RESUMEN
PURPOSE: Open reduction and internal fixation with a locking plate are performed frequently to treat fractures of the proximal humerus. Avascular necrosis and non-union or malunion are potential complications of this procedure, which lead to specific fracture sequelae. The aim of this study was to investigate the clinical and radiological results of patients treated by removal of a failed locking plate of the proximal humerus and simultaneous implantation of a reverse total shoulder prosthesis. METHODS: Twenty-one patients (f = 17, m = 4; mean age 70 years) out of 29 patients were available for follow-up after a mean period of 45 (30-65) months. At follow-up, all patients were assessed with the constant score and the ASES score as well as plain radiographs. RESULTS: In comparison with the preoperative values, abduction (31° vs. 115°; p < 0.001) and forward flexion (34° vs. 121°; p < 0.001) improved until follow-up, while the pain score on a visual analog scale decreased (6.7 vs. 0.9; p < 0.001). At follow-up, the mean ASES score rated 73 and the constant score rated 62. The radiologic findings included scapular notching (n = 7; 33%), radiolucency (n = 4; 19%), heterotopic ossifications (n = 3; 14%), and stress shielding (n = 4; 19%). CONCLUSION: Reverse total shoulder arthroplasty is a useful instrument for the treatment of failed locking plate osteosynthesis of the proximal humerus in elderly patients. The patients benefit from both pain relief and improved shoulder function. The rate of radiologic changes like scapular notching, radiolucency, stress-shielding and heterotopic ossifications at follow-up is notable.
Asunto(s)
Artroplastía de Reemplazo de Hombro/métodos , Placas Óseas , Remoción de Dispositivos , Fracturas del Hombro/cirugía , Anciano , Femenino , Estudios de Seguimiento , Fijación Interna de Fracturas/instrumentación , Humanos , Masculino , Osificación Heterotópica/diagnóstico por imagen , Rango del Movimiento Articular , Reoperación , Estudios Retrospectivos , Fracturas del Hombro/complicaciones , Fracturas del Hombro/diagnóstico por imagenRESUMEN
Aims: The reasons for failure of a hemirthroplasty (HA) when used to treat a proximal humeral fracture include displaced or necrotic tuberosities, insufficient metaphyseal bone-stock, and rotator cuff tears. Reverse total shoulder arthroplasty (rTSA) is often the only remaining form of treatment in these patients. The aim of this study was to evaluate the clinical outcome after conversions from a failed HA to rTSA. Material and Methods: A total of 35 patients, in whom a HA, as treatment for a fracture of the proximal humerus, had failed, underwent conversion to a rTSA. A total of 28 were available for follow-up at a mean of 61 months (37 to 91), having been initially reviewed at a mean of 20 months (12 to 36) postoperatively. Having a convertible design, the humeral stem could be preserved in nine patients. The stem was removed in the other 19 patients and a conventional rTSA was implanted. At final follow-up, patients were assessed using the American Shoulder and Elbow Surgeons (ASES) score, the Constant Score, and plain radiographs. Results: At final follow-up, the mean ASES was 59 (25 to 97) and the mean adjusted Constant Score was 63% (23% to 109%). Both improved significantly (p < 0.001). The mean forward flexion was 104° (50° to 155°) and mean abduction was 98° (60° to 140°). Nine patients (32%) had a complication; two had an infection and instability, respectively; three had a scapular fracture; and one patient each had delayed wound healing and symptomatic loosening. If implants could be converted to a rTSA without removal of the stem, the operating time was shorter (82 minutes versus 102 minutes; p = 0.018). Conclusion: After failure of a HA in the treatment of a proximal humeral fracture, conversion to a rTSA may achieve pain relief and improved shoulder function. The complication rate is considerable. Cite this article: Bone Joint J 2018;100-B:761-6.
