Giulia Bugelli

Total hip replacement in osteoarthritis: the role of bone metabolism and its complications.

Osteoarthritis is one of the most common joint disorder. For treatment of hip symptomatic osteoarthritis, when conservative medical therapy has failed, total hip arthroplasty (THA) is a successful orthopaedic procedures that reduces pain and improves function and quality of life. Incidence of osteoarthritis is constantly increasing with raising life expectancy. This aging process also has led to an increasing number of patients with osteoporosis who need hip replacement for osteoarthritis. Osteoporosis have 3 major potential complications in total hip arthroplasty: perioperative fracture, an increased risk of periprosthetic fracture, and late aseptic loosening. The purpose of the present study was to examine the effects of osteoporosis on total hip replacement procedure outcome and highlight the importance of adequate study of calcium-phosphorus metabolism in patient candidate for hip surgery, and the need to start a suitable therapy to recover the bone mass before surgery. Bone quality of the hip joint has become an important risk factor limiting the durability of THA.

Reverse Shoulder Arthroplasty with a New Convertible Short Stem: Preliminary 2- to 4-year Follow-up Results:

Background The Grammont-style reverse shoulder arthroplasty (RSA) has demonstrated complications intrinsic to its design such as tuberosity fracture and scapular notching. A new short-stem press-fit humeral component with an onlay tray has been devised to avert these issues. We hypothesize that the clinical outcomes and rates of humeral complications of this new stem will be comparable to those of the traditional Grammont design and the lateralization obtained from the stem’s lower neck-shaft angle will decrease the rate of notching without creating instability. Methods We retrospectively evaluated 100 patients who underwent RSA with an onlay short-stem humeral component with a minimum follow-up of 2 years. Clinical outcomes as well as standard radiological examinations were documented pre- and postoperatively. Several correlations were analyzed. Results At mean 32.6-month follow-up, the cohort demonstrated a significant improvement in several outcomes: Constant score increased from 25.5 to 69.7 points, mean anterior elevation increased from 82.1° to 141.9°, external rotation from 5.6° to 25.1°, and internal rotation from sacrum to the L3 vertebral level. There was a 30% rate of stem malalignment and 37% rate of scapular notching, not associated with any adverse clinical outcomes. The overall rate of complications was 15%, of which scapular fractures were most common (5%). Conclusion Our short-term results suggest that the clinical outcomes and rates of humeral complications are similar to those reported for the Grammont RSA, demonstrating less scapular notching, but increased scapular stress fractures and potential subsidence of the prosthesis due to the metaphyseal press-fit require further investigations.

Stemless humeral component in reverse shoulder prosthesis in patient with Parkinson's disease: a case report.

INTRODUCTION In patients with Parkinsons disease falling is very common and for this reason, the prosthetic surgical indication in shoulder is reserved for special cases. PD has been linked to several interrelated factors that may contribute to failure of shoulder arthroplasty. CASE PRESENTATION A 65-year-old woman with PD, severe pain, recurrent bursitis, swelling and functional limitation to all movements in left shoulder presented to our attention. Radiographic and CT exams show cuff-tear arthropathy. The patient was submitted to implantation of a Reverse Shoulder Comprehensive Nano cementless modular system (Biomet(®), Warsaw, IN, USA) with anterosuperior surgical approach. We chose this kind of solution of stemless humeral component after bone mineral consideration. DISCUSSION Reverse shoulder arthroplasty represents an option in the management of glenohumeral arthritis. Poor functional results of RTSA in patients with PD have been attributed to increased muscle tone, severity of tremor and an increased mortality rate. In general, post operative complications related to the humeral component are dominated by fractures (between 1 and 3%): in patients with PD this percentage is higher because of falls often occur. With a stemless implant revisions can be performed easily. Overall, the anterosuperior surgical exposure gives a low risk of postoperative instability. CONCLUSION In selected cases of patients with PD, after carefully analysis of bone quality, the use of a stemless component is of benefit in the possible revision cases for periprosthetic fractures and the use of an anterosuperior exposure reduces the percentage of instability. The results obtained about the pain relief are excellent in contrast with functional outcomes that remain poor.

