Reinhold Ortmaier

Peripheral Nerve Blocks in Shoulder Arthroplasty: How Do They Influence Complications and Length of Stay?

BackgroundRegional anesthesia has proven to be a highly effective technique for pain control after total shoulder arthroplasty. However, concerns have been raised about the safety of upper-extremity nerve blocks, particularly with respect to the incidence of perioperative respiratory and neurologic complications, and little is known about their influence, if any, on length of stay after surgery.Questions/purposesUsing a large national cohort, we asked: (1) How frequently are upper-extremity peripheral nerve blocks added to general anesthesia in patients undergoing total shoulder arthroplasty? (2) Are there differences in the incidence of and adjusted risk for major perioperative complications and mortality between patients receiving general anesthesia with and without nerve blocks? And (3) does resource utilization (blood product transfusion, intensive care unit admission, length of stay) differ between groups?MethodsWe searched a nationwide discharge database for patients undergoing total shoulder arthroplasty under general anesthesia with or without addition of a nerve block. Groups were compared with regard to demographics, comorbidities, major perioperative complications, and length of stay. Multivariable logistic regressions were performed to measure complications and resource use. A negative binomial regression was fitted to measure length of stay.ResultsWe identified 17,157 patients who underwent total shoulder arthroplasty between 2007 and 2011. Of those, approximately 21% received an upper-extremity peripheral nerve block in addition to general anesthesia. Patients receiving combined regional-general anesthesia had similar mean age (68.6 years [95% CI: 68.2–68.9 years] versus 69.1 years [95% CI: 68.9–69.3 years], p < 0.0043), a slightly lower mean Deyo (comorbidity) index (0.87 versus 0.93, p = 0.0052), and similar prevalence of individual comorbidities, compared to those patients receiving general anesthesia only. Addition of regional anesthesia was not associated with different odds ratios for complications, transfusion, and intensive care unit admission. Incident rates for length of stay were also similar between groups (incident rate ratio = 0.99; 95% CI: 0.97–1.02; p = 0.467)ConclusionsAddition of regional to general anesthesia was not associated with an increased complication profile or increased use of resources. In combination with improved pain control as known from previous research, regional anesthesia may represent a viable management option for shoulder arthroplasty. However, further research is necessary to better clarify the risk of neurologic complications.Level of EvidenceLevel IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Posterior open wedge osteotomy of the scapula neck for the treatment of advanced shoulder osteoarthritis with posterior head migration in young patients

BACKGROUND Treatment of young, active patients with symptomatic glenohumeral osteoarthritis, excessive glenoid retroversion, and static posterior humeral subluxation is challenging. Correction of glenoid retroversion may lead to centric loading and perhaps recenter the humeral head. We describe the functional and radiologic outcomes after corrective osteotomy of the glenoid in this population of patients. MATERIALS AND METHODS In this retrospective study, we included 10 shoulders (8 patients) that were observed for a mean of 33.4 months (range, 24-52 months) after corrective osteotomy of the glenoid. The mean age at surgery was 41.5 years (range, 24-51 years). On standardized axial images, glenoid retroversion and posterior static humeral subluxation were measured preoperatively and postoperatively and at the final follow-up. At final follow-up, anterior and posterior axial radiographs were performed to determine humeral head position in different arm positions. Clinical follow-up included Constant-Murley score, subjective shoulder value, and patient satisfaction. RESULTS The mean Constant-Murley score improved significantly from 45.1 points (range, 24-71) to 64.1 points (range, 44-92; P < .001). The average degree of anterior flexion improved significantly from 117° (range, 50°-160°) to 143° (range, 110°-180°; P = .006). The mean glenoid retroversion changed from 16° (range, 11°-31°) preoperatively to 5° (range, 13° anteversion-16° retroversion; P = .003) at the final follow-up. The mean posterior static subluxation of the humeral head changed from 5 mm (range, 0-10 mm) preoperatively to 6 mm (range, 0-14 mm; P = .259) at the final follow-up. CONCLUSIONS This study shows that posterior open wedge osteotomy of the glenoid neck provides excellent correction of glenoid retroversion.

