Shoulder & Elbow

Proximal humeral fractures in the elderly: delayed reverse total shoulder arthroplasty is an option

ORIF or arthroplasty for distal humeral fractures: which is more cost-effective?

ORIF or arthroplasty for radial head fractures?

Complex unstable radial head fractures are a unique surgical challenge due to their association with instability of the elbow and/or forearm. While the ‘terrible triad’ is well recognized, there is also a range of other patterns of elbow instability associated with poor outcomes. In all instances, the aim of treatment is to restore stability, with restoration of the radiocapitellar contact and radial column often an essential step. Radial head excision is only really possible when there is no evidence of instability, leaving fixation or arthroplasty as the surgical options. Some literature has suggested that unstable fracture patterns managed with internal fixation are prone to failure, nonunion, and inferior functional outcomes. That said, radial head arthroplasty opens up the difficulties of revision surgery, implant infection, and loosening. The treatment of the isolated radial head fracture is also the subject of much debate, with surgeons favouring one treatment or another, and the evidence is mostly small cohort or randomized trials. In this network meta-analysis from Hamilton (Canada), the authors analyzed 20 studies, including four randomized controlled trials (RCTs) and 16 cohort studies, with sample sizes ranging from 25 to 165 patients.³ The aim of the analysis was to compare interventions for treatment of displaced radial head fractures. The demographics of those included were consistent with those reported in the current literature. The RCTs looked at fixation with metal implants, fixation with biodegradable implants, and radial head arthroplasty. For the network meta-analysis of functional outcomes, the Broberg and Morrey Score was available in 281 patients; the authors reported greater odds of attaining a good or excellent outcome with arthroplasty when compared with metal (odds ratio (OR) 22.5) or biodegradable fixation (OR 11.8). Similarly, the analysis of postoperative complications in 288 patients found reduced odds of developing a complication with arthroplasty when compared with metal (OR 0.15) or biodegradable fixation (OR 0.16). The authors acknowledge the small sample sizes and the limited quality of the trials included. The effect estimates reported in the study were very low to moderate for the functional outcome scores, and very low to low for complications. The authors were also unable to make any meaningful comparisons with regard to other treatment methods such as excision or nonoperative management. However, here at 360, we would support the study’s suggestion that radial head arthroplasty is superior to fixation, as this would seem to negate any potential concerns regarding fixation failure and, more importantly, loss of elbow or forearm stability.

Nonoperative management of distal biceps ruptures: how bad can it be?

Surgical repair of distal biceps tendon ruptures is commonly performed, with 95% of patients reported to have a good or excellent outcome with comparable strength testing to the contralateral side. Despite this, complications do occur and can be catastrophic for the patient, with a recent study discussed in 360 reporting the notable major and minor complication rates following surgery. The outcome of nonoperative management is relatively unknown and the loss of power, in particular of supination, does not always correlate with an overall poor outcome for the patient. This prospective cross-sectional study from two centres, Pittsburgh, Pennsylvania (USA) and London (Canada), compared a conservatively managed cohort of 14 patients with a unilateral distal biceps rupture against a matched uninjured group of 18 control volunteers.⁴ Criteria to be included in the study were: a minimum of six months of nonoperative management of a complete distal biceps tendon rupture, diagnosed by a positive hook test and on MRI; and no pre-existing condition or surgery in the injured or contralateral arm. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Single Assessment Numerical Evaluation (SANE), the Biceps Disability Questionnaire (BDQ), and mechanical testing (including supination arc and power). The control group were male volunteers aged between 40 and 65 years of age who had no history of injury to their biceps and no pre-existing condition that would compromise the mechanical assessment. The groups were well matched in terms of basic demographics, with a mean time from rupture of 3.1 years. The authors reported significantly inferior DASH score (23 vs 6) and SANE score (60 vs 100) for the nonoperative group when compared with the control group. In terms of the mechanical repetitive testing in the nonoperative group when compared with their contralateral uninjured arm, the authors found a decreased supination arc and an adaptive increased shoulder contribution to rotation. Despite these adaptations, the average corrected supination power was still significantly decreased by 47%. This study is limited by selection bias, the small number of patients included, and the older patient population when compared with the current literature. Although the authors performed a post hoc analysis that determined that only nine patients per arm were required to detect a 15% difference in the mechanical testing variables, whether this correlates with patient-reported outcome measures (PROMs) is unknown and it would seem wise that future studies should be powered to a PROM. Nevertheless, this series is one of the larger studies to date documenting the outcome following nonoperative management of these injuries, and it provides useful prognostic information when counselling patients regarding management. The authors demonstrated clinically meaningful impairment on the functional scores in the DASH score (23.2 (sd 10.3)) and SANE score (59.6 (sd 16.2)). However, it is important to remember that the comparator here is a normal individual, not an operated biceps tendon rupture, where a pre-rupture outcome is extremely unlikely.

What is a critical-sized glenoid defect?

