Ultrafast underwater self-healing piezo-ionic elastomer via dynamic hydrophobic-hydrolytic domains.

The development of advanced materials capable of autonomous self-healing and mechanical stimulus sensing in aquatic environments holds great promise for applications in underwater soft electronics, underwater robotics, and water-resistant human-machine interfaces. However, achieving superior autonomous self-healing properties and effective sensing simultaneously in an aquatic environment is rarely feasible. Here, we present an ultrafast underwater molecularly engineered self-healing piezo-ionic elastomer inspired by the cephalopod's suckers, which possess self-healing properties and mechanosensitive ion channels. Through strategic engineering of hydrophobic C-F groups, hydrolytic boronate ester bonds, and ions, the material achieves outstanding self-healing efficiencies, with speeds of 94.5% (9.1 µm/min) in air and 89.6% (13.3 µm/min) underwater, coupled with remarkable pressure sensitivity (18.1 kPa-1) for sensing performance. Furthermore, integration of this mechanosensitive device into an underwater submarine for signal transmission and light emitting diode modulation demonstrates its potential for underwater robotics and smarter human-machine interactions.

Does age affect patient outcomes after humeral head replacement in the treatment of acute proximal humeral fractures? A comparative cohort study with a minimum 10 years long-term follow-up.

BACKGROUND: Humeral head replacement (HHR) is now rarely recommended for complex proximal humeral fractures (PHFs) in older patients. However, in relatively young and active patients with unreconstructable complex PHFs, controversy still exists regarding the treatment options of reverse shoulder arthroplasty and HHR. The goal of this study was to compare the survival, functional, and radiographic outcomes of HHR in patients aged <70 years and those aged ≥70 years after a minimum 10 years follow-up. METHODS: Eighty-seven out of 135 patients undergoing primary HHR were enrolled and then divided into 2 groups based on age: <70 years and ≥70 years. Clinical and radiographic evaluations were performed with a minimum follow-up of 10 years. RESULTS: There were 64 patients (mean, 54.9 years) in the younger group and 23 patients (mean, 73.5 years) in the older group. The younger and older groups had comparable 10-year implant survivorship (98.4% vs. 91.3%). Patients aged ≥70 years had worse American Shoulder and Elbow Surgeons scores (74.2 vs. 81.0, P = .042) and lower satisfaction rates (12% vs. 64%, P < .001) than younger patients. At the final follow-up, older patients had worse forward flexion (117° vs. 129°, P = .047) and internal rotation (17 vs. 15, P = .036). More greater tuberosity complications (39% vs. 16%, P = .019), glenoid erosion (100% vs. 59%, P = .077), and humeral head superior migration (80% vs. 31%, P = .037) were also identified in patients aged ≥70 years. CONCLUSIONS: Unlike the increased risk for revision and functional deterioration over time after reverse shoulder arthroplasty for PHFs in younger patients, a high implant survival rate with lasting pain relief and stable functional outcomes could be observed in younger patients after HHR during long-term follow-up. Patients aged ≥70 years had worse clinical outcomes, lower patient satisfaction, more greater tuberosity complications, and more glenoid erosion and humeral head superior migration than those aged <70 years. HHR should not be recommended for the treatment of unreconstructable complex acute PHFs in older patient populations.

Toward Highly Matching the Dura Mater: A Polyurethane Integrating Biocompatible, Leak-Proof, and Self-Healing Properties.

The dura mater is the final barrier against cerebrospinal fluid leakage and plays a crucial role in protecting and supporting the brain and spinal cord. Head trauma, tumor resection and other traumas damage it, requiring artificial dura mater for repair.  However, surgical tears are often unavoidable. To address these issues, the ideal artificial dura mater should have biocompatibility, anti-leakage, and self-healing properties. Herein, this work has used biocompatible polycaprolactone diol as the soft segment and introduced dynamic disulfide bonds into the hard segment, achieving a multifunctional polyurethane (LSPU-2), which integrated the above mentioned properties required in surgery. In particular, LSPU-2 matches the mechanical properties of the dura mater and the biocompatibility tests with neuronal cells demonstrate extremely low cytotoxicity and do not cause any negative skin lesions. In addition, the anti-leakage properties of the LSPU-2 are confirmed by the water permeability tester and the 900 mm H2 O static pressure test with artificial cerebrospinal fluid. Due to the disulfide bond exchange and molecular chain mobility, LSPU-2 could be completely self-healed within 115 min at human body temperature. Thus, LSPU-2 comprises one of the most promising potential artificial dura materials, which is essential for the advancement of artificial dura mater and brain surgery.

