Difference In Constant Score Research Articles

Comparison between CFR-PEEK and titanium plate for proximal humeral fracture: A meta-analysis.

The aim of the present meta-analysis was to compare the efficacy and safety of the carbon fiber-reinforced polyetheretherketone (CFR-PEEK) and titanium plate for the treatment of proximal humeral fractures (PHFs) from clinical comparative trials. A comprehensive search of English databases was carried out, such as PubMed, Web of Science, ScienceDirect, Springer and Cochrane Library databases. The RevMan version 5.1 software was applied for statistical analysis, and the mean difference (MD) and risk difference (RD) as the combined variables, and "95%" as the confidence interval (CIs). One randomized-controlled trial and five retrospective controlled studies including 282 PHFs were considered eligible and finally included. Meta-analysis demonstrated that there were significant differences in Constant score (CS) (MD=9.23; 95% CI: 5.02, 13.44; p<0.0001), anterior elevation (MD=18.83; 95% CI: 6.27, 31.38; p=0.003), lateral elevation (MD=18.42; 95% CI: 3.64, 33.19; p=0.01) and adduction (MD=3.53; 95% CI: 0.22, 6.84; p=0.04). No significant differences were observed regarding Constant score compared to the contralateral shoulder, Oxford Shoulder Score, internal rotation, external rotation, screw perforation and cutout, varus/valgus malalignment, humeral head collapse/necrosis, implant removal, and revision surgery between the two groups. Compared to titanium plate, CFR-PEEK plate showed better Constant score, anterior elevation, lateral elevation and adduction in treating PHFs. The complications are comparable to those achieved with conventional titanium plates.

Could intraoperative ultrasound improve clinical and radiological outcomes during arthroscopic calcification evacuation of rotator cuff?

IntroductionMartinel et al described an intraoperative ultrasound technique to easier identify calcification under arthroscopy. Our hypothesis was that intra-operative ultrasound monitoring allowed better evacuation of calcific tendinitis (CT). Our aim was to determine whether ultrasound monitoring improved the short-term clinical and radiological outcomes of CT. MethodsA prospective, single-center, single-operator, consecutive study conducted between February 2020 and June 2023. The inclusion criterion was surgical treatment for evacuation of symptomatic macro-centimetric calcification (CA) type A or B. The first 20 patients were operated on using the standard surgical technique and the next 20 under ultrasound control.The mean age at surgery was 49.8 years (minimum: 28 years; maximum: 64 years). Patients were reviewed at 6 weeks and 3 months. The evacuation of the CA was checked at 6 weeks by X-ray. ResultsIn the standard technique group, the mean preoperative Constant score was 41.4/100 (± 15.07). Postoperatively, the Constant score was 58.88/100 (± 15.28) at 6 weeks and 69.16/100 (± 13.86) at 3 months. The mean preoperative Subjective Shoulder Value (SSV) was 39.0% (± 18.61). Postoperatively, the SSV was 64.0% (± 17.21) at 6 weeks and 79.47% (± 16.06) at 3 months.In the ultrasound control group, the preoperative Constant score was 44.48/100 (± 14.28) and 58.18/100 (± 15.64) at 6 weeks and 66.87/100 (± 18.45) at 3 months postoperatively. The mean preoperative SSV was 40.0% (± 16.54) and 61.75% (± 18.59) at 6 weeks and 76.05% (± 19.62) at 3 months postoperatively.There was no significant postoperative difference in Constant score (p=0.732) or SSV (p=0.566) between the two groups.There was a significant difference (p=0.004) between the two groups in terms of complete evacuation of the CA with the standard technique in 65% of cases (13 patients out of 20) and with intraoperative ultrasound monitoring in 95% of cases (19 patients out of 20). ConclusionThere was no significant postoperative difference in Constant score and SSV between the two groups in the short term.

