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JSES International Jan 2021Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused,... (Review)
Review
BACKGROUND
Globally, reverse shoulder arthroplasty (RSA) has moved away from the Grammont design to modern prosthesis designs. The purpose of this study was to provide a focused, updated systematic review for each of the most common complications of RSA by limiting each search to publications after 2010. In this part II, the following were examined: (1) instability, (2) humerus/glenoid fracture, (3) acromial/scapular spine fractures (AF/SSF), and (4) problems/miscellaneous.
METHODS
Four separate PubMed database searches were performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Overall, 137 studies for instability, 94 for humerus/glenoid fracture, 120 for AF/SSF, and 74 for problems/miscellaneous were included in each review, respectively. Univariate analysis was performed with chi-square and Fisher exact tests.
RESULTS
The Grammont design had a higher instability rate vs. all other designs combined (4.0%, 1.3%; < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; = .02). The rate for intraoperative humerus fracture was 1.8%; intraoperative glenoid fracture, 0.3%; postoperative humerus fracture, 1.2%; and postoperative glenoid fracture, 0.1%. The rate of AF/SSF was 2.6% (371/14235). The rate for complex regional pain syndrome was 0.4%; deltoid injury, 0.1%; hematoma, 0.3%; and heterotopic ossification, 0.8%.
CONCLUSIONS
Focused systematic reviews of recent literature with a large volume of shoulders demonstrate that using non-Grammont modern prosthesis designs, complications including instability, intraoperative humerus and glenoid fractures, and hematoma are significantly reduced compared with previous studies. As the indications continue to expand for RSA, it is imperative to accurately track the rate and types of complications in order to justify its cost and increased indications.
PubMed: 33554177
DOI: 10.1016/j.jseint.2020.07.018 -
JSES International Dec 2020Deltoid compartment syndrome is a rare entity. The purpose of this study was to report a recent case and perform a systematic literature review.
BACKGROUND
Deltoid compartment syndrome is a rare entity. The purpose of this study was to report a recent case and perform a systematic literature review.
METHODS
Patient data were gathered from chart review and clinical encounters. For the review, the MEDLINE, Embase, and Ovid databases were queried for deltoid compartment syndrome cases. Seventeen articles reporting on 18 patients with deltoid compartment syndrome were included.
RESULTS
Including our patient, 9 of 19 patients (47.4%) presented with compartment syndrome limited to the deltoid. Most patients presented with additional affected compartments, most commonly in the ipsilateral arm (7 of 19, 37%). Isolated deltoid involvement often resulted from iatrogenic injury; of 10 iatrogenic reports, 8 involved only the deltoid. Of 19 cases, 5 (26%) occurred in powerlifters, climbers, or anabolic steroid or testosterone injectors. In 13 of 19 cases (68%), the patients were men aged 18-36 years, and only 1 female case (5%) was reported. Prolonged recumbence owing to substance abuse was documented in 6 of 19 cases (32%).
CONCLUSION
Deltoid compartment syndrome is rare, with only 19 reported cases, including our patient. Men are more commonly affected, and isolated deltoid compartment syndrome occurs in about 50% of reported cases. More than half of cases are iatrogenic, secondary to prolonged lateral decubitus positioning, injections, and surgical interventions about the shoulder. Prolonged recumbence from intoxication is also a common etiology. Providers should be aware of and recognize deltoid compartment syndrome to facilitate urgent surgical management.
PubMed: 33345211
DOI: 10.1016/j.jseint.2020.07.016 -
Plastic and Reconstructive Surgery.... Sep 2020Brachial plexus and axillary nerve injuries often result in paralysis of the deltoid muscle. This can be functionally debilitating for patients and have a negative...
BACKGROUND
Brachial plexus and axillary nerve injuries often result in paralysis of the deltoid muscle. This can be functionally debilitating for patients and have a negative impact on their activities of daily living. In these settings, transferring the branch of the radial nerve innervating the triceps to the axillary nerve is a viable treatment option. Additional nerve transfers may be warranted. This study sought to determine the efficacy of nerve transfer procedures in the setting of brachial plexus and axillary nerve injuries and factors affecting clinical outcomes.
METHODS
The U.S. National Library of Medicine's website "PubMed" was queried for "radial to axillary nerve transfer" and "brachial plexus nerve transfer." An initial review by two authors was performed to identify relevant articles followed by a third author validation utilizing inclusion and exclusion criteria. Individual patient outcomes were recorded and pooled for final analysis.
RESULTS
Of the 80 patients, 66 (82.5%) had clinical improvement after surgical nerve transfer procedures. Significant difference in clinical improvement following nerve transfer procedures was correlated with patient age, mechanism of injury, brachial plexus vs isolated axillary nerve injuries, multiple nerve transfers vs single nerve transfers, and surgery within the first 7 months of injury. The branch of the radial nerve supplying the triceps long head showed improved clinical results compared with the branch of the radial nerve supplying the triceps medial head and anconeus.