Long-term outcomes of shoulder hemiarthroplasty for acute proximal humeral fractures.

PURPOSE: Shoulder hemiarthroplasty (HA) is now rarely indicated for complex proximal humeral fractures due to its unpredictable characteristic of the greater tuberosity (GT) healing. Despite the increasing popularity of reverse shoulder arthroplasty (RSA) in fracture treatment, there are still concerns about failure revision and its application in young populations. The complete negation of HA for fracture treatment is still under debate. METHODS: Eighty-seven out of 135 patients with acute proximal humeral fractures treated with HA were enrolled. Clinical and radiographic evaluations were performed. RESULTS: With a mean follow-up time of 14.7 years, the 10-year prosthetic survival rate was 96.6%. The mean ASES score and Constant score were 79.3 and 81.3, respectively, the mean VAS was 1.1, the average forward flexion was 125.9°, external rotation was 37.2°, and internal rotation was at the L4 level. Nineteen patients (21.8%) displayed GT complications and showed significantly worse outcomes. Glenoid erosion was observed in 64.9% of the patients and resulted in inferior outcomes. The patients who showed good postoperative two year functional outcomes and good acromiohumeral distances usually maintained their results without deterioration over time. CONCLUSIONS: With strict patient selection, a proper surgical technique and closely supervised postoperative rehabilitation, HA could achieve a 96.6% ten year survival rate and good pain relief at an average follow-up of 15 years. Although rarely indicated, HA should have a role in the treatment of acute complex proximal humeral fractures in relatively young and active patients with good GT bone and intact cuff.

The Correlation between Variation of Labral Attachment and Lesions of the Long Head of the Biceps Tendon in Patients with Rotator Cuff Tears.

OBJECTIVE: There was no universally accepted classification system that describes LHBT lesions as a type of its' pathology in patients with shoulder pain. This study aimed to determine the correlation of anatomic variants of glenoid labrum attachment of long head of biceps tendon (LHBT) and to assess their association, if any, with its lesions in rotator cuff tear (RCT) patients. METHODS: All RCT patients from January 2016 to December 2019 were assessed arthroscopically to classify the LHBT labrum attachment according to its' anatomical location. A simplified classification was created to describe the LHBT as normal, tendinitis, subluxation or dislocation, partial tear and superior labral tear from anterior to posterior (SLAP) lesion beyond type II The RCT were classified as three types as partial, small to medium and large to massive. The correlation of variants of LHBT labral attachment with type of LHBT lesions in different RCT groups was evaluated. RESULTS: In total, 669 patients were included for evaluation. The attachment of the LHBT was entirely posterior in 23 shoulders (3.4%), posterior-dominant in 81 shoulders (12.1%), and equal in 565 shoulders (84.4%). In equal distribution LHBT attachment group, age > 60 (odds ratio: 2.928, P < 0.001) and size of RCT (P < 0.001) were significant risk factors of LHBT lesions. In the analysis of all patients, comparing with the partial thickness rotator cuff tear (PTRCT), the odds ratio of small to medium RCT and large to massive RCT was 2.398 and 6.606 respectively. In addition, age > 60 (odds ratio: 2.854, P < 0.001) and size of RCT (P < 0.001) were significant risk factors of LHBT lesions. In posterior dominant group, size of RCT was a significant risk factor of LHBT lesions but not any others (P < 0.001). In entirely posterior group, no risk factor of LHBT lesions was found. It showed that the variation of LHBT attachment was not a significant risk factor of LHBT lesions in rotator cuff repaired patients (p = 0.075). CONCLUSIONS: There are three types of LHBT labrum attachment in RCT patients on arthroscopic observation. 84.4% were equal distribution of LHBT attachment on glenoid labrum, followed by posterior-dominant (12.1%) and entirely posterior type (3.4%) in present study. Although the variation of LHBT attachment was not a significant risk factor of LHBT lesion in rotator cuff repaired(RCR) patients, there were different risk factors among three LHBT labral attachment types. In RCR patients, age > 60 and RCT size were significant risk factors of LHBT lesions.

Acid-triggered, degradable and high strength-toughness copolyesters: Comprehensive experimental and theoretical study.

