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PURPOSE: To evaluate the clinical and radiographic outcomes of an all-arthroscopic rotator cuff repair technique involving muscle advancement and double-layer lasso loop (DLLL) repair for massive, retracted posterosuperior cuff tears. METHODS: This was a retrospective case series of patients with massive, retracted posterosuperior cuff tears who underwent the all-arthroscopic muscle advancement technique from March 2017 to September 2021, with a minimum follow-up of 12 months. Key steps included suprascapular nerve release, advancement of the supraspinatus and infraspinatus muscles, and DLLL repair. Preoperative and postoperative visual analog scale score for pain, American Shoulder and Elbow Surgeons (ASES) shoulder score, Constant score, University of California, Los Angeles (UCLA) shoulder score, active range of motion, and strength were compared. Preoperative and postoperative structural radiologic characteristics were analyzed. RESULTS: We evaluated 43 shoulders in 38 patients with a mean follow-up period of 18.8 months (range, 12-55 months). Of the 43 shoulders, 4 showed repair failure (9.3% retear rate). Visual analog scale, ASES, Constant, and UCLA scores significantly improved (P < .001) in patients who showed healing on postoperative magnetic resonance imaging (n = 39). ASES, Constant, and UCLA scores were significantly better in the healed group, with 100% exceeding the minimal clinically important difference for the ASES score and UCLA score and 84.2%, for Constant score. A lower proportion of patients in the retear group achieved the minimal clinically important difference. Active range of motion in all planes significantly improved for patients who had healed repairs (P < .001). Relative abduction strength, supraspinatus strength, and infraspinatus strength were at least 90% of those on the contralateral side. The recovery rate of pseudoparalysis (7 patients) was 100%. CONCLUSIONS: All-arthroscopic muscle advancement, coupled with DLLL repair, leads to a high healing rate with excellent clinical outcomes and recovery of strength to at least 90%, even in patients with pseudoparalysis. LEVEL OF EVIDENCE: Level IV, retrospective case series.
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BACKGROUND: Component positioning affects clinical outcomes of reverse shoulder arthroplasty, which necessitates an implantation technique that is reproducible, consistent, and reliable. This study aims to assess the accuracy and precision of positioning the humeral component in planned retroversion using a forearm referencing guide. METHODS: Computed tomography scans of 54 patients (27 males and 27 females) who underwent primary reverse shoulder arthroplasty for osteoarthritis or cuff tear arthropathy were evaluated. A standardized surgical technique was used to place the humeral stem in 15° of retroversion. Version was assessed intraoperatively visualizing the retroversion guide from above and referencing the forearm axis. Metal subtraction techniques from postoperative computed tomography images allowed for the generation of 3D models of the humerus and for evaluation of the humeral component position. Anatomical humeral plane and implant planes were defined and the retroversion 3D angle between identified planes was recorded for each patient. Accuracy and precision were assessed. A subgroup analysis evaluated differences between male and female patients. RESULTS: The humeral retroversion angle ranged from 0.9° to 22.8°. The majority (81%) of the measurements were less than 15°. Mean retroversion angle (±SD) was 9.9° ± 5.8° (95% CI 8.4°-11.5°) with a mean percent error with respect to 15° of -34% ± 38 (95% CI -23 to -44). In the male subgroup (n = 27, range 3.8°-22.5°), the mean retroversion angle was 11.9° ± 5.4° (95% CI 9.8°-14.1°) with a mean percent error with respect to 15° of -21% ± 36 (95% CI -6 to -35). In the female subgroup (n = 27, range 0.9°-22.8°), mean retroversion angle was 8.0° ± 5.5° (95% CI 5.8°-10.1°) and the mean percent error with respect to 15° was -47% ± 36 (95% CI -32 to -61). The differences between the 2 gender groups were statistically significant (P = .006). CONCLUSION: Referencing the forearm using an extramedullary forearm referencing system to position the humeral stem in a desired retroversion is neither accurate nor precise. There is a nonnegligible tendency to achieve a lower retroversion than planned, and the error is more marked in females.
