Citations

Aims Patients with a failed reverse shoulder arthroplasty (RSA) have limited salvage options. The aim of this study was to determine the outcome of revision RSA when used as a salvage procedure for a failed primary RSA. Patients and Methods We reviewed all revision RSAs performed for a failed primary RSA between 2006 and 2012, excluding patients with a follow-up of less than two years. A total of 27 revision RSAs were included in the study. The mean age of the patients at the time of revision was 70 years (58 to 82). Of the 27 patients, 14 (52% were female). The mean follow-up was 4.4 years (2 to 10). Results Six patients (22%) developed complications requiring further revision surgery, at a mean of 1.7 years (0.1 to 5.3) postoperatively. The indication for further revision was dislocation in two, glenoid loosening in one, fracture of the humeral component in one, disassociation of the glenosphere in one, and infection in one. The five-year survival free of further revision was 85%. Five additional RSAs developed complications that did not need surgery, including dislocation in three and periprosthetic fracture in two. Overall, patients who did not require further revision had excellent pain relief, and significant improvements in elevation and external rotation of the shoulder (p < 0.01). The mean postoperative American Shoulder and Elbow Surgeons (ASES), and simple shoulder test (SST) scores were 66 and 7, respectively. Radiological results were available in 26 patients (96.3%) at a mean of 4.3 years (1.5 to 9.5). At the most recent follow-up, six patients (23%) had glenoid lucency, which were classified as grade III or higher in three (12%). Smokers had a significantly increased risk of glenoid lucency (p < 0.01). Conclusion Revision RSA, when used to salvage a failed primary RSA, can be a successful procedure. At intermediate follow-up, survival rates are reasonable, but dislocation and glenoid lucency remain a concern, particularly in smokers. Cite this article: Bone Joint J 2018;100-B:1493–98.

Restoration of shoulder lateral rotation remains a significant challenge following brachial plexus injury. Transfer of the accessory nerve to suprascapular nerve (SSN) has been widely performed, although with generally poor outcomes for lateral rotation. A recent report suggested a selective infraspinatus reinnervation technique using a radial nerve branch for SSN transfer. This cadaveric study was performed in 7 specimens (14 shoulders). We present technical modifications to achieve additional length to the recipient nerve (suprascapular) that would facilitate direct repair. Key elements of the technique are (1) isolation of the SSN immediately distal to its motor branch to supraspinatus near the superior transverse scapular ligament; and (2) delivery of the transected SSN through the spinoglenoid notch and deep to the infraspinatus for emergence in the infraspinatus‐teres minor interval. Nerve overlap of at least 21 mm was observed in all 14 dissected shoulders between the harvested SSN and radial nerve branches. The mean nerve overlap between harvested branches was 26 mm (range 21–32 mm). The mean harvested SSN length was 59 mm (range 46–80 mm). The mean length of the harvested radial nerve branch was 72 mm (range 65–85 mm). No measurements were significantly different between left and right shoulders or between males and females (smallest P value = 0.1249). Nerve diameter of the two harvested branches was judged to be appropriately compatible for surgical coaptation in all 14 dissected shoulders. We present a variation on a described technique to increase recipient suprascapular nerve length. Additional length of the recipient nerve is achieved through utilization of a more proximal dissection of the suprascapular nerve near the level of the superior transverse scapular ligament and delivering the nerve through the teres minor‐infraspinatus interval. These surgical modifications are of clinical interest when selective reinnervation of the infraspinatus muscle is considered. We believe such a targeted approach can potentially increase shoulder lateral rotation function. Clin. Anat. 32:131–136, 2019. © 2018 Wiley Periodicals, Inc.

BackgroundAdamantinomas are rare bone tumors, commonly affecting the tibia. Due to the rare nature of disease, previous studies are small or from multiple centers. The purpose of this study is to investigate outcomes of patients with adamantinoma treated in a single institution.MethodsForty‐six histological confirmed adamantinomas of the extremities were reviewed at our institution between 1939 and 2012. Follow‐up data included clinical and radiographical information focusing on complications, local recurrence, metastasis, and overall survival after the treatment. The mean follow‐up was 16 years (range 2‐42 years).ResultsThe most common location was the tibia (n = 31). Patients commonly presented with pain and swelling. The mean age was 24 years (7‐79 years). Thirty‐seven patients were treated with limb salvage. The 39% of patients required a reoperation. The 10‐year disease specific‐ and recurrence free survival was 92% and 72%, with three patients having a recurrence over 15 years postoperative. Older (> 20 years) patients and males were at increased risk of local recurrence (P < 0.05).ConclusionTreatment of adamantinoma of the long bone consists of limb‐salvage surgery. Male patients should be cautioned on their increased risk of disease recurrence, and advocate for continued surveillance of patients even greater than 15‐years postoperatively due to late tumor recurrence.

