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Protesi inversa di spalla con componente glenoidea lateralizzata con innesto osseo o metallo per preservare il bone-stock glenoideo: analisi dei parametri radiografici e dei risultati clinici
No full textIntroduzione: La protesi inversa rappresenta una opzione valida per il trattamento dell’artrosi di spalla con severa deformità ossea glenoidea, ma richiede un alesaggio correttivo esteso per il ripristino della versione ed inclinazione glenoidea nativa, con relativi rischi di medializzazione della glenoide e fallimento della fissazione. L’utilizzo di un innesto osseo, prelevato dalla testa omerale e fissato sul “baseplate” all’ interfaccia della glenoide nativa, è stato proposto per minimizzare l’alesaggio glenoideo e ripristinare il bone stock glenoideo (“Bony-Increased Offset, BIO- RSA”). Il “baseplate” aumentato metallico ("Metallic-Increased Offset – MIO-RSA”), rappresenta un’alternativa alla BIO-RSA per ripristinare la interlinea articolare. Ad oggi, persistono ancora delle controversie sulla scelta del “bone graft” o dell’ “augment” metallico nella protesi inversa di spalla lateralizzata.
Obiettivi: Abbiamo testato due ipotesi: i) la MIO-RSA garantisce risultati clinici e un tasso di “scapular notching” simile alla BIO-RSA, ii)la integrazione del graft osseo nella BIO-RSA è compromessa nel tempo, aumentando il rischio fallimento della fissazione.
Materiali e Metodi: Abbiamo arruolato in modo retrospettivo 72 pazienti (74 spalle) sottoposti a BIO-RSA (44) o MIO-RSA (30). La deformità glenoidea primaria (A1, A2, B1, B2, B3, C, D) e secondaria a rottura di cuffia (E1, E2, E3, E4), è stata classificata secondo specifici criteri, utilizzando la tomografia computerizzata. La mobilità attiva e il “Western Ontario Osteoarthritis of the Shoulder (WOOS) Index” sono stati usati per la misura dell’ ”outcome” clinico.
Tutte le alterazioni radiografiche postoperatorie dell’impianto sono state valutate all’ultimo follow-up.
Presenza e dimensione delle linee di radiolucenza glenoidea sono state utilizzate per valutare la integrazione del “bone graft” (gruppo BIO-RSA) e il “baseplate seating” (gruppo MIO-RSA) (assenza di radiolucenza: “perfect seating”; linee di radiolucenza 2 mm: mobilizzazione).
Abbiamo valutato lo spessore del “bone graft” (mm), la posizione della glenosfera sulla glenoide (alta, centrata, bassa, molto bassa), la versione (metodo di Friedman) e la inclinazione (“ angle”) glenoidea preoperatoria e postoperatoria.
Risultati: Al follow-up medio di 36.5 mesi gli “scores” preoperatori e postoperatori sono aumentati in modo significativo in entrambi i gruppi (p < 0.001). Morfologia ossea glenoidea preoperatoria, radiolucenza glenoidea postoperatoria, ossificazioni scapolari ed omerali eterotopiche, “spot welds” omerali sono risultati simili nei due gruppi. Lo scapular notching non ha mostrato differenze. Le linee di condensazione omerali sono state più comuni nella MIO-RSA (p = 0.01), l’assottigliamento corticale e riassorbimento tuberositario è stato maggiore nel gruppo BIO-RSA (p= 0.027 e p = 0.004). La retroversione glenoidea postoperatoria è risultata simile, ma i “delta score” preoperatori e postoperatori sono stati più alti nella BIO-RSA (p < 0.001). Linee di radiolucenza < 2 mm intorno al “bone graft” in 16 pazienti (36.4%) e ridotto spessore in 15 pazienti (34.1%) sono state registrate nella BIO-RSA. La integrazione del bone graft è stata del 64%. “Incomplete baseplate seating” è stato trovato in 3 spalle del gruppo MIO-RSA.