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Artroplastia do Ombro , Antebraço , Úmero , Tomografia Computadorizada por Raios X , Humanos , Feminino , Masculino , Artroplastia do Ombro/métodos , Idoso , Antebraço/cirurgia , Antebraço/diagnóstico por imagem , Úmero/cirurgia , Úmero/diagnóstico por imagem , Pessoa de Meia-Idade , Osteoartrite/cirurgia , Osteoartrite/diagnóstico por imagem , Articulação do Ombro/cirurgia , Articulação do Ombro/diagnóstico por imagem , Prótese de Ombro , Estudos Retrospectivos , Idoso de 80 Anos ou mais , Artropatia de Ruptura do Manguito Rotador/cirurgia , Artropatia de Ruptura do Manguito Rotador/diagnóstico por imagemRESUMO
INTRODUCTION: The degree of atrophy and fatty infiltration of rotator cuff muscle belly is a key predictor for cuff repairability. Traditionally, Goutallier grading of fatty infiltration is assessed at sagittal scapular Y-view. Massive rotator cuff tears are associated with tendon retraction and medial retraction of cuff musculature, resulting in medialization of the muscle bulk. Thus, standard Y-view can misrepresent the region of interest and may misguide clinicians when assessing repairability. It is hypothesized that by assessing the muscle belly with multiple medial sagittal MRI sections at medial scapular body, the Medial Scapular Body - Goutallier Classification (MSB-GC) will improve reliability and repeatability giving a more representative approximation to the degree of fatty infiltration, as compared with original Y-view. METHODS: Fatty infiltration of the rotator cuff muscles were classified based on the Goutallier grade (0 to 4) at three defined sections section 1: original Y-view; section 2: level of suprascapular notch; section 3: three cm medial to suprascapular notch on MRI scans. Six sub-specialist fellowship trained shoulder surgeons, and three musculoskeletal radiologists independently evaluated deidentified MRI scans of included patients. RESULTS: Out of 80 scans, 78% (n=62) were massive cuff tears involving supraspinatus, infraspinatus and subscapularis tendon. Inter-observer reliability (consistency between observers) for Goutallier grade was excellent for all three predefined sections (range:0.87-0.95). Intra-observer reliability (repeatability) for Goutallier grade was excellent for all three sections and four rotator cuff muscles (range:0.83-0.97). There was a moderate to strong positive correlation of Goutallier grades between sections 1 and 3 and between sections 2 and 3 and these were statistically significant (p<0.001). There was a reduction in the severity of fatty infiltration on the Goutallier classification from sections 1 to 3 across all muscles. 42.5% of both supraspinatus and infraspinatus were downgraded by one, 20% of supraspinatus and 3.8% of infraspinatus were downgraded by 2 and 2.5% of supraspinatus were downgraded by 3. CONCLUSION: This study found that applying the Goutallier classification to more medial MRI sections (MSB-GC) resulted in assignment of lower grades for all rotator cuff muscles. Additionally, this method demonstrated excellent test-retest reliability and repeatability. Inclusion of a more medial view or whole scapula on MRI, especially in advanced levels of tear retraction, could be more reliable and representative for assessment of the degree of fatty infiltration within the muscle bulk that could help predict tear repairability and therefore improve clinical decision-making which should be studied further in clinical studies.
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BACKGROUND: The accuracy of human pose tracking using smartphone camera (2D-pose) to quantify shoulder range of motion (RoM) is not determined. METHODS: Twenty healthy individuals were recruited and performed shoulder abduction, adduction, flexion, or extension, captured simultaneously using a smartphone-based human pose estimation algorithm (Apple's vision framework) and using a skin marker-based 3D motion capture system. Validity was assessed by comparing the 2D-pose outcomes against a well-established 3D motion capture protocol. In addition, the impact of iPhone positioning was investigated using three smartphones in multiple vertical and horizontal positions. The relationship and validity were analysed using linear mixed models and Bland-Altman analysis. RESULTS: We found that 2D-pose-based shoulder RoM was consistent with 3D motion capture (linear mixed model: R2 > 0.93) but was somewhat overestimated by the smartphone. Differences were dependent on shoulder movement type and RoM amplitude, with adduction the worst performer among all tested movements. All motion types were described using linear equations. Correction methods are provided to correct potential out-of-plane shoulder movements. CONCLUSIONS: Shoulder RoM estimated using a smartphone camera is consistent with 3D motion-capture-derived RoM; however, differences between the systems were observed and are likely explained by differences in thoracic frame definitions.
