Fernando Santana

Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively.

Objectives: Functional and quality-of-life outcomes of conservatively treated proximal humeral fractures. Design: Prospective study. Setting: University orthopedic department at a hospital. Patients/Participants: Seventy consecutive patients between the ages of 60 and 85 years. Intervention: Conservative treatment. Main Outcome Measurements: Functional outcome measured according to the Constant score, quality of life assessed using EuroQol-5D, and fracture pattern analyzed with x-ray and computed tomography scan. Results: All fractures consolidated uneventfully with no loss of reduction in either group. Four-part fractures obtained the worst functional results (33.66) followed by three-part fractures (54.64) and finally two-part fractures (65.88 and 71). Mild pain was expected in three- and four-part fractures, whereas two-part fractures achieved near complete pain relief. Nondisplaced fractures obtained a final Constant score of 73.58 and displaced fractures a score of 59.41 with significant differences in all Constant score items with the exception of external rotation. Although patients older than 75 years scored lower (54.63) than those younger than 75 years (70.83), there was no difference in the quality-of-life perception. Conclusion: Conservative treatment of proximal humeral fractures in those patients older than age 75 years provides good pain relief with limited functional outcome. Despite limited functional outcome, this appears to have no effect on the quality-of-life perception in the population studied. Four-part fractures present the worst results and treatment options may need to be discussed with the patient to adjust treatment to patient expectations.

The minimal clinically important difference for function and strength in patients undergoing reverse shoulder arthroplasty

HYPOTHESIS Despite a statistically significant improvement in functional scores after receiving a reverse shoulder arthroplasty (RSA) in a cuff-deficient shoulder, not all patients perceive a minimal clinically important difference (MCID) in every functional domain of the score. METHODS This was a prospective longitudinal study including 60 consecutive patients with a cuff-deficient shoulder treated with a RSA. The Constant score was recorded before surgery and at a 1-year follow-up assessment. At the 1-year follow-up, all patients also filled out a 15-item anchor questionnaire to assess their perception of change in their overall function, forward elevation, lateral rotation, internal rotation, and strength to determine the MCID. RESULTS The mean Constant score was 30.1 (standard deviation, 10.7) before surgery and was 58.4 (standard deviation, 16.2) at the 1-year follow-up, with statistically significant improvement (P < .001). A statistically significant improvement was found in the domains of forward elevation (P < .001), lateral rotation (P < .001), and strength (P < .001) except for internal rotation (P = .15). The MCID for overall function, forward elevation, lateral rotation, internal rotation, and strength in the Constant score increased by 8, 6, 2, 2, and 11.5 points, respectively; only 46.7%, 20%, 50%, 45.8%, and 33.3% of the patients, respectively, exceeded the MCID on each domain after surgery. CONCLUSIONS A statistically significant improvement in the Constant score is expected after receiving an RSA in a cuff-deficient shoulder, but a considerable number of patients do not reach the MCID in the function and strength domains. A small improvement in rotation is perceived to be beneficial by patients, whereas large improvements in forward elevation are required for the improvement to be perceived to be beneficial.

Decreased axial coracoid inclination angle is associated with rotator cuff tears

Purpose: Coracoid morphology has been related to coracoid impingement mainly resulting in anterior shoulder pain aggravated by forward flexion and internal rotation. However, the coracoid process morphology can also affect the inclination of the coracoacromial ligament and subsequently the subacromial space in the same way that acromial slope does. The purpose of this study was to evaluate the influence of the coracoid body–glenoid surface, coracoid tip–glenoid surface, and coracoid body–coracoid tip angles (coracoid inclination angles) on rotator cuff tears (RCTs). Methods: Fifty patients with documented RCT and 50 patients with normal rotator cuff (control) were included. The coracoid inclination angles were determined in both groups by measuring on computed tomography scans the angle created by the coracoid body and the glenoid surface (A1), the angle created by the coracoid tip and the glenoid surface (A2), and the angle created by the coracoid body and the coracoid tip (A3). Results: All angles were significantly lower in the RCT group compared to the control group: mean A1 angle of 49.7° and 54.61°, respectively (p = 0.011); mean A2 angle of 76.45° and 93.6°, respectively (p < 0.001); and mean A3 angle of 132.33° and 144.34°, respectively (p < 0.001). Conclusions: Decreased coracoid body–glenoid surface, coracoid tip–glenoid surface, and coracoid body–coracoid tip angles are associated with RCT. Decreased angles may reduce subacromial space by projecting the coracoacromial ligament more vertically.