Conclusioni: I risultati clinici simili, ottenuti con i modelli BIO-RSA e MIO-RSA, confermano la prima ipotesi dello studio. Il “baseplate seating” completo riscontrato in > 90% dei pazienti con MIO-RSA esprime la eccellente stabilità e capacità di fissazione del metallo. Il tasso di riassorbimento del “bone graft” conferma la seconda ipotesi dello studio sui potenziali rischi di fallimento del “baseplate” a lungo termine.Background : Reverse shoulder arthroplasty (RSA) is a valid option to address shoulder osteoarthritis with severe glenoid deformity, but requires an extensive reaming to restore the native version with high risk of baseplate failure. The use of autologous bone graft harvested from the humeral head and fixed on the baseplate at the interface of the native glenoid, was proposed to minimize glenoid reaming and restore glenoid bone stock (Bony-Increased Offset, BIO- RSA).
Metallic-augmented glenoid components (Metallic-Increased Offset – MIO-RSA) have been proposed as viable alternative to BIO-RSA, preserving more native bone stock and restoring the joint line, with a final goal of increasing the baseplate support.
Thus, controversies still exist about the choice of bone grafting or metal augments in RSA.
Objectives: In this study we tested two hypotheses: i) metal augmented baseplate give similar clinical outcomes and rate of scapular notching compared with BIO-RSA patients, ii) bone graft viability and healing in BIO-RSA patients are impaired over time, thus making concern about baseplate fixation and stability in the long-term.
Materials and Methods: This was a retrospective study involving seventy-two consecutive patients (74 shoulders) who underwent RSA with glenoid lateralization using bone (BIO-RSA group, 44) or metal augmented baseplate (MIO-RSA group, 30).
Glenoid deformities was classified according to established criteria by computed tomography in primary osteoarthritis (A1, A2, B1, B2, B3, C, D) and cuff tear arthropathy (E1, E2, E3, E4).
Active range of motion, and the Western Ontario Osteoarthritis of the Shoulder (WOOS) Index were assessed before arthroplasty and at the last follow-up visits.
Radiologic changes around the humeral and glenoid components were recorded at latest follow-up and compared with immediate postoperative X-rays. Glenoid radiolucent lines and their size were used to evaluate bone graft healing (BIO-RSA group) and baseplate seating (MIO-RSA group) (no radiolucent lines: perfect seating; radiolucent lines 2 mm: loosening). Postoperative thickness of bone graft (mm) was also measured. Glenosphere position was recorded as: high, flush, low and very low. Glenoid version (Friedman method) and inclination ( angle) were recorded and compared with preoperative values.
Results: At a mean follow-up of 36.5 months the preoperative and postoperative shoulder mobility and WOOS Index were significantly different in both groups (all p < .0001). The two groups showed a similar rate of preoperative glenoid deformities. The rate of postoperative glenoid radiolucency, scapular notching, scapular spurs, glenosphere position, heterotopic ossifications and humerus spot weld were similar. We found higher rate of humerus condensation lines in MIO-RSA group (p= 0.01) and higher rate of cortical tinning and tuberosity resorption in the BIO-RSA group (p= 0.027 and p = 0.004, respectively).
Postoperative glenoid retroversion and inclination were similar in the two groups but the preoperative and postoperative delta score were higher in the BIO-RSA group (p < 0.001). BIO-RSA group showed radiolucent lines < 2mm around bone graft in 16 patients (36.4%) and decreased thickness in 15 (34.1%). The bone graft healing was 64%. Incomplete baseplate seating found in 3 shoulders of MIO-RSA group.
Conclusion: The clinical outcomes and rate of notching found in BIO-RSA and MIO-RSA patients confirm the first hypothesis of this study. The complete baseplate seating found in most of MIO-RSA patients explains the excellent stability and fixation of the metal. Our findings about bone graft healing confirm the second hypothesis about the risk of baseplate failure in the long-term
Infraspinatus strength assessment and ultrasound evaluation of posterior capsulotenodesis after arthroscopic Hill-Sachs remplissage in traumatic anterior glenohumeral instability: a retrospective controlled study protocol
Full text linkGiovanni Merolla Co-investigator: Giuseppe Porcellini Investigation performed at the Biomechanics Laboratory "Marco Simoncelli", D. Cervesi Hospital, Cattolica - Italy PLAN OF CLINICAL INVESTIGATION (PCI): Version 1.0 of June 12, 2012 Approved by AV/IRST Ethical Committee (Comitato Etico Area Vasta Romagna) and authorized by AUSL RN ("Determina AUSL Rimini numero 326 del 29/03/2013: Remplissage U.O Chirurgia della Spalla - Valutazione clinica ed ultrasonografica dell'infraspinato dopo capsulo-tenodesi artroscopica (remplissage) nell'instabilità anteriore traumatica di spalla con lesione di Bankart e difetto omerale di Hill-Sachs")
Instruments and techniques for the analysis of wheelchair propulsion and upper extremity involvement in patients with spinal cord injuries: current concept review
Full text linkThe correct functionality of the upper limbs is an essential condition for the autonomy of people with disabilities, especially for those in wheelchair.