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Telefone Celular , Ombro , Humanos , Captura de Movimento , Smartphone , Amplitude de Movimento ArticularRESUMO
BACKGROUND: The deltopectoral approach is well accepted for shoulder arthroplasty procedures. The extended deltopectoral approach with detachment of the anterior deltoid from the clavicle allows increased joint exposure and can protect the anterior deltoid from traction injury. The efficacy of this extended approach has been demonstrated in anatomic total shoulder replacement surgery. However, this has not been shown in reverse shoulder arthroplasty (RSA). The primary aim of this study was to evaluate the safety of the extended deltopectoral approach in RSA. The secondary aim was to evaluate the performance of the deltoid reflection approach in terms of complications and surgical, functional, and radiologic outcomes up to 24 months after surgery. METHODS: A prospective, nonrandomized comparative study was performed between January 2012 and October 2020 including 77 patients in the deltoid reflection group and 73 patients in the comparative group. The decision for inclusion was based on patient and surgeon factors. Complications were recorded. Patients were followed up for ≥24 months to evaluate their shoulder function and undergo ultrasound evaluation. Functional outcome measures included the Oxford Shoulder Score, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, pain intensity (rated on visual analog scale [VAS] from 0 to 100), and range of motion (forward flexion, abduction, and external rotation). A regression analysis was performed to evaluate any factors of influence on the VAS score. RESULTS: There were no significant differences in the complication rate between the 2 groups (14.5% in deltoid reflection group and 13.8% in comparative group, P = .915). Ultrasound evaluation was available in 64 patients (83.1%), and no proximal detachment was observed. In addition, there were no significant differences in functional outcome measures both preoperatively and at 24 months after surgery between the groups assessed based on the mean VAS pain score, Oxford Shoulder Score, Disabilities of the Arm, Shoulder and Hand score, American Shoulder and Elbow Surgeons score, forward flexion, abduction, and external rotation. Adjustment for possible confounders in a regression model indicated that only prior surgery significantly influenced the VAS pain score after surgery (P = .031; 95% confidence interval, 0.574-11.67). Deltoid reflection (P = .068), age (P = .466), sex (P = .936), use of glenoid graft (P = .091), prosthesis manufacturer (P = .382), and preoperative VAS score (P = .362) were not of influence. DISCUSSION: The results of this study show that an extended deltopectoral approach for RSA is safe. Selected reflection of the anterior deltoid muscle improved exposure and prevented anterior deltoid muscle injury followed by reattachment. Patients had similar functional scores preoperatively and at 24 months postoperatively compared with a comparative group. Furthermore, ultrasound evaluation showed intact reattachments.
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Artroplastia do Ombro , Artroplastia de Substituição , Músculo Deltoide , Articulação do Ombro , Humanos , Artroplastia de Substituição/métodos , Artroplastia do Ombro/métodos , Músculo Deltoide/cirurgia , Dor , Estudos Prospectivos , Amplitude de Movimento Articular/fisiologia , Estudos Retrospectivos , Ombro/cirurgia , Articulação do Ombro/diagnóstico por imagem , Articulação do Ombro/cirurgia , Resultado do TratamentoRESUMO
BACKGROUND: The Latarjet coracoid transfer procedure reliably stabilizes the glenohumeral joint for shoulder instability. However, complications such as graft osteolysis, nonunion and fracture continue to affect patient clinical outcomes. The double-screw (SS) construct is regarded as the gold standard method of fixation. SS constructs are associated with graft osteolysis. More recently, a double-button technique (BB) has been suggested to minimize graft-related complications. However, BB constructs are associated with fibrous nonunion. To mitigate this risk, a single screw combined with a single button (SB) construct has been proposed. It is thought that this technique incorporates the strength of the SS construct and allows micromotion superiorly to mitigate stress shielding-related graft osteolysis. AIMS: The primary aim of this study was to compare the failure load of SS, BB, and SB constructs under a standardized biomechanical loading protocol. The secondary aim was to characterize the displacement of each construct throughout testing. METHODS: Computed tomography scans of 20 matched-pair cadaveric scapulae were performed. Specimens were harvested and dissected free of soft tissue. SS and BB techniques were randomly assigned to specimens for matched-pair comparison with SB trials. A patient-specific instrument (PSI)-guided Latarjet procedure was performed on each scapula. Specimens were tested using a uniaxial mechanical testing device under cyclic loading (100 cycles, 1 Hz, 200 N/s) followed by a load-to-failure protocol (0.5 mm/s). Construct failure was defined by graft fracture, screw avulsion, and/or graft displacement of more than 5 mm. RESULTS: Forty scapulae from 20 fresh frozen cadavers with a mean age of 69.3 years underwent testing. On average, SS constructs failed at 537.8 N (SD 296.8), whereas BB constructs failed at 135.1 N (SD 71.4). SB constructs required a significantly greater load to fail compared with BB constructs (283.5 N, SD 162.8, P = .039). Additionally, SS (1.9 mm, IQR 0.87) had a significantly lower maximum total graft displacement during the cyclic loading protocol compared with SB (3.8 mm, IQR 2.4, P = .007) and BB (7.4 mm, IQR 3.1, P < .001) constructs. CONCLUSION: These findings support the potential of the SB fixation technique as a viable alternative to SS and BB constructs. Clinically, the SB technique could reduce the incidence of loading-related graft complications seen in the first 3 months of BB Latarjet cases. The study is limited to time-specific results and does not account for bone union or osteolysis.