CONCLUSION
Nerve transfers have been shown to be effective in restoring shoulder abduction in both isolated axillary nerve injuries and brachial plexus injuries.
PubMed: 33133948
DOI: 10.1097/GOX.0000000000003096 -
BMJ Open Sport & Exercise Medicine 2020To investigate the influence of trunk and lower limb motion on electromyography (EMG) muscle activity and recruitment patterns around the shoulder. (Review)
Review
Role of the kinetic chain in shoulder rehabilitation: does incorporating the trunk and lower limb into shoulder exercise regimes influence shoulder muscle recruitment patterns? Systematic review of electromyography studies.
OBJECTIVE
To investigate the influence of trunk and lower limb motion on electromyography (EMG) muscle activity and recruitment patterns around the shoulder.
DESIGN
Systematic review.
DATA SOURCES
MEDLINE, CINAHL, PEDro, AMED, PubMed, Cochrane Central Register of Controlled trials, Cochrane Database of Systematic reviews, SportsDiscuss and PROSPERO.
ELIGIBILITY CRITERIA
Studies investigating both multiregional kinetic chain (KC) shoulder exercises localised non-kinetic chain (nKC) shoulder exercises in healthy subjects under the same experimental conditions were included in this review.
RESULTS
KC exercises produced greater EMG activation levels in 5 of 11 studies for the lower trapezius. Of the remaining studies, five found no difference between the exercise types and one favoured nKC exercises. KC exercises produced greater EMG activation levels in 5 of 11 studies for the serratus anterior. Of the remaining studies, three reported the opposite and three found no significant difference between the exercise types. nKC exercises produced greater EMG activation in infraspinatus in three of four studies. KC exercises produced the lowest trapezius muscle ratios in all studies. Studies investigating the upper trapezius, middle trapezius, supraspinatus, subscapularis, biceps brachii, latifissimus dorsi, pectoralis major, deltoid, and trapezius and serratus anterior ratios showed inconsistency.
CONCLUSION
This review found evidence that integrating the KC during shoulder rehabilitation may increase axioscapular muscle recruitment, produce lower trapezius muscle ratios and reduce the demands on the rotator cuff. Stepping appears preferable to squatting.
PROSPERO REGISTRATION NUMBER
CRD42015032557, 2015.
PubMed: 32405430
DOI: 10.1136/bmjsem-2019-000683 -
Foot & Ankle Orthopaedics Oct 2019Isolated distal fibular fractures resulting from supination external rotation (SER) injuries without evidence of obvious talar shift on standard radiographs present a...
BACKGROUND
Isolated distal fibular fractures resulting from supination external rotation (SER) injuries without evidence of obvious talar shift on standard radiographs present a diagnostic dilemma for clinicians. The status of the deep deltoid ligament, the main stabilizer of the ankle joint, is assessed by an increase in medial clear space (MCS) on radiographs. Therefore, these injuries can be either stable or unstable. In recent years, considerable clinical and research efforts have been made to determine ankle stability following SER fracture. The purpose of this systematic review was to evaluate and compare the role of different stress radiograph modalities in assessing stability of the ankle with SER fractures with no obvious talar subluxation on standard radiographs.
METHODS
The electronic databases MEDLINE, EMBASE, Ovid, Cochrane Central, CINAHL, and Google Scholar were searched from January 2000 to January 2018 to identify literature relating to radiologic assessment of stability of SER ankle fractures.
RESULTS
Our literature search revealed 10 peer-reviewed articles that fulfilled inclusion criteria. This yielded a total of 698 patients. The systematic review found 3 broad categories of radiographic investigations in the assessment of ankle joint stability: external rotation (ER) stress radiographs, gravity stress views (GSV), and weightbearing (WB) radiographs. Proponents of WB radiographs have demonstrated how axial load can normalize ankle joint alignment in cases of proven instability. There was a consistently high grade of evidence for using a medial clear space (MCS) value of more than 4 to 5 mm to indicate an unstable ankle following SER fracture.
CONCLUSION
In conclusion, the results of this systematic review support an MCS value of less than 4 to 5 mm as a good indicator of stability, regardless of choice of stress imaging modality. These patients can be allowed early weightbearing with expected good functional outcomes. Recent published literature favors WB stress radiographs as a reliable and safe technique for assessing stability in SER ankle fractures. However, it should be kept in mind that this is based on studies with relatively low grades of evidence.
LEVEL OF EVIDENCE
Level II, systematic review of variable quality studies.
PubMed: 35097353
DOI: 10.1177/2473011419890861 -
BMC Surgery Sep 2019The pectoralis major flap has been considered the workhorse flap for chest and sternoclavicular defect reconstruction. There have been many configurations of the...
