Lateralising reverse shoulder arthroplasty using bony increased offset (BIO-RSA) or increasing glenoid component diameter: comparison of clinical, radiographic and patient reported outcomes in a matched cohort.

BACKGROUND: This study aims to compare the range of motion (ROM) of reverse shoulder arthroplasty lateralised by bony increased offset (BIO-RSA) using a standard 38-mm (mm) component to regular reverse shoulder arthroplasty (RSA) lateralised by using a 42-mm glenoid component. The secondary aims are to compare patient-reported and radiographic outcomes between the two groups. MATERIALS AND METHODS: All patients with a BIO-RSA and size 38 glenosphere were retrospectively identified and matched to patients with a regular RSA and size 42 glenosphere. Matched patients were invited for a follow-up visit. ROM was assessed as well as radiographic outcomes (lateralisation, distalisation, inferior overhang, scapular notching, heterotopic bone formation, radiolucency, stress shielding, bone graft healing and viability and complications) and patient-reported outcomes (subjective shoulder value, Constant score, American Shoulder and Elbow Surgeons, activities of daily living which require internal rotation, activities of daily living which require external rotation and a visual analogue scale for pain). Outcomes were compared between the two groups. RESULTS: In total, 38 BIO-RSAs with a size 38 glenosphere were matched to 38 regular RSAs with a size 42 glenosphere. Of the 76 matched patients, 74 could be contacted and 70 (95%) were included. At the final follow-up, there were no differences between the two groups in ROM, patient-reported outcomes or radiographic outcomes (p > 0.485). CONCLUSIONS: Using a larger glenosphere is a feasible alternative to BIO-RSA for lateralising RSA, providing comparable ROM, patient-reported and radiographic results, while potentially decreasing costs, operative time and complication rates.

High Vertical and Horizontal Stability at Short-Term Follow-Up After an All-Endoscopic Double Cerclage Endobutton Technique for Acute Acromioclavicular Joint Separations.

PURPOSE: To evaluate the clinical and radiological outcomes in the treatment of acute acromioclavicular (AC) joint separations using an all-endoscopic double cerclage endobutton technique compared with an arthroscopic-assisted single-bundle endobutton technique and to analyze the complication, failure, and revision rates of both procedures. METHODS: All patients with acute Rockwood type IIIB and V AC joint separations who were operated on using an all-endoscopic double cerclage technique (2019-2022) or an arthroscopic-assisted single-bundle technique (2017-2019) were included. The follow-up period was at least 12 months. Clinical and radiographic assessment was performed at follow-up. Complications, failures, and revisions were also investigated. RESULTS: Twenty-eight patients (14 double cerclage group, 14 single-bundle group, all male) with an average age of 37 years (interquartile range [IQR], 15) were available for follow-up after 45 months (IQR, 38). The median time between trauma and surgery was 7 days (IQR, 8). Very good clinical results without significant differences were observed in both groups (Constant score, 94 [IQR, 12] vs 95 [IQR, 15], P = .427, AC joint instability score, 95 [IQR, 11] vs 87 [IQR, 22], P = .210). All patients returned to sport, with an average sports level of 95% compared with preoperative status. The single-bundle group showed significantly increased anteroposterior instability (6 vs 0, P = .006). A total of 5 complications occurred (2 vs 3), leading to 1 revision surgery in each group. CONCLUSIONS: Excellent clinical results and high vertical and horizontal stability can be achieved with the all-endoscopic double cerclage technique. Horizontal instability occurred significantly more frequently with the single-bundle technique. The prolonged operation time in the double cerclage group had no negative impact on postoperative outcomes, including complication and failure rates, and a learning curve to reduce this prolonged operative time should be considered. LEVEL OF EVIDENCE: Level III, retrospective comparative clinical series.

Surgical treatment of fracture sequelae of the proximal humerus according to a pathology-based modification of the Boileau classification results in improved clinical outcome after shoulder arthroplasty.