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Instabilidade Articular , Osteólise , Articulação do Ombro , Humanos , Idoso , Articulação do Ombro/cirurgia , Instabilidade Articular/cirurgia , Escápula/cirurgia , Parafusos Ósseos , Complicações Pós-OperatóriasRESUMO
OBJECTIVE: To demonstrate the utility of MRI in separating clinically relevant from minor or incidental lesions of the triangular fibrocartilage complex and the major interosseous ligaments in the wrist. MATERIALS AND METHODS: In this retrospective study, we identified 89 patients and correlated MRI finding with subsequent arthroscopy. Triangular fibrocartilage complex abnormalities have been subdivided into disc lesions-central and radial-or ulnar-sided tears according to MRI appearances and surgical findings as the clinical and surgical approach is very different. Interosseous ligament tears were subdivided into partial or complete, highlighting the principle of recognising surgically relevant lesions. RESULTS: For simple central to radial tears and perforations of the triangular fibrocartilage complex, MRI was 98.3% accurate. MRI identified all peripheral triangular fibrocartilage complex tears seen at arthroscopy; however, the specificity of 66.7% may reflect partly the use of arthroscopy limited to the radiocarpal joint. MRI proved 95.4% accurate for surgically relevant scapholunate interosseous ligament tears and was highly accurate at separating limited from complete lunotriquetral interosseous ligament tears showing 100% accuracy for complete tears. CONCLUSIONS: The study shows excellent correlation between MRI and arthroscopic findings that determine surgical relevance with a very high sensitivity for triangular fibrocartilage complex lesions and accurate separation of minor versus surgically relevant ligamentous tears.
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Fibrocartilagem Triangular , Traumatismos do Punho , Artroscopia , Humanos , Ligamentos , Ligamentos Articulares/diagnóstico por imagem , Ligamentos Articulares/cirurgia , Imageamento por Ressonância Magnética , Estudos Retrospectivos , Fibrocartilagem Triangular/diagnóstico por imagem , Fibrocartilagem Triangular/cirurgia , Punho , Traumatismos do Punho/diagnóstico por imagem , Traumatismos do Punho/cirurgia , Articulação do Punho/diagnóstico por imagem , Articulação do Punho/cirurgiaRESUMO
BACKGROUND: Cutibacterium acnes is a commensal, gram-positive, facultatively anaerobic bacillus that resides in the dermis. Historically thought to be a contaminant when identified on cultured specimens, recent advances in diagnostic technology have now implicated it as the most common organism responsible for postoperative shoulder infections. Despite a recognition of the role of this organism and a significant research interest in recent years, there is clear lack of consensus guideline on strategies to prevent, diagnose, and treat postoperative shoulder infection. METHOD: The electronic databases PubMed, MEDLINE, CINAHL, Scopus, and Web of Science were searched in March 2020. All experimental and nonexperimental studies that investigate C acnes in shoulder surgery were included. Inclusion was limited to articles published after 2000 and written in English; reviews, gray literature, or abstracts were excluded. A total of 70 studies were included in this review. This scoping review was performed in accordance with the Extended Preferred Reporting Items of Systematic Reviews and Meta-Analyses Statement for Scoping Reviews (PRISMA-ScR). RESULTS: Standard surgical prophylactic regimens such as intravenous antibiotics and topical chlorhexidine are ineffective at removing C acnes from the deep layer of the dermis, and there is a shift toward using topical benzoyl peroxide with significantly improved efficacy. An improved understanding of the bacteria has demonstrated that a prolonged culture time of up to 14 days is needed, especially in cases of established infection. Advances in diagnostics such as sonication and molecular-based testing are promising. Although usually thought to be susceptible to a broad range of antibiotics, resistance is emerging to clindamycin. An improved understanding of its ability to form a biofilm highlights the difficulty in treating an established infection. CONCLUSION: The role of C acnes causing postoperative infection following shoulder surgery is being increasingly recognized. Strategies for prevention, diagnosis, and treatment have been outlined from both an antimicrobial and surgical perspective. A number of these strategies are emerging and require further research to demonstrate efficacy before implementation into clinical guidelines.
