Comparing therapy and repair for rotator cuff tears of 3 cm or less http://t.co/oLrrhF6vKt
— Dr Frederick Matsen (@shoulderarth) septiembre 18, 2014
Dr Michell Ruiz
Cirugía de hombro y del Manguito rotador
martes, 30 de septiembre de 2014
Comparing therapy and repair for rotator cuff tears of 3 cm or less
Conversion of an anatomic to a reverse total shoulder, when is a 'platform' prosthesis of benefit?
http://shoulderarthritis.blogspot.mx/2014/09/conversion-of-anatomic-to-reverse-total.html
Tuesday, September 30, 2014
Conversion of an anatomic to a reverse total shoulder, when is a 'platform' prosthesis of benefit?
An anatomic arthroplasty can fail for many reasons, including malposition, instability, delayed cuff failure and pseudo paralysis. In these situations consideration can be given to conversion of the anatomic prosthesis to a reverse total shoulder as shown here. As demonstrated in that post out preferred method for managing a failed anatomic arthroplasty is to completely remove the existing implant, obtain cultures, and then implant the reverse prosthesis. This approach allows full access to the glenoid and optimal positioning of the humeral component of the reverse. Removal of the anatomic implant is almost always possible and is particularly straightforward if it was inserted using impaction grafting.
In certain cases, such as that shown here, a well fixed stem can be retained and the proximal end converted to a reverse total shoulder with insertion of a glenosphere. Here's another post regarding conversion with retention of the anatomic stem.
Recently, there has been the advent of 'platform' prostheses, in which a humeral stem is fixed in the humeral canal that can be attached to either an anatomic or a reverse proximal humeral prosthesis. Several examples are shown below.
It is important to recognize that in a reverse, (1) the glenosphere is placed inferiorly on the glenoid face, (2) the proximal humeral part of the reverse is bigger than that of an anatomic humeral arthroplasty and (3) the soft tissue tensioning considerations of a reverse are different from those of an anatomic arthroplasty. Therefore, the proximal-distal positioning of the humeral component needs to be fine tuned to achieve the ideal reverse arthroplasty. While some systems provide various adaptors to adjust the height, inclination and version of the proximal humeral prosthesis, the flexibility in positioning is limited by the use of the 'platform' fixed in the humeral canal.
Fortunately, we now have a clearer understanding of the indications for a reverse total shoulder, so that the needs for convertible prostheses is diminishing. For example, it is becoming evident that proximal humeral fractures in elderly individuals are often best managed by a primary reverse total shoulder - the idea of 'trying' an anatomic arthroplasty that is convertible to a reverse later is not so appealing. Similarly, individuals with arthritis, cuff deficiency, and instability are also best managed by a primary reverse.
In certain cases, such as that shown here, a well fixed stem can be retained and the proximal end converted to a reverse total shoulder with insertion of a glenosphere. Here's another post regarding conversion with retention of the anatomic stem.
Recently, there has been the advent of 'platform' prostheses, in which a humeral stem is fixed in the humeral canal that can be attached to either an anatomic or a reverse proximal humeral prosthesis. Several examples are shown below.
It is important to recognize that in a reverse, (1) the glenosphere is placed inferiorly on the glenoid face, (2) the proximal humeral part of the reverse is bigger than that of an anatomic humeral arthroplasty and (3) the soft tissue tensioning considerations of a reverse are different from those of an anatomic arthroplasty. Therefore, the proximal-distal positioning of the humeral component needs to be fine tuned to achieve the ideal reverse arthroplasty. While some systems provide various adaptors to adjust the height, inclination and version of the proximal humeral prosthesis, the flexibility in positioning is limited by the use of the 'platform' fixed in the humeral canal.
