Outcome of reverse shoulder arthroplasty with pedicled pectoralis transfer in patients with deltoid paralysis

Shoulder synovial sarcoma radical excision with pedicled inverted pectoralis major flap

Synovial sarcoma, a rare soft tissue malignancy, predominantly affects adolescents and young adults, with a predilection for extremities. We present the case of a 19-year-old woman with a rapidly growing left shoulder synovial sarcoma, initially managed with neoadjuvant chemotherapy to reduce tumor size. Subsequently, she underwent radical surgical resection, necessitating complex anatomical dissection due to tumor involvement extending into the coracoid and deltoid. Given limitations in current literature regarding reconstructive options for shoulder defects following sarcoma resection, the use of a pedicled pectoralis major flap demonstrates feasibility and functional outcomes.

Reverse Allograft Prosthetic-Composite Versus Endoprosthesis Reconstruction for Massive Proximal Humerus Bone Loss: A Systematic Review and Meta-analysis of Outcomes and Complications

Background

This systematic review and meta-analysis sought to compare the clinical outcomes after proximal humerus reconstruction with a reverse allograft-prosthetic composite (APC) versus reverse endoprosthesis.

Methods

Per PRISMA guidelines, we queried PubMed/MEDLINE, Embase, Web of Science, and Cochrane databases to identify articles reporting clinical outcomes of reverse APC or reverse endoprosthesis reconstruction of the proximal humerus for massive bone loss secondary to tumor, fracture, or failed arthroplasty. We compared postoperative range of motion, outcome scores, and the incidence of complications and revision surgery.

Results

Of 259 unique articles, 18 articles were included (267 APC, 260 endoprosthesis). There were no significant differences between the APC and endoprosthesis cohort for postoperative forward elevation (P = .231), external rotation (P = .634), ASES score (P = .420), Constant score (P = .414), MSTS (P = .815), SST (P = .367), or VAS (P = .714). Rate of complications was 15% (31/213) in the APC cohort and 19% (27/144) in the endoprosthesis cohort. The rate of revision surgery was 12% after APC cohort and 7% after endoprosthesis. APC-specific complications included a 10% APC nonunion/malunion/resorption rate and 6% APC fracture/fragmentation rate.

Discussion

Reverse APC and endoprosthesis are reasonable options for proximal humerus reconstruction. APC carries additional risks for complications, warranting evaluation of patients' healing capacity and surgeon experience.

Level of Evidence

Level IV; Systematic Review.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43465-024-01248-7.

Pedicled Pectoralis Major Transfer for Axillary Nerve Palsy and Greater Tuberosity Nonunion: A Case Report

CASE

A 46-year-old male patient presented with shoulder pain, limited range of motion, and loss of sensation for a year after undergoing hemiarthroplasty for a proximal humerus fracture. Workup demonstrated a greater tuberosity nonunion and deltoid paralysis secondary to upper trunk brachial plexopathy. The pectoralis major (PM) for deltoid transfer successfully restored shoulder function and resolved pain without requiring any subsequent intervention.

CONCLUSION

A PM transfer for deltoid and rotator cuff insufficiency restored shoulder stability and improves biomechanics for shoulder abduction and flexion in this case. Dynamic radiography demonstrates enhanced fluidity of shoulder kinematics with improved scapulohumeral motion.

Tendon transfers in the setting of shoulder arthroplasty

Background

Tendon transfers in conjunction with reverse total shoulder arthroplasty can significantly improve functional outcomes in patients with glenohumeral arthritis and irreparable rotator cuff deficiency. There have been multiple promising new techniques described within the last 20 years that shoulder surgeons should become familiar with.

Methods

The authors reviewed the literature on tendon transfers in the setting of reverse total shoulder arthroplasty. Procedures to restore various shoulder functions were described including surgical anatomy, techniques, pearls and pitfalls, and photos.

