Ali Narvani

Surface replacement arthroplasty for glenohumeral arthropathy in patients aged younger than fifty years: results after a minimum ten-year follow-up

BACKGROUND The role of cementless surface replacement arthroplasty (CSRA) in young individuals is currently unclear. The aim of this study was to evaluate CSRA long-term results for glenohumeral arthritis in young patients. METHODS Between 1990 and 2003, 54 CSRAs were performed on 49 patients (25 men, 24 women) aged younger than 50 years. Mean age was 38.9 years (range, 22-50 years). Three patients (4 shoulders) died over time and 8 were lost to follow-up, leaving 38 patients (42 shoulders) with a mean follow-up of 14.5 years (range, 10-25 years). There were 17 total shoulder replacements with metal back glenoid, and 37 underwent humeral head resurfacing with microfracture of the glenoid. RESULTS The indications were avascular necrosis, 16; rheumatoid arthritis, 20; instability arthropathy, 7; primary osteoarthritis, 5; fracture sequelae, 3; postinfection arthritis, 2; and psoriatic arthritis, 1. The mean relative Constant score increased from 11.5% to 71.8% (P < .0001), and the mean patient satisfaction at final follow-up was 8.7 of 10. The mean relative Constant score for the humeral head resurfacing with microfracture of the glenoid improved to 77.7% compared with 58.1% for total resurfacing arthroplasty. Two required early arthrodesis due to instability and deep infection. Seven were revised to stemmed prosthesis: 1 for traumatic fracture and 1 for glenoid erosion 16 years after the index procedure. Five shoulders in 4 patients (4 rheumatoid arthritis, 1 avascular necrosis) were revised at 8 to 14 years after surgery for cuff failure and loosening. Three were revised to stemless reverse total shoulder arthroplasty due to rotator cuff failure at 23, 16, and 13 years after surgery. CONCLUSIONS CSRA provides good long-term symptomatic and functional results in the treatment of glenohumeral arthropathy in patients aged younger than 50 years in 81.6% of the patients. This improvement is maintained over more than 10 years after surgery, with high patient satisfaction (8.7 of 10). However, 10 shoulders (of 54) (18.5%) underwent revision arthroplasty. Resurfacing offers a valuable tool in treating young patients with glenohumeral arthritis, providing reasonably good long-term results in 81.6% of the patients, while allowing preservation of bone stock if the need for revision arises. All the revision arthroplasty options are preserved, including less invasive procedures.

Arthroscopically assisted internal fixation of the symptomatic unstable os acromiale with absorbable screws.

BACKGROUND Symptomatic meso- type os acromiale is a common pathology with inconsistent outcomes of treatment with various surgical techniques. We report the outcome of a new technique for arthroscopic fusion of symptomatic os acromiale with absorbable screws. MATERIALS AND METHODS The study included 8 shoulders in 8 patients with symptomatic meso- type os acromiale who were treated with the use of a new technique for arthroscopic fusion with absorbable screws. The mean age was 54 years (range, 38-67 years), and the mean time from onset of symptoms to surgery was 18 months (range, 9-25 months). No patients reported a specific traumatic event before the onset of symptoms, and all noted the insidious onset of pain with no precipitating event. RESULTS The average length of follow-up was 22 months (range, 12-36 month). The average Constant score improved from 49 points (range, 35-57 points) to 81 points (range, 75-86 points). The average satisfaction score improved from 4.5 of 10 (range, 2-6) to 8.5 of 10 (range 7-9). All patients made a good clinical recovery at 3 to 6 months after surgery. At the last follow-up, full radiographic union was observed in 6 patients, partial union in 1 patient, and persistent radiologic nonunion in 1 patient. Anterior bulging of the absorbable screws was noted in 2 patients, and the screws were trimmed 6 months after the first procedure. CONCLUSIONS We have found that this new arthroscopic technique of fixation of os acromiale with absorbable screws provides promising clinical, cosmetic, and radiologic results with high patient satisfaction.