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Infecções por Bactérias Gram-Positivas , Articulação do Ombro , Peróxido de Benzoíla , Clindamicina , Humanos , Propionibacterium acnes , Ombro , Articulação do Ombro/cirurgiaRESUMO
BACKGROUND: Distal radius fractures are among the most common fractures seen in the hospital emergency department. Of these, over 40% are considered unstable and require some form of fixation. In recent years with the advent of low profile plating, open reduction and internal fixation (ORIF) using volar plates has become the surgical treatment of choice in many hospitals. However, it is currently unknown which plating system has the lowest complication rate and/or superior clinical and radiological outcomes following surgery. Few studies have compared different types of plates, which may have various features, different plate and screw designs or may be manufactured from different materials (for example, stainless steel or titanium). This study will specifically investigate and compare the clinical and radiological outcomes and complication rates of two commonly used volar plating systems for fixation of distal radius fractures: one made from stainless steel (Trimed™ Volar Plate, Trimed™, California, USA) and the other made from titanium (Medartis® Aptus Volar Plate, Medartis®, Basel, Switzerland). The primary aim of this study is to determine if there is a difference on the Patient Reported Wrist Evaluation six months following ORIF using a volar plate for adult patients with a distal radius fracture. METHODS/DESIGN: This study will implement a randomized prospective clinical trial study design evaluating the outcomes of two different types of volar plates: one plate manufactured from stainless steel (Trimed™ Volar Plate) and one plate manufactured from titanium (Medartis® Aptus Volar Plate). The surgery will be performed at a major trauma hospital in Brisbane, Australia. Outcome measures including function, adverse events, range of movement, strength, disability, radiological findings and health-related quality of life will be collected at 6 weeks, 3, 6, 12 and 24 months following surgery. A parallel economic analysis will also be performed. This randomized clinical trial is due to deliver results in December 2016. DISCUSSION: Results from this trial will contribute to the evidence on operative management of distal radius fractures and plate material type. TRIAL REGISTRATION: ACTRN12612000969864.
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Placas Ósseas , Fixação Interna de Fraturas/instrumentação , Fraturas do Rádio/cirurgia , Aço Inoxidável , Titânio , Protocolos Clínicos , Fratura de Colles/diagnóstico por imagem , Fratura de Colles/reabilitação , Fratura de Colles/cirurgia , Desenho de Equipamento , Feminino , Consolidação da Fratura , Força da Mão , Humanos , Masculino , Medição da Dor , Seleção de Pacientes , Qualidade de Vida , Radiografia , Fraturas do Rádio/diagnóstico por imagem , Fraturas do Rádio/reabilitação , Amplitude de Movimento Articular , Recuperação de Função Fisiológica , Índices de Gravidade do Trauma , Traumatismos do Punho/cirurgiaRESUMO
Background: The use of reverse shoulder arthroplasty as a primary and revision implant is increasing. Advances in implant design and preoperative surgical planning allow the management of complex glenoid defects. As the demand for treating severe bone loss increases, custom allograft composites are needed to match the premorbid anatomy. Baseplate composite structural allografts are used in patients with eccentric and centric defects to restore the glenoid joint line. Preserving bone stock is important in younger patients where a revision surgery is expected. The aim of this article is to present the assessment, planning, and indications of femoral head allografting for bony defects of the glenoid. Methods: The preoperative surgical planning and the surgical technique to execute the plan with a baseplate composite graft are detailed. The preliminary clinical and radiological results of 29 shoulders which have undergone this graft planning and surgical technique are discussed. Clinical outcomes included visual analogue score of pain (VAS), American Shoulder and Elbow Surgeons score (ASES), Constant-Murley score (CS), satisfaction before and after operation, and active range of motion. Radiological outcomes included graft healing and presence of osteolysis or loosening. Results: The use of composite grafts in this series has shown excellent clinical outcomes, with an overall graft complication rate in complex bone loss cases of 8%. Conclusion: Femoral head structural allografting is a valid and viable surgical option for glenoid bone defects in reverse shoulder arthroplasty.
