Neuropathy of the suprascapular and axillary nerves in rotator cuff arthropathy: a prospective electrodiagnostic study.

PURPOSE: Prevalence of axillary (AN) and/or suprascapular (SSN) neuropathy in rotator cuff tear arthropathy (RCTA) is unknown. We aimed to prospectively evaluate for preoperative neurodiagnostic abnormalities in order to determine their prevalence, location, and influence on reverse shoulder arthroplasty (RSA) outcomes. METHODS: Patients who underwent RSA for RCTA were prospectively included. An electromyography and nerve conduction study were performed pre and post-surgery. Clinical situation: VAS, Relative Constant-Murley Score (rCMS) and ROM over a minimum of two years follow-up. RESULTS: Forty patients met the inclusion criteria; mean follow-up was 28.4 months (SD 4.4). Injuries in RCTA were present in 83.9% (77.4% in AN and 45.2% in SSN). There were no differences on preoperative VAS, ROM, and rCMS between patients with and without preoperative nerve injuries. Four acute postoperative neurological injuries were registered under chronic preoperative injuries. Six months after RSA, 69% of preoperative neuropathies had improved (82.14% chronic injuries and 77.7% disuse injuries). No differences in improvement between disuse and chronic injuries were found, but patients with preoperative neuropathy that had not improved at the postoperative electromyographic study at six months, scored worse on the VAS (1.44 vs 2.66; p .14) and rCMS (91.6 vs 89.04; p .27). CONCLUSIONS: The frequency of axillary and suprascapular neuropathies in RCTA is much higher than expected. Most of these injuries improve after surgery, with almost complete neurophysiological recovery and little functional impact on RSA. However, those patients with preoperative neuropathies and absence of neurophysiological improvement six months after surgery have lower functional results.

Do the humeral radiographic changes at 5-year follow-up affect the clinical outcomes of press-fit humeral stems in primary reverse shoulder arthroplasties?

INTRODUCTION: The purposes of this study were to analyze and compare the functional outcomes and radiological changes around the press-fit humeral components in two contemporary medialized reverse total shoulder arthroplasty (RTSA) systems at a minimum of 5-year follow-up. MATERIALS AND METHODS: Between December 2003 and December 2015, 249 consecutive RTSAs were performed at our hospital. Of these, 68 primary uncemented RTSA met our inclusion criteria. The Constant-Murley score (CMS), the modified Constant score, a visual analog scale (VAS) and active shoulder range of motion (ROM) were measured pre- and postoperatively. Radiological assessment was performed by plain radiographs at a minimum of 5 years postoperatively. RESULTS: At a mean follow-up of 80.2 months, there was no significant difference (p = .59) between the postoperative functional scores and range of motion of the two groups (Delta Xtend and Lima SMR). Radiological data of stress-shielding were observed in 38 patients (55.9%) being slightly more frequent in the Lima SMR group (21 patients) than in the Delta Xtend group (17 patients) (p = .62). CONCLUSIONS: Our study shows that the good functional results are similar between the two uncemented RTSA systems used and that they do not depend on the presence of radiological changes (stress-shielding) in the humeral stem at a minimum 5-year follow-up.

Functional results of Circumferential Capsular Release in adhesive shoulder capsulitis. Comparative study of patients over and under fifty years of age.

INTRODUCTION: The aim of our study is to evaluate the functional and mobility outcomes in patients who have undergone arthroscopic circumferential arthrolysis of the shoulder and to find out if there are differences in the results in relation to the patient's age. MATERIALS AND METHODS: This is a retrospective case series of patients with idiopathic adhesive capsulitis treated by arthroscopic 360º circumferential capsulotomy in lateral position and followed for a minimum of 2 years. Range of motion (ROM), functional outcomes using the Constant Score (CS), health-related quality of life outcomes with the EuroQol Five Dimensions tool (EQ-5D), pain using the Visual Analogue Scale (VAS). RESULTS: A total of 26 shoulders were included, 10 men (41.7%) and 14 women (58.3%), with 2 patients being bilateral. The mean age was 48.64 ± 7.5 years, and the mean follow-up was 50.2 months. Postoperative ROM improved significantly compared to preoperative ROM (p < 0.05). Shoulder forward flexion improved by 38.6° (95%CI 22.3-54.9, p < 0.01), abduction by 35.2° (95%CI 17.6-52.8, p < 0.01) and external rotation by 21.9° (95%CI 12.8-30.9, p < 0.01 p < 0.01). Median internal rotation improved from buttock to T12 (p < 0.01). The mean improvement in CS was 54.3 ± 24.4 points (p < 0.01). The EQ-5D and VAS scores at the end of follow-up were 0.73 ± 0.23 and 2.73 ± 2.55, respectively. There were no statistical differences between young patients and patients aged 50 years or older in ROM or functional results. CONCLUSIONS: Patient age did not affect outcomes significantly, with patients older than 50 years showing similar results to younger patients.