Fortunately, we now have a clearer understanding of the indications for a reverse total shoulder, so that the needs for convertible prostheses is diminishing. For example, it is becoming evident that proximal humeral fractures in elderly individuals are often best managed by a primary reverse total shoulder - the idea of 'trying' an anatomic arthroplasty that is convertible to a reverse later is not so appealing. Similarly, individuals with arthritis, cuff deficiency, and instability are also best managed by a primary reverse.
sábado, 27 de septiembre de 2014
jueves, 25 de septiembre de 2014
Dolor de hombro: Pinzamiento del Manguito rotador
Dolor de hombro: Pinzamiento del Manguito rotador. Consulta frecuente en #Ortopedia.Que es?. http://t.co/P69FuVTOSr pic.twitter.com/BxSNu28jHW
— Osteonoticias (@osteonoticias) agosto 27, 2014
miércoles, 24 de septiembre de 2014
Rotator cuff repair vs. non-repair of cuff tears in individuals over the age of 60 years.
http://shoulderarthritis.blogspot.mx/2014/09/rotator-cuff-repair-vs-non-repair-of.html
Is rotator cuff repair appropriate in patients older than 60 years of age? Prospective, randomised trial in 103 patients with a mean four-year follow-up
These authors compared surgical rotator cuff repair to acromioplasty and biceps tenotomy in patients older than 60 years of age with a mean follow-up of 4 years.
Patients were randomly allocated to acromioplasty and tenotomy (AT group) or to acromioplasty, tenotomy, and tendon suture (CR group). In the repair group tendon suture was consistently achieved using metal anchors inserted into the tip of the greater tuberosity after abrasion of the footprint, in a single-row (n = 21) or double-row (n = 33). After surgery patients wore a sling for 4 weeks with
The complication rate was 4%. The mean Constant Score was 44 preoperatively; values after 4 years were 76 overall. The repair group had slightly greater Constant Scores (78) than the acromioplasty group (73). Less than 2/3 rds of the repairs (63%) were healed by sonography.
Monday, September 22, 2014
Rotator cuff repair vs. non-repair of cuff tears in individuals over the age of 60 years.
Is rotator cuff repair appropriate in patients older than 60 years of age? Prospective, randomised trial in 103 patients with a mean four-year follow-up
These authors compared surgical rotator cuff repair to acromioplasty and biceps tenotomy in patients older than 60 years of age with a mean follow-up of 4 years.
Exclusion criteria included subscapularis tear, spontaneous long head biceps tear, and irreparable tear as determined arthroscopically.
Patients were randomly allocated to acromioplasty and tenotomy (AT group) or to acromioplasty, tenotomy, and tendon suture (CR group). In the repair group tendon suture was consistently achieved using metal anchors inserted into the tip of the greater tuberosity after abrasion of the footprint, in a single-row (n = 21) or double-row (n = 33). After surgery patients wore a sling for 4 weeks with
passive self-rehabilitation on day 1. After 4 weeks, physiotherapy sessions were prescribed if needed.
Of 130 initially included patients older than 60 years of age and having rotator cuff tears deemed amenable to surgical repair, 103 (79%) were evaluated after a mean of 4 years.
The tear was distal in 41 patients, intermediate in 40, and retracted in 22.
The complication rate was 4%. The mean Constant Score was 44 preoperatively; values after 4 years were 76 overall. The repair group had slightly greater Constant Scores (78) than the acromioplasty group (73). Less than 2/3 rds of the repairs (63%) were healed by sonography.
The Constant Score was significantly better when tendon healing was achieved (82/73, P < 0.001). In the AT group, the acromio-humeral distance was significantly smaller (6.9 mm/7.8 mm, P = 0.03) and eccentric humeral head position was more common (44%/26%,P = 0.01).
Comment: It would have been interesting to know how many of the shoulders with cuff tears examined arthroscopically were deemed 'irreparable' and how this determination was made. Because the constant score includes a strength component, it is expected that shoulders with healed repairs would score better than those with unhealed or unrepaired tears. It is interesting to note, however, that the difference between repair and non-repair reported in this article did not reach the level of the minimal clinically important difference for rotator cuff tears (=10). Finally it is of note that acromioplasty sacrifices part of the coracoacromial arch and may not be benign for unrepaired cuffs. For that reason, we prefer thesmooth and move procedure when cuff repair is not possible or desirable.