Uncemented reverse shoulder arthroplasty in proximal humeral fractures: comparative study of two different press fit stems

BackgroundReverse shoulder arthroplasty (RSA) has extended its indications in recent years to include complex proximal humerus fractures (PHFs) in elderly patients. The traditional approach in cases of PHF has been to cement the stem but, as in orthopedic surgery, the current trend in PHF is to avoid cementing the humeral stem as well. MethodsWe evaluated 63 patients (representing 63 shoulders) who underwent RSA with uncemented stem after acute fracture of the proximal humerus. We analyzed the clinical and radiological outcomes, as well as medium-term complications, using two different prosthesis models. ResultsThe mean postoperative follow-up period was 21-23 months, and the mean age of the patients was 74.5 years. The average Constant Score was 56.94 points; there were no statistical significant differences in Constant Score depending on the prosthesis model used. No cases of aseptic loosening were observed. However, there was evidence of stress-shielding in prostheses with diaphyseal fixation, although this phenomenon did not appear to have functional or clinical consequences for the patients. Intraoperative complications occurred in 6.35% of cases, and postoperative complications were noted in 4.92%. ConclusionBased on the results of this study, we can affirm that the use of RSA with cementless stems in PHF can be a safe alternative, providing satisfactory clinical, functional, and radiographic results in the short term without the need to use cement in their fixation. The choice of prosthesis model may influence the occurrence of radiographic phenomena but does not seem to affect clinical outcome.

Intraoperative repair of functional subscapularis during RSA by deltopectoral approach could improve internal rotation but does not prevent anterior dislocation

IntroductionThe role of the subscapularis following reverse shoulder arthroplasty (RSA) remains controversial as repair could restore adequate internal rotation and shoulder stability, but might compromise external rotation. The purpose of this multi-centre study, on a large cohort of RSAs performed using the deltopectoral approach, was to determine the effect of subscapularis preoperative status and intraoperative repair on range of motion, clinical scores and rates of complications at a minimum follow-up of 2 years. HypothesisRepair of a functional subscapularis grants better internal rotation and stability without compromising external rotation. Materials and methodsWe retrospectively reviewed records of all RSAs (n=916) performed by 14 surgeons that participated in a large national society symposium, and excluded 234 operated by the anterosuperior approach, 42 operated for rheumatoid arthritis, fractures, instability or post traumatic sequalae, and eight that had adjuvant latissimus dorsi tendon transfer (LDTT). This left 632 RSAs, in which the subscapularis was detached in 594, and repaired after detachment in 495. Patients completed pre- and postoperative Constant Score and postoperative Subjective Shoulder Value (SSV). Active forward elevation, active external rotation (ER), and active internal rotation (IR) were recorded pre- and postoperatively. Complications following RSA that required conservative treatment, reoperation without implant removal, as well as reoperation with implant removal were recorded. ResultsOf the initial cohort of 632 shoulders, 120 (19%) were lost to follow-up, 12 (2%) died due to causes unrelated to RSA, and 26 (4%) were revised with implant removal. Of the remaining 474 shoulders, 259 (55%) had a functional repaired subscapularis (Group FR), 59 (12%) had a non-functional repaired subscapularis (Group nFR), whereas 68 (14%) had a not repaired subscapularis (Group nR). Comparison of patient demographics revealed no significant differences among the three groups. Postoperative Constant Score (p=0.031) and SSV (p=0.016) were significantly different among the three groups, but effect sizes were small and not clinically relevant. Differences in postoperative ER as well as postoperative IR were not significant among the three groups: 91 (35%) gained functional IR in Group FR, 11 (19%) in Group nFR, and 13 (19%) in Group nR. Three shoulders (1.2%) reported subjective instability and 1 (0.4%) dislocated in Group FR, but none in either Groups nFR or nR. DiscussionDespite statistically significant differences in Constant Score and SSV among the three groups, the clinical relevance of these differences is negligible, so repair of functional subscapularis has little or no influence on functional outcomes. During RSA by deltopectoral approach, repair of a functional subscapularis could slightly improve internal rotation in some patients but does not compromise external rotation, forward elevation or clinical scores, while repair of a non-functional subscapularis, compared to non-repair, did not improve range of motion or clinical scores. Level of evidenceIII; retrospective comparative.

Prospective Multicenter Randomized Controlled Trial of Surgical Versus Nonsurgical Treatment for Acute Rockwood Type 3 Acromioclavicular Injury.

