Anatomic total shoulder arthroplasty (TSA) has become more common as surgical indications have expanded. However, the burden of revision shoulder arthroplasty has inevitably increased as well. Multiple studies have examined the use of reverse total shoulder arthroplasty (rTSA) as a revision option for failed anatomic TSA with a massive irreparable rotator cuff tear. Successful reconstruction of failed TSA with rTSA requires sufficient glenoid bone to place the glenoid segment, enough proximal humeral bone to allow for implantation of the humeral component, and sufficient tension in the soft-tissue envelope to ensure implant stability. In this article, we describe our preferred rTSA revision technique for the treatment of a failed TSA.
Massive tears of the rotator cuff can result in severe functional deficits due to loss of the axial force couple and effective fulcrum that the intact cuff normally provides. For massive, irreparable rotator cuff tears, especially in the setting of early to moderate degenerative changes, reverse total shoulder arthroplasty functions to modify the center of joint rotation, allowing the deltoid and intact components of the cuff to carry out shoulder function more effectively. Our preferred technique uses a standard open deltopectoral shoulder approach with a 3-dimensional glenoid baseplate model and a 135° prosthesis in an onlay configuration to reduce the risk of scapular notching and increase lateralization of the humerus.
Modern approaches to resuscitation seek to bring patient interventions as close as possible to the initial trauma. In recent decades, fresh or cold-stored whole blood has gained widespread support in multiple settings as the best first agent in resuscitation after massive blood loss. However, whole blood is not a panacea, and while current guidelines promote continued resuscitation with fixed ratios of blood products, the debate about the optimal resuscitation strategy-especially in austere or challenging environments-is by no means settled. In this narrative review, we give a brief history of military resuscitation and how whole blood became the mainstay of initial resuscitation. We then outline the principles of viscoelastic hemostatic assays as well as their adoption for providing goal-directed blood-component therapy in trauma centers. After summarizing the nascent research on the strengths and limitations of viscoelastic platforms in challenging environmental conditions, we conclude with our vision of how these platforms can be deployed in far-forward combat and austere civilian environments to maximize survival.
Hypothesis and Background: There is no differences in abduction, internal rotation, or external rotation strength after reverse total shoulder arthroplasty (rTSA) with or without subscapularis repair. Repair of the subscapularis can be effective in the setting of rTSA. However, consensus has yet to be reached on whether postoperative strength after rTSA differs based on subscapularis management. The purpose of this review is to evaluate shoulder strength outcomes after rTSA with and without subscapularis tendon repair. Methods: A comprehensive literature review was conducted using the key terms "subscapularis" AND "reverse total shoulder arthroplasty" AND "muscle strength" in PubMed, Embase, Web of Science, Cochrane Reviews and Trials, and Scopus. Original, English-language studies evaluating shoulder strength outcomes after rTSA published from January 1, 2000, to present were evaluated. Strength outcomes reported included abduction strength (kg) and internal rotation strength (kg) using an electric spring balance and external rotation strength (lb) using a handheld dynamometer. Heterogeneity of data in the included studies did not allow for meta-analysis. Resuts: The search yielded 4253 unique results, which were screened for inclusion according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two articles met eligibility criteria and were included in the final full-text review. A total of 267 shoulders were represented, 111 with subscapularis repair and 156 without subscapularis repair. No significant differences in abduction (P = .39), internal rotation (P = .09), and external rotation (P = .463) strength were observed between subscapularis repair and nonrepair groups. Conclusion: There were no differences in abduction, internal rotation, or external rotation strength after rTSA with or without subscapularis repair. The literature on postoperative strength outcomes after rTSA is limited, and further study in this area is warranted.
Hypothesis/Background: There is no consensus on whether to repair the subscapularis in the setting of reverse total shoulder arthroplasty (rTSA). There have been an assortment of studies showing mixed results regarding shoulder stability and postoperative strength outcomes when looking at subscapularis repair in rTSA. The purpose of this systematic review was to investigate differences in biomechanical strength outcomes of cadaveric subscapularis repair vs. no repair in rTSA.Increased force will be required to move the shoulder through normal range of motion (ROM) in cadaveric rTSA shoulders with the subscapularis repaired when compared with no subscapularis repair. Methods: A comprehensive literature review was conducted in accordance with the 2009 Preferred Reporting Items for Systematic Review and Meta-Analysis statement. The databases used to search the keywords used for the concepts of subscapularis, reverse total shoulder arthroplasty, and muscle strength were PubMed (includes MEDLINE), Embase, Web of Science, Cochrane Reviews and Trials, and Scopus. Original, English-language cadaveric studies evaluating rTSA and subscapularis management were included, with subscapularis repair surgical techniques and strength outcomes being evaluated for each article meeting inclusion criteria. Results: The search yielded 4113 articles that were screened for inclusion criteria by 4 authors. Two articles met inclusion criteria and were subsequently included in the final full-text review. A total of 11 shoulders were represented between these 2 studies. Heterogeneity of the data across the 2 studies did not allow for meta-analysis. Hansen et al found that repair of the subscapularis with rTSA significantly increased the mean joint reaction force and the force required by the posterior deltoid, total deltoid, infraspinatus, teres minor, total posterior rotator cuff, and pectoralis major muscles. Giles et al found that rotator cuff repair and glenosphere lateralization both increased total joint load. Conclusion: The present review of biomechanical literature shows that repair of the subscapularis in the setting of rTSA can effectively restore shoulder strength by increasing joint reactive forces and ROM force requirements of other rotator cuff muscles and of the deltoid muscle. Available biomechanical evidence is limited, and further biomechanical studies evaluating the strength of various subscapularis repair techniques are needed to evaluate the effects of these techniques on joint reactive forces and muscle forces required for ROM.
