1
|
Cho SH, Park CJ, Kim SJ, Lee KG, Baek GR, Chung MS, Hui AT, McGarry MH, Lee TQ, Jung S, Kim J, Kim YS. Varus-valgus alignment of humeral short stem in reverse total shoulder arthroplasty: does it really matter? J Shoulder Elbow Surg 2024; 33:1762-1770. [PMID: 38242527 DOI: 10.1016/j.jse.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/15/2023] [Accepted: 11/19/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND The utilization of short humeral stems in reverse total shoulder arthroplasty has gained attention in recent times. However, concerns regarding the risk of misalignment during implant insertion are associated with their use. METHODS Eight fresh-frozen cadaveric shoulders were prepared for dissection and biomechanical testing. A bespoke humeral implant was fabricated to facilitate assessment of neutral, varus, and valgus alignments using a single stem, and 10° was established as the maximum permissible angle for misalignments. Shift in humerus position and changes in deltoid length attributable to misalignments relative to the neutral position were evaluated using a Microscribe 3DLx system. The impingement-free range of motion, encompassing abduction, adduction, internal rotation, and external rotation (ER), was gauged using a digital goniometer. The capacity for abduction was evaluated at maximal abduction angles under successive loading on the middle deltoid. A specialized traction system coupled with a force transducer was employed to measure anterior dislocation forces. RESULTS Relative to the neutral alignment, valgus alignment resulted in a more distal (10.5 ± 2.4 mm) and medial (8.3 ± 2.2 mm) translation of the humeral component, whereas the varus alignment resulted in the humerus shifting more superiorly (11.2 ± 1.3 mm) and laterally (9.9 ± 0.9 mm) at 0° abduction. The valgus alignment exhibited the highest abduction angle than neutral alignment (86.2°, P < .001). Conversely, the varus alignment demonstrated significantly higher adduction (18.4 ± 7.4°, P < .001), internal rotation (68.9 ± 15.0°, P = .014), and ER (45.2 ± 10.5°, P = .002) at 0° abduction compared to the neutral alignments. Anterior dislocation forces were considerably lower (23.8 N) in the varus group compared to the neutral group at 0°ER (P = .047). Additionally, abduction capability was markedly higher in varus alignment at low deltoid loads than the neutral alignment (5N, P = .009; 7.5 N, P = .007). CONCLUSIONS The varus position enhances rotational range of motion (ROM) but increases instability, while the valgus position does not significantly impact ROM or instability compared to the neutral position.
Collapse
Affiliation(s)
- Sung-Hyun Cho
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chan-Joo Park
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang-Jae Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kyoung-Geun Lee
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Gyu Rim Baek
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Min-Shik Chung
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Aaron T Hui
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Michelle H McGarry
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Thay Q Lee
- Orthopaedic Biomechanics Laboratory, Congress Medical Foundation, Pasadena, CA, USA
| | - Sungwook Jung
- Central R&D Center, Corentec Co., Ltd., Seoul, Republic of Korea
| | - Jaewon Kim
- Central R&D Center, Corentec Co., Ltd., Seoul, Republic of Korea
| | - Yang-Soo Kim
- Department of Orthopedic Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
| |
Collapse
|
2
|
Levin JM, Gobbi F, Pandy MG, Di Giacomo G, Frankle MA. Optimizing Muscle-Tendon Lengths in Reverse Total Shoulder Arthroplasty: Evaluation of Surgical and Implant-Design-Related Parameters. J Bone Joint Surg Am 2024:00004623-990000000-01102. [PMID: 38753817 DOI: 10.2106/jbjs.23.01123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
BACKGROUND Optimizing the function of muscles that cross the glenohumeral articulation in reverse total shoulder arthroplasty (RTSA) is controversial. The current study used a geometric model of the shoulder to systematically examine surgical placement and implant-design parameters to determine which RTSA configuration most closely reproduces native muscle-tendon lengths of the deltoid and rotator cuff. METHODS A geometric model of the glenohumeral joint was developed and adjusted to represent small, medium, and large shoulders. Muscle-tendon lengths were assessed for the anterior deltoid, middle deltoid, posterior deltoid, and supraspinatus from 0 to 90° of scaption; for the subscapularis from 0° to 60° of internal rotation (IR) and 0° to 60° of scaption; for the infraspinatus from 0° to 60° of external rotation (ER) and 0° to 60° of scaption; and for the teres minor from 0° to 60° of ER at 90° of scaption. RTSA designs were virtually implanted using the following parameters: (1) surgical placement with a centered or inferior glenosphere position and a humeral offset of 0, 5, or 10 mm relative to the anatomic neck plane, (2) implant design involving a glenosphere size of 30, 36, or 42 mm, glenosphere lateralization of 0, 5, or 10 mm, and humeral neck-shaft angle of 135°, 145°, or 155°. Thus, 486 RTSA-shoulder size combinations were analyzed. Linear regression assessed the strength of association between parameters and the change in each muscle-tendon length from the native length. RESULTS The configuration that most closely restored anatomic muscle-tendon lengths in a small shoulder was a 30-mm glenosphere with a centered position, 5 mm of glenoid lateralization, 0 mm of humeral offset, and a 135° neck-shaft angle. For a medium shoulder, the corresponding combination was 36 mm, centered, 5 mm, 0 mm, and 135°. For a large shoulder, it was 30 mm, centered, 10 mm, 0 mm, and 135°. The most important implant-design parameter associated with restoration of native muscle-tendon lengths was the neck-shaft angle, with a 135° neck-shaft angle being favored (β = 0.568 to 0.657, p < 0.001). The most important surgical parameter associated with restoration of native muscle-tendon lengths was humeral offset, with a humeral socket placed at the anatomic neck plane being favored (β = 0.441 to 0.535, p < 0.001). CONCLUSIONS A combination of a smaller, lateralized glenosphere, a humeral socket placed at the anatomic neck plane, and an anatomic 135° neck-shaft angle best restored native deltoid and rotator cuff muscle-tendon lengths in RTSA. CLINICAL RELEVANCE This study of surgical and implant factors in RTSA highlighted optimal configurations for restoration of native muscle-tendon lengths of the deltoid and rotator cuff, which has direct implications for surgical technique and implant selection. Additionally, it demonstrated the most influential surgical and implant factors with respect to muscle-tendon lengths, which can be used to aid intraoperative decision-making.