BACKGROUND: Fracture sequelae of the proximal humerus were classified by Boileau into four types. Since there are pathomorphological differences and specific characteristics within the four types, we have developed a subclassification. For elderly patients, shoulder arthroplasty is mostly recommended. Based on the available literature and clinical trial results, a subclassification could be created that suggests a specific therapy for each subgroup. The aim of this study was to evaluate the endoprosthetic therapy according to the proposed subclassification and to provide an overview of the clinical and radiological results after endoprosthetic treatment of proximal humerus fracture sequelae. METHODS: Patients with fracture sequelae of the proximal humerus who underwent arthroplasty according to the suggestion of the subclassification were included. Minimum time to follow-up was twelve months. General condition and several specific shoulder scores as the Constant-Murley Score (CS) were recorded at the follow-up examination. Complication and revision rates were analyzed. RESULTS: In total, 59 patients (72.6 ± 10.0 years, 47 females, 12 males) were included. Mean follow-up time was 31.3 ± 17.0 months. Reverse shoulder arthroplasty was performed in 49 patients and anatomic shoulder arthroplasty was performed in ten patients. The CS increased by 47.3 points from preoperative (15.0) to postoperative (62.3). Good or very good clinical results were seen in 61% of the patients. Complications were observed in twelve (20%) patients and revision surgery was performed in nine (15%) patients. CONCLUSION: Due to of the variety of fracture sequelae of the proximal humerus, a modification of the Boileau classification seems necessary. This study shows that endoprosthetic treatment for fracture sequelae can significantly improve the shoulder function in elderly patients. Good clinical results can be achieved with a comparatively low revision rate following the treatment suggestions of the proposed subclassification of the Boileau classification. LEVEL OF EVIDENCE IV: Case series.

Correct positioning of the calcar screw leads to superior results in proximal humerus fractures treated with carbon-fibre-reinforced polyetheretherketone plate osteosynthesis with polyaxial locking screws.

BACKGROUND: Plate osteosynthesis with implants made of carbon-fibre-reinforced polyetheretherketone (CFR-PEEK) has recently been introduced for the treatment of fractures of the proximal humerus (PHFs). The advantages of the CFR-PEEK plate are considered to be its radiolucency, its favourable modulus of elasticity, and the polyaxial placement of the screws with high variability of the angle. The primary aim of this study is to investigate the influence of calcar screw positioning on the complication and revision rates after CFR-PEEK plating of PHFs. The secondary aim is to assess its influence on functional outcome. MATERIAL AND METHODS: Patients were identified retrospectively. Minimum follow-up was 12 months. The cohort was divided into two groups depending on the distance of the calcar screw to the calcar (group I: < 12 mm, group II: ≥ 12 mm). The range of motion (ROM), Subjective Shoulder Value Score (SSV) and Constant-Murley Score (CS) were analysed at follow-up examination. Subjective complaints, complications (e.g. humeral head necrosis, varus dislocation) and the revision rate were evaluated. RESULTS: 51 patients (33 female, 18 male) with an average age of 68.6 years were included after a period of 26.6 months (group I: 32 patients, group II: 19 patients). Apart from the gender distribution, no significant differences were seen in the patient characteristics. The outcome scores showed significantly better clinical results in group I: SSV 83.4 vs 71.2, p = 0.007; CS 79.1 vs 67.8, p = 0.013. Complications were seen less frequently in group I (18.8 % vs 47.4 %, p = 0.030). CONCLUSION: This study shows that the positioning of the calcar screw is relevant for CFR-PEEK plate osteosynthesis in PHFs with a good reduction of the fracture. Optimal positioning of the calcar screw close to the calcar (< 12 mm) is associated with a lower rate of complications, resulting in significantly superior functional outcomes. LEVEL OF EVIDENCE: III, retrospective cohort study.

Functional results and unfavorable events after treatment of proximal humerus fractures using a new locking plate system.

BACKGROUND: Proximal humerus fractures are often treated with a fixed-angle titanium plate osteosynthesis. Recently, plates made of alternative materials such as carbon fibre-reinforced polyetheretherketone (CFR-PEEK) have been introduced. This study presents the postoperative results of patients treated with a CFR-PEEK plate. METHODS: Patients with proximal humerus fractures treated with a CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) were included. In follow-up examination, age and gender adjusted Constant-Murley Score (ACS), Subjective Shoulder Value (SSV), Quick Disabilities of the Arm, Shoulder and Hand Score (QDASH) and pain score (Visual Analog Scale (VAS)) were analyzed. General condition at follow-up was measured by European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L). Range of motion was recorded. In addition, radiographs at follow-up, unfavorable events and revision rate were analyzed. RESULTS: In total, 98 patients (66.0 ± 13.2 years, 74 females, 24 males) were reexamined. Mean follow-up was 27.6 ± 13.2 months. There were 15 2-part, 28 3-part and 55 4-part fractures. The functional scores showed good results: SSV 83.3 ± 15.6%, QDASH 13.1 ± 17.0 and ACS 80.4 ± 16.0. A 4-part-fracture, head split component, nonanatomic head shaft reposition and preoperative radiological signs of osteoarthritis were significant negative predictors for poorer clinical scores. Unfavourable events were observed in 27 patients (27.6%). Revision surgery was performed in 8 (8.2%) patients. Risk factors for an unfavourable event were female gender, age of 50 years and older, diabetes, affected dominant hand, 4-part fracture, head split and preoperative radiological signs of osteoarthritis. CONCLUSION: There are several advantages of the CFR-PEEK plate (PEEKPower™ Humeral Fracture Plate (HFP)) such as the polyaxial screw placement and higher stability of locking screws. In summary, the CFR-PEEK plate osteosynthesis is a good alternative with comparable clinical results and some biomechanical advantages. Proximal humerus fractures show good clinical results after treatment with a CFR-PEEK plate. The revision rate and the risk of unfavorable events are not increased compared to conventional titanium plate osteosynthesis. LEVEL OF EVIDENCE: IV.

