Revision shoulder arthroplasty and proximal humeral bone loss: a comprehensive review and proposal of a new algorithm of management.

With the rising prevalence of shoulder arthroplasty, the incidence of revision shoulder arthroplasty is also increasing. The complexity of these revision procedures poses significant challenges, with bone loss being a critical factor impacting treatment outcomes. Addressing substantial humeral bone defects is crucial for ensuring implant stability and functionality. A comprehensive literature review was conducted using PubMed, Medline, and Google Scholar to identify existing classification systems for proximal humeral bone loss in the context of revision shoulder arthroplasty. The study assessed the advantages and limitations of these classifications, using this information to propose a new diagnostic and therapeutic algorithm. Several classification systems for proximal humeral bone loss were identified. McLendon et al. classify proximal humeral bone loss based on a 5-cm bone loss threshold and suggest an allograft prosthesis composite for losses exceeding this limit. Boileau's system stratifies bone loss into four types based on the extent of loss, with specific recommendations for each category. The PHAROS classification provides a detailed anatomical assessment but lacks quantitative precision. The proposed PHBL-SCORe system offers a novel algorithm incorporating preoperative radiographic measurements to determine the percentage of bone loss and guide treatment options. Proximal humeral bone loss presents significant challenges in revision shoulder arthroplasty, necessitating precise preoperative planning and classification to guide surgical intervention. Existing classification systems provide valuable frameworks but often rely on average population values, neglecting individual anatomical variations. The proposed PHBL-SCORe system offers a patient-specific approach, improving the accuracy of bone loss assessment and optimizing treatment strategies. Implementing this classification in clinical practice could enhance surgical outcomes and reduce complications associated with rRSA (revision Reverse Shoulder arthroplasty). Further studies are required to validate this algorithm and explore its long-term efficacy in diverse patient populations.

Bone Density Changes at the Origin of the Deltoid Muscle following Reverse Shoulder Arthroplasty.

Background: Reverse total shoulder arthroplasty (RSA) significantly impacts deltoid length, tension, and structure. Studies have extensively investigated various modifications in deltoid characteristics, such as perfusion, elasticity, caliber, histological changes, and strength post-RSA. However, to date, there is a notable absence of research evaluating changes in bone mineral density (BMD) at the deltoid muscle origin after the RSA procedure. Methods: A retrospective analysis of a consecutive series of RSAs performed between May 2011 and May 2022 was conducted. Inclusion criteria comprised primary RSAs with both preoperative and last follow-up shoulder CT scans and a minimum follow-up of 12 months. Trabecular attenuation measured in Hounsfield units (HU) was calculated using a rapid region-of-interest (ROI) method. BMD analysis involved segmenting three ROIs in both pre- and postoperative CT scans of each patient: the acromion, clavicle, and spine of the scapula. Results: A total of 44 RSAs in 43 patients, comprising 29 women and 14 men, were included in this study. The mean follow-up duration was 49 ± 22.64 months. Significant differences were observed between preoperative and postoperative HU values in all analyzed regions. Specifically, BMD increased in the acromion and spine, while it decreased in the clavicle (p-values 0.0019, <0.0001, and 0.0088, respectively). Conclusions: The modifications in shoulder biomechanics and, consequently, deltoid tension post-implantation result in discernible variations in bone quality within the analyzed regions. This study underscores the importance of thorough preoperative patient planning. By utilizing CT images routinely obtained before reverse shoulder replacement surgery, patients at high risk for fractures of the acromion, clavicle, and scapular spine can be identified.

Reverse Shoulder Prosthesis for Proximal Humeral Fractures: Primary Treatment vs. Salvage Procedure.

