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BACKGROUND: Patients with severe glenoid bone loss are at increased risk for poor implant fixation, scapular notching, dislocation, joint kinematic disturbances, and prosthetic failure following reverse total shoulder arthroplasty (rTSA). Glenoid bone grafting has proven useful when performing rTSA in patients with inadequate glenoid bone stock, although the current literature is limited. The purpose of this study is to evaluate clinical outcomes in patients with significant glenoid deformity undergoing primary rTSA with one-stage glenoid reconstruction using a humeral head autograft. METHODS: A database of prospectively enrolled patients was reviewed to identify patients who underwent primary rTSA with humeral head autograft (n=40) between 2008 and 2020 by six high-volume shoulder arthroplasty surgeons with minimum two-year follow-up. Variables studied included demographics, medical comorbidities, range of motion (ROM), Constant score, American Shoulder and Elbow Surgeons (ASES) score, pain score, patient satisfaction, glenoid deformity, revisions and complications. Preoperative glenoid deformity was characterized using glenoid version and beta-angles, measured on computed tomography (CT). Improvement at final follow-up was compared to a matched control group of 120 standard primary rTSA patients. Following the post hoc Bonferroni correction, an adjusted alpha value of 0.004 was used to define statistical significance. RESULTS: Forty patients were included with a mean follow-up of 5.3 (range, 2.0-13.2) years. Patients exhibited a mean preoperative glenoid retroversion and beta-angle of 29° and 80°, respectively. At final follow-up, patients who received a graft exhibited lower mean scores for active external rotation (25° vs. 39°; p = 0.001) in comparison to those who did not receive a graft. No differences were observed in active abduction (p = 0.029), active forward elevation (p = 0.009), active internal rotation (p = 0.147), passive external rotation (p = 0.082), Global Shoulder Function score (p = 0.157), Constant score (p = 0.036), ASES score (p = 0.009), or pain score (p = 0.186) between groups. Seven patients (17.5%) exhibited complications of which the most common being aseptic glenoid loosening (15%). CONCLUSION: This study demonstrates that patients undergoing primary rTSA with autogenous humeral head autograft for severe glenoid deficiency experience postoperative improvements in ROM and functional outcome scores that exceeded the minimal clinically important difference and substantial clinical benefit but inferior to matched controls. This suggests that glenoid reconstruction using a resected humeral head autograft is an effective strategy when conducting primary rTSA in patients with significant glenoid deformity.
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PURPOSE: Clinical decision support tools (CDSTs) are software that generate patient-specific assessments that can be used to better inform healthcare provider decision making. Machine learning (ML)-based CDSTs have recently been developed for anatomic (aTSA) and reverse (rTSA) total shoulder arthroplasty to facilitate more data-driven, evidence-based decision making. Using this shoulder CDST as an example, this external validation study provides an overview of how ML-based algorithms are developed and discusses the limitations of these tools. METHODS: An external validation for a novel CDST was conducted on 243 patients (120F/123M) who received a personalized prediction prior to surgery and had short-term clinical follow-up from 3 months to 2 years after primary aTSA (n = 43) or rTSA (n = 200). The outcome score and active range of motion predictions were compared to each patient's actual result at each timepoint, with the accuracy quantified by the mean absolute error (MAE). RESULTS: The results of this external validation demonstrate the CDST accuracy to be similar (within 10%) or better than the MAEs from the published internal validation. A few predictive models were observed to have substantially lower MAEs than the internal validation, specifically, Constant (31.6% better), active abduction (22.5% better), global shoulder function (20.0% better), active external rotation (19.0% better), and active forward elevation (16.2% better), which is encouraging; however, the sample size was small. CONCLUSION: A greater understanding of the limitations of ML-based CDSTs will facilitate more responsible use and build trust and confidence, potentially leading to greater adoption. As CDSTs evolve, we anticipate greater shared decision making between the patient and surgeon with the aim of achieving even better outcomes and greater levels of patient satisfaction.
