Complex trauma to the shoulder girdle, including the proximal humerus, the clavicle, and the scapula: current concepts in diagnosis and treatment.

Fractures to the shoulder girdle are common injuries in an aging population. Many techniques and theories lie behind the treatment of such injuries. Knowledge and understanding of current concepts for diagnosing and treating proximal humeral, clavicular, and scapular fractures and the theory behind them will help surgeons make informed decisions with regard to patient care.

Results of closed management of acute dislocation after reverse shoulder arthroplasty.

BACKGROUND: Postoperative instability continues to be one of the most common complications limiting outcomes of reverse shoulder arthroplasty (RSA). The optimal management of this complication remains unknown. The purpose of this study was to evaluate the outcomes of patients with postoperative dislocation after RSA managed with closed reduction. METHODS: All patients who were treated with a closed reduction for dislocation after RSA in the period between May 2002 and September 2011 were identified and retrospectively reviewed. Final outcomes including recurrent instability, need for revision surgery, American Shoulder and Elbow Surgeons outcome score, and range of motion were evaluated. RESULTS: A total of 21 patients were identified. Nearly 50% of cases (10 of 21) had previous surgery, with 80% (8 of 10) of these being previous arthroplasty. The average time to first dislocation was 200 days, with 62% (13 of 21) occurring in the first 90 days. At average follow-up of 28 months, 62% of these shoulders remained stable (13 of 21), 29% required revision surgery (6 of 21), and 9% remained unstable (2 of 21). The average American Shoulder and Elbow Surgeons score was 68.0 for patients treated with closed reduction for instability and 62.7 for those treated with revision surgery (P = .64). DISCUSSION: This study shows that an initial dislocation episode after RSA with use of this implant can be successfully managed with closed reduction and temporary immobilization in more than half of cases. Given that outcomes after revision surgery are not different from those after closed treatment, we would continue to recommend an initial attempt at closed reduction in the office setting in all cases of postoperative RSA dislocation.

The effects of glenoid wear patterns on patients with osteoarthritis in total shoulder arthroplasty: an assessment of outcomes and value.

BACKGROUND: Despite the success of total shoulder arthroplasty (TSA), concerns remain about the longevity of the implant, in particular, glenoid component survivorship. The purpose of this study was to determine whether preoperative glenoid wear patterns affect clinical outcomes and value in patients undergoing TSA. METHODS: A comparative cohort study was conducted of 309 patients with a total of 344 TSA procedures, performed for primary glenohumeral osteoarthritis. Computed tomography scans were obtained in all patients, with preoperative glenoid wear pattern characterized as either concentric (n = 196; follow-up time, 49.2 months) or eccentric (n = 148; follow-up time, 52.3 months) according to a modified Levine classification. A clinical, radiographic, and economic assessment was performed between the 2 wear patterns. RESULTS: There was no significant difference in American Shoulder and Elbow Surgeons (ASES) score in the concentric group (80.8 ± 20.8) compared with the eccentric group (77.6 ± 21.2) at final follow-up (P = .159). Range of motion and final visual analog scale for pain score were similar between the 2 groups. Radiographic evidence of gross glenoid loosening was significantly lower in the concentric group [11 of 195 (5.6%)] compared with the eccentric group [18 of 147 (12.2%)] (P = .030). Revision rates were similar between the concentric group [4 of 195 (2.0%)] and the eccentric group [3 of 147 (2.0%)]. A value assessment also showed no significant difference between the concentric and eccentric groups [concentric 26.1 vs. eccentric 25.5 (ΔASES score/$10,000 hospital cost) (P = .479)]. CONCLUSIONS: Similar clinical results and value can be expected with both concentric and eccentric glenoid wear patterns in TSA. Concerns arise, however, as the eccentric group demonstrated a more than 2-fold increased rate of glenoid component loosening compared with the concentric group.

Reverse shoulder arthroplasty for massive rotator cuff tear: risk factors for poor functional improvement.

BACKGROUND: Some patients unexpectedly have poor functional improvement after reverse shoulder arthroplasty (RSA) for massive rotator cuff tear without glenohumeral arthritis. Our aim was to identify risk factors for this outcome. We also assessed the value of RSA for cases with poor functional improvement vs. METHODS: The study was a retrospective case-control analysis for primary RSA performed for massive rotator cuff tear without glenohumeral arthritis with minimum 2-year follow-up. Cases were defined as Simple Shoulder Test (SST) score improvement of ≤1, whereas controls improved SST score ≥2. Risk factors were chosen on the basis of previous association with poor outcomes after shoulder arthroplasty. Latissimus dorsi tendon transfer results were analyzed as a subgroup. Value was defined as improvement in American Shoulder and Elbow Surgeons (ASES) score per $10,000 hospital cost. RESULTS: In a multivariate binomial logistic regression analysis, neurologic dysfunction (P = .006), age <60 years (P = .02), and high preoperative SST score (P = .03) were independently associated with poor functional improvement. Latissimus dorsi tendon transfer patients significantly improved in active external rotation (-0.3° to 38.7°; P < .01). The value of RSA (ΔASES/$10,000 cost) for cases was 0.8 compared with 17.5 for controls (P < .0001). CONCLUSIONS: Young age, high preoperative function, and neurologic dysfunction were associated with poor functional improvement. Surgeons should consider these associations in counseling and selection of patients. Concurrent latissimus dorsi transfer was successful in restoring active external rotation in a subgroup of patients. The critical economic importance of improved patient selection is emphasized by the very low value of the procedure in the case group.

