Early outcome of humeral head replacement with glenoid reaming arthroplasty (Ream and Run) for treatment of advanced glenohumeral osteoarthritis.

INTRODUCTION: Long-term outcomes of anatomic total shoulder arthroplasty (aTSA) can be compromised by glenoid loosening and failure. The purpose of this study was to evaluate the short- and midterm outcomes of humeral head replacement with glenoid reaming arthroplasty (Ream and Run) for the treatment of advanced glenohumeral osteoarthritis, and to identify associations between preoperative factors and outcomes. METHODS: Forty-nine shoulders (mean age 60 ± 7 years) with minimum 2-year follow-up (mean 4.6 ± 1.7) were evaluated. Forty-three (87.8%) were male. Thirteen (26.5%) had previous nonarthroplasty shoulder surgery. There were 19 (38.8%) Walch type A and 30 (61.2%) type B glenoids. Pre- and postoperative shoulder motion, patient-reported outcomes (PROMs), and health-related quality of life (HRQoL) were assessed. Pre- and postoperative plain radiographs were evaluated. Mixed effects models were used to investigate factors associated with outcomes. RESULTS: Active forward elevation and active external rotation improved from 111.7° ± 23.8° to 139.2° ± 21.1° and 13.3° ± 20.7° to 38.7° ± 14.7°, respectively (P < .001). The mean American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), Simple Shoulder Test (SST), and visual analog scale (VAS) shoulder pain scores at the most recent follow-up were 86.6 ± 19.9, 10.1 ± 14.1, 10.5 ± 2.2, and 1.5 ± 2.3, respectively. The mean changes of PROMs were significant and exceeded the minimal clinically important difference for aTSA. The percentage maximal possible improvement for ASES, DASH, and SST were greater than 75%. Male sex (P < .008) and not having prior shoulder surgery (P < .04) were significantly associated with better absolute and greater change in PROMs. Age, preoperative shoulder motion, and Walch glenoid classification were not associated with PROMs. Five (10.2%, 95% confidence interval [CI] 1.8%-18.6%) patients underwent revision for pain. Three additional patients were dissatisfied at final follow-up without undergoing revision, resulting in 16.7% (95% CI 6.1%-27.2%) of patients being dissatisfied with their outcome after their initial RnR. Mean Short Form-6 Dimensions scores improved from 0.66 ± 0.12 to 0.77 ± 0.13 and mean EuroQol-5 Dimensions scores improved from 0.68 ± 0.20 to 0.85 ± 0.17 (P < .001). Improvement in HRQoL was significantly associated with nondominant arm treatment, increased age, and greater preoperative SST score. Annual medialization of the humeral head center of rotation was 0.56 ± 1.6 mm/yr. No radiographic measure was associated with long-term PROMs. CONCLUSION: Ream and Run can provide significant and clinically important improvement in PROMs and HRQoL for a high percentage of patients at short- and midterm follow-up. This procedure is an appropriate alternative to aTSA in select patients.

Forces and translation distance during an inferior glide of the shoulder in asymptomatic individuals measured with the novel pliance glove and ultrasound imaging.

BACKGROUND: There has been limited research on how the variance of force affects manual therapy outcomes and what the best practices should be. No specific force threshold necessary to achieve a predetermined translational distance within the joint has been quantified within the literature. PURPOSE: To quantify the amount of force necessary to perform an inferior glide to the glenohumeral joint and reach to end range. A secondary aim was to determine the impact of co-variables, such as gender, height, weight, and age, on the amount of force required to translate the humeral head within the glenohumeral joint. METHODS: A convenience sample of 64 healthy subjects were recruited. Musculoskeletal ultrasound imaging using the GE LogiQe was used to measure the translation of the humeral head. The manipulation force was measured using the novel pliance glove device and software. The ANOVA was used to determine if there was a difference in translation distance and force between trials. The Pearson's correlation was used to correlate translation and force and between covariables. RESULTS: There was no significant difference in translation distance between trials (p = .14). There was no significant difference in the mean force for this translation (p = .45). There was a poor correlation between age and force (r = 0.28) and weight and force (r = 0.12). CONCLUSION: An average force of 14.27 N (n = 61) was needed to displace the humeral head to reach end range. This was the first study using the combination of a flexible force sensor technology and real-time ultrasound imaging to measure humeral head translation.