Evidence for the superiority of surgical versus nonsurgical treatment of Rockwood type 3 acromioclavicular joint (ACJ) dislocation is still lacking. It was hypothesized that surgical treatment will outperform nonsurgical treatment. Randomized controlled trial; Level of evidence, 1. A prospective randomized trial involving 4 study centers was performed from January 1, 2011, to March 31, 2016. A total of 85 patients with acute Rockwood type 3 ACJ dislocations were allocated randomly to receive either nonsurgical or surgical treatment. A total of 70 patients were treated as allocated, and 8 patients made an early crossover from nonsurgical to surgical treatment, leaving 47 patients treated surgically and 31 patients nonsurgically. All patients were followed up longitudinally, including clinical evaluation using the Constant score and standardized radiographic evaluation, with final follow-up after 2 years. At no follow-up time point was there a significant difference in Constant score between the surgically and nonsurgically treated patients. Radiographic analysis showed not only an inferior coracoclavicular distance at all follow-up points for surgical treatment but also a higher incidence of posttraumatic osteoarthritis and heterotopic ossifications, without any negative clinical correlation. With regard to complications, 1 patient (3%) in the nonsurgical group underwent secondary surgical ACJ stabilization. The revision rate after surgical treatment was 17% (P < .001). Neither primary horizontal instability nor younger age were associated with inferior clinical outcomes after nonsurgical treatment. Surgical treatment of ACJ Rockwood type 3 injuries did not lead to superior functional outcomes. Neither younger age nor horizontal instability were associated with inferior outcomes after nonsurgical treatment. Surgical treatment led to a slower recovery and to higher complication and revision rates. ISRCTN registry (study ID: ISRCTN92265154).

Increased operative time has a negative impact on clinical outcome in arthroscopic rotator cuff repair.

Few data are available about the impact of operative time on outcome of rotator cuff repair. The aim of this study was to evaluate the impact of operative time on clinical outcome and tendon healing after arthroscopic rotator cuff repair. Patients operated on for distal supraspinatus tear in our institution between 2012 and 2018 were included retrospectively. Operative time, from skin incision until skin closure, was extracted from medical files. For statistical analysis, operative time was treated as a quantitative variable. Endpoints were clinical outcome (Constant score, range of motion), tendon healing (on CT or MRI) and complications at 1year. The significance threshold was set at p = 0.05. A total of 219 Patients, with a mean age of 54.6years (range 40-70years), were included. Mean operative time 44.9min (range 14-140min). Significant correlations (p < 0.05) were found for Constant score and external rotation at 1year: increasing operative time by 1min led to a decrease in Constant score of 0.115 points, or 6.9 points for a 60-min increase (p = 0.0167) and a decrease in external rotation of 0.134°, or 8.04° for a 60-min increase (p = 0.0214). No significant correlations were found for anterior elevation at 1year (p = 0.2577), tendon healing at 1year (p = 0.295) or onset of complications during follow-up (p = 0.193). The minimal clinically important difference in Constant score in patients undergoing rotator cuff surgery is between 6 and 10 points. An increase of more than 60min in operative time significantly impacted clinical outcome of arthroscopic distal supraspinatus repair, but not tendon healing. Level III: Retrospective Cohort Design. Therapeutic Study.

Aquatic therapy following arthroscopic rotator cuff repair enables faster improvement of Constant score than land-based therapy or self-rehabilitation therapy

PurposeTo compare the clinical and functional outcomes of arthroscopic rotator cuff repair over a period of 2 years using three postoperative rehabilitation modalities: aquatic therapy, land-based therapy, and self-rehabilitation therapy. The null hypothesis was that aquatic therapy would provide no difference in Constant score compared to land-based therapy and self-rehabilitation therapy.MethodsA prospective study was performed on subjects scheduled for arthroscopic rotator cuff repair between 2012 and 2017 that complied with the following criteria: (i) small to medium sized symptomatic supraspinatus and/or infraspinatus tendon tears, (ii) low to moderate tendon retraction according to Patte, and (iii) fatty infiltration stage ≤2. Patients were allocated to perform either aquatic therapy, land-based therapy, or self-rehabilitation therapy for 2-4 months. Independent observers blinded to the study design collected Constant score, SSV, and patient satisfaction at 2 months, 3 months, 6 months, 1 year and 2 years.Study designLevel III, cohort studyResultsAt 2 months follow-up, patients performing aquatic therapy had significantly higher Constant scores (p < 0.001) and SSV (p < 0.001) compared to those performing land-based therapy or self-rehabilitation therapy. At 3 months follow-up, patients performing aquatic therapy had significantly higher Constant scores (p < 0.001), and SSV (p < 0.001), both of which exceeded the respective minimal clinically important differences (MCIDs) of 10.4 and 12. Patients performing aquatic therapy continued to have significantly higher Constant scores and SSV at 6 months, 1 year, and 2 years.ConclusionAquatic therapy has a positive effect on clinical outcomes at 3 months after surgery, but yields no relevant improvements on function or satisfaction at 1 to 2 years follow-up.