Resurfacing humeral arthroplasty can cause bone loss beneath the component
http://shoulderarthritis.blogspot.mx/2014/09/resurfacing-humeral-arthroplasty-can.html
Resurfacing humeral arthroplasty can cause bone loss beneath the component
Stress-shielding induced bone remodelling in cementless shoulder resurfacing arthroplasty: A finite element analysis and in-vivo results
These authors explore the concern that cementless surface replacement arthroplasty may result in stress shielding and bone remodelling beneath the prosthesis. They studied bone remodelling using 3-dimensional finite element analysis (FEA) as well as evaluation of contact radiographs from human implant retrievals.
These authors explore the concern that cementless surface replacement arthroplasty may result in stress shielding and bone remodelling beneath the prosthesis. They studied bone remodelling using 3-dimensional finite element analysis (FEA) as well as evaluation of contact radiographs from human implant retrievals.
FEA included one native humerus model with a normal and one with a reduced bone stock quality. The compressive strains were evaluated before and after virtual resurfacing prosthesis implantations.
They also studied the bone remodelling and stress-shielding pattern of 8 human cementless surface replacement arthroplasty retrievals.
FEA revealed for both bone stock models increased compressive strains at the stem and outer implant rim for both cementless surface replacement arthroplasty designs indicating an increased bone formation at those locations. Unloading of the bone was seen for both designs under the central implant shell indicating high bone resorption. Those effects appeared more pronounced for the reduced than for the normal bone stock model.
These assumptions of the FEA were confirmed in the cementless surface replacement arthroplasty retrieval analysis which showed bone apposition at the outer implant rim and stems with highly reduced bone stock below the central implant shell. Overall, clear signs of stress shielding were observed for cementless surface replacement arthroplasty in the in-vitro FEA and human retrieval analysis. Especially beneath the central part of the cementless surface replacement arthroplasty the bone stock was highly resorbed.
Comment: As pointed out in our post from two days ago, resurfacing humeral hemiarthroplasty has been proposed as a more conservative approach to managing shoulder arthritis, but it has the disadvantages of (1) non addressing the glenoid side of glenohumeral arthritis, (2) blocking access to the glenoid if a glenoid component is considered, and (3) making it difficult to detect if the humeral component is subsiding. This article adds 'stress shielding' and resulting loss of the supporting bone as a fourth concern.
Stemless reverse total shoulder
http://shoulderarthritis.blogspot.mx/2014/09/humeral-head-resurfacing-analysis-of.html
Stemless reverse total shoulder
The TESS reverse shoulder arthroplasty without a stem in the treatment of cuff-deficient shoulder conditions: clinical and radiographic results.
These authors, including the co-conceptor of the design, enrolled 101 patients having 105 stemless reverse total shoulders in a prospective study, with a minimum follow-up period of 24 months. 91 procedures in 87 patients (61 men and 26 women), with a mean age of 73 years, were available at a mean follow-up of 41 months (range, 24-69 months).
Ninety-six percent of patients rated their satisfaction as good or excellent. Mean flexion was 143° (range, 90°-170°), and mean external rotation was 39° (range, 20°-70°). The Constant score improved from 40 points preoperatively to 68 points at last follow-up (P < .001). The mean American Shoulder and Elbow Surgeons score was 24 points. The mean neck-shaft angle was 154° (range, 142°-165°). Inferior scapular notching occurred in 17 cases (19%). The notching rate was higher when the glenometaphyseal angle increased (P < .001), when the inferior tilt decreased (P = .003), and when the neck-shaft angle increased. The authors reported no evidence of component loosening.
These authors, including the co-conceptor of the design, enrolled 101 patients having 105 stemless reverse total shoulders in a prospective study, with a minimum follow-up period of 24 months. 91 procedures in 87 patients (61 men and 26 women), with a mean age of 73 years, were available at a mean follow-up of 41 months (range, 24-69 months).