Collapse
Affiliation(s)
- Jay M Levin
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Fabrizio Gobbi
- Department of Orthopaedic Surgery, Concordia Hospital, Rome, Italy
| | - Marcus G Pandy
- Department of Mechanical Engineering, University of Melbourne, Parkville, Victoria, Australia
| | | | - Mark A Frankle
- Shoulder and Elbow Specialty, Florida Orthopaedic Institute, Tampa, Florida
| |
Collapse
|
3
|
Haeffner BD, Cueto RJ, Abdelmalik BM, Hones KM, Wright JO, Srinivasan RC, King JJ, Wright TW, Werthel JD, Schoch BS, Hao KA. The association between humeral lengthening and clinical outcomes after reverse shoulder arthroplasty: a systematic review and meta-analysis. J Shoulder Elbow Surg 2023; 32:e477-e494. [PMID: 37379967 DOI: 10.1016/j.jse.2023.05.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 05/04/2023] [Accepted: 05/13/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate the relationship between humeral lengthening and clinical outcomes after reverse shoulder arthroplasty (RSA) with stratification based on measurement method and implant design. METHODS This systematic review was performed using PRISMA-P guidelines. PubMed/Medline, Cochrane Trials, and Embase were queried for articles evaluating the relationship between humeral lengthening and clinical outcomes inclusive of range of motion (ROM), strength, outcome scores, and pertinent complications (acromial and scapular spine fractures, nerve injury) after RSA. The relationship between humeral lengthening and clinical outcomes was reported descriptively overall and stratified by measurement method and implant design (globally medialized vs. lateralized). A positive association was defined as increased humeral lengthening being associated with greater ROM, outcome scores, or a greater incidence of complications, whereas a negative association denoted that increased humeral lengthening was associated with poorer ROM, outcome scores, or a lower incidence of complications. Meta-analysis was performed to compare humeral lengthening between patients with and without fractures of the acromion or scapular spine. RESULTS Twenty-two studies were included. Humeral lengthening was assessed as the acromiohumeral distance (AHD), the distance from the acromion to the greater tuberosity (AGT), the acromion to the deltoid tuberosity (ADT), and the acromion to the distal humerus (ADH). Of 11 studies that assessed forward elevation, a positive association with humeral lengthening was found in 6, a negative association was found in 1, and 4 studies reported no association. Of studies assessing internal rotation (n = 9), external rotation (n = 7), and abduction (n = 4), all either identified a positive or lack of association with humeral lengthening. Studies assessing outcome scores (n = 11) found either a positive (n = 5) or no (n = 6) association with humeral lengthening. Of the studies that assessed fractures of the acromion and/or scapular spine (n = 6), 2 identified a positive association with humeral lengthening, 1 identified a negative association, and 3 identified no association. The single study that assessed the incidence of nerve injury identified a positive association with humeral lengthening. Meta-analysis was possible for AGT (n = 2) and AHD (n = 2); greater humeral lengthening was found in patients with fractures for studies using the AGT (mean difference 4.5 mm, 95% CI 0.7-8.3) but not the AHD. Limited study inclusion and heterogeneity prohibited identification of trends based on method of measuring humeral lengthening and implant design. CONCLUSION The relationship between humeral lengthening and clinical outcomes after RSA remains unclear and requires future investigation using a standardized assessment method.