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Artroplastía de Reemplazo de Hombro , Sistemas de Apoyo a Decisiones Clínicas , Articulación del Hombro , Humanos , Artroplastía de Reemplazo de Hombro/métodos , Articulación del Hombro/cirugía , Resultado del Tratamiento , Satisfacción del Paciente , Rango del Movimiento Articular , Estudios RetrospectivosRESUMEN
INTRODUCTION: We compared the 2-year clinical outcomes of both anatomic and reverse total shoulder arthroplasty (ATSA and RTSA) using intraoperative navigation compared to traditional positioning techniques. We also examined the effect of glenoid implant retroversion on clinical outcomes. HYPOTHESIS: In both ATSA and RTSA, computer navigation would be associated with equal or better outcomes with fewer complications. Final glenoid version and degree of correction would not show outcome differences. MATERIAL AND METHODS: A total of 216 ATSAs and 533 RTSAs were performed using preoperative planning and intraoperative navigation with a minimum of 2-year follow-up. Matched cohorts (2:1) for age, gender, and follow-up for cases without intraoperative navigation were compared using all standard shoulder arthroplasty clinical outcome metrics. Two subanalyses were performed on navigated cases comparing glenoids positioned greater or less than 10° of retroversion and glenoids corrected more or less than 15°. RESULTS: For ASTA, no statistical differences were found between the navigated and non-navigated cohorts for postoperative complications, glenoid implant loosening, or revision rate. No significant differences were seen in any of the ATSA outcome metrics besides higher internal and external rotation in the navigated cohort. For RTSA, the navigated cohort showed an ARR of 1.7% (95% CI 0%, 3.4%) for postoperative complications and 0.7% (95% CI 0.1%, 1.2%) for dislocations. No difference was found in the revision rate, glenoid implant loosening, acromial stress fracture rates, or scapular notching. Navigated RTSA patients demonstrated significant improvements over non-navigated patients in internal rotation, external rotation, maximum lifting weight, the Simple Shoulder Test (SST), Constant, and Shoulder Arthroplasty Smart (SAS) scores. For the navigated subcohorts, ATSA cases with a higher degree of final retroversion showed significant improvement in pain, Constant, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), SST, University of California-Los Angeles shoulder score (UCLA), and Shoulder Pain and Disability Index (SPADI) scores. No significant differences were found in the RTSA subcohort. Higher degrees of version correction showed improvement in external rotation, SST, and Constant scores for ATSA and forward elevation, internal rotation, pain, SST, Constant, ASES, UCLA, SPADI, and SAS scores for RTSA. CONCLUSION: The use of intraoperative navigation shoulder arthroplasty is safe, produces at least equally good outcomes at 2 years as standard instrumentation does without any increased risk of complications. The effect of final implant position above or below 10° of glenoid retroversion and correction more or less than 15° does not negatively impact outcomes.
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Artroplastía de Reemplazo de Hombro , Prótesis Articulares , Articulación del Hombro , Humanos , Artroplastía de Reemplazo de Hombro/efectos adversos , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/cirugía , Resultado del Tratamiento , Prótesis Articulares/efectos adversos , Complicaciones Posoperatorias/etiología , Dolor de Hombro/etiología , Estudios Retrospectivos , Rango del Movimiento ArticularRESUMEN
BACKGROUND: Internal rotation (IR) with reverse total shoulder arthroplasty (rTSA) can be unpredictable. Identifying the factors associated with loss of or improved IR could aid preoperative patient counseling. This study quantifies the change in IR experienced by rTSA patients with nonfracture indications and identifies the patient, implant, and operative factors associated with IR loss or gain at 2-year minimum follow-up. METHODS: A total of 1978 primary rTSA patients were analyzed from an international database of a single rTSA prosthesis to quantify IR at 2 years' minimum follow-up. rTSA patients were divided into 2 cohorts based on their preoperative IR score, with group 1 patients having less active IR as defined by a preoperative IR score ≤3 and group 2 patients having greater active IR as defined by a preoperative IR score ≥4 (ie, L5 or higher). For both group 1 and 2 patients, univariate and multivariate analyses were performed to quantify the risk factors associated with IR loss after rTSA. RESULTS: Overall, 58.9% of rTSA patients experienced IR improvement and 17.0% lost IR after rTSA. The occurrence of IR loss or gain was dependent on preoperative IR score, as 73.2% of group 1 patients improved IR and only 40.1% of group 2 patients improved IR, whereas 31.0% of group 2 patients lost IR and only 6.3% of group 1 patients lost IR after rTSA. Numerous risk factors for IR loss were identified. For group 1 patients, male sex (P = .004, odds ratio [OR] = 2.056), tobacco usage (P = .004, OR = 0.348), larger humeral stem diameter (P = .008, OR = 0.852), and not having subscapularis repaired (P = .002, OR = 2.654) were significant risk factors for IR loss. For group 2 patients, male sex (P = .005, OR = 1.656), higher body mass index (P = .002, OR = 0.946), a diagnosis other than osteoarthritis (P < .001, OR = 2.189), nonaugmented baseplate usage (P < .001, OR = 2.116), and not having subscapularis repaired (P < .001, OR = 3.052) were significant risk factors for IR loss. CONCLUSION: The majority of patients improve IR after rTSA in the nonfracture setting. rTSA patients with substantial IR prior to surgery had a greater probability for losing IR compared to patients with poor preoperative IR. Numerous risk factors for IR loss were identified; these risk factors are useful for counseling patients considering rTSA, as some patients are more likely to lose IR than others.