Background: Obesity is a known risk factor for wound complications; however, unlike elective upper extremity procedures, where obesity can be modified preoperatively, excision of soft tissue sarcomas (STSs) is not elective, and as such, obesity cannot be modified. There is a paucity of data concerning the impact of obesity on wound healing in upper extremity sarcoma surgery. Methods: A total of 261 (159 males and 102 females) patients with a STS of the upper extremity from 2006-2014 were reviewed. The mean age and body mass index (BMI) were 56 (18-97) years and 26.6 (15.4-40.8) kg/m 2 , respectively. Sixty-nine patients (26%) were classified as obese (BMI ⩾30 kg/m 2 ): class I (obese, BMI = 30-34.9 kg/m 2 ; n = 48, 18%), class II (severely obese, BMI = 35.0-39.9 kg/m 2 ; n = 16, 6%), and class III (morbidly obese, BMI ≥ 40 kg/m 2 ; n = 5, 2%). Functional outcomes were also compared between obese and nonobese patients using the Musculoskeletal Tumor Society (MSTS) 1993 rating system and Toronto Extremity Salvage Scores (TESS). Results: Forty-nine patients (19%) sustained a wound dehiscence, delayed healing, or infection. Class III obesity increased the risk of wound complications (hazard ratio [HR] = 8.19, 95% confidence interval [CI] = 1.96-22.96, P < .001) and infection (HR = 10.09, 95% CI = 1.60-34.83, P = .01). There was no difference in the mean TESS (93 vs 90, P = .13) or MSTS93 (95 vs 93, P = .39) between obese and nonobese patients. Conclusions: The results of this study indicate morbid obesity significantly increased the risk of a postoperative wound complication and infection. However, following upper extremity limb salvage surgery, obese patients should expect to have excellent functional outcome.

Background: The vertical rectus abdominis myocutaneous flap has been used to reliably reconstruct posterior soft-tissue defects following resection of high sacral tumors, providing skin and soft-tissue bulk. Current literature examining the use of these flaps for high sacral reconstruction is limited. The purpose of this study was to report the authors’ institution's outcome on the use of the vertical rectus abdominis myocutaneous flap to reconstruct a high sacral defect following an oncologic resection. Methods: Eighty-seven patients (29 female and 58 male) underwent vertical rectus abdominis myocutaneous flap surgery to reconstruct a posterior wound following high sacral tumor resection from 1994 to 2016. The mean age and body mass index were 52 years and 27.8 kg/m2, respectively. The mean follow-up was 6 years. Results: Sixty-eight patients (79 percent) sustained a complication, most commonly a wound complication [n = 41 (47 percent)]. Twenty patients (23 percent) sustained a donor-site wound complication, most commonly a wound dehiscence (n = 10). Complications resulted in a reoperation in 44 patients (51 percent), with total flap failure occurring in one (1 percent). Preoperative radiotherapy and obesity were found to increase the risk of wound complications (p = 0.004 and p = 0.02, respectively) and deep infection (p = 0.03 and p = 0.02, respectively). Conclusions: Complications were common following vertical rectus abdominis myocutaneous flap surgery; however, total flap loss was not. Patients with obesity and preoperative radiotherapy should be cautioned on their increased risk of complications. Currently, the vertical rectus abdominis myocutaneous flap is the authors’ preferred means of soft-tissue reconstruction following high sacral tumor resection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Background: Lower extremity intercalary allograft reconstruction has traditionally been used to facilitate limb salvage. Combining the allograft with a free vascularized fibula graft has been described; however, there is a paucity of data comparing the outcome of these reconstructions. Methods: Twenty-nine pediatric patients (15 boys and 14 girls) underwent lower extremity limb salvage with the use of intercalary cadaveric allograft at a mean age of 12 years. The most common diagnosis was osteosarcoma (n = 18). Patients underwent reconstruction with an allograft alone (n = 11) or supplemented with a free vascularized fibula graft (n = 18). Results: The mean time to union of the allograft was 11 months, with 10 patients requiring additional bone grafting. There was no difference in the need for an additional bone graft (OR, 0.87; p = 1.0) between patients with a free vascularized fibula graft and those without. The allograft was revised in three patients because of fracture (n = 2) and fracture and infection (n = 1). In all of these patients, the allograft was not supplemented with a free vascularized fibula graft (p < 0.001). Five patients underwent an amputation, most commonly for disease recurrence. At last follow-up, the mean Mankin and Musculoskeletal Tumor Society rating was 90 percent, with 19 patients (66 percent) who achieved a “good” or “excellent” outcome according to the Mankin score. Conclusion: Use of an intercalary allograft to reconstruct a lower extremity provides a durable means of reconstruction; however, supplementation with a free vascularized fibula graft reduces the risk of allograft revision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background: Deficient soft tissue following total knee arthroplasty (TKA) can jeopardize outcome. The gastrocnemius flap is an important means of providing coverage of a knee with deficient soft tissue. There is a paucity of long-term studies on the use of the gastrocnemius flap in the setting of TKA. The purpose of this study was to review the outcomes after the use of pedicled gastrocnemius flaps for coverage of a soft-tissue defect at the time of TKA. Methods: Eighty-three patients in whom a gastrocnemius flap had been used to cover the site of a primary (n = 18) or revision (n = 65) TKA over a 25-year period were identified. There were 48 women (58%) and 35 men (42%) with a mean age and body mass index (BMI) of 65 years and 32.6 kg/m 2 . The mean wound size was 49 cm 2 , and the wound was most commonly located over the anterior aspect of the knee/patellar tendon (n = 33). Patients were followed to the time of implant or flap revision, amputation, or death or for a minimum of 2 years (mean, 8 years). Clinical outcomes were assessed using the Knee Society Score (KSS) for pain and the KSS for function. The Kaplan-Meier method was used to assess revision and amputation-free survival. Risk factors for amputation and revision were identified with Cox regression. Results: The 10-year revision and amputation-free survival rates following gastrocnemius flap coverage were 68% and 79%, respectively. The risk of implant failure was increased by morbid obesity (BMI of ≥40 kg/m 2 ) (hazard ratio [HR] = 2.82, 95% confidence interval [CI] = 1.09 to 7.32, p = 0.03) and ≥5 prior surgical procedures on the knee (HR = 2.68, 95% CI = 1.04 to 6.88, p = 0.04). The risk of amputation was increased in patients with ≥5 prior surgical procedures (HR = 10.76, 95% CI = 2.38 to 48.58, p = 0.002), an age of ≥65 years (HR = 4.94, 95% CI = 1.10 to 22.09, p = 0.03), and a wound size of ≥50 cm 2 (HR = 3.29, 95% CI = 1.14 to 9.53, p = 0.02). Preoperatively the mean KSSs for pain and function were 46 and 28, and these scores significantly (p < 0.05) improved to 78 and 43, respectively, at the time of follow-up. Conclusions: The gastrocnemius flap reliably provides coverage of components used in complex knee reconstruction. A history of multiple surgical procedures on the knee and larger soft-tissue defects increase the risk of revision TKA and of amputation. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: Allograft-prosthetic composite (APC) reconstruction of the humerus represents an appealing surgical technique when implantation of a reverse prosthesis is considered in the setting of substantial proximal humeral bone loss 1–4 . Humeral APCs have been successfully performed in the past with a non-reverse shoulder prosthesis 4,5 . Reconstruction of the proximal part of the humerus with an allograft provides adequate support and fixation for the humeral component, allows restoration of length and lateral offset, and provides an opportunity for soft-tissue reattachment when needed. On the basis of the available peer-reviewed data, healing at the allograft-host junction is reliable, and complication rates, including instability, are relatively low 3,6 . Description: Once the glenoid reverse component has been implanted, a proximal humeral allograft is prepared to receive the humeral component of a reverse arthroplasty. The allograft is procured by our institutional bone and tissue bank, purchased from a number of vendors. The graft is selected after review of the description and radiographs provided by the vendor. The priority is to obtain a graft with sufficient length and soft tissues attached. If possible, the graft selected should have a diameter close to the diameter of the humerus of the recipient. The desired allograft length is selected on the basis of preoperative planning and intraoperative measurements, and the distal portion of the allograft is resected accordingly. Depending on the length of the defect, host bone quality, and surgeon preferences, the humeral component may or may not bypass the host-graft junction. The stem bypasses the host-graft junction for shorter APCs, as well as when