Results

Subscapularis insufficiency can be reconstructed with a pectoralis major transfer or latissimus dorsi transfer, with the latter having better clinical outcomes and a more anatomic line of pull. Posterosuperior rotator cuff deficiency can be reconstructed with a latissimus transfer (L'Episcopo transfer) or lower trapezius transfer, with the latter proving superior in biomechanical and short-term studies. Deltoid deficiency can be reconstructed with a pedicled upper pectoralis major transfer. Massive proximal humerus bone loss can be reconstructed with an allograft-prosthetic composite, and any of the aforementioned transfers can be utilized in this setting as well.

Conclusion

Tendon transfers in conjunction with reverse shoulder arthroplasty can significantly improve functional outcomes in patients with glenohumeral arthritis and irreparable rotator cuff deficiency. There have been multiple promising new techniques described within the last 20 years that shoulder surgeons should become familiar with.

Systematic review on the incidence, operative treatments, and outcomes of deltoid ruptures

Background

A deltoid rupture can result in significant losses of shoulder function, and in the setting of a rotator cuff tear, the deltoid serves as the sole abductor of the shoulder. Deltoid ruptures can be secondary to trauma, a consequence of massive rotator cuff tears, or a result of postoperative complications. There is a paucity of literature on the management of deltoid ruptures. In this systematic review, we aim to report on the incidence of deltoid ruptures, the surgical treatment options, and the outcomes following operative treatment.

Methods

A literature search was conducted on February 1, 2023 on MEDLINE and Google Scholar. Titles and abstracts were screened and the full text versions of articles that met criteria were reviewed. Criteria for inclusion included peer-reviewed studies evaluating the outcomes following surgical treatment of deltoid ruptures (direct repair, mobilization, reconstruction, and pedicled pectoralis transfer, with or without a reverse total shoulder arthroplasty). Secondary outcomes included incidence and causes of deltoid ruptures.

Results

A total of 101 studies were retrieved. After review and additional studies identified from reference lists, a total of 14 studies were included in the review. The incidence of deltoid ruptures ranged from 0.3% to 7%, and large, full-thickness rotator cuff tears were found to be a significant risk factor. Surgical treatment options for deltoid ruptures include direct repair, rotationplasty, and pedicelled muscle-tendon transfers; and when indicated, these procedures can be paired with a reverse total shoulder replacement. Postoperatively, the operative extremity should be immobilized in the position of least tension (forward flexion and abduction, 30°-70°) for 4-8 weeks. Most patients in this systematic review who underwent surgical treatment of their deltoid rupture had significant improvements in pain and mean postoperative forward elevation and abduction above 90°.

Discussion

The current available literature demonstrates that direct deltoid repair, rotationplasty, or reconstruction (muscle tendon transfer) with or without a concomitant reverse total shoulder arthroplasty can be an acceptable treatment option in patients with deltoid defects and massive rotator cuff tear. The average shoulder flexion and abduction increased postoperatively with improvements in pain.

Irreparable Cuff Injuries: Treatment Options and Clinical Outcomes

Rotator cuff tear is a common source of pain and disfunction in shoulder, with prevalence increasing with age. Nonsurgical treatment is adequate for many patients; however, for those for whom surgical treatment is indicated, rotator cuff repair provides reliable pain relief and good functional results. However, massive and irreparable tears due to tear size, tendon retraction, muscle atrophy, fatty infiltration are a significant challenge for surgeons. Whenever irreparable tears coexist with cartilage degeneration/arthritis (rotator cuff arthropathy), the indication of reverse shoulder arthroplasty is the golden standard. However, in young patients without arthritis, joint preserving procedures, from debridement to muscle transfers, are preferred. Choosing the most appropriate treatment is not quite established in literature, each treatment modality present particular indications, advantages and disadvantages.

Proximal Humerus Reconstruction for Bone Sarcomas: A Critical Analysis

» The proximal humerus is a common location for primary bone tumors, and the goal of surgical care is to obtain a negative margin resection and subsequent reconstruction of the proximal humerus to allow for shoulder function.» The current evidence supports the use of reverse total shoulder arthroplasty over hemiarthroplasty when reconstructing the proximal humerus after resection of a bone sarcoma if the axillary nerve can be preserved.» There is a lack of high-quality data comparing allograft prosthetic composite (APC) with endoprosthetic reconstruction of the proximal humerus.» Reverse APC should be performed using an allograft with donor rotator cuff to allow for soft-tissue repair of the donor and host rotator cuff, leading to improvements in shoulder motion compared with an endoprosthesis.

