Reverse shoulder arthroplasty in patients 85 years and older is safe, effective, and durable.

BACKGROUND: Reverse shoulder arthroplasty (RSA) was originally indicated for older adults, but outcomes in the oldest patients have not been studied. The purpose of this study was to report on patients aged ≥85 years undergoing RSA. We hypothesized that RSA would be safe, effective, and durable. METHODS: Sixty-one RSAs were performed in 58 patients aged ≥85 years (16 patients aged ≥90 years); 40 RSAs were performed for arthritis with cuff deficiency, 14 were performed for proximal humeral fractures, and 7 were performed as revisions. Active range of motion and patient-reported outcomes, comprising the American Shoulder and Elbow Surgeons score, Simple Shoulder Test score, and visual analog scale pain score, were obtained preoperatively and at final follow-up. Hospital length of stay, discharge disposition, and complications were recorded. Kaplan-Meier survivorship was computed with revision surgery or death as an endpoint. RESULTS: The mean age at RSA was 88.0 years. Mean forward elevation improved from 50.5° to 105.3°; abduction, from 48.7° to 96.1°; and external rotation, from 10.2° to 26.9° (P < .001 for all). Similarly, at a mean follow-up of 2.4 years, the visual analog scale pain score improved from 6.1 to 0.6; Simple Shoulder Test score, from 2.2 to 7.0; and American Shoulder and Elbow Surgeons score, from 33.6 to 78.2 (P < .001 for all). The mean length of stay was 3.6 days, and 15 patients were discharged home. Seven patients received a blood transfusion, and only 2 patients underwent a reoperation, neither of whom required explantation. DISCUSSION AND CONCLUSION: Improvements in active range of motion and patient-reported outcomes in our patients were comparable to those observed in younger cohorts and exceeded published minimal clinically important differences for most patients undergoing RSA for cuff deficiency. Additionally, to date, the patients in our study who died had lived with their RSA for a mean of 3.4 years and living patients had lived with their RSA for a mean of 4.3 years. RSA in patients aged ≥85 years is safe, effective, and durable for their remaining life expectancy. This information may help counsel older patients who are considering RSA, electively or for fractures.

Proximal humeral fractures treated with an intramedullary cage and plate: clinical and radiographic outcomes at a minimum of 1 year postoperatively.

BACKGROUND: Proximal humeral fractures are common injuries. Although certain fracture types may benefit from surgery including open reduction-internal fixation (ORIF), the optimal method for fixation is unclear. Newer implant designs that improve healing by minimizing hardware failure and recurrent fracture displacement may optimize clinical outcomes. METHODS: Over a 27-month period, 37 consecutive patients with proximal humeral fractures were treated by a single surgeon with a lateral humeral plate through which an intramedullary nitinol cage was inserted. Additional screws were placed through the tuberosities and cage as required. Fractures were classified by both the Neer classification and angulation or displacement in the coronal plane. At most recent follow-up, radiographic results, patient-reported outcome measurements, range of motion, complications, and reoperations were recorded. RESULTS: Thirty-one patients had a minimum of 1 year of clinical and radiographic follow-up. The average follow-up period was 91 weeks. By use of the Neer classification, there were 4 two-part, 21 three-part, and 6 four-part fractures. Twenty-one fractures were displaced in valgus and 10 in varus. Outcome measurements at most recent follow-up demonstrated an average American Shoulder and Elbow Surgeons score of 68; Single Assessment Numeric Evaluation score of 70; Quick Disabilities of the Arm, Shoulder and Hand score of 27; Veterans RAND-12 Physical Component Score of 37 and Mental Component Score of 51; Constant score of 55; Patient-Reported Outcomes Measurement Information System score of 29; and Oxford Shoulder Score of 23. Average active range of motion showed forward elevation of 134°, abduction of 91°, external rotation with the arm at the side of 30° (range, -10° to 60°), and internal rotation with the arm at the side to L1 (range, T6-S4). There were 11 complications (35%), including 2 cases of axillary nerve neurapraxia that resolved and 4 cases of avascular necrosis (13%). Unplanned reoperations were performed in 6 patients (19%). One patient underwent revision for loose hardware removal, 1 patient underwent revision ORIF after a fall, and 4 patients required component removal and revision to shoulder arthroplasty. No screw cutout or varus head collapse occurred. CONCLUSION: The management of proximal humeral fractures remains challenging. Our results demonstrate similar fracture healing, clinical improvement, and complication rates compared with conventional ORIF with screws and a side plate. At 1 year of follow-up, there were low rates of recurrent fracture displacement and screw cutout. There was a higher-than-expected rate of avascular necrosis as compared with other studies using a similar fixation construct. Larger studies and longer follow-up may demonstrate decreased rates of revision surgery and superior outcomes. Additional studies may determine whether this fixation method is superior to others for proximal humeral fractures.

