Torsional stability of modular and non-modular reverse shoulder humeral components in a proximal humeral bone loss model (original) (raw)
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Reverse glenoid component fixation: Is a posterior screw necessary?
Journal of Shoulder and Elbow Surgery, 2010
Background: Reverse shoulder arthroplasty has become more prevalent for the treatment of complex shoulder issues. Prosthetic designs vary in both the number and orientation of screws recommended for securing the glenoid base plate. This study examined the contribution of the posterior glenoid screw for stabilizing the glenosphere by comparing constructs with no posterior screw, a standard posterior screw directed into the glenoid neck, and a long posterior screw (LPS) into the scapular spine. Material and methods: The Tornier RTSA glenoid implant was fixed into 2 groups of matched cadaveric scapulae. In both groups, the controls were fixed with a standard posterior screw (SPS). Matching scapulae had a screw configuration that omitted the posterior screw (NPS) in group I or utilized an LPS in group II. Specimens were tested using a ''rocking-horse'' protocol. During cyclic loading (50,000 cycles), the vertical displacement of the glenoid component was monitored using a digital caliper. Results: In group I, NPS constructs demonstrated a significantly higher mean rate of loosening than SPS constructs. In group II, the LPS constructs demonstrated lower loosening rates than SPS constructs. Mean initial displacements were greater for NPS than SPS in group I and similar for SPS and LPS in group II Discussion: The posterior glenoid screw contributes significantly to stability of the reverse glenoid base plate. If an SPS does not obtain good purchase into the scapula, glenoid component fixation will be enhanced by the addition of an LPS into the scapular spine. Level of evidence: Basic Science Study.
Journal of Shoulder and Elbow Surgery, 2011
Hypothesis: Navigation can improve accuracy of placement of the glenoid component in reversed shoulder arthroplasty. Material and methods: A glenoid component of a reversed shoulder prosthesis was implanted in 14 paired scapulohumeral cadaver specimens. Seven procedures with standard instrumentation were compared with 7 procedures using navigation. The intraoperative goal was to place the component centrally in the glenoid in the axial plane and 10 inferiorly tilted in the frontal plane. Glenoid component version and tilt and screw placement were studied using CT scan and macroscopic dissection. Results: The mean version of the glenoid component in the standard instrumentation group was 8.7 of anteversion, compared with 3.1 of anteversion in the navigated group. The mean tilt of the glenoid component was 0.9 in the standard group and 5.4 of inferior tilt in the navigated group. Using navigation, the range of error for version was 8 (SD 3.3 ) compared to 12 (SD 4.1 ) in controls. For tilt, the range of error was 8 (SD 3.6 ) in navigated specimens and 16 (SD 6.0 ) for controls. In the control group, there were no perforations of the central peg, but 1 inferior screw and 4 superior screws were malpositioned. In the navigation group, no central peg perforated, all inferior screws were correctly positioned, and 2 superior screws were malpositioned. Conclusion: Computer navigation was more accurate and more precise than standard instrumentation in its placement of the glenoid component in reversed shoulder arthroplasty. Level of evidence: Basic Science Study.
European Journal of Orthopaedic Surgery & Traumatology, 2021
Background Randomized controlled trials (RCT) are regarded as the gold standard for effect evaluation in clinical interventions. However, RCTs may not produce relevant results to all patient groups. We aimed to assess the external validity of a multicenter RCT (DelPhi trial). Methods The DelPhi RCT investigated whether elderly patients with displaced proximal humeral fractures (PHFs) receiving reversed total shoulder prosthetic replacement (RTSA) gained better functional outcomes compared to open reduction and internal fixation (ORIF) using an proximal humerus locking plate (PHILOS). Eligible patients were between 65 and 85 years old with severely displaced 11-B2 or 11-C2 fractures (AO/OTA-classification, 2007). We compared baseline and follow-up data of patients for two of the seven hospitals that were included in the DelPhi trial (n = 54) with non-included patients (n = 69). Comparisons were made based on reviewing medical records regarding demographic, health and fracture paramet...