OBJECTIVES
The pectoralis major flap has been considered the workhorse flap for chest and sternoclavicular defect reconstruction. There have been many configurations of the pectoralis major flap reported in the literature for use in reconstruction sternoclavicular defects either involving bone, soft tissue elements, or both. This study reviews the different configurations of the pectoralis major flap for sternoclavicular defect reconstruction and provides the first ever classification for these techniques. We also provide an algorithm for the selection of these flap variants for sternoclavicular defect reconstruction.
METHODS
EMBASE, Cochrane library, Ovid medicine and PubMed databases were searched from its inception to August of 2019. We included all studies describing surgical management of sternoclavicular defects. The studies were reviewed, and the different configurations of the pectoralis major flap used for sternoclavicular defect reconstruction were cataloged. We then proposed a new classification system for these procedures.
RESULTS
The study included 6 articles published in the English language that provided a descriptive procedure for the use of pectoralis major flap in the reconstruction of sternoclavicular defects. The procedures were classified into three broad categories. In Type 1, the whole pectoris muscle is used. In Type 2, the pectoralis muscle is split and either advanced medially (type 2a) or rotated (type 2b) to fill the defect. In type 3, the clavicular portion of the pectoralis is islandized on a pedicle, either the thoracoacromial artery (type 3a) or the deltoid branch of the thoracoacromial artery (type 3b).
CONCLUSION
There are multiple configurations of the pectoralis flap reported in the English language literature for the reconstruction of sternoclavicular defects. Our classification system, the Opoku Classification will help surgeons select the appropriate configuration of the pectoralis major flap for sternoclavicular joint defect reconstruction based on size of defect, the status of the vascular anatomy, and acceptability of upper extremity disability. It will also help facilitate communication when describing the different configurations of the pectoralis major flap for reconstruction of sternoclavicular joint defects.
Topics: Algorithms; Clavicle; Humans; Infections; Osteomyelitis; Pectoralis Muscles; Plastic Surgery Procedures; Sternum; Surgical Flaps; Thoracic Wall; Wounds and Injuries
PubMed: 31519173
DOI: 10.1186/s12893-019-0604-7 -
Orthopaedics & Traumatology, Surgery &... Apr 2019To investigate the evidence of deltoid-split approach (DS) versus deltopectoral approach (DP) in treatment of proximal humerus fractures from current RCT and prospective... (Meta-Analysis)
Meta-Analysis
PURPOSE
To investigate the evidence of deltoid-split approach (DS) versus deltopectoral approach (DP) in treatment of proximal humerus fractures from current RCT and prospective literatures.
METHODS
The electronic literature database of Pubmed, Embase, and Cochrane library was searched at December 2017. The data complications (including implant failure, humeral head necrosis, infection, radiological adverse events, nonunion rate, subacromial impingement, and damage of the axillary nerve), functional outcomes (including Constant, NEER, DASH, ADL, VAS score), operation time, hospital stay and intraoperative blood loss were extracted and analyzed by STATA 11.0 software.
RESULTS
Three RCTs and three prospective comparative studies were included in this meta-analysis. The meta-analysis showed that the DS group had a significantly low humeral head necrosis rate and short operation time. No significant difference was found in total complication rate, functional outcome, and other Perioperative parameters between DS and DP groups.
CONCLUSION
The prospective evidence suggested that DS approach for proximal humerus fractures had less humeral head necrosis and short operation time than DP approach. Both DS and DP approach had similar results in functional outcomes, total complication, VAS, and hospital stay.
Topics: Bone Plates; Deltoid Muscle; Fracture Fixation, Internal; Humans; Operative Time; Radiography; Shoulder Fractures
PubMed: 30878231
DOI: 10.1016/j.otsr.2018.12.004 -
Journal of Orthopaedic Surgery and... Jan 2019This review compares the outcomes and complication rates of three surgical strategies used for the management of symptomatic os acromiale. The purpose of this study was...
BACKGROUND
This review compares the outcomes and complication rates of three surgical strategies used for the management of symptomatic os acromiale. The purpose of this study was to help guide best practice recommendations.
METHODS
A systematic review of nine prospective studies, seven retrospective studies, and three case studies published across ten countries between 1993 and 2018 was performed. Adult patients (i.e., ≥ 18 years of age) with a symptomatic os acromiale that failed nonoperative management were included in this review. Surgical techniques utilized within the included studies include excision, acromioplasty, and open reduction and internal fixation (ORIF). The primary outcomes of interest included patient satisfaction. Range of motion and several standardized outcome measurement tools were also included in the final analysis.