What is the effect of postoperative scapular fracture on outcomes of reverse shoulder arthroplasty?

BACKGROUND: Postoperative scapular fracture is a common complication after reverse shoulder arthroplasty (RSA). The purpose of this study was to determine its effect on RSA patient outcomes. METHODS: A retrospective, case-control study of 25 nonoperatively treated postoperative scapular fractures after RSA were analyzed with a minimum 2-year follow-up from surgery and 1-year follow-up from fracture. Eligible patients were matched 1:4 to a control group for age, sex, follow-up time, surgery indication, and primary operation vs revision. Outcome measures, including American Shoulder and Elbow Surgeons (ASES) score and range of motion, were compared between fracture cases and controls. Also analyzed were radiographic features, including fracture location (acromion vs scapular spine) and healing. RESULTS: Incidence of scapular fracture after RSA in this series was 3.1%. Fractures occurred from 1 to 94 months postoperatively. The revision rate was higher in the fracture group (8% vs. 2%) but did not reach statistical significance (P = .18). Fracture patients had improved (ΔASES, 21) but inferior clinical outcomes, with a postoperative ASES score of 58.0 compared with 74.2 (P ≤ .001). Change in range of motion also diminished in the fracture group, with a mean gain of 26° forward elevation compared with 76° (P < .001). Fracture location (P = .54) or healing (P = .40) did not affect outcome. CONCLUSION: Postoperative scapular fractures may occur at any point postoperatively; increasing incidence is likely as longer follow-up becomes available. This complication leads to inferior clinical results compared with controls. However, patients show improvement compared with their preoperative measurements, even at longer-term follow-up. Patients with postoperative scapular fractures may have increased risk of revision. LEVEL OF EVIDENCE: Level III, case-control study, treatment study.

Low incidence of tendon rerupture after distal biceps repair by cortical button and interference screw.

BACKGROUND: The use of cortical suspensory fixation in conjunction with an interference screw to treat distal biceps ruptures has yielded favorable results. However, literature examining the incidence of fixation failure in a large consecutive series of patients treated with this technique is lacking. METHODS: A retrospective review of electronic medical records identified 170 distal biceps ruptures in 168 consecutive patients (164 men and 4 women) treated using a cortical button in conjunction with an interference screw. The study group was an average age of 48 years (range, 20-71 years). Records were reviewed from the time of the initial clinic visit to the most recent follow-up. Early failures were defined as those that occurred within 12 weeks of the index procedure. Failed repair was defined as tendon defect, deformity, or significant weakness in supination. RESULTS: The early incidence of failure was 1.2%, with 2 of the fixations meeting the criteria for failure. One patient had significant brachial artery thrombosis. Other complications included posterior interosseous nerve palsy, lateral antebrachial cutaneous nerve-related complication, and numbness about the radial nerve. CONCLUSION: The use of a cortical suspensory fixation device in conjunction with an interference screw is an effective method of repairing a distal biceps rupture, with a low early rate of failure.

Arthrodesis for failed total elbow arthroplasty with deep infection.

BACKGROUND: Elbow arthrodesis is typically reserved as a salvage procedure. Current literature suggests that satisfactory outcomes can be expected if fusion occurs. There is a paucity of literature on outcomes of elbow arthrodesis after failed elbow arthroplasty with deep infection. METHODS: Five elbow arthrodeses were performed after a failed elbow arthroplasty due to deep infection. Clinical data were retrospectively reviewed for all surviving patients. Fusion angle, complications, and time to fusion or resection arthroplasty were recorded. The procedure was considered a failure if resection arthroplasty was required or there was a failure of bone union after 1 year. RESULTS: The average age at arthrodesis was 49 years (range, 35-69 years). One patient died 3 months after arthrodesis and was excluded from analysis. No patients had confirmed union at final follow-up. Two developed a fibrous union and were not symptomatic. All patients required at least 1 reoperation; 6 reoperations were required in total for the entire group. Three patients required revision arthrodesis after hardware failure. Two patients ultimately underwent a resection arthroplasty. One patient required débridement and hardware removal after wound dehiscence. Other complications included 2 patients with transient ulnar neuritis. CONCLUSION: Elbow arthrodesis is not recommended as a salvage procedure for failed total elbow arthroplasty after infection because of a high reoperation rate and difficulty in achieving solid fusion.