Suprascapular nerve injury after reverse total shoulder arthroplasty: correlation with screw out of vault penetration and functional situation: prospective study.

BACKGROUND: Baseplate screws have been suggested as a possible cause of suprascapular neuropathy after reverse total shoulder arthroplasty. This study aims to investigate the association between screw penetration out of the vault, electromyographic study, and the clinical outcomes. METHODS: A total of 31 patients who underwent reverse total shoulder arthroplasty for cuff tear arthropathy were prospectively enrolled. They were followed up for a minimum of 24 months. All patients underwent computed tomography 6 months postoperatively to determine the extraosseous position of the screws (perforation of the second bone cortex and protrusion into the supra- or infraspinatus fossa). Electrodiagnostic evaluation was performed preoperatively and postoperatively to stablish any relation between cortex perforation of the screw and suprascapular nerve (SSN) injury. Clinical outcomes pre- and postoperatively (Constant score, ranges of motion, and visual analog scale) of patients with and without documented injury were recorded. RESULTS: A total of 14 patients (45.2%) had an abnormal preoperative SSN electrodiagnostic study (chronic or disuse injuries), and 6 patients (19.4%) had an abnormal postoperative study (acute injury). Of the 6 patients, 2 cases appeared over the pre-existing lesion and 4 appeared over an intact preoperative nerve, all of them affecting the infraspinatus branch of the SSN. Perforation of the second cortex was detected for 60% of superior screws and 40% of posterior screws. The mean lengths of the superior and posterior screws were 30 and 18.2 mm, respectively. Patients with screw perforation of the second cortex were assessed as having a high risk of nerve injury (40% vs. 9.5%). CONCLUSIONS: Preoperative SSN injuries do not have a significant clinical impact and do not predispose to an acute postoperative SSN lesion. The Constant score and visual analog scale score for patients with acute SSN injuries were not statistically different from those without SSN injury. The extraosseous position of the screw increases the probability of an SSN injury to 31%. This risk is higher with the posterior screw, which leads us to question whether it is really necessary to use it.

Shoulder problems after percutaneous antegrade intramedullary nailing in humeral diaphyseal fractures using contemporary straight third-generation nail.

BACKGROUND: Antegrade intramedullary nailing in humeral shaft fracture has been abandoned by certain orthopedic surgeons because of rotator cuff injury caused by first- and second-generation intramedullary nails (IMNs). However, only a few studies have specifically addressed the results of antegrade nailing for the treatment of humeral shaft fractures with a straight third-generation IMN; thus, complications need to be re-evaluated. We hypothesized that fixation of displaced humeral shaft fractures with a straight third-generation antegrade IMN with the percutaneous technique avoid shoulder problems (stiffness and pain) incurred by first- and second-generation IMNs. METHODS: This was a retrospective, single-center, nonrandomized study of 110 patients with a displaced humeral shaft fracture between 2012 and 2019 treated surgically with a long third-generation straight IMN. Mean follow-up was 35.6 months (range, 15-44 months). RESULTS: There were 73 women and 37 men with a mean age of 64.7 ± 19 years. All fractures were closed (37.3% 12A1, 13.6% 12B2, and 13.6% 12B3 AO/OTA classification). Mean Constant score was 82 ± 19, Mayo Elbow Performance Score 96 ± 11 and the mean EQ-5D visual analog scale score was 69.7 ± 21.5. Mean forward elevation 150° ± 40°, abduction 148° ± 45°, and external rotation 38° ± 15°. Symptoms associated with rotator cuff disease were present in 6.4%. Evidence of radiographic fracture healing was detected in all but 1 case. One postoperative nerve injury and 1 adhesive capsulitis were present. Overall, 6.3% underwent second surgeries (4.5% were minor surgeries like hardware removal). CONCLUSION: Percutaneous antegrade intramedullary nailing of humeral shaft fractures with a straight third-generation nail considerably reduced complications related to shoulder problems and achieved good functional results.

The Spanish version of the Constant-Murley Shoulder Score: translation, cultural adaptation, and validity.