Increased scapular spine fractures after reverse shoulder arthroplasty with a humeral onlay short stem: an analysis of 485 consecutive cases

BACKGROUND Scapular stress fractures after reverse shoulder arthroplasty (RSA) are a potentially serious complication with modern lateralized and onlay implants. The aim of this study was to report the scapular spine stress fracture rate after RSA with an onlay, 145° humeral stem, analyzing potential fracture risk factors and clinical outcomes in a large cohort of patients. METHODS A consecutive series of 485 RSAs were implanted with the Aequalis Ascend Flex stem. Data collection included preoperative and postoperative clinical and radiographic assessment findings (rotator cuff Goutallier grade; Hamada, Walch, and Favard classifications; range of motion; Constant score) and perioperative data. Patients with a scapular spine fracture following RSA were matched with nonfracture control patients, and preoperative variables were tested to determine whether they were predictive of a scapular spine fracture. RESULTS A scapular spine fracture following RSA occurred in 21 patients (4.3%), with a mean time to diagnosis of 8.6 months (range, 1-34 months). No preoperative factor was found to be a significant predictor of scapular spine fracture. Both groups showed significant improvements in active mobility measurements and Constant scores from preoperatively to final follow-up (P < .001). The control group scored significantly better than the scapular spine fracture group regarding the Constant score and forward flexion. CONCLUSION Scapular spine fractures have shown an increased prevalence after onlay-design RSA. This series was not able to link any clear risk factors. Functional results are limited, regardless of the fracture management.

Scapular fractures in reverse shoulder arthroplasty (Grammont style): prevalence, functional, and radiographic results with minimum 5-year follow-up

BACKGROUND Scapular fractures after reverse shoulder arthroplasty (RSA) are an increasingly reported complication. Information is missing regarding midterm to long-term follow-up consequences. The aim of this study was to determine the rate of scapular fracture (acromial base and spine) after Grammont-style RSA and to report functional and radiographic results of patients with a minimum 5-year follow-up. MATERIALS AND METHODS We retrospectively reviewed 1953 Grammont-style RSAs in 1745 patients in a multicenter study. Of these, 953 patients (1035 RSAs) had minimum 5-year follow-up for functional and radiographic assessment (anteroposterior and scapular Y views. RESULTS Twenty-six patients (1.3%) had sustained a scapular fracture; of these, 19 (10 acromial base and 9 spine fractures) had minimum 5-year follow-up and were reviewed at a mean follow-up of 97 months. Three patients (15.8%) were diagnosed at the last follow-up after an undiagnosed fracture. There were 3 traumatic cases (15.8%) and 13 (68.4%) without antecedent trauma. These 16 patients underwent nonoperative treatment. The fracture was healed in 8 (4 acromion and 4 spine). The average active forward elevation was 109° (range, 50°-170°), and the Constant score was 47.0 points (range, 8-81 points). CONCLUSIONS Scapular fractures after Grammont-style RSAs are rare (1.3%) but remain a concern. These fractures occur mainly in the early postoperative 6 months. Immobilization with an abduction splint frequently resulted in nonunion or malunion. Final functional outcomes are poor regardless of acromial or spine fracture compared with primary RSA without fracture.

Algodystrophy: complex regional pain syndrome and incomplete forms.

The algodystrophy, also known as complex regional pain syndrome (CRPS), is a painful disease characterized by erythema, edema, functional impairment, sensory and vasomotor disturbance. The diagnosis of CRPS is based solely on clinical signs and symptoms, and for exclusion compared to other forms of chronic pain. There is not a specific diagnostic procedure; careful clinical evaluation and additional test should lead to an accurate diagnosis. There are similar forms of chronic pain known as bone marrow edema syndrome, in which is absent the history of trauma or triggering events and the skin dystrophic changes and vasomotor alterations. These incomplete forms are self-limited, and surgical treatment is generally not needed. It is still controversial, if these forms represent a distinct self-limiting entity or an incomplete variant of CRPS. In painful unexplained conditions such as frozen shoulder, post-operative stiff shoulder or painful knee prosthesis, the algodystrophy, especially in its incomplete forms, could represent the cause.