Factors that predict postoperative motion in patients treated with reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has proven to be a useful yet inconsistent tool to manage a variety of pathologic conditions. Factors believed to lead to poor postoperative range of motion (ROM) may be associated with preoperative diagnosis, poor preoperative ROM, and surgical factors such as inability to lengthen the arm. The purpose of this study was to analyze multiple factors that may be predictive of motion after RSA. Our hypothesis is that intraoperative ROM is most predictive of postoperative ROM. METHODS: Between February 2003 and April 2011, 540 patients (217 men and 323 women) treated with RSA were evaluated with measurements of preoperative, intraoperative, and postoperative ROM at a follow-up, where ROM was found to have plateaued at 1 year as determined by a pilot study. A regression analysis was performed to define independent predictive factors of postoperative active ROM. RESULTS: Intraoperative forward flexion was the strongest predictor of final postoperative ROM, followed by gender and preoperative ROM. Age and arm lengthening were not significant independent predictors. Controlling for gender and preoperative ROM, patients with an intraoperative elevation of 90° gained 29° in postoperative forward elevation (P < .001), 120° gained approximately 40° in postoperative forward elevation (P < .001), 150° gained approximately 56° in postoperative forward elevation (P < .001) and 180° gained approximately 62° in postoperative forward flexion (P < .001). CONCLUSIONS: Intraoperative forward flexion is the strongest predictor of postoperative ROM. Surgeons may use intraoperative motion as a powerful decision-making tool regarding soft tissue tension in RSA.

Distal Humerus Fractures: Open Reduction Internal Fixation.

Distal humerus fractures are challenging injuries for the upper extremity surgeon. However, recent techniques in open reduction internal fixation have been powerful tools in getting positive outcomes. To get such results, the surgeon must be aware of how to properly use these techniques in their respective practices. The method of fixation depends on the fracture, taking the degree of comminution and the restoration of the columns and articular surface into account. This article helps surgeons understand the concepts behind open reduction internal fixation of the distal humerus and makes them aware of pitfalls that may lead to negative results.

Outcomes and Costs of Reverse Shoulder Arthroplasty in the Morbidly Obese: A Case Control Study.

BACKGROUND: The rising number of morbidly obese patients has important consequences for the health-care system. We investigated the effect of morbid obesity on outcomes, complications, discharge disposition, and costs in patients undergoing reverse shoulder arthroplasty. METHODS: Our joint registry was searched for all patients who had undergone primary reverse shoulder arthroplasty for a reason other than fracture from 2003 to 2010 and had a minimum of twenty-four months of follow-up. Twenty-one patients with a body mass index (BMI) of ≥40 kg/m2 were identified (follow-up, 45 ± 16 months; sex, seventeen female and four male; age, 69 ± 7 years) and were compared with sixty-three matched control patients with a BMI of <30 kg/m2 (follow-up, 48 ± 20 months; sex, fifty female and thirteen male; age, 71 ± 6 years) after an a priori sample size calculation. Outcome instrument data were obtained preoperatively and postoperatively. The Charlson-Deyo comorbidity index (CDI) score, total comorbidities, operative time, blood loss, duration of hospital stay, discharge disposition, costs, and complications were recorded. RESULTS: Compared with nonobese patients, morbidly obese patients had similar improvements in functional outcomes (e.g., American Shoulder and Elbow Surgeons score, 32 to 69 compared with 40 to 78) and in shoulder motion (e.g., forward flexion, 61° to 140° compared with 74° to 153°); all improvements were significant (p < 0.05). Morbidly obese patients had a similar rate of scapular notching (odds ratio [OR] = 0.58, p = 0.63), more total comorbidities excluding obesity (six compared with four, p = 0.001), a higher CDI (2 compared with 1, p = 0.025), and a higher rate of obstructive sleep apnea (OR = 27.7, p = 0.0001). Their operative time was thirteen minutes longer (p = 0.014) and their blood loss was 40 mL greater (p = 0.008). Morbidly obese patients had a similar duration of stay (3.1 compared with 2.6 days, p = 0.823) and hospital readmission rate (OR = 16.3, p = 0.08) but a sixfold higher rate of discharge to rehabilitation facilities rather than to home (OR = 8, p < 0.0001). Hospital costs were higher by $2974 (p = 0.009). The rates of major complications (n = 4 compared with 8, p = 0.479) and of minor complications (n = 3 compared with 14, p = 0.440) were similar. No intraoperative complications or mechanical device failures were noted in either group. CONCLUSIONS: Reverse shoulder arthroplasty appears to be as safe and effective in morbidly obese patients, although it has an increased cost and patients have a lower rate of discharge to home and greater care needs after discharge. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.