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Musculoskeletal conditions affect an estimated 1.7 billion people worldwide, causing intense pain and disability. These conditions lead to 30 million emergency room visits yearly, and the numbers are only increasing. However, diagnosing musculoskeletal issues can be challenging, especially in emergencies where quick decisions are necessary. Deep learning (DL) has shown promise in various medical applications. However, previous methods had poor performance and a lack of transparency in detecting shoulder abnormalities on X-ray images due to a lack of training data and better representation of features. This often resulted in overfitting, poor generalisation, and potential bias in decision-making. To address these issues, a new trustworthy DL framework has been proposed to detect shoulder abnormalities (such as fractures, deformities, and arthritis) using X-ray images. The framework consists of two parts: same-domain transfer learning (TL) to mitigate imageNet mismatch and feature fusion to reduce error rates and improve trust in the final result. Same-domain TL involves training pre-trained models on a large number of labelled X-ray images from various body parts and fine-tuning them on the target dataset of shoulder X-ray images. Feature fusion combines the extracted features with seven DL models to train several ML classifiers. The proposed framework achieved an excellent accuracy rate of 99.2%, F1Score of 99.2%, and Cohen's kappa of 98.5%. Furthermore, the accuracy of the results was validated using three visualisation tools, including gradient-based class activation heat map (Grad CAM), activation visualisation, and locally interpretable model-independent explanations (LIME). The proposed framework outperformed previous DL methods and three orthopaedic surgeons invited to classify the test set, who obtained an average accuracy of 79.1%. The proposed framework has proven effective and robust, improving generalisation and increasing trust in the final results.
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Artrite , Aprendizado Profundo , Doenças Musculoesqueléticas , Humanos , Ombro/diagnóstico por imagem , Raios X , Serviço Hospitalar de EmergênciaRESUMO
Deep learning (DL) in orthopaedics has gained significant attention in recent years. Previous studies have shown that DL can be applied to a wide variety of orthopaedic tasks, including fracture detection, bone tumour diagnosis, implant recognition, and evaluation of osteoarthritis severity. The utilisation of DL is expected to increase, owing to its ability to present accurate diagnoses more efficiently than traditional methods in many scenarios. This reduces the time and cost of diagnosis for patients and orthopaedic surgeons. To our knowledge, no exclusive study has comprehensively reviewed all aspects of DL currently used in orthopaedic practice. This review addresses this knowledge gap using articles from Science Direct, Scopus, IEEE Xplore, and Web of Science between 2017 and 2023. The authors begin with the motivation for using DL in orthopaedics, including its ability to enhance diagnosis and treatment planning. The review then covers various applications of DL in orthopaedics, including fracture detection, detection of supraspinatus tears using MRI, osteoarthritis, prediction of types of arthroplasty implants, bone age assessment, and detection of joint-specific soft tissue disease. We also examine the challenges for implementing DL in orthopaedics, including the scarcity of data to train DL and the lack of interpretability, as well as possible solutions to these common pitfalls. Our work highlights the requirements to achieve trustworthiness in the outcomes generated by DL, including the need for accuracy, explainability, and fairness in the DL models. We pay particular attention to fusion techniques as one of the ways to increase trustworthiness, which have also been used to address the common multimodality in orthopaedics. Finally, we have reviewed the approval requirements set forth by the US Food and Drug Administration to enable the use of DL applications. As such, we aim to have this review function as a guide for researchers to develop a reliable DL application for orthopaedic tasks from scratch for use in the market.
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Total shoulder arthroplasty (TSA) has been the gold standard of care for end-stage glenohumeral arthritis. Outcomes are varied and have been affected by both patient and implant characteristics. Patient factors, such as age, preoperative diagnosis, and preoperative glenoid morphology, can affect the outcomes after TSA. Similarly, the different glenoid and humeral component designs significantly affect the survivorship of TSA. Significant evolution has occurred in the design of the glenoid component with the aim of decreasing the glenoid-sided causes of failure in TSA. On the other hand, focus on the humeral component has been increasing as well, with a trend towards using shorter humeral stems. This article aims to look at the outcomes of TSA as affected by the various patient characteristics and design options for the glenoid and the humeral components. This review also aims to compare survivorship data from global literature and the Australian joint replacement registry and to provide insights into the implant combination that may provide the best patient outcome.