The Evolution of Reverse Total Shoulder Arthroplasty-Where Do We Stand and What Comes Next?

Over 35 years ago, the pioneer Paul Grammont from Lyon published his ideas of a reversed semi-constraint prosthesis improving the moment arm of the deltoid by medializing the center of rotation and lengthening of the arm and thus increasing deltoid muscle tension [...].

Latissimus dorsi tendon transfer to restore shoulder abduction in patients with deltoid paralysis: A novel technique

Background

Shoulder abduction is an essential movement for placement of the hand in space and thus for upper limb function. The objective of this study was to introduce and test the effectiveness of a new technique of latissimus dorsi tendon transfer to deltoid insertion to restore shoulder abduction.

Methods

We prospectively included 10 male patients with a lost deltoid function. Their mean age was 34.6 years (range, 25-46). We describe a new technique to compensate for the loss of the deltoid function using a latissimus dorsi tendon transfer augmented with a semitendinosus tendon graft. The tendon graft is passed over the acromion and attached to the anatomical deltoid insertion. Postoperatively, a shoulder spica in 90° abduction was used for six weeks followed by physiotherapy.

Results

Patients were followed up for a mean of 25.4 months (range, 12-48). The mean range of active shoulder abduction rose to 110° (range, 90-140°) with a mean gain of 83° of abduction.

Conclusions

This procedure can be a useful technique for restoration of a significant range and strength of active shoulder abduction.

Avascular Necrosis and Posttraumatic Arthritis After Proximal Humerus Fracture Internal Fixation: Evaluation and Management

PURPOSE OF REVIEW

Avascular necrosis (AVN) and posttraumatic arthritis (PTA) are common complications following both conservative treatment and open reduction and internal fixation (ORIF) of proximal humerus fractures (PHFs). Despite the frequent utilization of ORIF, information regarding these leading causes of failure is limited. This review includes a discussion of incidence, risk factors, and evaluation of AVN and PTA following PHF. The mechanisms of treatment options and associated outcomes are also reviewed.

RECENT FINDINGS

Recent best available evidence demonstrates significant rates of AVN and PTA following ORIF of PHF. This is particularly true of complex fracture patterns. A thorough workup is required in the setting of failure caused by AVN and PTA. This includes a careful patient history, clinical exam, plain film radiographs, and CT scans. EMG and/or aspiration may also be indicated. Special consideration is given to the examination of the deltoid muscle, neurovascular status, rotator cuff function, and the possibility of infection. Biological supplementation, anatomic total shoulder replacement (aTSA), and fusion are rarely employed in the treatment of AVN and/or PTA. Due to satisfactory patient outcomes, reverse total shoulder replacement (rTSA) has increased in popularity for the elderly population, while hemiarthroplasty (HA) may be appropriate for some young, active patients. With careful patient selection and meticulous surgical technique, AVN and PTA can be mitigated. Careful indications for ORIF may decrease the frequency of these complications. For most patients, rTSA is the optimal treatment option. Given the frequent utilization of ORIF and the higher than acceptable complication and failure rates, AVN and PTA warrant our attention.

Management of Massive Rotator Cuff Tears Without Arthropathy

Arthroplasty is not an optimal treatment for massive rotator cuff tears in patients who are active and without glenohumeral arthritis. Several surgical techniques have been developed for these patients, including arthroscopic rotator cuff repair with single-/double-row repair (with or without interval slides, margin convergence, graft augmentation), graft bridging, superior capsular reconstruction, tuberoplasty, and tendon transfers. Complete, tension-free, anatomic repair is ideal; however, tendon atrophy and retraction associated with massive tears often complicate repairs. All surgical treatments significantly increase patient-reported functional outcomes 1 year after intervention, with many treatments demonstrating improved mid-term and long-term outcomes. [Orthopedics. 2023;46(1):e1-e12.].