RESULTS
Patient satisfaction was highest in the excision and ORIF groups, with 92% and 82% of patients reporting good to excellent postoperative results, respectively, compared to 63% in the acromioplasty group. All three patient groups experienced improvements in postoperative outcomes (i.e., active range of motion and patient-reported outcome scores). The excision group experienced a complication rate of 1%, while the acromioplasty group experienced a complication rate of 11% and the ORIF group a rate of 67%.
CONCLUSION
This study reports on the largest sample of patients who underwent surgical treatment for a symptomatic os acromiale. We have demonstrated that excision of the os with meticulous repair of the deltoid resulted in the best clinical outcomes with the least complications. In healthy adult patients with a large os fragment and a normal rotator cuff, surgical fixation may provide increased preservation of deltoid function while offering good to excellent patient satisfaction. However, patients must be informed that a second procedure may be required to remove symptomatic hardware.
Topics: Acromion; Arthroscopy; Bone Diseases, Developmental; Humans; Open Fracture Reduction; Postoperative Complications; Prospective Studies; Retrospective Studies; Treatment Outcome
PubMed: 30674325
DOI: 10.1186/s13018-018-1041-5 -
Journal of Anatomy Jan 2019The moment arm of a muscle represents its leverage or torque-producing capacity, and is indicative of the role of the muscle in joint actuation. The objective of this...
The moment arm of a muscle represents its leverage or torque-producing capacity, and is indicative of the role of the muscle in joint actuation. The objective of this study was to undertake a systematic review of the moment arms of the major muscles spanning the glenohumeral joint during abduction, flexion and axial rotation. Moment arm data for the deltoid, pectoralis major, latissimus dorsi, teres major, supraspinatus, infraspinatus, subscapularis and teres minor were reported when measured using the geometric and tendon excursion methods. The anterior and middle sub-regions of the deltoid had the largest humeral elevator moment arm values of all muscles during coronal- and scapular-plane abduction, as well as during flexion. The pectoralis major, latissimus dorsi and teres major had the largest depressor moment arms, with each of these muscles exhibiting prominent leverage in shoulder adduction, and the latissimus dorsi and teres major also in extension. The rotator cuff muscles had the largest axial rotation moment arms regardless of the axial position of the humerus. The supraspinatus had the most prominent elevator moment arms during early abduction in both the coronal and scapular planes as well as in flexion. This systematic review shows that the rotator cuff muscles function as humeral rotators and weak humeral depressors or elevators, while the three sub-regions of the deltoid behave as substantial humeral elevators throughout the range of humeral motion. The pectoralis major, latissimus dorsi and teres major are significant shoulder depressors, particularly during abduction. This study provides muscle moment arm data on functionally relevant shoulder movements that are involved in tasks of daily living, including lifting and pushing. The results may be useful in quantifying shoulder muscle function during specific planes of movement, in designing and validating computational models of the shoulder, and in planning surgical procedures such as tendon transfer surgery.
Topics: Arm; Biomechanical Phenomena; Humans; Movement; Muscle, Skeletal; Range of Motion, Articular; Shoulder Joint
PubMed: 30411350
DOI: 10.1111/joa.12903 -
The Open Orthopaedics Journal 2017The proximal humerus is a common location for both primary and metastatic bone tumors. There are numerous reconstruction options after surgical resection. There is no... (Review)
Review
PURPOSE
The proximal humerus is a common location for both primary and metastatic bone tumors. There are numerous reconstruction options after surgical resection. There is no consensus on the ideal method of reconstruction.
METHODS
A systematic review was performed with a focus on the surgical reconstructive options for lesions involving the proximal humerus.
RESULTS
A total of 50 articles and 1227 patients were included for analysis. Reoperation rates were autograft arthrodesis (11%), megaprosthesis (10%), RSA (17%), hemiarthroplasty (26%), and osteoarticular allograft (34%). Mechanical failure rates, including prosthetic loosening, fracture, and dislocation, were highest in allograft-containing constructs (APC, osteoarticular allograft, arthrodesis) followed by arthroplasty (hemiarthroplasty, RSA, megaprosthesis) and lowest for autografts (vascularized fibula, autograft arthrodesis). Infections involving RSA (9%) were higher than hemiarthroplasty (0%) and megaprosthesis (4%). Postoperative function as measured by MSTS score were similar amongst all prosthetic options, ranging from 66% to 74%, and claviculo pro humeri (CPH) was slightly better (83%). Patients were generally limited to active abduction of approximately 45° and no greater than 90°. With resection of the rotator cuff, deltoid muscle or axillary nerve, function and stability were compromised even further. If the rotator cuff was sacrificed but the deltoid and axillary nerve preserved, active forward flexion and abduction were superior with RSA.
DISCUSSION
Various reconstruction techniques for the proximal humerus lead to relatively similar functional results. Surgical choice should be tailored to anatomic defect and functional requirements.
PubMed: 28458733
DOI: 10.2174/1874325001711010203