the bone quality of the native humerus is compromised. Cemented fixation into the graft is universally used. Compression plating is used for graft-to-host fixation, supplemented by implantation of the stem across the junction in selected cases. Care is taken during the freehand cut to obtain optimal contact and compression. Once the ideal humeral bearing thickness has been selected, the polyethylene bearing is implanted and the joint relocated. If the posterior cuff can be repaired to cuff allograft, sutures are placed prior to relocation and are tied after relocation. Other musculotendinous units, such as the deltoid or pectoralis major, are repaired to the allograft if needed. Alternatives: Implantation of a reverse prosthesis with a proximal humeral metal body (a so-called tumor prosthesis) is the main alternative to proximal humeral APC reconstruction. In patients with shorter defects, adequate soft-tissue tension may be obtained by implanting a glenosphere with a large inferior eccentricity and cementing the humeral component in a more proximal position than is usually performed. Alternatively, when implantation of the glenoid component of a reverse prosthesis is not possible, a hemiarthroplasty-APC construct may be performed 1,4,5,7–10 , adding a synthetic sleeve such as an aortic Dacron graft to enhance soft-tissue stability if needed. Rationale: When reverse arthroplasty is performed in the setting of substantial humeral bone loss, the humeral component may be poorly supported and at risk for loosening. In addition, the absence of proximal humeral bone stock may lead to shortening and/or loss of lateral offset. Finally, the posterosuperior cuff, subscapularis, deltoid, and pectoralis tendons may remain detached. The potential consequences of humeral bone loss in the setting of reverse arthroplasty include humeral loosening, dislocation, and poor active motion (particularly poor active elevation). Allograft reconstruction of the proximal part of the humerus provides an opportunity for better support of the component, restoration of humeral length and lateral offset, and attachment sites for the musculotendinous structures around the shoulder, if needed.

Background: Reverse total shoulder arthroplasty (RTSA) performed in the setting of massive proximal humeral bone loss often requires special reconstructive techniques. Restoration of the proximal part of the humerus with an allograft provides a number of theoretical benefits, including implant support, restoration of humeral length, deltoid tensioning, and an opportunity to repair the posterior aspect of the cuff to improve strength in external rotation and repair of the subscapularis to improve stability. However, reverse allograft-prosthesis composites (APCs) are costly, are technically demanding to use, and can be compromised by progressive allograft resorption. Methods: Between 2005 and 2012, the lead author used an APC reconstruction in 8 primary and 18 revision RTSAs (26 patients; mean age, 62 years; mean body mass index, 27.9 kg/m 2 ). The indications for the primary RTSAs included severe proximal humeral bone loss after trauma (n = 5) and tumor resection (n = 3). The indications in the revision setting were failed hemiarthroplasty (n = 11), anatomic total shoulder arthroplasty (n = 4), and reverse arthroplasty (n = 3). The most common reason for revision was instability (n = 10). A compression plate was used for graft-to-host fixation in all shoulders. Shoulders were assessed for pain, motion, American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST) score, Neer score, revision or reoperation, radiographic evidence of graft union or resorption, and implant fixation. The mean duration of follow-up was 4 years (range, 2 to 10 years). Results: RTSA using an APC construct resulted in substantial improvements in pain scores (p < 0.0001), elevation (p < 0.0001), and external rotation (p = 0.004). With the numbers available, there were no significant differences in clinical outcomes between primary and revision cases. No patients required revision surgery for nonunion at the host-allograft junction. The mean time to union was 7 months, with 1 patient requiring bone-grafting for delayed union. Other complications included dislocation, deep infection, graft fracture, and periprosthetic fracture distal to the previous APC construct in 1 patient each. The 2 and 5-year revision-free survival rate was 96%. Conclusions: Reconstruction of proximal humeral bone loss with an APC at the time of primary or revision RTSA is safe and effective, with acceptable functional outcomes and complication rates. Level of Evidence: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.