Posterior-approach total shoulder arthroplasty: a case series with a minimum of 2-year outcomes.

BACKGROUND: A posterior approach to shoulder arthroplasty has been described that may improve exposure to the retroverted glenoid and spare the rotator cuff. The purpose of this study was to evaluate posterior total shoulder arthroplasty (PTSA) at a minimum of 2 years. METHODS: Between September 2016 and October 2017, 28 patients (30 shoulders) who underwent PTSA were retrospectively identified. Patients were monitored at baseline and at 6 weeks, 3 months, 6 months, 1 year, and a minimum of 2 years after surgery for range of motion, American Shoulder and Elbow Surgeons (ASES) and Simple Shoulder Test scores, radiographic outcomes, complications, and patient satisfaction. Radiographs were assessed for head height, neck-shaft angle, humeral head centering, and the presence or absence of glenoid-component cement lines. Repeated-measures analysis-of-variance models were implemented to compare the means for each outcome variable over time. RESULTS: Of the 28 patients (30 shoulders), 24 patients (26 shoulders) (87%) were available for follow-up at a minimum of 2 years (average, 31.2 months; range, 23-40 months). At latest follow-up, the average ASES pain score was 45.2 (standard deviation [SD], 10.9; range, 20-50; 95% confidence interval [CI], 40.8-49.6); average ASES function score, 42.3 (SD, 8.9; range, 21.7-50; 95% CI, 38.7-45.8); average ASES total score, 87.5 (SD, 18.8; range, 31.7-100; 95% CI, 79.8-95.1); and average Simple Shoulder Test score, 10.2 (SD, 2.0; range, 5-12; 95% CI, 9.4-11.0). Average forward flexion was 164° (SD, 13.9°; range, 130°-180°; 95% CI, 158.3°-170.4°); average external rotation, 78° (SD, 9.2°; range, 55°-90°; 95% CI, 74.3°-82.3°); and average internal rotation, T10 (SD, 2; range, L3 to T6; 95% CI, T10 to T8). The average head height was 0.86 mm above the greater tuberosity (range, -6.5 to 6.9 mm), the average neck-shaft angle was 128° (range, 113°-148°), and the average implant placement was 0.12 mm superior to the center of the neck cut (range, -3.3 to 3.5 mm). Six implants were considered malpositioned based on the criterion of >5 mm of head height above or below the tuberosity or >2 mm off-center. Glenoid cement lines were present in 7 shoulders. Two patients experienced complications: 1 patient had symptomatic glenoid loosening 29 months postoperatively that required revision to an anterior reverse total shoulder arthroplasty, and 1 patient had postoperative weakness that resolved by 6 months. CONCLUSION: PTSA is safe and efficacious at 2 years, spares the rotator cuff, and may improve early postoperative function. PTSA is more easily performed with stemless arthroplasty. Challenges with creation of the humeral head osteotomy and identification of the center of the cut humeral head surface can affect the accuracy of implant positioning. Further improvements in technique will likely improve the feasibility of this approach.

Posterior approach shoulder arthroplasty: a cadaveric study assessing access.