Management of first-time dislocations of the shoulder in patients older than 40 years: the prevalence of iatrogenic fracture.

Objective: To evaluate the prevalence of iatrogenic humeral neck fracture after attempted closed reduction in patients older than 40 years who present with a first-time anterior dislocation. Design: Retrospective cohort study, evidence-based medicine level IV. Patients: Ninety-two patients older than 40 years (mean 66.6 years of age) with a first-time anterior dislocation of the shoulder. Intervention: Closed reductions by the emergency medicine physicians under conscious sedation, in the emergency department. Main Outcome Measurements: Prevalence of iatrogenic fracture on postreduction radiographs. Results: Nineteen (20.7%) patients were diagnosed with a concomitant greater tuberosity fracture on initial radiograph. In the postreduction radiographs, 5 patients (5.4%) were identified with a postreduction humeral neck fracture, and all of them had a greater tuberosity fracture on initial radiographs. A highly significant association (P < 0.0001) was observed between the finding of a greater tuberosity fracture on the initial radiographs and the occurrence of iatrogenic humeral neck fracture after close reduction. Discussion: Previous case reports have described an iatrogenic humeral neck fracture with reduction attempt of shoulder dislocation. In our retrospective study, 21% of the cohort of patients older than 40 years had a concomitant greater tuberosity fracture; 26% of them had an iatrogenic humeral neck fracture after reduction attempt under sedation in the emergency room. These patients ended up with poor outcome. Conclusions: Patients older than 40 years, presenting with a first-time anterior shoulder dislocation with an associated fracture of the greater tuberosity have a significant rate of iatrogenic humeral neck fracture during closed reduction under sedation. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medium to long-term outcome of thoracoscapular arthrodesis with screw fixation for facioscapulohumeral muscular dystrophy

BACKGROUND Shoulder girdle muscle weakness is the most constant feature of facioscapulohumeral muscular dystrophy and leads to scapular winging. Mechanical fixation of the scapula to the thoracic wall provides a stable fulcrum on which the deltoid muscle can exert its action on the humerus. The aim of this study was to evaluate the medium to long-term outcome of thoracoscapular arthrodesis with screw fixation (the modified Howard-Copeland technique). METHODS All patients with facioscapulohumeral dystrophy who underwent thoracoscapular arthrodesis with screw fixation and bone-grafting from July 1997 to July 2010 were retrospectively reviewed. Preoperative and postoperative clinical assessment included active shoulder elevation, the Constant score, a patient satisfaction score, and cosmetic satisfaction. Union was determined both clinically and radiographically. RESULTS Thoracoscapular arthrodesis was performed in thirty-five shoulders in twenty-four patients; eleven patients underwent bilateral procedures. The principal study group consisted of thirty-two shoulders in twenty-one patients with a minimum follow-up of twenty-four months (mean, eighty-eight months; range, twenty-four to 174 months). The mean Constant score increased from 30 (range, 17 to 41) preoperatively to 61 (range, 30 to 90) postoperatively. The mean satisfaction score increased from 1 (range, 0 to 4) to 8.4 (range, 4 to 10). Early complications consisted of one pneumothorax, one superficial wound infection, and four early failures, two of which were associated with noncompliance with the postoperative regimen. Late complications consisted of one posttraumatic fracture resulting in loosening and one painful nonunion; both were treated successfully with revision. CONCLUSIONS Thoracoscapular arthrodesis with screw fixation prevented scapular winging and improved short-term and long-term shoulder function in patients with facioscapulohumeral dystrophy. LEVEL OF EVIDENCE Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

Pattern and time phase of shoulder function and power recovery after arthroscopic rotator cuff repair