BACKGROUND: The Constant-Murley Score (CMS) is one of the most employed tools for assessing shoulder function. It was first devised in 1987 for the English population and is now widely used internationally. However, it had yet to be cross-culturally adapted and validated to Spanish, which is the world's second-most native language. Formal adaptation and validation of clinical scores is paramount for them to be used with rigorous scientific methodology. METHODS: Following international recommendations for the cross-cultural adaptation of self-report measures, the CMS was first adapted into Spanish in six stages: translation, synthesis, back-translation, a review by expert committee, pretesting, and final appraisal by expert committee. After conducting a pretest with 30 individuals, the Spanish version of the CMS was tested on 104 patients with various shoulder pathologies to assess content, construct, criterion validity, and reliability. RESULTS: No major conflicts were encountered in the process of cross-cultural adaptation, with 96.7% of pretested patients having a full understanding of every item in the test. The validation showed excellent content validity (content validity index = .90), construct validity (strong correlation between items within the same subsection of the test), and criterion validity (CMS - Simple Shoulder Test, Pearson r = .587, P = .01; CMS - American Shoulder and Elbow Surgeons, Pearson r = .690, P = .01). Reliability of the test was also excellent, with high internal consistency (Cronbach's α = .819), interrater reliability (intraclass correlation coefficient = .982), and intrarater reliability (intraclass correlation coefficient = .937), without showing ceiling or floor effects. CONCLUSION: Spanish version of the CMS has been proved to accurately reproduce the original score and to be easily comprehensible by native Spanish speakers with acceptable intrarater-interrater reliability and construct validity. INTRODUCCIóN: La escala de Constant-Murley (CMS) es una de las más empleadas para evaluar la función del hombro. Se ideó por primera vez para la población inglesa en 1987 y actualmente es ampliamente empleada a nivel internacional. Sin embargo, su validación y adaptación transcultural no se han realizado al español, la segunda lengua nativa más hablada en el mundo. Actualmente no puede resultar admisible el empleo de escalas en las que no tengamos la seguridad de que existe una equivalencia conceptual, cultural y lingüística entre la versión original y la empleada. MATERIAL Y MéTODO: La versión traducida al español de la CMS se realizó siguiendo las recomendaciones internacionales: traducción, síntesis de la traducción, retrotraducción, revisión por comité de expertos, pretest y validación. Tras la realización del pretest en 30 individuos, la versión española de la escala de CMS se probó en 104 pacientes con diferentes patologías de hombro para evaluar las propiedades psicométricas de la escala: contenido, constructo, validez de criterio y fiabilidad. RESULTADOS: No se encontraron problemas importantes durante el proceso de adaptación transultural con un entendimiento completo de todos los ítems del pretest por el 96.7% de los pacientes. La escala adaptada demostró una excelente validez de contenido (índice de validez de contenido = .90), de constructo (fuerte correlación entre ítems de la misma subsección del test), y de criterio (CMS-SST Pearson's r = .587, p = .01; CMS-ASES Pearson's r = .690, p = .01). La Fiabilidad del test resultó excelente, con una elevada consistencia interna (Cronbach's α = .819), fiabilidad interobservador (ICC = .982) e intraobservador (ICC = .937), sin efectos techo y suelo. CONCLUSIóN: La versión Española de la CMS garantiza la equivalencia con respecto al cuestionario original. Los presentes resultados, sugieren que esta versión es válida, fiable y reproducible para la evaluación de la patología de hombro en nuestro entorno.

Poor Results After Arthroscopic Treatment of Irreparable Rotator Cuff Tears Using a Subacromial Balloon Spacer.

INTRODUCTION: Arthroscopic balloon spacer arthroplasty (BSA) is a relatively recent procedure for patients with irreparable rotator cuff tears, conceived to prevent degenerative joint changes and relieve subacromial pain. METHODS: This is a retrospective case series of 16 consecutive patients treated with BSA and followed up for a minimum 12 months. Besides BSA, partial tendon repair was done whenever possible. Radiographical parameters such as acromiohumeral distance and Hamada stage were measured preoperatively and postoperatively. Range of motion, functional results (Constant score; Simple Shoulder Test; American Shoulder and Elbow Surgeons score; and Disabilities of the Arm, Shoulder, and Hand score), health-related quality of life results with the EuroQol Five Dimensions tool, complications, and patient satisfaction were also analyzed. RESULTS: The mean age was 64 ± 10.3 years, and the male/female ratio was 6/10. Partial repair was achieved in five patients (31.2%) and did not influence functional or health-related quality of life results ( P = 0.11). The mean acromiohumeral distance and Hamada stage worsened from preoperative measures (3.7 ± 2.0 mm and 2.3 ± 1.1) to final follow-up measures (3.1 ± 2.4 mm and 3.1 ± 1.3). Shoulder abduction increased by 7.8° ± 26.8° and forward flexion decreased by 25.5° ± 32.4° after surgery. The functional results at the final follow-up were Constant 49.5 ± 18.0; American Shoulder and Elbow Surgeons 60.2 ± 27.2; Simple Shoulder Test 8.5 ± 4.6; and Disabilities of the Arm, Shoulder, and Hand 32.7 ± 12.1. The mean index value for the EuroQol Five Dimensions was 0.79, and perceived quality of life was 85.6 ± 15.4 of 100 points. 62.5% of the patients (10) were satisfied with surgery. The complication rate was 13% (2), accounting for one deep infection and one balloon migration. CONCLUSION: Theoretical benefits of BSA for delaying superior humeral head translation and arthropathic changes could not be demonstrated in our series. Its functional results and satisfaction rates are low, but self-reported quality of life after surgery does not seem impaired. Complications do not occur frequently but require reintervention and endanger joint viability. LEVEL OF EVIDENCE: Level IV (case series).

