A kinematic and electromyographic comparison of a Grammont-style reverse arthroplasty combined with a l'Episcopo transfer compared to a lateralized humeral component reverse for restoration of active external rotation.

PURPOSE: To assess kinematic and electromyographic findings of two designs of reverse total shoulder arthroplasty (RTSA). We tested two hypotheses: (H1) Grammont-style (RTSA) with l'Episcopo tendon transfer gains similar postoperative kinematic findings of a lateralized humeral component RTSA without a tendon transfer; (H2) RTSA with lateralized humeral component induces earlier shoulder muscle activation during shoulder motion compared with standard Grammont prosthesis with l'Episcopo transfer. METHODS: Twenty-five patients with a cuff tear arthropathy, pseudoparalysis, and a positive dropping sign were sequentially included. A Grammont-style RTSA with a l'Episcopo tendon transfer was implanted in 13 patients (medialized humerus and transfer group) and an on-lay curved-stem RTSA in 12 (lateralized humerus group). Constant score; the disabilities of the arm, shoulder, and hand (DASH) score; and active shoulder range of motion (flexion, abduction, external rotation, and internal rotation) were measured pre- and postoperatively. Upper limb kinematic and surface electromyography (EMG) (anterior and posterior deltoid; upper, middle, and lower trapezius; and the upper and lower latissimus dorsi muscles) were recorded during active range of motion. RESULTS: At > 24 months of follow-up, the Constant and DASH scores and active shoulder range of motion improved in both groups (p < 0.0001). Internal rotation was significantly higher in the lateralized humerus group than in the medialized humerus and transfer group (p = 0.004). The dropping sign was found in 0/12 patients in the lateralized humerus group and in 5/13 patients in the medialized humerus and transfer group (p < 0.001). Kinematic findings were similar between groups (p = 0.286). A pattern of earlier muscle activation in the lateralized humerus group was found as compared to the transfer group as follows: (i) posterior deltoid during external rotation (p = 0.004); (ii) upper latissimus dorsi and middle and lower trapezius during flexion (p = 0.004, p = 0.005, and p = 0.042, respectively); (iii) lower latissimus dorsi during abduction (p = 0.016). CONCLUSION: RTSA with a lateralized humeral component provided similar active external rotation restoration to a Grammont-style RTSA with a l'Episcopo procedure in patients with a dropping sign. The posterior deltoid muscle underwent earlier activation during active external rotation in the lateralized humerus RTSA group as compared to the tendon transfer group. Our findings demonstrated the H1 and only partially demonstrated the H2 of the study.

Grammont humeral design versus onlay curved-stem reverse shoulder arthroplasty: comparison of clinical and radiographic outcomes with minimum 2-year follow-up.

BACKGROUND: There are few investigations comparing lateralized and medialized reverse total shoulder arthroplasty (RTSA) in patients with cuff tear arthropathy. This study assessed the outcomes of 2 RTSA designs. METHODS: Sixty-eight consecutive cuff tear arthropathy patients (74 shoulders) with a follow-up of at least 24 months received a Grammont or an onlay curved short-stem humeral component, with or without glenoid lateralization; a cementless humeral stem was implanted in >90%. Clinical outcome measures included active range of motion (anterior and lateral elevation, external and internal rotation), pain, and the Constant-Murley score. Radiologic outcomes included radiolucency, condensation lines, cortical thinning, spot weld, loosening and subsidence, and tuberosity resorption for the humeral component and radiolucency, scapular notching, formation of scapular bone spurs, ossifications, and loosening for the glenoid component. RESULTS: Both prostheses provided significant differences between preoperative and postoperative scores and showed a similar complication rate. Scapular fractures were found only in the patients who received the curved short-stem implant. Glenoid bone grafting did not significantly affect clinical scores. Both implants provided similar postoperative shoulder mobility, even though the lateralized curved stem was associated with higher delta scores for external rotation (P = .002) and lower rates of scapular notching (P = .0003), glenoid radiolucency (P = .016), and humeral bone remodeling (P = .004 and P = .030 for cortical thinning and spot weld, respectively). CONCLUSIONS: Medialized and short-stem lateralized RTSA implants provided similar midterm clinical outcomes and range of motion. The curved short stem was associated with higher delta scores for external rotation and a lower rate of radiographic risk factors.

Shoulder Rehabilitation Exercises With Kinematic Biofeedback After Arthroscopic Rotator Cuff Repair: Protocol for a New Integrated Rehabilitation Program.

