A rare giant geode of humeral head in an uncontrolled rheumatoid arthritis: a case report.

INTRODUCTION: Rheumatoid Arthritis (RA) is a chronic inflammatory disease depicted by peripheral bone erosive damage leading to joint destruction, deformity and functional impairment. Shoulder involvement is less frequent than hands, wrists and feet, and relevant joint damage may be underdiagnosed if a lower threshold for careful analysis of this joint is not settled, especially in uncontrolled disease. CASE REPORT: A 70-year-old male with a difficult-to-manage RA since 2010, presenting severe shoulder arthritis with MRI showing a striking giant geode in the left humeral head. CONCLUSION: An impressive MRI image showing a giant geode in poorly controlled RA should alert rheumatologists to raise suspicion of shoulder involvement for early investigation and treatment.

The Hertel classification can't predict the risk of humeral head osteonecrosis after osteosynthesis using an anterolateral approach.

BACKGROUND: Proximal humeral fractures can progress to osteonecrosis of the humeral head. Hertel developed a binary classification system (12 subtypes) and demonstrated that some patterns have more risk to develop osteonecrosis. Hertel described the prevalence and the risk factors for Humeral head osteonecrosis after osteosynthesis using a Deltopectoral approach. Few studies have evaluated the prevalence and the capacity of Hertel's classification to predict Humeral Head osteonecrosis following osteosynthesis of proximal Humeral fractures through the anterolateral approach. The objectives of this study were to correlate osteonecrosis predictors established by the Hertel classification with the risk of developing osteonecrosis and its prevalence after osteosynthesis using the anterolateral approach. METHODS: This was a retrospective study of patients who underwent osteosynthesis of proximal humerus fractures using an anterolateral approach. Patients were divided into two groups: high risk for necrosis (group 1) and low risk for necrosis (group 2) according to Hertel's criteria. The overall prevalence of osteonecrosis and the prevalence in each group were calculated. A radiological examination was performed in the true anteroposterior (Grashey), scapular, and axillary views, before and after the operation (minimum 1 year after surgery). A Kaplan-Meier curve was used to assess the pattern of the temporal evolution of osteonecrosis. The groups were compared using the Chi-square test or Fisher's exact test. The unpaired t-test (parametric variables - age) and the Mann-Whitney test (non-parametric time between trauma and surgery) were used. RESULTS: In total, 39 patients were evaluated. The postoperative follow-up time was 14.5 ± 3.3 months. The time to onset of necrosis was 14.1 ± 3.9 months. Sex, age, and time between trauma and surgery did not influence the risk of necrosis. Type 2, 9, 10, 11, and 12, or fractures with posteromedial head extension less than or equal to 8 mm, or diaphysis deviation greater than 2 mm, as well as grouping did not influence the risk for osteonecrosis. CONCLUSIONS: Hertel's criteria were not able to predict the development of osteonecrosis after osteosynthesis of proximal humerus fractures performed through the anterolateral approach. The total prevalence of osteonecrosis was 17.9% with a tendency toward an increased incidence after 1 year of surgical treatment.

Can Rapid Progression in Nonambulatory Cerebral Palsy Scoliosis Be Predicted Using Humeral Head Ossification?

BACKGROUND: Patients with cerebral palsy scoliosis (CPS) experience higher complication rates compared with idiopathic scoliosis and often present for surgery with larger curves. Prediction of an inflection point for rapid deformity progression has proven difficult. A proximal humerus-based skeletal maturity staging system (HS) has been recently validated and is commonly visible on the posteroanterior radiograph. The authors hypothesize that this system can be used to identify a period at which CPS may progress rapidly, perhaps facilitating discussion of timely surgical intervention. METHODS: A retrospective review was conducted for nonambulatory pediatric patients with CPS who presented between 2009 and 2018 at our institution. All patients were considered for inclusion regardless of operative or nonoperative management. Patients who were skeletally mature at initial evaluation or had prior spine surgery were excluded. The authors analyzed radiographs in each HS available. Survival was calculated for cutoffs of 60 and 70 degrees (numbers found to increase intraoperative and postoperative complications for CPS). RESULTS: Eighty-six patients with CPS were identified (54 male individuals). Major curves increased significantly between HS 1 and 2 (27.7 to 46.6 degrees, P=0.009) and HS 3 and 4 (53.1 to 67.9 degrees, P=0.023). The proportion of curves ≥70 degrees were significantly different between HS (P<0.001), with the greatest increase between HS 3 and 4 (24% to 51%; ≥70 degrees). The largest drop in the 60/70-degree survival curves was between HS 3 and 4. In a subanalysis, 69% of patients with curves ≥40 degrees but <70 degrees in stage 3 would progress ≥70 degrees by stage 4. CONCLUSIONS: Identifying a period of rapid curve progression may guide surgical planning before CPS curves become large, stiff, and more difficult to fix. Our findings suggest that humeral skeletal maturity staging is a valuable decision-making tool in neuromuscular scoliosis, with the HS 3 to 4 transition representing the time of the greatest risk of progression. Consider a surgical discussion or shortened follow-up interval for patients with CPS with curves ≥40 degrees who are HS 3. LEVEL OF EVIDENCE: Level II.