Treatment of avascular necrosis of the humeral head - Postoperative results and a proposed modification of the classification.

BACKGROUND: Avascular necrosis of the humeral head after proximal humeral fracture i.e. type 1 fracture sequelae (FS) according to the Boileau classification is a rare, often painful condition and treatment still remains a challenge. This study evaluates the treatment of FS type 1 with anatomic and reverse shoulder arthroplasty and a new subclassification is proposed. METHODS: This single-center, retrospective, comparative study, included all consecutive patients with a proximal humeral FS type 1 treated surgically in a four-year period. All patients were classified according to the proposed 3 different subtypes. Constant score (CS), Quick DASH score, subjective shoulder value (SSV) as well as revision and complication rate were analyzed. In the preoperative radiographs the acromio-humeral interval (AHI) and greater tuberosity resorption were examined. RESULTS: Of 27 with a FS type 1, 17 patients (63%) with a mean age of 64 ± 11 years were available for follow-up at 24 ± 10 months. 7 patients were treated with anatomic and 10 with reverse shoulder arthroplasty. CS improved significantly from 16 ± 7 points to 61 ± 19 points (p < 0.0001). At final follow-up the mean Quick DASH Score was 21 ± 21 and the mean SSV was 73 ± 21 points. The mean preoperative AHI was 9 ± 3 mm, however, 8 cases presented an AHI < 7 mm. 4 cases had complete greater tuberosity resorption. The complication and revision rate was 19%; implant survival was 88%. CONCLUSION: By using the adequate surgical technique good clinical short-term results with a relatively low complication rate can be achieved in FS type 1. The Boileau classification should be extended for fracture sequelae type 1 and the general recommendation for treatment with hemiarthroplasty or total shoulder arthroplasty has to be relativized. Special attention should be paid to a decreased AHI and/or resorption of the greater tuberosity as indirect signs for dysfunction of the rotator cuff. To facilitate the choice of the adequate prosthetic treatment method the suggested subclassification system should be applied.

Locked fracture dislocations of the proximal humerus: postoperative results and a proposed modification of the classification.

BACKGROUND: Locked dislocations of the glenohumeral joint are disabling and often painful conditions and the treatment is challenging. This study evaluates the functional outcome and the different prosthetic treatment options for chronic locked dislocations of the glenohumeral joint and a subclassification is proposed. METHODS: In this single-center retrospective case series, all patients with a chronic locked dislocation treated surgically during a four-year period were analyzed. Constant score (CS), Quick Disabilities of Shoulder and Hand Score (DASH), patient satisfaction (subjective shoulder value (SSV)), revision rate and glenoid notching were analyzed. RESULTS: 26 patients presented a chronic locked dislocation of the glenohumeral joint. 16 patients (62%) with a mean age of 75 [61-83] years were available for follow-up at 24 ± 18 months. CS improved significantly from 10 ± 6 points to 58 ± 21 points (p < 0.0001). At the final follow-up, the mean DASH was 27 ± 23 and the mean SSV was 58 ± 23 points. The complication rate was 19% and the revision rate was 6%; implant survival was 94%. Scapular notching occurred in 2 (13%) cases (all grade 1). CONCLUSION: With good preoperative planning and by using the adequate surgical technique, good clinical short-term results with a low revision rate can be achieved. The authors suggest extending the Boileau classification for fracture sequelae type 2 and recommend using a modified classification to facilitate the choice of treatment as the suggested classification system includes locked posterior and anterior dislocations with and without glenoid bone loss. LEVEL OF EVIDENCE: IV.