Alberto Fontanarosa

Background: Treatment of failed osteosynthesis of fractures of the proximal humerus with one-stage or two-stage surgery is difficult and clinical results are poor. The aim of this work is to evaluate the microbiological positivity of devices removed due to osteosynthesis failure. Furthermore, the clinical outcomes of these patients were evaluated at a follow-up of minimum 6 months, to assess the recovery of range of motion and the reduction in pain. Methods: A retrospective analysis was performed on 15 patients treated from September 2021 to September 2023 for failure of previous proximal humerus synthesis. These treatments included implant removal and arthrolysis. None of these patients showed signs of infection. Demographic data, VAS, ASES, Constant score, and range of motion (ROM) were assessed before surgery and at least 6 months of follow-up. Removed devices were processed in MicroDTTect^® system, to increase the sensitivity of microbiological cultures. The cultural and clinical results of device removal surgery were analyzed. Results: Culture results were positive in eight out of 15 patients. Slow-growing anaerobic bacteria were the most isolated microorganisms, particularly C. acnes (62.5%). Improvement in patients’ passive ROM was observed. The patients went from a preoperative VAS of 8.4 (±1.1) to a VAS of 2 (±1.1) at follow-up. Similarly, we observed an increase in ASES from 9 ± 6 to 50.2 ± 2.3 and Constant score from 17 (15–18) to 40.7 ± 3.3 at a follow-up of at least 6 months. Conclusions: Two-stage procedure should always be considered in the context of proximal humerus synthesis failure. Arthrolysis with postoperative physiotherapy prepares the shoulder for definitive prosthesis implantation.

Background: The purpose of this study was to evaluate the impact of software updating on measurements of the glenoid inclination and version, along with humeral head subluxation performed by an automated 3D planning program. The hypothesis was that the software update could significantly modify the values of the glenoid inclination and version, as well as of the humeral head subluxation. Methods: A comprehensive pool of 76 shoulder computed tomography (CT) scans of patients who underwent total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA) were analyzed with the automated program Blueprint in 2018 and again in 2020 after a software update. Results: A statistically significant difference of 8.1 ± 8.2 and 5.4 ± 7.8 (mean difference of −2.8 ± 5.0, p < 0.001) was indeed reached when comparing the mean glenoid inclination achieved with Blueprint 2018 and Blueprint 2020, respectively. The glenoid version, as well as the humeral head subluxation evaluations, were not significantly different between the two software versions, with mean values being −9.4 ± 8.9 and −9.0 ± 7.4 and 60.1 ± 12.6 and 61.8 ± 12.0, respectively (p = 0.708 and p = 0.115, respectively). In 22% of CT scans, the software update determined a variation of the glenoid inclination of more than 5° or 10°. Conclusion: The present study shows the software update of an automated preoperative planning program may significantly modify the values of glenoid inclination. Even though without a significant difference, variations were also found for the glenoid version and humeral head subluxation. Accordingly, these results should further advise surgeons to carefully and critically evaluate data acquired with automated software.

Background: The purpose of the study was to evaluate the suitability of reverse total shoulder arthroplasty (RTSA) with a cementless and metaphyseal stem fixation as a treatment for complex proximal humeral fractures (PHFs) with a calcar fragment when this may be fixed with a steel wire cerclage. Clinical and radiographic outcomes were compared with the same RTSA for PHFs without a calcar fragment at a minimum of five-year follow-up. Methods: A retrospective analysis was performed on acute PHFs “with a medial calcar fragment” (group A) and “without a calcar fragment” (group B) treated with a RTSA and cementless metaphyseal stem fixation. Results: At an average follow-up of 6.7 years (5–7.8 years), no statistical difference was observed comparing group A (18 patients) to group B (50 patients) for active anterior elevation (141 ± 15° vs. 145 ± 10°, p = 0.67), active external rotation ER1 (49 ± 15° vs. 53 ± 13°, p = 0.55), and active internal rotation (5 ± 2 vs. 6 ± 2, p = 0.97). Similarly, a comparison of ASES score (89.2 ± 10 vs. 91.6 ± 9, p = 0.23) and Simple Shoulder Test score (91.1 ± 11 vs. 90.4 ± 10, p = 0.49) revealed no significant difference. Conclusion: RTSA with a cementless and metaphyseal stem fixation represents a safe and feasible treatment for complex PHFs with a medial calcar fragment when this may be fixed with a steel wire cerclage.

Purpose: the aim of this study was to evaluate preliminary clinical and radiographic results of arthroscopic treatment of cam-type femoroacetabular impingement (FAI). Methods: thirty-eight patients underwent hip arthroscopy for cam-type FAI between 2009 and 2012. Preoperative assessment was based on clinical examination, modified Harris Hip Score (mHHS) and radiographic examination with anteroposterior pelvis, frogleg and Lequesne views. The patients’ clinical conditions at follow-up were assessed using the mHHS administered as a telephone survey. Radiographic outcome measurements evaluated pre and postoperatively were the alpha angle and femoral head-neck offset. Results: the patients were clinically evaluated at a mean follow-up of 36 months. Radiographic follow-up was performed at an average of 12.7 months. Thirty of the 38 patients (79%) were satisfied with the results of the arthroscopic procedure. A total of nine patients subsequently underwent a total hip replacement. All 30 patients who declared themselves satisfied recorded an mHHS increase; in particular, the mHHS increased from a mean of 52.9 preoperatively (range: 27.5-82.5) to a mean of 85.6 postoperatively (range: 45.1-100.1). Three significant differences between the two groups of patients (satisfied and not satisfied) were recorded: mean age, alpha angle and BMI were all significantly greater in the patients who were not satisfied with the treatment. Conclusions: a crucial aspect in order to obtain good clinical outcomes of arthroscopic treatment of camtype impingement is correct selection of patients who are likely to benefit from this kind of surgery. Hip arthroscopy should be avoided in patients aged over 50 years with risk factors for early osteoarthritis (high BMI and a significantly increased alpha angle). Level of evidence: Level IV, therapeutic case series.