Influence of glenosphere size on the development of scapular notching: a prospective randomized study

HYPOTHESIS The objective of the study was to evaluate the development of scapular notching in reverse shoulder arthroplasty by comparing larger glenospheres (42 mm) with smaller glenospheres (38 mm). METHODS This was a prospective randomized study of 81 patients who had undergone reverse shoulder arthroplasty with a 2-year follow-up. Patients were randomized to receive either a 42-mm glenosphere (38 patients) or a 38-mm glenosphere (43 patients). Scapular notching development was assessed with an anteroposterior radiograph at the end of the follow-up. Functional outcome was assessed with the Constant score before surgery and at the end of follow-up. An independent blinded observer carried out radiologic and clinical assessments. RESULTS Scapular notching was present in 48.8% of the patients receiving a 38-mm glenosphere and in 12.1% of the patients receiving one of 42 mm, with significant differences between both (P < .001). No significant differences were noted between the 2 glenosphere size groups in terms of the total Constant score. Patients with a 42-mm glenosphere had a mean glenoid-glenosphere overhang of 6.1 mm, whereas patients with a 38-mm glenosphere had one of 4.2 mm, with significant differences between them (P < .001). No significant differences in the total Constant score were found between the patients whether they had scapular notching or not. CONCLUSION Bigger glenospheres (42 mm) significantly reduce development of scapular notching compared with smaller glenospheres (38 mm). Glenosphere size has no significant influence on functional outcomes measured with the Constant score.

Morbimortalidad en fracturas de húmero proximal tratadas quirúrgicamente

BACKGROUND The aim of the present study is to analyse the factors associated with mortality and the capacity to perform daily life activities (DLA) in patients with surgically treated proximal humeral fractures. METHODS A retrospective study was conducted on 94 patients with a surgically treated proximal humeral fracture, with a mean follow-up of 8 years (2 - 12 years). A correlation analysis was performed to determine the relationship between the type of fracture, surgical technique, comorbidities and mortality and DLA. The Student t test was used for statistical analysis. RESULTS A total of 72 patients were identified, 18.6% of them died during follow-up, all diagnosed with some comorbidity. There was no correlation between mortality, type of fracture or the technique used. Most of the patients (85.4%) had comorbidities, and 79.5% were completely independent for DLA. Although there was no relationship with the type of fracture, there was a significant reduction in the performing of DLA in patients treated with hemiarthroplasty, and in patients with neurological disorders. CONCLUSIONS There was a mortality of 18.6% among patients with surgically treated proximal humerus fractures. The majority of surgically treated patients were fully independent for DLA at long-term follow-up.

Distal Clavicle Osteolysis after Modified Weaver-Dunn’s Procedure for Chronic Acromioclavicular Dislocation: A Case Report and Review of Complications

Distal clavicle osteolysis after acromioclavicular joint stabilization has only been described after the use of hardware for clavicle stabilization or synthetic graft causing a foreign body reaction. This paper reports a very rare case of distal clavicle osteolysis after modified Weaver-Dunn procedure for the treatment of chronic acromioclavicular joint dislocation. The paper also provides a comprehensive review of complications of this surgical technique and discusses a potential vascular etiology and preventive strategies aimed at avoiding clavicle osteolysis.

Retaining or excising the supraspinatus tendon in complex proximal humeral fractures treated with reverse prosthesis: a biomechanical analysis in two different designs

PurposeWe aimed to biomechanically evaluate the effect of the supraspinatus tendon on tuberosity stability using two different reverse shoulder arthroplasty (RSA) models for complex proximal humeral fractures (PHFs).MethodsFour-part proximal humeral fractures were simulated in 20 cadaveric shoulders. Two different RSA designs were implemented: a glenosphere-medialized model and a glenosphere-lateralized model. Tuberosities were reconstructed, and displacement of bony fragments was measured (mm) by placing three sensors: in the humeral diaphysis (D), in the greater tuberosity (GT), and in the lesser tuberosity (LT). Axial forces were induced and measured in Newton (N). The test was performed twice in each specimen, with and without the supraspinatus tendon. The regression line (RL) was measured in mm/N.ResultsIn the medialized model, the GT–D displacement was greater in the supraspinatus preserving model than that in the tendon excision model (p < 0.001), as well as for the LT–D displacement (p < 0.001). In the lateralized model, GT–D displacement and GT–LT distance were greater in the preserving model than that in the excision model (p < 0.001, p = 0.04).ConclusionThe supraspinatus tendon resection leads to a more biomechanically stable tuberosity construct when performing RSA for PHFs, while the rest of the rotator cuff tendons (infraspinatus and teres minor) are retained in the greater tuberosity.Level of evidenceBasic science study. Cadaveric study.