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Artroplastía de Reemplazo de Hombro , Articulación del Hombro , Artroplastía de Reemplazo de Hombro/efectos adversos , Humanos , Masculino , Rango del Movimiento Articular , Estudios Retrospectivos , Articulación del Hombro/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Preoperative planning software is widely available for most anatomic total shoulder arthroplasty (ATSA) systems. It can be most useful in determining implant selection and placement with advanced glenoid wear. The purpose of this study was to quantify inter- and intrasurgeon variability in preoperative planning of a series of ATSA cases. METHODS: Forty-nine computed tomography scans were planned for ATSA by 9 fellowship-trained shoulder surgeons using the ExactechGPS platform (Exactech Inc., Gainesville, FL, USA). Each case was planned a second time between 4 and 12 weeks later. Variability within and between surgeons was measured for implant type, size, version and inclination correction, and implant face position. Interclass correlation coefficients, Pearson, and Light's kappa coefficients were used for statistical analysis. RESULTS: There was considerable variation in the frequency of augment use between surgeons and between rounds for the same surgeon. Thresholds for augment use also varied between surgeons. Interclass correlation coefficients for intersurgeon variability were 0.37 for version, 0.80 for inclination, 0.36 for implant type, and 0.36 for implant size. Pearson coefficients for intrasurgeon variability were 0.17 for version and 0.53 for inclination. Light's kappa coefficient for implant type was 0.64. CONCLUSIONS: This study demonstrates substantial inter- and intrasurgeon variability in preoperative planning of ATSA. Although the magnitude of differences in correction was small, surgeons differed significantly in the use of augments to achieve the resultant plan. Surgeons differed from each other on thresholds for augment use and maximum allowable residual retroversion. This suggests that there may a range of acceptable corrections for each shoulder rather than a single optimal plan.
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Artroplastía de Reemplazo de Hombro , Desviación Ósea/diagnóstico por imagen , Cuidados Preoperatorios/métodos , Articulación del Hombro , Prótesis de Hombro , Cirugía Asistida por Computador/métodos , Artroplastía de Reemplazo de Hombro/métodos , Desviación Ósea/prevención & control , Desviación Ósea/cirugía , Humanos , Imagenología Tridimensional , Variaciones Dependientes del Observador , Escápula/diagnóstico por imagen , Escápula/cirugía , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/cirugía , Programas Informáticos , Cirugía Asistida por Computador/normas , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Preoperative planning software is gaining utility in reverse total shoulder arthroplasty (RTSA), particularly when addressing pathologic glenoid wear. The purpose of this study was to quantify inter- and intrasurgeon variability in preoperative planning a series of RTSA cases to identify differences in how surgeons consider optimal implant placement. This may help identify opportunities to establish consensus when correlating plan differences with clinical data. METHODS: A total of 49 computed tomography scans from actual RTSA cases were planned for RTSA by 9 fellowship-trained shoulder surgeons using the same platform (Exactech GPS, Exactech Inc., Gainesville, FL, USA). Each case was planned a second time 6-12 weeks later. Variability within and between surgeons was measured for implant selection, version correction, inclination correction, and implant face position. Interclass correlation coefficients, and Pearson and Light's kappa coefficient were used for statistical analysis. RESULTS: There was considerable variation in the frequency of augmented baseplate selection between surgeons and between rounds for the same surgeon. Thresholds for augment use also varied between surgeons. Interclass correlation coefficients for intersurgeon variability ranged from 0.43 for version, 0.42 for inclination, and 0.25 for baseplate type. Pearson coefficients for intrasurgeon variability were 0.34 for version and 0.30 for inclination. Light's kappa coefficient for baseplate type was 0.61. CONCLUSIONS: This study demonstrates substantial variability both between surgeons and between rounds for individual surgeons when planning RTSA. Although average differences between plans were relatively small, there were large differences in specific cases suggesting little consensus on optimal planning parameters and opportunities to establish guidelines based on glenoid pathoanatomy. The correlation of preoperative planning with clinical outcomes will help to establish such guidelines.