PURPOSE: The purpose of this meta-analysis and systematic review was to critically evaluate the biomechanical outcomes of different fixation constructs for a variety of biceps tenodesis techniques in cadaveric models based on both type of fixation and location. METHODS: A PROSPERO-registered systematic review (CCRD42018109243) of the current literature was conducted with the terms "long head of biceps" AND "tenodesis" AND "biomechanics" and numerous variations thereof in the PubMed, Embase, and Cochrane databases, yielding 1,460 abstracts. After screening by eligibility criteria, 18 full-text articles were included. The individual biomechanical factors evaluated included ultimate load to failure (in newtons), stiffness (in newtons per millimeter), and cyclic displacement (in millimeters). After reviewing the included literature, we performed a quality analysis of the studies (Quality Appraisal for Cadaveric Studies scale score) and a meta-analysis comparing raw mean differences in data between the suprapectoral and subpectoral fixation location groups, as well as between the fixation construct groups. RESULTS: Among the 18 included studies, 347 cadaveric specimens were evaluated for ultimate load to failure, stiffness, and cyclic displacement when comparing both location (suprapectoral vs subpectoral) and tenodesis fixation type (interference screw vs cortical button, suture anchor, or all-soft-tissue techniques). Interference screw fixation showed significantly greater mean stiffness by 8.0 N/mm (P = .013) compared with the other grouped techniques but did not show significant differences when evaluated for ultimate load to failure and cyclic displacement (P = .28 and P = .18, respectively). Additionally, no difference in construct strength was seen when comparing the fixation strength of suprapectoral versus subpectoral techniques for stiffness, ultimate load to failure, and cyclic loading (P = .47, P = .053, and P = .13, respectively). CONCLUSIONS: In this meta-analysis, no significant biomechanical differences were found when the results were stratified by specific surgical technique (interference screw vs other tenodesis techniques) and location (suprapectoral vs subpectoral biceps tenodesis). CLINICAL RELEVANCE: As a result of this study, when biomechanically evaluating specific tenodesis constructs, the individual clinician has the liberty of choosing the fixation technique based on his or her preference and knowledge of shortcomings of each type of fixation construct.
Muscle, Skeletal/surgery , Tenodesis/methods , Arm/surgery , Biomechanical Phenomena , Bone Screws , Cadaver , Humans , Suture Anchors
Chronic instability of the sternoclavicular (SC) joint is a challenging clinical problem, particularly in a patient population for which nonoperative forms of treatment prove ineffective. Patients present after experiencing recurrent subluxation events and subsequent pain, which commonly result in increasing functional limitation. Recurrent SC joint instability of this nature can lead to damage of the SC joint cartilage and bone, and in cases of posterior subluxation or dislocation, damage to mediastinal structures. While the precise treatment algorithm requires tailoring to individual patients and their respective pathologies, we have demonstrated successful outcomes in correcting chronic SC joint instability by means of SC joint reconstruction with semitendinosus allograft, SC joint capsular reconstruction, and, in cases of arthritic damage, resection of a small portion of the degenerative component of the medial clavicle. The purpose of this Technical Note is to describe a technique that uses a semitendinosus allograft to stabilize the SC joint combined with a capsular reconstruction in patients who have previously failed nonoperative treatment methods.
Recurrent multidirectional shoulder instability (MDI) is a challenging clinical problem, particularly in the setting of connective tissue diseases, and there is a distinct lack of literature discussing strategies for operative management of this unique patient group. These patients frequently present with significant glenoid bone loss, patulous and abnormal capsulolabral structures, and a history of multiple failed arthroscopic or open instability procedures. Although the precise treatment algorithm requires tailoring to the individual patient, we have shown successful outcomes in correcting recurrent MDI in the setting of underlying connective tissue disorders by means of a modified T-plasty capsular shift and rotator interval closure in conjunction with distal tibial allograft bony augmentation. The purpose of this Technical Note was to describe a technique that combines a fresh distal tibial allograft for glenoid bony augmentation with a modified T-plasty capsular shift and rotator interval closure for the management of recurrent shoulder MDI in patients presenting with Ehlers-Danlos syndrome or other connective tissue disorders after failed Latarjet stabilization.
