Reverse shoulder arthroplasty in obstetric brachial plexus injury: our experience with shoulder motion analysis.

BACKGROUND: Obstetric brachial plexus injury (OBPI) is a weakening or paralysis of the upper arm caused by brachial plexus injury followed by a muscle paralysis with severe repercussions on the movement of the shoulder joint following a progressive glenohumeral joint deformity. This case series analyzes the clinical and radiological outcomes of reverse total shoulder arthroplasty (RSA) in OBPI patients with a follow-up of 2 years. MATERIALS AND METHODS: OBPI patients with secondary end-stage glenohumeral arthritis were enrolled in the study and they were treated with RSA. Patient demographics and clinical outcomes [Range of Motion (ROM), Visual Analog Scale (VAS), Oxford Shoulder Score (OSS)] were evaluated. A novel Shoulder motion analysis was carried out to investigate specific movement patterns of scapulothoracic movements in these patients. This study is a prospective cohort study. RESULTS: Four Patients (M: F = 1:3) were enrolled in the study, the mean age was 49.3 years (+ 2.75), the mean OSS (Oxford Shoulder Score) decreased from 48.8 (± 2.5) preoperatively to 18.30 (± 2.78), the mean VAS (Visual Analog Scale) decreased from 7.25 (± 0.5) to 1.7 (± 0.3) in the follow up (∆% relative pain reduction:- 76.5%), Shoulder ROM obtained an improvement (p < 0.05) except for abduction and external rotation. The average follow-up time was 26.3 months (+- 4.5). Shoulder motion analysis showed a complete loss of the scapular tilting above 90 degrees of flexion compared to the typical one of standard RSA with a pattern shifted towards scapular retraction (engaging trapezius and rhomboid muscles) to compensate the loss of the posterior tilting. CONCLUSIONS: RSA in OBPI patients demonstrated a significant improvement of pain symptoms and a moderate improvement in daily activities, anyway with a more appreciable quality of life over time even if the marked hypotrophy especially of the posterior shoulder muscles showed some limits in maintaining suspension of the upper limb and a minor external rotation, with an internal rotation attitude during the movements. LEVEL OF EVIDENCE: Level IV, Case series.

Navigation in reverse shoulder arthroplasty: how the lateralization of glenosphere can affect the clinical outcome.

INTRODUCTION: One of the main causes of RSA failure is attributable to the malpositioning of the glenoid component. Initial experiences with computer-assisted surgery have shown promising results in increasing the accuracy and repeatability of placement of the glenoid component and screws. The aim of this study was to evaluate the functional clinical results, in terms of joint mobility and pain, by correlating them with intraoperative data regarding the positioning of the glenoid component. The hypothesis was that the lateralization more than 25 mm of the glenosphere can led to better stability of the prosthesis but should pay in term of a reduced range of movement and increased pain. MATERIALS AND METHODS: 50 patients were enrolled between October 2018 and May 2022; they underwent RSA implantation assisted by GPS navigation system. Active ROM, ASES score and VAS pain scale were recorded before surgery. Preoperative data about glenoid inclination and version were collected by pre-op X-Rays an CT. Intraoperative data-inclination, version, medialization and lateralization of the glenoid component-were recorded using computer-assisted surgery. 46 patients had been further clinically and radiographically re-evaluated at 3-months, 6-months, 1-year, and 2-years follow-up. RESULTS: We found a statistically significant correlation between anteposition and glenosphere lateralization value (DM - 6.057 mm; p = 0.043). Furthermore a statistically significant correlation has been shown between abduction movement and the lateralization value (DM - 7.723 mm; p = 0.015). No other statistically significant associations were found when comparing the values of glenoid inclination and version with the range of motion achieved by the patients after reverse shoulder arthroplasty. CONCLUSION: We observed that the patients with the best anteposition and abduction results had a glenosphere lateralization between 18 and 22 mm. When increasing the lateralization above 22 mm or reducing it below 18 mm, on the other hand, both movements considered decreased their range. LEVEL OF EVIDENCE: Level IV; Case Series; Treatment Study.

Locked anterior glenohumeral dislocation: is it always recommendable a conservative treatment?

PURPOSE: Chronic anterior shoulder dislocation represents a rare condition, and there is still lack of consensus in its treatment. Purpose of this study is to evaluate the clinical and radiological outcome of painful locked dislocation underwent shoulder replacement, with a minimum follow-up of two years. Second endpoint is to assess the glenoid bone graft, harvested from the humeral head. METHODS: Eight patients underwent shoulder replacement for locked anterior shoulder dislocation. Four patients with a mean age of 23 y.o. were treated with Pyrocarbon-hemiarthroplasty and four patients with a mean age of 76 y.o. were treated with reverse shoulder arthroplasty. Glenoid single stage reconstruction was performed with a bone autograft harvested from the resected humeral head. Patients were observed for a clinical and radiological follow-up for a minimum period of 2 years; ASES and Constant score were assessed. RESULTS: Pain and ROM improvement was reported in all the patients. In one case, postoperative recurrent RSA instability was found. Glenoid reconstruction was performed in seven cases, showing a good integration and no reabsorption issues in all but one cases. ASES and Constant-Murley functional outcomes were rated as excellent by 1 patient with pyrocarbon HA and 1 patient with RSA, good by 3 patients with RSA and 2 patients with HA, fair by 1 patient with HA and poor by one patient with RSA. CONCLUSION: The treatment of locked anterior glenohumeral dislocation still represents a challenge in symptomatic patients. Shoulder replacement showed good results in young and older patients, with HA and RSA, respectively. Autograft from the humeral head is reliable for glenoid defect, even in ream and run procedure. Locked dislocation lasting more than one year, surgery is debatable for higher risk of a poor outcome and recurrent instability.

