubled for technique evolution in the following 12 cases (57%) achieving a graft thickness of 3 mm. Active ROM significantly improved with a mean increase of active forward flexion from 72.8° ± 7.5° to 120.6° ± 4.5°, active abduction from 68.3° ± 10.2° to 140.2° ± 8.8° and external rotation from 38.2° ± 11.2° to 56.7° ± 6.8° at the last follow-up. The mean Constant score significantly improved from 40.4 ± 6.7 to 73.3 ± 8.2. A graft tear revealed in 52% (11/21) of overall patients was significantly more frequent in single layer graft when compared to double layer (77% vs 33%, p < 0.05). Location and type of graft tear significantly influenced final outcomes. Patients with a healed (graft continuity with bone at medial and lateral insertion) or medial graft tear showed statistically significant better outcomes when compared with patients in which the graft was completely reabsorbed or torn on humeral side (p < 0.05). CONCLUSION: Arthroscopic superior capsule reconstruction using an acellular porcine dermal xenograft may be a viable alternative to treat massive posterosuperior rotator cuff tear in patients with a painful pseudoparalysis without anterosuperior escape. Structural failure may strongly influence final outcomes with significant role played by tear location.

Success of staged revision reverse total shoulder arthroplasty in eradication of periprosthetic joint infection.

INTRODUCTION: Management of periprosthetic joint infection (PJI) in shoulder arthroplasty remains a challenge, with no established gold standard treatment. This study presents the unique experience of a high-volume single-surgeon, single-institution approach on staged revision reverse total shoulder arthroplasty (RTSA) for infection. The authors theorize that staged revision RTSA is an effective treatment for PJI. MATERIALS AND METHODS: Between 2013 and 2018, 38 patients underwent a staged RTSA for treatment of PJI. Patient histories were collected and classified using Cierny-Mader classification. Infection workup for all patients included radiographs, laboratory indices, and computed tomographic aspiration arthrogram. PJI was identified based on high clinical and radiographic suspicion, elevated serologic markers, and/or aspirate culture results per 2018 International Consensus Meeting Shoulder guidelines on Orthopedic Infections. All patients underwent first stage with implant removal, irrigation and débridement, and antibiotic spacer placement. Next, intravenous antibiotics were administered by infectious disease consultants for a minimum of 6 weeks. Infection workup was then repeated and, if normalized, final-stage revision commenced with antibiotic spacer removal and revision to RTSA. If indices were persistently abnormal, an additional stage of débridement and spacer placement procedure was performed. Treatment failure was defined as recurrent periprosthetic infection after final prosthesis implantation or persistently elevated indices despite adequate débridement and spacer placement. RESULTS: Mean age of the cohort was 68 (standard deviation [SD] 8.9) years and mean follow-up was 33 (SD 14) months with 34 Cierny-Mader C hosts and 4 B hosts. Patients underwent a mean of 2 (SD 1.1) previous surgeries. The staged revision protocol was successful in 34 (89.5%) patients for management of PJI. Four patients (10.5%) were considered failures with recurrent infections at a mean of 13 months (range 2-26 months) after the final RTSA implantation and underwent repeat staged revisions. Of the 34 patients who had successful infection eradication, 31 had 2-stage treatment and 3 had to undergo 3 stages. There were no treatment-associated mortalities and 10 major complications (26%), including permanent neuropathy, instability, and periprosthetic fractures. The most common cultured microorganism was Cutibacterium acnes (18%), with no polymicrobial infections detected. DISCUSSION: Although there are multiple treatment options for PJI management, staged revision remains an effective means of treatment. Although there were several patients who required an additional stage of treatment, and a significant complication rate, staged revision RTSA proved successful in the ultimate eradication of the PJI.

Rotator cuff repair protected with subacromial balloon spacer shows a low rate of non-healing.

PURPOSE: The purpose of this study was to evaluate clinical outcomes and tendon integrity on magnetic resonance imaging (MRI) of chronic posterosuperior rotator cuff tears treated with single-row tensionless repair and subacromial balloon spacer as protection with a minimum follow-up of 2 years. The hypothesis of this study was that this procedure would have acceptable clinical outcomes and tendon-healing rate without increased complications. METHODS: This is a retrospective study of patients with chronic posterosuperior rotator cuff tears repaired with a single-row technique protected with a subacromial balloon device. Patients were followed up for a minimum of 2 years. Clinical outcomes were evaluated with American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) and Numerical Rating Scale (NRS) for pain. MRI study was obtained likewise after at least 2 years to assess tendon-healing rate. Statistical comparison was performed between pre-operative and at least 2-year clinical and imaging follow-up. RESULTS: Thirty-two patients were included in the study with a mean follow-up of 27 ± 7 (range 24-48). The mean age of this cohort was 58 ± 6 (range 41-66) including 15 males and 17 females. The tear size was on average 2.3 cm (range 2-4) and a mean of 2.1 triple-loaded anchors were used (range 2-3). The ASES score significantly increased from a mean of 39 ± 12 points to a mean of 89 ± 12 at the final follow-up (P < 0.001). Similarly, pain significantly reduced from a mean pre-operative NRS of 6.8 ± 1.4 to 0.8 ± 1.5 at the final follow-up (P < 0.001). MRI scans showed that repair occurred in 26 patients (81.3%). Significant higher ASES score was reached at final follow-up in patients with a "healed" (Sugaya I-III) tendon when compared to patients with an evidence of tendon discontinuity on MRI study (Sugaya IV-V), 93 ± 9 and 74 ± 13, respectively (P < 0.001). CONCLUSIONS: Arthroscopic repair of chronic posterosuperior rotator cuff tears using a single-row tensionless repair and subacromial spacer as protection resulted in an 81.3% of tendon integrity at a mean follow-up of 27 months. Clinical outcomes and pain scores significantly improved without severe complications reported after a minimum follow-up of 2 years. LEVEL OF EVIDENCE: III.

