Hombro/Shoulder/Shulter/Épaule: Peor si tiene sobrepeso

Obesity is associated with increased postoperative complications after operative management of proximal humerus fractures
Brian C. Werner, Justin W. Griffin, Scott Yang, Stephen F. Brockmeier, F. Winston Gwathmey
Journal of Shoulder and Elbow Surgery
Published Online: October 30, 2014

Background
Obesity has become a significant public health concern in the United States. The goal of this study was to assess the effect of obesity on postoperative complications after operative management of proximal humerus fractures by use of a national database.

Methods
Patients who underwent operative management of a proximal humerus fracture were identified in a national database by Current Procedural Terminology codes for procedures in patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for proximal humerus fracture, including (1) open reduction and internal fixation, (2) intramedullary nailing, (3) hemiarthroplasty, and (4) total shoulder arthroplasty. These groups were then divided into obese and nonobese cohorts by use of ICD-9 codes for obesity, morbid obesity, or body mass index >30. Each cohort was then assessed for local and systemic complications within 90 days and mortality within 2 years postoperatively. Odds ratios and 95% confidence intervals were calculated.

Results
From 2005 to 2011, 20,319 patients who underwent operative management of proximal humerus fractures were identified, including 14,833 (73.0%) open reduction and internal fixation, 1368 (9.2%) intramedullary nail, 3391 (16.7%) hemiarthroplasty, and 727 (3.6%) shoulder arthroplasty. Overall, 3794 patients (18.7%) were coded as obese, morbidly obese, or body mass index >30. In each operative group, obesity was associated with a substantial increase in local and systemic complications.

Conclusions
Obesity and its resultant medical comorbidities are associated with increased rates of postoperative complications after operative management of proximal humerus fractures. Obese patients for whom operative management of proximal humerus fractures is planned should be counseled preoperatively about their increased risk for postoperative complications.

Level of evidence:
Level III, Retrospective Cohort Design from Large Database, Treatment Study

Hombro/Shoulder/Schulter/Épaule: En casos dolorosos de pseudoartrosis de húmero proximal, prótesis invertida

Reverse total shoulder replacement for nonunion of a fracture of the proximal humerus
Zafra, M., Uceda, P., Flores, M., Carpintero, P.
Bone Joint J 2014;96-B:1239–43

Patients with pain and loss of shoulder function due to nonunion of a fracture of the proximal third of the humerus may benefit from reverse total shoulder replacement.

This paper reports a prospective, multicentre study, involving three hospitals and three surgeons, of 35 patients (28 women, seven men) with a mean age of 69 years (46 to 83) who underwent a reverse total shoulder replacement for the treatment of nonunion of a fracture of the proximal humerus.

Using Checchia’s classification, nine nonunions were type I, eight as type II, 12 as type III and six as type IV. The mean follow-up was 51 months (24 to 99). Post-operatively, the patients had a significant decrease in pain (p < 0.001), and a significant improvement in flexion, abduction, external rotation and Constant score (p < 0.001), but not in internal rotation. A total of nine complications were recorded in seven patients: six dislocations, one glenoid loosening in a patient who had previously suffered dislocation, one transitory paresis of the axillary nerve and one infection.

Reverse total shoulder replacement may lead to a significant reduction in pain, improvement in function and a high degree of satisfaction. However, the rate of complications, particularly dislocation, was high.

Hombro / Shoulder / Schulter: Un repaso de las complicaciones de las PTHi

Problems, complications, reoperations, and revisions in reverse total shoulder arthroplasty: A systematic review

Matthias A. Zumstein, Miguel Pinedo, Jason Old, Pascal Boileau

The use of hemiarthroplasty in patients with an arthritic rotator cuff deficient shoulder has been shown to provide limited function and inconsistent pain relief.

