Treatment of proximal humeral fractures with reverse shoulder arthroplasty in elderly patients

BACKGROUND

Proximal humeral fractures in four or even only three parts, with metaphyseal hinge distances of <8 mm, represent a serious and widely debated problem. Reduction is complex and plating is often instable, especially in elderly patients. Failures, sometimes involving necrosis of the head, are frequent. Hemiarthroplasty has long been used for 3- or 4-part complex fractures, even in young patients, although often with sub-optimal results, due to reabsorption of tuberosities. This complication has partly been overcome with reverse shoulder prostheses which, although more invasive than partial ones, may lead to less disappointing results, even in cases of reabsorption of tuberosities. We have data on a homogeneous series of patients treated with reverse shoulder arthroplasty for proximal fractures, with a maximum follow-up of 10 years. The aim of this study was mainly to identify which cases can be selected for effective treatment and which technical aspects are best to adopt.

MATERIALS AND METHODS

There were 33 patients in this study, mean age 76.6 years (range 54-85). Fractures were classified according to Neer. Surgery was undertaken on average 4.4 days after trauma. The deltopectoral approach was used. Sutures were hooked over the major and lesser tubercles for later reduction and fixation after the prosthesis had been applied. This passage was sometimes not possible in cases of serious degeneration of the rotator cuff. One day after surgery, a shoulder brace providing an abducted angle of 15° was applied for 30 days. Patients were re-assessed with DASH and Constant scores (CS), and the ratio between healthy and operated shoulders was calculated. Physical examination was followed by X-rays, mainly to evaluate and classify any infraglenoid scapular notching according to Nerot.

RESULTS

Mean follow-up was 42.3 months (range 10-121). According to the CS, mean pain was 12.6/15 (range 3-15/15), activities of daily living 16.3/20 (range 8-20/20), ROM 21.8 (range 8-32/40) and power 5.4/25 (range 2-12/25). Total mean CS was 56.4 (range 23-80/100). The mean DASH score was 49.7 (range 32-90). The ratio of the CS parameters between opposite and operated shoulders was on average 72.8 % (range 28-90 %). Long-term complications were eight cases of scapular notching (24.2 %) of which four of grade 2 (12.1 %) and four of grade 1 (12.1 %).

CONCLUSIONS

Total reverse prostheses are more invasive because they also compromise the glenoid surface of the scapula, but they do offer good stability, even in cases of damage to the rotator cuff. Reverse prostheses have great advantages as regards to ROM, allowing functional recovery, which is good in cases with re-insertion of tuberosities, and acceptable in cases when tuberosities are not re-inserted or resorbed. In our cases, the first 3 reverse prostheses lasted 10, 8.3 and 7.3 years, and we believe that they will become increasingly long-lived, so that applying them in cases of complex fractures becomes more feasible. We prefer the deltopectoral approach because it can reduce and stabilize possible intra-operative diaphyseal fractures. Possible scapular notching must be foreseen when inserting the glenosphere. We had eight cases (24.2 %), of which four were Nerot grade 1 and four were grade 2. Applying the Kirschner wire in an infero-anterior position allows the glenosphere to be lowered with a tilt of 10°. Reverse prostheses are suitable for 3- or 4-part complex proximal humeral fractures in patients over 65. Prolonged physiokinesitherapy is essential.

Genetic diversity of Streptococcus suis clinical isolates from pigs and humans in Italy (2003-2007)

Streptococcus suis, a major porcine pathogen, is emerging as a zoonotic agent capable of causing severe invasive disease in humans exposed to pigs or pork products. S. suis infection is rare in industrialised countries and usually arises as sporadic cases, with meningitis the most common clinical presentation in humans. Recent reports of two cases of meningitis in Sardinia and north-eastern Italy prompted this first characterisation of Italian S. suis isolates. Fifty-nine S. suis strains, the two recent human strains and 57 swine clinical isolates collected between 2003 and 2007 from different Italian herds and regions, were tested for antimicrobial susceptibility, PCR-screened for virulence and antibiotic resistance genes, and subjected to molecular typing. Phenotypic and genotypic analysis demonstrated an overall high genetic diversity among isolates, the majority of which were resistant to macrolides (78%) and tetracyclines (90%). The erm(B), tet(O), mosaic tet(O/W/32/O), tet(W), and tet(M) genes were detected. The tet(O/W/32/O) gene, the most frequent tet gene after tet(O), had never been described in the genus Streptococcus before. In addition, a virulent cps2, erm(B) tet(O) clone, belonging to sequence type 1 (ST1) of the ST1 complex, was found to be prevalent and persistent in Italian swine herds. Finally, the two human isolates (both ST1) carrying cps2, erm(B) and tet(W) were seen to be closely related to each other.

