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Martelli S, Perilli E, Fan X, Rapagna S, Gupta A. Time-elapsed microstructural imaging of failure of the reverse shoulder implant. J Orthop Surg Res 2024; 19:180. [PMID: 38475917 DOI: 10.1186/s13018-024-04652-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 03/01/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Reverse Shoulder Arthroplasties (RSA) have become a primary choice for improving shoulder function and pain. However, the biomechanical failure mechanism of the humeral component is still unclear. The present study reports a novel protocol for microstructural imaging of the entire humerus implant under load before and after fracture. METHODS A humerus specimen was obtained from a 75-year-old male donor. An expert surgeon implanted the specimen with a commonly used RSA implant (Aequalis reversed II, Stryker Orthopaedics, USA) and surgical procedure. The physiological glenohumeral contact force that maximized the distal implant migration was selected from a public repository ( orthoload.com ). Imaging and concomitant mechanical testing were performed using a large-volume micro-CT scanner (Nikon XT H 225 ST) and a custom-made compressive stage. Both when intact and once implanted, the specimen was tested under a pre-load and by imposing a constant deformation causing a physiological reaction load (650 N, 10 degrees adducted). The deformation of the implanted specimen was then increased up to fracture, which was identified by a sudden drop of the reaction force, and the specimen was then re-scanned. RESULTS The specimen's stiffness decreased from 874 N/mm to 464 N/mm after implantation, producing movements of the bone-implant interface consistent with the implant's long-term stability reported in the literature. The micro-CT images displayed fracture of the tuberosity, caused by a combined compression and circumferential tension, induced by the distal migration of the implant. CONCLUSION The developed protocol offers detailed information on implant mechanics under load relative to intact conditions and fracture, providing insights into the failure mechanics of RSA implants. This protocol can be used to inform future implant design and surgical technique improvements.
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Affiliation(s)
- Saulo Martelli
- School of Mechanical Medical and Process Engineering, Queensland University of Technology, Gardens Point Campus, P'Block, Level 7, Room 717, Brisbane, QLD, 4000, Australia.
- Medical Devices Research Institute, College of Science and Engineering, Flinders University, Adelaide, SA, Australia.
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD, Australia.
| | - Egon Perilli
- Medical Devices Research Institute, College of Science and Engineering, Flinders University, Adelaide, SA, Australia
| | - Xiaolong Fan
- School of Mechanical Medical and Process Engineering, Queensland University of Technology, Gardens Point Campus, P'Block, Level 7, Room 717, Brisbane, QLD, 4000, Australia
| | - Sophie Rapagna
- Medical Devices Research Institute, College of Science and Engineering, Flinders University, Adelaide, SA, Australia
| | - Ashish Gupta
- Greenslopes Private Hospital, Brisbane, QLD, Australia
- Queensland Unit for Advanced Shoulder Research (QUASR), Queensland University of Technology, Brisbane, QLD, Australia
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Maturana C, Peterson B, Shi B, Mooney B, Clites T, Kremen TJ. Reverse total shoulder arthroplasty with proximal bone loss: a biomechanical comparison of partially vs. fully cemented humeral stems. J Shoulder Elbow Surg 2024:S1058-2746(24)00136-8. [PMID: 38417733 DOI: 10.1016/j.jse.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/21/2023] [Accepted: 01/01/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND The appropriate amount of cementation at the time of reverse total shoulder arthroplasty with significant proximal bone loss or resection is unknown. Extensive cementation of a humeral prosthesis makes eventual revision arthroplasty more challenging, increasing the risk of periprosthetic fracture. We analyzed the degree of subsidence and torque tolerance of humeral components undergoing standard cementation technique vs. our reduced polymethyl methacrylate (PMMA) protocol. Reduced cementation may provide sufficient biomechanical stability to resist physiologically relevant loads, while still permitting a clinically attainable torque for debonding the prosthesis. METHODS A total of 12 cadaveric humeri (6 matched pairs) underwent resection of 5 cm of bone distal to the greater tuberosity. Each pair of humeri underwent standard humeral arthroplasty preparation followed by either cementation using a 1.5-cm PMMA sphere at a location 