The semiconstrained reverse shoulder prosthesis, designed by Grammont in the late 1980s, was invented based on 2 biomechanical concepts: lowering the humerus and medialization of the center of rotation at the glenoid component. This design has the dual advantage of tensioning the deltoid muscle to increase its functional strength, and decreasing mechanical torque at the glenoid component, thus avoiding glenoid loosening. The first series of reverse shoulder arthroplasty (RSA) with at least 2 years of follow-up confirmed the preliminary results, with excellent functional outcome and stable glenoid fixation. However, these series had a small numbers of patients and reported variable compli-cation and revision rates of 15% to 50% and reoperation rates of 4% to 40%. One reason for the high variability was unclear definitions of complications and revisions, which varied markedly between the series. Furthermore, it is difficult to draw conclusions from small numbers of patients.

The purpose of the present study was to determine the incidence and functional significance of adverse events after RSA, including problems, complications, reopera-tions, and revisions. We established a study design and specific objectives before commencing the literature research. These objectives were (1) to perform a systematic review of the published literature to determine the overall rates of problems, complications, reoperations, and revi-sions after RSA; (2) to compare their influence on the final functional outcome; and, (3) to analyze the different problems, complications, reoperations, and revisions based on the etiology of the RSA

Hombro / Shoulder / Schulter: El subescapular implicado en la inestabilidad de la PTHi

Instability after reverse total shoulder replacement.

Gallo RA, Gamradt SC, Mattern CJ, Cordasco FA, Craig EV, Dines DM, Warren RF

J Shoulder Elbow Surg 2011 Jun; 20(4):584-90.

Abstract

BACKGROUND

Despite advances in technique and implant design, instability after reverse total shoulder arthroplasty remains a challenging postoperative complication.

MATERIALS AND METHODS

We examined our institutions' first 57 reverse total shoulder arthroplasties performed during a 3-year period (2004-2006). There were 9 cases of instability, all occurring within the first 6 months after surgery.

RESULTS

All 9 patients had compromise of the subscapularis tendon at the time of initial reverse total shoulder implantation. With regard to implant positioning, 2 patients had superiorly inclined metaglenes and 3 had metaglenes positioned superior to the inferior glenoid. Each patient with a dislocation had at least 1 revision surgery, and 4 patients had underlying infection. At most recent follow-up, only 3 patients had a concentrically reduced reverse total shoulder arthroplasty in place whereas 3 remained explanted, 2 chronically dislocated, and 1 chronically subluxated.

CONCLUSIONS

Early instability after reverse total shoulder arthroplasty can be related to inadequate soft tissue, inadequate deltoid tension, malpositioned implants, and/or infection, and outcomes of treatment of early instability are generally poor.

Hombro / Shoulder: Menos luxaciones si se inclina hacia abajo la glenosfera

Optimal glenoid component inclination in reverse shoulder arthroplasty. How to improve implant stability.

Randelli P, Randelli F, Arrigoni P, Ragone V, D'Ambrosi R, Masuzzo P, Cabitza P, Banfi G

Musculoskelet Surg 2014 Mar 23.

Abstract

PURPOSE

The purpose of this study is to demonstrate that inferior inclination of the glenosphere is a protecting factor from joint dislocation in reverse total shoulder replacement. The hypothesis is that an average of 10° of inferior inclination of the glenoid component would determine a significant inferior rate of dislocation as compared to neutral inclination.

METHODS

A retrospective case (dislocation)-control (stability of the implant) study was performed. Inclusion criteria were the homogeneity of the prosthetic model and availability of pre- and postoperative imaging of the shoulder, including antero-posterior and axillary X-ray views. Glenoid and glenosphere inclination were calculated according to standardized methods. Difference in between the angles determined the inferior tilt.

RESULTS

Thirty-three cases fit the inclusion criteria. Glenoid and glenosphere inclination measured, respectively, 74.1° and 83.5°. The average tilt of the glenosphere measured 9.4°. The average tilt in stable patients was 10.2°. Tilt in patients with atraumatic dislocation measured, respectively, -6.9° (superior tilt) and 2.4°, while it was 8.3° for the patient with traumatic instability. The association between the tilt of glenosphere and atraumatic dislocation was significant.

CONCLUSIONS

A 10° inferior tilt of the glenoid component in reverse shoulder arthroplasty is associated with a reduced risk of dislocation when compared to neutral tilt.