Relationship between speed of recovery of range of motion and rotator cuff healing: A study of 1154 consecutive arthroscopic supraspinatus repairs

Our purpose was to analyze the impact of the speed of recovery of ROM on tendon healing in patients undergoing an isolated arthroscopic SSN repair and the same rehabilitation protocol. We hypothesized that a faster recovery of ROM would lead to a better functional outcome without compromising tendon healing. This was a prospective monocentric study. All primary isolated arthroscopic SSN repairs for small to medium tears, without retraction (Patte 1), significant fatty infiltration (Goutallier < 2) and glenohumeral osteoarthritis were eligible. Patients who did not complete all follow-ups were excluded. An experienced orthopedic surgeon performed all procedures using a double-row technique. All patients followed the same rehabilitation protocol. It included a sling and progressive passive overhead stretches and ER with the elbow at side during the first 6 weeks followed by active mobilization. An independent observer assessed all patients before and at 6 weeks, 3 and 6 months after surgery. Collected data at each follow-up included passive and active EA and ER as well as the VAS for pain. The Constant score was obtained before and at 6 months after surgery. A single radiologist examined the healing of the repair by ultrasound at 6 months postoperatively according to Sugaya. 1323 consecutive patients between 2010 and 2020 were eligible. 169 were excluded according to the aforementioned criteria. Finally, 1154 arthroscopic SSN repairs were included. The healing rate was 87.3 %. Preoperative characteristics of healed and non-healed repairs were similar in terms of passive and active ROM, VAS pain, and Constant score. Compared to the non-healed repairs, the healed ones were slightly younger (57.8 ± 8.0 vs. 61.5 ± 8.5 years; p < 0.001) and had a lower passive AE and ER at 6 weeks and 3 months postoperatively. However, this difference faded by 6 months after surgery. There was no difference in Constant score and VAS pain between healed and non-healed repairs. In both cases, the SSN repair resulted in an improvement of the Constant score at 6 months postoperatively and a decrease in the VAS pain already from the 6th postoperative week. Our study shows that the speed of recovery of passive ROM influences tendon healing after isolated arthroscopic SSN repair. Repairs that resulted in healing had lower AE and ER up to 3 months after surgery. This difference did not affect the level of pain and/or shoulder function, which were similar.

Outcomes Between Stemmed and Stemless Total Shoulder Arthroplasty: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Both stemmed and stemless designs for total shoulder arthroplasty (TSA) have demonstrated efficacious outcomes for the surgical treatment of primary glenohumeral joint osteoarthritis. The purpose of this systematic review and meta-analysis was to compare the clinical outcomes of stemmed versus stemless TSA in randomized controlled trials. We hypothesized that there would be no differences in Constant Score (CS), range of motion, or adverse events, such as periprosthetic fracture and/or revision surgery. Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, a systematic review of the literature was done using MEDLINE, SPORTDiscus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Registry of Controlled Trials, Embase, and Web of Science databases. Outcomes of interest included CS, range of motion, and adverse events (periprosthetic fracture and revision). Summary effect estimates of the mean difference between stemmed and stemless TSA for each outcome were estimated in random effects models. The search yielded 301 articles with 4 appropriate for qualitative analysis, including the results of 229 stemmed and 358 stemless TSAs. No significant difference was observed in postoperative CS (P = 0.36), forward flexion (P = 0.93), abduction (P = 0.30), or external rotation (P = 0.34) between stemmed and stemless TSA. No significant difference was observed in change in CS (P = 0.27), forward flexion (P = 0.25), or external rotation (P = 0.74). A change in abduction was significantly different between stemmed and stemless TSA (standardized mean difference = -0.64; 95% confidence interval, -1.20 to -0.08) in favor of stemmed TSA (P = 0.02), attributed to preoperative differences. No significant difference was observed in periprosthetic fractures (P = 0.07) or revision (P = 0.90). TSA with stemless versus stemmed humeral components was not associated with notable differences in functional and clinical outcomes. No difference was observed between stemmed and stemless designs in postoperative forward flexion, abduction, or external rotation. Similarly, there was no difference in change in forward flexion or external rotation. A markedly greater improvement in abduction was observed with stemmed TSA, likely due to the lower preoperative motion in the stemmed cohort in one of the studies. No differences were observed between stemmed and stemless designs in the rate of humeral fracture or risk of revision. Level II; systematic review and meta-analysis of prospective randomized controlled trials.