BACKGROUND It has been our observation that early during rehabilitation after rotator cuff repair, patients may take a step back before improving. The purpose of this study is to investigate the pattern and time phase of changes in Constant score and strength recovery after arthroscopic rotator cuff repair. MATERIALS AND METHODS Forty-five patients undergoing arthroscopic rotator cuff repair were prospectively enrolled in this study. Patients underwent scoring preoperatively with the Constant score. All were followed up at 3 months and 6 months after surgery. The Constant score and strength at 3 months were compared with those at the 6-month mark. RESULTS The mean Constant score improved from 46.4 points (SD, 17.3) preoperatively to 51.8 points (SD, 13.5) 3 months postoperatively (P = .0777). At 6 months postoperatively, the mean Constant score was 69.0 points (SD, 11.1), a significant increase from both the preoperative (P < .0001) and 3-month (P < .0001) results. The mean preoperative strength result of 4.5 kg (SD, 3.2) decreased significantly to 3.3 kg (SD, 1.8) at 3 months postoperatively (P = .0154) before improving to 5.8 kg (SD, 2.6) at 6 months postoperatively. The improvement in strength at 6 months was significant compared with both the preoperative (P = .0070) and 3-month (P < .0001) results. CONCLUSIONS Although there is highly significant improvement in overall function (Constant score) and strength 6 months postoperatively, patients appear to take a step back before improving, in fact with a drop in strength at 3 months. This may cause concern in patients and may require assurance that time and effort with physiotherapy will improve function and symptoms.

Fixation of fractures of the proximal humerus

Proximal humerus fractures are common injuries in the elderly.1 While most of these injuries are treated non-operatively with satisfactory results, surgical intervention is used for the more unstable fractures. Open reduction and internal fixation (ORIF) with plates is one available surgical option. Traditional plate osteosynthesis faced the problems of screw pull out from osteopenic metaphyseal bone. Various alternative techniques such as tension band wiring, suture fixation, intramedullary nailing and hemi-arthroplasty were designed to overcome problems of plate osteosynthesis with varying success. Fixed angled locking plates (FALPs) introduced in the late 1990s combine the advantages of locking plates with those of older, fixed-angle devices. These plates have reduced risks of screw pull they are ideal for osteopenic fractures.2 These plates are anatomically contoured to provide a template against which fractures can be reduced. They are expected to meet the challenges posed by the fracture pattern, the weak osteopenic bone, and the deforming forces around the shoulder. They also have eyelet holes to allow suture fixation of any displaced tuberosities.

Locked bucket-handle tear of the anterior labrum causing persistent subluxation of a dislocated shoulder

Department of Radiology, Royal Berkshire Hospital, Reading, UKPersistent subluxation of a dislocated shoulder afterreduction is uncommon. We present a case-report ofpersistent subluxation caused by a locked bucket-handletear of the anterior labrum extending superiorly. This wastreated arthroscopically with resection of the lockedbucket-handle tear and biceps tenotomy, with immediatereduction of the shoulder.

Acromioclavicular joint acceleration-deceleration injury as a cause of persistent shoulder pain: Outcome after arthroscopic resection.

Background: Shoulder pain in general and acromioclavicular joint (ACJ) pain specifically is common after acceleration-deceleration injury following road traffic accident (RTA). The outcome of surgical treatment in this condition is not described in the literature. The aim of the present study was to report the outcome of arthroscopic resection of the ACJ in these cases Materials and Methods: Nine patients with localized ACJ pain, resistant to nonoperative treatment were referred on an average 18 months after the injury. There were 3 male and 6 females. The right shoulder was involved in seven patients and the left in two. The average age was 38.9 years (range 29-46 years). All presented with normal X-rays but with torn acromioclavicular joint disc and effusion on magnetic resonance imaging (MRI). Arthroscopic ACJ excision arthroplasty was performed in all patients. Results: At a mean followup of 18 month, all patients had marked improvement. The Constant score improved from 36 to 81, the pain score from 3/15 to 10/15 and the patient satisfaction improved from 3.5/10 to 9.3/10. Conclusion: Arthroscopic ACJ excision arthroplasty, gives good outcomes in patients not responding to conservative management in ACJ acceleration-deceleration injury.