Segmental Humeral Head Reconstruction in Patients with Chronic Locked Posterior Shoulder Dislocation.

Background and Objectives: The goal of this study was to evaluate the functional outcomes of patient treatment using an allograft after chronic locked posterior shoulder dislocation associated with a bony defect of the upper edge of the humerus that involves 25-50% of the articular surfaces. Materials and Methods: A total of 20 patients were included in this study. Electrocution was the cause of injury in eight patients; in ten patients, the cause was direct trauma; and in two patients, the cause of injury was a fall due to hypoglycemic coma. A standard deltoid pectoral approach was used and a fresh-frozen osteochondral allograft of the femoral condyle was applied. In evaluating the results, Constant's scoring scale was used. Results: The average value of Constant's point scale for the operated shoulder is 84.14 points. This result is good according to the average value of Constant's point scale. Conclusions: Patients with locked chronic posterior dislocation in combination with a bony defect of the humeral head that covers 25-50% of the articular surface, in our opinion, should be treated using bone allografts rather than non-anatomical reconstruction methods.

[Problems of expert application of «Medical criteria to determine the severity of harm caused to human health¼ in closed injury of the shoulder joint]. / Problemy ekspertnogo primeneniya «Meditsinskikh kriteriev opredeleniya stepeni tyazhesti vreda, prichinennogo zdorov'yu cheloveka¼ pri zakrytoi travme plechevogo sustava.

The represented analysis shows the mechanism of formation of traumatic shoulder dislocation and potential intra-articular anatomic-morphological damages of humeral head according to the Hill-Sachs type in order to objectify the criteria of determination the severity of harm caused to human health. The potential Hill - Sachs classifications of shoulder dislocation are considered depending on size of humeral head defect. During the period of 2015 to 2020, 250 «conclusions¼ of forensic investigations of patients with the injuries of the shoulder joint were analyzed, performed by an expert traumatologist. It was identified, that in 8 patients with shoulder joint dislocation among 32 cases of shoulder injury, experts interpret this injury as a severe harm caused to human health without sufficient justification, using the conclusions of radiology specialists who gave a very brief description of X-rays indicating the diagnosis «fracture of humeral head according to the Hill-Sachs type¼. The severe harm caused to human health was detected correctly only in 2 patients with impression fracture of humeral head.

[Bilateral posterior shoulder dislocation with associated reverse Hill-Sachs lesions after electrical injury].

After workers suffer electric shock, the ankylosis and contraction of muscle groups around the shoulder joint are more likely to lead to posterior dislocation and fracture, of which 80% are complicated with reverse Hill-Sachs injury of humeral head. This paper reports a case of bilateral posterior dislocation of shoulder joint combined with Hill-Sachs injury caused by electric shock in the Department of Orthopedics, Affiliated Huzhou Hospital, Zhejiang University School of Medicine in August 2020. The diagnosis of left posterior shoulder dislocation was clear, and the diagnosis of right posterior shoulder dislocation was missed. The patient successfully reconstructed the stability of the shoulder joint by actively performing shoulder arthroscopic surgery to repair the joint capsule. After 6 months of follow-up, there was no further dislocation and the function was good.

Luxación de prótesis humeral / Humeral prosthesis dislocation

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Atypical biceps-related complication of proximal humerus fracture leading to internal shoulder impingement due to tendon stump dislocation.

Non-displaced proximal humerus fractures are usually managed non-operatively despite of minor malalignment. Biceps tendon rupture due to attrition after malunion is rare around the proximal humerus. Rupture of the long head of biceps (LHB) tendon usually occurs inside the joint close to the origin at the labrum. Treatment is usually non-operative with good outcomes. We report a rare case of a 48-year-old female patient with persistent locking and internal impingement 8 months after a proximal humerus fracture with anterior angulation leading to extra-articular reversed LHB tendon rupture with intra-articular dislocation of the proximal stump. Interposition of the tendon (3.5 cm) between the glenoid and the humeral head was confirmed on MRI arthrogram. Arthroscopic proximal tenotomy and stump removal resulted in immediate relief with improved function (subjective shoulder value 95%; Constant Score: 96). False interpretation of symptoms as posttraumatic stiffness should be avoided by a thorough examination and complementary MRI arthrogram investigation.

