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- Author: Patrick Goetti x
- Shoulder & Elbow x
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Despite recent improvements in surgical implants and techniques, distal humerus nonunion does occur between 8% and 25% of the time.
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Careful identification and improvement of any modifiable risk factors such as smoking, metabolic disorders, immunosuppressant medications, poor nutritional status and infection is mandatory.
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A recent computed tomography scan is paramount to determine the nonunion pattern, assess residual bone stock, identify previously placed hardware, and determine whether there is evidence of osteoarthritis or malunion of the articular surface.
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Internal fixation is the treatment of choice in the majority of patients presenting with reasonable bone stock and preserved articular cartilage; total elbow arthroplasty is an appealing alternative for elbows with severe destruction of the articular cartilage or severe bone loss at the articular segment, especially in older, female patients. Internal fixation requires not only achieving a stable fixation, but also releasing associated elbow contractures and the liberal use of bone graft or substitutes.
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Although reported union rates after internal fixation of distal humerus nonunions are excellent (over 95%), the complication rate remains very high, and unsatisfactory results do occur.
Cite this article: EFORT Open Rev 2020;5:289-298. DOI: 10.1302/2058-5241.5.190050
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Faculty of Medicine, University of Geneva, Geneva, Switzerland
Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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The stability of the glenohumeral joint depends on soft tissue stabilizers, bone morphology and dynamic stabilizers such as the rotator cuff and long head of the biceps tendon. Shoulder stabilization techniques include anatomic procedures such as repair of the labrum or restoration of bone loss, but also non-anatomic options such as remplissage or tendon transfers.
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Rotator cuff repair should restore the cuff anatomy, reattach the rotator cable and respect the coracoacromial arch whenever possible. Tendon transfer, superior capsular reconstruction or balloon implantation have been proposed for irreparable lesions.
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Shoulder rehabilitation should focus on restoring balanced glenohumeral and scapular force couples in order to avoid an upward migration of the humeral head and secondary cuff impingement. The primary goal of cuff repair is to be as anatomic as possible and to create a biomechanically favourable environment for tendon healing.
Cite this article: EFORT Open Rev 2020;5:508-518. DOI: 10.1302/2058-5241.5.200006
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Division of Orthopaedics and Trauma Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
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The biomechanics of the shoulder relies on careful balancing between stability and mobility. A thorough understanding of normal and degenerative shoulder anatomy is necessary, as the goal of anatomic total shoulder arthroplasty is to reproduce premorbid shoulder kinematics.
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With reported joint reaction forces up to 2.4 times bodyweight, failure to restore anatomy and therefore provide a stable fulcrum will result in early implant failure secondary to glenoid loosening.
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The high variability of proximal humeral anatomy can be addressed with modular stems or stemless humeral components. The development of three-dimensional planning has led to a better understanding of the complex nature of glenoid bone deformity in eccentric osteoarthritis.
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The treatment of cuff tear arthropathy patients was revolutionized by the arrival of Grammont’s reverse shoulder arthroplasty. The initial design medialized the centre of rotation and distalized the humerus, allowing up to a 42% increase in the deltoid moment arm.
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More modern reverse designs have maintained the element of restored stability but sought a more anatomic postoperative position to minimize complications and maximize rotational range of motion.
Cite this article: EFORT Open Rev 2021;6:918-931. DOI: 10.1302/2058-5241.6.210014