Conservative management in an elderly woman with proximal humeral head fracture and massive rotator cuff tear who refused surgery: A case report.

BACKGROUND: Proximal humerus fractures (PHFs) account for between 4% and 10% of all fractures in the elderly people and osteoporosis is frequently related to PHF. Furthermore, rotator cuff (RC) tears are also extremely common, affecting at least 10% of people aged over 60 in the United States. Among shoulder pathologies, the periarticular soft tissue disorders, including the RC, this is considered to be the most common. The incidence of full thickness RC tears increases with age. An aggressive surgical approach is often required for patients with massive RC tear and PHFs to restore the patients' functional daily living activities. To the best of the authors' knowledge, this is the first case report describing a successful conservative management in an elderly patient with a full thickness RC tear and PHF that refused surgery. CASE DESCRIPTION: This report describes the case of a 90-year-old woman with a massive RC tear who fell over on the sidewalk and sustained a PHF. The patient refused surgery even though it was recommended and prescribed by an orthopaedic surgeon. INTERVENTION: After having her shoulder immobilized with a brace as prescribed by the orthopaedic physician, the patient began a shoulder rehabilitation program with progressive work load exposure, functional movements and a pain and kinesiophobia education program. OUTCOMES: After 3 and a half months, the patient achieved full recovery to her pre-injury level of function. Such outcome was assessed using the Numeric Pain Rating Scale (NPRS), the Disability of the Arm, Shoulder and Hand (DASH) scale, the Fear-Avoidance Beliefs Questionnaire (FABQ), the Pain Catastrophysing Scale (PCS), and the Global Rating of Change (GROC) scale. DISCUSSION AND CONCLUSION: In an elderly patient with a massive RC tear and an undisplaced PHFs, patient education, pain reconceptualization and change of beliefs in combination with progressive work load exposure appeared to be an effective management strategy to achieve a return to the pre-injury level of function.

The effect of shoulder position on inferior glenohumeral mobilization.

STUDY DESIGN: Cross-sectional clinical measurement study. INTRODUCTION: Inferior mobilizations are used to treat patients with shoulder dysfunctions. Common positions recommended for promoting an inferior glide include: (1) an open-packed position (OPP) in which the shoulder is in 55° of abduction, 30° of horizontal adduction, and no rotation; (2) neutral position (NP) of the shoulder; and (3) position of 90° of shoulder abduction (ABDP). Studies comparing the impact of position on inferior mobilization are lacking. PURPOSE OF THE STUDY: To determine the effect of shoulder position on humeral movement and mobilization force during inferior mobilizations. METHODS: Twenty-three subjects were tested bilaterally. Subjects were placed in the OPP, and an ultrasound transducer placed over the superior glenohumeral joint. As inferior mobilization forces were applied through a dynamometer, ultrasound images were taken at rest and during 3 grades of inferior mobilization. This process was repeated in the NP and the ABDP. RESULTS: In the NP, movements during grade 1, 2, and 3 mobilizations were 1.8, 3.8, and 4.5 mm, respectively. Movements measured in the OPP (1.0, 2.4, and 3.6 mm, respectively) and in the ABDP (1.0, 2.2, and 2.3 mm, respectively) were less. Forces were higher in the NP during grade 1, 2, and 3 mobilizations (51.8, 138.7, and 202.1 N, respectively) than in the OPP (37.2, 91.2, and 139.9 N, respectively) and the ABPD (42.5, 115.3, and 165.5 N, respectively). DISCUSSION: Mobilization position altered the movement and force during inferior mobilizations. CONCLUSIONS: Shoulder position should be considered when utilizing inferior mobilizations. LEVEL OF EVIDENCE: NA.

