RESUMEN
BACKGROUND: Proximal humeral bone loss in shoulder arthroplasty is a complex problem with a heterogeneous presentation. Different etiologies may contribute to varying degrees of severity in bone loss that dictate different treatment approaches. OBJECTIVES: The purpose of this is article is to describe our technique for treatment of proximal humeral bone loss with proximal humeral allograft prosthetic composites (APC) and identify factors that may predict when larger allografts may be necessary. MATERIALS AND METHODS: Ninety-nine patients were identified that had undergone reverse total shoulder arthroplasty with use of a proximal humeral allograft. Thirty-nine of these had large allografts that involved a significant portion of the diaphysis. Preoperative characteristics were examined to identify factors that may be associated with use of a larger diaphyseal-incorporating allograft. RESULTS: Well-fixed humeral stems could be treated with short metaphyseal allografts in 55 of 65 (85%) cases. Loose stems required longer diaphyseal-incorporating allografts in 28 of 31 (90%) cases, and these were commonly associated with periprosthetic fractures (n = 10), failed prior APC (n = 6), and infection (n = 5). Noncemented stems required diaphyseal grafts in 75% of cases, compared to cemented stems which required larger grafts in 34% of cases. CONCLUSIONS: Proximal humeral bone loss in the setting of revision shoulder arthroplasty can be successfully managed with a reverse total shoulder and proximal humeral allograft. Larger allografts are frequently required for loose humeral stems, and noncemented stems appear more likely to require larger allografts than cemented stems.
Asunto(s)
Aloinjertos , Artroplastía de Reemplazo de Hombro/métodos , Trasplante Óseo/métodos , Complicaciones Posoperatorias/cirugía , Diseño de Prótesis , Ajuste de Prótesis , Infecciones Relacionadas con Prótesis/cirugía , Cementos para Huesos/uso terapéutico , Estudios de Seguimiento , Humanos , Complicaciones Posoperatorias/diagnóstico por imagen , Falla de Prótesis , Infecciones Relacionadas con Prótesis/diagnóstico por imagenRESUMEN
We retrospectively reviewed 21 patients (22 shoulders) who presented with deep infection after surgery to the shoulder, 17 having previously undergone hemiarthroplasty and five open repair of the rotator cuff. Nine shoulders had undergone previous surgical attempts to eradicate their infection. The diagnosis of infection was based on a combination of clinical suspicion (16 shoulders), positive frozen sections (> 5 polymorphonuclear leukocytes per high-power field) at the time of revision (15 shoulders), positive intra-operative cultures (18 shoulders) or the pre-operative radiological appearances. The patients were treated by an extensive debridement, intravenous antibiotics, and conversion to a reverse shoulder prosthesis in either a single- (10 shoulders) or a two-stage (12 shoulders) procedure. At a mean follow-up of 43 months (25 to 66) there was no evidence of recurrent infection. All outcome measures showed statistically significant improvements. Mean abduction improved from 36.1 degrees (sd 27.8) pre-operatively to 75.7 degrees (sd 36.0) (p < 0.0001), the mean forward flexion from 43.1 degrees (sd 33.5) to 79.5 degrees (sd 43.2) (p = 0.0003), and mean external rotation from 10.2 degrees (sd 18.7) to 25.4 degrees (sd 23.5) (p = 0.0037). There was no statistically significant difference in any outcome between the single-stage and the two-stage group.
Asunto(s)
Artroplastia de Reemplazo , Complicaciones Posoperatorias/cirugía , Lesiones del Manguito de los Rotadores , Manguito de los Rotadores/cirugía , Articulación del Hombro/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Terapia Combinada , Desbridamiento , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Dolor/tratamiento farmacológico , Dolor/cirugía , Complicaciones Posoperatorias/diagnóstico por imagen , Complicaciones Posoperatorias/tratamiento farmacológico , Infecciones Relacionadas con Prótesis/diagnóstico por imagen , Infecciones Relacionadas con Prótesis/tratamiento farmacológico , Infecciones Relacionadas con Prótesis/cirugía , Radiografía , Rango del Movimiento Articular , Reoperación , Estudios Retrospectivos , Manguito de los Rotadores/diagnóstico por imagen , Articulación del Hombro/diagnóstico por imagen , Estadísticas no Paramétricas , Infección de la Herida Quirúrgica/diagnóstico por imagen , Infección de la Herida Quirúrgica/tratamiento farmacológico , Infección de la Herida Quirúrgica/cirugíaRESUMEN
We present six patients with chronic dislocation of the elbow who were treated by primary semiconstrained total elbow arthroplasty. All were women with a mean age of 65 years (51 to 76), the mean interval between dislocation and surgery was 17 weeks (5 to 52) and the mean follow-up 58 months (24 to 123). The most dramatic improvement was in function. The mean American Shoulder and Elbow Surgeon score was 5.2 times better (p < 0.001) and the mean total range of movement increased from 33 degrees to 121 degrees (p < 0.001) after operation. Three patients developed wear of polyethylene. One required revision for a periprosthetic fracture, and another required a bushing exchange. Primary semiconstrained elbow arthroplasty provides significant, predictable functional improvement. Potential solutions for wear of polyethylene include a different operative technique or design of implant. Despite the high incidence of such wear, total elbow arthroplasty should be considered as a viable treatment option for chronic dislocation of the elbow in elderly patients.
