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Optimizing Outcomes After Reverse Total Shoulder Arthroplasty: Rehabilitation, Expected Outcomes, and Maximizing Return to Activities. Curr Rev Musculoskelet Med 2023; 16:145-153. [PMID: 36867393 PMCID: PMC10043097 DOI: 10.1007/s12178-023-09823-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW Given the touted clinical and patient-reported outcomes of reverse shoulder arthroplasty (RTSA) in improving pain and restoring function, shoulder surgeons are rapidly expanding the indications and utilization of RTSA. Despite its increasing use, the ideal post-operative management ensuring the best patient outcomes is still debated. This review synthesizes the current literature regarding the impact of post-operative immobilization and rehabilitation on clinical outcomes following RTSA including return to sport. RECENT FINDINGS Literature regarding the various facets of post-operative rehabilitation is heterogeneous in both methodology and quality. While most surgeons recommend 4-6 weeks of immobilization post-operatively, two recent prospective studies have shown that early motion following RTSA is both safe and effective with low complication rates and significant improvements in patient-reported outcome scores. Furthermore, no studies currently exist assessing the use of home-based therapy following RTSA. However, there is an ongoing prospective, randomized control trial assessing patient-reported and clinical outcomes which will help shed light on the clinical and economic value of home therapy. Finally, surgeons have varying opinions regarding return to higher level activities following RTSA. Despite no clear consensus, there is growing evidence that elderly patients are able to return to sport (e.g., golf, tennis) safely, though caution must be taken with younger or more high-functioning patients. While post-operative rehabilitation is believed to be essential to maximize outcomes following RTSA, there is a paucity of high-quality evidence that guides current rehabilitation protocols. There is no consensus regarding type of immobilization, timing of rehabilitation, or need for formal therapist-directed rehabilitation versus physician-guided home exercise. Additionally, surgeons have varied opinions regarding return to higher level activities and sports following RTSA. There is burgeoning evidence that elderly patients can return to sport safely, though caution must be taken with younger patients. Further research is needed to clarify the optimal rehabilitation protocols and return to sport guidelines.
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2
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Polio W, Brolin TJ. Postoperative Rehabilitation After Shoulder Arthroplasty. Phys Med Rehabil Clin N Am 2023; 34:469-479. [PMID: 37003664 DOI: 10.1016/j.pmr.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Total shoulder arthroplasty (TSA), including anatomic TSA (aTSA) and reverse TSA (rTSA), has increased in popularity due to reliably good patient outcomes. Postoperative physical therapy (PT) is considered essential to the success of this operation and has become standard practice. The authors present general rehabilitation principles as well as preferred postoperative PT protocols for aTSA and rTSA, which are based on evidence-based literature and the different early postoperative concerns for each of these procedures.
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Affiliation(s)
- William Polio
- University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA
| | - Tyler J Brolin
- University of Tennessee Health Science Center-Campbell Clinic, 1211 Union Avenue, Suite 510, Memphis, TN 38104, USA.
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3
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Bidwai R, Kumar K. Outcomes of different stem sizes in shoulder arthroplasty. J Orthop 2023; 35:37-42. [PMID: 36387763 PMCID: PMC9647328 DOI: 10.1016/j.jor.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/20/2022] [Accepted: 10/21/2022] [Indexed: 11/05/2022] Open
Abstract
Background The successive refinement in implant design and operative technique alongwith improved understanding has resulted in increased incidence of total shoulder arthroplasty (TSA). Simultaneously, the indications of TSA have widened and include a range of shoulder pathologies. Methods Using the keywords and relevant literature, we have described an overview of the different stem sizes used in shoulder arthroplasty. Relevant description of clinical and radiological outcome is done with regards to different stem sizes. Discussion There are plethora of shoulder replacement systems, based on unique philosophy and having their own advantages and disadvantages. Additionally, the rise in ageing population had increased the need for revision TSA, thereby necessitating the judicious choice of implant at primary TSA. We further present the role of cemented and uncemented humeral stems and discuss the findings of finite element analysis. The choice of humeral stem size and use of cemented or uncemented stems have been reported to affect the clinical and radiological outcomes.
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Affiliation(s)
- Rohan Bidwai
- Aberdeen Upper Limb Unit, Department of Trauma and Orthopaedics, Woodend Hospital, NHS Grampian , Aberdeen, UK
| | - Kapil Kumar
- Aberdeen Upper Limb Unit, Department of Trauma and Orthopaedics, Woodend Hospital, NHS Grampian , Aberdeen, UK
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4
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Lu Z, Nazari G, Almeida PH, Pontes T, MacDermid JC. The clinical outcome of physiotherapy after reversed shoulder arthroplasty: a systematic review. Disabil Rehabil 2022; 44:6997-7008. [PMID: 34618652 DOI: 10.1080/09638288.2021.1985633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE The purpose of this systematic review was to analyze the current literature on the clinical outcomes of physiotherapy (PT) program after reversed total shoulder arthroplasty (rTSA) and to summarize the improvements in this population. METHODS A search was performed in four databases (MEDLINE, Embase, PubMed, Google Scholar) from its inception to 30 April 2020. Data were extracted to describe the study design and rehab programs. The quality of evidence was assessed as high, moderate, and low-level according to the Evaluation of Quality of an Intervention Study critical appraisal criteria. RESULTS There were 22 eligible studies including two randomized controlled trials, four prospective cohort studies, 10 retrospective reviews, five case-series, and one case-control study, with the sample sizes ranging from 9 to 474 patients followed for 1-10 years. All studies indicated substantial improvement in patients after PT program in terms of functional outcomes and forward flexion. CONCLUSIONS High-quality RCTs are required to provide more conclusive results. We identified substantial variation in the post-operative PT programs except for the progressive mobilization strategy and the common management following surgery to increase the soft tissue healing within 4-6 weeks.Implications for RehabilitationThe reverse shoulder arthroplasty (rTSA) has been widely utilized for patients with rotator cuff arthropathy, primary arthritis, and proximal fractures.A successful outcome of rTSA is not only depending on the surgical management, but also depended on physiotherapy (PT) programs.Our systematic review concluded that a 12-week PT program starting with immobilization for 4-6 weeks, followed by 3-4 phases PT exercises including PROM, AAROM, AROM, and strength training was recommended as common management for patients received rTSA.Due to the huge variation in the included studies, the evidence of PT protocol in our study was not sufficient to summarize the better clinical practice suggestions regarding rTSA rehabilitation.
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Affiliation(s)
- Ze Lu
- School of Rehabilitation Science, McMaster University, Hamilton, Canada.,Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Canada
| | - Goris Nazari
- School of Physical Therapy, Faculty of Health Science, Western University, London, Canada.,Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University, London, Canada
| | - Pedro H Almeida
- School of Physical Therapy, Faculty of Health Science, Western University, London, Canada
| | - Tatiana Pontes
- Occupational Studies, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Joy C MacDermid
- Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Hospital, London, Canada.,School of Physical Therapy, Faculty of Health Science, Western University, London, Canada.,Collaborative Program in Musculoskeletal Health Research, Bone and Joint Institute, Western University, London, Canada
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5
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Kachi T, Shitara H, Ichinose T, Sasaki T, Hamano N, Chikuda H. Arthroscope-assisted reduction of humeral head impression fracture: a case report. J Surg Case Rep 2022; 2022:rjac476. [DOI: 10.1093/jscr/rjac476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/21/2022] [Indexed: 11/28/2022] Open
Abstract
Abstract
We experienced a case of humeral head impression fracture accounting for approximately 20% of the anterior articular surface. Open reduction and internal fixation of the proximal humeral fracture combined with arthroscope-assisted reduction and internal fixation of the humeral head impression fracture were performed, and good clinical and radiographic outcomes were obtained. Untreated impression fracture may be a potential risk for subluxation or osteoarthritis. However, our arthroscopic approach is minimally invasive and allows for the prevention of these risks.