The popularization and widespread use of degradable polymers is hindered by their poor mechanical properties. It is of great importance to find a balance between degradation and mechanical properties. Herein, poly(butylene terephthalate) (PBT) modified by SPG diol from 10% to 40 mol% were synthesized through a two-step polycondensation reaction. Chemical structures, thermal properties, mechanical properties, viscoelastic behavior and degradation of poly(butylene terephthalate-co-spirocyclic terephthalate) (PBST) were investigated. The SPG could toughen the copolyesters and the elongation at break of PBST20 was up to 260%. Moreover, the introduction of SPG enables to provide an acid-triggered degradable unit in the main chain. PBSTs copolymers maintain stable structures in a neutral environment, and the degradation under acid conditions will be unlocked. As tailoring the content of SPG, the degradation rate of the chain scission in response to acid stimuli will be adjusted. The acid degradation was proved to be occurred at the SPG units in the amorphous phase by DSC, XRD, GPC and 1H NMR tests. After the acid degradation, the hydrolysis rate will also be accelerated, adapting to the requirements of different degradation schedules. The plausible hydrolytic pathways and mechanisms were proposed based on Fukui function analysis and density functional theory (DFT) calculation.

Clinical Outcome of a Modified Coracoid Tunnel-Free Coracoclavicular Sling Technique With Remnant Preservation for the Treatment of High-Grade Acromioclavicular Joint Separation: A Report of 48 Cases With 2 to 5 Years of Follow-up.

BACKGROUND: High-grade acromioclavicular (AC) joint separation injuries (Rockwood type IV or V) are surgically indicated because of complete disruption of the AC and coracoclavicular (CC) ligaments, leading to instability and pain. In surgical techniques that require a suspensory system, coracoid tunnel-related complications are not uncommon. PURPOSE: To report subjective and objective clinical outcomes and complication rates of a modified coracoid tunnel-free CC sling technique combined with CC ligament remnant preservation for a minimum 2-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Between January 2014 and January 2017, we prospectively enrolled patients who underwent a modified CC sling technique performed by 1 senior surgeon using the AC TightRope System in a coracoid tunnel-free fashion. The CC distance (CCD) and Rockwood AC joint classification were evaluated on radiographs preoperatively, immediately postoperatively, and at the final follow-up. The visual analog pain score, range of motion, American Shoulder and Elbow Surgeons score, Constant-Murley score, and University of California Los Angeles score were recorded preoperatively and at the final follow-up. RESULTS: In total, 48 of 54 patients (88.9%) were included for the evaluation with a mean ± SD follow-up of 39.3 ± 8.9 months (range, 24.7-64.3 months). The CCD was significantly decreased from 22.7 ± 4.2 to 9.8 ± 2.3 mm (P < .01) immediately after surgery and to 11.2 ± 1.8 mm (P < .01) at final follow-up. At the final follow-up, the side-to-side difference of CCD was 3.5 ± 0.6 mm. Compared with the preoperative level, all subjective evaluations were significantly improved at the final follow-up. We observed that 4 of the 48 patients (8.3%) had a loss of reduction at the final follow-up, but no pain or instability was documented. Further, no coracoid-related complication or other complications were recorded. CONCLUSION: The coracoid tunnel-free CC sling technique using the AC TightRope System combined with CC ligament remnant preservation demonstrated significant improvement regarding both clinical and radiological outcomes, with a reduction loss rate of 8.3%. It is a safe method that could achieve satisfactory result without any coracoid drilling-related complications.

Toughening Polylactic Acid by a Biobased Poly(Butylene 2,5-Furandicarboxylate)-b-Poly(Ethylene Glycol) Copolymer: Balanced Mechanical Properties and Potential Biodegradability.

Polylactic acid (PLA) is a biodegradable thermoplastic polyester produced from natural resources. Because of its brittleness, many tougheners have been developed. However, traditional toughening methods cause either the loss of modulus and strength or the lack of degradability. In this work, we synthesized a biobased and potentially biodegradable poly(butylene 2,5-furandicarboxylate)-b-poly(ethylene glycol) (PBFEG50) copolymer to toughen PLA, with the purpose of both keeping mechanical strength and enhancing the toughness. The blend containing 5 wt % PBFEG50 exhibited about 28.5 times increase in elongation at break (5.5% vs 156.5%). At the same time, the tensile modulus even strikingly increased by 21.6% while the tensile strength was seldom deteriorated. Such a phenomenon could be explained by the stretch-induced crystallization of the BF segment and the interconnected morphology of PBFEG50 domains in PLA5. The Raman spectrum was used to identify the phase dispersion of PLA and PBFEG50 phases. As the PBFEG50 content increased, the interconnected PBFEG50 domains start to separate, but their size increases. Interestingly, tensile-induced cavitation could be clearly identified in scanning electron microscopy images, which meant that the miscibility between PLA and PBFEG50 was limited. The crystallization of PLA/PBFEG50 blends was examined by differential scanning calorimetry, and the plasticizer effect of the EG segment on the PLA matrix could be confirmed. The rheological experiment revealed decreased viscosity of PLA/PBFEG50 blends, implying the possible greener processing. Finally, potential biodegradability of these blends was proved.