In vivo topical anti-inflammatory and in vitro antioxidant activities of two extracts of Thymus satureioides leaves

Four extracts at increasing polarity were prepared from the leaves of Thymus satureioides Coss. (Labiatae) and assayed for the in vivo topical anti-inflammatory effect using the croton oil ear test in mice, and for in vitro both antioxidant (DPPH degrees test) and anti-bacterial (broth microdilution method) activities. The chloroform extract showed a topical anti-inflammatory activity (ID50=282 microg cm(-2)), only three times lower than that of the reference drug indomethacin (ID50=93 microg cm(-2)) and its active components were identified as ursolic and oleanolic acids. The methanol extract, showing a significant radical-scavenging effect (SC50=14.54 microg), was characterized by the isolation and identification of some flavonoids. On the contrary, the extracts did not show any anti-bacterial effect against four standard aerobial bacteria strains.

Screening of anti-bacterial activity of medicinal plants from Belize (Central America)

Twenty-one extracts from seven herbal drugs, Aristolochia trilobata (Aristolochiaceae) leaves and bark, Bursera simaruba (Burseraceae) bark, Guazuma ulmifolia (Sterculiaceae) bark, Hamelia patens (Rubiaceae) leaves and Syngonium podophyllum (Araceae) leaves and bark, used in traditional medicine of Belize (Central America) as deep and superficial wound healers, were evaluated for their anti-bacterial properties. Activity was tested against standard strains of Escherichia coli ATCC 25922, Pseudomonas aeruginosa ATCC 27853, Staphylococcus aureus ATCC 25923 and Enterococcus faecalis ATCC 29212. Almost all the extracts were able to inhibit the growth of one or more of the bacterial strains, except that of Enterococcus faecalis. For the first time an anti-microbial activity is reported for Aristolochia trilobata as well as for Syngonium podophyllum. The hexane extracts of Aristolochia trilobata leaves and bark were the most active extracts against Staphylococcus aureus (MIC=0.31 and 0.625mg/ml, respectively).

[Surveillance of antibiotic-resistant microorganisms for the rational use of antimicrobial drugs]

An epidemiological survey of 703 bacterial strains isolated in Pordenone was performed in the first eight months of 1998, to verify the predominant bacterial incidence, the susceptibility to antimicrobial drugs in this period, and variations in the resistance patterns. The study demonstrated some interesting variations in this period: for example, there is a considerable increase in antimicrobial resistance of Escherichia coli (especially to cotrimoxazole, ampicillin, piperacillin and ciprofloxacin) and Pseudomonas aeruginosa (to aztreonam and ciprofloxacin). The results suggest the importance of constant epidemiological surveillance in the hospital and community setting.

[Survey on ciprofloxacin resistance: the epidemiological situation in Pordenone (Italy)]

An epidemiological survey on 2859 bacterial strains was performed in the first nine months of 1998, to verify the predominant susceptibility to ciprofloxacin of the main microrganisms isolated in this period. Our results showed that the use of ciprofloxacin would probably decrease in future because of increasing resistance with respect to previous period. An increase in antimicrobial resistance occurred in some gram positive (as Enterococci) and especially gram negative strains such as Escherichia coli, that are common and frequent bacterial causes of infections in hospital and in the community. The study demonstrated that there are also interesting and important variations in resistance patterns with respect to previous studies

[A proposal for guidelines of antimicrobial prophylaxis in surgery and surveillance of their application]

Not available

["In vitro" sensitivity of bacterial strains isolated from urine cultures in the period 1995/96]

Urinary tract infections represent a very frequent pathology. An epidemiologic survey on 6632 urine samples has been performed in the years 1995/96 to verify the bacterial incidence and susceptibility to antimicrobial drugs in this period, and variations in the resistance patterns with respect to a previous study. The results suggest the importance of a constant epidemiological surveillance in the community setting.

[Epidemiologic surveillance of streptococcus pyogenes resistances to macrolides and lincosamides]

With the changing face of modern medicine and increased use of new antimicrobial compounds against Streptococcus pyogenes, as macrolides, in recent years more strains developed new resistance to macrolides and lincosamides. This is of interest because some scientists believe that the new antibiotics policies possibly influence the rate of resistance in Streptococcus pyogenes: the pattern of resistance to macrolides is complex and involving cross or co-resistance with chemically unrelated or related agents, as lincosamides. To obtain current epidemiological data on antimicrobial resistance of Streptococcus pyogenes, we performed an year surveillance study: the rate of resistance to erythromycin was from 4% in October 1994 to 55% in December 1995, and in the same time clarithromycin was from 0% to 46% and clindamycin from 0% to 32%.

[Not Available]

The author describes three cases of pirogenic reaction in patients in treatment with hemodialysis: Pseudomonas aeruginosa and Enterobacter cloacae were isolated from water of dyalisis machines. He, moreover, analyses different antibacterial decontamination systems