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Affiliation(s)
- Takuma Kachi
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine , Maebashi, Gunma , Japan
| | - Hitoshi Shitara
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine , Maebashi, Gunma , Japan
| | - Tsuyoshi Ichinose
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine , Maebashi, Gunma , Japan
| | - Tsuyoshi Sasaki
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine , Maebashi, Gunma , Japan
| | - Noritaka Hamano
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine , Maebashi, Gunma , Japan
| | - Hirotaka Chikuda
- Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine , Maebashi, Gunma , Japan
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6
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Surgical management of bilateral concomitant posterior fracture-dislocation of the shoulder. Trauma Case Rep 2022; 41:100691. [PMID: 36017398 PMCID: PMC9396229 DOI: 10.1016/j.tcr.2022.100691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2022] [Indexed: 11/26/2022] Open
Abstract
We present the case of a 71-year-old man who suffered a bilateral posterior fracture-dislocation of the shoulder after an idiopathic seizure. After immediate closed reduction, CT-scan images revealed bilateral anterior reverse Hill–Sachs lesion superior to 30 % of the articular humeral head. A surgical treatment was performed for reconstruction of segmental defects of the articular humeral heads followed by filling the defect using lesser tuberosity transposition. Early rehabilitation protocol was prescribed. After 14 months, the patient returned to normal daily activities with no complaint. Anatomical humeral head reconstruction and bone defect filling resulted in a good clinical outcome after posterior shoulder dislocation. It can be the treatment of choice for large humeral head defects, especially in younger patients with good bone stock.
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7
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Kennedy JS, Reinke EK, Friedman LGM, Cook C, Forsythe B, Gillespie R, Hatzidakis A, Jawa A, Johnston P, Nagda S, Nicholson G, Sears B, Wiesel B, Garrigues GE, Hagen C, Hong I, Roach M, Jones N, Mahendraraj K, Michaelson E, Bader J, Mauter L, Mengers S, Renko N, Strony J, Hart P, Steele E, Naylor A, Gaudette J, Sprengel K. Protocol for a multicenter, randomised controlled trial of surgeon-directed home therapy vs. outpatient rehabilitation by physical therapists for reverse total shoulder arthroplasty: the SHORT trial. Arch Physiother 2021; 11:28. [PMID: 34886910 PMCID: PMC8662891 DOI: 10.1186/s40945-021-00121-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 09/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background Reverse total shoulder arthroplasty (RTSA) has emerged as a successful surgery with expanding indications. Outcomes may be influenced by post-operative rehabilitation; however, there is a dearth of research regarding optimal rehabilitation strategy following RTSA. The primary purpose of this study is to compare patient reported and clinical outcomes after RTSA in two groups: in one group rehabilitation is directed by formal, outpatient clinic-based physical therapists (PT group) as compared to a home therapy group, in which patients are instructed in their rehabilitative exercises by surgeons at post-operative appointments (HT group). Secondary aims include comparisons of complications, cost of care and quality of life between the two groups. Methods This randomised controlled trial has commenced at seven sites across the United States. Data is being collected on 200 subjects by clinical research assistants pre-operatively and post-operatively at 2, 6, and 12 weeks, 6 months, 1 and 2 year visits. The following variables are being assessed: American Shoulder and Elbow Surgeons (ASES), pain level using the numeric pain scale, the Single Assessment Numeric Evaluation (SANE) score, and shoulder active and passive range of motion for analysis of the primary aim. Chi square and t-tests will be used to measure differences in baseline characteristics of both groups. Repeated measures linear mixed effects modeling for measurement of differences will be used for outcomes associated with ASES and SANE and scores, and range of motion measures. Secondary aims will be analyzed for comparison of complications, cost, and quality of life assessment scores using data obtained from the PROMIS 29 v. 2, questionnaires administered at standard of care post-operative visits, and the electronic health record. Subjects will be allowed to crossover between the PT and HT groups, and analysis will include both intention-to-treat including patients who crossed over, and a second with cross-over patients removed, truncated to the time they crossed over. Discussion RTSA is being performed with increasing frequency, and the optimal rehabilitation strategy is unclear. This study will help clarify the role of formal physical therapy with particular consideration to outcomes, cost, and complications. In addition, this study will evaluate a proposed rehabilitation strategy. Trial registration This study is registered as NCT03719859 at ClincialTrials.gov. Supplementary Information The online version contains supplementary material available at 10.1186/s40945-021-00121-2.
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Affiliation(s)
- June S Kennedy
- Department of Physical and Occupational Therapy, Duke University Health System, 3475 Erwin Rd, Durham, NC, 27705, USA.
| | - Emily K Reinke
- Department of Orthopaedic Surgery, Duke University Medical Center, 3475 Erwin Rd, Durham, NC, 27705, USA
| | - Lisa G M Friedman
- Department of Orthopedics, Geisinger Medical Center, 100 N Academy Ave, Danville, PA, 17822, USA
| | - Chad Cook
- Department of Orthopaedic Surgery, Duke University Medical Center, 3475 Erwin Rd, Durham, NC, 27705, USA.,Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, 27701, USA.,Duke Department of Population Health Sciences, Duke University, 215 Morris St, Durham, NC, 27701, USA
| | - Brian Forsythe
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 400, Chicago, IL, 60612, USA
| | - Robert Gillespie
- Department of Orthopaedic Surgery, University Hospitals Cleveland, 11000 Euclid Ave, Cleveland, OH, 44106, United States
| | | | - Andrew Jawa
- Boston Sports and Shoulder Center, 40 Allied Dr., Suite 102, Dedham, MA, 02026, USA
| | - Peter Johnston
- Centers for Advanced Orthopaedics, 25500 Point Lookout Road, Leonardtown, MD, 20650, USA
| | - Sameer Nagda
- Anderson Orthopaedic Clinic, 2445 Army Navy Drive, Arlington, VA, 22206, USA
| | - Gregory Nicholson
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 400, Chicago, IL, 60612, USA
| | - Benjamin Sears
- Western Orthopaedics, 1830 Franklin St, 450, Denver, CO, 80218, USA
| | - Brent Wiesel
- MedStar Orthopaedic Institute, 3800 Reservoir Road Northwest, Washington, DC, 20007, USA
| | - Grant E Garrigues
- Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St., Suite 400, Chicago, IL, 60612, USA
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8
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Mi M, Zhang JM, Jiang XY, Huang Q. Management of Locked Posterior Shoulder Dislocation with Reverse Hill-Sachs Lesions via Anatomical Reconstructions. Orthop Surg 2021; 13:2119-2126. [PMID: 34636160 PMCID: PMC8528979 DOI: 10.1111/os.13152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To evaluate the outcomes of locked posterior shoulder dislocation with reverse Hill–Sachs lesions in patients treated with anatomical reconstructions. Methods Patients who were treated at our institution between January 2016 and June 2020 were retrospectively reviewed. The demographics of the patients including gender, age, occupation, and dominant arm were recorded. Eleven cases from 10 patients qualified in this study. Nine males and one female were included. The mean age of the patients was 44.8 years (range, 33–54 years). Mechanism of injury, duration between injuries and definitive diagnosis, misdiagnosis, size of humeral head impaction, treatment maneuver, and details of operation performed were reviewed. Plain radiographs and computed tomography (CT) scan were taken to determine the size of defects preoperatively and fracture healing during follow‐up. During surgery, the deltopectoral approach was employed. Anatomical reconstruction procedure including reduction, disimpaction, bone grafting, and fixation were sequentially performed. Either cancellous autograft from iliac crest or allograft were used and the fractures were anatomically reduced and stabilized by screws or plates. Visual Analog Scale (VAS) and Constant–Murley score were recorded to determine the functional outcomes preoperatively, at 3 months and 6 months postoperatively, and at the last follow‐up. The range of motion in forward flexion was recorded at 6 months follow‐up postoperatively. Results Causes of injuries included epileptic seizure in four cases, fall in three cases, and road traffic accident in three cases. Misdiagnoses occurred in five out of 10 patients. The mean time between injury and definitive treatment among those misdiagnosed was 112 days. The mean size of the impacted reverse Hill–Sachs lesions was 33.95% (range, 19.1%–42.6%). All patients received surgical management with anatomical reconstruction approach, including open reduction, disimpaction, bone grafting, and internal fixation. The mean amount of bleeding during operation was 450 mL. The mean follow‐up period was 22.6 months. Fracture healing was observed by 8 weeks in all cases postoperatively and evidence of bone grafting could not be further detected on CT scan at 6 month during follow‐up. VAS was significantly lower at the last follow‐up (0.68 ± 0.21) in comparison to preoperative scores (4.96 ± 0.97) (P < 0.05). Constant–Murley was improved significantly at the last follow‐up (91.7 ± 8.3) in comparison to that preoperatively (40.6 ± 10.3) (P < 0.05). The mean range of motion in forward flexion was 38.25° ± 9.36° preoperatively and significantly improved to 162.48° ± 12.68° at 6‐month follow‐up (P < 0.05). Conclusion The anatomical reconstruction procedure by open reduction and bone augmentation for the treatment of locked posterior shoulder dislocation with reverse Hill–Sachs lesion was promising in both fracture healing and functional outcomes.