Establishment of a True En Face View in the Evaluation of Glenoid Morphology for Treatment of Traumatic Anterior Shoulder Instability.

PURPOSE: To develop an accurate and reproducible method for establishment of a true en face view of the glenoid with a traumatic bone defect. METHODS: A total of 50 sets of computed tomography images of the glenoid were used for 3-dimensional reconstruction. Both a quantitative definition and a practical method were designed for creation of the true en face view of the glenoid with a traumatic bone defect. The accuracy and reliability of the quantitative definition and the practical method were evaluated by calculating the maximal projection area and the simulated bone defect size. RESULTS: The glenoid surface could be fit with a sphere with a radius of 26.11 ± 2.15 mm (P < .001, R2 = 0.98). The true en face view could be established with the quantitative definition, which resulted in the maximal projection area, whereas any tilt would lead to decreased values (P < .05). To establish the true en face view on the glenoid with a traumatic bone defect, a vector from the center of the best-fit sphere of the glenoid surface to the middle point of an arc connecting the supraglenoid and infraglenoid tubercles was generated, which served as a perpendicular for glenoid reorientation. Cases off the true en face view would result in less accurate estimation of the bone defect size (P < .05). CONCLUSIONS: This study provided a quantitative definition and a practical method for generation of the true en face view in the presence of a traumatic bone defect based on the best-fit sphere of the glenoid surface as well as the anatomic landmark of the supraglenoid and infraglenoid tubercles. This study may improve the reliability of the quantification of traumatic bone defects of the glenoid. CLINICAL RELEVANCE: The practical method for establishment of the true en face view of the glenoid would be useful in decision making for the treatment of traumatic anterior shoulder instability.

Arthroscopic Latarjet Procedure With Anterior Capsular Reconstruction: Clinical Outcome and Radiologic Evaluation With a Minimum 2-Year Follow-Up.

PURPOSE: To investigate the clinical and radiographic outcomes of the modified arthroscopic Latarjet procedure at a minimum of 2 years after surgery. METHODS: Patients who had traumatic unidirectional anterior shoulder instability and treated with a modified arthroscopic Latarjet procedure were included. During surgery, the anterior capsule was preserved and repaired back to the glenoid after the coracoid transfer. The clinical results (range of motion, American Shoulder and Elbow Surgeons [ASES] score, Constant-Murley score, and Rowe score) and computed tomographic results were followed. RESULTS: From February 2013 to September 2014, 52 consecutive patients were included. The average duration of follow-up was 28.4 months (range, 24.0-41.7 months). At final follow-up, no recurrent dislocation had occurred. The ASES score and Rowe score improved significantly (ASES score from 85.6 ± 12.7 before surgery to 93.6 ± 5.4 after surgery, P < .0001; Rowe score from 41.5 ± 7.2 before surgery to 92.2 ± 8.7 after surgery, P < .0001). No significant change was found regarding range of motion and the Constant-Murley score. Bone union was achieved in all cases. The transferred coracoid was at the level of the glenoid in all cases. The transferred coracoid was placed below the equator in 48 of 52 cases (92.3%). The orientation of the screw was 22.6° ± 10.8°. Bone resorption around the proximal screw was significantly more prominent than that around the distal screw (P < .0001). CONCLUSIONS: The arthroscopic Latarjet procedure with concomitant anterior capsular reconstruction can achieve satisfactory clinical outcomes for the treatment of anterior shoulder instability with marked glenoid bone loss at a minimum of 2 years' follow-up. A satisfactory coracoid graft position, proper screw orientation, and high healing rate of the transferred coracoid can be expected. Bone resorption around the proximal screw is more severe than that around the distal screw. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

[Perspective randomized control study on different NSAIDs drugs after rotator cuff repair].