3 cm inferior to the porous coating or standard full stem cementation. A 6-degree-of-freedom robot was used to perform all testing. Each humeral sample underwent 200 cycles of abduction, adduction, and forward elevation while being subjected to a physiologic compression force. Next, the samples were fixed in place and subjected to an increasing torque until implant-cement separation or failure occurred. Paired t tests were used to compare mean implant subsidence vs. a predetermined 5-mm threshold, as well as removal torque in matched samples. RESULTS Fully and partially cemented implants subsided 0.49 mm (95% CI 0.23-0.76 mm) and 1.85 mm (95% CI 0.41-3.29 mm), respectively, which were significantly less than the predetermined 5-mm threshold (P < .001 and P < .01, respectively). Removal torque between fully cemented stems was 45.22 Nm (95% CI 21.86-68.57 Nm), vs. 9.26 Nm (95% CI 2.59-15.93 Nm) for partially cemented samples (P = .021). Every fully cemented humerus fractured during implant removal vs. only 1 in the reduced-cementation group. The mean donor age in our study was 76 years (range, 65-80 years). Only 1 matched pair of humeri belonged to a female donor with comorbid osteoporosis. The fractured humerus in the partially cemented group belonged to that donor. CONCLUSION Partially and fully cemented humeral prostheses had subsidence that was significantly less than 5 mm. Partially cemented stems required less removal torque for debonding of the component from the cement mantle. In all cases, removal of fully cemented stems resulted in humeral fracture. Reduced cementation of humeral prostheses may provide both sufficient biomechanical stability and ease of future component removal.
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Affiliation(s)
- Carlos Maturana
- Anatomical Engineering Group, Department of Mechanical and Aerospace Engineering, Henry Samueli School of Engineering, University of California, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Brandon Peterson
- Anatomical Engineering Group, Department of Mechanical and Aerospace Engineering, Henry Samueli School of Engineering, University of California, Los Angeles, CA, USA
| | - Brendan Shi
- Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Bailey Mooney
- Anatomical Engineering Group, Department of Mechanical and Aerospace Engineering, Henry Samueli School of Engineering, University of California, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Tyler Clites
- Anatomical Engineering Group, Department of Mechanical and Aerospace Engineering, Henry Samueli School of Engineering, University of California, Los Angeles, CA, USA; Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Thomas J Kremen
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA; Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA.
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de Geofroy B, Micicoi G, Olmos M, Boileau P, Bronsard N, Gonzalez JF, Gauci MO. Early morbidity and mortality after one-stage bilateral shoulder arthroplasty. INTERNATIONAL ORTHOPAEDICS 2024; 48:505-511. [PMID: 37853140 DOI: 10.1007/s00264-023-06003-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
PURPOSE One-stage bilateral shoulder arthroplasty has the advantage of requiring a single hospital stay and a single anaesthesia. The topic has been little reported, unlike one stage bilateral hip and knee arthroplasty, which have demonstrated their interest. The aim of the present study was to determine peri- and early post-operative morbidity and mortality after this procedure. The study hypothesis was that peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty is low in selected patients and that satisfaction is high. METHODS A single-centre retrospective study assessed peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty. Twenty-one patients, aged < 80 years, with ASA score ≤ 3, were consecutively operated on between 1999 and 2020. Indications comprised primary osteoarthritis, aseptic osteonecrosis, inflammatory arthritis, massive rotator cuff tear, and dislocation fracture, involving both shoulders. RESULTS There were no early deaths. The complication rate was 10% (4/21 cases). No prosthesis dislocation or sepsis was reported. Mean blood loss was 145 ± 40 cc, mean surgery time 164 ± 63 min, and mean hospital stay five ± four days. Only one patient required postoperative transfusion. Functional results at six months showed significantly improved range of motion and good patient satisfaction. CONCLUSIONS One-stage bilateral shoulder arthroplasty was feasible in selected patients. Mortality was zero, and morbidity was low. Surgery time was reasonable and required no repositioning. Postoperative home help is indispensable for patient satisfaction during rehabilitation.