Collapse
Affiliation(s)
- Brett D Haeffner
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Robert J Cueto
- College of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Keegan M Hones
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jonathan O Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | | | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | | | - Bradley S Schoch
- Department of Orthopaedic Surgery, Mayo Clinic, Jacksonville, FL, USA.
| | - Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| |
Collapse
|
4
|
Postoperative acromiohumeral interval affects shoulder range of motions following reverse total shoulder arthroplasty. Sci Rep 2022; 12:21011. [PMID: 36470933 PMCID: PMC9722688 DOI: 10.1038/s41598-022-25173-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
Reverse total shoulder arthroplasty (RTSA) improves function and reduces pain for patients with complex shoulder problems. However, there is a lack of literature regarding the association of radiographic parameters on clinical outcomes after RTSA. The aim of this study was to analyze various radiographic parameters that may be predictive of clinical outcomes after RTSA. A total of 55 patients treated with RTSA were enrolled. Shoulder radiographic parameters were used for measurement of critical shoulder angle, acromial index, acromiohumeral interval, deltoid lever arm, acromial angulation, glenoid version, and acromial height. Preoperative and postoperative clinical outcomes were evaluated at a minimum 2-year follow-up. An analysis of correlations between radiographic parameters and clinical outcomes was then performed. A significant change in critical shoulder angle, acromiohumeral interval, and deltoid lever arm was observed between preoperative and postoperative radiographic measurements. A significant improvement was observed in all clinical outcomes and range of motions from preoperative to postoperative (all p < 0.001). A negative correlation of postoperative acromiohumeral interval with forward flexion (r = - 0.270; p = 0.046), external rotation (r = - 0.421; p = 0.001), and internal rotation (r = 0.275; p = 0.042) was observed at final follow-up. In addition, postoperative acromiohumeral interval less than 29 mm had an 86% positive predictive value of obtaining 130° of forward flexion and 45° of external rotation. It was found that postoperative acromiohumeral interval showed an association with active range of motion in patients who underwent RTSA. In particular, excessive distalization reduced forward flexion and external rotation motion of the shoulder in patients treated with RTSA.
Collapse
|
5
|
Hao KA, Dean EW, Hones KM, King JJ, Schoch BS, Dean NE, Farmer KW, Struk AM, Wright TW. Influence of humeral lengthening on clinical outcomes in reverse shoulder arthroplasty. Orthop Traumatol Surg Res 2022; 109:103502. [PMID: 36470370 DOI: 10.1016/j.otsr.2022.103502] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/28/2022] [Accepted: 09/07/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Deltoid tensioning secondary to humeral lengthening after reverse shoulder arthroplasty (RSA) is commonly theorized to be crucial to improving range of motion (ROM) but may predispose patients to acromial/scapular spine fractures and neurologic injury. Clinical evidence linking patient outcomes to humeral lengthening is limited. This study assesses the relationship between humeral lengthening and clinical outcomes after RSA. METHODS A single institution review of 284 RSAs performed in 265 patients was performed. Humeral lengthening was defined as the difference in the subacromial height preoperatively to postoperatively as measured on Grashey radiographs. The subacromial height was measured as the vertical difference between the most inferolateral aspect of the acromion and the most superior aspect of the greater tuberosity. The relationship between humeral lengthening and clinical outcomes was assessed on a continuous basis. Secondarily, clinical outcomes were assessed using a dichotomous definition of humeral lengthening (≤25 vs. >25mm) based on prior clinical and biomechanical work purporting a correlation with clinical outcomes. Improvement exceeding the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) for ROM and outcome scores after RSA were also compared. RESULTS Humeral lengthening demonstrated a nonlinear relationship with postoperative ROM, clinical outcome scores, and shoulder strength and their improvement preoperatively to postoperatively. Furthermore, there were minimal differences in ROM measures, outcome scores, and shoulder strength when stratified using the dichotomous definition of humeral lengthening. No difference in the proportion of patients exceeding the MCID or SCB when stratified by humeral lengthening ≤25 vs. >25mm was found. There was no difference in humeral lengthening in patients with versus without complications. CONCLUSION No clear relationship between humeral lengthening and clinical outcomes was identified. The previously purported 25mm threshold for humeral lengthening did not predict improved patient outcomes. Outcomes after RSA are multifactorial; the relationship between humeral lengthening and outcomes is likely confounded by other patient and surgical factors. LEVEL OF EVIDENCE IV; Case Series.
Collapse
Affiliation(s)
- Kevin A Hao
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Ethan W Dean
- Piedmont Orthopedics
- OrthoAtlanta, Atlanta, GA, USA
| | - Keegan M Hones
- College of Medicine, University of Florida, Gainesville, FL, USA
| | - Joseph J King
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Bradley S Schoch
- Department of Orthopedic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Natalie E Dean
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kevin W Farmer
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Aimee M Struk
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA
| | - Thomas W Wright
- Department of Orthopaedic Surgery and Sports Medicine, University of Florida, Gainesville, FL, USA.