Management of proximal humeral fractures: Surgeons don't agree
Journal of Shoulder and Elbow Surgery, 2010
Hypothesis: The management options for proximal humeral fractures have expanded in recent years. Patients with displaced, unstable proximal humeral fractures may have improved outcomes if managed operatively. We investigated the decision making of fellowship-trained orthopedic surgeons when presented with the same group of cases. We hypothesized that interobserver and intraobserver agreement for surgical management would be poor and independent of fellowship training. Method: Eight fellowship-trained orthopedic surgeons (3 shoulder, 5 trauma) viewed the preoperative plain radiographs of patients with proximal humeral fractures. All surgeons viewed the same 38 radiographs in a blinded fashion. Surgeons chose from 1 of 6 management options. Interobserver variability was calculated by using the weighted k coefficient. Intraobserver variability was calculated by comparing each surgeon's survey results with the operation they originally performed. Results: Overall interobserver agreement on management was moderate (weighted k ¼ 0.41) and did not differ significantly between trauma surgeons and shoulder surgeons. Reducing the number of management choices increased agreement between all surgeons. Testing for intraobserver agreement showed that surgeons picked the same operation in the survey as in the actual clinical setting only 56% of the time. Conclusion: Interobserver agreement was moderate overall and improved when the number of management choices was reduced. Intraobserver agreement was less frequent, however, raising the question about consistent decision making by a given surgeon. Although surgeons agree in the method of treatment only to a modest degree, it remains for further outcomes research to establish if the choice of treatment actually influences the clinical outcome. Level of evidence: Level 4, case series.
Path analysis of factors for functional outcome at one year in 463 proximal humeral fractures
Journal of Shoulder and Elbow Surgery, 2011
Background: Path analysis methods were used to test the prognostic value of 10 patient-related and treatment-related factors on the 1-year functional outcome of 463 proximal humeral fractures measured using the Constant score. Complex inter-relationships between these factors were also evaluated. Materials and methods: Data were collected from a prospective cohort study that included 3 operative groups repaired using nail or plate fixation and 1 nonoperative group. From the available information, various factors potentially having a direct influence on the functional Constant score were identified. The process of creating a hypothetical causal path diagram was undertaken to order the factors in a sequence of associations or cause-and-effect relationships. Results: Our final multivariable regression model for the 1-year Constant score included the 6 factors of age, sex, treatment, occurrence of intraoperative and local post-treatment complications, and anatomic restoration. Being a woman aged older than 40 years, treated with a locking proximal humeral plate (LPHP), having experienced intraoperative and local post-treatment complications, and varus deformity of more than 30 were negative predictors of the Constant score (ie, poor shoulder function 1 year after treatment initiation). Three factors, the dominant side fractured and the Neer and AO fracture type, showed only significant association on intermediate factors. The presence of concomitant disease did not show any significant direct or indirect effect. A final pathway outlines these associations and inter-relationships. Conclusion: Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture. Level of evidence: Level I, Prospective Design, Prognosis Study.
Impact of previous rotator cuff repair on the outcome of reverse shoulder arthroplasty
Journal of Shoulder and Elbow Surgery, 2011
Background: Our purpose was to evaluate the outcome of the Delta reverse shoulder prosthesis (DePuy France, Saint Priest, France) in a consecutive series of 68 shoulders and perform a comparison of patients with and without previous shoulder arthroscopy for cuff tear reconstruction. Patients and methods: We assessed 68 shoulders in 66 patients (36 women and 30 men) with a mean age of 66 years (range, 53-84 years), first preoperatively and then at a minimum of 2 years' follow-up, using the Constant score for pain; Constant Shoulder Score; Oxford Shoulder Score; University of California, Los Angeles shoulder rating scale; and Disabilities of the Arm, Shoulder and Hand score. Any complications were assessed according to Goslings and Gouma. Results: We report statistically significant improvements of all obtained scores at a mean follow-up of 42 months (range, 24-96 months) in both groups. Significant outcome differences between 29 patients with previous shoulder arthroscopy for cuff tear reconstruction and 39 patients without previous shoulder arthroscopy were not observed. In total, 8 complications occurred: 1 nerve lesion, 3 cases of loosening of the humeral stem, and 4 cases of luxation of the glenoid component. Conclusion: We conclude that reverse total shoulder arthroplasty with the Delta prosthesis is significantly beneficial in terms of less shoulder pain, greater stability, and gain in range of motion without this beneficial effect being significantly weakened by previous insufficient shoulder arthroscopy for cuff tear reconstruction. We believe that previous arthroscopic cuff tear reconstruction should therefore be included in the treatment algorithm. Level of evidence: Level III, Case-Control Study, Treatment Study.
Journal of Bone and Joint Surgery, 2020
Background: Almost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate. Methods: The DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients. Results: There were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, 23.8 to 19.1 points; p = 0.19). Conclusions: At a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. P roximal humeral fractures are among the most common fractures in the elderly. The incidence increases with age, more than two-thirds of patients with these fractures are female, and most patients live at home at the time of the injury. Proximal humeral fractures are the cause of considerable disability and societal costs, with expensive treatment and patients Disclosure: Sophies Minde Ortopedi AS (https://sophiesminde.no) contributed to the study with research grants. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked "yes" to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/F685). A data-sharing statement is provided with the online version of the article (http://links.lww.com/JBJS/F687).