Preoperative Muscle Biopsy to Assess Motor End Plate Integrity as a Predictor for Successful Nerve Transfer: A Case Report

CASE

A 60-year-old right-hand-dominant man was referred for persistent right deltoid weakness, lateral shoulder numbness, and severe functional deficit 3 months after undergoing proximal humerus open reduction and internal fixation with plate and fibular strut allograft. Deltoid muscle biopsy demonstrated motor end plate (MEP) degeneration. After partial radial-to-axillary nerve transfer, repeat deltoid muscle biopsy revealed successful regeneration of MEPs with reinnervation of deltoid confirmed with postnerve transfer electromyography.

CONCLUSION

Selective nerve transfer can successfully rescue a denervated target muscle from further degeneration by restoration of healthy MEPs.

Management of Proximal Humeral Oncologic Lesions

The proximal humerus is a common location for primary tumors, benign lesions, and metastatic disease. Advances in neoadjuvant and adjuvant therapy have allowed for limb-salvage surgery in most of the cases. There are numerous of options for surgical management of proximal humerus lesions and the decision to pursue one over another depends on factors such as age, comorbidities, pathology, location within the proximal humerus, planned resection margins/size of defect, and bone quality. Long-term outcomes for these techniques tend to be retrospective comparative studies, with recent studies highlighting the improved outcomes of reverse total shoulders.

Muscle Tendon Transfers Around the Shoulder: Diagnosis, Treatment, Surgical Techniques, and Outcomes

➤

Muscle tendon transfers (MTTs) are effective surgical procedures for reducing pain and for improving active shoulder range of motion and patient-reported outcomes for a wide range of pathologies, including serratus anterior and trapezius muscle palsy, irreparable subscapularis tears, irreparable posterosuperior rotator cuff tears, irreparable posterior rotator cuff tears in the setting of reverse shoulder arthroplasty, and symptomatic complete deltoid deficiency.

➤

The principles of MTT include ensuring that the transferred muscle is expendable, the muscle tendon unit has similar excursion, the line of pull of the transferred tendon and of the recipient muscle are similar in terms of biomechanical force, and the transferred muscle should replace at least 1 grade of strength of the deficient recipient muscle.

➤

When MTT procedures are considered, patients must have exhausted all nonoperative management, have preserved passive range of motion, and have an understanding of the postoperative expectations and potential complications.

➤

For patients with scapulothoracic abnormal motion (STAM) due to long thoracic nerve palsy, the indirect or direct pectoralis major tendon transfer is an effective procedure for reducing pain and improving active forward elevation. For patients with STAM due to spinal accessory nerve palsy, the Eden-Lange or the triple tendon transfer procedures reduce pain and improve active forward elevation and abduction as well as patient-reported clinical outcomes.

➤

Both pectoralis major and latissimus dorsi transfer procedures for isolated irreparable subscapularis deficiency without anterosuperior humeral head escape result in improvement with respect to pain, patient-reported outcomes, and forward elevation, with the pectoralis major tendon transfer demonstrating durable long-term outcomes.

➤

The latissimus dorsi or lower trapezius tendon transfer procedures for irreparable posterosuperior rotator cuff tears reliably improve patient-reported outcomes, forward elevation, abduction, and external rotation range of motion. Additionally, latissimus dorsi transfer with or without teres major transfer can be used to restore active external rotation, both in the native shoulder and in the setting of reverse shoulder arthroplasty.

➤

The complications of MTTs include infection, hematoma, and failure of tendon transfer healing; therefore, it is recommended that these complex procedures be performed by shoulder surgeons with appropriate training.

Revision Reverse Total Shoulder Arthroplasty With Pectoralis Major Transfer for Anterior Deltoid Deficiency: A Case Report

CASE

A 70-year-old male patient presented with anterior deltoid weakness from Parsonage-Turner neuropathy status post failed nerve transfer and a failed total shoulder arthroplasty with pseudoparalysis. The patient underwent revision to a reverse total shoulder arthroplasty with concomitant pectoralis major transfer to substitute for the anterior deltoid. An excellent functional result was attained as early as 6 weeks after surgery.