Relationship between postoperative integrity of subscapularis tendon and functional outcome in reverse shoulder arthroplasty.

The role of the subscapularis in reverse shoulder arthroplasty (RSA) remains controversial. Studies have shown that subscapularis repair has no significant influence on the functional outcomes of patients. However, few studies have assessed the postoperative integrity of the subscapularis tendon after RSA. The aims of this study were to investigate the postoperative healing of the subscapularis after RSA via ultrasound and to evaluate the relationship between tendon integrity and functional outcomes. We hypothesized that subjects with a healed subscapularis after RSA would have higher Constant scores and better internal rotation (IR) than those without a healed subscapularis. This was a retrospective review of all patients who underwent primary RSA with subscapularis tenotomy repair performed by a single surgeon with a minimum 2-year follow-up period. The inclusion criteria were (1) primary RSA and (2) complete intraoperative repair of the subscapularis tenotomy if the tendon was amenable to repair. The total Constant score and active and passive range of motion were measured preoperatively and at every postoperative visit. IR was further subcategorized into 3 functional types (type I, buttock or sacrum; type II, lumbar region; and type III, T12 or higher). The integrity of the subscapularis on ultrasound at 2 years was reported using the Sugaya classification. The correlation between subscapularis integrity and functional outcomes including functional IR was evaluated. A total of 86 patients (mean age, 73 ± 7.4 years; age range, 50-89 years) were evaluated. The mean postoperative Constant score for all patients significantly improved from 38 points to 72 points (P < .001) at last follow-up (mean, 3.3 years). There was significant improvement in all Constant score functional subscales and in terms of range of motion. The rate of sonographic healing of the subscapularis was 52.6%. There was no difference in Constant scores between "intact" and "failed" tendon repairs; however, intact tendons demonstrated significantly better IR with no difference in external rotation (P < .01). The healing rate of the subscapularis following RSA was only 52.6%. IR function in patients with an intact subscapularis at 2 years after RSA was significantly better than in patients with failed or absent tendon repairs. Primary repair of reparable subscapularis tendons during RSA should be strongly considered.

Rotator Cuff Repairs With and Without Acromioplasties Yield Similar Clinical Outcomes: A Meta-analysis and Systematic Review

This meta-analysis reviews the current literature comparing the patient-reported outcome measures of patients who underwent rotator cuff repairs with and without acromioplasties. A comprehensive literature search was performed using PubMed, EMBASE, and Scopus databases, obtaining 1,456 studies for the review. After the filtering process, 8 studies remained for our meta-analysis, of which 7 were prospective trials. From the included studies, the postoperative outcomes of 3,034 shoulders were studied. Data were analyzed using Mantel-Haenszel statistics and random-effect models where appropriate. Our meta-analysis revealed that there was no significant difference in American Shoulder and Elbow Surgeons scores (standardized mean difference [SMD], 0.09; 95% confidence interval [CI],-0.10 to 0.28; I2= 9%; P= .36), University of California at Los Angeles scores (SMD, 0.17; 95% CI, -0.07 to 0.40; I2=0%; P= .17), and rate of further surgery (odds ratio, 0.49; 95% CI, 0.04 to 5.66; I2= 59%; P= .57) between the acromioplasty and nonacromioplasty groups. There was a statistical difference in the Constant score (SMD, 0.25; 95% CI, 0.02 to 0.48; I2= 0%; P= .03) of both groups. However, with the Constant score having an SMD of only 0.25, the difference in Constant score was not clinically significant. There were no clinically significant differences in postoperative functional scores and pain scores for patients who underwent rotator cuff repairs with and without acromioplasties. Level II, meta-analysis of Level I and II studies.