Comparison between reverse shoulder arthroplasty and Humerusblock in three- and four-part proximal humerus fractures in elderly patients

PurposeWe set out to compare osteosynthesis using the minimally invasive, semi-rigid, Humerusblock to reverse shoulder arthroplasty (RSA) for primary fracture treatment in three- and four-part fractures in patients over 65 years old.MethodsIn the study period from 2008 to 2011, we conducted a matched-pair analysis of 25 patients treated with reverse shoulder arthroplasty (group 1) to 25 patients treated with the Humerusblock (group 2). At the time of follow-up, a complete physical examination of the shoulders, including evaluation with the Constant–Murley score and the VAS pain scale, was performed. In addition, standard radiographs (true AP and axillary views) were taken to evaluate signs of malreduction, malunion, nonunion, scapular notching or radiolucent lines around the prosthesis.ResultsAfter a minimum follow-up of 12 months, the mean CMS differed significantly between groups 1 and 2 (47.4 vs 64.4, p<0.01). The mean abduction (97.6° vs 126.8°, p<0.01), anterior flexion (103.2° vs 139.6°, p<0.01) and external rotation (16° vs 39.6°; p<0.01) were significantly worse in group 1. The VAS pain score was significantly lower in group 2 compared to group 1 (0.92 vs 3.12, p<0.01).ConclusionsThis is the first study that compared the Humerusblock to reverse shoulder arthroplasty for primary fracture treatment. In this study, the functional outcome was superior in the Humerusblock group.

Initially unrecognised lunate dislocation as a cause of carpal tunnel syndrome.

A patient was admitted reporting tingling pain and numbness in the right hand. Neurological examination—including nerve conduction studies—diagnosed carpal tunnel syndrome. Operative carpal tunnel release was performed without complications. Four months postoperatively the otherwise healthy patient presented again due to persistent complaints, although preoperative symptoms had improved. On this occasion, the patient reported loss of strength accompanied by rigidity in the wrist. Clinical examination showed some swelling adjacent to the operation wound. A postoperative ganglion cyst was suspected and a conservative treatment option—splinting the wrist—was chosen. Four weeks later the patient presented again with further swelling and increasing rigidity of the wrist. Surgical intervention was planned. Preoperative plain radiographs of the wrist revealed chronic palmar dislocation of the lunate to be the cause of the symptoms in our patient. Radiological signs of scapholunate advanced collapse arthritis (SLAC wrist) were also observed.

Minimally Invasive Treatment of Displaced Proximal Humeral Fractures in Patients Older Than 70 Years Using the Humerusblock

Background. Surgical treatment of proximal humeral fractures (PHF) in osteoporotic bone of elderly patients is challenging. The aim of this retrospective study was to evaluate the clinical and radiological outcome after percutaneous reduction and internal fixation of osteoporotic PHF in geriatric patients using the semirigid Humerusblock device. Methods. In the study period from 2005 to 2010, 129 patients older than 70 years were enrolled in the study. After a mean follow-up of 23 months, a physical examination, using the Constant-Murley score and the VAS pain scale, was performed. Furthermore radiographs were taken to detect signs of malunion, nonunion, and avascular necrosis. Results. The recorded Constant-Murley score was 67.7 points (87.7% of the noninjured arm) for two-part fractures, 67.9 points (90.8%) for three-part fractures, and 43.0 points (56.7%) for four-part fractures. In ten shoulders (7.8%) loss of reduction and in four shoulders (3.1%) nonunion were the reason for revision surgery. Avascular humeral head necrosis developed in eight patients (6.2%). Conclusions. In two- and three-part fractures postoperative results are promising. Sufficient ability for the activities of daily living was achieved. In four-part fractures the functional results were less satisfying regarding function and pain with a high postoperative complication rate. In those patients other treatment strategies should be considered. Study design. Therapeutic retrospective case series (evidence-based medicine (EBM) level IV).

Diagnostic parameters in periprosthetic infections: the current state of the literature

Despite progress in recent years, a definitive diagnosis of PPI is not yet possible. Due to new diagnostic possibilities and the further development of already existing diagnostic tools, a more accurate diagnostic clarification of uncertain cases should be possible. The following article includes an overview of common existing diagnostic tools and instruments, which will likely gain importance in the future.

