Dani Rotman

Purpose Greater tuberosity (GT) fragment healing has been associated with improved outcomes following reverse total shoulder arthroplasty (RTSA) for proximal humerus fractures, yet the relationship between pre-operative GT fragment volume and clinical outcomes remains largely unexplored. We hypothesised that larger GT volumes would be associated with improved outcomes and larger anatomical dimensions. Methods We retrospectively studied 153 patients who underwent RTSA for proximal humerus fracture. GT fragment volume was measured on pre-operative computed tomography (CT). Clinical outcomes included forward flexion, abduction, external and internal rotation, visual analogue scale (VAS) pain score, Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, and Subjective Shoulder Value (SSV). Anatomical parameters and patient sex were also evaluated. Associations were assessed using Spearman and point-biserial correlations. Results GT fragment volume showed no significant correlation with any clinical outcome measure (all p ≥ 0.15) or with radiographic tuberosity healing (r = − 0.135, p = 0.15); this persisted in 91 patients with confirmed healing. In contrast, it correlated with maximal tuberosity length on radiographs (r = 0.54) and CT (r = 0.52), glenoid surface area (r = 0.35), and male sex (r = 0.32), all significant after Bonferroni correction; a weak correlation with humeral head diameter (r = 0.18) did not survive correction. Conclusion GT fragment volume correlates with anatomical shoulder dimensions and reflects overall skeletal size but does not predict clinical outcomes or tuberosity healing following RTSA. Surgeons should not rely on it to predict outcomes, healing potential, or to guide surgical decision-making.

Background: The coracobrachialis (CB) is an important anterior shoulder stabilizer, yet no study has previously reported its electromyography (EMG). The purpose of this study was to validate a novel technique for surface EMG (sEMG) of the CB. Methods: Thirty-two (21 females) healthy individuals participated in this cross-sectional study. A surface landmark for recording the CB was identified within the medial aspect of the proximal arm using real-time ultrasound imaging and cadaver dissection. The EMG from this landmark as well as from the biceps brachii (BB) were simultaneously recorded during shoulder horizontal adduction (SHAd) (a CB-dominant test), and during elbow flexion (EFlx) and forearm supination (FSup) (BB-dominant tests). Differences between CB and BB activation (% maximal voluntary isometric contraction) within each test were assessed. Results: CB activation was significantly greater than BB during SHAd (36.51% versus 4.09%, P < 0.001). BB activation was significantly greater than CB during FSup (34.85% versus 27.70%, P = 0.045). No difference between CB and BB activation was noted during EFlx (41.82% versus 28.64%, P = 0.061). Conclusions: The moderate activation of the CB with simultaneous minimal activation of the BB during SHAd supports this novel sEMG technique. This technique may assist the design of exercises to train the CB. Level of evidence: III.

Background: The timing of operative debridement for open upper extremity fractures has not been consistently shown to impact infection rates. Nevertheless, current treatment protocols continue to advocate for prompt surgical debridement in the operating room. We hypothesized that delaying the surgical treatment of low-grade open forearm fractures beyond 24 h from presentation does not increase the likelihood of infection. Methods: The medical charts of patients who presented to a level one trauma center with Gustilo type 1 or 2 open forearm fractures between 2017 and 2020 were retrospectively reviewed. Treatment protocols for these low-grade open fractures included prompt wound irrigation in the emergency department and intravenous antibiotic treatment for 72 h, without emphasizing the timing of surgical intervention. Outcome measures included time to surgery, infection rate, and union rate. Results: The mean ± standard deviation age of the 62-patient cohort was 57 ± 20 years, and 30 (48%) were males. There were 9 proximal third, 16 midshaft, and 37 distal third fractures, of which 41 involved both bones. Forty-eight fractures were classified as Gustilo type 1 and fourteen as Gustilo type 2. Surgery was performed at a median interval of 47 h following presentation, with 43 (69%) patients undergoing surgery later than 24 h following presentation. There was one case (1.6%) of infection and three cases (4.8%) of non-union. Conclusions: Subject to small numbers, our findings suggest that in patients without risk factors, surgical treatment for low-grade open forearm fractures can be safely deferred without an apparent increase in infection rates. Accordingly, treatment protocols for these fractures may prioritize prompt and adequate antibiotic administration over the urgency of surgical intervention.

Background: The mortality rate following proximal humerus fractures (PHFs) in elderly patients is increased, but currently, there are no medium-term studies comparing mortality following treatment with Reverse Total Shoulder Arthroplasty (RTSA) to non-surgical treatment. Methods: This retrospective study compares two groups of elderly patients (aged 75 to 95 at the time of injury) who were diagnosed with PHFs. A total of 79 patients (mean age: 83.1 ± 4.6) were treated conservatively between 2008 and 2010, a time when RTSA was not yet considered a treatment option, and 81 patients (mean age: 82.4 ± 4.4) underwent RTSA between 2012 and 2017. Also, 1-month, 1-year, and 5-year mortality rates were recorded. Results: The 1-month, 1-year, and 5-year mortality rates were 1.2%, 7.4%, and 33.3% in the RTSA group and 2.5%, 11.4%, and 38.0% in the non-surgical treatment group (p = 0.98, p = 0.55, p = 0.65). A subgroup analysis revealed that the mild difference between groups can be attributed to male patients only. Conclusions: This study explored the impact of RTSA versus non-surgical treatment on mortality in elderly patients with PHFs and found similar mortality rates over five years. Better segmentation of the patient population may reveal subgroups with different mortality patterns.