A Long-Term Follow-Up of Post-Operative Periprosthetic Humeral Fracture in Shoulder Arthroplasty.

BACKGROUND: During the last decades, the growing number of shoulder replacement has increased the associated complications. Periprosthetic fractures have a low incidence but can be a severe clinical condition, especially in elderly population. There are still no guidelines to define the best treatment protocol for post-operative periprosthetic humeral fractures. Factors associated to these fractures and consequently the decision-making for the best treatment seem to be patient-related but also correlated with the type of implant. The aim of this study is to analyze the patient's risk factors, fracture pattern, implant type and treatment, evaluating the outcome with a long-term follow-up. METHODS: A retrospective study was performed on more than 2700 shoulder prostheses implanted over 10 years in two specialized centers, identifying 19 patients who underwent surgery for post-operative periprosthetic fracture. Gender, age, comorbidities, type of prosthetic implant, type of fracture, and cortical index of each patient were evaluated. All patients underwent surgery and were evaluated with a mean follow-up of 5 years with radiographic controls and functional assessment with the Constant-Murley score. RESULTS: Complete healing was achieved in 18 of 19 patients. All patients presented a lower Constant-Murley score than the pre-fracture score, there were no significant differences between prosthetic implants, and the cortical index was lower than the threshold level in more than 60% of cases. CONCLUSION: The results of this study showed that a correct preoperative planning is essential to evaluate the type of implant and possible signs of stem mobilization. With a stable stem, it is preferable to maintain it and proceed to a synthesis. The decision process is more complex in periprosthetic fractures with a reduced cortical index, when some radiolucency lines are present in stems with high primary stability, because it is not always indicative of an unstable stem. LEVEL OF EVIDENCE: Therapeutic III.

Surgical tips and tricks for coronal shear fractures of the elbow.

INTRODUCTION: Coronal shear fractures of the distal humerus represent an uncommon lesion and could be burdened by high complications. This complex lesion requires an accurate reduction and surgical fixation for a better outcome. Different techniques have been described, however no standard protocol have been proposed. Purpose of this retrospective study, is to evaluate the clinical and radiological outcome with posterior cannulated self-tapping headless screws followed by an early-active-motion protocol and to outline the surgical tips and tricks for different fracture patterns. MATERIALS AND METHODS: From 2013 to 2019, a consecutive series of 24 patients with coronal shear fracture undergoing ORIF were included in the study. Fractures were classified according to Dubberley's classification. Cannulated self-tapping headless screws were used to fix the fragments. When necessary, additional cannulated half-threaded screws on the lateral edge of the humerus were used, as well as bone chips and fibrin sealant on severe comminution. All patients underwent an assisted early-active-motion rehabilitation protocol. Mean follow-up was 30 months; patients underwent standard X-rays and clinical outcome assessment with range of motion, Broberg and Morrey score and MEPI score. RESULTS: Surgical fixation with headless screw guaranteed complete healing of all shear fractures examined, no loss of reduction were reported. ROM assessment showed good results with an average arc of 113.1°. Excellent to good Broberg-Morrey and MEPI score were reported. No cases of avascular necrosis nor post-traumatic osteoarthritis resulted in our series. Complications occurred in 16.6% of the patients. CONCLUSION: Coronal shear fracture represents a challenging injury to treat. Anatomical reduction and the use of cannulated self-tapping headless screws from posterior provide a stable fixation, high union rates and good elbow function, with a low cartilage damage and risks of necrosis over 2 years of follow-up. LEVEL OF EVIDENCE: Therapeutic III.

Acute elbow dislocation: comparison between magnetic resonance imaging and intra-operative finding of ligament injury.

PURPOSE: The aim of this current study was to assess elbow ligament tears after dislocation using magnetic resonance imaging (MRI) and to correlate any pre-operative imaging with intra-operative findings of elbow ligament tears. METHODS: We prospectively included 32 patients with acute elbow dislocation investigated by MRI at a means of five days from dislocation. A simple elbow dislocation was diagnosed in 14 patients (44%); associated bone injuries were identified in 18 elbows (56%). Surgical repair of elbow ligaments was carried out in 23 patients, and nine cases were treated non-operatively. A blinded MRI evaluation of all 32 elbows was performed by an orthopaedic surgeon (rater 1) and a musculoskeletal radiologist (rater 2). RESULTS: Inter-rater agreement for MRI evaluation of 32 was poor for lateral ulnar collateral ligament (LUCL) tears, fair for radial collateral ligament (RCL), moderate for annular ligament (AL), and fair for ulnar collateral ligament (UCL). All tears were reported as complete by rater 1; 13/32 partial tears were identified by rater 2 (LUCL = 2, RCL = 2, UCL = 9). Correlation between surgical and MRI findings showed good inter-rater agreement for LUCL and AL tears in both raters. Agreement for RCL tear was poor for rater 1 and fair for rater 2; agreement for UCL tear was fair for rater 1 and poor for rater 2. Intra-operative findings showed ten radial head fractures (RHFs) and ten coronoid fractures (CFs). LUCL tears were found in the four cases of type II RHFs and in 3/4 cases of CFs. Bone injuries and ligament tears were not significantly associated. CONCLUSION: MRI scan supported surgeons to identify soft tissue injuries and to address the most suitable surgical approach after acute elbow dislocation. Inter-observer agreement for intra-operative findings was high for LCL complex injuries and poor for UCL.