The rotation of the humeral head does not alter radiographic evaluation of the head-shaft angle.

BACKGROUND: The head-shaft angle is used to plan osteotomies and arthroplasties and to assess the radiographic outcomes of surgical treatment for proximal humerus fractures. There are no published data showing whether different degrees of arm rotation interfere with the evaluation of this angle. METHODS: Eighteen humeri from adult cadavers were used. Radiographs were taken with the specimens initially placed in a true anteroposterior position and then subsequently positioned with internal and external rotations of 10°, 20°, and 30°. All radiographs were evaluated by 3 shoulder and elbow surgeons at 2 different times 3 months apart. The head-shaft angle was measured using a picture archiving and communication system. RESULTS: For the humerus in the neutral position, the head-shaft angle was 137° ± 4°. With the anatomic specimen positioned with increasing external and internal rotations, there was a maximum difference of 2° compared with the value observed in the neutral position, which was not a significant difference (P = .911). Measurements of the head-shaft angle showed a good interobserver correlation coefficient, with a value of 0.788 (0.728-0.839) for all measurements. The intraobserver correlation coefficient ranged from moderate to excellent (0.536-0.938). CONCLUSION: The head-shaft angle did not change significantly with varying degrees of humeral rotation. The interobserver correlation coefficient showed good reliability, and the intraobserver correlation was moderate to excellent.

Humeral internal rotation osteotomy for the treatment of Erb-Duchenne-type obstetric palsy: clinical and radiographic results.

OBJECTIVE: To evaluate the functional and radiographic results in patients undergoing shoulder anterior soft tissue stretching in association with open reduction and internal rotation osteotomy to centralize the humeral head as a treatment for Erb-Duchenne obstetric palsy sequelae. METHOD: A total of 35 patients underwent this surgical treatment, and the mean follow-up was 4.6 years. The Mallet scale was applied before and after the surgical procedure. A total of 20 patients underwent computed tomography to assess the glenoid version and humeral head subluxation. RESULTS: Functional improvement was achieved, as evidenced by an increase in the Mallet scale score from 12.14 to 16.46 (p<0.001). The correction of retroversion was achieved once the glenoid version ranged from -21.4 to -12 degrees (p<0.001). The humeral head subluxation improved from 6.5 to 35.2% (p<0.001). Patients older than 6 years of age did not achieve glenohumeral joint improvement with respect to dysplastic abnormalities. CONCLUSION: Internal rotation osteotomy in association with the stretching of anterior soft tissues of the shoulder in patients under the age of 7 years provided improvements in the function, retroversion, and subluxation of the glenohumeral joint.

[Posterior locked shoulder fracture-dislocation: anatomical resconstruction of reverser Hill-Sachs lession]. / Fractura-luxación posterior inestable del hombro: reconstrucción anatómica de la lesión de Hill-Sachs invertida.

The posterior instability of the shoulder only represents 4% of the shoulder instabilities. For the diagnosis, the antero-posterior, transtoracic and axilar radiographic projections are recommended. The inverted Hill-Sachs lesion is a fracture caused by compression of the antero-medial part of the humeral head during the posterior dislocation. Its treatment results, at least, controverted. Choosing the treatment of these lesions one of the main factors is the size of the defect in the humeral head. When it is smaller than 20%, the simple reduction usually is enough. Between 20-40%, we can opt for a transposition of the subescapular insertion to the bony defect (technique of MacLaughlin) or the anatomical reconstruction of the head by means of the fixation of an allograft. The transposition of the subescapular´s tendon carries a reduction of the internal rotation by medializing its insertion, for this reason, we opted for the anatomical reconstruction with allograft of femoral head that reestablishes the muscular balance. The shoulder artroplasty is elective when bony defects are bigger (>40-50 % of the articulation surface). We present the case of a 32 year-old patient, with the antecedent of convulsive crisis. Clinically he suffered intense pain with functional impotence and elastic limitation for the external rotation in left shoulder. The radiographic studies evidenced an instable posterior fracture-dislocation with inverted Hill-Sachs lesion associated that involved the 30% of the articular surface. The patient was surgically treated, opting for a reconstructive technique for humeral head. After six months, the range of motion is almost symmetrical with regard to the healthy shoulder, without any clinic of instability.