| |
Collapse
|
6
|
Serrano Mateo L, Maranillo Alcaide E, Arvinius C, Sañudo Tejero JR, Marco F. Elongation of the brachial plexus after reverse shoulder arthroplasty: an anatomical study. Surg Radiol Anat 2022; 44:861-868. [PMID: 35381847 DOI: 10.1007/s00276-022-02929-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 03/15/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The use of reverse shoulder arthroplasty (RSA) is becoming more extended and its clinical results are good or excellent according to the literature. The main biomechanical characteristic of RSA is that it lowers and medializes the centre of rotation of the shoulder causing an arm lengthening. Although the number of neurological complications is low (5%), there are more neurophysiological changes in the brachial plexus with RSA than with the anatomic shoulder arthroplasty. The main goal of this study was to quantify the lengthening of the terminal branches of the brachial plexus suffered after RSA implantation. MATERIALS AND METHODS 20 Embalmed cadavers were analysed. Four distances using bone references were employed to measure the lengthening of the arm and subacromial space. The brachial plexus and its terminal branches (radial, axillary, ulnar, musculocutaneous and median nerves) and the axillary artery, were identified and marked. Measurements were made to determine the change of position of the neurovascular structures, the arm lengthening and the lengthening of each nerve before and after the implantation of RSA. Two models of RSA were used: SMR®(Lima) and Delta Xtend®(DePuy-Synthes). RESULTS The mean arm elongation was 10.5 mm. The subacromial space suffers an elongation of 20.5-29.8%. All the neurovascular structures suffered elongation: median nerve 23.1%, musculocutaneous nerve 22.1%, ulnar nerve 19%, radial nerve 17%, axillary nerve 12-14.5%, axillary artery 24.8%. There were no differences in the results between the types of prosthesis. CONCLUSIONS Due to its design, the RSA causes an arm lengthening which is reflected by the elongation of the neurovascular structures of the arm.
Collapse
Affiliation(s)
- Laura Serrano Mateo
- Trauma and Orthopaedic Department, Clínico San Carlos Hospital, Professor Martin Lagos s/n st, 28040, Madrid, Spain.
| | - Eva Maranillo Alcaide
- Anatomy and Embryology Department, Medicine Faculty, Complutense University, Madrid, Spain
| | - Camilla Arvinius
- Trauma and Orthopaedic Department, Clínico San Carlos Hospital, Professor Martin Lagos s/n st, 28040, Madrid, Spain
| | | | - Fernando Marco
- Trauma and Orthopaedic Department, Clínico San Carlos Hospital, Professor Martin Lagos s/n st, 28040, Madrid, Spain
| |
Collapse
|
7
|
Haidamous G, Lädermann A, Hartzler RU, Parsons BO, Lederman ES, Tokish JM, Denard PJ. Radiographic parameters associated with excellent versus poor range of motion outcomes following reverse shoulder arthroplasty. Shoulder Elbow 2022; 14:39-47. [PMID: 35154401 PMCID: PMC8832695 DOI: 10.1177/1758573220936234] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The purpose was to evaluate the relationship of component size and position to postoperative range of motion following reverse shoulder arthroplasty. The hypothesis was that increased lateralization, larger glenospheres, and a decreased acromiohumeral distance would be associated with excellent postoperative range of motion. METHODS A retrospective multicenter study was performed at a minimum of one year postoperatively on 160 patients who underwent primary reverse shoulder arthroplasty with a 135° humeral component. Outcomes were stratified based on postoperative forward flexion and external rotation into excellent (n = 42), defined as forward flexion >140° and external rotation > 30°, or poor (n = 36), defined as forward flexion <100° and external rotation < 15°. Radiographic measurements and component features were compared between the two groups. RESULTS A larger glenosphere size was associated with an excellent outcome (p = 0.009). A 2-mm posterior offset humeral cup (p = 0.012) and an increased inferior glenosphere overhang (3.1 mm vs 1.4 mm; p = 0.002) were also associated with excellent outcomes. Humeral lateralization and distalization were not associated with an excellent outcome.Conclusion: Larger glenosphere size and inferior positioning as well as posterior humeral offset are associated with improved postoperative range of motion following reverse shoulder arthroplasty. LEVEL OF EVIDENCE Level 3, retrospective comparative study.
Collapse
Affiliation(s)
| | - Alexandre Lädermann
- Division of Orthopedics and Trauma Surgery, La Tour Hospital, Meyrin, Switzerland
| | | | | | - Evan S Lederman
- University of Arizona College of Medicine Phoenix and the Orthopedic Clinic Association, Phoenix, AZ, USA
| | | | - Patrick J Denard
- Southern Oregon Orthopedics, Medford, OR, USA,Department of Orthopaedic & Rehabilitation, Oregon Health & Science University, Portland, OR, USA,Patrick J Denard, Southern Oregon Orthopedics, 2780 E. Barnett Road, Suite 200, Medford, OR 97530, USA.
| |
Collapse
|
8
|
Chalmers PN, Lindsay SR, Smith W, Kawakami J, Hill R, Tashjian RZ, Keener JD. Infraspinatus and deltoid length and patient height: implications for lateralization and distalization in reverse total shoulder arthroplasty. J Shoulder Elbow Surg 2021; 30:712-719. [PMID: 32711102 PMCID: PMC7854847 DOI: 10.1016/j.jse.2020.07.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/30/2020] [Accepted: 07/07/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Restoration of muscular strength is predicated on restoration of muscle length. The purpose of this study was to describe infraspinatus and deltoid length preoperative to reverse total shoulder arthroplasty (RTSA) to guide distalization and lateralization to restore preoperative muscle length. METHODS This was a retrospective radiographic study. We measured the infraspinatus length on preoperative computed tomographic images and the deltoid length on preoperative radiographs. For all measurements, reliability was first established by comparing measurements between 2 observers, and intraclass correlation coefficients (ICCs) were calculated. We then calculated descriptive statistics for these muscle lengths and developed a formula to predict these muscle lengths from patient demographics. RESULTS We measured infraspinatus length in 97 patients and deltoid length in 108 patients. Inter-rater reliability was excellent, with all ICCs >0.886. The mean infraspinatus length was 15.5 cm (standard deviation 1.3) and ranged from 12.6-18.9 cm, whereas the deltoid length was 16.2±1.7 cm and ranged from 12.5-20.2 cm. Both infraspinatus (r = 0.775, P < .001) and deltoid length (r = 0.717, P < .001) were highly correlated with patient height but did not differ between diagnoses. Formulae developed through linear regression allowed prediction of muscle length to within 1 cm in 78% and within 2 cm in 100% for the infraspinatus and 60% and 88% for the deltoid. CONCLUSION Deltoid and infraspinatus length are variable but highly correlated with patient height. To maintain tension, 2 mm of lateralization and distalization should be added for every 6 inches (∼15 cm) of height above average for a Grammont-style RTSA.
