Is the reverse shoulder prosthesis for proximal humeral nonunions really worth the risk? Commentary on an article by Patric Raiss, MD, et al.: "Reverse shoulder arthroplasty for the treatment of nonunions of the surgical neck of the proximal part of the humerus (type-3 fracture sequelae)".

Abstract

Commentary Patients with neuromuscular scoliosis are a diverse group who are challenging to treat, with higher rates of surgical site infection following posterior spinal fusion than patients with idiopathic scoliosis1. Surgical site infection after posterior spinal fusion is costly, is difficult to manage, and may require multiple procedures including implant removal. Ramo et al. performed a retrospective review of patients at one institution who underwent posterior spinal fusion for neuromuscular scoliosis over a thirty-year period. They examined surgical site infection in this population and reviewed patient and treatment factors associated with surgical site infection. The study, which spans three decades, is the largest reported in the literature, with 428 patients and an overall surgical site infection rate of 10.3%. Important highlights from the analyses that are consistent with other published reports include a 22% infection rate for the sixty-five patients with myelomeningocele2, a high rate of gram-negative infections (41%), and a high rate of polymicrobial infections (45%). On multivariate logistic regression analysis, factors that were significantly related to surgical site infection included incontinence, inadequate cefazolin dosing for weight (≤20 mg/kg), occurrence of other major complications, and length of hospital stay. Although retrospective, the study provides excellent information based on the very large number of patients included. In addition, the length of time over which the study was conducted allows a look at changes in practice with posterior spinal fusion in neuromuscular scoliosis over three decades. The infection rate was examined by decade, and although univariate analysis showed it to be higher earlier in the study period, this was not significant on multivariate analysis. Ramo et al. bring the story right up to 2009, a time when we began refocusing on surgical site infection nationally in scoliosis surgery. Many factors were being examined for their impact on surgical site infection in this group, including dosing and timing of antibiotics, instrumentation construct and type of metal, blood loss and its management, close monitoring of the nutritional status of patients, and use of drains. Simultaneously, Best Practice Guidelines3 for preventing surgical site infection in neuromuscular scoliosis were being constructed. This study will allow excellent comparisons in the current decade for implementations of new Best Practice Guidelines. Overall, the findings in the large number of patients in this study add to a good foundation for construction of Best Practice Guidelines aimed at decreasing the rate of surgical site infection after spinal surgery for neuromuscular scoliosis. Coordinated efforts and prospective studies on the subject will ultimately help us decrease the rate of this complication and increase the safety of posterior spinal fusion in neuromuscular scoliosis.