Asunto(s)
Traumatismos del Brazo/cirugía , Artroplastia de Reemplazo/métodos , Lesiones de Codo , Luxaciones Articulares/cirugía , Anciano , Traumatismos del Brazo/diagnóstico por imagen , Traumatismos del Brazo/fisiopatología , Enfermedad Crónica , Articulación del Codo/fisiopatología , Articulación del Codo/cirugía , Femenino , Fracturas Óseas/diagnóstico por imagen , Fracturas Óseas/fisiopatología , Fracturas Óseas/cirugía , Humanos , Luxaciones Articulares/diagnóstico por imagen , Luxaciones Articulares/fisiopatología , Persona de Mediana Edad , Dimensión del Dolor/métodos , Polietileno , Complicaciones Posoperatorias/etiología , Radiografía , Rango del Movimiento Articular , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Variable outcomes in the prosthetic reconstruction of 4-part humerus fractures often can be attributed to inconsistent and nonanatomic tuberosity placement. To compare the effects of anatomic (anterior fin) versus nonanatomic (lateral fin) tuberosity placement, we developed a dynamic cadaver model for shoulder motion. With the use of a robotically driven, computer-controlled articulator, we tested external rotation torque in 5 fresh human shoulders. After evaluation of the intact shoulders, we experimentally induced 4-part humerus fractures in the specimens. These were then repaired by hemiarthroplasty, with the use of standard techniques to secure the greater and lesser tuberosities in either anatomic or nonanatomic positions; order was randomized. Nonanatomic tuberosity reconstruction led to significant impairment in external rotation kinematics and an 8-fold increase in torque requirements (P =.001). In contrast, anatomic reconstruction produced results indistinguishable from normal shoulder controls. This study underscores the importance of rotational alignment of tuberosities during reconstruction. Failure to properly position tuberosity fragments in the horizontal plane may result in insurmountable postoperative motion restriction.
Asunto(s)
Artroplastia de Reemplazo/métodos , Fracturas del Húmero/cirugía , Implantación de Prótesis/métodos , Articulación del Hombro/fisiología , Adulto , Anciano , Fenómenos Biomecánicos , Cadáver , Femenino , Fijación de Fractura/métodos , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Rango del Movimiento Articular , TorqueRESUMEN
Twenty-one elbow dislocations with an associated radial head fracture were treated with immediate joint reduction, stabilization, and early range-of-motion exercises. In all cases initial treatment involved closed reduction of the ulnohumeral joint. For those cases involving minimally displaced and a few moderately displaced radial head fractures, treatment consisted of benign neglect (4 of 21). Of the more severely displaced fractures (17 of 21), 9 were treated with open-reduction internal fixation and 8 with immediate silicone head replacement. Despite radial head treatment, 6 of these cases remained unstable, prompting primary repair of collateral ligaments; 3 eventually required application of a hinged fixator as a salvage option. Results confirmed that initial radial head displacement predicts functional outcome. Our study demonstrates that fracture dislocations of the elbow demand a broad consideration of treatment options and that reconstruction of elbow stability requires either primary repair of collateral ligaments or the possible use of a hinged fixator device.