Background: Various fracture-specific reverse shoulder arthroplasty (RSA) systems exist on the market. We set out to examine whether the type of prosthesis used and the means of fixation (cemented or non-cemented) influenced the rate of tuberosity healing or the functional outcome of the operation. Methods: This retrospective cohort multicenter study included 146 patients who underwent RSA for an acute three- or four-part proximal humerus fracture and had a minimum follow-up of one year. Six fellowship-trained surgeons at two different centers performed all operations. The implants were either Tornier Aequalis or Depuy Delta Xtend, both fracture-specific Grammont-style systems. Results: The mean age ± standard deviation (SD) was 76 ± 7 years, and 83% of patients were female. The mean ± SD follow-up time was 30 ± 31 months. The Aequalis prosthesis was used in 82 patients (56%), and the Delta Xtend in 64 patients (44%). A total of 105 RSAs (72%) were cemented. Tuberosity healing rate was similar for the two implant systems (71% Aequalis vs. 82% Delta Xtend, p = 0.15) and for the cemented or non-cemented, respectively (73% cemented vs. 83% non-cemented, p = 0.22). There was no significant difference in the motion and functional outcomes between the two implant systems in this study. Conclusions: RSA for complex PHF in the elderly has similar short-term results, regardless of the type of fracture-specific implant or the fixation technique (cemented vs. cementless).

Background: Radiocapitellar arthritis can cause pain, loss of motion, and impaired elbow function. Current surgical treatment options are limited. We have developed an original and simple surgical technique to address this, called arthroscopic matched osteoplasty of the radial head (AMOR). In AMOR, the radial head is partially resected and recontoured to match the capitellum and decompress the degenerate radiocapitellar articulation while preserving the ulnohumeral articulation where the cartilage is usually well preserved.Methods: Indications and the surgical technique of the AMOR procedure are described. A retrospective observational service evaluation study was conducted from electronic patient records. Collected clinical outcomes included range of motion, pain level, subjective functional score, and general satisfaction with the results of the procedure. The radiographic outcome was radiocapitellar joint space.Results: Between 2017 and 2021, eight consecutive patients underwent AMOR as part of an arthroscopic osteocapsular arthroplasty procedure. Radiographically, the mean radiocapitellar joint space improved from an average of 1.7 mm to 4.6 mm. Clinically, the mean pain score decreased from 8/10 to 3/10. Six of the eight patients (75%) were satisfied with their results. In two cases, initial improvement following surgery lasted less than 1 year, and one of these patients underwent total elbow arthroplasty for painful ulnohumeral osteoarthritis. There were no complications of surgery recorded.Conclusions: AMOR is a safe treatment option for painful radiocapitellar osteoarthritis and can be incorporated as an “add-on” procedure by surgeons performing elbow osteocapsular arthroplasty in cases with a positive grip and grind test and radiographic evidence of radiocapitellar OA.Level of evidence: IV.

Introduction: Self-reduction of a shoulder dislocation may reduce the time from injury to reduction and to the relief of patient discomfort. The purpose of this study was to assess adherence to earlier acquired self-reduction techniques during real-time recurrent shoulder dislocation. Methods: A telephone survey was conducted among 58 patients previously taught shoulder self-reduction via an instructional video sent to their smartphones during a visit to the emergency department (ED) for the treatment of anterior shoulder dislocation. Participants were queried on recurrent dislocations, use of self-reduction methods, success rate, the effect that instruction in self-reduction had on their willingness to participate in recreational sports activities, on the decision to avoid surgery, and on the overall level of satisfaction with self-reduction methods. Results: Forty-five patients (77.6%; average age 31.4±11.7 y, 10 females) were available for follow-up at an average 60.8±11.0 mo after the index visit to the ED. Eighteen of 23 patients (78.2%) who experienced a recurrent dislocation during the follow-up period attempted self-reduction, and 12 of them successfully achieved self-reduction. Sixteen patients (35.6%) reported that the knowledge in self-reduction increased their willingness to participate in recreational sports activities, whereas 4 (8.9%) patients reported that knowledge in self-reduction affected their decision not to undergo surgical stabilization. Conclusions: Individuals who sustain recurrent shoulder dislocations should be educated on shoulder self-reduction with the aims of minimizing discomfort, obviating referral to the ED, and motivating participation in recreational activities.