Neck shaft angle in reverse shoulder arthroplasty: 135 vs. 145 degrees at minimum 2-year follow-up.

BACKGROUND: The most common complication with reverse shoulder arthroplasty Grammont based design with a 155° neck shaft angle (NSA) is scapular notching. Scapular notching has been associated with reduced clinical outcomes. Reducing the humeral NSA from 155° has been shown to reduce the incidence of scapular notching however it is unknown whether there is a difference in scapular notching between a 145° and 135° NSA. The purpose of this study was to evaluate the effect of decreasing the NSA on scapular notching rate and postoperative range of motion comparing 145° and 135° NSA stems at minimum 2 yr of follow-up. METHODS: Consecutive patients undergoing primary reverse shoulder arthroplasty with a NSA of either 145° or 135° between January 2014 and February 2019 were retrospectively reviewed. Patients were included if they were over the age of 18, had minimum clinical follow-up of 24 mo with true postoperative anteroposterior radiographic view. RESULTS: One hundred and three patients were included for the final analysis: 73 with a 145° NSA and 30 with a 135° NSA stem. The mean age and mean follow-up were respectively 70.9 yr (range, 52.0-89.0) and 32.1 mo. The overall incidence of scapular notching was 46.6 %. There was a statistically significant difference in scapular notching between the 145° (53.4%) and 135° (30%) NSA groups (P = .028). There was no difference in terms of postoperative Constant-Murley Score (mean, 66.1 vs. 68.2; P = .395), Subjective Shoulder Value (mean, 76.5 vs. 83.1%, P = .167), forward flexion (mean, 140° vs. 142°, P = .704), abduction (mean, 123.2° vs. 121.5°, P = .771), external rotation with the arm at the side (mean, 34.1° vs. 37.3°, P = .341) and internal rotation (mean, 5.3 vs. 5.4 pts P = .336) between the 2 groups. CONCLUSION: This is the first study to compare the effect of a 145° vs. 135° NSA on scapular notching rates. The key finding of this study is that scapular notching rate was significantly reduced from 53% to 30% in 135° NSA compared to 145° NSA, after at least 24 mo of follow-up. Our data also show that glenoid lateralization and inferiorization has an influence on scapular notching. We are unable to state that the reduced scapular notching rate was due to a reduction in NSA alone. Despite a lower rate of scapular notching, the 135° NSA group has not shown any significant better clinical and functional outcomes.

Survivorship of shoulder arthroplasty in young patients with osteoarthritis: an analysis of the Australian Orthopaedic Association National Joint Replacement Registry.

BACKGROUND: The treatment of shoulder osteoarthritis in the young patient remains challenging. The higher functional demands and higher expectations of the young patient cohort are often coupled with increased failure and revision rates. Consequently, shoulder surgeons are faced with a unique challenge with implant selection. The aim of this study was to compare the survivorship and reasons for revision of 5 classes of shoulder arthroplasty in patients aged <55 years with a primary diagnosis of osteoarthritis by use of data from a large national arthroplasty registry. METHODS: The study population included all primary shoulder arthroplasty procedures undertaken for osteoarthritis in patients aged <55 years and reported to the registry between September 1999 and December 2021. Procedures were grouped into the following classes: total shoulder arthroplasty (TSA), hemiarthroplasty resurfacing (HRA), hemiarthroplasty stemmed metallic head (HSMH), hemiarthroplasty stemmed pyrocarbon head (HSPH), and reverse total shoulder arthroplasty (RTSA). The outcome measure was the cumulative percent revision, which was defined using Kaplan-Meier estimates of survivorship to describe the time to the first revision. Hazard ratios (HRs) were calculated from Cox proportional hazards models, adjusting for age and sex, to compare revision rates among groups. RESULTS: There were 1564 shoulder arthroplasty procedures in patients aged <55 years, of which 361 (23.1%) were HRA, 70 (4.5%) were HSMH, 159 (10.2%) were HSPH, 714 (45.7%) were TSA, and 260 (16.6%) were RTSA. HRA had a higher rate of revision than RTSA after 1 year (HRA = 2.51 (95% CI 1.30, 4.83), P = .005), with no difference prior to that time. In addition, HSMH had a higher rate of revision than RTSA for the entire period (HR, 2.69 [95% confidence interval, 1.28-5.63], P = .008). There was no significant difference in the rate of revision for HSPH and TSA when they were compared with RTSA. Glenoid erosion was the most common cause of revision for HRA (28.6% of revisions) and HSMH (50%). Instability/dislocation was the leading cause of revision for RTSA (41.7%) and HSPH (28.6%), and for TSA, the majority of revisions were for either instability/dislocation (20.6%) or loosening (18.6%). CONCLUSION: These results should be interpreted within the context of the lack of availability of long-term data on RTSA and HSPH stems. RTSA outperforms all implants regarding revision rates at mid-term follow-up. The high early dislocation rate associated with RTSA, as well as the lack of revision options available to address this, indicates that careful selection of patients and a greater appreciation of anatomic risk factors are needed in the future.

