Incidence of avascular necrosis following biceps tenodesis during proximal humerus open reduction and internal fixation

Avascular necrosis (AVN) may occur in up to 77% of proximal humeral fractures and can cause fixation failure. Risk factors include fracture position, calcar length and medial hinge integrity. We routinely perform intra-articular biceps tenotomy with tenodesis at the level of pectoralis major to facilitate fragment identification and potentially ameliorate post-operative pain relief. Concern exists that tenotomising the biceps damages the adjacent arcuate artery, potentially increasing the rate of AVN. The purpose of this study was to evaluate whether biceps tenodesis is associated with an increased risk of radiographically evident humeral head AVN. 61 fractures surgically treated over a 52-month period were retrospectively reviewed and radiographically assessed in accordance with Neer’s classification, calcar-length and medial hinge integrity. 40, 20 and 1 were four-, three- and two-part fractures respectively. 37 had a calcar-length less than 8mm and 26 suffered loss of the medial hinge. The median radiographic follow-up was 23 months. There was radiographic evidence of humeral head AVN in only one case, comparing favourably to rates quoted in current literature. In our experience, intra-articular biceps tenotomy with the deltopectoral approach was thus not associated with a significantly increased risk of humeral head AVN, even in complex four-part fractures.

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Surgical treatment of degenerative and traumatic spinal diseases with expandable screws in patients with osteoporosis: 2-year follow-up clinical study

Journal of Neurosurgery Spine ◽

10.3171/2016.3.spine151294 ◽

2016 ◽

Vol 25 (5) ◽

pp. 610-619 ◽

Cited By ~ 15

Author(s):

Roberto Gazzeri ◽

Raffaelino Roperto ◽

Claudio Fiore

Keyword(s):

Pedicle Screw ◽

Spinal Instrumentation ◽

Pedicle Screws ◽

Posterior Fixation ◽

Spinal Diseases ◽

Fixation Failure ◽

Increased Risk ◽

Screw Breakage ◽

The Mean

OBJECTIVE Pedicle screw instrumentation of the osteoporotic spine carries an increased risk of screw loosening, pullout, and fixation failure. A variety of techniques have been used clinically to improve pedicle screw fixation in the presence of compromised bone. Pedicle screws may be augmented with cement, but this may lead to cement leakage and result in disastrous consequences. To avoid these complications, a multiaxial expandable pedicle screw has been developed. This was a prospective, single-center study designed to evaluate the clinical results of patients with osteoporosis with traumatic and degenerative spinal diseases treated with expandable pedicle screws. METHODS Thirty-three patients (mean age 61.4 years) with osteoporosis and traumatic or degenerative spinal diseases underwent spinal posterior fixation with expandable screws. Preoperative and postoperative visual analog scale (VAS) for pain and Oswestry Disability Index (ODI) questionnaire scores were obtained. The immediate postoperative screw position was measured and compared with the final position on lateral plain radiographs and axial CT scans at the 1- and 2-year follow-up examinations. RESULTS A total of 182 pedicle screws were used, including 174 expandable and 8 regular screws. The mean preoperative patient VAS score improved from 8.2 to 3.6 after surgery. The mean ODI score improved from 83.7% before surgery to 29.7% after the operation and to 36.1% at the final follow-up. No screw migration had occurred at the 1-year follow-up, but 1 screw breakage/migration was visualized on spinal radiography at the 2-year follow-up. CONCLUSIONS The results of this study show that the multiaxial expandable pedicle screw is a safe and practical technique for patients with osteoporosis and various spinal diseases and adds a valuable tool to the armamentarium of spinal instrumentation.

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Increased risk for coronary heart disease after avascular necrosis of femoral head: A 3-year follow-up study

American Heart Journal ◽

10.1016/j.ahj.2010.02.020 ◽

2010 ◽

Vol 159 (5) ◽

pp. 803-808.e1 ◽

Cited By ~ 9

Author(s):

Jiunn-Horng Kang ◽

Herng-Ching Lin

Keyword(s):

Coronary Heart Disease ◽

Heart Disease ◽

Femoral Head ◽

Avascular Necrosis ◽

Follow Up Study ◽

Increased Risk ◽

Necrosis Of Femoral Head

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Results of Arthroplasty for Avascular Necrosis of the Humeral Head in Sickle Cell Patients.