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Affiliation(s)
- Bernard de Geofroy
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France
| | - Grégoire Micicoi
- Department of Orthopaedic Surgery and Sport Surgery, University Institute of Locomotion and Sport, University Hospital of Nice, 30 Av Voie Romaine, 06000 Cedex 1, Nice, CS, France
| | - Manuel Olmos
- Department of Orthopaedic Surgery and Sport Surgery, University Institute of Locomotion and Sport, University Hospital of Nice, 30 Av Voie Romaine, 06000 Cedex 1, Nice, CS, France
| | - Pascal Boileau
- Institut de Chirurgie Réparatrice, Groupe Kantys, Locomoteur & Sport, Clinique St Antoine7 Av Durante, 06000, Nice, France
| | - Nicolas Bronsard
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France
| | - Jean-François Gonzalez
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France
| | - Marc Olivier Gauci
- Department of Orthopedic Surgery and Traumatology, Military Teaching Hospital, 34 Boulevard Laveran, 13384, Marseille, France.
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Apiwatanakul P, Meshram P, Harris AB, Bervell J, Łukasiewicz P, Maxson R, Best MJ, McFarland EG. Use of custom glenoid components for reverse total shoulder arthroplasty. Clin Shoulder Elb 2023; 26:343-350. [PMID: 37957883 DOI: 10.5397/cise.2023.00563] [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: 06/28/2023] [Accepted: 09/02/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Our purpose was to evaluate a custom reverse total shoulder arthroplasty glenoid baseplate for severe glenoid deficiency, emphasizing the challenges with this approach, including short-term clinical and radiographic outcomes and complications. METHODS This was a single-institution, retrospective series of 29 patients between January 2017 and December 2022 for whom a custom glenoid component was created for extensive glenoid bone loss. Patients were evaluated preoperatively and at intervals for up to 5 years. All received preoperative physical examinations, plain radiographs, and computed tomography (CT). Intra- and postoperative complications are reported. RESULTS Of 29 patients, delays resulted in only undergoing surgery, and in three of those, the implant did not match the glenoid. For those three, the time from CT scan to implantation averaged 7.6 months (range, 6.1-10.7 months), compared with 5.5 months (range, 2-8.6 months) for those whose implants fit. In patients with at least 2-year follow-up (n=9), no failures occurred. Significant improvements were observed in all patient-reported outcome measures in those nine patients (American Shoulder and Elbow Score, P<0.01; Simple Shoulder Test, P=0.02; Single Assessment Numeric Evaluation, P<0.01; Western Ontario Osteoarthritis of the Shoulder Index, P<0.01). Range of motion improved for forward flexion and abduction (P=0.03 for both) and internal rotation up the back (P=0.02). Pain and satisfaction also improved (P<0.01 for both). CONCLUSIONS Prolonged time (>6 months) from CT scan to device implantation resulted in bone loss that rendered the implants unusable. Satisfactory short-term radiographic and clinical follow-up can be achieved with a well-fitting device. Level of evidence: III.