Collapse
Affiliation(s)
- Peter N Chalmers
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA.
| | - Spencer R Lindsay
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Weston Smith
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Jun Kawakami
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Ryan Hill
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| | - Robert Z Tashjian
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT, USA
| | - Jay D Keener
- Department of Orthopaedic Surgery, Washington University, St. Louis, MO, USA
| |
Collapse
|
9
|
Negligible Correlation between Radiographic Measurements and Clinical Outcomes in Patients Following Primary Reverse Total Shoulder Arthroplasty. J Clin Med 2021; 10:jcm10040809. [PMID: 33671318 PMCID: PMC7923193 DOI: 10.3390/jcm10040809] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 11/17/2022] Open
Abstract
Previous attempts to measure lateralization, distalization or inclination after reverse total shoulder arthroplasty (rTSA) and to correlate them with clinical outcomes have been made in the past years. However, this is considered to be too demanding and challenging for daily clinical practice. Additionally, the reported findings were obtained from heterogeneous rTSA cohorts using 145° and 155° designs and are limited in external validity. The purpose of this study was to investigate the prognostic preoperative and postoperative radiographic factors affecting clinical outcomes in patients following rTSA using a 135° prosthesis design. In a multi-center design, patients undergoing primary rTSA using a 135° design were included. Radiographic analysis included center of rotation (COR), acromiohumeral distance (AHD), lateral humeral offset (LHO), distalization shoulder angle (DSA), lateralization shoulder angle (LSA), critical shoulder angle (CSA), and glenoid and baseplate inclination. Radiographic measurements were correlated to clinical and functional outcomes, including the American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test (STT), Single Assessment Numeric Evaluation (SANE), and Visual Analogue Scale (VAS) score, active forward elevation (AFE), external rotation (AER), and abduction (AABD), at a minimum 2-year follow-up. There was a significant correlation between both DSA (r = 0.299; p = 0.020) and LSA (r = −0.276; p = 0.033) and the degree of AFE at final follow-up. However, no correlation between DSA (r = 0.133; p = 0.317) and LSA (r = −0.096; p = 0.471) and AER was observed. Postoperative AHD demonstrated a significant correlation with final AFE (r = 0.398; p = 0.002) and SST (r = 0.293; p = 0.025). Further, postoperative LHO showed a significant correlation with ASES (r = −0.281; p = 0.030) and LSA showed a significant correlation with ASES (r = −0.327; p = 0.011), SANE (r = −0.308, p = 0.012), SST (r = −0.410; p = 0.001), and VAS (r = 0.272; p = 0.034) at terminal follow-up. All other correlations were found to be non-significant (p > 0.05, respectively). Negligible correlations between pre- and postoperative radiographic measurements and clinical outcomes following primary rTSA using a 135° prosthesis design were demonstrated; however, these observations are of limited predictive value for outcomes following rTSA. Subsequently, there remains a debate regarding the ideal placement of the components during rTSA to most sufficiently restore active ROM while minimizing complications such as component loosening and scapular notching. Additionally, as the data from this study show, there is still a considerable lack of data in assessing radiographic prosthesis positioning in correlation to clinical outcomes. As such, the importance of radiographic measurements and their correlation with clinical and functional outcomes following rTSA may be limited.