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Artroplastía de Reemplazo de Hombro/métodos , Pautas de la Práctica en Medicina , Articulación del Hombro/diagnóstico por imagen , Articulación del Hombro/cirugía , Cirujanos , Artroplastía de Reemplazo de Hombro/instrumentación , Cavidad Glenoidea/diagnóstico por imagen , Cavidad Glenoidea/cirugía , Humanos , Periodo Preoperatorio , Escápula/cirugía , Prótesis de Hombro , Programas Informáticos , Tomografía Computarizada por Rayos XRESUMEN
For acute distal humeral fractures not amenable to open reduction and internal fixation, total elbow arthroplasty has become an established alternative. However, lifelong activity restrictions designed to prevent early mechanical failure make this a poor option for some patients. This has led to a renewed interest in distal humeral hemiarthroplasty. Using modern implants and techniques, distal humeral hemiarthroplasty has shown outcomes comparable to those of total elbow arthroplasty at short- to mid-term follow-up, with an overall higher but different complication rate. Long-term data are needed, but the available literature suggests that distal humeral hemiarthroplasty be considered as another option on the treatment spectrum in select patient populations. [Orthopedics. 2017; 40(1):13-23.].
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Artroplastia de Reemplazo de Codo/métodos , Hemiartroplastia/métodos , Fracturas del Húmero/cirugía , Codo/cirugía , Articulación del Codo/cirugía , Epífisis/cirugía , Humanos , Húmero/cirugía , Resultado del TratamientoRESUMEN
BACKGROUND: Our primary efficacy objective was to evaluate the effectiveness of the internal joint stabilizer of the elbow (IJS-E) in maintaining concentric location of the elbow during and after removal of the device in the treatment of persistent or recurrent instability after elbow fracture or dislocations, or both. The secondary study objectives were to assess range of motion, Broberg-Morrey functional score, Broberg-Morrey categorical rating, the Disabilities of the Arm, Shoulder and Hand score, and the rate of complications and adverse events after the use of IJS-E. METHODS: Twenty-four patients were studied in a multicenter, nonrandomized, prospective, single-arm study. The IJS-E was used to provide temporary stabilization of the elbow joint and allow a functional range of motion while ligaments and fractures healed. RESULTS: The elbow remained concentrically aligned in 23 of 24 patients. One coronoid-deficient elbow did not maintain concentric reduction. At the last evaluation a minimum of 6 months after device removal, the mean arc of elbow flexion was 119° (range, 80°-150°; standard deviation [SD], 18°), and the mean arc of forearm rotation was 151° (range, 90°-190°; SD, 24°). The mean and median Broberg-Morrey scores were 93 and 97, respectively. Categorically the results were excellent in 14, good in 8, fair in 1, and poor in 1. The mean Disabilities of the Arm, Shoulder and Hand score was 16 (range, 0-68; SD, 18). CONCLUSION: The IJS-E maintains concentric reduction, allows elbow motion, and avoids the inconveniences and pin problems of percutaneous fixation.
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Articulación del Codo , Fijación Interna de Fracturas/instrumentación , Fracturas Intraarticulares/cirugía , Luxaciones Articulares/cirugía , Inestabilidad de la Articulación/cirugía , Adulto , Anciano , Remoción de Dispositivos , Femenino , Humanos , Fracturas Intraarticulares/complicaciones , Fracturas Intraarticulares/diagnóstico por imagen , Luxaciones Articulares/complicaciones , Luxaciones Articulares/diagnóstico por imagen , Inestabilidad de la Articulación/diagnóstico por imagen , Inestabilidad de la Articulación/etiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Radiografía , Rango del Movimiento Articular , Recuperación de la Función , Resultado del TratamientoRESUMEN
Moderate to severe fatty infiltration and rotator cuff atrophy are commonly associated with poor clinical outcomes and failed rotator cuff repair. Numerous animal and human studies have attempted to elucidate the etiology of fatty infiltration and rotator cuff atrophy. Mechanical detachment of the tendon in rotator cuff tears is primarily responsible. Suprascapular nerve injury may also play a role. CT, MRI, and ultrasonography are used to evaluate severity. The Goutallier staging system is most commonly used to evaluate fatty infiltration, and rotator cuff atrophy is measured using multiple techniques. The presence and severity of fatty infiltration have been associated with increasing age, tear size, degree of tendon retraction, number of tendons involved (ie, massive tears), suprascapular neuropathy, and traumatic tears. Fatty infiltration is irreversible and progressive if left untreated. Slight reversal of muscle atrophy has been noted after repair in some studies. Novel therapies are currently being evaluated that may eventually allow clinicians to alter the natural history and improve patient outcomes.