Blood ◽

10.1182/blood.v106.11.3809.3809 ◽

2005 ◽

Vol 106 (11) ◽

pp. 3809-3809

Author(s):

Michelle W. Lau ◽

Leesa M. Galatz ◽

Kimberly Williams ◽

Morey A. Blinder

Keyword(s):

Sickle Cell Disease ◽

Avascular Necrosis ◽

Sickle Cell ◽

Shoulder Arthroplasty ◽

Humeral Head ◽

Cell Disease ◽

Assessment Scores ◽

The Mean ◽

Operative Assessment

Abstract Avascular necrosis (AVN) of the humeral head is a debilitating complication of sickle cell disease (SCD) estimated to occur in ~5% of patients for which the optimal therapy is not well defined. Although shoulder replacement is often used for AVN in other settings, little information is available about the outcome of shoulder arthroplasty in this population. In this study, medical records, radiographs, and pre-operative assessment scores of eight adult patients with sickle cell disease were reviewed. Post-operative assessment scores and radiographs were prospectively collected by an independent observer at follow-up appointments. All eight patients had >2 years of follow up. The mean age of the patients at the time of surgery was 37 years old and there were 4 males and 4 females. Six of the patients had Hgb SS, one had Hgb SC and one had Hgb Sβ+ thalassemia. The average duration of symptoms prior to surgery was 26 months. Based on pre-operative shoulder radiographs, 5 of 7 evaluable patients had grade 3 or greater disease. Seven of eight patients had a hemiarthroplasty and one patient had a total arthroplasty. The mean follow up was 51 months. Complications included two episodes of sickle cell crises in the immediate post-operative period, and one intraoperative rotator cuff tear. One patient developed stiffness that required arthroscopic capsular release 22 months after his initial surgery. No infections were seen in the operated shoulder and no shoulder revisions were performed. At the most recent follow-up, the average American Shoulder and Elbow Society (ASES) score improved 31 points, indicating substantial functional improvement (J Shoulder Elbow Surg. 3(6):347–352, 1994). However, only 25% of the patients reported improvement in pain as assessed by a visual analog scale. While two patients had dramatic improvements in all aspects of our outcome measures, two other patients had decreased functional capacity with no improvement in pain. Radiographs at the most recent follow up revealed slight loosening of the prosthetic stem in one patient but no other radiographic complications. In conclusion, shoulder arthroplasty provides improvements in range of motion and joint function in the majority of patients. However, pain relief is less predictable, suggesting that other causes of sickle cell related pain are occuring. Nevertheless, given the limited options available for the treatment of AVN in sickle cell patients who have failed conservative approaches, shoulder arthroplasty is a reasonable treatment option.

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Transosseous Suture Fixation of True 4-part Valgus Impacted Fractures of the Proximal Humerus: Clinical and Radiological Outcome in 49 Patients

The Open Orthopaedics Journal ◽

10.2174/1874325001812010041 ◽

2018 ◽

Vol 12 (1) ◽

pp. 41-52

Author(s):

Andreas Panagopoulos ◽

Irini Tatani ◽

Seferlis Yannis ◽

Bavelou Aikaterini ◽

Antonis Kouzelis ◽

...

Keyword(s):