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Artroplastia do Ombro , Prótese de Ombro , Humanos , Seguimentos , Resultado do Tratamento , Sobrevivência , AustráliaRESUMO
The surgical Latarjet procedure aims to stabilise the glenohumeral joint following anterior dislocations. Despite restoring joint stability, the procedure introduces alterations of muscle paths which likely modify the shoulder dynamics. Currently, these altered muscular functions and their implications are unclear. Hence, this work aims to predict changes in muscle lever arms, muscle and joint forces following a Latarjet procedure by using a computational approach. Planar shoulder movements of ten participants were experimentally assessed. A validated upper-limb musculoskeletal model was utilised in two configurations, i.e., a baseline model, simulating normal joint, and a Latarjet model simulating its related muscular alterations. Muscle lever arms and differences in muscle and joint forces between models were derived from the experimental marker data and static optimisation technique. Lever arms of most altered muscles, hence their role, were substantially changed after Latarjet. Altered muscle forces varied by up to 15% of the body weight. Total glenohumeral joint force increased by up to 14% of the body weight after Latarjet, mostly due to increase in compression force. Our simulation indicated that the Latarjet muscular alterations lead to changes in the muscular recruitment and contribute to the stability of the glenohumeral joint by increasing compression force during planar motions.
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Instabilidade Articular , Luxação do Ombro , Articulação do Ombro , Humanos , Articulação do Ombro/fisiologia , Ombro/fisiologia , Luxação do Ombro/cirurgia , Fenômenos Mecânicos , Modelos TeóricosRESUMO
Background: Restoration of the glenoid joint line in shoulder arthroplasty is important for implant positioning and function. Medialization of the glenohumeral joint line due to glenoid bone loss is commonly encountered in primary and revision of shoulder arthroplasty albeit the direction and location of bone loss varies with different pathology. Three-Dimensional (3D) planning software has assisted in preoperative planning of complex glenoid deformities. However, limited literature is available defining a reliable 3D method to evaluate the glenoid joint line preoperatively. Aims: The purpose of this study is to identify a set of reliable scapular landmarks to be used as reference points to measure the premorbid glenoid joint line using 3D segmented models of healthy scapulae. Methods: Bilateral computed tomography scans from 79 patients eligible for primary stabilization procedures were retrospectively selected from our institutional surgical database (mean age 35 ± 10 years, 58 males and 21 females). 3D models of the contralateral healthy scapulae were created via computed tomography scan segmentation using Mimics 24.0 software (Materialise, Leuven, Belgium). Anatomical landmarks were identified using 3-Matic 16.0 software (Materialise, Leuven, Belgium). The distance between identified landmarks and a sagittal plane created on the deepest point of the glenoid was recorded for each scapula and reliability of each landmark was assessed. Inter- and intra-observer reliabilities were also evaluated using intraclass correlation coefficients (ICCs). Results: Four landmarks showed statistically significant results: the scapular notch (SN), the centroid of the coracoid (CC), a point on the most medial border of the scapula in line with the scapular spine (TS), and the most lateral point of the acromion (AL). The mean (± standard deviation) joint line measured from the SN, CC, TS and AL were 28.36 ± 2.97 mm, 11.66 ± 2.07 mm, 107.52 ± 8.1 mm, and 29.72 ± 4.46 mm, respectively. Inter-observer reliability analysis for SN, TS, and AL showed excellent agreement with ICC values of 0.966, 0.997, and 0.944, respectively, and moderate agreement for CC with ICC of 0.728. Conclusion: The results from this study assist in estimating joint line medialization preoperatively and in planning its subsequent restoration. A set of reliable landmarks can be used as references to estimate the premorbid glenoid joint line preoperatively.
