Complications with reverse total shoulder arthroplasty and recent evolutions

Since its description by Paul Grammont from Dijon, France, several tens of thousands of reverse total shoulder arthroplasties (RTSA) have been performed for diverse conditions. The purpose of this analysis is to identify the complications of this procedure in the literature and in clinical practice. A total of 240 papers concerning RTSA published between 1996 and 2012 have been identified. Over 80 papers describe complications associated with this type of implant. A list of prostheses satisfying European and US standards, CE and FDA approved, has been produced on the basis of information provided by the manufacturers. Data from the literature do not support a meta-analysis. The inventory of best practices shows excellent results in the short and medium term in specific indications, while the number of complications varies between 10 and 65 % in long-term series. Complications can be classified into (A) non-specific including infections (superficial and deep), phlebitis, haematoma, neurological complications of the suprascapular, radial and axillary nerves and (B) specific complications associated with RTSA including (1) on the glenoid side: intraoperative fracture of the glenoid and acromion, late fracture of the scapula, impingement at the scapular neck (notching), glenoid loosening, dissociation of the glenoid component (snatching of the glenosphere) and fractures of the glenoid baseplate; (2) on the humeral side: metaphyseal deterioration, humeral loosening, instability of the shoulder, stiffness with limitation of external and/or internal rotation; and (3) muscular complications with fatty degeneration of the deltoid. Additionally we have identified specific situations related to the type of implant such as the disassembly of the humeral or the glenoid component, dissociation of the polyethylene humeral plate, dissociation of the metaphysis and osteolysis of the tuberosities. The integration of results from different clinical series is difficult because of the lack of a database and the multitude of implants used.

Management of the stiff shoulder

Shoulder stiffness occurs as a result of (1) contractures of the intraarticular capsule or muscle-tendon units or (2) adhesions within the extraarticular humeroscapular or scapulothoracic motion interface. These contractures or adhesions may occur independently or in combination. A thorough history and physical examination usually reveal the diagnosis (idiopathic frozen shoulder or posttraumatic stiff shoulder) and the anatomical locations of fibrosis that is causing stiffness, and identifies other treatable conditions associated with shoulder stiffness (such as diabetes). A gentle home program of passive stretching is effective in most patients. When the home program is not effective, a manipulation or surgical release may be indicated. If manipulation is not effective, capsular contractures are best released arthroscopically as this allows circumferential release without damaging the rotator cuff and thus allows rehabilitation without the need to protect the rotator cuff. The humeroscapular motion interface adhesions can be released either open or arthroscopically, but we believe that an open release combined with an arthroscopic capsular release is quicker and does not interfere with rehabilitation. When necessary, operative management coupled with an aggressive rehabilitation program can provide significant relief of pain and restoration of shoulder motion. Approximately 90% of patients can expect a good result with this treatment algorithm.

Observations on retrieved polyethylene glenoid components

It is recognized that retrieved polyethylene hip and knee components may undergo substantial changes from their preimplantation form. Little information is available, however, regarding retrieved polyethylene glenoid components. We report on 39 glenoid components removed at an average of 2.5 years after implantation. Of components for which clinical data were available, the commonest reason for the revision arthroplasty was loosening of the glenoid component; many components also showed glenohumeral instability. The articular surface contours of most of the components were altered. Of components, 28 had obvious erosion of the rim, 27 had surface irregularities, 11 were fractured, and 9 had central wear. These observations in retrieved glenoid components point to the potential of polyethylene for deformation in vivo, especially when the mechanics of the arthroplasty are compromised.

Adult multifocal pigmented villonodular synovitis--clinical review

Pigmented villonodular synovitis (PVNS) is a rare, benign proliferative disease of the synovial tissue that affects a single joint or a tendon sheath. Data from the literature present only a few cases of multifocal PVNS. This paper presents multifocal PVNS in the adult. This disease can affect bilateral shoulders, hips and knees. The diagnosis may be delayed by the slow evolution of the disease (up to ten years); some patients may be seen with late-stage degenerative joints, serious complications, painful and functionally uncompensated, with significant locomotion deficit. PVNS requires a radical treatment with prosthetic arthroplasty associated with synovectomy. Complex imaging (X-Rays, magnetic resonance imaging (MRI), ultrasound) and macroscopic appearance of the lesions during surgery confirms the clinical diagnosis of multifocal PVNS with secondary bone lesions. Histology marks the final diagnosis of multifocal PVNS. The postoperative results are good, with recovery in functional parameters of the joints with endoprosthesis.