Ninety-six percent of patients rated their satisfaction as good or excellent. Mean flexion was 143° (range, 90°-170°), and mean external rotation was 39° (range, 20°-70°). The Constant score improved from 40 points preoperatively to 68 points at last follow-up (P < .001). The mean American Shoulder and Elbow Surgeons score was 24 points. The mean neck-shaft angle was 154° (range, 142°-165°). Inferior scapular notching occurred in 17 cases (19%). The notching rate was higher when the glenometaphyseal angle increased (P < .001), when the inferior tilt decreased (P = .003), and when the neck-shaft angle increased. The authors reported no evidence of component loosening.
Comment: These patients had the diagnosis of either cuff tear arthropathy or failed cuff repair - patients with the important diagnoses of failed anatomic arthroplasty or fracture were not included, probably because this prosthesis is not suitable in these situations.
The preoperative flexion averaged 96 degrees and abduction averaged 89 degrees with some patients having as much as 160 degrees of preoperative elevation. Thus all these patients did not have the classic indications for a reverse (pseudoparalysis or anterosuperior escape).
The results point out the variability in the position in which the components can be inserted.
lunes, 22 de septiembre de 2014
sábado, 20 de septiembre de 2014
jueves, 18 de septiembre de 2014
martes, 16 de septiembre de 2014
Surgical Excision of a Symptomatic Congenital Coracoclavicular Joint
http://www.healio.com/orthopedics/journals/ortho/2014-9-37-9/%7B68439682-8a8e-48ab-82de-f6e9b804d2bb%7D/surgical-excision-of-a-symptomatic-congenital-coracoclavicular-joint
CASE REPORT
Surgical Excision of a Symptomatic Congenital Coracoclavicular Joint
Biomechanical Analysis of Rotator Cuff Repairs With Extracellular Matrix Graft Augmentation
http://www.healio.com/orthopedics/journals/ortho/2014-9-37-9/%7B18908427-3686-4407-8a62-9d3fcdecf6dd%7D/biomechanical-analysis-of-rotator-cuff-repairs-with-extracellular-matrix-graft-augmentation
THE CUTTING EDGE
Biomechanical Analysis of Rotator Cuff Repairs With Extracellular Matrix Graft Augmentation
- Orthopedics
- September 2014 - Volume 37 · Issue 9: 608-614
- DOI: 10.3928/01477447-20140825-05
Abstract
Despite advances in surgical techniques, 20% to 90% of rotator cuff (RTC) repairs fail. They tend to fail at the suture-tendon junction due to tension at the repair and gap formation prior to healing. This study evaluated the gap formation and ultimate tensile failure loads of a RTC repair with a decellularized human dermal allograft. Augmentation of a RTC repair with an extracellular matrix graft decreased gap formation and increased load to failure in a human RTC repair model. [Orthopedics.2014; 37(9):608–614.]...
lunes, 15 de septiembre de 2014
martes, 9 de septiembre de 2014
Eight important stories to read regarding rotator cuff tears
http://www.healio.com/orthopedics/shoulder-elbow/news/online/%7B15181472-1972-4591-bac9-23dd6b976a66%7D/eight-important-stories-to-read-regarding-rotator-cuff-tears
Eight important stories to read regarding rotator cuff tears
Orthopedics Today has highlighted eight stories to keep your practice up-to-date regarding rotator cuff tears and their fixation. Read more
Eight important stories to read regarding rotator cuff tears
Eight important stories to read regarding rotator cuff tears
Orthopedics Today has highlighted eight stories to keep your practice up-to-date regarding rotator cuff tears and their fixation. Read more
Study reveals shifting trends in the surgical treatment of SLAP lesions
http://www.healio.com/orthopedics/shoulder-elbow/news/online/%7B33d50607-dddb-4057-a485-cfe4df0d3272%7D/study-reveals-shifting-trends-in-the-surgical-treatment-of-slap-lesions
IN THE JOURNALS
IN THE JOURNALS
Study reveals shifting trends in the surgical treatment of SLAP lesions
lunes, 8 de septiembre de 2014
Combined axillary, suprascapular nerve block improves rotator cuff repair outcomes
http://www.healio.com/orthopedics/arthroscopy/news/online/%7Bde1fa8fd-b7a0-48f5-a5d1-d5788702c3a2%7D/combined-axillary-suprascapular-nerve-block-improves-rotator-cuff-repair-outcomes
IN THE JOURNALS
IN THE JOURNALS
Combined axillary, suprascapular nerve block improves rotator cuff repair outcomes
miércoles, 3 de septiembre de 2014
lunes, 1 de septiembre de 2014
Un poco de anatomía / Manguito rotador, que es y que función tiene
http://www.fisioterapiatualcance.es
Manguito rotador, que es y que función tiene / Fisioterapia a tu alcance
El manguito rotador es un término anatómico dado al conjunto de músculos y tendones que ademas de producir un movimiento rotatorio proporcionan estabilidad al hombro.La articulación del hombro es la que más variedad y amplitud de movimientos posee del cuerpo humano.