Collapse
|
10
|
Romano AM, Braile A, Casillo P, Nastrucci G, Susanna M, Di Giunta A, Ascione F. Onlay Uncemented Lateralized Reverse Shoulder Arthroplasty for Fracture Sequelae Type 1 with Valgus/Varus Malunion: Deltoid Lengthening and Outcomes. J Clin Med 2020; 9:jcm9103190. [PMID: 33019637 PMCID: PMC7599608 DOI: 10.3390/jcm9103190] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 12/18/2022] Open
Abstract
The successful treatment of proximal humeral fractures remains challenging for shoulder surgeons, and failure rates are high, regardless of initial treatment. This study aimed to analyze the clinical and radiographic midterm results of onlay lateralized cementless stem reverse shoulder arthroplasty (RSA) in patients with valgus/varus malunion proximal humerus fracture sequelae without metaphyseal osteotomy. We retrospectively studied 35 cases with the diagnosis of fracture sequelae of the proximal part of the humerus with valgus/varus malunion. The mean duration of follow-up was 4.6 years (range, 2 to 7 years), and the mean time between fracture and arthroplasty was 6 years (1 to 32 years). Seventeen patients (48.6%) had initially been treated nonoperatively. The Constant score (CS), active range of motion, and radiographs of the affected shoulders, as well as the acromion to greater tuberosity (AGT) distance and deltoid length (DL), were analyzed before surgery and at their latest follow-up. A total of thirty-three patients (94.3%) rated their outcome as very good or good. Mean CS, forward flexion, and external rotation improved significantly (p < 0.0001), as did internal rotation and pain (p < 0.05). AGT distance significantly increased postoperatively from 14.7 to 43.3 mm, as did DL from 143 to 170 mm (p < 0.05). There was no correlation between the outcomes and valgus/varus deformity, previous surgeries, or AGT distance/DL. A total of four complications occurred (11.4%): two dislocations were detected (5.7%) and successfully revised with a longer cemented stem. Onlay lateralized uncemented stem RSA improves clinical outcomes and decreases complications when treating valgus/varus malunion fracture sequelae, avoiding intraoperative technical challenges, such as tuberosities osteotomy conscious of bone loss and proper deltoid tensioning.
Collapse
Affiliation(s)
- Alfonso Maria Romano
- Orthopedics and Sport Medicine Unit, Campolongo Hospital, 84025 Salerno, Italy; (A.M.R.); (P.C.); (G.N.)
- Department of Orthopaedic and Trauma Surgery, Ospedale Buon Consiglio Fatebenefratelli, 80123 Naples, Italy
| | - Adriano Braile
- Dipartimento Multidisciplinare di Specialità Medico-Chirurgiche ed Odontoiatriche, Università degli Studi della Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Pasquale Casillo
- Orthopedics and Sport Medicine Unit, Campolongo Hospital, 84025 Salerno, Italy; (A.M.R.); (P.C.); (G.N.)
| | - Guglielmo Nastrucci
- Orthopedics and Sport Medicine Unit, Campolongo Hospital, 84025 Salerno, Italy; (A.M.R.); (P.C.); (G.N.)
| | - Massimiliano Susanna
- Orthopedic and Traumatology Unit, San Donà di Piave Hospital, 30027 Venice, Italy;
| | - Angelo Di Giunta
- Orthopaedic Division of Policlinico ‘G.B. Morgagni’, 95100 Catania, Italy;
| | - Francesco Ascione
- Orthopedics and Sport Medicine Unit, Campolongo Hospital, 84025 Salerno, Italy; (A.M.R.); (P.C.); (G.N.)
- Department of Orthopaedic and Trauma Surgery, Ospedale Buon Consiglio Fatebenefratelli, 80123 Naples, Italy
- Correspondence: ; Tel.: +39-347-611-9973
| |
Collapse
|
11
|
Preoperative deltoid assessment by contrast-enhanced ultrasound (CEUS) as predictor for shoulder function after reverse shoulder arthroplasty: a prospective pilot study. Arch Orthop Trauma Surg 2020; 140:1001-1012. [PMID: 31624864 DOI: 10.1007/s00402-019-03281-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Although the deltoid represents the main motor muscle after reverse shoulder arthroplasty (RSA), its standardized preoperative assessment regarding morphology and function is still not established. Its clinical relevance and interactions with major biomechanical parameters like the medialization of the center of rotation (COR) regarding shoulder function after RSA are yet unknown. We evaluated contrast-enhanced ultrasound (CEUS) of the deltoid as possible surrogate marker for individual deltoid properties of patients receiving an RSA, and its predictive value for postoperative shoulder function. MATERIALS AND METHODS 35 patients were prospectively assessed. Before and 6 months after RSA, dynamic deltoid perfusion, caliber and a combination of both (PE*caliber, named DeltoidEfficacy) was quantified by CEUS. Changes of deltoid properties and the predictive value of preoperative CEUS-based deltoid properties for shoulder function after RSA were assessed. To analyze interrelating effects with deltoid properties, COR-medialization and deltoid lengthening were quantified. RESULTS Deltoid caliber and perfusion significantly increased after RSA (p = 0.0004/p = 0.002). Preoperative deltoid caliber, perfusion and the combined value DeltoidEfficacy significantly correlated with shoulder function after RSA within the whole study cohort (caliber: r = 0.445, p = 0.009; perfusion: r = 0.593, p = 0.001; DeltoidEfficacy: r = 0.66; p = 0.0002). The predictive value of DeltoidEfficacy for shoulder function after RSA varied among patient subgroups: Multivariate regression analysis revealed the strongest prediction in patients with either very high or very low deltoid properties (Beta = 0.872, r = 0.84, p = 0.0004), independent from COR-medialization or deltoid lengthening. Contrary, in patients with intermediate deltoid properties, COR-medialization revealed the strongest predictive value for shoulder function after RSA (Beta = 0.660, r = 0.597; p = 0.024). CONCLUSION Deltoid CEUS seems to allow an assessment of individual deltoid properties and deltoid adaptations after RSA. Deltoid CEUS seems to predict shoulder function after RSA and might support an identification of patients requiring special attention regarding COR positioning.