CONCLUSION

Pectoralis major transfer can be an effective treatment option for isolated anterior deltoid insufficiency, even in the setting of a reverse total shoulder arthroplasty.

Allograft prosthetic composite reconstruction using a reverse total shoulder arthroplasty for failed oncologic proximal humerus reconstruction

INTRODUCTION

Endoprosthetic or allograft reconstruction are the preferred reconstruction techniques for proximal humeral bone tumors. Failure of these reconstructions may occur, but historically revision is performed rarely due to the lack of reliable options. Reverse shoulder arthroplasty with an allograft prosthetic composite (rAPC) may provide a revision option. The purpose of the current study was to evaluate our institutional outcome of these procedures.

METHODS

Eleven (6 male, 5 female) patients (mean age 51 ± 17 years) underwent revision of a failed oncologic reconstruction of the proximal humerus utilizing a rAPC. The most common indication for revision was subluxation (n = 6) and the most common previous implant was an endoprosthesis (n = 5).

RESULTS

Revision resulted in improvements in shoulder elevation (39° vs. 62°, p = 0.02), external rotation (13° vs. 25°, p = 0.04), American Shoulder and Elbow Surgeons score (39 vs. 58, p = 0.004) and Musculoskeletal Tumor Society Scores (51% vs 69%, p = 0.002). There were 2 re-revision procedures performed. One for an allograft fracture and one for allograft resorption and loosening.

CONCLUSIONS

Revision with a rAPC can effectively restore patient function. Due to the complexity of the cases, we advocate for these procedures to be performed by subspecialty upper extremity surgeons trained in complex revision shoulder arthroplasty.

Poor results after pyrocarbon interpositional shoulder arthroplasty

BACKGROUND

This study aimed to describe the clinical outcomes and complications of 10 cases of pyrocarbon interposition shoulder arthroplasty (PISA).

METHODS

The clinical and radiographic records of 10 patients who underwent PISA using the InSpyre shoulder prosthesis (Tornier-Wright) between July 2012 and March 2017 were reviewed. The mean age at surgery was 55 years. Surgical indications included patients aged <60 years with Walch type B glenoid glenohumeral osteoarthritis (n = 7), avascular necrosis (AVN) of the humeral head (n = 1), or secondary severe glenohumeral osteoarthritis with axillary nerve dysfunction (n = 2). Outcomes of interest were postoperative complications and need for revision surgery, preoperative and postoperative patient-reported outcomes (Constant score [CS] and Subjective Shoulder Value [SSV]), and range of motion. The radiographic characteristics of the implants were evaluated.

RESULTS

Among the 10 patients, 5 underwent revision to reverse shoulder arthroplasty during the study period owing to poor clinical outcomes based on the CS and SSV. All 5 revised patients had Walch type B glenoid morphology at the time of the index procedure. The mean time to revision surgery in this subset of patients was 60 months. The remaining 5 patients who did not undergo any revision procedure had significant improvement in mean CS and SSV from 30-65 points and 32%-87%, respectively, but at a shorter duration of follow-up of 35 months.

CONCLUSION

High clinical failure rate and poor results at mean 5-year follow-up were found in younger PISA patients with baseline Walch B glenohumeral osteoarthritis. We would caution against use of PISA in this challenging patient population. PISA yielded more favorable short-term outcomes in patients with humeral-sided deformity or severe secondary glenohumeral osteoarthritis with axillary nerve dysfunction; however, longevity of the implant in this population remains unclear.

Reverse Allograft-Prosthesis Composite with Pectoralis Major Transfer After Shoulder Osteosarcoma: A Case Report

CASE REPORT

We present a case of a 30-year-old man with proximal humerus osteosarcoma and periarticular soft-tissue involvement. Severe humeral and glenoid bone loss was observed, with nonfunctional deltoid after limb-sparing resection and a failed attempt of stabilization. The shoulder was reconstructed using a reverse allograft-prosthesis composite, with deltoid reconstruction by pectoralis major transfer.

CONCLUSIONS

To the best of our knowledge, this is the first time that this reconstruction technique has been reported in an oncological patient. Favorable clinical and radiological results were achieved at the 24-month follow-up.