Does fracture of the dominant shoulder have any effect on functional and quality of life outcome compared with the nondominant shoulder

HYPOTHESIS Proximal humeral fractures involving the dominant arm are not predisposed to worsen the functional outcome and the quality of life compared with proximal humeral fractures of the nondominant arm. METHODS This was a retrospective study including 179 consecutive proximal humeral fractures divided into 2 groups: fractures involving the dominant arm (n = 97) and fractures involving the nondominant arm (n = 82). Both groups were prospectively assessed for 2 years, and at the end of the follow-up, all patients underwent functional assessment by Constant score and quality of life assessment through the 36-Item Short Form Health Survey (SF-36). RESULTS At the 2-year follow-up, the mean Constant score of the whole series was 65.5 (64.1 in the dominant group and 66.8 in the nondominant group). No significant differences were noted between groups in the total Constant score or among any of the items of the Constant score (total Constant score, P = .43; pain, P = .63; activities of daily living, P = .70; forward elevation, P = .57; abduction, P = .52; lateral rotation; P = .90; internal rotation, P = .32; and strength, P = .24). The mean physical component summary score of the SF-36 at the 2-year follow-up was 40.8 (39.7 in the dominant group and 41.9 in the nondominant group). The mean mental component summary score of the SF-36 at the 2-year follow-up was 43.5 (44.2 in the dominant group and 42.7 in the nondominant group). No significant differences were noted between groups in any item of the SF-36 (physical component summary score, P = .29; mental component summary score, P = .51). CONCLUSION No significant difference could be found relating to dominance in functional outcome and in the quality of life perception in proximal humeral fractures. Dominance of the affected shoulder has no influence and should not be used to make treatment decisions.

3D reconstruction does not improve agreement and results in an increase in surgical indications in proximal humeral fractures

The objective of this study is to analyze the effect of different imaging modalities in treatment decision making in proximal humeral fractures. After evaluation of 116 consecutive proximal humeral fractures, observers were asked to give treatment recommendation (conservative vs. surgery). If surgery was proposed, they were told to select surgery of choice. When 3D imaging was added, complexity of fractures significantly increased (p < 0.001), number of surgeries significantly increased (p < 0.000) and number of ORIF treatments significantly increased (p < 0.0004). Addition of 3D imaging of proximal humeral fractures significantly increases number of surgical decisions when compared to radiographs alone or together with CT.

Reverse shoulder arthroplasty for the treatment of acute complex proximal humeral fractures: Influence of greater tuberosity healing on the functional outcomes:

Purpose: To investigate the influence of greater tuberosity healing on the functional outcomes of reverse shoulder arthroplasty (RSA) for the treatment of acute complex proximal humeral fractures (PHFs), and to investigate the influence of patient- and surgery-related factors in the healing of the greater tuberosity. Methods: Retrospective study including 41 consecutive PHFs treated using RSA with minimum 2-year follow-up. In all the cases, tuberosities were reattached with a standardized technique. All the patients were assessed at the last follow-up with constant score. Body mass index, surgery delay, comorbidities, polyethylene size, glenosphere size, overhanging of glenosphere, and scapular notch were recorded, and their influence in final constant score and in greater tuberosity healing was analyzed. Results: Mean final constant score was of 60.7 points (standard deviation (SD) = 9.9). Greater tuberosity healed in proper position in 68% of the cases. There were no significant differences in constant score between patients with (mean = 61; SD = 9.5) and without (mean = 61; SD = 11.3) the healing of greater tuberosity. All patients scored above 90° in forward elevation. Scapular notch was reported in 14.6% of the cases. Age significantly affected the constant score (p = 0.008). Comorbidities significantly interfered with greater tuberosity healing (p = 0.03). There was one reoperation after dislocation. Conclusion: In spite of expecting good functional outcome with low complication rate after RSA for acute PHFs, the influence of greater tuberosity healing on shoulder function could not be demonstrated. The presence of comorbidities, but not age or gender, negatively influenced the healing of the greater tuberosity.