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Tejido Adiposo/patología , Atrofia Muscular/etiología , Manguito de los Rotadores , Animales , Humanos , Imagen por Resonancia Magnética , Atrofia Muscular/patología , Manguito de los Rotadores/patología , Manguito de los Rotadores/cirugía , Lesiones del Manguito de los RotadoresAsunto(s)
Lesiones de Codo , Fracturas del Húmero/cirugía , Húmero/cirugía , Luxaciones Articulares/cirugía , Adulto , Articulación del Codo/diagnóstico por imagen , Humanos , Fracturas del Húmero/diagnóstico por imagen , Húmero/diagnóstico por imagen , Húmero/lesiones , Imagenología Tridimensional , Luxaciones Articulares/diagnóstico por imagen , Masculino , Tomografía Computarizada por Rayos XAsunto(s)
Ligamentos Colaterales/lesiones , Lesiones de Codo , Traumatismo Múltiple/diagnóstico , Músculo Esquelético/lesiones , Fracturas del Radio/diagnóstico , Accidentes por Caídas , Adolescente , Traumatismos en Atletas , Niño , Ligamentos Colaterales/cirugía , Terapia Combinada , Articulación del Codo/cirugía , Femenino , Estudios de Seguimiento , Fijación Interna de Fracturas/métodos , Humanos , Imagen por Resonancia Magnética/métodos , Masculino , Traumatismo Múltiple/cirugía , Músculo Esquelético/cirugía , Fracturas del Radio/cirugía , Rango del Movimiento Articular/fisiología , Procedimientos de Cirugía Plástica/métodos , Recuperación de la Función , Medición de Riesgo , Rotura/diagnóstico , Rotura/cirugía , Muestreo , Tomografía Computarizada por Rayos X/métodos , Resultado del Tratamiento , Adulto JovenRESUMEN
Phalangeal and metacarpal fractures with severe comminution and/or soft tissue compromise can present a challenge for the orthopedic surgeon. Maintaining viability of the soft tissues while providing rigid fixation of bony injuries is the goal when treating these injuries. Commercially available mini external fixators can help to achieve these goals. However, these devices are costly and are not always available when the surgeon needs them. In this technique study, we discuss the implementation of a mini external fixator using readily available implements in the operating room that is efficient, cost effective, and easy to apply.
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Fijadores Externos , Traumatismos de los Dedos/cirugía , Fracturas Óseas/cirugía , Traumatismos de la Mano/cirugía , Cementos para Huesos/economía , Clavos Ortopédicos/economía , Hilos Ortopédicos/economía , Diseño de Equipo , Fijadores Externos/economía , Traumatismos de los Dedos/diagnóstico por imagen , Fracturas Óseas/diagnóstico por imagen , Traumatismos de la Mano/diagnóstico por imagen , Humanos , RadiografíaRESUMEN
The results of reconstruction for chronic instability after coronoid fracture have not been previously described. Patients with persistent instability after coronoid fracture-dislocation were assessed after reconstruction. A satisfactory outcome was considered to be present based on the Mayo Elbow Performance Score and on the patient's willingness to repeat the operation. The length of follow-up was a minimum of 2 years, averaging over 5 years. Overall, 13 of 21 patients (62%) were classified as having a successful outcome objectively, and 17 of 21 (81%) were classified as having a successful outcome subjectively. The duration of the delay to definitive treatment was closely associated with the ultimate outcome (P < .01), as the outcome of only 1 of 7 elbows with a delay greater than 7 weeks was classified as an objective success. Of the patients, 19 had a fractured radial head, 11 of which were initially treated with a radial head excision; none was subsequently reconstructed. Sixteen patients were treated with a hinged external fixator. Of the elbows, 13 remained reduced whereas 8 had variable amounts of anterior or posterior instability. Two failures were ultimately reconstructed with a total elbow arthroplasty. Instability that persists after the initial unsuccessful management of a coronoid fracture and an elbow dislocation is a difficult problem to salvage with subsequent reconstruction. This experience emphasizes the need for better reconstructive options and especially underscores the need for appropriate initial management of this difficult injury.