The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty

BACKGROUND

There remains a paucity of epidemiologic data from recent years on the incidence of shoulder arthroplasty. We aimed to examine the recent trends and predict future projections of hemiarthroplasty (HA), anatomic (aTSA), and reverse shoulder arthroplasty (RSA), as well as compare these predictions to those for total hip (THA) and knee arthroplasty (TKA).

METHODS

The National Inpatient Sample was queried from 2011 to 2017 for HA, aTSA, and RSA, as well as TKA and THA. Linear and Poisson regression was performed to project annual procedural incidence and volume to the year 2025.

RESULTS

Between 2011 and 2017, the number of primary shoulder arthroplasties increased by 103.7%. In particular, RSA increased by 191.3%, with 63,845 RSAs performed in 2017. All projection models demonstrated significant increases in shoulder arthroplasty volume and incidence from 2017 to 2025. By 2025, the linear model predicts that shoulder arthroplasty volume will increase by 67.2% to 174,810 procedures whereas the Poisson model predicts a 235.2% increase, to 350,558 procedures by 2025. These growth rate projections outpace those of THA and TKA.

CONCLUSIONS

The number of shoulder arthroplasties has been increasing in recent years, largely because of the exponential increases in RSA. The overall incidence is increasing at a greater rate than TKA or THA, with projections continuing to rise over the next decade. These data and projections can be used by policy makers and hospitals to drive initiatives aimed at meeting these projected future demands.

Comparison of reconstructive techniques following oncologic intraarticular resection of proximal humerus

INTRODUCTION

The proximal humerus is a common site of primary and metastatic disease in the upper extremity. Historically, the goal of a hemiarthroplasty reconstruction was to provide a stable platform for hand and elbow function, with limited shoulder function. Techniques utilizing a reverse endoprosthesis (endoprosthetic replacement [EPR]) and allograft-prosthetic composite (APC) have been developed; however, there is a paucity of comparative studies.

METHODS

A total of 83 (42 females, 41 males) patients undergoing an intraarticular resection of the humerus were reviewed. Reconstructions included 30 reverse and 53 hemiarthroplasty; including hemiarthroplasty EPR (n = 36) and APC (n = 17), and reverse EPR (n = 20) and APC (n = 10).

RESULTS

Reverse reconstructions had improved forward elevation (85° vs. 44°, p < .001) and external rotation (30° vs. 21°; p < .001) versus a hemiarthroplasty. Reverse reconstructions had improved American Shoulder and Elbow Surgeons scores (65 vs. 57; p = .01) and Musculoskeletal Tumor Society 93 scores (72 vs. 63; p < .001) versus hemiarthroplasty. Subluxation of the reconstruction was a common (n = 23, 27%), only occurring in hemiarthroplasty patients (EPR [n = 13, 36%] and APC [n = 10, 59%]).

CONCLUSION

The current series highlights the improved functional outcome in patients undergoing reconstruction with a reverse arthroplasty compared to the traditional hemiarthroplasty. Currently reverse shoulder arthroplasty (APC or EPR) is our preferred methods of reconstruction in this patient population.

The modern reverse shoulder arthroplasty and an updated systematic review for each complication: part II

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%; P < .001), and the onlay humerus design had a lower rate than the lateralized glenoid design (0.9%, 2.0%; P = .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.

How to Optimize Reverse Shoulder Arthroplasty for Irreparable Cuff Tears

PURPOSE OF THE REVIEW

Reverse shoulder arthroplasty (RSA) is commonly considered as one of the options for surgical management of the functionally irreparable rotator cuff tear (FIRCT). This article reviews tips and tricks to optimize the outcome of RSA when performed specifically for this indication.