In this review we focused on the biomechanics of wheelchair propulsion and we described the instrumental analysis of techniques for the acquisition of wheelchair propulsio
Clinical and Radiographic Mid-Term Outcomes After Total Shoulder Replacement: A Retrospective Study Protocol Including 400 Anatomical and Reverse Prosthetic Implants
Full text linkTo obtain outcomes data on anatomical and reverse total shoulder arthroplasty by analysis of clinical scores and standard radiographs
Robotics in shoulder rehabilitation
Full text linkIn the last few decades, several researches have been conducted in the field of robotic rehabilitation to meet the intensive, repetitive and task-oriented training, with the goal to recover the motor function. Up to now, robotic rehabilitation studies of the upper extremity have generally focused on stroke survivors leaving less explored the field of orthopaedic shoulder rehabilitation. In this review
we analyse the present status of robotic technologies, in order to understand which are the current indications and which may be the future perspective for their application in both neurological and orthopaedic shoulder rehabilitation
Functional assesment of symptomatic snapping scapula after scapulothoracic arthroscopy: a prospective study protocol
Full text linkGiovanni Merolla Co-investigator: Giuseppe Porcellini Investigation performed at Biomechanics Laboratory "Marco Simoncelli", D. Cervesi Hospital, Cattolica - Italy PLAN OF CLINICAL INVESTIGATION (PCI): Version 1.0 of December 10, 2012 Approved by AV/IRST Ethical Committee (Comitato Etico Area Vasta Romagna) Reg. Sperimentazioni 914 Prot. N°: 1785/2013/I.5/46
Conservative management of rotator cuff tears: literature review and proposal for a prognostic. Prediction Score
No full textRotator cuff tears are a common cause of pain and shoulder dysfunction. The prevalence of the rotator cuff tears increases with the age reaching the 80% in patients aged more than 80 year. Symptomatic shoulders usually are initially treated conservatively and then, in case of poor outcomes, with surgery. Different parameters are still used to decide between the conservative or surgical treatment in patients with rotator cuff tears. Aim of the current study is to characterize the various features used in decision making and to validate a "Prediction Score" that let us know which patients could have a good and stable outcome with non operative treatment. We enrolled 60 patients (mean age 52 years) with symptomatic rotator cuff tears who were assigned to conservative treatment and were evaluated at 6,9 and 12 months follow-up. We developed a score based on 18 clinical and radiographic parameters. 27 patients ("non conservative") (45%) with a mean prediction score of 16.1 ± 1.7 interrupted the conservative treatment, while 33 patients ("conservative") (55%) with an average prediction score of 11.3 ± 1.8 remained conservatively treated at last follow-up. The conservative patients were 14 years older than non conservative patients. According to the results of this study we identified a value of 13 points as a "cut-off" score to predict good results by conservative management of rotator cuff tear. These outcomes support the assumption that a predictive prognostic score may guarantee a rational approach in the management of subjects with RC tears, especially in elderly who continue to have the higher rate of recurrence and therefore could be well treated with standard conservative therapies
Pectoralis minor tendon transfer for irreparable anterosuperior cuff tears
No full textBackground: Tears of the subscapularis tendon are a frequent cause of shoulder dysfunction. Tendon transfer techniques have been devised to treat irreparable tears. The objectives of this study were to explore the anatomic feasibility of using the pectoralis minor tendon as a graft for subscapularis tendon tears, the safety of the procedure, and the scope of this approach in improving shoulder function. Materials and methods: We performed open pectoralis minor transfer in 27 patients (22 men; mean age, 60 years) with irreparable tears of the upper two-thirds of the subscapularis tendon, grade III fatty degeneration, and irreparable supraspinatus tears. Constant and Simple Shoulder