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Affiliation(s)
- Meng Mi
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Jin-Ming Zhang
- Department of Orthopaedics, Beijing Mentougou District Hospital, Beijing, China
| | - Xie-Yuan Jiang
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
| | - Qiang Huang
- Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China
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9
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Schiffman CJ, Prabhakar P, Hsu JE, Shaffer ML, Miljacic L, Matsen FA. Assessing the Value to the Patient of New Technologies in Anatomic Total Shoulder Arthroplasty. J Bone Joint Surg Am 2021; 103:761-770. [PMID: 33587515 DOI: 10.2106/jbjs.20.01853] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Publications regarding anatomic total shoulder arthroplasty (TSA) have consistently reported that they provide significant improvement for patients with glenohumeral arthritis. New TSA technologies that have been introduced with the goal of further improving these outcomes include preoperative computed tomography (CT) scans, 3-dimensional preoperative planning, patient-specific instrumentation, stemless and short-stemmed humeral components, as well as metal-backed, hybrid, and augmented glenoid components. The benefit of these new technologies in terms of patient-reported outcomes is unknown. METHODS We reviewed 114 articles presenting preoperative and postoperative values for commonly used patient-reported metrics. The results were analyzed to determine whether patient outcomes have improved over the 20 years during which new technologies became available. RESULTS The analysis did not identify evidence that the results of TSA were statistically or clinically improved over the 2 decades of study or that any of the individual technologies were associated with significant improvement in patient outcomes. CONCLUSIONS Additional research is required to document the clinical value of these new technologies to patients with glenohumeral arthritis. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Corey J Schiffman
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Pooja Prabhakar
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | - Jason E Hsu
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
| | | | - Ljubomir Miljacic
- The Mountain-Whisper-Light Statistical Consulting, Seattle, Washington
| | - Frederick A Matsen
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington
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10
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Hachem AI, Bascones KR, Costa D’O G, Rondanelli S R, Rius X. Arthroscopic Knotless Subscapularis Bridge Technique for Reverse Hill-Sachs Lesion With Posterior Shoulder Instability. Arthrosc Tech 2021; 10:e103-e116. [PMID: 33532216 PMCID: PMC7823086 DOI: 10.1016/j.eats.2020.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 09/20/2020] [Indexed: 02/03/2023] Open
Abstract
Posterior shoulder dislocations are an uncommon cause of glenohumeral instability; they are frequently missed and are associated with humeral head defects and capsulolabral lesions. Despite surgical treatment often being mandatory, there is still no standardized treatment for anterior impaction fractures of the humeral head (reverse Hill-Sachs lesions). Arthroscopic surgery is typically indicated, with a tendency toward resorting to knotless techniques in recent years. We present a method for the treatment of posterior shoulder dislocations with engaging reverse Hill-Sachs lesions that achieves full defect coverage using an arthroscopic all-in-the-box knotless subscapularis bridge technique with 2 anchors-with one crossing the subscapularis tendon and the other embracing it-along with posterior capsulolabral complex restoration. This promising technique is a potentially superior alternative for the treatment of these lesions that can also be used in the presence of concomitant partial subscapularis tears.
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Affiliation(s)
- Abdul-ilah Hachem
- Shoulder Unit, Department of Orthopedic and Trauma Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain,University of Barcelona, Barcelona, Spain,Address correspondence to Abdul-Ilah Hachem, M.D., C/ Feixa Llarga S/N Hospital de Bellvitge Pl 10, Traumatology and Orthopedic Secretary, Hospital Universitari de Bellvitge (L’Hospitalet de Llobregat), Barcelona, Spain 08907.
| | - Karla R. Bascones
- Shoulder and Elbow Unit, Department of Orthopaedic and Trauma Surgery, Hospital Asepeyo Sant Cugat, Barcelona, Spain
| | - Gino Costa D’O
- Shoulder Unit, Department of Orthopedic and Trauma Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Rafael Rondanelli S
- Shoulder Unit, Department of Orthopedic and Trauma Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Xavi Rius
- Shoulder Unit, Department of Orthopedic and Trauma Surgery, Hospital Universitari de Bellvitge, Barcelona, Spain
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11
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Kennedy JS, Garrigues GE, Pozzi F, Zens MJ, Gaunt B, Phillips B, Bakshi A, Tate AR. The American Society of Shoulder and Elbow Therapists' consensus statement on rehabilitation for anatomic total shoulder arthroplasty. J Shoulder Elbow Surg 2020; 29:2149-2162. [PMID: 32534209 PMCID: PMC8262512 DOI: 10.1016/j.jse.2020.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/04/2020] [Accepted: 05/12/2020] [Indexed: 02/01/2023]
Abstract
Anatomic total shoulder arthroplasty is the gold standard shoulder replacement procedure for patients with an intact rotator cuff and sufficient glenoid bone to accommodate prosthetic glenoid implant and offers reliable patient satisfaction, excellent implant longevity, and a low incidence of complications. Disparity exists in the literature regarding rehabilitation strategies following anatomic total shoulder arthroplasty. This article presents a consensus statement from experts in the field on rehabilitation following anatomic total shoulder arthroplasty. The goal of this consensus statement is to provide a current evidence-based foundation to inform the rehabilitation process after anatomic total shoulder arthroplasty. These guidelines apply to anatomic total shoulder arthroplasty (replacement of the humeral head and glenoid), hemiarthroplasty (replacing only the humeral head), and hemiarthroplasty with glenoid reaming or resurfacing. The consensus statement integrates an extensive literature review, as well as survey results of the practice patterns of members of the American Society of Shoulder and Elbow Therapists and the American Shoulder and Elbow Surgeons. Three stages of recovery are proposed, which initially protect and then gradually load soft tissue affected by the surgical procedure, such as the subscapularis, for optimal patient outcomes. The proposed guidelines should be used in collaboration with surgeon preferences and patient-specific factors.
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Affiliation(s)
- June S Kennedy
- Department of Physical and Occupational Therapy, Duke University Health Systems, Durham, NC, USA.
| | | | | | | | - Bryce Gaunt
- Human Performance Rehabilitation Centers at St Francis Rehabilitation Center, Columbus, GA, USA
| | - Brian Phillips
- Human Performance Rehabilitation Centers at St Francis Rehabilitation Center, Columbus, GA, USA
| | - Ashim Bakshi
- The Hand and Orthopedic Rehab Clinic, Terre Haute, IN, USA
| | - Angela R Tate
- Excel Physical Therapy, Blue Bell, PA, USA; Arcadia University, Glenside, PA, USA
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12
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A Modified Reverse Remplissage Procedure for Management of a Locked Posterior Shoulder Dislocation. Case Rep Orthop 2020; 2020:8625368. [PMID: 32550033 PMCID: PMC7275965 DOI: 10.1155/2020/8625368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/15/2020] [Accepted: 05/20/2020] [Indexed: 11/18/2022] Open
Abstract
Posterior shoulder dislocation is rare and often represents a diagnostic and therapeutic challenge. An impaction fracture of the anteroinferior aspect of the humeral head (called a reverse Hill-Sachs (RHS) fracture) is always present in case of chronic locked posterior dislocation. Surgical management is required and decided on the delay between the trauma and the diagnosis and the importance of the RHS (in percentage). The authors present a chronic locked posterior shoulder dislocation in a 32-year-old active male with a reverse Hill-Sachs lesion of more than 40%. An open reduction was required, and stabilization was achieved with a modified remplissage technique with detachment of the upper quarter of the subscapularis tendon. Three years after the surgery, the patient recovered an excellent functional level with a stable shoulder.
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13
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Return to Sport after Anatomic and Reverse Total Shoulder Arthroplasty in Elderly Patients: A Systematic Review and Meta-Analysis. J Clin Med 2020; 9:jcm9051576. [PMID: 32456117 PMCID: PMC7291255 DOI: 10.3390/jcm9051576] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/12/2020] [Accepted: 05/21/2020] [Indexed: 01/10/2023] Open
Abstract
The aim of this systematic review and meta-analysis was to evaluate the rate of return to sport in elderly patients who underwent anatomic (ATSA) and reverse (RTSA) total shoulder arthroplasty, to assess postoperative pain and functional outcomes and to give an overview of postoperative rehabilitation protocols. A systematic search in Pubmed-Medline, Cochrane Library, and Google Scholar was carried out to identify eligible randomized clinical trials, observational studies, or case series that evaluated the rate of return to sport after RTSA or ATSA. Six retrospective studies, five case series, and one prospective cohort study were included in this review. The overall rate of return to sport was 82% (95% CI 0.76–0.88, p < 0.01). Patients undergoing ATSA returned at a higher rate (90%) (95% CI 0.80–0.99, p < 0.01) compared to RTSA (77%) (95% CI 0.69–0.85, p < 0.01). Moreover, the results showed that patients returned to sport at the same or a higher level in 75% of cases. Swimming had the highest rate of return (84%), followed by fitness (77%), golf (77%), and tennis (69%). Thus, RTSA and ATSA are effective to guarantee a significative rate of return to sport in elderly patients. A slightly higher rate was found for the anatomic implant.