The autoclaving and re-implantation of an infected prosthesis as a spacer during resection knee arthroplasty: a systematic review.

BACKGROUND: Hofmann et al., in 1995, first described an articulating spacer made by cleaning and autoclaving the original femoral component, which is then re-implanted with a new tibial polyethylene. This systematic review aims to assess the state of existing evidence on the intraoperative autoclaving and re-use of an infected prosthesis, as a spacer, during a two-stage revision following Periprosthetic Joint Infections (PJI). METHODS: A systematic review was conducted with methods described in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. OVID-MEDLINE®, EMBASE, Cochrane Library, SCOPUS, Web of Science, Google Scholar and PubMed were searched from 1995 to April 2020 to identify relevant studies. RESULTS: Fourteen studies were included in this systematic review: two prospective case series; six retrospective comparative studies and six retrospective case series. The reviewed studies included 567 patients (571 knees): 394 patients treated with autoclaved components and 173 with a spacer made of new components. The cumulative re-infection rate in patients treated with re-used autoclaved components was 13.7% (54 re-infections in 394 patients), whereas in control patients the re-infection rate was 13.3% (23 re-infections in 173 patients). The final Range of Movement in patients treated using the autoclaved components as a spacer, compared with patients receiving static spacers, was significantly higher in three out of four comparative studies. CONCLUSION: There is a moderate level of evidence that the intraoperative autoclaving and re-use of an infected prosthesis as a spacer, during a knee resection arthroplasty, is an effective procedure in the management of knee PJI.

Pulsed electromagnetic fields after intramedullary nailing of tibial fractures: a case control study.

PURPOSE: To compare clinical and functional outcomes of two groups of patients undergoing reduction and nailing fixation for diaphyseal fractures of the tibia with (PEMF group) and without (control group) post-operative pulsed electromagnetic field (PEMF) application. METHODS: This is a retrospective study on 50 patients (mean age 43.3 years, 28 males and 22 females) with diaphyseal tibial fractures managed between 2017 and 2019. Twenty-five patients underwent reduction, nailing fixation, and PEMF application post-operatively (PEMF group) and 25 patients underwent nailing fixation. Radiographic imaging assessment was performed every month until fracture healing had been evident. Use of analgesics, fracture healing time, post-operative lower limb alignment, and post-operative complications were recorded. Patients were asked about return to preinjury activity. All patients were assessed at 3 months and at an average follow-up of 13 months. The VAS scale and Johner-Wruhs criteria were used for pain assessment and functional recovery, respectively. RESULTS: Comparing groups, VAS values were significantly lower in the PEMF group at three months and comparable at one year. The patients in the PEMF group took an average of 4.1 months to resume their preinjury activities, and control patients took an average of 5.3 months (P < 0.0001). According to the Johner-Wruhs score, the effective rate was 100% (25/25) in the PEMF group and 92% (23/25) in the control group (P = 0.14). CONCLUSIONS: PEMF application after intramedullary nailing is safe and reduces post-operative pain, use of analgesics, and the time of healing fracture. At one year, there is no difference in outcome measures, regardless of PEMF application.

Elite professional goalkeepers report high rate of sport resumption after shoulder surgery.

PURPOSE: The aim of this study is to evaluate the return to sport after surgical treatment of shoulder injuries in professional goalkeepers in relationship with the mechanism of injury and the pattern of related shoulder lesions. METHODS: Twenty-six shoulders in nineteen elite male professional soccer goalkeepers were retrospectively analyzed considering multiple diseases (instability, rotator cuff, biceps or other tendon injuries). Data was collected for injury modality and context, pathological findings, surgical procedures, time, level of return to sport, and complications. RESULTS: The mechanism of injury was "mild trauma without contact" in 46% of the cases and 54% of injuries happened during training. 11 patients (42%) reported multiple pattern lesions and 9 patients (35%) classic anterior instability lesions. The mean time for return to differentiated training and unrestricted sport activity was 14 and 20.2 weeks, respectively. 15 athletes (62.5%) reported 100% return to sport, 4 (16.7%) to 90%, 1 (4.2%) to 85%, 3 (12.5%) to 80% and 1 athlete to 50%, stopping professional activity. 21% of the cases reported the persistence of some shoulder symptoms. 3 cases experienced a new injury. Patients with classic anterior instability had significantly lower age (30.7 vs 19.8 years, P = 0.001), experienced injury in different context and reported symptoms more frequently compared to multiple lesion patients (4/8 vs 0/10, P = 0.011). CONCLUSION: Professional elite goalkeepers which required shoulder surgery for different causes demonstrated high-rate level of return to play despite the persistence of mild symptoms. The high frequency of multiple lesions, patients' characteristics, injury context and mechanism, increase the concern for injuries in overstressed shoulder for this category of sport. LEVEL OF EVIDENCE: IV.