Darren S. Drosdowech

Proximal humeral fractures: A systematic review of treatment modalities

A systematic review was conducted of primary intervention of proximal humeral fracture, which is a common injury with significant morbidity. Keywords of proximal humeral fracture were entered into PubMed and Embase databases. Two evaluators reviewed abstracts from 1985 to 2004 for inclusion and exclusion criteria yielding 66 articles. These articles were evaluated independently for outcomes and quality of evidence using the Structured Effectiveness Quality Evaluation Scale and Sacketts Levels of Evidence. Patient characteristics and outcomes were recorded. The 66 studies included 2155 patients grouped by fracture types according to the Neer classification system. Studies differed by intervention, methods, outcome measures and results. Quality scores averaged 15/48; only 2 articles included randomized groups. Current studies typically lack randomization, comparators, and independent evaluation, with a resultant inability to produce clinical conclusions. Further research comparing primary treatment methods in a properly designed and controlled fashion is required, ideally using randomized controlled trials.

Comminuted radial head fractures treated with a modular metallic radial head arthroplasty : Study of outcomes

BACKGROUND Comminuted fractures of the radial head are challenging to treat with open reduction and internal fixation. Radial head arthroplasty is an alternative treatment with results that compare favorably with those reported after open reduction and internal fixation of similar fractures. The purpose of this study was to evaluate the two-year outcomes and the rate of recovery of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with a modular metallic prosthesis. METHODS Twenty-six patients (seventeen female and nine male; mean age, fifty-four years) with an unreconstructible comminuted radial head fracture and associated elbow injuries were treated with a modular metallic radial head arthroplasty. Patients who had presented more than four weeks following the injury or had had the radial head arthroplasty as a second-stage or salvage procedure were excluded. Of the twenty-six patients, twenty-two had an associated elbow dislocation, and thirteen of them also had an associated fracture of the coronoid process. Patients were prospectively followed at three, six, twelve, and twenty-four months. Self-reported limb function, general health, range of motion, and isometric strength were assessed by an independent observer. RESULTS Following treatment of the injury, significant decreases in self-reported and measured impairments were noted over time, with the majority of the recovery occurring by six months and little further recovery noted between six and twenty-four months. There were slight-to-moderate deficits in the range of motion and strength compared with the values on the contralateral, unaffected side. Patient satisfaction was high at three months and remained high at two years. All elbow joints remained stable, no implant required revision, and there was no evidence of overstuffing of the joint. Mild osteoarthritis was seen in five (19%) of the twenty-six patients. CONCLUSIONS An arthroplasty with a modular metallic radial head is a safe and effective option for the treatment of unreconstructible radial head fractures associated with other elbow injuries. Recovery primarily occurs by six months, with minimal additional improvements over the next eighteen months.

Improved accuracy of computer assisted glenoid implantation in total shoulder arthroplasty: an in-vitro randomized controlled trial.

BACKGROUND Glenoid replacement is challenging due to the difficult joint exposure and visualization of anatomical reference landmarks. Improper positioning of the glenoid component or inadequate correction of the retroversion using currently available instrumentation may lead to early failure. The objective of this study was to evaluate a computer-assisted technique to achieve a more accurate placement of the glenoid component compared to traditional techniques. METHODS Sixteen paired cadaveric shoulders were randomized to either traditional or computer-assisted glenoid implantation. Preoperative planning consisting of CT scanning with 3-dimensional image modeling of the shoulder specimens and intraoperative tracking with real-time feedback provided to the surgeon was employed in the computer-assisted group. A validated, previously published, standardized protocol for tracking the orientation of the glenoid in space using 3 glenoid surface landmarks was employed. All phases of glenoid implantation (initial guide pin insertion, reaming, drilling of the peg holes, and final component implantation) were tracked and recorded by the computer. A post-implantation CT scan was performed in both groups to compare how accurately the implants were placed. RESULTS The computer-assisted technique was more accurate in achieving the correct version during all phases of glenoid implantation and as measured on the post-implantation CT scan (P < .05). The largest errors with traditional glenoid implantation were observed during drilling and, more so, during reaming. The trend was to overly retrovert the glenoid. CONCLUSIONS Computer assisted navigation results in a more accurate glenoid component placement relative to traditional techniques. LEVEL OF EVIDENCE Basic Science Study.