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Kirsch JM, Namdari S. Rehabilitation After Anatomic and Reverse Total Shoulder Arthroplasty: A Critical Analysis Review. JBJS Rev 2020; 8:e0129. [PMID: 32224631 DOI: 10.2106/jbjs.rvw.19.00129] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Postoperative rehabilitation is believed to be essential in optimizing clinical outcome and function following shoulder arthroplasty. Despite this long-held notion, there is a paucity of high-quality evidence to guide rehabilitation protocols and practice. For patients undergoing anatomic total shoulder arthroplasty (ATSA), there are insufficient comparative data regarding type or duration of sling utilization. Based on current evidence, there is no appreciable benefit to early motion compared with a delayed-motion protocol following ATSA. There is insufficient literature to support the use of formal physical therapy over a physician-directed program following ATSA. At the present time, no high-quality evidence exists to guide the postoperative rehabilitation of patients undergoing reverse total shoulder arthroplasty (RTSA). Prospective randomized controlled trials evaluating postoperative management and rehabilitation following ATSA and RTSA are needed to guide best practices and optimize clinical outcomes.
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Affiliation(s)
- Jacob M Kirsch
- Departments of Orthopaedic Surgery and Shoulder and Elbow Surgery, The Rothman Institute-Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Surena Namdari
- Departments of Orthopaedic Surgery and Shoulder and Elbow Surgery, The Rothman Institute-Thomas Jefferson University, Philadelphia, Pennsylvania
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15
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A Systematic Review of Proposed Rehabilitation Guidelines Following Anatomic and Reverse Shoulder Arthroplasty. J Orthop Sports Phys Ther 2019; 49:337-346. [PMID: 31021690 DOI: 10.2519/jospt.2019.8616] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Total shoulder arthroplasty (TSA) is indicated for patients with glenohumeral arthritis. In this procedure, the humeral head and glenoid surface are replaced with prosthetic components. Reverse total shoulder arthroplasty (RTSA) is indicated for patients with glenohumeral arthritis and a poorly functioning rotator cuff. In this procedure, a glenosphere articulates with a humerosocket. While those surgeries are commonly performed, a thorough review of the literature is required to determine the areas of agreement and variations in postoperative rehabilitation. OBJECTIVES To describe the literature on rehabilitation protocols following anatomic TSA and RTSA. METHODS For this systematic review, a computerized search was conducted in medical databases from inception to May 21, 2018 for relevant descriptive studies on TSA and RTSA rehabilitation protocols. The methodological index for nonrandomized studies tool and the modified Downs and Black tool for randomized controlled trials were used for assessment of the individual studies. RESULTS Sixteen studies met the inclusion criteria, of which 1 provided level I evidence, 1 provided level III evidence, 2 provided level IV evidence, and 12 provided level V evidence. Ten of the studies described rehabilitation guidelines for TSA and 6 described those for RTSA. Following TSA, the use of a sling was recommended for a duration that varied from 3 to 8 weeks, and 4 of the 10 published protocols included resisted exercise during the initial stage of healing (the first 6 weeks after surgery). Seven of 10 published protocols recommended limiting shoulder external rotation to 30° and that passive range of motion be fully restored by 12 weeks post surgery. Suggested use of a sling post RTSA varied from "for comfort only" to 6 weeks, motion parameters varied from no passive range of motion to precautionary range limits, and all protocols agreed on performing deltoid isometric exercises early post surgery. There was a high level of heterogeneity for the rehabilitation guidelines and associated precautions for both TSA and RTSA. CONCLUSION The majority of published protocols were descriptive in nature. Published rehabilitation strategies following TSA and RTSA are based on biomechanical principles, healing time frames, and exercise loading principles, with little consistency among protocols. There is a need to determine optimal rehabilitation approaches post TSA and RTSA based on clinical outcomes. LEVEL OF EVIDENCE Therapy, level 5. J Orthop Sports Phys Ther 2019;49(5):337-346. doi:10.2519/jospt.2019.8616.
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16
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Rehabilitation Strategies After Shoulder Arthroplasty in Young and Active Patients. Clin Sports Med 2018; 37:569-583. [DOI: 10.1016/j.csm.2018.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
This article provides an anatomical and biomechanical framework for the postoperative management and progression of treatment for shoulder arthroplasty. The clinical relevance of normal shoulder anatomy, biomechanics, and pathomechanics related to this surgery is emphasized to provide the reader with an understanding of the rationale for treatment. We review the rehabilitation implications of surgical indications and technique for both traditional total shoulder arthroplasty and reverse total shoulder arthroplasty procedures with an emphasis on biomechanical considerations. Relevant factors that affect rehabilitation outcomes are discussed along with supporting evidence from the literature. Principles to guide and progress treatment are highlighted with a discussion on return to sports with the ultimate objective of providing a comprehensive approach for successful rehabilitation.
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Affiliation(s)
- Aviva L Wolff
- Leon Root Motion Analysis Laboratory, Hospital for Special Surgery, New York, NY, USA.
| | - Lee Rosenzweig
- Department of Rehabilitation, Hospital for Special Surgery, New York, NY, USA
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Kelly BJ, Field LD. Arthroscopic Transfer of the Subscapularis Tendon for Treatment of a Reverse Hill-Sachs Lesion. Arthrosc Tech 2017; 6:e2061-e2064. [PMID: 29399472 PMCID: PMC5793892 DOI: 10.1016/j.eats.2017.06.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 06/26/2017] [Indexed: 02/03/2023] Open
Abstract
Posterior shoulder instability occurs less often than anterior shoulder instability but is increasingly recognized as a relatively common condition. The reverse Hill-Sachs lesion is present in some patients with posterior instability and is best described as an impaction fracture of the anterior humeral head. These reverse Hill-Sachs lesions can predispose the patient to recurrent instability events and may need to be addressed directly at the time of surgery. Multiple open and arthroscopic procedures have been described to transfer bone or soft tissue structures into this reverse Hill-Sachs defect. An arthroscopic technique for the transfer of the subscapularis tendon into the defect using a standard 30° arthroscope, standard portals, and suture anchors is described.
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Affiliation(s)
- Brian J. Kelly
- Address correspondence to Brian J. Kelly, M.D., Mississippi Sports Medicine and Orthopaedic Center, 1325 East Fortification Street, Jackson, MS 39202, U.S.A.Mississippi Sports Medicine and Orthopaedic Center1325 East Fortification StreetJacksonMS39202U.S.A.