The Telegraph nail for proximal humeral fractures: a prospective four-year study

Proximal humeral fractures in 67 patients older than 50 years treated with the Telegraph nail (FH Orthopedics, Heimsbrunn, France) were monitored for 4 years to assess the fracture pattern (weighted Constant score), ranges of motion, and patient satisfaction. The outcome was best in patients with extraarticular surgical neck fractures (mean weighted Constant score, 93.5%); scores were 85% and 77.5%, respectively, for valgus impacted fractures and intraarticular displaced or dislocated fractures. Some or all of the hardware was removed in 21 patients (31%). Two required implant removed for mechanical problems related to screw positioning or migration; 8 were revised because proximal migration of the implant resulted in subacromial impingement. Avascular necrosis occurred in 18% of valgus impacted fractures and in 37.5% of displaced articular or dislocated fractures. Secondary migration of the tuberosities occurred in 6 (all 4-part fractures). The Telegraph nail provides a reproducible and satisfactory outcome for surgical neck and valgus impacted fractures in older patients. The outcome was less satisfactory for unstable articular or dislocated fractures.

Long-term survival of the glenoid components in total shoulder replacement for arthritis

PURPOSE

Aseptic glenoid component loosening remains a common problem in total shoulder arthroplasty (TSA). This study presents long-term prospective follow-up after implantation of a glenoid component using the "cancellous compaction technique" and its effect on clinical outcome and presence and progression of radiolucent lines (RLLs).

METHOD

Thirty-nine TSAs were performed for primary osteoarthritis by one surgeon using the same technique. For the glenoid side, a keeled, polyethylene, convex-backed component was implanted using the "cancellous compaction technique" consisting of minimal reaming, compaction bone grafting of the glenoid and minimal addition of cement. Postoperative clinical outcome was analysed using Constant scores and patient's subjective evaluation. Independent observers evaluated postoperative X-rays for radiolucent lines (RLL) around the base plate and keel.

RESULTS

At an average follow-up of 8.5 years (range 4.7-12.5), the Constant score improved from 33.5 to 73.0 points (P < 0.0001). Active anterior elevation improved from an average 95 ° to 140° (P < 0.0001), and active external rotation improved from 20° to 45° (P < 0.0001). Pain score improved from 3.1 to 13.6 (P < 0.0001). Radiologically, the RLL score increased from 1.09 (range, 0-3) postoperative to 5.7 (range, 0-18) (P < 0.0001) at final follow-up. The occurrence of definite radiological glenoid loosening was 15.5 %. Constant scores deteriorated with the progression of RLLs (P = 0.006). The rate of revision surgery for glenoid loosening was 2.5 %.

CONCLUSIONS

This study showed highly satisfactory clinical outcomes and low rates of revision for glenoid loosening using a bone-saving compaction technique for implantation of an all-polyethylene glenoid component.

Intrinsic stability of unused and retrieved polyethylene glenoid components

The surface geometry of polyethylene components can be altered by in vivo use. The purpose of this investigation is to document the effects of these changes on the intrinsic stability provided by the glenoid component. We validated a method of measuring the intrinsic stability of glenoid components as indicated by the balance stability angle (the maximal angle between the glenoid centerline and the resultant humeral force before dislocation of the humeral head occurs). We compared observed values with those predicted for unused glenoid components for which the geometry was known. We then applied this method to retrieved glenoid components in which the surface geometry had been altered by in vivo use. The balance stability angles measured in retrieved glenoids were often substantially reduced: 11 of 24 glenoids had diminished balance stability angles of at least 30% in at least one direction. We concluded that the surface geometry of polyethylene glenoid components can be altered by in vivo use in a manner that may compromise their contribution to glenohumeral stability.

Human dermal allograft for massive rotator cuff tears

Previously published studies reported variable results using various suture techniques and reconstruction options for massive rotator cuff tears. Therefore, the current authors retrospectively studied 21 consecutive patients/shoulders with massive rotator cuff tears treated from January 2005 to October 2011 with a human dermal allograft through a mini-open approach. Mean patient age was 58 years (range, 33-72 years). Mean follow-up was 29 months (range, 18-52 months). Ten patients underwent revision repair for a failed rotator cuff repair. The authors measured the tendon gap (mean, 1.7 cm) and acromiohumeral interval (mean, 6.5 mm). They evaluated pain, shoulder range of motion (ROM) and function, patient satisfaction with the operation and outcome, and complications. At last follow-up, all patients experienced significant pain relief (P=.001) and improved ROM (P=.001) and American Shoulder and Elbow Surgeons (ASES) score (P=.001). Eighteen patients reported that they were satisfied or very satisfied and 3 reported that they were not satisfied with the operation and outcome. Comparison of outcomes between patients who underwent primary repair and those who underwent revision repair and between patients who had muscle atrophy and fatty infiltration grades 0 to II and those who had grades III to IV showed no statistically significant differences. A statistically significant correlation was observed between the size of the tendon gap and postoperative pain, ROM (except external rotation), and ASES score (P<.050). No significant correlation was observed between postoperative pain, ROM, and ASES score and the acromiohumeral interval (P>.050). Complications related to the dermal human allograft were not observed.