Test scores and functional outcomes were evaluated at 3, 12, and 24 months. All patients were available for follow-up. Results: The pectoralis minor tendon easily reached the subscapularis footprint. There were no cases of musculocutaneous nerve or brachial plexus injury or graft failure. Active forward flexion improved from 127° to 177°; external rotation with the arm at the side declined by 11°. The Simple Shoulder Test score improved by 5 points and the Constant score by 41 points, although the strength subscore did not rise significantly. Conclusions: This study showed that it is anatomically feasible to use the pectoralis minor tendon as a graft to treat upper subscapularis lesions; the procedure is safe in terms of brachial plexus and musculocutaneous nerve injury; and pectoralis minor transfer can improve shoulder function and provide pain relief in patients with Lafosse grade III subscapularis tears, likely through a tenodesis effect, even in the presence of irreparable supraspinatus tears. © 2013 Journal of Shoulder and Elbow Surgery Board of Trustees
Latarjet procedure: is the coracoid enough to restore the glenoid surface?
No full textPurpose: The aim of this study was to establish whether anterior glenoid bone loss in patients with large glenoid rim defects can be restored with a coracoid graft (Latarjet procedure). Methods: A total of 143 consecutive patients with chronic anterior shoulder instability and glenoid bone deficiency were treated in 2013. A pre-operative computed tomography (CT) scan using the PICO method was obtained to estimate anterior glenoid rim erosion. The 23 patients with anterior glenoid deficiency exceeding 20 % were included in the study. A post-operative CT scan was obtained to establish whether coracoid transfer had fully restored the glenoid surface. Results: Mean bone loss was 26 ± 3.9 % of the glenoid surface (range 20–34 %) compared with the contralateral glenoid. Mean coracoid dimensions were 26.3 ± 2.9 mm × 7.6 ± 0.65 mm. The graft successfully restored the glenoid surface in all patients (mean filling, 102.4 ± 0.8 %). Discussion: The Latarjet procedure is a valuable approach to treat patients with chronic shoulder instability and glenoid deficiency. Conclusion: Coracoid transfer restored the glenoid surface even in patients with large defects. The Eden-Hybinette technique seems to be more appropriate for revision surgery and for patients with a failed Latarjet procedure
Computed tomography quantification of bone density adjacent to cemented pegged polyethylene glenoid components in shoulder arthroplasty
No full textBackground: Cemented polyethylene devices are the prostheses implanted more frequently, but there is no agreement on the optimal glenoid component design. In this study, bone mineral density (BMD) adjacent to cemented all-polyethylene glenoid components was assessed to gain insights into the characteristics of glenoid bone as a potential risk factor implicated in the failure of shoulder arthroplasty. Patients and methods: Twenty-two subjects were examined at an average follow-up of 31 months using the Constant-Murley score (CS) and multi-detector computed tomography. BMD was measured in 5 regions of interest (ROIs) at the sites where radiolucent lines are usually detected. BMD differences among the ROIs were tested. The relationship between BMD and a number of variables (CS subscores, age, gender, follow-up duration) was explored. Results: There was a significant increase in CS scores (p < 0.05). Significantly different BMD (p = 0.0039) was found in the 5 ROIs, especially between ROIs 2 and 5 (p = 0.016, Bonferroni's test) and between ROIs 3 and 5 (p = 0.005, Bonferroni's test). BMD was lower in ROI 1 than ROI 3 and in ROI 2 than ROI 4, but the difference was not significant. Discussion: The heterogeneous BMD distribution may be related to: (1) an interindividual variability in glenoid BMD; (2) the fixation technique; or (3) the different bone response to eccentric loading of the prosthetic head on the glenoid component. Conclusions: BMD analysis may contribute to extent our knowledge on glenoid component loosening and encourage further techniques of glenoid fixation. © 2013 Springer-Verlag
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