Humeral Head Bone Defects: Remplissage, Allograft, and Arthroplasty

The Hill-Sachs lesion is a well-known entity that threatens recurrent instability, but the treatment options are multiple and the surgical indications remain undefined. The evidence for each operative technique is limited to retrospective reviews and small case series without controls. The decision of which technique to use resides with the surgeon. Older, osteopenic patients, especially those with underlying arthritis and large defects, should be managed with complete humeral resurfacing. Humeralplasty is best used in younger patients with good quality bone in an acute setting with small- to moderate-sized bone defects. Partial resurfacing and remplissage are best used with small to moderate lesions, and both require further study. Allograft humeral reconstruction is an established technique for patients with moderate to large defects, and is best applied to nonosteopenic bone. Surgeons must be able to recognize the presence of humeral bone loss via specialized radiographs or cross-sectional imaging and understand its implications. The techniques to manage humeral bone loss are evolving and further biomechanical and clinical studies are required to define the indications and treatment algorithms.

The Simple Shoulder Test Is Responsive in Assessing Change Following Shoulder Arthroplasty

STUDY DESIGN Prospective cohort study with repeated measures. OBJECTIVE To establish the responsiveness of the Simple Shoulder Test (SST) in comparison to other commonly used clinical outcomes in patients undergoing shoulder arthroplasty. BACKGROUND Responsiveness statistics are a useful means to compare different outcomes in terms of their ability to detect clinical change. While the responsiveness of the SST has been established for rotator cuff repair, it has not been determined for patients undergoing arthroplasty. METHODS Patients undergoing shoulder arthroplasty (n=120) were evaluated prior to surgery and 6 months after. The evaluation included the SST, Disabilities of the Arm, Shoulder and Hand questionnaire, range of motion, and isometric strength. Responsiveness to change was assessed using standardized response mean (SRM), while longitudinal construct validity was evaluated using Pearson correlation. Receiver operating characteristics curves were plotted to determine clinically important difference of SST. RESULTS The SST and Disabilities of the Arm, Shoulder and Hand questionnaire were highly responsive (SRM, >1.70) for this population. For the assessment of impairment, range of motion (SRM, 0.64-1.03) was moderately to highly responsive, while isometric strength was minimally to moderately responsive (SRM, 0.32-0.69). The clinically important difference of the SST was established at 3.0 SST points. Pearson correlations indicated moderate associations between the change scores of the SST and the Disabilities of the Arm, Shoulder and Hand questionnaire (r=0.49). CONCLUSIONS The SST has been previously shown to be valid and highly reliable. The present results show that the SST is also responsive following shoulder arthroplasty and that it has a clinically important difference of 3.0 SST points. This should provide confidence to clinicians who wish to use a brief shoulder-specific measure in their practice.

The concurrent validity of a hand-held versus a stationary dynamometer in testing isometric shoulder strength.

STUDY DESIGN Clinical Measurement-Validity. INTRODUCTION Validity of the JTech PowerTrack II hand-held dynamometer (JTech; JTech Medical, Salt Lake City, UT) for measuring shoulder strength has yet to be established. PURPOSE OF THE STUDY To examine the concurrent validity of isometric strength scores obtained with the JTech PowerTrack II, and on a stationary dynamometer, the LIDO WorkSET (LIDO; LoredanBiomedical, West Sacramento, CA). METHODS Thirty-eight subjects performed three maximal efforts of shoulder flexion, abduction, and external rotation on a single occasion on the two dynamometers. Two testers were randomly assigned to administer the tests. RESULTS Pearson correlations between the scores on the two dynamometers (r.0.81) indicated a good concurrent validity. Correlations were similar when the results were subdivided by tester or gender. CONCLUSIONS This study suggests that either the JTech PowerTrack II or LIDOWorkSET provide comparable scores for shoulder strength. Although not interchangeable because of the differences in units of measurement, the relative conclusions about strength should be similar, regardless of which instrument is used. LEVEL OF EVIDENCE Not applicable.