Dislocation after reverse total shoulder arthroplasty using contemporary medialized modular systems. Can we still consider it such a frequent complication?

INTRODUCTION: Improvement in reverse total shoulder arthroplasty (RTSA) prosthesis and technique has reduced the initially high complication and revision rates associated with this implant. However, instability continues to be a leading cause of reoperation after RTSA, being related in previous studies with medialized designs. The aim of this study was to determine the dislocation rate with the employment of two medialized modular systems of RTSA in our institution. MATERIALS AND METHODS: A retrospective review of two different modular systems of RTSA (SMR Modular Shoulder System and Delta XTEND Reverse Shoulder) was performed between 2009 and 2017 with a minimum 3-year follow-up. Baseline demographic, clinical (Constant, ASES and ROM), and radiographic data were collected. Characteristics of postoperative instability cases were also evaluated. RESULTS: 237 primary RTSA (41% SMR/59% Delta) and 34 revision RTSA (44% SMR/56% Delta) with a mean follow-up of 75.6 ± 5.2 months (79.2 SMR/86.3 Delta, p = .586) were included in the present study. Indications for primary RTSA were osteoarthritis, rotator cuff tear arthropathy and massive irreparable rotator cuff tear (64%), acute fracture (32%), and fracture sequelae (4%). Subscapularis tendon was always repaired in degenerative pathology and tuberosities reattached in traumatic cases. The mean age of the global series was 76.5 ± 5.3 years (75.8 SMR/78.6 Delta, p = .104) with a mean Constant/ASES score at final follow-up of 68.5 ± 4.3/72.9 ± 20.3 (71/68 SMR and 69/74 Delta, p = .653 and .642). Only 2 patients (one acute fracture and one fracture sequelae) suffered an early postoperative anterior dislocation (before 3 months) which represents a rate of .84% in primary cases and .73% including revision surgery. Closed reduction manoeuvres were not successful, and both patients required revision surgery. At the end follow-up, both were stable and had no further dislocations. CONCLUSION: The dislocation rate after RTSA with the employment of two contemporary modular systems with a medialized centre of rotation is extremely low, especially when compared with the previously published series with the original Grammont design. Acute fracture and fracture sequelae were the main diagnoses associated with this instability. The reasons for the low dislocation rate are multifactorial, but the improvement in the baseplate position according to the more recent standards of "ideal position" and technical aspects such as subscapularis repair or tuberosity reattachment in fractures probably play an important role in this aspect.

Third-generation intramedullary nailing for displaced proximal humeral fractures in the elderly: quality of life, clinical results, and complications.

INTRODUCTION: Antegrade insertion of third-generation intramedullary nail (IMN) has been shown to provide excellent results in young patients for treatment of displaced two-part surgical neck fracture. In elderly patients, osteoporosis makes internal fixation problematic and frequently contributes to failed fixation and poor clinical results. The purpose of this study was to report the health-related quality of life (HRQoL), functional results, and postoperative complications obtained with straight third-generation antegrade nailing of proximal humerus fractures (PHFs) in elderly patients. METHODS: A retrospective review of 32 patients aged 80 y.o. or older presenting a two-part or three-part PHFs treated with a straight IMN with a minimum follow-up of 12 months. Results assessed included 1) radiographic measures 2) clinical data: Charlson Comorbidity Index (CCI), VAS, range of motion (ROM), Individual Relative Constant score (IRC), Simple Shoulder Test (SST) and 3) Health-related Quality of life (HRQoL) with the EQ-5D index/EQ-VAS. RESULTS: Mean age was 82.1 (range 80-90) and mean follow-up was 45.6 months (range 16-53 months) with 91% of female patients and a mean CCI 4.6. 81% were two-part surgical neck fractures and 19% were three-part greater tuberosity fractures. The mean neck-shaft angle (NSA) at final follow-up was 132º ± 17.9º. 15.6% underwent hardware removal because of subacromial impingement and one patient (3%) was revised to RSA because of severe secondary fracture displacement. Mean IRC was 67,7 ± 30, the mean SST and VAS-Pain were 8.1 ± 3.1 and 3.2 ± 3.2, respectively, and the mean EQ-5D/EQ-VAS were 0.40 ± 0.33/64.2 ± 8.9. At last review, mean active forward flexion, abduction, and external rotation were 115º ± 35º, 100º ± 35º, and 20º ± 15º, respectively. CONCLUSION: Appropriate selection of fracture and proper operative technique with a third-generation nail result in good functional results and good HRQol with a low complication rate in elderly population.