Background: The optimal treatment for complex proximal humerus fractures (PHFs) lacks consensus, with reverse total shoulder arthroplasty (RTSA) often being a final resort rather than a primary approach. This study aimed to compare outcomes and satisfaction rates of primary RTSA for PHFs versus salvage RTSA for previously unsuccessful treatments. We hypothesized that primary RTSA would yield superior clinical outcomes, functional scores, and patient satisfaction. Methods: A retrospective analysis of RSA procedures between 2011 and 2021 was conducted, focusing on primary RTSA for PHFs or salvage RTSA for failed osteosynthesis. Patients meeting inclusion criteria underwent clinical and radiological follow-up for at least two years. Demographic characteristics, outcomes scores, and range of motion (ROM) were assessed. Results: Of 63 patients, 42 underwent primary RTSA and 21 underwent salvage RTSA. The median follow-up was 50 months. Statistically significant differences favored primary RTSA in forward flexion, abduction, internal rotation, and Constant shoulder score. Patient satisfaction levels did not significantly differ between groups. Complications occurred in 7.15% of primary RTSA cases and 14.28% of salvage RTSA cases. Conclusions: Primary RTSA may yield slightly better outcomes and lower complication rates compared to salvage RTSA. Further prospective studies are necessary to validate these findings.

Pediatric Floating Elbow: Case Report and Review of the Literature.

Floating elbow is defined as concomitant fracture of ipsilateral humerus and forearm. It is an uncommon injury with high potential to develop elevated forearm compartment pressures with potentially devastating neurological sequel. Several treatments have been reported. Although conservative treatment has been considered in the English literature, percutaneous or minimally invasive fixations is a goal when it is possible, soft tissue and growth plate preservation is crucial for fracture healing, mobility and bone growth.

Rotator Cuff Repair in Pediatric and Adolescent Athletes: Indications and Outcomes.

Rotator cuff (RC) tears in pediatric and adolescent athletes are rare events. In these patients, RC tears are more likely to be traumatic or related to overuse among overhead. Repeated movements of abduction and external rotation are frequent mechanisms of injury. The supraspinatus is the most commonly involved tendon and the articular-sided tears are more common than the bursal side. Magnetic resonance imaging is considered the gold standard for diagnosing RC tears. Conservative treatment, arthroscopic, and open repair are all effective treatment methods depending on the type of injury. The risk of growth plate injury in these patients should be always considered when planning surgical interventions. Return to sport for competitive-level throwing athletes represents the greatest challenge in the treatment of these injuries.

New tip-apex distance and calcar-referenced tip-apex distance cut-offs may be the best predictors for cut-out risk after intramedullary fixation of proximal femur fractures.

Cut-out is one of the most common mechanical failures in the internal fixation of trochanteric hip fractures. The tip-apex distance (TAD), and the calcar-referenced tip apex distance (CalTAD) are the radiographic parameters that most predict the risk of cut-out. The optimal CalTAD value has not yet been defined, but the optimal TAD value is reported as 25 mm or less. However, this cut-off is highly specific but poorly sensitive. The aim of this study was to determine highly specific and sensitive TAD and CalTAD values and shed light on the role of other clinical variables. A total of 604 patients were included in this retrospective cross-sectional study. For each patient the following data were recorded: number of cut-out, AO/OTA classification, quality of the reduction, type of nail, cervicodiaphyseal angle, type of distal locking, post-operative weight-bearing, TAD and CalTAD values, and the position of the screw head in the femoral head according to the Cleveland system. The incidence of cut-out across the sample was 3.1%. The median TAD in the cut-out group was 38.72, while in the no cut-out group it was 22.16. The median CalTAD in the cut-out group was 39.34, while in the no cut-out group it was 22.19. The cut-off values for TAD and CalTAD with highest value of sensitivity and specificity for the risk of cut-out were 34.8 and 35.2, respectively. The incidence of cut-out can be reduced by performing careful minimal reduction and ensuring stable fixation by avoiding TAD > 34.8 mm and CalTAD > 35.2 mm.

Impact of COVID-19 on surgical activities and personnel: lessons for the future.