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19
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Hasan S, McGee A, Garofolo G, Hamula M, Oh C, Kwon Y, Zuckerman J. Changes in Driving Performance Following Shoulder Arthroplasty. J Bone Joint Surg Am 2016; 98:1471-7. [PMID: 27605691 DOI: 10.2106/jbjs.15.00162] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND With this study, we sought to quantify perioperative changes in driving performance among patients who underwent anatomic or reverse shoulder arthroplasty. METHODS Using a driving simulator, 30 patients (20 anatomic and 10 reverse total shoulder arthroplasties) were tested preoperatively and at 2 weeks (PO2), 6 weeks (PO6), and 12 weeks (PO12) postoperatively. The total number of collisions, centerline crossings, and off-road excursions (when the vehicle traversed the lateral road edge), and scores on a visual analog scale (VAS) for pain and the Shoulder Pain and Disability Index (SPADI) were recorded at each driving trial. RESULTS The mean number of collisions increased from 5.9 preoperatively to 7.4 at PO2 and subsequently decreased to 5.6 at PO6 and 4.0 at PO12 (p = 0.0149). In addition, the number of centerline crossings decreased from 21.4 preoperatively to 16.3 at PO12 (p < 0.05). Multivariate analysis of the data demonstrated that increased VAS for pain scores, older age, and less driving experience had a negative impact on driving performance. CONCLUSIONS Driving performance returned to preoperative levels at 6 weeks after shoulder arthroplasty. By 12 weeks postoperatively, patients demonstrated improved driving performance compared with preoperative performance. On the basis of our findings, clinicians can suggest a window of 6 to 12 weeks postoperatively for the gradual return to driving. However, for patients of older age, with less driving experience, or with greater pain, a return to driving at closer to 12 weeks postoperatively should be recommended. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Saqib Hasan
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Alan McGee
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Garret Garofolo
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Mathew Hamula
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Cheongeun Oh
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Young Kwon
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
| | - Joseph Zuckerman
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, NY
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Posterior shoulder fracture–dislocation: an update with treatment algorithm. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:285-294. [DOI: 10.1007/s00590-016-1840-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/11/2016] [Indexed: 11/27/2022]
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Rodia F, Theodorakis E, Touloupakis G, Ventura A. Fixation of complex proximal humeral fractures in elderly patients with a locking plate: A retrospective analysis of radiographic and clinical outcome and complications. Chin J Traumatol 2016; 19:156-9. [PMID: 27321296 PMCID: PMC4908216 DOI: 10.1016/j.cjtee.2016.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The optimal surgical treatment of displaced type B and C fractures of the proximal humerus in the elderly remains controversial. Good clinical results have been reported by plating these fractures as well as a high rate of complications. Our retrospective study aims to evaluate clinical recovery and complications using the S3 locking plate in elderly patients. METHODS Fifty-one patients older than 65 years of age, with a complex proximal humeral fracture type B or C (AO classification system), were included. Patients have been followed up for a minimum of 12 months. We assessed callus formation, radiological results, clinical outcome (according to the Constant Shoulder Score System) and complications. Any difference in the clinical recovery among the 2 types of fracture pattern (B and C) was investigated. RESULTS The mean time of fracture healing was 12.4 weeks. The mean Constant score at 3, 6 and 12 months was 68, 73 and 75 respectively. No statistically significant difference in the clinical outcome was observed between the B and C fracture patterns (p > 0.05). We noticed an overall of 5 complications (9.8%). There was no need to revision any of the implants. CONCLUSION Anatomic reduction and proper plate positioning are essential for minimizing implantrelated complications. In our experience the S3 angular stability system offers a proper osteosyntesis and a good clinical recovery with a low rate of complications.
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Affiliation(s)
- Fabio Rodia
- Department of Orthopaedics and Traumatology, CTO Hospital “A Alesini”, Roma 00185, Italy
| | - Emmanouil Theodorakis
- Department of Orthopaedics and Traumatology, Aurelia Hospital, Roma 00185, Italy,Corresponding author. Tel.: +39 3407444861.
| | - Georgios Touloupakis
- Department of Orthopaedics and Traumatology, Aurelia Hospital, Roma 00185, Italy
| | - Angelo Ventura
- Department of Orthopaedics and Traumatology, CTO Hospital “A Alesini”, Roma 00185, Italy
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Arthroscopic Reverse Remplissage for Posterior Instability. Arthrosc Tech 2016; 5:e43-7. [PMID: 27073776 PMCID: PMC4809750 DOI: 10.1016/j.eats.2015.09.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 09/22/2015] [Indexed: 02/03/2023] Open
Abstract
Posterior shoulder dislocation is an unusual injury often associated with electrical shock or seizure. As with anterior instability, patients frequently present with an impaction injury to the anterior aspect of the humeral head known as a "reverse Hill-Sachs lesion." The treatment of this bony defect is controversial, and multiple surgical procedures to fill the defect in an effort to decrease recurrence have been described. Most of the reports have focused on an open approach using variations of lesser tuberosity and subscapularis transfers, bone allograft, and even arthroplasty to assist with persistent instability. We advocate an arthroscopic technique that involves a suture anchor-based distal tenodesis of the subscapularis tendon or a reverse remplissage procedure.
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Hoel S, Jensen TG, Falster O, Ulstrup A. Hemiarthroplasty for proximal humerus fracture and consequences of a comminuted greater tubercle fragment. Musculoskelet Surg 2015; 100:9-14. [PMID: 26660499 DOI: 10.1007/s12306-015-0393-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND A prerequisite for a satisfying functional result in the treatment of comminuted fractures of the proximal humerus with hemiarthroplasty is anatomical reduction, fixation and healing of the tuberculi around the prosthetic neck in order to restore normal function of the rotator cuff. PURPOSE This was a retrospective study to examine the outcome after hemiarthroplasty using a prosthetic stem designed to optimise re-attachment and healing of the tuberculi (Aequalis; Tornier and Global Fx, DePuy). A special emphasis was on the effect on outcome a comminuted greater tubercle might have. MATERIALS AND METHODS At follow-up, clinical results were evaluated using the Constant score and WOOS index. All patients had radiographs taken of the injured shoulder. Quality of tubercle healing and prosthetic height were estimated; acromiohumeral distance was registered as well as greater tubercle comminution and resorption. RESULTS Thirty-four patients with 35 hemiarthroplasties were included. Mean age was 71 years (range 47-88) at the time of injury. At follow-up (mean 38 months, range 23-67), the mean Constant score was 44 points (range 18-87). The mean WOOS index was 58 (range 15-96). A comminuted tubercle was associated with tubercle resorption and superior migration of the arthroplasty. Also, there was a correlation for the functional Constant score, but for the WOOS index, there was none. CONCLUSION Like several other studies, we generally saw a group of patients with limited pain but poor range of movement in the shoulder. Our hypothesis was that comminution of the greater tubercle would correlate with both rotator cuff arthropathic radiographical features and more detrimental functional scores than average. Thus, a subtype of fracture could be identified at the time of injury and perhaps be allocated to a different treatment than hemiarthroplasty. Due to a limited number of patients in this study, we are unable to make any strong statistically supported conclusions regarding this hypothesis. LEVEL OF EVIDENCE Level 4 evidence.
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Affiliation(s)
- S Hoel
- Department of Orthopaedic Surgery, Holbæk Hospital, Smedelundsgade 60, 4300, Holbæk, Denmark
| | - T G Jensen
- Department of Orthopaedic Surgery, Holbæk Hospital, Smedelundsgade 60, 4300, Holbæk, Denmark
| | - O Falster
- Department of Orthopaedic Surgery, Holbæk Hospital, Smedelundsgade 60, 4300, Holbæk, Denmark
| | - A Ulstrup
- Department of Orthopaedic Surgery, Holbæk Hospital, Smedelundsgade 60, 4300, Holbæk, Denmark.
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Abstract
Historically, posterior shoulder instability has been a challenging problem for contact athletes and orthopedic surgeons alike. A complete understanding of the normal shoulder anatomy and biomechanics and the pathoanatomy responsible for the instability is necessary for a successful clinical outcome. In addition, the surgeon must be familiar with the diagnostic imaging and physical examination maneuvers required for the correct diagnosis without missing any other concurrent abnormalities. This understanding will allow orthopedists to plan and execute the appropriate management, whether this may involve conservative or surgical intervention. The goal should always be to correct the abnormality and have the patient return to play with full strength and no recurrent instability.
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25
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Salamh PA, Speer KP. Post-Rehabilitation Exercise Considerations Following Total Shoulder Arthroplasty. Strength Cond J 2013. [DOI: 10.1519/ssc.0b013e318291cb98] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Duey RE, Burkhart SS. Arthroscopic treatment of a reverse hill-sachs lesion. Arthrosc Tech 2013; 2:e155-9. [PMID: 23875143 PMCID: PMC3716231 DOI: 10.1016/j.eats.2013.01.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 01/15/2013] [Indexed: 02/03/2023] Open
Abstract
Acute traumatic posterior shoulder instability is a rare injury. Such injuries can result in significant bone defects of the anterior humeral head that require surgical intervention. In the past, small to medium defects have been treated by a soft-tissue or bone transfer into the lesion. We present an arthroscopic technique for addressing these lesions in which the middle glenohumeral ligament is sutured into the defect, thereby making it an extra-articular defect and preventing it from engaging the posterior glenoid.
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Affiliation(s)
- Richard E. Duey
- The San Antonio Orthopaedic Group, San Antonio, Texas, U.S.A
| | - Stephen S. Burkhart
- The San Antonio Orthopaedic Group, San Antonio, Texas, U.S.A,Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, U.S.A,Address correspondence to Stephen S. Burkhart, M.D., 150 E Sonterra Blvd, Ste 300, San Antonio, TX 78259, U.S.A.