All-Arthroscopic Trillat Procedure Using Screw Fixation for Recurrent Shoulder Instability.

The Trillat procedure has been described for the management of shoulder instability in younger patients but also for shoulder instability in older patients with irreparable rotator cuff tears. We describe an all-arthroscopic technique using screw fixation. This technique allows for safe dissection, clearance and osteotomy of the coracoid, and direct visualization during screw tensioning and fixation to minimize the risk of subscapularis impingement. We outline our stepwise approach to medialize and distalize the coracoid process using arthroscopic screw fixation and present pearls to avoid fracture through the superior bone bridge.

Stress reactions and fractures around the elbow in athletes.

Stress fractures of the upper limb affect athletes from a wide range of sports. Athletes involved in throwing sports are particularly susceptible along with athletes from sports involving high repetitive and compressive loads such as gymnastics. Diagnosis can be made from clinical history, examination and radiography in some cases however MRI imaging is often required for definitive diagnosis. The mainstay of management is rest and activity modification however advanced pathology often requires surgical management for successful resolution and return to play. In the elbow, the bones susceptible to excessive stress in sport are the distal humerus, the olecranon process of the ulna, the coronoid process of the ulna, the sublime tubercle and the radial head. In immature patients, medial epicondyle apophysis is the most common location. The article presents a narrative review of the literature.

Arthroscopic-Assisted Lower Trapezius Tendon Transfer for Massive Irreparable Posterosuperior Rotator Cuff Tears Using an Achilles Tendon-Bone Allograft.

The lower trapezius tendon (LTT) transfer has been described for the management of irreparable posterosuperior rotator cuff tears. Here we describe our technique of an arthroscopic-assisted LTT transfer using an Achilles tendon-bone allograft. This technique allows for augmentation of the tendon transfer using an Achilles tendon allograft while also keeping the calcaneal bone insertion, which allows for added bony fixation into the humerus and also minimizing the risk of the "killer turn" phenomenon at the aperture of fixation.

Epithelial-macrophage interactions determine pulmonary fibrosis susceptibility in Hermansky-Pudlak syndrome.

Alveolar epithelial cell (AEC) dysfunction underlies the pathogenesis of pulmonary fibrosis in Hermansky-Pudlak syndrome (HPS) and other genetic syndromes associated with interstitial lung disease; however, mechanisms linking AEC dysfunction and fibrotic remodeling are incompletely understood. Since increased macrophage recruitment precedes pulmonary fibrosis in HPS, we investigated whether crosstalk between AECs and macrophages determines fibrotic susceptibility. We found that AECs from HPS mice produce excessive MCP-1, which was associated with increased macrophages in the lungs of unchallenged HPS mice. Blocking MCP-1/CCR2 signaling in HPS mice with genetic deficiency of CCR2 or targeted deletion of MCP-1 in AECs normalized macrophage recruitment, decreased AEC apoptosis, and reduced lung fibrosis in these mice following treatment with low-dose bleomycin. We observed increased TGF-ß production by HPS macrophages, which was eliminated by CCR2 deletion. Selective deletion of TGF-ß in myeloid cells or of TGF-ß signaling in AECs through deletion of TGFBR2 protected HPS mice from AEC apoptosis and bleomycin-induced fibrosis. Together, these data reveal a feedback loop in which increased MCP-1 production by dysfunctional AECs results in recruitment and activation of lung macrophages that produce TGF-ß, thus amplifying the fibrotic cascade through AEC apoptosis and stimulation of fibrotic remodeling.