Technical note: subscapularis-sparing approach to perform anatomic total shoulder arthroplasty using a multiplanar humeral osteotomy and angled glenoid instruments

Background Anatomic total shoulder arthroplasty is typically performed through the deltopectoral approach followed by either a subscapularis tenotomy, tendon peel, or lesser tuberosity osteotomy to provide adequate exposure. These subscapularis-takedown methods have been associated with incomplete subscapularis healing, however, and as a result often lead to functional deficits and complications. Subscapularis-sparing approaches have been introduced to mitigate these complications, but thus far have either been limited to hemiarthroplasty or resulted in residual inferior humeral head osteophytes and humeral component size mismatch. The present technique demonstrates the possibility for surgeons to capitalize on the improved patient outcomes that are afforded by subscapularis-sparing approaches, while still utilizing the deltopectoral interval to perform a total glenohumeral joint arthroplasty. Methods This article describes in detail the placement of a stemless anatomic TSA with the use of angled glenoid instruments through a subscapularis-sparing deltopectoral approach. Postoperatively, patients are placed in a sling but are instructed to remove as tolerated, as early as the 1st postoperative week. Physical therapy is started at week 1 with a 4-phase progression. Conclusions This technique using a TSA system with a polyaxial glenoid reamer and angled pegs on the backside of the glenoid allows the potential for maintenance of the strong postoperative radiographic and patient-reported outcomes that are achieved using traditional TSA approaches, with the advantage of accelerated rehabilitation protocols and decreased risk of subscapularis insufficiency that result from the use of subscapularis-sparing approaches.

Stress shielding following stemless anatomic total shoulder arthroplasty

Background Finite element analysis has suggested that stemless implants may theoretically decrease stress shielding. The purpose of this study was to assess the radiographic proximal humeral bone adaptations seen following stemless anatomic total shoulder arthroplasty. Methods A retrospective review of 152 prospectively followed stemless total shoulder arthroplasty utilizing a single implant design was performed. Anteroposterior and lateral radiographs were reviewed at standard time points. Stress shielding was graded as mild, moderate, and severe. The effect of stress shielding on clinical and functional outcomes was assessed. Also, the influence of subscapularis management on the occurrence of stress shielding was determined. Results At 2 years postoperatively, stress shielding was noted in 61 (41%) shoulders. A total of 11 (7%) shoulders demonstrated severe stress shielding with 6 occurring along the medial calcar. There was one instance of greater tuberosity resorption. At the final follow-up, no humeral implants were radiographically loose or migrated. There was no statistically significant difference in clinical and functional outcomes between shoulders with and without stress shielding. Patients undergoing a lesser tuberosity osteotomy had lower rates of stress shielding, which was statistically significant ( p = 0.021) Discussion Stress shielding does occur at higher rates than anticipated following stemless total shoulder arthroplasty, but was not associated with implant migration or failure at 2 years follow-up. Level of evidence IV, Case series.

Effect of Electroacupuncture on Shoulder Subluxation in Poststroke Patients with Hemiplegic Shoulder Pain: A Sham-Controlled Study Using Multidimensional Musculoskeletal Ultrasound Assessment

Objective. This study aimed to use multidimensional musculoskeletal ultrasound imaging technique to investigate the effect of electroacupuncture (EA) on shoulder subluxation in poststroke patients with hemiplegic shoulder pain. Methods. In this prospective single-blind, randomized, sham-controlled study, thirty-four patients with shoulder subluxation and hemiplegic shoulder pain were recruited and randomly assigned into the EA group or the sham EA (SEA) group. In the EA group, EA was applied to the Jian yu (LI15), Bi nao (LI14), Jian zhen (SI9), and Jian liao (TE14) acupoints. In the SEA group, the EA was applied 15 mm away from the Lou gu (SP7), Di ji (SP8), Jiao xin (KI8), and Zhu bin (KI9) acupoints. Both groups underwent treatment 30 minutes/day, five days a week, for two weeks using dense waves with a frequency of 2/100 Hz. A Visual Analogue Scale (VAS) was used to evaluate the effectiveness of treatment in reducing shoulder pain. Musculoskeletal ultrasound was used to evaluate the changes of measures of shoulder subluxation in multidimensions (i.e., the acromiohumeral distance, AHD; acromion-greater tuberosity, AGT; and acromion-lesser tuberosity, ALT). Both the within- and between-groups treatment effects were assessed. Results. The pain intensity measured by VAS and shoulder subluxation measured by musculoskeletal ultrasound (i.e., AHD, AGT, and ALT) showed significant ( p < 0.05 ) within-group difference in both groups. The between-group difference appeared in the pain intensity ( p < 0.05 ), while it disappeared in the three measures of shoulder subluxation ( p > 0.05 ). Conclusions. Using VAS for measuring pain intensity and multidimensional musculoskeletal ultrasound imaging technique for measuring shoulder subluxation, this study finds that the hemiplegic shoulder pain can be improved significantly by the EA while the shoulder subluxation cannot be. Our findings further reveal the analgesic mechanism of EA on hemiplegic shoulder pain following stroke.

Lesser Tuberosity Avulsion Fracture in an 11-Year-Old Baseball Player due to Batting

Case. We report an 11-year-old male who sustained a lesser tuberosity avulsion fracture of the proximal humerus upon making contact with a baseball during an at-bat. This injury was neglected for 14 months and was eventually detected by an axillary radiograph and subsequent MRI. He successfully underwent an open surgical repair and regained full range of motion and level of activity at 1-year follow-up. Conclusion. In pediatric baseball players, lesser tuberosity avulsion fractures may occur upon striking a baseball with a bat. Even after being neglected for several months, these injuries can be treated successfully with an open surgical repair.