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27
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Fusaro I, Orsini S, Stignani S, Creta D, Cava FC, Benedetti MG. Proposal for SICSeG guidelines for rehabilitation after anatomical shoulder prosthesis in concentric shoulder osteoarthritis. Musculoskelet Surg 2013; 97 Suppl 1:31-7. [PMID: 23588829 DOI: 10.1007/s12306-013-0257-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 03/15/2013] [Indexed: 12/19/2022]
Abstract
PURPOSE The purpose of this paper is to provide up-to-date guidelines on rehabilitation after anatomical shoulder prosthesis for concentric shoulder osteoarthritis, as previous guidelines date back to late 1970s and are no longer adequate due to the evolution of prosthesis models and surgical techniques. METHODS The physiatric committee of the Italian Society of Shoulder and Elbow Surgery (SICSeG-Società Italiana di Chirurgia della Spalla e del Gomito) performed a search for all the existing literature related to rehabilitation after shoulder replacement. A total of 29 papers concerning shoulder rehabilitation were reviewed. In addition, the main Italian orthopedic surgeons and physiatrists dealing with shoulder surgery and rehabilitation were interviewed to obtain indications when literature was not conclusive. RESULTS From literature evaluation and expert consultation, we produced guidelines concerning: patient evaluation by means of adequate rating scales, preoperative treatment, early intermediate and advanced postoperative phases, rehabilitation of scapulo-thoracic joint, return to work and sports, length of rehabilitation and follow-up. CONCLUSIONS This proposal for guidelines was presented during the 11th SICSeG Congress on May 2012 and to the main scientific societies concerned in shoulder surgery and rehabilitation. A consensus conference is needed in order to formalize and make them usable from all the professional figures involved in this field.
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Affiliation(s)
- I Fusaro
- Physical Therapy and Rehabilitation Unit, Istituto Ortopedico Rizzoli, Via Pupilli 1, Bologna, Italy.
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Skendzel JG, Sekiya JK. Diagnosis and management of humeral head bone loss in shoulder instability. Am J Sports Med 2012; 40:2633-44. [PMID: 22343756 DOI: 10.1177/0363546512437314] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Humeral head bone defects (Hill-Sachs lesions) are caused by anterior shoulder dislocation with impaction of the posterosuperior humeral head onto the anterior glenoid rim. Frequently, these bony lesions are associated with glenohumeral instability, and large lesions may contribute to recurrent instability after failure of a soft tissue repair. To improve outcomes and minimize the risk of persistent instability, a thorough understanding of the biomechanics of humeral bone loss is required. Detection and quantification of clinically relevant humeral head bone loss are performed through an accurate history, physical examination, and interpretation of imaging studies. The diagnosis and treatment options for reverse Hill-Sachs lesions are discussed, and the various treatment options for Hill-Sachs lesions are reviewed, including operative techniques to limit engagement of the deformity by soft tissue transfer, rotational osteotomy, bone grafting, or osteochondral transplantation.
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Affiliation(s)
- Jack G Skendzel
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, 48106, USA
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29
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Timing of shoulder arthroplasty in comminuted proximal humerus fracture, how much does it matter? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 23:515-9. [PMID: 23412158 DOI: 10.1007/s00590-012-1025-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 06/15/2012] [Indexed: 10/28/2022]
Abstract
Shoulder hemiarthroplasty is a salvage treatment for comminuted fracture of the humerus especially in elderly patients. Several factors contribute to the final outcome like bone quality and tuberosity reposition. Timing of the surgery is considered one of these factors. This study was done to assess the effect of delaying the surgery up to 2 weeks on the final outcome. This retrospective study was done on 33 patients with four-part fracture of the humerus, divided into two groups, group 1 (17 patients) who had surgery within the first 3 days after trauma, and group 2 (16 patients) who had surgery within the second week after injury. Operations were done by the same surgeon, same technique, and same implant. Constant score was used to assess the final follow-up, and there was a significant better result for group one especially in the items of range of movements and power.
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30
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Locked posterior shoulder dislocation: treatment options and clinical outcomes. Arch Orthop Trauma Surg 2011; 131:1127-34. [PMID: 21567148 DOI: 10.1007/s00402-011-1310-9] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Posterior dislocation of the shoulder is a rare injury and often misdiagnosed during the initial presentation to a physician. Misdiagnosis is due to a lack of clear clinical signs compared to anterior dislocation and inappropriate radiographs. In contrast to anterior dislocations, the humeral head defect accounts for recurrent instability. Depending on the size of the defect and the duration of dislocation, different treatment options include elevation of the defect, bone grafting, McLaughlin procedure, rotation osteotomy or arthroplasty. METHODS We reviewed 35 patients who presented to our institution with a locked posterior dislocation of the shoulder between January 1999 and August 2009. In 6 patients, the shoulder remained stable after closed reduction, so the treatment was conservative; 29 patients underwent surgery. RESULTS The mean follow-up was 55 months (range 11-132 months). The interval between trauma and the diagnosis of posterior shoulder dislocation was 66 days (min. 0, max. 365). Patients treated conservatively achieved a Constant Score of 85 points; patients who underwent operative treatment had a slightly worse outcome with an average Constant Score of 79 points. There was a high correlation between the time to the correct diagnosis and the outcome. CONCLUSION Although locked posterior shoulder dislocation is uncommon and often initially misdiagnosed, satisfying results can be achieved by different surgical treatment options. Early diagnosis by detailed clinical examination and sufficient radiographic evaluation with true anterior-posterior and axillary views is essential to improve clinical results. Levl of evidence: IV.
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Mulieri PJ, Holcomb JO, Dunning P, Pliner M, Bogle RK, Pupello D, Frankle MA. Is a formal physical therapy program necessary after total shoulder arthroplasty for osteoarthritis? J Shoulder Elbow Surg 2010; 19:570-9. [PMID: 19800258 DOI: 10.1016/j.jse.2009.07.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 06/09/2009] [Accepted: 07/12/2009] [Indexed: 02/01/2023]
Abstract
HYPOTHESIS A retrospective analysis was conducted of 2 consecutive groups of patients undergoing total shoulder arthroplasty (TSA) for primary osteoarthritis. One group was treated with formal physical therapy (PT), and one group was treated with home-based, physician-guided PT. We hypothesized that patients with a formal postoperative PT protocol would have significantly better postoperative clinical outcomes than patients with no formal PT. METHODS Group A (43 patients) had a standard PT program. Group B (38 patients) had a home-based, physician-guided PT program. Clinical outcomes (preoperatively, 3, 6, and 12 months and most recent follow-up) were analyzed. A minimum sample size of 31 patients gives power to detect a 10-point American Shoulder and Elbow Surgeons (ASES) score (alpha=0.05, beta=0.80). RESULTS ASES and Simple Shoulder Test (SST) scores significantly improved in both groups at all follow-up periods. Forward flexion and abduction were significantly improved in group B at all time points, whereas an initial improvement in forward flexion and abduction in group A was lost at final follow-up. There were no significant differences in final ASES or SST scores between groups at final follow-up. However, forward flexion, abduction, and the Short Form-36 physical component summary in group B were significantly better than group A at final follow-up. No significant improvements in internal rotation or SF-36 mental component summary were seen within or between the groups at final follow-up. Overall, there was no difference in patient satisfaction, with 88% satisfaction in group A and 95% satisfaction in group B (chi(2)=0.471, P=.4924). CONCLUSIONS A home-based, physician-guided therapy program may provide adequate rehabilitation after TSA, allowing for a reduction in cost for the overall procedure.
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Affiliation(s)
- Philip J Mulieri
- Shoulder & Elbow Division, Florida Orthopaedic Institute, Tampa, FL, USA
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34
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Diklic ID, Ganic ZD, Blagojevic ZD, Nho SJ, Romeo AA. Treatment of locked chronic posterior dislocation of the shoulder by reconstruction of the defect in the humeral head with an allograft. ACTA ACUST UNITED AC 2010; 92:71-6. [PMID: 20044682 DOI: 10.1302/0301-620x.92b1.22142] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The treatment of a chronic posterior dislocation of the shoulder is often determined by the size of the associated impression fracture of the humeral head. Our hypothesis was that patients with a chronic unreduced posterior dislocation of the shoulder and a defect in the humeral head involving between 25% to 50% of the articular surface, would do better if reconstructed with an allograft from the femoral head rather than treated by a non-anatomical reconstruction. We reviewed ten men and three women with a mean age of 42 years (36 to 51) at a mean follow-up of 54 months (41 to 64) who had this procedure. At follow-up, nine had no pain or restriction of activities of daily living. Their mean Constant-Murley shoulder score was 86.8 (43 to 98). No patient had symptoms of instability of the shoulder. Reconstruction of the defect in the humeral head with an allograft provides good pain relief, stability and function for patients with a locked, chronic posterior dislocation where the defect involves between 25% and 50% of the circumference of the articular surface.