Biomechanical analysis of fixation of middle third fractures of the clavicle.

Objective: This biomechanical study compares four different techniques of fixation of middle third clavicular fractures. Methods: Twenty fresh-frozen clavicles were randomized into four groups. Each group used a different fixation device (3.5 Synthes reconstruction plate, 3.5 Synthes limited contact dynamic compression plate, 3.5 Synthes locking compression plate, and 4.5 DePuy Rockwood clavicular pin). All constructs were mechanically tested in bending and torque modes both with and without a simulated inferior cortical defect. Bending load to failure was also conducted. The four groups were compared using an analysis of variance test. Results: The plate constructs were stiffer than the pin during both pure bending and torque loads with or without an inferior cortical defect. Bending load to failure with an inferior cortical defect revealed that the reconstruction plate was weaker compared with the other three groups. The limited contact and locking plates were stiffer than the reconstruction plate but demonstrated statistical significance only with the cortical defect. Conclusions: As hypothesized, the 3.5 limited contact dynamic compression plate and 3.5 locking compression plate demonstrated the greatest resistance to bending and torque loads, especially in the presence of simulated comminution of a middle third clavicular fracture. The reconstruction plate demonstrated lower stiffness and strength values compared with the other plates, especially with a cortical defect, whereas the pin showed poor resistance to bending and torque loads in all modes of testing. This information may help surgeons to choose the most appropriate method of fixation when treating fractures of the middle third of the clavicle.

Rotational strength, range of motion, and function in people with unaffected shoulders from various stages of life

BackgroundDifferent measurements are used to assess shoulder function, including range of motion, strength, functional performance and self-report function. To understand disablement, it is necessary to understand the relationship between impairments and function in persons without shoulder problems. This study was conducted to enhance existing comparative data in subjects without upper extremity pathology, and to assess the relationships between impairments (range of motion, strength) and self-reported or measured function/disability. The impact of age, gender and dominance was determined.MethodsTwo-hundred ninety-four subjects with unaffected shoulders were recruited. The subjects (mean age: 37 years old) were divided into three subgroups, 18–39, 40–59, and over 60 years of age. During a single session, at least two of the following variables were measured: self-reported function (shoulder disability scales), range of motion, isometric rotational strength, or upper limb functional performance (FIT-HaNSA). Two-way analysis of variance was used to determine, for each variable, the effects of age and gender. The relationship between the outcomes was established using Pearson product correlations.ResultsMen were significantly stronger than women for all age categories. There was an age-related decline in strength in men in the over-60 age category. Significant negative correlations between strength and range of motion were demonstrated (-0.22 <r < -0.32). Women had a significantly higher range of motion than men for external rotation in the 40–59 age category. Furthermore, the subjects in the over-60 age category experienced a decrease of range of motion. There was minimal disability reported in all age groups on self-report scales. Only the Simple Shoulder Test demonstrated significant decreases in the over-60 age category and correlated with age (r = -0.202).ConclusionSelf-reported disability was low in individuals without upper extremity problems, although recruitment of such individuals was difficult in the older age groups due to the high prevalence of shoulder pathology. A low correlation between self-report disability and strength/range of motion in these unaffected subjects reflects the lack of disability reported by all subjects without pathology despite normal variations in strength and motion.