Here at 360, we rarely include papers based on computer-simulated data; however, we were interested to come across this finite element analysis study from London (UK), which has a clinically relevant message.⁵ The stability of the shoulder is dependent on the load upon it, and the authors of this study set out to establish the ‘critical size’ of glenoid defect that, under physiological loading, would lead to further anterior instability following an arthroscopic Bankart repair. The critical size of such a defect has been debated at length and has previously been stated to be 20% of the length of the glenoid. Two finite element models were generated to assess stability of the shoulder during 30 different activities of daily living. These were applied for the intact glenoid and in differing scenarios of anterior bony defects of increasing sizes in 2 mm increments. The critical defect size was defined as the smallest defects leading to dislocation and the finite element models were validated against in vitro cadaveric measurements of anterior stability of the shoulder. The dislocation forces were found to be within one standard deviation of experimental values. The model showed a high risk of dislocation during activities of daily living after a Bankart repair for defects of 16% of the length of the glenoid. To avoid that risk, our threshold for a bony procedure should perhaps therefore be lower than previously thought. There is, of course, considerable variation in the anatomy of defects in individual patients, and the model here showed a straight defect parallel to the longitudinal axis, which is clearly an oversimplification. Also oversimplified are the soft-tissue capsular ligamentous restraints and the fact that the results are only generalized to the mid-range of shoulder movements. However, we commend the study group for some excellent theoretical work, which may move forward our understanding of the subject.

Superior capsular reconstruction in irreparable cuff tears

For patients with irreparable rotator cuff repairs, there are few reconstructive options. While reverse total shoulder arthroplasty can relieve pain and restore motion, this is an aggressive and somewhat drastic solution for those patients with little or no glenohumeral osteoarthritis, and also comes with few possibilities for later revision in the event of failure. There have been a range of operative options suggested in the past, including allograft and artificial ‘hoods’. More recently, superior capsular reconstruction (SCR) has been proposed as a less aggressive arthroscopic treatment for irreparable rotator cuff repairs to relieve pain. The reports in the literature suggest that, in many cases, it has also been demonstrated to restore motion. This study from an internationally renowned group of shoulder arthroscopists in San Antonio, Texas (USA) investigated the rate and magnitude at which active forward flexion returned in patients who underwent SCR for massive irreparable rotator cuff tears in the presence of profound pseudoparalysis.⁶ This pseudoparalysis was quantified as active forward flexion of less than 45° seen in patients without significant glenohumeral osteoarthritis, who had an intact or reparable subscapularis, a massive rotator cuff tear, and full passive flexion. Follow-up of a minimum of 12 months was also required. These criteria resulted in the inclusion of ten patients, nine of whom regained active overhead use of the operative arm, with a mean postoperative active forward flexion of 159° (sd 15°). All secondary outcomes, including visual analogue scale for pain, American Shoulder and Elbow Surgeons (ASES) subjective shoulder score, and active external rotation, were also reported to demonstrate significant improvement. Seven of the ten SCR grafts undertaken demonstrated healing on MRI, with no complications reported. Overall, 90% of patients with massive irreparable rotator cuff tears with significant pseudoparalysis, which would otherwise require reverse total shoulder arthroplasty for pain relief and restoration of motion, were successfully treated with SCR. However, it should be noted that this cohort is small, retrospective, potentially subject to selection bias, and with limited follow-up. While these results are in keeping with previously published literature demonstrating the effectiveness of SCR in irreparable rotator cuff tears, it is important to recognize that this is a highly technical procedure with results reported in this investigation by a highly proficient arthroscopic shoulder surgeon, and results may not necessarily be generalizable.

Full-thickness rotator cuff tears and progression?

The evidence would suggest that while full-thickness rotator cuff tears are a primary cause of shoulder pain in the adult population, there are many full-thickness tears that are asymptomatic. It is unclear which tear characteristics lead to symptoms, and the overall role of tear progression in patient symptoms and the influence on patient outcomes are similarly unknown. There are some surgeons who believe that tear progression with delayed operative treatment worsens patient outcomes, but this conclusion itself remains controversial. This group from Calgary (Canada) have performed a fairly extensive systematic review to determine the rate of radiological tear progression in nonoperatively treated rotator cuff tears, and thereby establish the optimal treatment of these injuries.⁷ The published literature was reviewed for reports of full-thickness tears; reports of partial-thickness tears were excluded. These papers were analyzed for both clinical and radiological progression, as defined by an increase in tear size > 5 mm on ultrasound or MRI. Eight studies were suitable for inclusion in the review, with a mixture of level I to level IV evidence, and the reports of 411 tears were analyzed. No differences were demonstrated in the rate of tear progression between those patients in the asymptomatic and symptomatic groups, with progression rates of 40.6% at 46 months and 34.1% at 37 months, respectively. The number needed to treat was calculated for an 8% re-tear rate at two years’ follow-up, showing that seven rotator cuff repairs would be required to prevent one radiological progression. It should be noted that these tears are mainly chronic and degenerative in nature, and that the inherent propensity for tears to progress in size may well be independent of symptomology. The groups were also not perfectly matched in terms of demographics, with a slightly younger age and shorter follow-up in the symptomatic group, the effect of which is unclear. Furthermore, there was no standardization of nonoperative treatment protocols in this paper, and heterogeneity exists in the literature definitions of progression of cuff tear size. However, we can conclude from this study that it is likely that most tears will not progress significantly over short- to medium-term follow-up and, depending on the individual patient, most could be discharged with advice to re-present if symptomatic.

Bridge technique for bony Bankart lesions