Collapse
|
12
|
Zmistowski B, Gutman M, Horvath Y, Abboud JA, Williams GR, Namdari S. Acromial stress fracture following reverse total shoulder arthroplasty: incidence and predictors. J Shoulder Elbow Surg 2020; 29:799-806. [PMID: 31629651 DOI: 10.1016/j.jse.2019.08.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Increased use of reverse total shoulder arthroplasty (RTSA) has led to an understanding of unique complications such as acromial stress fractures (ASFs). The factors associated with ASFs are not fully known. This study investigates the incidence and predictors of ASFs following RTSA. METHODS All RTSAs performed at a single tertiary referral hospital were retrospectively reviewed. ASF findings were classified as a definitive acromial or scapular spine stress fracture based on radiographic findings or stress reaction based on clinical findings (pain and tenderness at the acromion or acromial spine) without radiographic changes. Preoperative and postoperative radiographs were reviewed for radiographic predictors of postoperative acromial stress pathology. Clinical factors and implant characteristics were also investigated. RESULTS Between September 2010 and January 2017, a total of 1170 RTSAs were performed, with 958 cases (81.9%) having at least 3 months' clinical follow-up (mean, 407 days; range, 90-1698 days). There were 40 ASFs (4.2%) and 61 acromial stress reactions (6.4%). For fractures and reactions, symptom onset averaged 8.8 and 7.3 months (P = .37), respectively, with durations of 4.5 and 2.9 months (P = .02), respectively, following RTSA. Independent predictors of acromial stress pathology were female sex, decreased change in deltoid length, and increased preoperative glenohumeral center-of-rotation medialization. CONCLUSION Acromion-related symptoms are common following RTSA. Female patients with increased preoperative center-of-rotation medialization had an increased incidence of ASFs. Although this study establishes which patients are at risk of ASFs, methods for prevention of ASFs in these patients remain unclear.
Collapse
Affiliation(s)
- Benjamin Zmistowski
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael Gutman
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Yael Horvath
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Gerald R Williams
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
| |
Collapse
|
13
|
A quantitative analysis of deltoid lengthening and deltoid-related complications after reverse total shoulder arthroplasty: A retrospective case-control study. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
14
|
Roberson TA, Shanley E, Abildgaard JT, Granade CM, Adams KJ, Griscom JT, Hunt Q, Nix Q, Kissenberth MJ, Tolan SJ, Hawkins RJ, Tokish JM. The influence of radiographic markers of biomechanical variables on outcomes in reverse shoulder arthroplasty. JSES OPEN ACCESS 2019; 3:59-64. [PMID: 30984894 PMCID: PMC6444123 DOI: 10.1016/j.jses.2018.11.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Controversy exists in reverse total shoulder arthroplasty in regard to variability in the center of rotation (COR), which modifies the superior-inferior position of the humerus to affect the acromiohumeral interval (AHI), and its effect on the deltoid lever arm (DLA), acromial index (AI), and critical shoulder angle (CSA). The purpose of this study was to investigate the variation in biomechanics and the association with patient-reported outcomes (PROs) and range of motion (ROM) measurements. Methods Radiographs, ROM, and 2-year PRO scores were retrospectively reviewed for 108 patients. Results There was large variability in preoperative and postoperative biomechanics. The COR was medialized 12.01 ± 4.8 mm. The CSA increased 2.64° ± 12.45°. The AHI increased 20.6 ± 9.80 mm. The DLA lengthened 21.21 ± 10.15 mm. The AI increased 0.009 ± 0.3. Postoperative AI positively correlated with American Shoulder and Elbow Surgeons score and Penn Shoulder Score (P = .03). Specifically, a postoperative AI of 0.62 corresponded to American Shoulder and Elbow Surgeons score (72.5 ± 18.3 vs. 62.3 ± 24.7; P = .02) and Penn Shoulder Score (71.2 ± 21.4 vs. 61.8 ± 25.6; P = .05), an average 10 points higher than AI of <0.6. Also, a smaller postoperative CSA (<25°) correlated with improved forward elevation (P = .02). Conclusions This is the first study that evaluates the variability of biomechanical factors and their impact on postoperative ROM and PROs. An increased AI and decreased CSA are associated with improved PROs in this study, and a smaller CSA is associated with better forward elevation. Change in the COR, AHI, or DLA, however, did not affect patient outcomes or ROM. Further study is warranted to determine the optimal position.