BACKGROUND: The recovery of scapular and humeral physiological kinematic parameters, as well as the sensorimotor control of movement, plays a primary role in the rehabilitation process after arthroscopic rotator cuff repair. A highly customized rehabilitation approach is required to achieve this aim. Biofeedback can be a useful tool, but there is poor evidence of its application in the rehabilitation after arthroscopic rotator cuff tear repair. OBJECTIVE: The aim of this paper is to outline an innovative exercise-based rehabilitation program exploiting visual biofeedback for the recovery of patients arthroscopically treated for rotator cuff repair. METHODS: For establishment of the innovative program, a multidisciplinary team involving experts in shoulder surgery, rehabilitation medicine, physical therapy, and biomedical and clinical engineering was formed. Starting from a conventional rehabilitation program, the team selected a set of exercises to be integrated with a biofeedback tool, named the INAIL (National Institute for Insurance against Accidents at Work) Shoulder and Elbow Outpatient program (ISEO program). ISEO is a motion analysis system based on inertial wearable sensors positioned over the thorax, scapula, humerus, and forearm. ISEO can return a visual biofeedback of humerus and scapula angles over time or of the scapula-humeral coordination, with possible overlap of patient-specific or asymptomatic reference values. A set of 12 progressive exercises was defined, divided into four groups based on humerus and scapula movements. Each group comprises 2-4 of the 12 exercises with an increasing level of complexity. Exercises can require the use of a ball, stick, rubber band, and/or towel. For each exercise, we present the starting position of the patient, the modality of execution, and the target position, together with notes about the critical factors to observe. The type of visual biofeedback to adopt is specified, such as the coordination between angles or the variation of a single angle over time. To guide the therapist in customizing the patient's rehabilitation program, a list of operative guidelines is provided. RESULTS: We describe various applications of the ISEO exercise program in terms of frequency and intensity. CONCLUSIONS: An innovative rehabilitation program to restore scapular and humeral kinematics after rotator cuff repair based on kinematic biofeedback is presented. Biofeedback is expected to increase patient awareness and self-correction under therapist supervision. Randomized controlled trials are needed to investigate the potential effect of the exercise-based biofeedback in comparison with conventional rehabilitation programs. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/35757.

Implant sonication versus intraoperative tissue sample cultures for Periprosthetic Joint Infection (PJI) of Shoulder Arthroplasty.

Introduction Periprosthetic joint infection (PJI) is the most problematic complications after shoulder arthroplasty. Many diagnostic tools have been identified to find infection, such as hystopatologic examination of tissue sections or cultures of intraoperative tissue. Implant sonication fluid culture showed good results in order to enhance diagnostic accuracy, but literature results are still controversial. Aim of our study is to compare the results of sonication with intraoperative tissue sample cultures. Patients and Methods From February 2016 to January 2018 we performed 102 revisions of Total Shoulder Arthroplasty (TSA) for suspected PJI.  Sixty - five patients respected the criteria for admission to the study. In each case periprostethic specimens were collected and explanted prosthesis were put inside sterile fluid, sonicated and then placed under culture. Results Among the sixty-five patients, 36 were considered as possible, probable or certain infection. Tissue cultures were positive for infection in thirty - four cases (52,3%) and in nineteen cases was found the positivity for Cutibacterium acnes. Sonication fluid cultures were positive in forty cases (61,5%), with a positivity for Cutibacterium acnes in twenty - seven cases. The sensitivities of sonication and tissue cultures for the diagnosis of shoulder PJI were 83.3% and 88,9% (P = 0,08); the specificities were 65.5%  and 93,1% (P < 0.01) respectively. Conclusion Our results suggest that sonication technique had not shown a clear advantage in postoperative shoulder PJI diagnosis, but it's a real aid to detect Cutibacterium acnes. In any case, sensitivity and mostly specificity were higher with  tissue cultures.

The incidence of hip, forearm, humeral, ankle, and vertebral fragility fractures in Italy: results from a 3-year multicenter study.

INTRODUCTION: We aimed to assess the incidence and hospitalization rate of hip and "minor" fragility fractures in the Italian population. METHODS: We carried out a 3-year survey at 10 major Italian emergency departments to evaluate the hospitalization rate of hip, forearm, humeral, ankle, and vertebral fragility fractures in people 45 years or older between 2004 and 2006, both men and women. These data were compared with those recorded in the national hospitalizations database (SDO) to assess the overall incidence of fragility fractures occurring at hip and other sites, including also those events not resulting in hospital admissions. RESULTS: We observed 29,017 fractures across 3 years, with hospitalization rates of 93.0% for hip fractures, 36.3% for humeral fractures, 31.3% for ankle fractures, 22.6% for forearm/wrist fractures, and 27.6% for clinical vertebral fractures. According to the analyses performed with the Italian hospitalization database in year 2006, we estimated an annual incidence of 87,000 hip, 48,000 humeral, 36,000 ankle, 85,000 wrist, and 155,000 vertebral fragility fractures in people aged 45 years or older (thus resulting in almost 410,000 new fractures per year). Clinical vertebral fractures were recorded in 47,000 events per year. CONCLUSIONS: The burden of fragility fractures in the Italian population is very high and calls for effective preventive strategies.