Cathodic Electrical Stimulation Combined With Vancomycin Enhances Treatment of Methicillin-resistant Staphylococcus aureus Implant-associated Infections.

BACKGROUND: Effective treatments for implant-associated infections are often lacking. Cathodic voltage-controlled electrical stimulation has shown potential as a treatment of implant-associated infections of methicillin-resistant Staphylococcus aureus (MRSA). QUESTIONS/PURPOSES: The primary purpose of this study was to (1) determine if cathodic voltage-controlled electrical stimulation combined with vancomycin therapy is more effective at reducing the MRSA bacterial burden on the implant, bone, and synovial fluid in comparison to either treatment alone or no treatment controls. We also sought to (2) evaluate the histologic effects of the various treatments on the surrounding bone; and to (3) determine if the cathodic voltage-controlled electrical stimulation treatment had an effect on the mechanical properties of the titanium implant as a result of possible hydrogen embrittlement. METHODS: Thirty-two adult male Long-Evans rats (Harlan Laboratories, Indianapolis, IN, USA) with surgically placed shoulder titanium implants were infected with a clinical strain of MRSA (NRS70). One week after infection, eight animals received a treatment of cathodic voltage-controlled electrical stimulation at -1.8 V versus Ag/AgCl for 1 hour (STIM), eight received vancomycin twice daily for 1 week (VANCO), eight received the cathodic voltage-controlled electrical stimulation and vancomycin therapy combined (STIM + VANCO), and eight served as controls with no treatment (CONT). Two weeks after initial infection, the implant, bone, and synovial fluid were collected for colony-forming unit (CFU) enumeration, qualitative histological analysis by a pathologist blinded to the treatments each animal received, and implant three-point bend testing. RESULTS: The implant-associated CFU enumerated from the STIM + VANCO (mean, 3.7 × 10(3); SD, 6.3 × 10(3)) group were less than those from the CONT (mean, 1.3 × 10(6); SD, 2.8 × 10(6); 95% confidence interval [CI] of difference, -4.3 × 10(5) to -9.9 × 10(3); p < 0.001), STIM (mean, 1.4 × 10(6); SD, 2.0 × 10(6); 95% CI of difference, -2.1 × 10(6) to -1.8 × 10(3); p = 0.002), and VANCO (mean, 5.8 x 10(4); SD, 5.7 × 10(4); 95% CI of difference, -6.4 × 10(4) to -1.7 × 10(4); p < 0.001) group. The bone-associated CFU enumerated from the STIM + VANCO group (6.3 × 10(1); SD, 1.1 × 10(2)) were less than those from the CONT (mean, 2.8 × 10(5); SD, 4.8 × 10(5); 95% CI of difference, -9.4 × 10(4) to -5.0 × 10(3); p < 0.001) and STIM (mean, 2.6 × 10(4); SD, 2.5 × 10(4); 95% CI of difference, -4.1 × 10(4) to -1.6 × 10(3); p < 0.001) groups. The VANCO group (4.3 × 10(5); SD, 6.3 × 10(2)) also had lower bone-associated CFU as compared with the CONT (mean 95% CI of difference, -9.3 × 10(4) to -4.5 × 10(3); p < 0.001) and STIM (95% CI of difference, -4.0 × 10(4) to -1.5 × 10(3); p < 0.001) groups. In comparison to the synovial fluid CFU enumerated from the CONT group (mean, 3.3 × 10(4); SD, 6.0 × 10(4)), lower synovial CFU were reported for both the STIM + VANCO group (mean, 4.6 × 10(1); SD, 1.2 × 10(2); 95% CI of difference, -4.9 × 10(3) to -3.0 × 10(2); p < 0.001) and the VANCO group (mean, 6.8 × 10(1); SD, 9.2 × 10(1); 95% CI of difference, -4.9 × 10(3) to -2.8 × 10(2); p = 0.007). The histological analysis showed no discernable deleterious effects on the surrounding tissue as a result of the treatments. No brittle fracture occurred during mechanical testing and with the numbers available, no differences in implant flexural yield strength were detected between the groups. CONCLUSIONS: In this rodent model, cathodic voltage-controlled electrical stimulation combined with vancomycin is an effective treatment for titanium implant-associated infections showing greater than 99.8% reduction in bacterial burden on the implant, surrounding bone, and synovial fluid as compared with the controls and the stimulation alone groups. CLINICAL RELEVANCE: Cathodic voltage-controlled electrical stimulation combined with vancomycin may enable successful treatment of titanium orthopaedic implant-associated infections with implant retention. Future studies will focus on optimization of the stimulation parameters for complete eradication of infection and the ability to promote beneficial host tissue responses.