The frequency of reduction loss after arthroscopic fixation of acute acromioclavicular dislocations using a double-button device, and its effect on clinical and radiological results

BackgroundThe aim of this study was to investigate the effect of reduction loss of more than 3 mm on clinical and radiological results after at least 2 years of follow-up after arthroscopic fixation of acute acromioclavicular joint dislocations using a double-button device.MethodsThirty-six patients who had acute (< 3 weeks old), type III or V acromioclavicular (AC) joint dislocations underwent arthroscopic fixation of the AC joint using a double-button device. Clinical and radiological evaluations were performed at preoperative, postoperative first day, 3 months and last follow-up. When the coracoclavicular (CC) distances of patients at the last follow-up were compared to the early postop CC distances, those with a difference of 3 mm or less were grouped as group A and those with a difference of more than 3 mm were grouped as group B.ResultsThere was no statistically significant difference between the groups in terms of age, gender, follow-up time, time from injury to surgery, return to work, and distribution of Rockwood classification. Pre-operative CC distance was reduced from 18.7 ± 3.5 to 8.5 ± 0.6 in the early postoperative period. Anatomic reduction was achieved in all patients compared with the unaffected side (CC distance 8.6 ± 0.7). However, the CC distance increased to 9.9 ± 1.5 at the third-month follow-up and increased to 11 ± 2.7 at the last follow-up. There were no significant Constant score differences between the groups in the preoperative and last follow-up periods (p > 0.05). At the last follow-up, the mean Acromioclavicular Joint Instability (ACJI) score of group A was 84.4 ± 8, whereas it was 68.3 ± 8.3 for group B, and the difference was statistically significant (p < 0.01). Furthermore, the subjective evaluation and aesthetic subjective satisfaction values of group B were lower than group A (p < 0.01).ConclusionsReduction loss of more than 3 mm was observed in 25% of patients after arthroscopic fixation of acute acromioclavicular dislocations using a double-button device. Although this loss did not create a statistically significant difference in Constant scores, AC joint-specific tests such as ACJI, subjective evaluation, and aesthetic subjective satisfaction values were significantly impaired.

The use of a synthetic shoulder patch for large and massive rotator cuff tears \u2013 a feasibility study

BackgroundThe aim of this study was to explore the feasibility of using a non-absorbable biocompatible polyester patch to augment open repair of massive rotator cuff tears (Patch group) and compare outcomes with other treatment options (Non-patch group).MethodsParticipants referred to orthopaedic clinics for rotator cuff surgery were recruited. Choice of intervention (Patch or Non-patch) was based on patient preference and intra-operative findings. Oxford Shoulder Score (OSS), Shoulder Pain and Disability Index (SPADI), and Constant score were completed at baseline and 6 months. Shoulder MRI was performed at baseline and 6 months to assess fat fraction and Goutallier classification pre- and post- treatment. Feasibility outcomes (including retention, consent and missing data) were assessed.ResultsSixty-eight participants (29 in the Patch group, 39 in Non-patch group) were included (mean age 65.3 years). Conversion to consent (92.6%), missing data (0% at baseline), and attrition rate (16%) were deemed successful feasibility endpoints. There was significant improvement in the Patch group compared to Non-patch at 6 months in OSS (difference in medians 9.76 (95% CI 2.25, 17.29) and SPADI: 22.97 (95% CI 3.02, 42.92), with no substantive differences in Constant score. The patch group had a higher proportion of participants improving greater than MCID for OSS (78% vs 62%) and SPADI (63% vs 50%) respectively. Analysis of the 48 paired MRIs demonstrated a slight increase in the fat fraction for supraspinatus (53 to 55%), and infraspinatus (26 to 29%) at 6 months. These differences were similar and in the same direction when the participants were analysed by treatment group. The Goutallier score remained the same or worsened one grade in both groups equally.ConclusionsThis study indicates that a definitive clinical trial investigating the use of a non-absorbable patch to augment repair of massive rotator cuff tears is feasible. In such patients, the patch has the potential to improve shoulder symptoms at 6 months.Trial registrationISRCTN, ISRCTN79844053, Registered 15th October 2014 (retrospectively registered).

PROXIMAL HUMERAL FRACTURES TREATED WITH OSTEOSYNTHESIS USING THE ANTEROLATERAL APPROACH.