Collapse
Affiliation(s)
- Troy A Roberson
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | | | - Jeffrey T Abildgaard
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Charles M Granade
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | | | - James T Griscom
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Quinn Hunt
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Quinn Nix
- University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
| | - Michael J Kissenberth
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Stefan J Tolan
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - Richard J Hawkins
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA
| | - John M Tokish
- Steadman Hawkins Clinic of the Carolinas, Greenville Health System, Greenville, SC, USA.,Mayo Clinic Arizona, Phoenix, AZ, USA
| |
Collapse
|
15
|
Werner BS, Ascione F, Bugelli G, Walch G. Does arm lengthening affect the functional outcome in onlay reverse shoulder arthroplasty? J Shoulder Elbow Surg 2017; 26:2152-2157. [PMID: 28735843 DOI: 10.1016/j.jse.2017.05.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 05/16/2017] [Accepted: 05/21/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND The concept of onlay design reverse shoulder arthroplasty has been introduced to overcome complications observed with the traditional Grammont-type prosthesis. The aim of this study was to determine the influence of arm lengthening on the short-term clinical outcome in onlay reverse shoulder arthroplasty and investigate the effect of humeral tray offset positioning on arm lengthening and range of motion. METHODS We retrospectively evaluated 56 patients undergoing reverse shoulder arthroplasty with the Aequalis Ascend Flex prosthesis (Tornier, Bloomington, MN, USA) at a minimum 2 years' follow-up. Arm lengthening was determined using bilateral scaled radiographs of the entire humerus. The Constant score and active range of motion were documented preoperatively and postoperatively. The relationship between arm lengthening, humeral tray offset position, and functional outcome was analyzed. RESULTS The Constant score improved from 25.5 ± 9.5 points to 71.5 ± 13.8 points at a mean follow-up of 30.1 ± 5.2 months. Mean postoperative anterior elevation was 145.2° ± 21.1°, and external rotation was 30.7° ± 20.3°. Arm lengthening exceeding 2.5 cm was related to a decrease in anterior elevation. We found a relationship between arm lengthening averaging 2.2 ± 1.7 cm and increased Constant score values. Humeral tray positioning demonstrated no influence on the functional outcome. There was a trend toward increased arm lengthening in lateral offset positioning. CONCLUSIONS Onlay reverse shoulder arthroplasty yields good short-term clinical results. In our population, arm lengthening averaging 1 to 2.5 cm was found to be the best compromise on postoperative range of motion.
Collapse
Affiliation(s)
- Birgit S Werner
- Clinic for Shoulder and Elbow Surgery, Bad Neustadt/Saale, Germany; Centre Orthopédique Santy, Hôpital Jean Mermoz, Lyon, France.
| | | | - Giulia Bugelli
- Humanitas Clinical and Research Center, Rozzano, Milano, Italy
| | - Gilles Walch
- Centre Orthopédique Santy, Hôpital Jean Mermoz, Lyon, France
| |
Collapse
|
16
|
Reproducibility of a new method for measuring lowering and medialisation of the humerus after reverse shoulder arthroplasty. INTERNATIONAL ORTHOPAEDICS 2017; 42:141-147. [PMID: 28573515 DOI: 10.1007/s00264-017-3510-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 05/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Reverse shoulder arthroplasty (RSA) requires lowering the humerus and medialisation of the centre of rotation. Several techniques based on standard X-rays are available in the literature. The aim of this study was to expose and validate a new technique for measuring these parameters. MATERIALS AND METHODS Radiographic data of 20 patients were included. Three observers examined each X-rays three times to establish the inter- and intra-reproducibility of each technique (Jobin, Renaud and our method). RESULTS Intra-observer reproducibility was between 0.10 and 0.94. The best intra-observer intraclass correlation coefficient (ICC) was obtained using Renaud's and our techniques. The inter-observer reproducibility was between 0.37 and 0.74. The best inter-observer ICC was obtained with our technique. DISCUSSION We describe a reliable and reproducible method to evaluate lowering and medialisation of the humerus after RSA. This technique may allow determine the optimal threshold of lengthening after RSA.
Collapse
|
17
|
Reverse total shoulder arthroplasty for the management of fractures of the proximal humerus: a systematic review. Musculoskelet Surg 2016; 100:83-91. [PMID: 27316439 DOI: 10.1007/s12306-016-0409-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 05/26/2016] [Indexed: 02/07/2023]
Abstract
Reverse total shoulder arthroplasty (RTSA) represents a good solution for the management of patients with fracture of the proximal humerus with associated severe osteoporosis and RC dysfunction. A systematic review of the literature according to the PRISMA guidelines was performed matching the following keywords: "reverse total shoulder arthroplasty"; "reverse total shoulder prostheses"; "fractures"; "fracture of the proximal humerus." Medline, EMBASE, Google Scholar, and Ovid database have been screened. Ten studies were considered in the qualitative analysis. No randomized prospective controlled trials have been found. A total of 256 patients received a RTSA for the management of fracture of the proximal humerus. There were 28 males (10.8 %) and 228 females (89.2 %). The mean age of patients was 75.5 ± 2.2 years (range 70-78 years). The mean follow-up period was 27.8 ± 21.8 months range (6-86 months). Overall, the mean Constant score was 56.7 ± 7.6 points (range 44-67.8 points), the mean DASH score was 39.9 ± 6 points (range 31.5-46.8 points), the ASES averaged 70.3 ± 6.8 points (range 65-78 points), and the OSS averaged 28.7 points (range 15-56 points). RTSA restores function and relieves pain in patients with proximal humeral fractures. However, no randomized controlled trials are available to support RTSA versus osteosintesis, anatomical prostheses or hemiarthroprotesis. Further studies are needed to evaluate the effectiveness of RTSA in the management of fracture of the proximal humerus.
Collapse
|