Asunto(s)
Artroplastía de Reemplazo de Hombro/métodos , Hemiartroplastia/efectos adversos , Reoperación/métodos , Fracturas del Hombro/cirugía , Prótesis de Hombro/efectos adversos , Anciano , Anciano de 80 o más Años , Artroplastía de Reemplazo de Hombro/efectos adversos , Femenino , Estudios de Seguimiento , Hemiartroplastia/métodos , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Rango del Movimiento Articular , Reoperación/efectos adversos , Articulación del Hombro/cirugía , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
Is reverse total shoulder arthroplasty a feasible treatment option for failed shoulder arthroplasty? A retrospective study of 44 cases with special regards to stemless and stemmed primary implants. BACKGROUND: Due to humeral or glenoid bone-loss and rotator cuff insufficiency reverse total shoulder arthroplasty often means the only remaining treatment option in revision shoulder arthroplasty. This study investigates the clinical outcome of patients treated with a reverse total shoulder in revision cases with special regard to stemless and stemmed primary implants. MATERIALS AND METHODS: From 2010 to 2012 60 failed shoulder arthroplasties were converted to reverse total shoulder arthroplasty. Forty-four patients were available for follow-up after a mean of 24 months. Patients were assessed with X-rays, Constant- and ASES Score and a questionnaire about their subjective satisfaction. RESULTS: The total number of observed complications was seven (16%). Ninety-eight percent of the patients were satisfied with their clinical result. Patients achieved a mean normalized constant score of 70.2% and a mean ASES Score of 65.3. Patients with stemless primary implants achieved a higher normalized constant score than patients with stemmed primary implants (82 vs. 61.8%; p = 0009). CONCLUSION: Reverse total shoulder arthroplasty provides satisfactory clinical results and a high patient satisfaction in revision shoulder arthroplasty. The complication rate needs to be considered and discussed with the patient prior to surgery. Presence or absence of a stem of revised shoulder arthroplasties interferes with the outcome. LEVEL OF EVIDENCE IV: (Retrospective study).
Asunto(s)
Artroplastía de Reemplazo de Hombro/métodos , Prótesis de Hombro , Anciano , Anciano de 80 o más Años , Artroplastia , Estudios de Factibilidad , Femenino , Humanos , Masculino , Diseño de Prótesis , Estudios Retrospectivos , Insuficiencia del TratamientoRESUMEN
BACKGROUND: Corrective osteotomies around the knee are a cost-efficient and joint-preserving treatment option for primary leg deformities. Incorrect indications, technical errors, and insufficient postoperative management may lead to severe complications. OBJECTIVES: This review discusses potential complications of corrective osteotomies around the knee and treatment and prevention strategies. MATERIALS AND METHODS: A selective review of the literature and a discussion of the authors' strategies for avoiding complications are presented. RESULTS: Major risk factors for complications are the indication for and the planning of an osteotomy. The indication should take into consideration the difference between primary (constitutional) and secondary deformity. Planning must be based on a long-leg X-ray with correct rotation of the leg. Joint space opening of the non-involved compartment must be considered to avoid over-correction. Intraoperative fractures can be avoided by the use of an optimized technique. The neurovascular structures must be protected during osteotomy of the posterior cortex. Delayed bone healing/pseudarthrosis may occur in open-wedge and in closed-wedge procedures. High-energy shock wave therapy or autologous cancellous bone grafts can be used to enable bone healing. Infection is usually associated with the implant. Early infection may be treated by debridement and antibiotics. Late infection requires removal of the implant and placement of an external fixator if the osteotomy is still unstable. CONCLUSIONS: Corrective osteotomies around the knee represent a safe treatment option if there is a proper indication and patient selection. Intra- and postoperative complications need to be identified quickly to maintain satisfactory postoperative results.