Cuff tear arthropathy in the nineteenth century: 'chronic rheumatic arthritis' with 'partial luxation upwards' of the humeral head.

INTRODUCTION: Cuff tear arthropathy of the shoulder is a common indication for insertion of an increasing number of reverse shoulder arthroplasties. It is widely believed that this condition was unknown to medical practitioners and writers prior to the introduction of the term cuff tear arthropathy by Charles Neer in 1977. PURPOSE: To search nineteenth-century written sources for pathoanatomical and biomechanical descriptions of the typical changes found in cuff tear arthropathy. METHODS: A historical review. Nineteenth-century medical textbooks, reviews, case series, autopsy reports and illustrations were systematically searched and retrieved for relevance. References were hand-searched. Illustrations were reproduced and interpreted. RESULTS: A richly illustrated nineteenth-century literature was identified. The typical changes in cuff tear arthropathy were termed 'chronic rheumatic arthritis' of the shoulder with 'partial luxation upwards' of the humeral head and interpreted within a pathoanatomical and biomechanical framework. Detailed descriptions and illustrations of massive rotator cuff tears, biceps pathology and the osseous changes were identified and presented. CONCLUSION: The pathoanatomical and biomechanical changes later termed cuff tear arthropathy were well understood and nicely described in nineteenth-century medical literature.

Treatment of a 4-Part Proximal Humeral Fracture with a Concomitant Glenoid Fracture in an Elderly Patient: A Case Report.

CASE: Reported here is a single case of a highly comminuted fracture of the proximal aspect of the humerus with substantial humeral head displacement and a concomitant glenoid fracture encompassing >20% of the glenoid width. The fractures were treated simultaneously with reverse total shoulder arthroplasty and open reduction and internal fixation, respectively. CONCLUSION: The 1-year follow-up demonstrated excellent pain control and a good functional outcome, with no signs of instability or implant complications.

Subtraction osteotomy of the humeral head in posterior shoulder dislocation: a case report.

Locked posterior dislocations of the shoulder with an impacted fracture of the humeral head and an articular surface defect greater than 35-40% are generally treated with a femoral head bone graft or prosthesis. We present a case in which a subtraction osteotomy with osteoclasia on the impacted zone was performed to try to make the articular surface of the humeral head congruent and continuous. With a 42-month follow-up, the clinical outcome, in terms of mobility and pain, was very good; X-rays show there was no avascular necrosis of the humeral head nor signs of articular arthrosis. The aim of this work is to present a detailed description of our procedure, which can be a therapeutic option for this type of pathology.

Complex humeral head fractures treated with blocked threaded wires: maintenance of the reduction and clinical results with two different fixation constructs.

BACKGROUND: Locking plates are the gold standard for treatment of 3-part humeral head fractures, although major complications range from 9% to 36%. Percutaneous techniques may allow vascular supply preservation, maintenance of fracture hematoma, scarce blood loss. Many configurations with Kirschner wires can be performed, generating confusion on result interpretation. We studied the correlation between system configuration, stability, and clinical results in patients with 3-part humeral head fractures treated with the same fixation system but with 2 different biomechanical constructs. MATERIALS AND METHODS: There were 52 consecutive patients (19 men, 33 women; mean age, 63.1 [standard deviation, 5.6] years; range, 48-82 years) with Hertel 7 humeral head fractures. Two fixation constructs composed of 3 couples (construct A) or 4 couples (construct B) of blocked threaded wires were used in 17 and 35 patients, respectively. At the final follow-up, the individual relative Constant Score (irCS) and visual analog scale were measured. Radiographic evaluation according to the Bahr criteria was performed. Statistical analysis was performed. RESULTS: The mean follow-up was 22 months. The mean irCS at the final follow-up was 89.7%. The mean irCS in patients treated with construct A and construct B was 86% and 93%, respectively (P = .043). One nonunion and 2 superficial infections occurred (6%). The postoperative reduction was excellent in 97% of patients and remained excellent in 89%. The mean postoperative neck shaft angle was 135.0° (construct A: 134.7°; construct B: 135.1°), and the final neck shaft angle was 132.9° (construct A: 131.3°; construct B: 133.8°; P = .047). CONCLUSIONS: The functional and radiologic outcomes obtained with percutaneous fixation or locking plates are similar; however, the percentage of major complications after percutaneous treatment is lower. Results of percutaneous fixation depend on the biomechanical construct.