Complications after open Latarjet procedure: influence of arm positioning on musculocutaneous and axillary nerve function.

BACKGROUND: Alterations in the anatomical relationships of the musculocutaneous (MCN) and axillary nerves and the influence of arm positioning on these relationships after a Latarjet procedure have been demonstrated in the cadaver, but there are no studies in the literature that establish if there is any neurophysiological repercussion. METHODS: We retrospectively identified 24 patients with a primary or revision open Latarjet procedure. A prospective clinical (Constant-Murley, Rowe and Walch-Duplay and active range of motion), radiographic (with CT), and electrodiagnostic evaluation was made at the most recent follow-up. RESULTS: Nonunion occurred in four patients (22%); there were, as well, one case of partial coracoid reabsorption (5%) and two (11%) with mild glenohumeral osteoarthritis. In the anatomical position, we found no alterations in the musculocutaneous nerve and two cases (11%) in the axillary nerve slight motor unit loss. In the risk position, 11 cases (61%) had neurophysiological involvement (36% had neurophysiological changes in the musculocutaneous nerve and 64% in the axillary nerve). No differences between patients with or without neurophysiologic changes were found: Constant 87/83; Rowe 89/90; Walch-Duplay 84/78; Forward elevation 175º/170º, abduction 165°/175°; external rotation 48°/45°. CONCLUSION: The rate of clinical electromyographic changes in the axillary and MCN in the abducted and externally rotated arm position (risk dislocation position) is higher than in neutral position. Nonunion of the coracoid process must play a role in these neurophysiological changes. Although in the medium-term they don't have clinical impact, further randomized prospective studies with a larger sample size are necessary to determine their true repercussion. LEVEL OF EVIDENCE: Level IV.

Radiographic changes around the glenoid component in primary reverse shoulder arthroplasty at mid-term follow-up.

BACKGROUND: Some local events after reverse shoulder arthroplasty (RSA) occur without the patient experiencing symptoms and yet may be detected on diagnostic imaging, thereby serving as indicators of future complications that may require revision. Most of these events involve the glenoid component, but radiographic studies evaluating this component are scarce, especially medium- and long-term studies. This study aimed to analyze the radiographic changes around the glenoid component and determine the risk factors associated with the presence of these radiographic changes. MATERIALS AND METHODS: A retrospective review of 105 primary Grammont-style RSAs implanted between 2003 and 2014 was conducted. Radiographic outcomes were evaluated in patients with ≥5 years of radiographic follow-up. Standardized digital radiographs obtained immediately postoperatively and at a minimum follow-up time of 5 years were analyzed to determine (1) glenoid component position (inclination and height) and (2) minor radiographic changes (Sirveaux grade 1 or 2 scapular notching; nondisplaced acromial fracture; radiolucent lines around 1 or 2 screws; Brooker grade 1a, 1b, or 2 heterotopic calcifications; or single screw rupture), as well as major radiographic changes (Sirveaux grade 3 or 4 scapular notching; radiolucent lines around ≥3 screws or central peg; Brooker grade 1c or 3 heterotopic calcifications; prosthetic dislocation; loosening or migration; or disassembly). RESULTS: Major radiologic changes were identified in 14.3% of the cases. Bivariate analysis showed that more changes were associated with the arthroplasties implanted in the first years of the study (odds ratio [OR] = 0.81, P = .012). This time-related variable was also associated with inclination (OR = 0.88, P = .045) and height (OR = 0.75, P = .001), improving in arthroplasties implanted in the last years of the study. Multivariate analysis revealed an increased risk of severe scapular notching mainly associated with superior tilt (OR = 2.52, P = .036) and a high (OR = 2.68, P = .019) or excessively high (OR = 7.55, P = .013) position and an increased risk of loosening signs associated with superior tilt (OR = 8.92, P = 9.1 × 10-6). CONCLUSIONS: The percentage of radiologic changes of the glenoid component in RSA is considerable, despite the detection of a decrease in their presence among the arthroplasties implanted outside the initial period. Superior tilt and an excessively high position appear to be associated with a severe degree of scapular notching development and increased risk of radiographic loosening signs. Knowledge of the factors associated with major radiologic changes in the medium-term follow-up will help to optimize the primary surgical technique for each patient and indication, improving implant survival in primary RSA surgery.

Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective randomized controlled trial.