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Affiliation(s)
- I D Diklic
- Belgrade University School of Medicine, Serbia
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35
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Castagna A, Delle Rose G, Borroni M, Markopoulos N, Conti M, Maradei L, Garofalo R. Modified MacLaughlin procedure in the treatment of neglected posterior dislocation of the shoulder. Musculoskelet Surg 2009; 93 Suppl 1:S1-5. [PMID: 19711163 DOI: 10.1007/s12306-009-0001-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Posterior dislocation of the shoulder is an unusual injury that most often occurs secondary to a high-energy trauma. Unfortunately the diagnosis is commonly missed, thus making its treatment a challenge. Neglected posterior dislocation is mainly characterised by an impression fracture on the anterior articular surface of the humeral head, which makes the dislocation often difficult to reduce. Diagnosis is based upon a careful history assessment, physical examination and radiological findings. Several treatment approaches have been described. The modified MacLaughlin procedure in our hands has been shown to be a reproducible technique allowing good results at medium- and long-term follow-up. According to our experience it is possible to adopt this technique also in patients with a locked posterior dislocation older than 6 months or in cases with a humeral head defect up to 50% when a shoulder prosthesis is not a good indication. Poorer results should be expected in patients with an associated fracture of the proximal humerus.
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Affiliation(s)
- Alessandro Castagna
- IRCCS Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano (MI), Italy
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Modi CS, Wicks L, Srinivasan K. Reconstruction of humeral head defect for locked posterior shoulder dislocation. Orthopedics 2009; 32:orthopedics.42858. [PMID: 19750995 DOI: 10.3928/01477447-20090728-43] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Locked posterior shoulder dislocation is a rare injury and is often missed on examination, usually due to inadequate imaging and potentially resulting in significant loss of shoulder function. An important feature of the physical examination is identification of the patient's inability to externally rotate their arm. These injuries are associated with defects in the humeral head articular surface, also known as reverse Hill-Sachs lesions. Medium-sized defects involving 25% to 50% of the articular surface can be reconstructed using several methods, including subscapularis or lesser tuberosity transfer, rotational osteotomy of the humerus, osteochondral autografting, and allograft reconstruction. We describe reconstruction of a 40% anteromedial humeral head articular surface defect associated with a missed locked posterior shoulder dislocation. Our technique used a deltopectoral approach with soft tissue dissection through the rotator interval to enable direct access to the defect with preservation of the rotator cuff muscles. The impacted articular surface was elevated, and the void was filled with moldable putty consisting of tricalcium phosphate with carboxymethylcellulose (Calstrux; Stryker Biotech, Hopkinton, Massachusetts). The articular fragment was then secured in position with size 5 Ethibond (Ethicon, Inc, Somerville, New Jersey) bone sutures. The patient regained excellent function and range of motion, with computed tomography scanning at 9 months demonstrating a smooth humeral articular surface with excellent graft incorporation. This technique avoids donor site morbidity and potential risks with allograft use while maintaining normal shoulder joint anatomy with preservation of the rotator cuff muscles for less complicated prosthetic reconstruction if required in the future.
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Affiliation(s)
- Chetan S Modi
- Heart of England NHS Foundation Trust, 23 Harts Green Road, Harborne, Birmingham, West Midlands, United Kingdom
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The use of precontoured humeral locking plates in the management of displaced proximal humerus fracture. J Am Acad Orthop Surg 2009; 17:582-90. [PMID: 19726742 DOI: 10.5435/00124635-200909000-00005] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Bigliani LU, Cofield RH, Flatow EL, Fukuda HA, Hawkins RJ, Matsen FA, Morrison DS, Rockwood CA, Warren RF. Charles Neer: on the giant of the shoulder. J Shoulder Elbow Surg 2009; 18:333-8. [PMID: 19393927 DOI: 10.1016/j.jse.2009.01.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2009] [Accepted: 01/31/2009] [Indexed: 02/01/2023]
Abstract
In the world of orthopedics, certain giants have become known as associated with a single subspecialty or for work on a single joint. Among these are John Charnley, for his work on total hip arthroplasty, and Amory Codman, for his work on the shoulder. But in the second half of the 20th century, the true giant of shoulder surgery was Charles Neer. His contributions to our subspecialty may not have been surpassed by any orthopedic surgeon for any subspecialty. This article explores his life and his contributions to shoulder surgery from those who knew him best.
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Affiliation(s)
- Louis U Bigliani
- Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
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Khayal T, Wild M, Windolf J. Reconstruction of the articular surface of the humeral head after locked posterior shoulder dislocation: a case report. Arch Orthop Trauma Surg 2009; 129:515-9. [PMID: 18815798 DOI: 10.1007/s00402-008-0762-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2008] [Indexed: 12/01/2022]
Abstract
Posterior dislocations of the glenohumeral joint are extremely rare (2-4% of all shoulder dislocations) and often associated with bone or ligamentary injuries. Though the reverse Hill-Sachs lesion is a common injury associated with posterior shoulder dislocation, there have been only few articles describing specific treatments for this type of humeral head defect. This article describes the successful operative treatment of an acute locked posterior shoulder dislocation by reconstructing the articular surface of the humeral head with the use of autologous bone graft taken from the iliac crest. The patient was doing quite well with no complaints, good range of shoulder motion and no recurrence of posterior shoulder dislocation despite several epileptic seizures, 1.5 years after surgical reconstruction of the anatomy of the humeral head. His right shoulder function revealed to be "excellent" or "good", assessed with an absolute Constant Score of 76 points and a relative Score of 88% when compared with an age- and sex-matched normal population.
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Affiliation(s)
- T Khayal
- Department of Trauma and Hand Surgery, Heinrich-Heine University Hospital, Moorenstrasse 5, 40225 Düsseldorf, Germany
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Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. ACTA ACUST UNITED AC 2008; 90:1407-13. [PMID: 18978256 DOI: 10.1302/0301-620x.90b11.21070] [Citation(s) in RCA: 138] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We performed a comprehensive systematic review of the literature to examine the role of hemiarthroplasty in the early management of fractures of the proximal humerus. In all, 16 studies dealing with 810 hemiarthroplasties in 808 patients with a mean age of 67.7 years (22 to 91) and a mean follow-up of 3.7 years (0.66 to 14) met the inclusion criteria. Most of the fractures were four-part fractures or fracture-dislocations. Several types of prosthesis were used. Early passive movement on the day after surgery and active movement after union of the tuberosities at about six weeks was described in most cases. The mean active anterior elevation was to 105.7 degrees (10 degrees to 180 degrees) and the mean abduction to 92.4 degrees (15 degrees to 170 degrees). The incidence of superficial and deep infection was 1.55% and 0.64%, respectively. Complications related to the fixation and healing of the tuberosities were observed in 86 of 771 cases (11.15%). The estimated incidence of heterotopic ossification was 8.8% and that of proximal migration of the humeral head 6.8%. The mean Constant score was 56.63 (11 to 98). At the final follow-up, no pain or only mild pain was experienced by most patients, but marked limitation of function persisted.
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Affiliation(s)
- G Kontakis
- Department of Orthopaedics and Trauma University Hospital of Heraklion, Crete, Greece 71110.
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41
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Kowalsky MS, Levine WN. Traumatic posterior glenohumeral dislocation: classification, pathoanatomy, diagnosis, and treatment. Orthop Clin North Am 2008; 39:519-33, viii. [PMID: 18803981 DOI: 10.1016/j.ocl.2008.05.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Posterior humeral dislocations often go undetected. Proposed explanations for the delay in diagnosis include failure of the evaluating physician to include the condition in the differential diagnosis, suboptimal radiographic evaluation and interpretation, and coincidental injuries such as fractures that can confound the patient's presentation. It is imperative that the orthopedic surgeon develop a complete understanding of the nature of this injury and its treatment so that patients who present with this condition can be diagnosed and treated effectively. This article provides a detailed discussion of the classification, pathoanatomy, diagnosis, and treatment of traumatic posterior glenohumeral dislocation.