[Primary fracture protheses and reverse shoulder arthroplasty in complex humeral head fractures : An alternative to joint-preserving osteosynthesis?] / Primäre Frakturprothese und inverse Schulterprothese bei komplexer Humeruskopffraktur : Eine Alternative zur gelenkerhaltenden Osteosynthese?

BACKGROUND: The surgical management of complex humeral head fractures has adapted dynamically over the course of the last decade. The primary use of reverse shoulder arthroplasty in elderly patients has gained in relevance due to promising short and middle-term results. Long-term results, however, are still pending. The appliance of anatomical hemiarthroplasty, on the other hand, has lost in significance in favour of osteosynthesis and reverse shoulder arthroplasty. INDICATIONS: This review article follows the question as to under which circumstances primary fracture arthroplasty reflects an alternative or even a preference to joint-preserving osteosynthesis in the treatment of complex proximal humeral fractures. It also specifies spectrums of indications for anatomical hemiarthroplasty and reverse shoulder arthroplasty.

A morphovolumetric study of head malposition in proximal humeral fractures based on 3-dimensional computed tomography scans: the control volume theory.

BACKGROUND: This study regards a volumetric analysis of proximal humeral fractures. The main purpose was to investigate the head displacement in relation to the shaft and its link to volume reductions ("bone loss") of the anatomic segments interposed between the head and the shaft: the tuberosities and the calcar. We call this area "control volume." METHODS: In 20 fractures, we used 3-dimensional virtual reconstruction to create a reference system that divides geometrically the control volume and allows the evaluation of displacement angles of the humeral head. We calculated the volumetric reduction of control volume segments for each fracture through a specific mathematical protocol. RESULTS: The measurement of the head displacement angles in 20 fractures led to following results: in the coronal plane, 10 varus, 6 valgus, 4 neutral; in the sagittal plane, 6 anterior tilt, 9 posterior tilt, 5 neutral position. There was a reduction of control volume in 19 of 20 fractures. Only in 1 fracture was the control volume intact and the fracture was nonimpacted. In 19 impacted fractures, the volume reduction was variable (4% minimum loss, 98% maximum loss). In head varus position, loss was greater in the medial area than in the lateral area. There was generally a clear correspondence between the positions assumed by the head and the volumetric losses of the respective control volume segments. CONCLUSIONS: The control volume is an important anatomic and functional area of the proximal humerus. A morphovolumetric 3-dimensional approach improves knowledge about pathomorphology of proximal humeral fractures.

Humeral head inferior subluxation in proximal humerus fractures.

PURPOSE: The objectives of this study are to propose a reliable radiologic method for detecting static inferior subluxation of humeral head, to calculate the relative intra- and inter-observer reliability, and to evaluate its presence pre- and post-surgery. METHODS: This is a retrospective observational study of patients surgically treated for a fracture of the proximal humerus. Fractures were classified using Codman-Lego criteria (radiographic, CT images), osteoporosis was assessed. To identify inferior subluxation, an original method is proposed. This measurement was done pre-operatively, at three and 12 month post-operatively. Clinical evaluation was recorded at final follow-up using Constant Score. RESULTS: One hundred fifty fractures surgically treated were studied. Intra- and inter-observer reliabilities were excellent and high, respectively. In pre-operative x-rays, a significant inferior subluxation was noted in 17/150 cases (11.3%), with significant correlation with fracture pattern (p=0.045), female sex (p=0.038), age older than 70 (p=0.003), obesity (BMI>30, p=0.03), and local osteoporosis (p=0.002). At three month of follow-up, 22 cases (14.6%) had inferior subluxation, with significant correlation with female sex (p=0.04), age older than 70 (p=0.002), obesity (p=0.02), pin or screw articular surface perforation (p<0.001). At 12 month of follow-up, seven cases showed persistent inferior subluxation, with significant correlation with age older than 70 (p=0.032), obesity (p=0.041), screw joint perforation and lower Constant Score (p<0.001). DISCUSSION: Inferior subluxation was mostly found in osteoporotic fractures of the elderly, obese, and of female sex both pre- and post-operatively. The intra- and inter-observer reliabilities of proposed radiographic measurement were high and excellent, respectively. CONCLUSIONS: In the early postoperative months, we found a high correlation between inferior subluxation and articular surface perforation; when persisting at later follow-ups, we might speculate that it could represent an early phase of avascular necrosis of the humeral head. LEVEL OF EVIDENCE: Level III, observational study.