BACKGROUND: Proximal humeral fractures (PHFs) are among the most common fractures in elderly patients, but there is insufficient evidence from randomized controlled trials (RCTs) to determine which interventions are the most appropriate for their management. To date, no RCT has directly compared reverse shoulder arthroplasty (RSA) with nonoperative treatment for 3- or 4-part PHFs in elderly patients. METHODS: This was a prospective RCT. The primary objective was to compare pain and function 12 months after fracture using the Constant score in patients aged 80 years or older with 3- and 4-part PHFs, treated by either RSA or nonoperative treatment. Secondary outcome measures included Disabilities of the Arm, Shoulder and Hand, visual analog scale (VAS), Short Form 12 (SF-12), EuroQol 5 Dimensions, and EQ-VAS scores. RESULTS: We analyzed 30 nonoperative and 29 RSA patients with mean ages of 85 years and 82 years, respectively. No differences between the nonoperative and RSA groups were noted for any patient-reported outcomes at 12 months' follow-up except the VAS pain score. The Constant scores were 55.7 in the nonoperative group and 61.7 in the RSA group (P = .071); the Disabilities of the Arm, Shoulder and Hand scores were 29 and 21, respectively (P = .075); the VAS scores were 1.6 and 0.9, respectively (P = .011); the physical SF-12 scores were 36 and 37, respectively (P = .709); the mental SF-12 scores were 43 and 42, respectively (P = .625); the EuroQol 5 Dimensions scores were 0.89 and 0.92, respectively (P = .319); and the EQ-VAS scores were 65 and 67, respectively (P = .604). CONCLUSIONS: This study yields important evidence for the treatment of complex PHFs in elderly patients suggesting minimal benefits of RSA over nonoperative treatment for displaced 3- and 4-part PHFs. At short-term follow-up, the main advantage of RSA appeared to be less pain perception.

Adverse effects of xenogenic scaffolding in the context of a randomized double-blind placebo-controlled study for repairing full-thickness rotator cuff tears.

PURPOSE: The purpose of the study was to compare the safety and efficacy of autologous mesenchymal stem cells (MSCs) embedded in a xenogenic scaffold for repairing the supraspinatus tendon. METHODS: This was a randomized, double-blind and placebo-controlled trial evaluating patients with full-thickness rotator cuff tears (Eudra-CT, 2007-007630-19). Effectiveness was evaluated using the Constant score and a visual analogue pain scale (VAS). Constant score has four domains including pain (15 possible points), activities of daily living (20 possible points), mobility (40 possible points), and strength (25 possible points). Scores range from 0 points (most disability) to 100 points (least disability). The structural integrity of the repaired tendon was assessed by magnetic resonance imaging (MRI) according to Patte and Thomazeau classification criteria. The primary study end point was an improvement in the Constant score by 20 points at one year compared to initial assessment. RESULTS: The trial was stopped due to adverse effects observed in both groups. Only thirteen patients were included and analyzed. The Constant questionnaire showed a significant improvement in the MSC treatment group compared with the preoperative data (p = 0.0073). Secondary outcome measures were similar in both groups. CONCLUSIONS: Our study showed preliminary inconclusive clinical outcomes in the patients treated with MSCs. Adverse events revealed the need for further approaches using scaffolds of a different nature or perhaps no scaffolds, in the context of small joints. TRIAL REGISTRATION: Eudra-CT, 2007-007630-19 . Registered on 30 January 2008. LEVEL OF EVIDENCE: A Level 1 of evidence treatment study.

Reverse total shoulder arhroplasty for the treatment of failed fixation in proximal humeral fractures.

BACKGROUND: This study evaluates the clinical outcomes in patients with proximal humerus fractures (PHF) treated with reverse total shoulder arthroplasty (RTSA) as a revision procedure for failed fixation that have more than 5 years of follow-up. MATERIALS AND METHODS: This is a retrospective study of 270 RTSA. The inclusion criteria for this study consisted of patients initially treated with either open reduction and plate fixation (ORIF) or fixation using an intramedullary nail (IMN), who were managed with a single-stage revision to a RTSA, and had a minimum of 24 months clinical and radiological follow-up. Six patients with failed fixation of displaced PHF were revised with RTSA. One patient was excluded from the study because she died. Five shoulders were reviewed for the purpose of this study. The patients were evaluated using Constant score, relative Constant score and visual analogue scale for pain. RESULTS: The mean follow-up was 89 months (65-108). The mean absolute Constant score improved from 31, 81 to 44, 2 and the relative Constant score improved from 31,81% to 67,2%. Mean VAS improved from 6, 8 to 2. One patient rated their outcome excellent, 1good, 1 satisfied and 2 poor. CONCLUSION: RTSA is an appropriate treatment as a revision surgery for failed fixation of PHF. Patients should be adequately warned that they will improve their function but may have complications following this salvage procedure.

Injury to the axillary and suprascapular nerves in rotator cuff arthropathy and after reverse shoulder arthroplasty: a prospective electromyographic analysis.