OBJECTIVE: To compare the effectiveness and safety of ibuprofen, celecoxib and flurbiprofen axetil after arthroscopic rotator cuff repair. METHODS: From Dec., 2012 to Dec., 2012, 63 arthroscopy rotator cuff repaired patients in Department of Orthopedics&Traumatology, Beijing Jishuitan Hospital, were selected and divided randomized into 3 groups:flurbiprofen axetil, ibuprofen and celecoxib. Each group had 21 patients. All groups take drugs 5 days continuously after operation. In first five days postoperatively, visual analogue scale (VAS) was used to compare pain alleviation. The side effects were assessed among three groups. VAS, Shoulder evaluation functional score, range of shoulder forward elevation, external rotation and internal rotation were recorded, compared between the same patients preoperatively and postoperatively and compared also among three groups. RESULTS: Pain was relieved postoperatively with time being in all patients. From 4 day postoperatively, flurbiprofen axetil showed significant difference on pain relieving compared with ibuprofen and celecoxib (P<0.05). Side effects of ibuprofen, celecoxib and flurbiprofen axetil was 33.3%, 14.3% and 9.5% separately. No significant difference was found among three groups. Preoperatively, VAS=7.2, SST=6.5, Constant=67.6, UCLA=17; FE=132.6°, ER=37.7°, IR=L1on average. One year postoperatively, in ibuprofen, celecoxib and flurbiprofen axetil group, VAS was 2.0, 2.1, 1.9; SST was 9.2, 8.5, 10.5; Constant was 82.7, 91.2, 90.5; UCLA was 29.9, 33.2, 30.3; FE was 151.2°, 150.0°, 160.3°, ER was 49.2°, 50.7°, 56.7°; IR was ip to T12, T12, T8 level separately. All patients showed significant improvement on VAS, function evaluation score and range of motion one year postoperatively and no significant difference were found among three groups. CONCLUSION: Flurbiprofen axetil showed better result compared with ibuprofen and celecoxib on pain control, although all three COX inhibitors are highly-efficient and safe for rotator cuff repaired patients. There is no significant difference among three groups according to side effects and no delayed on tendon healing.

Do Different Cyclooxygenase Inhibitors Impair Rotator Cuff Healing in a Rabbit Model?

BACKGROUND: The effect of selective and non-selective cyclooxygenase (COX) inhibitors on tendon healing was variable. The purpose of the study was to evaluate the influence of non-selective COX inhibitor, ibuprofen and flurbiprofen axetil and selective COX-2 inhibitor, celecoxib on the tendon healing process in a rabbit model. METHODS: Ninety-six New Zealand rabbits were used as rotator cuff repair models. After surgery, they were divided randomly into four groups: ibuprofen (10 mg·kg-1·d-1), celecoxib (8 mg·kg-1·d-1), flurbiprofen axetil (2 mg·kg-1·d-1), and control group (blank group). All drugs were provided for 7 days. Rabbits in each group were sacrificed at 3, 6, and 12 weeks after tendon repair. Tendon biomechanical load failure tests were performed. The percentage of type I collagen on the bone tendon insertion was calculated by Picric acid Sirius red staining and image analysis. All data were compared among the four groups at the same time point. All data in each group were also compared across the different time points. Qualitative histological evaluation of the bone tendon insertion was also performed among groups. RESULTS: The load to failure increased significantly with time in each group. There were significantly lower failure loads in the celecoxib group than in the control group at 3 weeks (0.533 vs. 0.700, P = 0.002), 6 weeks (0.607 vs. 0.763, P = 0.01), and 12 weeks (0.660 vs. 0.803, P = 0.002), and significantly lower percentage of type I collagen at 3 weeks (11.5% vs. 27.6%, P = 0.001), 6 weeks (40.5% vs. 66.3%, P = 0.005), and 12 weeks (59.5% vs. 86.3%, P = 0.001). Flurbiprofen axetil showed significant differences at 3 weeks (failure load: 0.600 vs. 0.700, P = 0.024; percentage of type I collagen: 15.6% vs. 27.6%, P = 0.001), but no significant differences at 6 and 12 weeks comparing with control group, whereas the ibuprofen groups did not show any significant difference at each time point. CONCLUSIONS: Nonsteroidal anti-inflammatory drugs can delay tendon healing in the early stage after rotator cuff repair. Compared with nonselective COX inhibitors, selective COX-2 inhibitors significantly impact tendon healing.