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Affiliation(s)
- Marc S Kowalsky
- Department of Orthopaedic Surgery, Center for Shoulder, Elbow, and Sports Medicine, Columbia University Medical Center, 622 W. 168th Street, PH-1117, New York, NY 10032, USA
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de Oliveira AS, de Morais Carvalho M, de Brum DPC. Activation of the shoulder and arm muscles during axial load exercises on a stable base of support and on a medicine ball. J Electromyogr Kinesiol 2008; 18:472-9. [PMID: 17218116 DOI: 10.1016/j.jelekin.2006.09.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2004] [Revised: 08/15/2006] [Accepted: 09/29/2006] [Indexed: 12/01/2022] Open
Abstract
The purpose of this study was to compare SEMG activities during axial load exercises on a stable base of support and on a medicine ball (relatively unstable). Twelve healthy male volunteers were tested (x=23+/-7 y). Surface EMG was recorded from the biceps brachii, anterior deltoid, clavicular portion of pectoralis major, upper trapezius and serratus anterior using surface differential electrodes. All SEMG data are reported as percentage of RMS mean values obtained in maximal voluntary contractions for each muscle studied. A 3-way within factor repeated measures analysis of variance was performed to compare RMS normalized values. The RMS normalized values of the deltoid were always greater during the exercises performed on a medicine ball in relation to those performed on a stable base of support. The trapezius showed greater mean electric activation amplitude values on the wall-press exercise on a medicine ball, and the pectoralis major on the push-up. The serratus and biceps did not show significant differences of electric activation amplitude in relation to both tested bases of support. Independent of the base of support, none of the studied muscles showed significant differences of electric activation amplitude during the bench-press exercise. The results contribute to the identification of the levels of muscular activation amplitude during exercises that are common in clinical practice of rehabilitation of the shoulder and the differences in terms of type of base of support used.
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Affiliation(s)
- Anamaria Siriani de Oliveira
- Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Ribeirão Preto School of Medicine, São Paulo University - USP, Brazil.
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Abstract
Reverse or inverse total shoulder arthroplasty (rTSA) is becoming a widely accepted surgical intervention. This procedure is specifically designed for the treatment of glenohumeral (GH) joint arthritis or complex fractures, when associated with irreparable rotator cuff (RC) damage or in the presence of RC arthropathy. Additionally, rTSA is an option for the revision of a previously failed conventional total shoulder arthroplasty (TSA) or hemiarthroplasty (HA) in the RC-deficient shoulder. The physical therapist, surgeon, and patient must take into consideration that the postoperative course for a patient following rTSA should be different than the rehabilitation following a traditional TSA. rTSA has only recently been approved by the Food and Drug Administration in the United States; however, nearly a 20-year history of its use exists in Europe. To date, we are aware of no peer-reviewed published descriptions of the postoperative rehabilitation for patients having undergone this procedure. The purpose of this paper is to review the indications for rTSA, focusing on underlying pathology, and to outline a rehabilitation protocol founded on basic science principles and our experience working with patients following rTSA.
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Abstract
Osteoarthritis of the glenohumeral joint in younger, active patients presents a difficult situation to the surgeon, who would like to delay the necessity for hemiarthroplasty or total shoulder replacement until the patient is older and less active. This report outlines our technique of arthroscopic debridement and capsular release. By using electrocautery to release the rotator interval, anterior capsule, posterior capsule, and axillary recess, we have been able to improve the range of motion and to achieve pain relief. In 8 patients the mean improvement in range of motion was as follows: forward elevation, 21.4 degrees ; external rotation, 16.6 degrees; and internal rotation, 31.1 degrees. We believe that a reduction in joint contact pressures through a greater range of motion is the primary mechanism for pain relief resulting from capsular release.
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Abstract
As allogeneic musculoskeletal tissue is readily available, has minimal limitation in size or shape, and carries no donor site morbidity, it has become attractive for use in reconstructive shoulder surgery. Allograft is a viable option for treating osseous defects associated with glenohumeral instability and has been shown to achieve a stable shoulder with good clinical outcomes. Although there are mixed results on the use of allograft as rotator cuff augments or substitutes, new commercially processed materials such as GraftJacket are being tested to address the high failure rates associated with massive rotator cuff repair. Interposition arthroplasty as a treatment for glenohumeral arthritis in the young and active patient is a novel concept in which the arthritic glenoid is biologically resurfaced. Satisfactory results have been described using lateral meniscus and Achilles tendon allograft. Despite the promising reports on the use of allograft in reconstructive shoulder surgery, most of the published literature exists as retrospective, case reports. Additional large, controlled research is needed to prove the efficacy and safety of allograft tissue in the treatment of athletic injuries of the shoulder.
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Affiliation(s)
- Jason Y Ho
- New England Baptist Hospital, Boston, MA, USA.
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Abstract
Total shoulder arthroplasty (TSA) is a standard operative treatment for a variety of disorders of the glenohumeral joint. Patients, who have continued shoulder pain and loss of function in the presence of advanced joint pathology, despite conservative management, are often managed by undergoing a TSA. The overall outcomes that are reported after surgical intervention are quite good and appear to be primarily determined by the underlying pathology and the tissue quality of the rotator cuff. The current Neer protocol for postoperative TSA rehabilitation is widely used and based on tradition and the basic science of soft tissue and bone healing. The purpose of this paper is to review the indications for TSA, focusing on the underlying pathologies, and to describe the variables that impact the rehabilitation program of individuals who have had a TSA. A postoperative TSA rehabilitation protocol and algorithm, founded on basic science principles and tailored toward the specific clinical condition, are presented.
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Affiliation(s)
- Reg B Wilcox
- Outpatient Services, Department of Rehabilitation Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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48
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Abstract
The treatment of complex proximal humerus fractures that involve displacement of the greater tuberosity remains challenging. Good functional outcomes and decreased pain are possible with open reduction and internal fixation. Keys to a successful outcome include preservation of blood supply through decreased soft-tissue stripping, restoration of normal anatomic relationships (particularly the greater tuberosity), and stable internal fixation that allows early range of motion. To attain these goals, we advocate fixation with a fixed-angle locking proximal humerus plate using a 2-incision approach. A deltopectoral incision is used to expose the humeral shaft and head while the greater tuberosity is visualized by using a lateral incision. The fracture fragments are reduced and the plate is secured by working through these 2 incisions.
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Affiliation(s)
- Robert A Gallo
- Department of Orthopaedics, Allegheny General Hospital, Pittsburgh, PA 15212-4705, USA.
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Thomas S, Price AJ, Sankey RA, Thomas M. Shoulder hemiarthroplasty in patients with juvenile idiopathic arthritis. ACTA ACUST UNITED AC 2005; 87:672-6. [PMID: 15855370 DOI: 10.1302/0301-620x.87b5.15373] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Replacement of the shoulder in juvenile idiopathic arthritis is not often performed and there have been no published series to date. We present nine glenohumeral hemiarthroplasties in eight patients with systemic or polyarticular juvenile idiopathic arthritis. The mean follow-up was six years (59 to 89 months). The mean age at the time of surgery was 32 years. Surgery took place at a mean of 27 years after diagnosis. The results indicated excellent relief from pain. There was restoration of useful function which deteriorated with time, in part because of progression of the systemic disease in this severely affected group. No patient has required revision to date and there has been no radiological evidence of loosening or osteolysis around the implants. We discuss the pathoanatomical challenges unique to this group. There was very little space for a prosthetic joint and, in some cases, bony deformity and the small size necessitated the use of custom-made implants.
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Affiliation(s)
- S Thomas
- Heatherwood and Wexham Park Hospitals Trust, Wexham Street, Wexham, Berkshire SL2 4HL, UK.
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50
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Abstract
Posterior shoulder dislocations and fracture-dislocations are uncommon injuries that most often occur during seizures or as a result of high-energy trauma. Despite advances in imaging, they are frequently diagnosed late. Detection is facilitated by heightened clinical suspicion of the injury in high-risk individuals together with appropriate radiographic investigation. A wide variety of operative techniques, ranging from simple closed reduction to soft-tissue and bone stabilization procedures to prosthetic arthroplasty, are available to treat these injuries. Selection of the most appropriate treatment option is complex and multifactorial. Because of the rarity of these injuries, evidence-based treatment protocols are difficult to devise. Good functional outcomes are associated with early detection and treatment of isolated posterior dislocations that are associated with a small osseous defect and are stable following closed reduction. Poor prognostic factors include late diagnosis, a large anterior defect in the humeral head, deformity or arthrosis of the humeral head, an associated fracture of the proximal part of the humerus, and the need for an arthroplasty.
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Affiliation(s)
- C Michael Robinson
- The Royal Infirmary of Edinburgh, Old Dalkeith Road, Edinburgh EH16 4SU, United Kingdom.
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