Asunto(s)
Lesiones de Codo , Luxaciones Articulares/terapia , Fracturas del Radio/terapia , Adolescente , Adulto , Anciano , Terapia por Ejercicio , Femenino , Fijación Interna de Fracturas , Humanos , Luxaciones Articulares/complicaciones , Masculino , Persona de Mediana Edad , Fracturas del Radio/complicaciones , Fracturas del Radio/cirugía , Estudios RetrospectivosRESUMEN
From July 1977 through March of 1983, humeral head replacement was performed on 35 shoulders with osteoarthritis and 32 shoulders with rheumatoid arthritis and followed-up for an average of 9.3 years. Satisfactory pain relief was achieved in 44 (66%) and 52 of the shoulders (78%) were described by patients as being much better or better. Active elevation was improved from an average of 84 degrees to an average of 110 degrees with external rotation improving from 20 degrees to 44 degrees. Strength improvement also occurred. Only three complications developed, and these did not affect the final outcome. Because of moderate or severe pain, 12 shoulders (18%) required revision to total shoulder arthroplasty, and all patients were relieved of their pain. The result ratings were excellent in 10 shoulders, satisfactory in 23, and unsatisfactory in 34 (51%). With longer follow-up, a satisfactory level of pain relief may not continue for those patients with osteoarthritis and rheumatoid arthritis who have had humeral head replacement alone. Whereas this form of treatment should certainly be considered in those patients who have inadequate glenoid bone to support a glenoid implant and probably be considered in younger patients or patients who wish to remain more active, these latter patients must be fully appraised that the probability of continuing pain relief is less than has often been appreciated.
Asunto(s)
Artritis Reumatoide/cirugía , Húmero/cirugía , Prótesis Articulares , Osteoartritis/cirugía , Articulación del Hombro , Adulto , Anciano , Artritis Reumatoide/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis/diagnóstico por imagen , Periodo Posoperatorio , Radiografía , Resultado del TratamientoRESUMEN
Plate contouring is an essential part of plate osteosynthesis. Its safety and technical ease is dependent on plate factors (material and design) and the complexity of the contouring. Our purpose was to determine the range of plate contouring; estimate the strain on the plate from the radius of curvature in the area of contouring; and determine whether shaped plates had a reduction in their load carrying capacity. A retrospective analysis of 500 radiographed tibias that had undergone osteosynthesis with the conventional dynamic compression plate was conducted to evaluate the radius of curvature and degree of bend in the plates, and to determine whether plates were bent at screw holes. Contouring of the plate to fit the bone was done by the surgeon at the time of application. Postoperative radiographs were evaluated. We found that (a) the shorter the length of plate contoured, the greater the strain; (b) plates were bent at screw holes, and these tended to be the areas of highest strain; (c) the range of plate strain was 0.6-16% (average 1.6%); and (d) plates were bent from 10 to 90 degrees (average 20 degrees).
Asunto(s)
Placas Óseas , Fijación Interna de Fracturas/métodos , Fracturas de la Tibia/cirugía , Fenómenos Biofísicos , Biofisica , Humanos , Estudios RetrospectivosRESUMEN
A systematic and easily reproduced bone protocol was used over a 14-month period to evaluate bone histologically and by mycobacterial culture in patients with chronic osteomyelitis. On examination of 140 bone specimens, we found four patients with unsuspected tuberculous osteomyelitis whose diagnosis was obscured by a concomitant staphylococcal osteomyelitis. Three of the patients had axial skeleton involvement, and one had disease of the femur. No patient had a history of a positive skin test or of tuberculous disease, and none had coexistent pulmonary disease. The underlying granulomatous infection was initially revealed in one patient by histologic examination of bone and in three others only by mycobacterial culture of bone. Concomitant osseous tuberculosis should be excluded in patients with staphylococcal osteomyelitis. Evaluation using a bone protocol with histologic study and culture on Löwenstein-Jensen medium is effective in diagnosing occult osseous tuberculosis.
Asunto(s)
Osteomielitis/etiología , Infecciones Estafilocócicas/diagnóstico , Tuberculosis Osteoarticular/diagnóstico , Adulto , Anciano , Biopsia , Huesos/patología , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Infecciones Estafilocócicas/complicaciones , Tuberculosis Osteoarticular/complicacionesRESUMEN
Use of anabolic androgenic steroids among athletes has grown at an alarming rate in recent years, despite the knowledge that their use has resulted in such side effects as severe depression of high-density lipoprotein levels, increased low-density lipoprotein/cholesterol levels, and hepatocellular carcinoma. We report here the case of a 34-year-old man whose hobby was body building, in the course of which he had been taking various anabolic androgenic agents for four years. Seventeen days before a scheduled body physique contest, he developed an acute right hemiparesis and experienced difficulty in speaking. In the emergency room he developed a simple partial seizure activity; an electroencephalogram showed abnormal slowing suggestive of left hemispheric structural lesion. After rehabilitation, he was able to ambulate independently; he had mild motor weakness in the right upper extremity with no sensory changes at discharge. Physicians working with athletes who use anabolic androgenic steroids should warn them of the risk of stroke.