Coracoid bone graft resorption after Latarjet procedure is underestimated: a new classification system and a clinical review with computed tomography evaluation.

BACKGROUND: This study proposes a simple and reliable classification system to evaluate the severity of the bone resorption of the transferred coracoid bone block after the Latarjet procedure. The incidence and severity of the graft resorption was also investigated. METHODS: Between January 2009 and January 2012, 63 patients underwent an open Latarjet procedure and were included. Four independent surgeons used the classification system we proposed to evaluate the severity of the graft resorption on the computed tomography scan performed 1 year postoperatively. Each surgeon did the evaluation twice at a 3-month interval. The interobserver and intraobserver reliability of the classification system were analyzed using intraclass correlation coefficients. Among these 63 patients, 57 patients were available for clinical evaluation at 2 years postoperatively. RESULTS: The American Shoulder and Elbow Surgeons score, Constant-Murley score, and Rowe score were improved significantly after the surgery. No redislocation occurred during follow-up. The incidence of graft resorption was 90.5% based on the computed tomography evaluation. The coracoid graft resorption was classified as grade 0 in 6 patients, grade I in 26, grade II in 25, and grade III in 6. The classification system had excellent interobserver and intraobserver reliability. CONCLUSION: The open Latarjet procedure is effective in treating anterior shoulder instability with marked glenoid bone loss. The incidence of the graft resorption at 1 year postoperatively is high. Our classification system on the graft resorption after Latarjet procedure has good interobserver and intraobserver reliability.

Locked Posterior Shoulder Dislocation Associated With Isolated Fractures of the Lesser Tuberosity: A Clinical Study of 22 Cases With a Minimum of 2-Year Follow-up.

OBJECTIVES: To evaluate the clinical and radiographic outcomes of 2-part lesser tuberosity fracture with a locked posterior dislocation. DESIGN: Retrospective case series study. SETTING: Beijing Jishuitan Hospital ("first-level teaching hospital"). PATIENTS/PARTICIPANTS: Between April 2003 and June 2010, 29 patients received surgical treatment for 2-part lesser tuberosity fractures with an associated locked posterior shoulder dislocation. At the final follow-up, 22 of these patients were available for evaluation. INTERVENTION: Open reduction and internal fixation. MAIN OUTCOME MEASUREMENTS: The shoulder range of motion and visual analog scale pain score were recorded. The postoperative outcomes were evaluated using Score of University of California in Los Angeles (UCLA), Constant, and American Shoulder and Elbow Surgeons (ASES) Scale score. The degree of humeral head necrosis was analyzed according to plain radiographs. The effects of patients' age, dominant-side involvement, as well as time from initial injury to surgery (TFIS) on clinical outcomes and the degree of humeral head necrosis were evaluated. RESULTS: There were 21 men and 1 woman. The average age was 41.7 years. The dominant side was involved in 12 of 22 cases (54.5%). The average TFIS was 49.5 (range, 4-148) days. The mean follow-up period was 38.1 months. The TFIS was identified as the only risk factor regarding postoperative shoulder outcome scores. CONCLUSIONS: Acceptable outcomes can be achieved with surgical treatment for 2-part lesser tuberosity fracture with locked posterior shoulder dislocations. The TFIS has a negative impact on the final outcome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hemiarthroplasty for the treatment of complex proximal humeral fractures: does a trabecular metal prosthesis make a difference? A prospective, comparative study with a minimum 3-year follow-up.

BACKGROUND: Proper positioning and healing of the greater tuberosity are key for functional shoulder recovery after hemiarthroplasty for complex proximal humeral fractures. The purpose of this study was to compare the outcomes after hemiarthroplasty between a trabecular metal prosthesis and a conventional prosthesis in the treatment of complex proximal humeral fractures. METHODS: A prospective, comparative study was performed. We compared a trabecular metal shoulder prosthesis for the treatment of complex proximal humeral fractures in a cohort of 35 consecutive patients (TM group) with a conventional prosthesis in a cohort of 38 consecutive patients (conventional group). All the patients, with a mean age of 63.9 years, were prospectively followed-up for a mean time of 4.6 years (range, 3-6 years) after surgery. RESULTS: At the last follow-up, radiographic complication rates related to the greater tuberosity were lower in the TM group (6.1%) than in the conventional group (25.7%) (P = .028). The mean functional shoulder scores, as well as mean active forward elevation and external rotation, were better in the TM group than in the conventional group. CONCLUSIONS: Radiographic complication rates related to the greater tuberosity were significantly lower in the TM group than in the conventional group. The functional shoulder scores and active forward elevation and external rotation were all better in the TM group than in the conventional group. These findings could imply better healing potential of the greater tuberosity after hemiarthroplasty with a trabecular metal prosthesis to treat complex proximal humeral fractures.