BACKGROUND: COVID-19 pandemic has impacted professional, economic and social activities. In the surgical field, it has brought changes to operating activities, the organization of workforces, the protection measures for patients and personnel against possible intraoperative transmissions as well as training young surgeons. This study intends to assess the extent of this impact in our institution. METHODS: The patients operated on in nine Operating Units (OUs) in the period February 1 - March 31, 2020, with follow-ups on April 30, 2020, were evaluated both retrospectively and prospectively. Organizational, clinical and impact parameters on staff were evaluated. RESULTS: Of the 833 consecutive admitted patients, 742 were operated on, 705 of whom were recruited for the study. Compared to the same period in 2019 there was a decrease in the number of operations (742 compared to 1187), similar use of intensive care unit (ICU), a diagnostic activity only for symptomatic patients, heterogeneity in organizational behaviors, an impact on staff who highlighted concerns about getting sick or passing the infection on to others (87.64%) or their family members (75.14%). CONCLUSIONS: The present study made it possible to detect the need to make significant changes in the clinical, organizational and teaching fields, for which some operational proposals are suggested.

Diagnosis and treatment of melanoma bone metastasis: A multidisciplinary approach.

Bone is the fourth most common site of melanoma metastasis after lung, liver, and brain. Melanoma bone metastases typically occur in patients who already have widespread metastases in other organs. Current available approaches for bone metastases from melanoma include chemotherapy, radiotherapy, biological therapy, combination therapy, and surgery. In this narrative review, we describe the management of patients affected by melanoma bone metastases, discussing the diagnostic and treatment approaches as well as their impact on survival and quality of life. Despite the fact that clinical and surgical trials will be required to determine the most appropriate treatment, we do expect a newer and more important role of multidisciplinary approach in the management of melanoma patients with bone metastases in the next future.

Should evoked potential monitoring be used in degenerative cervical spine surgery? A systematic review.

BACKGROUND: Intraoperative somatosensory evoked potential (SSEP) and transcranial motor evoked potential (tcMEP) monitoring are frequently used in spinal as well as spinal cord surgery for so-called intraoperative neuromonitoring (IONM), while the combination of these techniques is known as concomitant multimodal intraoperative monitoring (MIOM). The aim of this review is to collect available evidence concerning use of IONM and MIOM in cervical decompression surgery in the degenerative setting and attempt to identify the best practice to be advocated. MATERIALS AND METHODS: A review of the PubMed and MEDLINE databases and Cochrane Central Registry of Controlled Trials was performed. Studies were included if they involved patients who underwent cervical spine decompression surgery for degenerative stenosis with use of IONM or MIOM and where sensitivity/specificity was reported. RESULTS: In the identified studies, the sensitivity of SSEP was estimated to be between 22 and 100% with constant specificity of 100%. In the included studies, the sensitivity of MEP was estimated to be between 78 and 100% with specificity ranging from 83.2 to 100%. CONCLUSIONS: On the basis of available evidence, MIOM could be a helpful tool in decompression cervical spine surgery in patients affected by degenerative spinal stenosis, since it is associated with high specificity and sensitivity for detection of intraoperative neural damage. However, evidence is still lacking regarding patient selection to identify individuals in whom monitoring is indicated. LEVEL OF EVIDENCE: IV (systematic review of studies with LOE II to IV).

Metastatic epidural spinal cord compression.

INTRODUCTION: Metastatic epidural spinal cord compression (MESSC) is a frequent event in patients affected by solid tumor metastases. Current available approaches for MESCC include corticosteroids, radiotherapy and surgery. In the last few years, surgery has evolved from decompression by laminectomy alone, with the introduction of instrumentation systems by metalware (screws and hooks), and this has been associated to an improvement of clinical results compared to radiotherapy alone. Areas covered: In this narrative review, we outline the phases of management of cancer patients affected by MESSC, and discuss the timing of treatments, their impact on the Quality of life (QoL), and the relative benefits and harms of surgery and radiotherapy. Expert commentary: Despite the fact that clinical and surgical trials will be required to determine the most appropriate surgical technique and timing of surgery, we do expect a newer and more important role for radiotherapy in the management of MESCC patients in the next future. In particular, the implementation of radiotactic stereosurgery as adjuvant to decompressive surgery is expected to increase in the next few years, above all in those patients that can be candidate to the so called separation surgery.