Short and midterm results of reverse shoulder arthroplasty according to the preoperative etiology
Archives of Orthopaedic and Trauma Surgery, 2013
Background Reverse shoulder arthroplasty (RSA) has shown promising results for cuff tear arthropathy but the indication has been extended to fracture sequelae and revision shoulder arthroplasty with different preconditions. Further, the clinical relevance of inferior scapular notching for different etiologies is uncertain. Our hypothesis was that preoperative etiology as well as the occurrence of scapular notching would significantly influence the clinical outcome. Methods We reviewed 76 reverse shoulder arthroplasties for cuff tear arthropathy (45 patients), fracture sequelae (10 patients) and revision arthroplasty (21 patients) retrospectively. The follow-up consisted of 71 patients and the mean follow-up period was 23 months (±14 months). All patients were evaluated postoperatively using the Constant score adjusted for age and gender and the simple shoulder test. A radiological investigation was performed preoperatively and at the time of the final follow-up including the evaluation of scapular notching according to Sirveaux. For further evaluation of scapular notching, patients were separated into three groups according to the inferior glenosphere overlap: negative or no inferior overlap-6-0 mm), mild overlap (1-4 mm) and pronounced overlap (5-9 mm). Results After a mean follow-up of 23 months the average age-and gender-adjusted Constant score (CS) was 77.8 % (±26 %). According to the etiology, patients with cuff tear arthropathy (CTA) showed a higher CS of 83 % compared with patients with fracture sequelae (CS 73 %) and compared with patients who had undergone RSA as a revision for failed shoulder arthroplasty (CS 69 %). The difference was significant comparing the cuff tear arthropathy patients with the revision surgery patients (p = 0.035). Within the group of fracture sequelae, patients with type three sequelae according to the Boileau classification (surgical neck nonunion) had a significantly worse outcome compared with the type four fracture sequelae patients (severe tuberosity dislocation) (CS 57 vs. 87 %, p = 0.01). The overall complication rate was 27 % with 8 % infections and 9 % dislocations. Revision surgery was necessary in 11.5 % with removal or replacement of the implants in 8 %. Inferior scapular notching was detected in 43 % of the patients. These patients had an inferior CS (70 ± 18 %) compared with patients without scapular notching (84 ± 25 %, p = 0.015). The incidence of scapular notching was significantly reduced with an increasing inferior overlap of the glenosphere. Conclusions In conclusion, we found the preoperative etiology to influence the clinical results after RSA with superior results given for cuff tear arthropathy and inferior results for revision arthroplasty and fracture sequelae type three. Further, we found a correlation between scapular notching and the clinical outcome. The inferior scapular notching was significantly reduced by an increased inferior glenosphere overlap. Level of evidence Level IV, case series, treatment study.
Journal of Shoulder and Elbow Surgery, 2019
Background: Proximal humeral fractures (PHFs) are among the most common fractures in elderly patients, but there is insufficient evidence from randomized controlled trials (RCTs) to determine which interventions are the most appropriate for their management. To date, no RCT has directly compared reverse shoulder arthroplasty (RSA) with nonoperative treatment for 3-or 4-part PHFs in elderly patients. Methods: This was a prospective RCT. The primary objective was to compare pain and function 12 months after fracture using the Constant score in patients aged 80 years or older with 3-and 4-part PHFs, treated by either RSA or nonoperative treatment. Secondary outcome measures included Disabilities of the Arm, Shoulder and Hand, visual analog scale (VAS), Short Form 12 (SF-12), EuroQol 5 Dimensions, and EQ-VAS scores. Results: We analyzed 30 nonoperative and 29 RSA patients with mean ages of 85 years and 82 years, respectively. No differences between the nonoperative and RSA groups were noted for any patientreported outcomes at 12 months' follow-up except the VAS pain score. The Constant scores were 55.7 in the nonoperative group and 61.7 in the RSA group (P ¼ .071); the Disabilities of the Arm, Shoulder and Hand scores were 29 and 21, respectively (P ¼ .075); the VAS scores were 1.6 and 0.9, respectively (P ¼ .011); the physical SF-12 scores were 36 and 37, respectively (P ¼ .709); the mental SF-12 scores were 43 and 42, respectively (P ¼ .625); the EuroQol 5 Dimensions scores were 0.89 and 0.92, respectively (P ¼ .319); and the EQ-VAS scores were 65 and 67, respectively (P ¼ .604).