Biomechanical effects of calcar screws and bone block augmentation on medial support in locked plating of proximal humeral fractures.

BACKGROUND: The objective of this study was to investigate the biomechanical effects of medial fracture gap augmentation in locked plating of an unstable 2-part proximal humeral fracture with calcar screws and insertion of a corticocancellous bone block. Furthermore the mechanical behavior of dynamic locking screws in the non-parallel arrangement of a proximal humeral plate was of interest. METHODS: Thirty-two fresh frozen humeri were randomized in four equal groups. An unstable 2-part fracture was fixed by locked plating in all specimens. The basic screw setup was supplemented by additional calcar screws in one group. Humeral head screws were replaced by dynamic locking screws in a second group. The third group featured an additional corticocancellous femoral head allograft. Assessment of stiffness was followed by cyclic loading and load to failure tests. Resulting stiffness, fracture gap deflection and ultimate load were compared utilizing Bonferroni corrected t-test for independent samples. FINDINGS: The mechanical effect of additional calcar screws was non-significant as compared to the basic screw configuration whereas bone block insertion significantly increased construct stiffness and failure load. The use of dynamic locking screws did not significantly reduce construct stiffness when compared to conventional locking screws. INTERPRETATION: Additional calcar screws alone did not improve the initial biomechanical properties of an unstable 2-part proximal humeral fracture model. However bone block augmentation appeared to be a reliable alternative of additional bony support by raising stiffness and failure load. Dynamic locking screws did not show their expected dynamic component when used in a non-parallel arrangement.

Técnica de Thrust para la disfunción de la cabeza humeral en superioridad / Thrust technique for the dysfunction of the humeral head in superiority

Las disfunciones en el hombro tienen una alta incidencia en lapoblación, entendiendo por hombro, el complejo articular compuesto de cinco articulaciones, entre la que cabría destacar, la articulación glenohumeral. Una de las lesiones más invalidantes de la articulación glenohumeral es la lesión de superioridad, debido a la estenosis del espacio subacromial que ésta provoca. El objetivo de la técnica de thrust para superioridad de la cabeza humeral será provocar el descenso de la cabeza humeral para recuperar la funcionalidad de la articulación gleno-humeral. Para realizar correctamente la técnica, previamente habría que aplicar un diagnóstico adecuado, basado en la inspección, palpación, pruebas de movilidad, pruebas musculares, pruebas ortopédicas y radilógicas. Este procedimiento tiene riesgos conocidos que deberán evitarse para obtener los beneficios terapéuticos deseados, en los pacientes que presenten indicaciones para su aplicación (AU)

Shoulder dysfunctions are very common in the population. By shoulder, one understands joint complex composed of five joints, among which one could highlight the gleno-humeral joint. One of the more incapacitating injuries of the gleno-humeral joints is the injury in superiority due to the stenosis of the subacromial space that this would cause. The aim of the thrust technique for superiority of the humeral head will be to cause the decline of the humeral head to regain functionality of the gleno-humeral joint. To successfully carry out the technique, it would be necessary to previously perform an appropriate diagnostic, based on inspection, palpation, mobility tests, muscle testing, orthopedic and x ray tests. This procedure has known risks that must be avoided to obtain desired therapeutic benefits in patients presenting indications for application (AU)