Shoulder Osteonecrosis: Pathogenesis, Causes, Clinical Evaluation, Imaging, and Classification

The humeral head is the second most common site for nontraumatic osteonecrosis after the femoral head, yet it has attracted relatively little attention. Osteonecrosis is associated with many conditions, such as traumatism, corticosteroid use, sickle cell disease, alcoholism, dysbarism (or caisson disease), and Gaucher's disease. The diagnosis is clinical and radiographic with MRI, with radiographs being the basis for staging. Many theories have been proposed to decipher the mechanism behind the development of osteonecrosis, but none have been proven. Because osteonecrosis may affect patients with a variety of risk factors, it is important that caregivers have a heightened index of suspicion. Early detection may affect prognosis because prognosis is dependent on the stage and location of the disease. In particular, the disease should be suspected in patients with a history of fractures, steroid usage, or sickle cell disease, and in divers. This report reviews osteonecrosis of the humeral head, with an emphasis on causes, clinical evaluation, imaging, and classification.

The lateral impaction of the shoulder

17 patients had radiographic demonstration of injury to the clavicle, scapula and ribs from an impact delivered to the lateral shoulder. The study included 13 males and 4 females whose ages ranged from 18 to 83 years (average 45 years). Most injuries were sustained in falls or motor vehicle accidents. Analysis of these cases suggests a biomechanical hypothesis concerning the transmission of the impact forces within the shoulder girdle. According to this hypothesis, the impaction force applied to the lateral shoulder is transmitted from outside inward following two paths. The anterior and superior path passes through the acromio-clavicular joint, the clavicle, the costo-clavicular joint and the sterno-clavicular joint. The posterior and inferior path is transmitted within the gleno-humeral joint, the scapula and the scapulo-thoracic joint. Major impacting force is required to disrupt the anterior and posterior arches of the shoulder girdle. When both of these supporting structures are damaged, the patient is at risk for more serious injuries, including disruption of the thorax, shoulder joint, brachial plexus and neck.

Scientific Misconduct (Fraud) in Medical Writing

Scientific misconduct (fraud) in medical writing is an important and not infrequent problem for the scientific community. Although noteworthy examples of fraud surface occasionally in the media, detection of fraud in medical publishing is generally not as straightforward as one might think. National bodies on ethics in science, strict selection criteria, a robust peer-review process, careful statistical validation, and anti-plagiarism and image-fraud detection software contribute to the production of high-quality manuscripts. This article reviews the various types of fraud in medical writing, discusses the related literature, and describes tools journals implement to unmask fraud. [Orthopedics. 2018; 41(2):e176-e183].

Setting standards for medical writing in orthopaedics

Once the privilege of few clinical scholars in the field of orthopaedics, medical writing has become a must for career advancement. The number of papers submitted and published yearly has increased steadily, and with the development of the Internet, manuscript and journals have become easily accessible. Medical writing has risen to become a discipline in itself, with rules and standards. However, heterogeneity in the quality of papers submitted still prevails, with large variations in both form and content. With countries such as China and India submitting an exponential number of manuscripts, it is important and helpful that standards of medical writing be emphasised to help writers who do not always have the required support to produce an outstanding manuscript. In this paper, we summarise what may become standards for medical writing in the field of orthopaedics.

The Dark Age of medieval surgery in France in the first part of Middle Age (500-1000): royal touch, wound suckers, bizarre medieval surgery, monk surgeons, Saint Healers, but foundation of the oldest worldwide still-operating hospital

PURPOSE

During the Middle Ages, the Christian church established itself as the dominant force over all aspects of medieval life, including the practice of medicine. As the Church's influence expanded across Europe, the role of lay practitioners in medicine declined, and clerics gradually assumed the role of healers in surgical practice as the cure of the soul was felt to take precedence over cure of bodily ills.

MATERIAL AND METHODS

A retrospective analysis of hospital foundation, old-school surgical techniques still used today was performed during the first part of the Middle Age.

RESULTS

The Hospital Hotel Dieu in Paris was founded and remains the oldest worldwide still-operating hospital. The monastery became a resting place for travelers, as well as a place of refuge for the sick. As this role expanded, monks often developed considerable surgical expertise. This led to fierce competition for saintly relics and pilgrims. Among the myriad of saints to whom powers of healing were ascribed, the names of Damian and Cosmas figure prominently in medical history. Old-school medieval surgery was also performed with some bizarre techniques such as lip service by wound suckers, cautery, blood-letting, leech therapy, and maggot therapy.

CONCLUSION

This account of surgery before it became scientific is based on a chronology that runs from the Clovis baptism to the reign of Charlemagne; much of the medicine in this period was based on ancient doctrines; indeed, much of the development of medicine in the period called as "Dark Age" was due to the slow and difficult business of recovering and trying to understand ancient medicine.