Esto es debido a un diseño en el que la cabeza humeral apenas está cubierta por la superficie articular glenoidea escapular.
Para compensar esta falta de contacto entre las dos superficies articulares, alrededor existen musculos que estabilizan la articulación o manguito rotador, evitando la luxación, en su parte anterior cuenta con unos ligamentos en forma de Z que
protegen al humero en los movimientos enteriores, entre estos ligamentos, contamos con la insercion del subescapular en completa sinergia con los ligamentos, complementa la funcion de coaptacion y estabilidad anterior del hombro.
En la vision posterior, tenemos una ausencia total de ligamentos, y el trabajo estabilizador queda totalmente a manos de los musculos, supra espinoso, infraespinoso y redondo menor, que mantendran una presion constante del humero contra la escapula.
Todos estos músculos conectan la escápula con la cabeza del húmero, formando un puño en la articulación. Su importancia estriba en mantener la cabeza del húmero
dentro de la cavidad articular o glenoídea de la escápula.
Por lo tanto grupo conocido como manguito rotador tiene una función fundamental a la hora de estabilizar la articulación glenohumeral y se compone de los musculos:
supraespinoso, infraespinoso redondo menor en la cara posterior de la escápula y El músculo subescapular en la parte anterior de la escápula
Para mas información dirígete a: http://www.fisioterapiatualcance.es
Para cualquier critica, consulta o aporte, escribe a: contacto@fisioterapiatualcance.es
Manguito rotador, que es y que función tiene / Fisioterapia a tu alcance
El manguito rotador es un término anatómico dado al conjunto de músculos y tendones que ademas de producir un movimiento rotatorio proporcionan estabilidad al hombro.La articulación del hombro es la que más variedad y amplitud de movimientos posee del cuerpo humano.
Esto es debido a un diseño en el que la cabeza humeral apenas está cubierta por la superficie articular glenoidea escapular.
Para compensar esta falta de contacto entre las dos superficies articulares, alrededor existen musculos que estabilizan la articulación o manguito rotador, evitando la luxación, en su parte anterior cuenta con unos ligamentos en forma de Z que
protegen al humero en los movimientos enteriores, entre estos ligamentos, contamos con la insercion del subescapular en completa sinergia con los ligamentos, complementa la funcion de coaptacion y estabilidad anterior del hombro.
En la vision posterior, tenemos una ausencia total de ligamentos, y el trabajo estabilizador queda totalmente a manos de los musculos, supra espinoso, infraespinoso y redondo menor, que mantendran una presion constante del humero contra la escapula.
Todos estos músculos conectan la escápula con la cabeza del húmero, formando un puño en la articulación. Su importancia estriba en mantener la cabeza del húmero
dentro de la cavidad articular o glenoídea de la escápula.
Por lo tanto grupo conocido como manguito rotador tiene una función fundamental a la hora de estabilizar la articulación glenohumeral y se compone de los musculos:
supraespinoso, infraespinoso redondo menor en la cara posterior de la escápula y El músculo subescapular en la parte anterior de la escápula
Para mas información dirígete a: http://www.fisioterapiatualcance.es
Para cualquier critica, consulta o aporte, escribe a: contacto@fisioterapiatualcance.es
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