Avascular Necrosis ◽

Humeral Head ◽

Proximal Humerus ◽

Constant Score ◽

Reverse Shoulder Arthroplasty ◽

Proximal Part ◽

Shoulder Function ◽

Functional Score ◽

Invasive Technique

Background: The valgus-impacted (VI) 4-part fractures are a subset of fractures of the proximal humerus with a unique anatomic configuration characterized by a relatively lower incidence of avascular necrosis after operative intervention. Objectives: The present study reports the midterm clinical and radiological results of a large series of consecutive patients with 4-part VI fractures treated with a minimal invasive technique of internal fixation. Methods: Over a ten-year period (2004-2014), we treated 56 patients with a true 4-part valgus impacted fracture of the proximal part of the humerus. Four patients were lost to follow-up and three died, leaving 49 patients (33 female, 16 males, average age 60,1 years) available for the study. Fracture fixation was achieved through the lateral transdeltoid approach with transosseous suturing of the tuberosities to each other, to the metaphysis and to the articular part of the humeral head avoiding gross disimpaction of the humeral head from the valgus position. Functional outcome assessment was performed using the parameters of the Constant-Murley score within a mean follow up period of 43,8 months (range, 24 to 115 months). Results: All fractures were united within the first 3 months except one that showed late displacement and finally nonunion. The median Constant score was 81,7 points and the functional score in comparison with the unaffected shoulder was 86.2%. There were three patients with total Avascular Necrosis (AVN) of the head revised to hemiarthroplasty. The nonunion case was revised to reverse shoulder arthroplasty 12 months after surgery. In five cases, absorption of the greater tuberosity was noted in the last radiographic control without any serious consequences to the shoulder function. Conclusion: Advantages of this minimally invasive technique can be summarized as shorter operative time, no use of hardware, minimal soft tissue damage, low incidence of avascular necrosis, stable osteosynthesis with “tension band effect” and adequate rotator cuff repair allowing for early joint motion.

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Biceps Tenodesis versus Tenotomy at the Time of Manipulation and Lysis of Adhesions for Adhesive Capsulitis

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00389 ◽

2019 ◽

Vol 7 (7_suppl5) ◽

pp. 2325967119S0038

Author(s):

Jourdan M. Cancienne ◽

James E. Christensen ◽

David R. Diduch ◽

Stephen F. Brockmeier ◽

Brian C. Werner

Keyword(s):

Outcome Measure ◽

Adhesive Capsulitis ◽

Secondary Outcome ◽

Categorical Variables ◽

Secondary Outcome Measure ◽

Biceps Tenodesis ◽

Biceps Tenotomy ◽

Increased Risk ◽

Significant Difference ◽

Chi Square Analysis

Objectives: Although rare in the treatment of adhesive capsulitis, arthroscopic lysis of adhesions and manipulation under anesthesia (LOA/MUA) may be necessary if the patient fails conservative therapy. Patients at the time of surgery often have biceps tendon, superior labrum anterior to posterior (SLAP) pathology, or other pathology requiring concurrent treatment. Common treatments for these can include biceps tenodesis or tenotomy. Some surgeons believe that concomitant repairs at the time of LOA/MUA can cause increased stiffness post-operatively due to need for immobilization or protection, possibly leading to poorer outcomes and potentially needing further interventions such as repeat injections or repeat LOA/MUA. The goal of this study was to compare patients who underwent LOA/MUA with biceps tenodesis to those who underwent LOA/MUA with biceps tenotomy. We hypothesized that biceps tenodesis at the time of LOA/MUA did not lead to an increased risk for further intervention in the form of post-operative injections for pain or stiffness or repeat LOA/MUA compared to biceps tenotomy. Methods: A retrospective review of consecutive LOA/MUA for adhesive capsulitis performed by 5 surgeons at a single center from 2010-2016 was performed. All included patients were required to have a minimum of 1 year of follow-up, and be a minimum 2 years post-procedure. Exclusion criteria included prior biceps tenodesis, surgery within six months prior to LOA/MUA, prior infection, prior shoulder fracture or fracture fixation, and concomitant rotator cuff repair. Patients without any biceps surgery (tenotomy or tenodesis) were also excluded. The primary outcome measure was a postoperative injection in the ipsilateral shoulder for recurrent adhesive capsulitis, pain or residual stiffness. The secondary outcome measure was a repeat LOA/MUA. Statistical analysis was completed in SPSS using a chi-square analysis for categorical variables and a student’s t-test for continuous variables. Results: Fifty-five patients were included in the study. Thirty-three patients underwent biceps tenotomy, and 22 patients underwent biceps tenodesis at the time of arthroscopic LOA/MUA. The average age in the tenotomy group was 53 years and 47 years in the tenodesis group (p = 0.383). There was no significant difference in the percentage of males in the tenodesis group (59%) versus tenotomy (48%) (p = 0.440). Average body mass index (BMI) was not significantly different between the two groups (p = 0.329). No patients from either group underwent repeat LOA/MUA. Of those patients who received a biceps tenotomy, 39% had an injection for pain or stiffness post-operatively compared to 18% for biceps tenodesis, which was not significant (p=0.17). Table 1 summarizes the outcomes in both groups. Conclusion: Patients who underwent biceps tenodesis with concurrent arthroscopic LOA/MUA for adhesive capsulitis did not have a higher rate of postoperative injections or repeat LOA/MUA compared to patients who underwent biceps tenotomy at the time of LOA/MUA. [Table: see text]