Asunto(s)
Artropatías/etiología , Artropatías/terapia , Traumatismos de la Rodilla/terapia , Articulación de la Rodilla/cirugía , Osteotomía/efectos adversos , Complicaciones Posoperatorias/terapia , Humanos , Artropatías/diagnóstico , Traumatismos de la Rodilla/diagnóstico , Traumatismos de la Rodilla/etiología , Articulación de la Rodilla/patología , Osteotomía/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/etiologíaRESUMEN
BACKGROUND: Knees with a limited range of motion caused by intraarticular scars benefit from arthroscopic arthrolysis. Usually these scars result from previous surgery, severe trauma with damage of intraarticular structures. Less frequent the reason is primary arthrofibrosis. Improvement of range of motion is achieved by arthroscopic release of scar tissue and removal of the fibrotic Hoffa fat pad. OBJECTIVES: To improve the patients' range of motion which is necessary for activities of daily living and labour is the aim of this surgery. Scar tissue is debrided and resected arthroscopically with a radiofrequency device, a shaver or a punch. INDICATIONS: Flexion deficit of maximum 40°, extension deficit to a maximum 20°, reduced mobility of patella, intraarticular reason for limited range of motion, cyclops after anterior cruciate liagment reconstruction, fibrotic Hoffa fat pad. CONTRAINDICATIONS: Origin of limited range of motion is extraarticular (e.g. fibrotic quadriceps muscle), local and general infection, major osteoarthritis, noncompliance, complex regional pain syndrome type I. SURGICAL TECHNIQUE: After creating an anterolateral and anteromedial standard portal, scar tissue is resected from the superior recess. Medial and lateral adhesions are detached. After removal of the fibrotic Hoffa fat pad, the notch is released while cruciate ligaments are preserved. After visualization of the posterior recessus, a posteromedial portal is placed. By releasing the posterior capsule, extension is improved. The range of motion is checked regularly during surgery. When mobility is restored and all attendant pathologies have been treated, the surgery is finished. POSTOPERATIVE MANAGEMENT: Continuous physical therapy to maintain range of motion. If necessary, continuous passive motion is implemented. Pain adapted weight-bearing. A sufficient oral and (when indicated) regional pain management is important to guarantee the benefit of the surgery. RESULTS: Patients with a lack of mobility of the knee gain considerably range of motion by arthroscopic procedures. Because of the minimal invasiveness, trauma of surgery and risk of infection are reduced. Between 2010 and 2014, 16 patients were treated by arthroscopic arthrolysis. Extension deficit decreased more than 10° from 13.6° to 3°, while flexion increased over 26° from 91.6° to 117.8°.
Asunto(s)
Artroplastia/métodos , Artroscopía/métodos , Contractura/diagnóstico , Contractura/cirugía , Articulación de la Rodilla/cirugía , Rango del Movimiento Articular , Artroplastia/rehabilitación , Artroscopía/rehabilitación , Femenino , Humanos , Articulación de la Rodilla/patología , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
OBJECTIVE: Knee flexion is increased by detachment of contracted quadriceps muscle from the pelvis and femur in combination with arthrolysis of the knee. INDICATIONS: Flexion contracture of the knee caused by extraarticular changes of quadriceps muscle (fibrosis, soft-tissue damage, infection, fracture). Failed intraarticular arthrolysis. Intraarticular treatment insufficient. CONTRAINDICATIONS: Isolated intraarticular fibrosis of the knee. Infection of the knee or the soft tissues. Soft tissue defects in the area of the incision. Noncompliance of patient. Neurologic reasons for flexion contracture. SURGICAL TECHNIQUE: Medial arthrotomy. Arthrolysis and resection of adhesions in the superior recess and lateral gutters. Incision of retinaculae preparing a lengthening. The vastus medialis muscle is dissected from the intermuscular septum from distal to proximal. The proximal third of the muscle is spared. The incision is now extended proximally and laterally. The vastus lateralis muscle is released from the intermuscular septum from distal to proximal. The insertion of vastus lateralis muscle is detached at the proximal femur. The conjoint tendons of rectus femoris muscle are released at the anterior inferior iliac spine. The knee is gradually flexed, residual adhesions are addressed. The proximal part of the vastus medialis has to be preserved since it covers the neurovascular supply of the quadriceps muscle. The knee is closed in flexion. The retinaculae are adapted as far as possible. Soft tissues and skin are closed in layers. POSTOPERATIVE MANAGEMENT: The patient in placed on a continuous passive motion device for 7 days under peridural anesthesia. Partial weight bearing with crutches is advised for 6 weeks, quadriceps training is started early to treat the active extension deficit. RESULTS: Our results reveal that operative treatment of complex flexion deficits lead to objective and subjective improvements. After 8.2 months, 17 of 19 patients had a mean gain of flexion of 26°. Subjectively 10 patients were highly satisfied and 7 were satisfied after operative treatment.