BACKGROUND: Neurologic pre- and postoperative injuries to the axillary and/or suprascapular nerve (SSN) have a higher incidence than expected and may lead to significantly decreased functional outcomes and increased risk of reverse shoulder arthroplasty (RSA) failure. METHODS: Patients who underwent a RSA for rotator cuff tear arthropathy (RCTA) were included from December 2014 to December 2015. This study focused on the clinical (Constant score), radiographic, and pre- and postoperative electromyographic evaluations at 3 and 6 months. RESULTS: Twenty patients met the inclusion criteria. One was lost to follow-up. Preoperatively, 15 patients showed changes on electromyography (9 SSN and 15 axillary nerve lesions); all of them were chronic and disuse injuries. The mean preoperative relative Constant score (rCS) of all included patients was 39 ± 9 (range, 19-64). At 3 months postsurgery, the prevalence of acute injuries for both nerves was 31.5%. At 6 months postsurgery, 2 axillary nerve injuries and 6 SSN injuries remain unchanged, and the rest improved or normalized. The mean postsurgery rCS of the entire cohort at 6-month follow-up was 78 ± 6.5. Mean postoperative rCS for acute postoperative nerve injury was 71 ± 3 for the axillary nerve and 64 ± 5 for SSN. CONCLUSIONS: Axillary and SSN injuries in RCTA have a much higher incidence than expected. Most of these axillary lesions are transient, with an almost complete recovery seen on electromyography at 6 months and with scarce functional impact. However, SSN lesions appear to behave differently, with poor functional results and having a lower potential for a complete recovery.

Midterm outcomes of bone grafting in glenoid defects treated with reverse shoulder arthroplasty.

BACKGROUND: Large glenoid defects are a difficult reconstructive problem for shoulder surgeons. The purpose of this study was to determine the complications, rate of healing, and functional results of glenoid bone grafting in primary or revision surgery with reverse shoulder arthroplasty. METHODS: We retrospectively reviewed 23 patients with glenoid bone loss who underwent primary or revision surgery using a glenoid bone graft with a minimum follow-up of 2 years. Range of motion and the Constant, American Shoulder and Elbow Surgeons, and visual analog scale scores were obtained from preoperative assessment and the latest follow-up visit. Radiographic evaluation included analysis of plain radiographs as well as preoperative and follow-up computed tomography. RESULTS: Three patients were excluded from the study. Allografts were used in 13 cases and autografts in 7 cases. The mean Constant score improved from 30.7 ± 9.4 to 51.3 ± 13.4 (P < .001). At a mean follow-up of 26 months, computed tomography imaging revealed that the glenoid bone graft was fully incorporated in 95% of cases. No statistically significant differences were found on analysis of the clinical and radiographic outcomes related to the graft source. There was a 20% postoperative complication rate: 1 case of aseptic glenoid component loosening, 1 surgical wound hematoma, 1 acromial fracture, and a symptomatic grade 3 scapular notching. CONCLUSIONS: The use of bone grafts in glenoid defects is a useful technique by which, in the majority of cases, single-stage reconstruction surgery may be performed, even in the presence of severe bone loss. Incorporation rates are high, with satisfactory clinical outcome.

Open reduction and internal fixation of coronal fractures of the capitellum in patients older than 65 years.

BACKGROUND: The aim of this study was to describe the fracture patterns of capitellum coronal fractures and to evaluate the complications and functional and radiographic outcomes of open reduction and internal fixation in patients older than 65 years. METHODS: A retrospective study of 23 patients with a mean follow-up of 48 months (36-105) was performed. Fractures were classified according to the Dubberley classification. All patients were evaluated by the Mayo Elbow Performance Index (MEPI) and the Disabilities of the Arm, Shoulder, and Hand (DASH) scores. RESULTS: Three patients were lost to follow-up. There were 16 type 1 and 4 type 2 fractures. The mean age was 71 years (66-79), and 65% were women. The mean MEPI score was 92 (60-100), and the mean DASH score was 9 (0-75). Either a concomitant fracture or an elbow dislocation was present in 50% of the patients. Mean sagittal plane range of motion at last follow-up was 122° ± 8°, with lower extension in type 2 and worse scores on MEPI (91 vs. 97) and DASH (3 vs. 0) scales. Placement of the screws in the posteroanterior direction was associated with better range of motion in flexion (130° vs. 122°) and better outcomes in functional scores (MEPI, 97 vs. 89; QuickDASH, 0 vs. 4). Complications were post-traumatic osteoarthritis in 3 patients, avascular necrosis in 1 patient, and heterotopic ossification in 5 patients. One patient required reoperation. CONCLUSIONS: Patients older than 65 years have no substantial risk of complex fracture patterns, but they have a large number of concomitant injuries. Open reduction and internal fixation with cannulated screws allow stable fixation and provide satisfactory functional results with a lower complication rate.