RECENT FINDINGS

RSA has been reported to provide satisfactory outcomes in a large proportion of patients with FIRCTs. However, subjective satisfaction is lesser in patients with well-maintained preoperative motion as well as those with isolated loss of active external rotation. The popularity of implants that provide some degree of global lateralization continues to increase. Optimizing the outcome of RSA for FIRCTs requires a careful balance between minimizing perimeter impingement and enhancing the function of intact muscles, in particular the deltoid and any remaining rotator cuff. Controversy continues regarding the benefits and disadvantages of subscapularis repair at the time of RSA. Tendon and muscle transfers performed at the time of RSA have the potential to optimize the outcome in selected patients with profound weakness in external rotation or those with severe deltoid dysfunction. When RSA is considered for patients with a FIRCT without arthritis, careful attention to indications and technical pearls may contribute to optimize outcomes.

Understanding and Treating Iatrogenic Nerve Injuries in Shoulder Surgery

As surgical techniques and technology continue to advance in shoulder surgery along with the increased use of regional anesthesia, it is important to remember that iatrogenic nerve injuries remain a possible complication. Iatrogenic nerve injuries associated with shoulder surgery lead to patient disability and distress, increased healthcare costs, and possibly additional procedures. To obtain the best possible outcome for the patient after the nerve injury has been discovered, a timely appreciation of the management options is necessary rather than expectant management. Early recognition, appropriate neurodiagnostic testing, and prompt treatment or referral are mandatory for optimal outcomes.

Survival, Tumor Recurrence, and Function Following Shoulder Girdle Limb Salvage at 24 to 35 Years of Follow-up

Limb salvage is the treatment of choice for malignant shoulder girdle tumors; however, there is a paucity of data examining the long-term outcome. The authors have previously reported on a cohort of patients at short- and mid-term follow-up. The purpose of this study was to report the long-term outcome of shoulder reconstruction in terms of oncological and functional outcome. The authors reviewed 53 patients who underwent a limb salvage procedure for treatment of a tumor of the shoulder girdle. At a mean of 28 years following the resection, 76% of surviving patients were contacted and administered functional outcome scores using the Musculoskeletal Tumor Society (MSTS) and Toronto Extremity Salvage (TESS). The 20-year survival and recurrence-free survival were 79% and 80%, respectively. Likewise, the 20-year revision survival was 75%, with a limb salvage rate of 94%. At last follow-up, the mean MSTS rating and TESS score were 75% and 85%, respectively, with 9 patients having improvement in their MSTS rating from the previous findings. Limb salvage following resection of shoulder girdle tumor resulted in acceptable means of oncological outcome and function. Some patients continued to experience improvements in functional outcome even at late (>20 years) follow-up. [Orthopedics. 2019; 42(6):e514-e520.].

How common are acromial and scapular spine fractures after reverse shoulder arthroplasty?: A systematic review

AIMS

Acromial fractures following reverse shoulder arthroplasty (RSA) have a wide range of incidences in reported case series. This study evaluates their incidence following RSA by systematically reviewing the current literature.

MATERIALS AND METHODS

A systematic review using the search terms "reverse shoulder", "reverse total shoulder", or "inverted shoulder" was performed using PubMed, Web of Science, and Cochrane databases between 1 January 2010 and 31 March 2018. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Studies were included if they reported on RSA outcomes and the incidence rate of acromial and/or scapular spine fractures. The rate of these fractures was evaluated for primary RSA, revision RSA, RSA indications, and RSA implant design.

RESULTS

The review included 90 articles out of 686 identified after exclusions. The incidence rate of acromial and/or scapular spine fractures was 2.8% (253/9048 RSAs). The fracture rate was similar for primary and revision RSA (2.8% vs 2.1%; p = 0.4). Acromial fractures were most common after RSA for inflammatory arthritis (10.9%) and massive rotator cuff tears (3.8%). The incidence was lowest in RSA for post-traumatic arthritis (2.1%) and acute proximal humerus fractures (0%). Lateralized glenosphere design had a significantly higher rate of acromial fractures compared with medial glenosphere designs.

CONCLUSION

Based on current English literature, acromial and/or scapular spine fractures occur at a rate of 2.8% after RSA. The incidence is slightly more common after primary compared with revision arthroplasty. Also, higher rates of acromial fractures are reported in RSA performed for inflammatory arthritis and in the lateralized glenoid design. Cite this article: Bone Joint J 2019;101-B:627-634.