ABSTRACTObjective:The main surgical approach in proximal humeral fractures is the deltopectoral approach. Many surgeons avoid the anterolateral approach, fearing its complications, especially axillary nerve injury. The objective of this study is to evaluate shoulder function and complications in patients with proximal humeral fractures treated using an anterolateral approach with direct observation of the axillary nerve.Methods:Retrospective study with postoperative radiological and functional evaluations (Constant and DASH scores) and review of the complications. The associations between fracture classification and the difference in Constant scores among the subjects and the final angle of consolidation were analyzed using Fisher's test or analysis of variance (ANOVA). The Constant scores were compared among the shoulders using the paired t-test.Results:The study evaluated 35 patients. Shoulder function was decreased, compared with the contralateral side (p<0.005). The only factor related to functional worsening was the Neer IV fracture. The main complication was malunion. There were no clinical changes related to the axillary nerve.Conclusion:The treatment using the extended anterolateral approach produced good functional results, although the function was decreased (Neer IV fractures). The main complication was malunion. There were no side effects due to exposure of the axillary nerve. Level of evidence III, Retrospective Study.

Shoulder Arthroscopy With Versus Without Suprascapular Nerve Release: Clinical Outcomes and Return to Sport Rate in Elite Overhead Athletes

To compare the clinical outcomes and return to sport rate between elite overhead athletes who underwent shoulder arthroscopy and decompression of the suprascapular nerve (SSN) versus overhead athletes who underwent shoulder arthroscopy without SSN release. From 2007 to 2014, high-level overhead athletes diagnosed with a rotator cuff tear and/or a glenoid labral lesion and SSN entrapment were included in the study if their symptoms did not improve with nonoperative treatment and if they agreed to undergo surgery and participate. Their preoperative University of California at Los Angeles (UCLA) shoulder score, bilateral postoperative Constant scores, postoperative UCLA score, and return to sport rate were evaluated and compared with those of a group of elite athletes who had a similar diagnosis but refused to undergo SSN decompression during shoulder arthroscopy. Thirty-five athletes (25 male, 10 female) were included in the SSN decompression group (group 1), and 21 athletes were included in the non-SSN decompression group (group 2). The mean age was 27years (range: 19-34) and 24years (range: 21-32) in group 1 and group 2, respectively (P= .56). The mean follow-up time was 38.4months (24-50months) in group 1 and 42.2months (26-53months) in group 2 (P= .09). Both groups had significantly improved UCLA scores after surgery (P < .05). The postoperative UCLA (P= .01) and Constant scores (P < .001) were significantly higher in the SSN decompression group. The mean difference in Constant score between the affected and the unaffected side was 4 points (range: 2-12) in the SSN decompression group and 8 points (range: 4-14) in the non-SSN decompression group postoperatively (P= .0002). In both groups, 100% of patients reached the patient acceptable symptom state value for Constant score at follow-up. For the UCLA score, patients who underwent SSN decompression had significantly higher pre- to postoperative improvement than the nondecompression group (P= .016). The return to sport rate was 97% in group 1 and 84% in group 2. The mean length of career was 2.1years (range: 1.5-2.4years) and 2.3years (range: 1.2-3.2years) in group 1 and group 2, respectively. In elite overhead athletes with shoulder pathology and SSN entrapment, combined shoulder arthroscopy and SSN release yield superior clinical outcomes, greater improvement in UCLA score, and a higher return to sport rate than shoulder arthroscopy without SSN decompression. Regardless of SSN treatment, both groups achieved the patient acceptable symptom state after shoulder arthroscopy. Level III, comparative case series.

A comparative study of displaced midshaft clavicle fracture managed by precontoured locking compression plates and titanium elastic nails

Background: Results of conservatively managed mid-shaft clavicle fractures are not as good as previously thought. This has lead to increasing interest in primary fixation of these fractures. There are two main techniques of internal fixation, namely, plate fixation and intra-medullary nail fixation. We have evaluated pre-contoured locking compression plates and titanium elastic nails for fixation of mid-shaft clavicle fractures and compared their results. Material and Methods: Between July 1st 2015 and June 30th 2017 42 cases of unilateral displaced mid-shaft clavicular fracture were studied. 23 were managed by open reduction internal fixation with pre-contoured locking compression plates and 19 were managed by closed or open reduction and internal fixation by Titanium Elastic nails. Patients were followed up monthly for 4 months and at 6 months and 9 months. Final results were computed at end of 6 months. Functional outcome was compared using Constant Score. Other complications like non-union, delayed union, infection, implant failure, hardware prominence, refracture and wound dehiscence were also studied. Results: There was significant difference in constant score of two group with plating group performing better. Nail impingement was major concern after intra-medullary nailing. Union time was slightly better in nailing group. Conclusion: Pre-contoured locking compression plates gave better functional outcome and were associated with complications in fewer cases as compared to titanium elastic nails when used for surgical fixation of displaced mid-shaft clavicle fractures.