Posttraumatische Arthrose des Glenohumeralgelenks

BACKGROUND Arthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results. OBJECTIVE Discussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration. METHODS Selective literature review and description of personal experience. RESULTS The geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article. CONCLUSION Each case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.ZusammenfassungHintergrundDie prothetische Versorgung symptomatischer Frakturfolgezustände nach proximaler Humerusfraktur stellt hohe Ansprüche an den Chirurgen. Nur mit exakter präoperativer Planung sind akzeptable Ergebnisse zu erreichen.FragestellungDarstellung der Überlegungen zu Operationsplanung und Implantatwahl unter Berücksichtigung der knöchernen Situation und der umgebenden Weichteile.MethodeSelektive Literaturrecherche sowie Auswertung des eigenen Patientenkollektivs.ErgebnisseGeometrie, Heilungssituation der knöchernen Strukturen und der Zustand der umgebenden Weichteile sind zu berücksichtigen und beeinflussen die Wahl des Implantats. Mangelhafte Planung kann nicht nur intraoperativ zu technischen Schwierigkeiten führen, sondern auch maßgeblich das subjektive postoperative Ergebnis für den Patienten beeinträchtigen. Durch resultierende Fehlbelastung können Komponenten rasch auslockern und es kommt damit zum Implantatversagen. Entscheidend zur Abschätzung des erreichbaren postoperativen Ergebnisses sind die Position und die Heilung der Tuberkula gegenüber dem Humerusschaft. Diese Tatsache spiegelt sich in der gebräuchlichen Einteilung nach Boileau wider, welche als Entscheidungshilfe über die Implantatwahl und chirurgische Strategie herangezogen werden kann. Da diese schwierig zu behandelnden Fälle glücklicherweise nicht sehr häufig vorkommen, ist auch die Datenlage in der Literatur zu entsprechenden Ergebnissen relativ gering und uneinheitlich. Diese Resultate werden einander gegenübergestellt und diskutiert.SchlussfolgerungDie Behandlung dieses heterogenen Patientengutes muss individuell geplant werden und sollte erfahrenen Schulterchirurgen vorbehalten sein.AbstractBackgroundArthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results.ObjectiveDiscussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration.MethodsSelective literature review and description of personal experience.ResultsThe geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article.ConclusionEach case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.

Posttraumatic arthrosis of the glenohumeral joint. From partial resurfacing to reverse shoulder arthroplasty

BACKGROUND Arthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results. OBJECTIVE Discussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration. METHODS Selective literature review and description of personal experience. RESULTS The geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article. CONCLUSION Each case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.ZusammenfassungHintergrundDie prothetische Versorgung symptomatischer Frakturfolgezustände nach proximaler Humerusfraktur stellt hohe Ansprüche an den Chirurgen. Nur mit exakter präoperativer Planung sind akzeptable Ergebnisse zu erreichen.FragestellungDarstellung der Überlegungen zu Operationsplanung und Implantatwahl unter Berücksichtigung der knöchernen Situation und der umgebenden Weichteile.MethodeSelektive Literaturrecherche sowie Auswertung des eigenen Patientenkollektivs.ErgebnisseGeometrie, Heilungssituation der knöchernen Strukturen und der Zustand der umgebenden Weichteile sind zu berücksichtigen und beeinflussen die Wahl des Implantats. Mangelhafte Planung kann nicht nur intraoperativ zu technischen Schwierigkeiten führen, sondern auch maßgeblich das subjektive postoperative Ergebnis für den Patienten beeinträchtigen. Durch resultierende Fehlbelastung können Komponenten rasch auslockern und es kommt damit zum Implantatversagen. Entscheidend zur Abschätzung des erreichbaren postoperativen Ergebnisses sind die Position und die Heilung der Tuberkula gegenüber dem Humerusschaft. Diese Tatsache spiegelt sich in der gebräuchlichen Einteilung nach Boileau wider, welche als Entscheidungshilfe über die Implantatwahl und chirurgische Strategie herangezogen werden kann. Da diese schwierig zu behandelnden Fälle glücklicherweise nicht sehr häufig vorkommen, ist auch die Datenlage in der Literatur zu entsprechenden Ergebnissen relativ gering und uneinheitlich. Diese Resultate werden einander gegenübergestellt und diskutiert.SchlussfolgerungDie Behandlung dieses heterogenen Patientengutes muss individuell geplant werden und sollte erfahrenen Schulterchirurgen vorbehalten sein.AbstractBackgroundArthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results.ObjectiveDiscussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration.MethodsSelective literature review and description of personal experience.ResultsThe geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article.ConclusionEach case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.