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Revision shoulder arthroplasty is increasing with the number of primary shoulder replacements rising globally. Complex primary and revisions of shoulder arthroplasties pose specific challenges for the surgeon, which must be addressed preoperatively and intraoperatively. This article aimed to present strategies for the management of revision of shoulder arthroplasties through a single-stage approach. Preoperatively, patient factors, such as age, comorbidities, and bone quality, should be considered. The use of planning software can aid in accurately evaluating implants in situ and predict bony anatomy that will remain after explantation during the revision surgery. The planning from such software can then be executed with the help of mixed reality technology to allow accurate implant placement. Single-stage revision is performed in two steps (debridement as first step, implantation and reconstruction as the second step), guided by the following principles: adequate debridement while preserving key soft tissue attachments (i.e., rotator cuff, pectoralis major, latissimus dorsi, deltoid), restoration of glenoid joint line using bone grafting, restoration of humeral length, reconstruction and/or reattachment of soft tissues, and strict compliance with the postoperative antibiotic regimen. Preliminary results of single-stage revision shoulder arthroplasty show improvement in patient outcomes (mean 1 year), successful treatment of infection for those diagnosed with periprosthetic joint infection, and improved cost-benefit parameters for the healthcare system.
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Arthroscopic capsular release has emerged as a safe and reliable method for treating severe frozen shoulder in patients with significant loss of range of motion. This article describes a reproducible technique for arthroscopic 360° release of the shoulder performed in the lateral decubitus position.
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BACKGROUND: Recurrent shoulder instability may be associated with glenoid erosion and bone loss. Accurate quantification of bone loss significantly influences the contemplation of surgical procedure. In addition, assessment of bone loss is crucial for surgical planning and accurate graft placement during surgery. PURPOSE: To quantify the concave surface area of glenoid bone loss by using 3-dimensional (3D) segmented models of the scapula and to compare this method with the best-fit circle and glenoid height/width methods, which use the glenoid rim for bone loss estimations. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: A total of 36 consecutive preoperative bilateral computed tomography scans of patients eligible for a primary Latarjet procedure were selected from our institutional surgical database (mean patient age, 29 ± 9 years; 31 men and 5 women). The 3D models of both scapulae were generated using medical segmentation software and were used to map the anatomic concave surface area (ACSA) of the inferior glenoid using the diameter of the best-fit circle of the healthy glenoid. Bone loss was calculated as a ratio of the difference between surface areas of both glenoids (healthy and pathological) against the anatomic circular surface area of the healthy glenoid (the ACSA method). These results were compared with bone loss calculations using the best-fit circle and glenoid height/width methods. Inter- and intraobserver reliability were also calculated. RESULTS: The mean (± SD) bone loss calculated using the ACSA, the best-fit circle, and glenoid height/width methods was 9.4% ± 6.7%, 14.3% ± 6.8%, and 17.6% ± 7.3%, respectively. The ACSA method showed excellent interobserver reliability, with an intraclass correlation coefficient (ICC) of 0.95 versus those for the best-fit circle (ICC, 0.71) and glenoid height/width (ICC, 0.79) methods. CONCLUSION: Quantification of instability-related glenoid bone loss is reliable using the 3D ACSA method.
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Symptomatic massive posterosuperior rotator cuff tears without glenohumeral joint arthritis and chronic medial retraction often are deemed "irreparable." These patients often are treated with alternative joint-sparing procedures including superior capsular reconstruction or tendon transfer procedures. Open and arthroscopic-assisted muscle advancement techniques allow maximal lateral tendon mobilisation during rotator cuff repair. In this report, we present an all-arthroscopic technique of complete supraspinatus and infraspinatus muscle scapular detachment and advancement in retracted massive posterosuperior rotator cuff tears. This allows for an anatomical tendon footprint reduction and tension-free repair.
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Exposure of the humeral articular surface through an anterior approach to the shoulder for grafting humeral bone defects requires partial or complete detachment of the subscapularis tendon and traditionally is achieved through a subscapularis tenotomy, peel tuberosity osteotomy, or lesser tuberosity osteotomy. This case report presents a technique of performing a pedicled-lesser tuberosity osteotomy to allow adequate access for allograft reconstruction of a large reverse Hill-Sachs lesion after a traumatic posterior dislocation, to restore humeral head sphericity and prevent recurrent glenohumeral joint instability. The inferior subscapularis insertion is left intact leaving a periosteal sleeve and preserving the blood supply to the lesser tuberosity and humeral head, with the aim of improving healing of the osteotomy and preventing graft-related complications, such as resorption. Successful union of the pedicled-lesser tuberosity osteotomy and allograft was seen on a 6-month follow-upcomputed tomography scan, with adequate restoration of subscapularis function.