JSES reviews, reports, and techniques最新文献

Background

Shoulder arthroplasty has become an increasingly common procedure used to treat degenerative, inflammatory, and traumatic conditions of the glenohumeral joint. With a significant increase in primary anatomic and reverse total shoulder arthroplasty, revision procedures have likewise increased. Updates in shoulder arthroplasty have allowed for the convertibility of implants, which allows for the retention of both glenoid and humeral components during revision surgery. This review aims to highlight the epidemiology, indications, and outcomes of convertible-platform total shoulder arthroplasty procedures.

Methods

A review of the current literature surrounding convertible-platform shoulder arthroplasty was completed to highlight the advantages and disadvantages of commercially available instrumentation and implant systems as well as their outcomes.

Discussion

Leading causes of shoulder arthroplasty revision surgery include glenoid failure, implant instability, and rotator cuff dysfunction. Variations in implant design between inlay and onlay humeral components and metal-backed glenoid components are important considerations at the time of revision surgery. Advantages of convertible-platform systems include increased efficiency and decreased complications during revision procedures as well as shorter recovery, lower cost, and better functional outcomes. Limitations of convertible systems include poorly positioned components during the index procedure, excessive soft-tissue tensioning, and problems associated with metal-backed glenoid implants. Changes in arm length have also been documented. These findings indicate the benefit of additional research and design to improve the effectiveness and utility of convertible-platform shoulder arthroplasty systems.

Background

Despite extensive literature dedicated to determining the optimal treatment of isolated greater tuberosity (GT) fractures, there have been few studies to guide the management of GT fracture dislocations. The purpose of this review was to highlight the relevant literature pertaining to all aspects of GT fracture dislocation evaluation and treatment.

Methods

A narrative review of the literature was performed.

Results

During glenohumeral reduction, an iatrogenic humeral neck fracture may occur due to the presence of an occult neck fracture or forceful reduction attempts with inadequate muscle relaxation. Minimally displaced GT fragments after shoulder reduction can be successfully treated nonoperatively, but close follow-up is needed to monitor for secondary displacement of the fracture. Surgery is indicated for fractures with >5 mm displacement to minimize the risk of subacromial impingement and altered rotator cuff biomechanics. Multiple surgical techniques have been described and include both open and arthroscopic approaches. Strategies for repair include the use of transosseous sutures, suture anchors, tension bands, screws, and plates. Good-to-excellent radiographic and clinical outcomes can be achieved with appropriate treatment.

Conclusions

GT fracture dislocations of the proximal humerus represent a separate entity from their isolated fracture counterparts in their evaluation and treatment. The decision to employ a certain strategy should depend on fracture morphology and comminution, bone quality, and displacement.

Biceps tenodesis is an accepted treatment option for various pathologies of the long head of the biceps tendon and labrum. Many techniques have been published, both arthroscopic and open, that utilize various fixation techniques and locations of the tenodesis, yet none has been proven to be superior. We introduce a novel method, the SALSA (subacromial locking stitch anchor), an all-arthroscopic suprapectoral biceps tenodesis utilizing a running locking stitch from a double-loaded biocomposite anchor. This technique provides a reliable method of multipoint fixation including the transverse humeral ligament that avoids many of the potential complications encountered with other techniques.

Fractures of the proximal humerus account for 4%-8% of injuries to the appendicular skeleton. Most are stable, minimally displaced osteoporotic fractures in the elderly, and are the result of low-energy falls. A large majority of these patients regain adequate shoulder function without operative intervention. Surgery is considered in approximately 20% of patients because they require improved shoulder function for their activities of daily living or because of the significant deformity of their fracture and the need to restore functional alignment, length, and rotation in active, higher demand individuals. However, fixation of these fractures can pose a challenge due to poor bone quality and displacing forces of the rotator cuff. This is especially true in 3-part and 4-part fractures. These factors lead to the high failure rates seen with early attempts at osteosynthesis. In the last 2 decades, locking plate technology has been an innovation in treating these complex fractures. Despite the improvements in torsional strength and rigidity, outcome studies on locking plate technology demonstrate equivocal results with complication rates as high as 20%-30% and a revision rate of 10%. Specifically, these complications include avascular necrosis, varus collapse, intra-articular screw penetration, and postoperative stiffness. Varus collapse occurs when the weak osteoporotic bone fails around the implant. In turn, fibular strut endosteal augmentation was introduced to provide additional support and decrease implant failure rates in displaced fractures with varus coronal malalignment and significant metaphyseal bone loss. Although clinically successful and biomechanically superior to plate-only constructs, a few concerns remain. In turn, we introduce a novel technique of creating individual cancellous femoral head allograft struts or “French fries” that provides structural support for the humeral head but does not have the potential problems of a cortical fibular strut.

Background

Determine the effect of a novel acellular cannulated dermal allograft on tendon-to-bone healing, retear rates, and clinical outcomes over a 12-month period.

Methods

This was a single surgeon prospective nonrandomized case series. Patients with medium sized full-thickness superior and posterosuperior rotator cuff tears, as confirmed by magnetic resonance imaging, were consented. Patients were excluded if they had fatty atrophy indicative of Goutallier grade III or IV. The allograft is a cannulated rectangular prism that has a 5-year shelf life, does not require prehydration, and does not need to be trimmed to size. Outcome metrics included ultrasound assessment at 1-year as well as 6-month patient-reported outcomes (PROs) scores.

Results

31 patients consented and enrolled in this consecutive cohort series. 9 patients were excluded, and statistical analysis was performed on the remaining 22 patients. There were 9 females and 13 males. The average age was 59.27 ± 7.48 year old. The average supraspinatus short axis measurement in males was 0.56 ± 0.12 cm and 0.52 ± 0.09 cm in females (P = .44). The average supraspinatus long axis measurement in males was 0.61 ± 0.18 cm and 0.55 ± 0.14 cm in females (P = .46). The average infraspinatus short axis measurement in males was 0.48 ± 0.10 cm and 0.50 ± 0.13 in females (P = .74). The average infraspinatus long axis measurement in males was 0.44 ± 0.12 cm and 0.43 ± 0.08 cm in females (P = .84). Of the 19 patients who completed baseline and 6-month PRO’s, 17 achieved the minimal clinical important difference for American Shoulder and Elbow Surgeons and Patient-Reported Outcomes Measurement Information SystemUE 7a. Retear occurred in 2 cases. The remaining 20 cases have all demonstrated healing or fully healed repairs at their most recent clinical visits with no additional cases of retears.

Conclusion

This study is the first to report the results of a novel acellular dermal allograft for rotator cuff repair augmentation. Satisfactory PRO measures and robust tendon healing at 1 year, as measured by ultrasound, demonstrate the utility of a cannulated human acellular dermal allograft as a viable biologic augmentation device for rotator cuff repair.