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Affiliation(s)
- Punyawat Apiwatanakul
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Prashant Meshram
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Andrew B Harris
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Joel Bervell
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Piotr Łukasiewicz
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Ridge Maxson
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Matthew J Best
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
| | - Edward G McFarland
- Division of Shoulder and Elbow Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD, USA
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Tuphe P, Caubriere M, Hubert L, Lancigu R, Sakek F, Loisel F, Obert L, Rony L. Early rehabilitation after reverse total shoulder prosthesis on fracture of proximal humerus in elderly patients provides better functional outcome. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2951-2957. [PMID: 36914883 PMCID: PMC10010947 DOI: 10.1007/s00590-023-03505-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/26/2023] [Indexed: 03/16/2023]
Abstract
PURPOSE Reverse total shoulder arthroplasty (RSA) has revolutionized the management of proximal humerus fractures (PHF) in the elderly patients. There is few or no consensus regarding to management of postoperative rehabilitation in elderly patients. An early rehabilitation from D1 allowed better functional results compared to rehabilitation started to D30 independently from tuberosities consolidation. METHODS 94 patients operated on for PHF were evaluated retrospectively, with a minimum radio-clinical follow-up of 2 years. Clinical evaluation included mobilities and four functional scores: ASES, quick DASH, gross constant, weighted constant. Radiological evaluation was performed on a frontal shoulder X-ray with evaluation of tuberosities' consolidation. RESULTS The mean follow-up was 45 ± 19 months (24-88 months). Early rehabilitation was significantly associated with a better Constant Score (71.1 ± 17.2 vs. 56.4 ± 15.8; p < 0.001), better adjusted Constant score (92.4 ± 14.2 vs. 80.3 ± 19.5; p < 0.001), better quick DASH (22.8 ± 19.8 vs. 36.7 ± 21.3; p < 0.01), better ASES (78.6 ± 20.2 vs. 63 ± 22; p < 0.001). CONCLUSION In traumatology, functional result of RSA seems not related in tuberosities' union but in rehabilitation in order to limit postoperative stiffness of operated shoulder. An early rehabilitation is related with better clinical and functional results, independently of tuberosities' union. LEVEL OF EVIDENCE 3, control-case study.
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Affiliation(s)
- P Tuphe
- Faculté de Médecine et de Pharmacie, Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main & CIC IT 808, C.H.U Besançon, Université de Franche Comte, 25033, Besançon, France
| | - M Caubriere
- Department of Orthopedic Surgery, C.H.U. Angers, 4 Rue Larrey, 49000, Angers, France
- Département de Chirurgie Osseuse, C.H.U. Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - L Hubert
- Department of Orthopedic Surgery, C.H.U. Angers, 4 Rue Larrey, 49000, Angers, France
- Département de Chirurgie Osseuse, C.H.U. Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - R Lancigu
- Department of Orthopedic Surgery, C.H.U. Angers, 4 Rue Larrey, 49000, Angers, France
- Département de Chirurgie Osseuse, C.H.U. Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - F Sakek
- Faculté de Médecine et de Pharmacie, Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main & CIC IT 808, C.H.U Besançon, Université de Franche Comte, 25033, Besançon, France
| | - F Loisel
- Faculté de Médecine et de Pharmacie, Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main & CIC IT 808, C.H.U Besançon, Université de Franche Comte, 25033, Besançon, France
| | - L Obert
- Faculté de Médecine et de Pharmacie, Service d'Orthopédie, de Traumatologie, de Chirurgie Plastique, Reconstructrice et Assistance Main & CIC IT 808, C.H.U Besançon, Université de Franche Comte, 25033, Besançon, France
| | - L Rony
- Department of Orthopedic Surgery, C.H.U. Angers, 4 Rue Larrey, 49000, Angers, France.
- Département de Chirurgie Osseuse, C.H.U. Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France.