Clinical outcomes and structural integrity of arthroscopic double-row versus suture-bridge repair for rotator cuff tears

The purpose of this study was to compare clinical outcomes and retear rate between arthroscopic double row (DR) and suture bridge (SB) repair for rotator cuff tears. Postoperative Constant score and MRI findings were compared between 52 patients underwent DR repair and 63 patients underwent SB repair with medium tear of the supraspinatus. There was no significant difference in Constant score between the two groups. Postoperative MRI revealed that retear rate of SB group was significantly lower than DR group. This study suggests that SB repair can provide better clinical and structural outcomes compared with DR repair.

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

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. 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. 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. 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.

Partial repair in irreparable rotator cuff tear: our experience in long-term follow-up.

Massive rotator cuff tears are a common source of shoulder pain and dysfunction, especially in middle age patient; these lesions represent about 20% of all rotator cuff tears and 80% of recurrent tears. Some lesions are not repairable or should not be repaired: in this case, a rotator cuff partial repair should be recommended. The aim of the study is to evaluate the outcome of rotator cuff partial repair in irreparable rotator cuff massive tear at medium and long-term follow-up. We have evaluated 74 consecutive patients treated with functional repair of rotator cuff by the same surgeon between 2006 and 2014. We divided patients into 2 groups, obtaining 2 average follow-up: at about 6,5 (group A) and 3 years (group B). In December 2015, we evaluated in every patient ROM and Constant Score. We analyzed difference between pre-operatory data and the 2 groups. Results: We found statistical significant difference in ROM and in Constant Score between pre-operatory data and group A and group B. Between group A and group B there is relevant difference in Constant Score but not in ROM. Partial repair can give good results in a medium follow-up, in terms of pain relief and improvement of ROM, as well as in quality of life. Difference in ROM and Constant Score between group A and group B may indicate the begin of partial repair failure; according to our data, 6-7 years may be the time limit for this surgery technique.

Proximal humeral fractures: non-operative treatment versus intramedullary nailing in 2-, 3- and 4-part fractures

BackgroundLittle is known about non-operative treatment of proximal humerus 4-part and severe displaced fractures as those are normally treated operatively. In this study, we present a historical collective of two level I trauma centers, where all humeral head fractures, despite displaced fractures, received non-operative treatment within a 10 years period. Functional and clinical results of 2-, 3- and 4-part fractures were compared to those after fixed angle intramedullary nailing by matched pair analysis. MethodsBetween 2000 and 2010, 167 patients with 2-, 3- and 4-part humeral head fractures were treated non-operatively in two level I trauma centers in Rostock. Complete clinical, functional and radiographic follow-up were available for 41 patients in the retrospective analysis. The results were compared by matched-pair analysis to a prospective series of 143 patients treated by antegrade intramedullary nailing using a proximal humeral nail. Of these 143 patients complete radiological and clinical 12 months’ follow-up was available for 117 patients. Thus, it was possible to built 41 pairs according to age, gender, and fracture type. Statistical significant differences in constant score (CS), pain, activity of daily living (ADL), range of motion (ROM) and muscle strength were evaluated by Wilcoxon test. Furthermore, x-ray analysis of fracture healing and complications were recorded. ResultsOperative treatment was not superior to non operative treatment concerning functional results, even in displaced fractures. The only significant difference was found in 3-part-fractures, where better ROM was reached in the non-operative group (p = 0.05). In contrast, there was a tendency toward better activity of daily living (ADL) in intramedullary nailing, but this did not reach statistical significance. X-ray findings revealed better anatomical reconstruction with less valgus and varus displacements after surgery (15% versus 50%, p < 0.005). The complication rate of 37% was higher in the surgery group with a reoperation rate of 32%. ConclusionIn our study, surgical treatment by fixed angle intramedullary nailing (Targon PH) seems not to be superior to non-operative treatment, regardless of fracture type. In 2-, 3- and 4-part fractures functional and clinical results were similar.