[Clinical outcomes of two-part lesser tuberosity fracture with locked posterior shoulder dislocation treated with modified McLaughlin procedure].

OBJECTIVE: To evaluate and compare the clinical and radiographic outcomes of both acute and chronic two-part lesser tuberosity fracture with locked posterior dislocation and analyze the risk factors for the clinical outcomes. METHODS: Between April 2003 and June 2010, 29 patients received surgical treatment for two-part lesser tuberosity fractures with a locked posterior shoulder dislocation. Eighteen of these patients received modified McLaughlin procedures and were available for both clinical and radiographic evaluation for more than 2 years. All of the 18 patients were male. The average age was (40 ± 11) years (range, 21-58 years). Nine patients had left arms involved while another 9 patients got right side involved, 9 of 18 patients had their dominant side involved. The average time from initial injury to surgery was (40 ± 42)days (range, 4-123 days). The patients received follow-up 3 months, 6 months and 1 year after the operation, and the follow-up was performed once a year. The shoulder range of motion and visual analogue scale (VAS) were recorded at the final follow-up. The functional outcomes were evaluated using University of California-Los Angeles Shoulder Scale (UCLA), Constant Score, and American Shoulder and Elbow Surgeons Shoulder Score (ASES). The degree of humeral head necrosis was analysed according to plain radiographs taken at the final follow-up. The risk factors including patients' age, dominant side involvement and time from injury to surgery on the final clinical outcomes and the degree of humeral head necrosis were also analysed using Pearson correlation analysis and Wilcoxon analysis methods. RESULTS: The mean follow-up period was (38 ± 16) months (range, 24-72 months). All of the patients regained shoulder stability postoperatively. At the final follow-up, the average VAS was 0.6 ± 0.9 (0-3). The average UCLA was 28 ± 4 (23-33). The average Constant was 85 ± 8 (71-96). The average ASES was 83 ± 7 (75-95). The time from injury to surgery was identified as the risk factor regarding UCLA (r = 0.648, P = 0.004), Constant score (r = 0.506, P = 0.032) and ASES score (r = 0.517, P = 0.028). CONCLUSIONS: Satisfactory results can be achieved with surgical treatment for lesser tuberosity fractures with locked posterior shoulder dislocations. The time from injury to surgery has a negative impact on the clinical function outcome.

Trabecular metal™ shoulder prosthesis in the treatment of complex proximal humeral fractures.

PURPOSE: Shoulder arthroplasty is one of the options for the treatment of complex proximal humeral fractures. The purpose of this study was to assess the clinical and radiographic results of the trabecular metal shoulder prosthesis in the treatment of complex proximal humeral fractures. METHODS: Fifty-one consecutive patients with complex proximal humeral fractures who underwent primary shoulder arthroplasties with the trabecular metal™ prosthesis were enrolled in this study. At the final follow-up appointment, 42 of the patients (82.4% of the total patients enrolled) were available for both clinical and radiographic evaluation. There were 28 women and 14 men with a mean age of 65.4 ± 10.7 years. The dominant arm was involved in 30 of the cases. According to Neer's classification, there were seven three-part fractures, 27 four-part fractures and eight head-splitting fractures. Additionally, there were 37 hemiarthroplasties and five total shoulder arthroplasties. RESULTS: After a mean follow-up of 37.0 ± 8.4 months (range 24-52 months), the average ranges of motion were: 38.6 ± 15.0° for external rotation, L3 level for internal rotation and 132.3 ± 36.0° for forward elevation. The mean American Shoulder and Elbow Surgeons, visual analogue scale and University of California, Los Angeles scores were 82.1 ± 14.1, 0.4 ± 1.1 and 28.8 ± 5.1, respectively. The post-operative radiographs exhibited an anatomically attached greater tuberosity in 39 of the 42 shoulders. Of the three patients with greater tuberosity complications, as displayed by their radiographs, two were observed with malpositioned tuberosities, while the other greater tuberosity was resorbed. Proximal migration of the prosthesis was observed in all three shoulders with greater tuberosity complications and in two shoulders with an anatomically attached greater tuberosity. No neurovascular injury, infection or prosthetic loosening was identified during the final follow-up appointments. CONCLUSIONS: Satisfactory results can be expected with the trabecular metal shoulder prosthesis for the treatment of complex proximal humeral fractures. The post-operative radiographs demonstrated an anatomically healed greater tuberosity in 93 % of the patients at a minimum follow-up time of two years.