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Oeding JF, Lu Y, Pareek A, Marigi EM, Okoroha KR, Barlow JD, Camp CL, Sanchez-Sotelo J. Understanding risk for early dislocation resulting in reoperation within 90 days of reverse total shoulder arthroplasty: extreme rare event detection through cost-sensitive machine learning. J Shoulder Elbow Surg 2023; 32:e437-e450. [PMID: 36958524 DOI: 10.1016/j.jse.2023.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/07/2023] [Accepted: 03/18/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Reliable prediction of postoperative dislocation after reverse total shoulder arthroplasty (RSA) would inform patient counseling as well as surgical and postoperative decision making. Understanding interactions between multiple risk factors is important to identify those patients most at risk of this rare but costly complication. To better understand these interactions, a game theory-based approach was undertaken to develop machine learning models capable of predicting dislocation-related 90-day readmission following RSA. MATERIAL & METHODS A retrospective review of the Nationwide Readmissions Database was performed to identify patients who underwent RSA between 2016 and 2018 with a subsequent readmission for prosthetic dislocation. Of the 74,697 index procedures included in the data set, 740 (1%) experienced a dislocation resulting in hospital readmission within 90 days. Five machine learning algorithms were evaluated for their ability to predict dislocation leading to hospital readmission within 90 days of RSA. Shapley additive explanation (SHAP) values were calculated for the top-performing models to quantify the importance of features and understand variable interaction effects, with hierarchical clustering used to identify cohorts of patients with similar risk factor combinations. RESULTS Of the 5 models evaluated, the extreme gradient boosting algorithm was the most reliable in predicting dislocation (C statistic = 0.71, F2 score = 0.07, recall = 0.84, Brier score = 0.21). SHAP value analysis revealed multifactorial explanations for dislocation risk, with presence of a preoperative humerus fracture; disposition involving discharge or transfer to a skilled nursing facility, intermediate care facility, or other nonroutine facility; and Medicaid as the expected primary payer resulting in strong, positive, and unidirectional effects on increasing dislocation risk. In contrast, factors such as comorbidity burden, index procedure complexity and duration, age, sex, and presence or absence of preoperative glenohumeral osteoarthritis displayed bidirectional influences on risk, indicating potential protective effects for these variables and opportunities for risk mitigation. Hierarchical clustering using SHAP values identified patients with similar risk factor combinations. CONCLUSION Machine learning can reliably predict patients at risk for postoperative dislocation resulting in hospital readmission within 90 days of RSA. Although individual risk for dislocation varies significantly based on unique combinations of patient characteristics, SHAP analysis revealed a particularly at-risk cohort consisting of young, male patients with high comorbidity burdens who are indicated for RSA after a humerus fracture. These patients may require additional modifications in postoperative activity, physical therapy, and counseling on risk-reducing measures to prevent early dislocation after RSA.
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Affiliation(s)
- Jacob F Oeding
- Mayo Clinic Alix School of Medicine, Rochester, MN, USA; Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway.
| | - Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Ayoosh Pareek
- Oslo Sports Trauma Research Center, Norwegian School of Sport Sciences, Oslo, Norway; Department of Orthopedic Surgery and Sports Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Erick M Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Hawkes D, Brookes-Fazakerley S, Robinson S, Bhalaik V. Intraoperative and early postoperative complications of reverse shoulder arthroplasty: A current concepts review. J Orthop 2023; 35:120-125. [PMID: 36471697 PMCID: PMC9718996 DOI: 10.1016/j.jor.2022.11.012] [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: 08/03/2022] [Revised: 10/19/2022] [Accepted: 11/19/2022] [Indexed: 11/27/2022] Open
Abstract
Background Reverse shoulder arthroplasty is a common procedure performed for a variety of shoulder pathologies. Aims and objectives This current concept review evaluates the intraoperative and early postoperative complications, with a specific focus given to neurological and vascular injury, fracture, dislocation and venous thromboembolism. Conclusion A detailed knowledge of potential complications will allow surgeons to mitigate risk and maximise outcomes.
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Affiliation(s)
- David Hawkes
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
| | - Steven Brookes-Fazakerley
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
| | - Simon Robinson
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
| | - Vijay Bhalaik
- Upper Limb Unit, Wirral University Teaching Hospital, Arrowe Park Rd, Upton, Birkenhead, Wirral, CH49 5PE, UK
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