Posttraumatische Arthrose des Glenohumeralgelenks@@@Posttraumatic arthrosis of the glenohumeral joint: Von der Teil- bis zur inversen Prothese@@@From partial resurfacing to reverse shoulder arthroplasty

BACKGROUND Arthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results. OBJECTIVE Discussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration. METHODS Selective literature review and description of personal experience. RESULTS The geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article. CONCLUSION Each case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.ZusammenfassungHintergrundDie prothetische Versorgung symptomatischer Frakturfolgezustände nach proximaler Humerusfraktur stellt hohe Ansprüche an den Chirurgen. Nur mit exakter präoperativer Planung sind akzeptable Ergebnisse zu erreichen.FragestellungDarstellung der Überlegungen zu Operationsplanung und Implantatwahl unter Berücksichtigung der knöchernen Situation und der umgebenden Weichteile.MethodeSelektive Literaturrecherche sowie Auswertung des eigenen Patientenkollektivs.ErgebnisseGeometrie, Heilungssituation der knöchernen Strukturen und der Zustand der umgebenden Weichteile sind zu berücksichtigen und beeinflussen die Wahl des Implantats. Mangelhafte Planung kann nicht nur intraoperativ zu technischen Schwierigkeiten führen, sondern auch maßgeblich das subjektive postoperative Ergebnis für den Patienten beeinträchtigen. Durch resultierende Fehlbelastung können Komponenten rasch auslockern und es kommt damit zum Implantatversagen. Entscheidend zur Abschätzung des erreichbaren postoperativen Ergebnisses sind die Position und die Heilung der Tuberkula gegenüber dem Humerusschaft. Diese Tatsache spiegelt sich in der gebräuchlichen Einteilung nach Boileau wider, welche als Entscheidungshilfe über die Implantatwahl und chirurgische Strategie herangezogen werden kann. Da diese schwierig zu behandelnden Fälle glücklicherweise nicht sehr häufig vorkommen, ist auch die Datenlage in der Literatur zu entsprechenden Ergebnissen relativ gering und uneinheitlich. Diese Resultate werden einander gegenübergestellt und diskutiert.SchlussfolgerungDie Behandlung dieses heterogenen Patientengutes muss individuell geplant werden und sollte erfahrenen Schulterchirurgen vorbehalten sein.AbstractBackgroundArthroplasty of symptomatic sequelae after fractures of the proximal humerus is a demanding procedure for surgeons. Exact preoperative planning is crucial in order to achieve acceptable functional results.ObjectiveDiscussion of preoperative considerations in planning the procedure and choosing the appropriate implant taking the osseous anatomy and surrounding soft tissue situation into consideration.MethodsSelective literature review and description of personal experience.ResultsThe geometry and consolidation status of bone fragments as well as the conditions of the surrounding soft tissue have to be taken into account and influence the choice of implant used. Insufficient planning will not only cause intraoperative technical problems but can also greatly influence the subjective patient assessment of the postoperative outcome. Unequal strain distribution can cause early loosening of components resulting in malfunctioning of the implant. In this respect, knowledge of the position and consolidation status of fractured tuberosities with respect to the humeral shaft is essential and allows an approximate estimation of the achievable outcome. This is taken into account by the classification of Boileau which can also help to decide on which type of implant to use. Because such cases are scarce, reported results in the literature are heterogeneous, which is discussed in this article.ConclusionEach case needs a thorough and individualized preoperative assessment along with exact planning and should therefore be reserved for experienced shoulder surgeons only.

Leriche-Like Syndrome as a Delayed Complication Following Posterior Instrumentation of a Traumatic L1 Fracture: A Case Report and Literature Review.

Study Design. Case report and review of literature. Objective. Case report of an acute Leriche‐like syndrome as an unusual complication after posterior transpedicular instrumentation of an L1 fracture. Summary of Background Data. Injuries to the aorta after pedicle screw placement are rare. Reports exist about acute hemorrhage, erosions, and pseudoaneurysm formation. Methods. A 47‐year‐old female developed an acute occlusion of the infrarenal aorta after posterior transpedicular instrumentation of an L1 burst‐fracture. The patient presented with increasing sensation of hypothermia in both lower extremities and cyanosis of the toes, as well as claudication‐like symptoms 15 days after the initial surgery. CT angiography showed bicortical placement of the left pedicle screw at L2 with perforation of the anterior cortex of 2.5 mm and complete obliteration of the infrarenal aorta up to the bifurcation. Results. The patient was treated with resection of the aorta and implantation of a silver graft prosthesis. Preoperative symptoms resolved immediately after surgery without reoccurrence. Conclusion. Although rare, the risk of iatrogenic injuries to the aorta during spine surgery exists, several complications have previously been described. However, this is the first report of an acute Leriche‐like syndrome after posterior instrumentation of the spine. Whereas bicortical pedicle screw placement in selected cases of posterior spinal instrumentation is intended, one has to be aware of the possible risks, as in our case where an acute aortic obliteration was observed. Preoperative CT‐based planning of surgery and profound knowledge of the neurovascular anatomy is mandatory. Level of Evidence: 5