Do reduction and healing of the bony fragment really matter in arthroscopic bony Bankart reconstruction?: a prospective study with clinical and computed tomography evaluations.

BACKGROUND: Bony Bankart lesions can be treated with arthroscopic repair. However, few studies have evaluated the importance of bony fragment reduction and healing to stability of the glenohumeral joint after arthroscopic bony Bankart repair. PURPOSE: To evaluate functional results after surgery and determine the correlation between reduction and healing of the fracture and postoperative stability of the glenohumeral joint. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 50 patients (47 men, 3 women; average age, 27.6 years; range, 16.5-50.1 years) with bony Bankart lesions and recurrent anterior shoulder dislocations were treated with arthroscopic reduction and internal fixation with suture anchors. The average follow-up period was 32.5 months (range, 24.3-61.2 months). Preoperative and postoperative range of motion and American Shoulder and Elbow Surgeons (ASES), Constant-Murley, and Rowe scores were compared to evaluate the results of the surgeries. Sequential 3-dimensional computed tomography (CT) scans were available for 37 patients and were analyzed to investigate the effect of the bony defect of the glenoid and the correlation between the success of the surgery and reduction and healing of the bony fragment. RESULTS: After surgery, active forward elevation was significantly improved (P < .05). No significant differences were found regarding external and internal rotations after surgery. The ASES, Constant-Murley, and Rowe scores improved significantly after surgery. Redislocations occurred in 3 patients, and a positive anterior apprehension sign was detected in 1 patient during follow-up. The overall failure rate was 8.0% (4/50). The CT scans during the follow-up period showed a nonunion of the bony fragment in 13.5% of cases (5/37). The reconstructed size of the glenoid was <80% in 3 of the 4 failure cases but >80% in all of the successful cases. CONCLUSION: Arthroscopic reduction and fixation of a bony Bankart lesion can achieve good results in selected cases. The size of the reconstructed glenoid is crucial to the success of the surgery.

[Primary shoulder arthroplasty for treatment of complex proximal humeral fractures with the trabecular metal prosthesis].

OBJECTIVE: To evaluate the clinical results of primary shoulder arthroplasty for the treatment of complex proximal humeral fractures with the trabecular metal prosthesis. METHODS: In the study, 57 consecutive patients with complex proximal humeral fractures underwent primary shoulder arthroplasty with the trabecular metal prosthesis, of whom 45 patients were available for the final follow-up (78.9%), and were retrospectively assessed. There were 15 men and 30 women with the average age of (64.9±10.6) years (range: 45 to 85 years), and 14 left shoulders and 31 right shoulders were involved. The mean time from injury to surgery was (10.2±4.8) days. According to Neer's classification, there were 3 patients with a three-part fracture, 4 with a three-part dislocation, 2 with a four-part fracture, 22 with a four-part dislocation, 4 with a four-part valgus-impaction, and 10 with a head splitting. Thirty-nine patients were treated with hemiarthroplasty, and the rest with total shoulder arthroplasty. RESULTS: After a mean follow-up time of (18.7±8.1) months (range: 12 to 41 months), the average range of motion of patients were 130.4°±36.5° for forward elevation, 37.6°±16.6° for external rotation and L3 level (±3 vertebrae) for internal rotation. The average VAS pain score, ASES score, Constant-Murley score and UCLA score were 0.5±1.2 (0-4), 81.4±13.9 (43-100), 81.6±13.6 (52-100) and 28.5±5.1 (16-35), respectively. The average patient satisfaction rate was 95.6%. The greater tuberosity healed anatomically in 42 patients, which was confirmed by the postoperative radiographs, while the greater tuberosity nonunion was found in the other three patients. Superior migration of humeral head was found in two patients. There were no complications, such as infection, prosthetic loosening or neurovascular injury, related to the surgery. CONCLUSION: Primary shoulder arthroplasty for complex proximal humeral fractures with the trabecular metal prosthesis could yield good clinical results. The healing rate of the greater tuberosity was 93.3%.