Arthroscopic Fixation of Avulsion Fractures of the Lesser Tuberosity of the Humerus: Clinical Outcomes With a Mean 3.5-Year Follow-up

Background: Avulsion fracture of the lesser tuberosity (AFLT) of the humerus has traditionally been treated with open reduction internal fixation using screw fixation. The clinical outcomes of arthroscopic repair with suture anchors remains unknown. Hypothesis: It was hypothesized that arthroscopic fixation with suture anchors would result in good clinical outcomes for the treatment of AFLT. Study Design: Case series; Level of evidence, 4. Methods: This study included 15 patients who underwent arthroscopic repair of AFLT of the humerus between January 2014 and October 2017. All patients had 3-dimensional computed tomography scans and magnetic resonance imaging to evaluate the avulsed fracture and concomitant injuries before surgery. The arthroscopic double-row and suture-bridge techniques were used based on the morphology of the avulsion fractures. Functional outcomes were assessed with range of motion, the visual analog scale (VAS) for pain, the Subjective Shoulder Value (SSV), the American Shoulder and Elbow Surgeons (ASES) score, and the University of California, Los Angeles (UCLA) shoulder score. The bear-hug test, liftoff test, and internal rotation resistance test at 90° abduction and external rotation (IRRT 90°) were used to evaluate subscapularis tendon integrity. Results: The mean follow-up time was 3.5 years (range, 3-5 years). Comminuted fractures with 1 large part and ≥1 small pieces were seen in 12 cases, partial tear of the supraspinatus in 2 cases, Bankart lesion in 2 cases, and superior labrum anterior to posterior injury in 2 cases. There was a statistically significant improvement from the baseline to the final follow-up in the VAS (from 6.9 ± 1.5 to 1.1 ± 1), SSV (from 30.7 ± 5.1 to 90.5 ± 11.6), ASES (from 28.5 ± 7.7 to 92.3 ± 4.5), and UCLA (from 29.5 ± 6.3 to 94.2 ± 8.3) scores ( P < .001 for all). All patients showed full range of shoulder motion and bilateral symmetric strength on physical examination with the bear-hug test, liftoff test, and IRRT 90° test. Conclusion: The arthroscopic repair of AFLT resulted in excellent reduction and healing of the displaced fragment. At the final follow-up, clinical and functional results were good. Associated injuries occurred in 40% of patients but did not affect outcomes.

Analysis of the subcapital two-part humerus fracture by fluoroscopy: objective criteria for classification and decision making

Background Surgical decision making in the treatment of proximal humerus fractures (PHFx) is primarily based on fracture classification using standard radiographs. Due to the lack of objective criteria, this classification process is associated with high interobserver variation. In this study, we investigate the fluoroscopic analysis of humerus fractures through the surgical neck using a semi-quantitative determination of distinct angulation patterns of the proximal humerus as they appear in the image intensifier. Methods Using a saw bone model, defined subcapital 2-part fracture configurations were generated and assessed radiographically. Anatomical landmarks—including the greater and lesser tuberosity as well as anatomical neck—were identified using an image converter, and the exact degree of fracture displacement with 10° up to 70° (in 10° increments) of posterior, varus or combined posterior-varus angulation was compared to nondisplaced controls. From the resultant series of radiographs, the appearance of these angulations in anteroposterior (AP) and scapular Y-views were also visualized and defined. Results An angulation of 50° or more of any given 2-part fracture through the surgical neck is present when the greater tuberosity becomes the most proximal point in AP view (varus and combined posterior-varus angulation) or a bimodal form is found for the superior contour of the head with the lesser tuberosity being the most proximal point in the Y-view (posterior angulation). Conclusion The radiological appearance of various PHFx constellations can be well visualized using the saw bone shoulder model. The presence of angulation in accordance with the Neer classification for group III fractures can be adequately determined by analyzing the relative position of the greater or lesser tuberosity to the humeral head calotte. This can assist the surgeon’s decision on whether to operate or opt for a conservative approach. Level of evidence Basic Science, Anatomy Study, Imaging.

Anatomic Total Shoulder Arthroplasty With a Stemless Humeral Component

Background: This technique video reviews anatomic total shoulder arthroplasty (TSA) with a stemless humeral component using a representative case example. Indications: Stemless TSA is indicated for patients with symptomatic glenohumeral arthritis typically younger than 65 years of age. Stemless TSA may be used for other glenohumeral degenerative conditions such as avascular necrosis or posttraumatic arthropathy, provided acceptable humeral bone quality is confirmed intraoperatively using a thumb-press test. Poor bone quality is the primary contraindication. Technique Description: Preoperatively, computed tomography is typically used for planning, and intraoperative navigation through magnetic resonance imaging is also useful. The procedure’s critical elements include beach chair positioning, standard deltopectoral approach with lesser tuberosity osteotomy (LTO), freehand proximal humeral osteotomy, perpendicular proximal humeral exposure and subsequent preparation over a central guidewire, stemless implant and humeral head sizing, perpendicular glenoid exposure and implant placement, and final humeral implantation with LTO repair/fixation. A phased rehabilitation protocol includes 6-week sling immobilization to protect the subscapularis/LTO repair and return to normal activities between 3 and 6 months postoperatively. Discussion/Conclusion: Stemless TSA shows promising early and mid-term outcomes with complication rates, including humeral loosening rates, similar to standard stemmed components. Potential complications include neurovascular injury, infection, glenoid or humeral component loosening, and rotator cuff failure.