ObjectiveTo summarize the effectiveness of two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of the proximal humeral fracture.MethodsBetween June 2014 and January 2018, 17 patients with deep infection and humeral head necrosis or bone nonunion after internal fixation of proximal humeral fractures were treated. There were 8 males and 9 females, aged from 52 to 78 years (mean, 63.8 years). The infection occurred at 19-66 months after the initial internal fixation (mean, 34.8 months). Microbial culture of joint fluid was positive in 14 cases and negative in 3 cases. The preoperative Constant score, American shoulder and elbow surgeons (ASES) score, and visual analogue scale (VAS) score were 36.41±8.65, 31.06±7.43, and 7.29±0.99, respectively. The preoperative ranges of forward flexion, abduction, external rotation were (45.88±12.46), (42.18±12.31), and (16.76±4.92)°, respectively. The preoperative range of internal rotation was buttock in 9 cases, lumbosacral joint in 3 cases, L3 in 5 cases. At the first-stage surgery, the thorough debridement was done and the antibiotic-impregnated bone cement spacer was placed after the removal of internal fixation. After the infections disappeared, the two-stage reverse total shoulder arthroplasty was performed. The mean interval between the two procedures was 4.2 months (range, 3.0-6.5 months).ResultsAll the incisions healed primarily and no complications such as recurrent infection or vascular nerve injury occurred. All patients were followed up 15-32 months (mean, 22.0 months). At last follow-up, the ranges of forward flexion, abduction, and external rotation were (109.00±23.66), (98.53±16.92), (41.41±6.82)°, respectively; and the range of internal rotation was lumbosacral joint in 5 cases, L3 in 8 cases, T12 in 4 cases. The range of motion of shoulder joints at last follow-up was significant improved when compared with the preoperative range of motion (P<0.05). The Constant score (64.88±8.70), ASES score (65.18±8.10), and VAS score (2.94±1.25) were significantly superior to the preoperative scores (P<0.05). X-ray films showed that no prosthesis loosening occurred.ConclusionTwo-stage reverse total shoulder arthroplasty is an effective treatment for the postoperative deep infection after internal fixation of the proximal humeral fracture, which has advantages of low risk of infection recurrence, good shoulder function, and satisfactory short-term effectiveness.
Objective To summarize the influencing factors on the effectiveness of reverse total shoulder arthroplasty (RTSA), so as to provide reference for clinical treatment. Methods The related research literature of RTSA at home and abroad was extensively consulted, and the factors that may affect the effectiveness were summarized from the aspects of surgical technique, muscle condition, general condition of patients, psychological expectation, and lifestyle. Results For surgical techniques, different surgical approaches have their own advantages. The glenoid notch, poor bone ingrowth, increased bone resorption, and infection would lead to the loosening of glenoid prosthesis. In addition, the neck shaft angle and inclination angle of humeral prosthesis affect the occurrence of glenoid notch and the range of motion of joint internal/external rotation after operation, respectively. For muscle condition, the quality of teres minor and deltoid muscle has an important influence on joint stability after operation. Moderate increase of deltoid muscle tension can improve joint mobility after operation, and suture repair of subscapular tendon during operation can relieve joint pain and improve function, range of motion, and strength. For the general condition of patients, gender, age, and body mass index are all related to postoperative joint function and complications, and different occupations and postoperative exercise levels affect the recovery. The patients with severe degenerative diseases, poor preoperative function, and long disease duration have lower expectations and higher satisfaction with the effectiveness, and bad lifestyle has a negative impact on the effectiveness. Conclusion The effectiveness of RTSA is related to surgical technique, muscle condition, general condition of patients, psychological expectation, and lifestyle. In order to avoid the loosening of glenoid prosthesis, the operator should choose humeral prosthesis with small neck shaft angle and large glenoid ball and put them down and inclined inferiorly during operation, and choose appropriate approach to eliminate space with drainage to reduce the risk of infection. After operation, patients should avoid activities that generate high anterior and posterior shear forces. In addition, the humeral prosthesis with a inclination angle of 10°-20° can achieve the best balance between the range of internal rotation and external rotation after operation. Proper deltoid tension can maintain joint stability and good range of motion. Suture of subscapular tendon is recommended.
Objective To compare the effectiveness and shoulder function of reverse total shoulder arthroplasty (RTSA) and open reduction and internal fixation (ORIF) in the treatment of Neer three/four-part proximal humeral fractures in the elderly. Methods Randomized controlled analysis was conducted on 68 patients over 70 years old with Neer three/four-part proximal humeral fractures treated with RTSA or ORIF between January 2020 and June 2022. The patients were randomly divided into RTSA group (n=32) and ORIF group (n=36). There was no significant difference (P>0.05) in the baseline data such as age, gender, body mass index, injured side, Neer classification, and preoperative Charlson comorbidity index, visual analogue scale (VAS) score, Constant shoulder score, Oxford shoulder score (OSS), and hemoglobin (Hb). The operation time, intraoperative blood loss, reduction of Hb on the 3rd day after operation, hospital stay, total cost of hospitalization, complication incidence, range of motion of shoulder joint at 2 years after operation, VAS score before operation and at 5 days and 1 month after operation, Constant shoulder score and OSS score before operation and at 2 years after operation, and imaging results during follow-up were recorded and compared between the two groups.ResultsCompared with the ORIF group, the RTSA group had longer operation time, less intraoperative blood loss, and higher total cost of hospitalization (P<0.05). There was no significant difference in Hb reduction on the 3rd day after operation between the two groups (P>0.05). The VAS scores significantly improved in both groups at 5 days and 1 month after operation (P<0.05), but there was no significant difference between the two groups (P>0.05). All patients were followed up 26-35 months, with an average of 31.2 months. In the RTSA group, there were 2 cases of poor healing of superficial incision and 1 case of transient nerve injury. There was no complication such as bone resorption around the prosthesis, lucent band, prosthesis loosening, or periprosthetic fracture in all patients. In the ORIF group, there was 1 case of poor healing of superficial incision, 3 cases of nonunion of fracture, 1 case of arthritis secondary to humeral head necrosis, and 1 case of bone absorption of large tuberosity, and no displacement or fracture failure of internal fixation was found in all patients. There was no significant difference in the incidence of complications [9.4% (3/32) vs 16.7% (6/36)] between the two groups [OR (95%CI): 0.828 (0.171, 4.014), P=0.814]. In the RTSA group, 28 cases were graded 0 and 4 cases were graded 1 at 2 years after operation. Constant and OSS scores of RTSA group were significantly better than those of ORIF group (P<0.05). The Constant score was significantly better than ORIF group in activity and strength, range of motion, lifting, abduction, and external rotation (P<0.05), and there was no significant difference in pain, daily function, and internal rotation between the two groups (P>0.05). The RTSA group had a significantly greater range of motion in lifting, abduction, and external rotation than ORIF group (P<0.05), but there was no significant difference in internal rotation between the two groups (P>0.05). ConclusionApplication of RTSA as the initial treatment of Neer three/four-part proximal humeral fractures in the elderly can achieve better rehabilitation of joint activity and lower risk of early reoperation, and improve the quality of life of elderly fracture patients. However, the difficulty of revision and the high cost of treatment require the surgeon to pay full attention and strictly grasp the indications.