Cemented versus uncemented fixation of humeral components in total shoulder arthroplasty for osteoarthritis of the shoulder: a prospective, randomized, double-blind clinical trial—A JOINTs Canada Project

BACKGROUND Although cemented humeral fixation is recognized as the standard of care in total shoulder arthroplasty (TSA), uncemented fixation has the potential to provide stable fixation, decrease operative time, and simplify potential revision procedures. This prospective, randomized, double-blind clinical trial compared cemented and uncemented humeral fixation in TSA for primary shoulder osteoarthritis. METHODS Patients with primary shoulder osteoarthritis requiring replacement were screened for eligibility. After providing informed consent, subjects received baseline clinical and radiologic assessments, computed tomography scans, and standardized TSA. After glenoid component insertion, patients were randomized to either a cemented or uncemented humeral component. The primary outcome was the WOOS (Western Ontario Arthritis of the Shoulder Index) score at 2 years. Other outcomes included the Short Form 12 score, American Shoulder and Elbow Surgeons score, McMaster-Toronto Arthritis Patient Preference Disability Questionnaire, operative time, complications, and revisions. Patients were assessed by a blinded evaluator at 2 and 6 weeks and 3, 6, 12, 18, and 24 months postoperatively. RESULTS In total, 161 patients consented to be included and were randomized: 80 in the cemented group and 81 in the uncemented group. There were no significant differences in demographics or baseline evaluations between groups, except for gender. The 12-, 18-, and 24-month WOOS scores showed a significant difference in favor of the cemented group. The cemented group also had better strength and forward flexion. As expected, the operative time was significantly less for the uncemented group. CONCLUSIONS These findings provide level I evidence that cemented fixation of the humeral component provides better quality of life, strength, and range of motion than uncemented fixation.

Radial Head Fractures Treated with Modular Metallic Radial Head Replacement: Outcomes at a Mean Follow-up of Eight Years.

BACKGROUND Radial head arthroplasty is commonly used to treat acute unreconstructible radial head fractures. The purpose of this study was to report on the clinical and radiographic outcomes at a minimum follow-up of five years after radial head arthroplasty with a modular metallic implant for the treatment of acute radial head fractures. METHODS The cases of fifty-five patients with unreconstructible radial head fractures treated acutely with a smooth-stemmed modular metallic radial head implant were retrospectively reviewed. A wide variety of injuries, which ranged from isolated radial head fractures to so-called terrible triad injuries, were included. All patients returned for an interview, physical examination, and radiographic evaluation at a mean of eight years (range, five to fourteen years) postoperatively. Elbow and forearm motion, elbow strength, and grip strength were measured. Radiographs were evaluated, and validated patient-rated outcome questionnaires were completed. A longitudinal subgroup analysis was performed for thirty-three patients who were previously evaluated at two years postoperatively. RESULTS At a mean of 8.2 ± 2.9 years, the mean arc of flexion (and standard deviation) of the affected elbow was 11° ± 14° to 137° ± 15°. Elbow strength and motion were significantly diminished compared with the unaffected elbow (p < 0.05). The mean Mayo Elbow Performance Index (MEPI) was 91 ± 13 points. Twenty-five patients (45%) had stem lucencies; twenty-one (38%), ulnohumeral arthritis; and twenty (36%), heterotopic ossification, including one with radioulnar synostosis. Two patients underwent secondary elbow surgery, but no patient required implant removal or revision. In the subgroup evaluated longitudinally, there was a significant improvement in MEPI scores from the two-year to the eight-year follow-up (p = 0.012), with no loss of motion or strength (p > 0.05). CONCLUSIONS The mid-term outcomes of radial head arthroplasty with a smooth-stemmed modular metallic prosthesis are comparable with previously reported short-term outcomes, with no evidence of functional deterioration. Radial head arthroplasty with a smooth-stemmed metallic modular implant is a good treatment option for patients with acute unreconstructible radial head fractures, and sustained clinical outcomes may be expected beyond five years of follow-up. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.