Cadaveric Analysis of Proximal Humerus Locking Plate Fit: Contour Mismatch May Lead to Malreduction.

OBJECTIVES: To investigate proximal humerus locking plate fit in a large sample of human proximal humeri. METHODS: A total of 97 cadaveric human humeri were selected. Humerus length, head diameter, and neck-shaft angle were measured. Three-hole and 5-hole 3.5-mm proximal humerus locking compression plates were affixed. A digital caliper was used to measure the maximum gap distance from the plate to the bone. Analysis of variance and student's t tests were conducted to evaluate differences in plate-bone distance between the 2 plate lengths, gender, race, age, and laterality. Correlation between plate-bone distance and humerus length, head diameter, and neck-shaft angle were determined. RESULTS: Mean plate-bone distance for the 3-hole plate was 1.5 ± 0.6 mm (range 0.3-2.9 mm), and for the 5-hole plate was 2.5 ± 0.9 mm (range 0.7-5.0 mm) (P = 0.01). Female and right-sided humeri were shown to have significantly larger plate-bone gap distance when compared with counterparts (P = 0.01). No correlation was found between plate-bone gap distance and humeral length (R = 0.03), head diameter (R = 0.05), or neck-shaft angle (R = 0.08). CONCLUSION: The proximal humerus locking plate was under-contoured and spanned all 97 specimens. Greater plate-bone distance was observed with the 5-hole plate versus the 3-hole plate. Applying the plate flush to bone may lead to medial displacement of the humeral head at the calcar increasing risk of loss of fracture fixation. In fractures with any metaphyseal comminution, malreduction will be more pronounced. Caution should be exercised when using the proximal humerus locking plate as a reduction aide.

Return to sports after plate fixation of humeral head fractures 65 cases with minimum 24-month follow-up.

BACKGROUND: Humeral head fractures requiring surgical intervention are severe injuries, which might affect the return to sports and daily activities. We hypothesize that athletic patients will be constrained regarding their sporting activities after surgically treated humeral head fractures. Despite a long rehabilitation program physical activities will change and an avoidance of overhead activities will be noticed. METHODS: Case series with 65 Patients, with a minimum follow-up of 24 months participated in this study. All patients were treated using a locking plate fixation. Their sporting activity was investigated at the time of the injury and re-investigated after an average of 3.83 years. The questionnaire setup included the evaluation of shoulder function, sporting activities, intensity, sport level and frequency evaluation. Level of evidence IV. RESULTS: At the time of injury 61 Patients (94%) were engaged in recreational sporting activities. The number of sporting activities declined from 26 to 23 at the follow-up examination. There was also a decline in sports frequency and duration of sports activities. CONCLUSION: The majority of patients remains active in their recreational sporting activity at a comparable duration and frequency both pre- and postoperatively. Nevertheless, shoulder centered sport activities including golf, water skiing and martial arts declined or were given up.

Treatment of Locked Posterior Shoulder Dislocation With Bone Defect.