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Results at 3-year follow-up of totally extraperitoneal (TEP) hernia surgery with long-term resorbable mesh

Hernia ◽

10.1007/s10029-019-02116-2 ◽

2020 ◽

Vol 24 (3) ◽

pp. 669-676 ◽

Cited By ~ 1

Author(s):

F. Ruiz-Jasbon ◽

K. Ticehurst ◽

J. Ahonen ◽

J. Norrby ◽

P. Falk ◽

...

Keyword(s):

Clinical Examination ◽

Negative Effects ◽

Hernia Surgery ◽

Tep Repair ◽

Post Operative Pain ◽

Increased Risk ◽

Permanent Implants ◽

Almost All

Abstract Introduction Synthetic non-resorbable mesh is almost standard in hernia surgery. However, several studies have showed negative effects of permanent implants such as chronic inflammation and complications involving different organs bordering the mesh. Such complications can raise the risk of chronic post-operative pain (CPP). Recently promising results regarding CPP have been published in patients with Lateral Inguinal Hernia (LIH) using a slowly resorbable mesh in Lichtenstein technique. For this reason the aim of the present study was to find the effect of a slowly resorbable implant on the long-term rate of hernia recurrence and chronic post-operative pain in patients with LIH repaired with TEP procedure. Methods Prospective pilot study of TEP repair using TIGR® Matrix Surgical Mesh in 35 primary LIH. At 3-year follow-up the Visual Analogue Scale (VAS) and the Inguinal Pain Questionnaire were employed to assess pain. Recurrence was determined by ultrasound and clinical examination. Results All patients completed the pain questionnaires but one patient did not attend the planned clinical examination for the 3-year follow-up. No patients had CPP, as defined in the World Guidelines for Groin Hernia Management. Almost all patients had lower VAS score in any activity 3 years following surgery in comparison to the preoperative period. Three patients (8.8%) suffered symptomatic recurrence during the 3-year follow-up. Conclusion TEP repair in patients with LIH using a synthetic long-term resorbable mesh was found to be encouraging respecting chronic post-operative pain at 3-year follow-up but at the cost of an increased risk of recurrence.

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Clinical and Radiological Results of Hemiarthroplasty and Total Shoulder Arthroplasty for Primary Avascular Necrosis of the Humeral Head in Patients Less Than 60 Years Old

Journal of Clinical Medicine ◽

10.3390/jcm10143081 ◽

2021 ◽

Vol 10 (14) ◽

pp. 3081

Author(s):

Anthony Hervé ◽

Mickael Chelli ◽

Pascal Boileau ◽

Gilles Walch ◽

Luc Favard ◽

...

Keyword(s):

Clinical Outcomes ◽

Avascular Necrosis ◽

Shoulder Arthroplasty ◽

Humeral Head ◽

Revision Rate ◽

Total Shoulder Arthroplasty ◽

Young Patients ◽

Clinical And Radiological Results ◽

Glenoid Loosening

Background: Total shoulder arthroplasty (TSA) and hemiarthroplasty (HA) have shown good clinical outcomes in primary avascular necrosis of the humeral head (PANHH) both in short and long terms. The purpose of this study was to assess the complications, the clinical and radiological outcomes of shoulder arthroplasty in young patients with PANHH. Methods: One hundred and twenty-seven patients aged under 60 years old and suffering from PANHH were operated with arthroplasty. Patients were assessed clinically and radiographically before surgery with a minimum of 2 years of follow up (FU). Results: HA was performed on 108 patients (85%). Two patients were revised for painful glenoid wear after 2 and 4 years. TSA was performed on 19 patients (15%). Five TSA had to be revised for glenoid loosening (n = 4) or instability (n = 1). Revision rate was 26% with TSA and 2% with HA. There were no significant differences between HA and TSA in terms of clinical outcomes. Conclusions: With a mean FU of 8 years, HA and TSA improved clinical outcomes of patients with PANHH. HA revisions for painful glenoid wear were rare (2%). The revision rate was excessively high with TSA (26%).

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