OP-1 Compared with Iliac Crest Autograft in Instrumented Posterolateral Fusion: A Randomized, Multicenter Non-Inferiority Trial.

BACKGROUND: Spinal fusion with the use of autograft is a commonly performed procedure. However, harvesting of bone from the iliac crest is associated with complications. Bone morphogenetic proteins (BMPs) are extensively used as alternatives, often without sufficient evidence of safety and efficacy. The purpose of this study was to investigate non-inferiority of osteogenic protein-1 (OP-1, also known as BMP-7) in comparison with iliac crest bone graft in posterolateral fusions. METHODS: This study was a randomized, controlled multicenter trial. Patients who underwent a single-level instrumented posterolateral fusion of the lumbar spine for degenerative or isthmic spondylolisthesis with symptoms of neurological compression were randomized to receive OP-1 combined with local bone (OP-1 group) or autologous bone graft from the iliac crest combined with local bone (autograft group). The primary outcome was overall success, defined as a combination of clinical success and evidence of fusion on computed tomography (CT) scans, at one year postoperatively. RESULTS: One hundred and nineteen patients were included in the study, and analysis of the overall outcome was performed for 113. Non-inferiority of OP-1 compared with iliac crest autograft was not found at one year, with a success rate of 40% in the OP-1 group versus 54% in the autograft group (risk difference = -13.3%, 90% confidence interval [CI] = -28.6% to +2.10%). This was due to the lower rate of fusion (the primary aim of OP-1 application) seen on the CT scans in the OP-1 group (54% versus 74% in the autograft group, p = 0.03). There were no adverse events that could be directly related to the use of OP-1. CONCLUSIONS: OP-1 with a collagen carrier was not as effective as autologous iliac crest bone for achieving fusion and cannot be recommended in instrumented posterolateral lumbar fusion procedures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Periprosthetic humeral fractures associated with reverse total shoulder arthroplasty: incidence and management.

PURPOSE: The purpose of this study was to record the incidence and management of periprosthetic humeral fractures (PHF) using reverse total shoulder arthroplasty (RTSA) in our institution. METHODS: We performed a retrospective study of 203 RTSA implanted in 200 patients between 2003 and 2014. The mean follow-up was 78.82 months (range, 12-141). Mean age of the study cohort was 75.87 years (range, 44-88). There were only 25 male patients (12.5 %). We assessed the presence of periprosthetic humeral fractures studying the medical files and X-rays of all patients. RESULTS: We identified seven periprosthetic humeral fractures in 203 RTSA (3.4 %): three intra-operative (1.47 %) and four post-operative (1.97 %). The average age at the time of the fracture was 75.14 years (59-83). All patients were women (100 %). Three patients with post-operative fractures type B were treated by osteosynthesis, and one patient with post-operative fracture type A was treated conservatively. All intra-operative fractures needed cerclage wire and in one case long cemented stem. All our periprosthetic fractures healed. CONCLUSIONS: Surgical treatment with osteosynthesis in type B post-operative fractures with a stable stem is recommended. Conservative treatment is sufficient in non-displaced type A post-operative fracture. Special attention should be paid to bone quality patients using non-cemented stems in primary surgery but especially in revision shoulder surgery.

Scapula insufficiency fractures after reverse total shoulder arthroplasty in rotator cuff arthropathy: What is their functional impact?

INTRODUCTION-OBJECTIVES: To describe the incidence, etiological factors, functional impairment and therapeutic management of scapular fractures after reverse shoulder arthroplasty (RSA) in rotator cuff arthropathy. MATERIAL AND METHOD: A retrospective study was conducted on 126 RSA between 2009 and 2011, in which 4 fractures were identified that were compared with a control group of 40 patients. An analysis was performed on the variables related to the surgical technique, functional results, and quality of life (Constant scale, EQ-5D). RESULTS: The fracture incidence was 3.28% with a mean age of 74.7 years. The mean time until diagnosis was 11.9 months. The preoperative Constant score in the control group was 37.3%, and 34.7% in the fracture group (P>.05); postoperative Constant score: 81.2 and 66.5%, respectively (P>.001). Forward elevation and abduction in fracture patients decreased by 39° (P=.02), and 34° (P=.057) respectively. The perceived quality of life (EQ-VAS) was lower in the fracture group (60 vs. 76) (P=.002). There were no instability cases, and no revision surgery was required. The union rate was 50% after a mean follow-up 39.6 months. CONCLUSIONS: Scapular fracture after RSA is a rare complication. Despite its presence, the functional outcomes and quality of life of these patients are higher than preoperatively; however, they are lower than that obtained in patients with RSA without this complication. More prospective studies are needed to define guidelines for therapeutic action against this complication.