Locked posterior shoulder dislocation is an uncommon condition and is associated with a reverse Hill-Sachs lesion in 50% of cases. The condition is likely to occur in cases of violent trauma, seizures, or electric shock. Unrecognized dislocation with humeral head fracture affects joint function and humeral head vascularity and may lead to chronic instability, osteonecrosis, and osteoarthritis. A group of 12 patients, including 10 men and 2 women, with neglected locked posterior shoulder dislocation with a reverse Hill-Sachs lesion were treated with the modified McLaughlin technique. The added bone graft from the iliac crest was impacted in the defect and fixed with screws. Mean follow-up was 30 months (range, 24-48 months). The range of forward flexion was 150˚ to 175˚ (average, 165˚), external rotation ranged from 60˚ to 80˚ (average, 75˚), internal rotation ranged from 40˚ to 60˚ (average, 50˚), and average abduction was 150˚ (range, 145˚-160˚). The modified University of California Los Angeles (UCLA) scoring system was used for postoperative clinical evaluation. Total UCLA scores immediately postoperatively ranged from 22 to 28 points (average, 26.5 points) and averaged 30 points (range, 28-33 points) at last follow-up. No recurrence of dislocation occurred during the follow-up period. Of the study patients, 10 returned to their previous job and 2 modified their manual work. The modified McLaughlin technique with added iliac crest bone graft to fill the defect and prevent humeral head deformity is a successful technique for the treatment of patients with chronic locked posterior shoulder dislocation. [Orthopedics. 2017; 40(3):e501-e505.].

Human Shoulder Response to High Velocity Lateral Impact.

The armies of the North Atlantic Treaty Organization need a shoulder injury criterion for the EuroSID-2re dummy that must be reliable over a large range of loading conditions, from high velocity, short duration impacts (28 m/s - 3 ms) to low velocity long, duration impacts (4 m/s - 50 ms). In the literature, the human shoulder response to lateral impact was investigated at bounds of the loading condition spectrum as previously mentioned. For the low velocities, the injuries were mainly clavicle fractures and the maximum compression between the acromion and the sternum (Cmax) was proposed as an injury criterion. For the high velocities, the typical injury was humerus fractures, including a crushed humeral head. The present study investigates the human shoulder response at an intermediate loading condition (14 m/s - 9 ms). Six lateral shoulder impact tests have been performed with three Post Mortem Human Subjects using a rigid impactor. The duration of the impact was controlled by means of an aluminum honeycomb that decelerated the impactor during the impact. The shoulder external deflection (impactor-to-sternum) ranged between 40 to 64 mm and the applied forces ranged from 4.3 kN to 8 kN. Four shoulders out of six sustained AIS2 injuries. Two acromio-clavicular joint dislocations, one clavicle fracture, and one scapula fracture were observed. Though the shoulder force responses were closer to those induced by the high velocity, short duration impacts, the injury patterns resembled those observed for low velocity, long duration loading conditions. Furthermore, the estimated acromion-to-sternum deflection values were not inconsistent with the prediction of the shoulder injury risk curve of the literature. Despite the relatively high-velocity impact (14.3 m/s), the shoulder injury mechanism appeared to be similar to those observed in the automotive field.

Balloon humeroplasty reconstruction for acute Hill-Sachs injury: A technical note.

Posterior Hill-Sachs humeral defects are present in 80% to 100% of cases of anterior shoulder dislocation and are a factor in recurrent instability. Several techniques have been described to fill the defect and avoid recurrence. We developed a percutaneous technique to fill the newly created defect in which a percutaneous balloon, analogous to the one used in vertebral kyphoplasty, is used to reduce the defect, which is then filled with calcium phosphate cement. One patient with an acute anterior dislocation of the shoulder with no previous history was treated using this method. Early imaging results showed adequate reduction of the defect and no cement resorption. The patient was followed for 12 months; he had normal function of the shoulder and no recurrent dislocation. Shoulder computed tomography (CT) arthrography with contrast after 3 months showed an intact capsule and no recurrence of the defect. While this technique is certainly in its infancy, we have demonstrated that emergency reduction of the defect in acute first occurrence anterior shoulder dislocation is feasible, helps to restore normal anatomy of the humeral head and leads to good clinical results. Whether it can improve clinical results and prevent recurrent shoulder dislocation remains to be evaluated.