BACKGROUND: Posterior shoulder arthroplasty is an approach to shoulder replacement. The goal of this cadaveric study was to determine anatomic feasibility for posterior approach shoulder arthroplasty by evaluating access to the glenoid, humerus, and canal. METHODS: Twelve fresh frozen shoulders (10 males; 2 females) (mean age, 76 [range, 55-92 years]; weight, 79 kg [range, 34-125 kg]) were used. Traditional exposure techniques and retractors were used to evaluate direct access. Exposure to the glenoid and humerus was evaluated using digital imaging software. Successful placement from stemmed arthroplasty was evaluated using digital radiographs and imaging software. RESULTS: The posterior approach permitted direct access to 88.8% ± 8.1% of the glenoid. There was access to the center of the humeral head cut surface in 12 of 12 specimens. In 10 specimens, there was 100% access to the entire cut surface of the humerus and peripheral edges. The average access to the humerus was 95.3% ± 13.4%. Average angulation with stem placement was 0.73° of varus (range, 4.4° of varus to 3.5° of valgus). Regarding lateral plane angulation, there was an average of 0.33° of posterior angulation (range, 3.3° of posterior angulation to 2.5° of anterior angulation). CONCLUSION: Access to the center of the glenoid and humerus was achieved in all cases. More research is needed to evaluate the clinical efficacy of posterior shoulder arthroplasty, including mid- and long-term outcome and safety studies.

Distal Humerus Fractures Managed With Elbow Hemiarthroplasty.

BACKGROUND: Distal humerus fractures not amenable to open reduction internal fixation (ORIF) present a unique dilemma, especially for patients that weight bear through assistive devices. The one accepted operative treatment for irreparable distal humerus fractures is total elbow arthroplasty (TEA). However, TEA commonly requires lifetime weight lifting restrictions and has limited long term results. Elbow hemiarthroplasty (EHA) represents an alternative treatment modality. This study reviews patients treated with EHA permitted to weight bear postoperatively. METHODS: Twelve patients underwent EHA for comminuted distal humerus fractures deemed non-reconstructable by ORIF. Patient survey data was collected retrospectively. All patients were allowed to weight bear as tolerated through the operative extremity. Outcome measures included Patient rated elbow evaluation (PREE), Mayo elbow performance score (MEPS), and whether revision surgery was required. RESULTS: The average MEPS score was 76.1 indicating fair outcomes and the average PREE score was 41. One patient required revision. Average follow up was 44.1 months. Three patients required an assistive device prior to injury. DISCUSSION: EHA serves as a viable option for non-reconstructable distal humerus fractures. EHA does not require a weight lifting restriction, which is a benefit over TEA. Overall, patients reported preserved functional capabilities but did report moderate pain. EHA demonstrated durability, although one patient required revision. CONCLUSION: With growing interest in use of EHA, further studies are required to evaluate EHA as a superior treatment for patients with nonreconstructable traumatic distal humerus fractures; however, this study does support use in elderly patients with intermediate follow up.

Comparing Diagnostic and Treatment Recommendations of Carpal Tunnel Syndrome Available on the Internet With AAOS Clinical Practice Guidelines.

Background: Carpal tunnel syndrome (CTS) is one of the most common diagnoses in a hand surgeon's office, with estimated cost exceeding US $2 billion annually in the United States. Due to this prevalence and cost, patients often turn to the Internet for their medical care. It has been estimated that 72% of Internet users have looked online for health information in the last year. There is concern that patients may be getting misinformation with their Internet medical searches. Methods: An informal survey of the Internet was conducted to evaluate the content available to the public on the Internet and social media platforms regarding the diagnosis and treatment of CTS. The top 20 listings of 3 major search engines and information within 3 major social media sites were included. Results: Information gleaned from the search showed that while most listings were helpful in providing accurate diagnostic information and appropriate treatment modalities, there was also a great number of treatment modalities mentioned that may not be recommended by the treating physician. The guidelines established by the American Academy of Orthopaedic Surgeons both in 2007 and in 2008 and more recently in 2016 were used as a general reference but not directly compared with the informal Internet search for statistical analysis. Conclusions: This search outlines the importance of the information readily available to patients and how this may potentially alter patients' expectations prior to their arrival in the office.