Hemiarthroplasty for proximal humerus fractures

There is currently discussion about whether a hemiarthroplasty or a reverse shoulder arthroplasty should be offered to elderly patients with osteopenia or 4 part proximal humerus fractures. The supporters of the reverse shoulder arthroplasty state that there is better pain relief after the surgery and if the tuberosities heal then the ROM will be satisfactory. The supporters of the hemiarthroplasty state that the procedure is revisable, if the tuberosities heal then the ROM is satisfactory most of the time, but if they do not then the patient will have poor ROM.

One of the main concerns of the reverse shoulder arthroplasty is still tuberosity healing.

1. Studies show that tuberosity healing is still of importance to avoid loss of motion after surgery
2. The tensioning of the soft tissues after reverse shoulder arthroplasty for fracture is not easy to be achieved as in primary surgery for arthritis. If the tuberosity healing fails then the construct can loose tension and dislocation may occur.
3. If the reverse arthroplasty fails,  then there is no easy solution other than conversion to (a) a hemiarthroplasty or (b) resection arthroplasty. Both of these procedures have poor outcomes


Below we demonstrate a patient who was treated with a hemiarthroplasty for a 4 part proximal humerus fracture. She is her 60s and for that reason we elected to proceed with a hemiarthroplasty. Although anatomic reduction of the tuberosities is important it seems that most important factor is the healing even if they are over-reduced.


The patient was pain free at 3 months postoperatively, her active forward elevation was equal to the opposite site. The final X-rays reveal healed but "over-reduced tuberosities".

The growing interest in shoulder replacement surgery. An increase of 445% between 1990s and 2000s.

There is an explosive increase in the number of publications regarding shoulder replacement surgery. The graph above shows the impressive increase. Between 1990-2000 the average number of studies published was 29.5 studies per year. After 2000 this number has increased to the astonishing number of 161 studies per year. This reflects an increase of 445%! This interest may reflect the aging population, may also reflect the increasing number of "free on line journals". One needs to be very careful in interpreting the results of a study. Without a doubt the computer era and the advanced programming techniques have contributed to the better analysis of patient databases. However, with this plethora of information it appears that the quality of information is also affected. Implant companies fund studies in an effort to promote their products. The studies funded by the implant industry are usually seen in peer reviewed journals in which the criteria for publication are no strict or scientifically correct. One needs to be particularly careful about conflicts of interest. We are in an era that the public as well as the physicians have to critically interpret the data, results and the statements made in these published studies. I fear that the pressure of the universities to publish studies, the pressure of the industry to publish studies and the well established need of the society to advance medicine may lead to an overwhelming volume of data and studies that will create more confusion than understanding of the nature of the diseases, the mechanisms of development and the best methods of treatment. In other words, it is time to read articles critically, the same way that you read an article in the newspaper.

Early radiolucent lines after glenoid component insertion for total shoulder arthroplasty

The clinical importance of the early radiolucent lines after glenoid component insertion for total shoulder arthroplasty remains a topic of debate. Our previous comprehensive review of the literature on the clinical importance of the glenoid component radiolucent lines indicated that these lines do progress. Eventually, these lucencies may lead to symptomatic glenoid component loosening. Some surgeons use pressurized and some unpressurized cementing techniques. In an effort to eliminate those lines some surgeons suggest the use of CO2 also known as carbojet to remove blood from the peg holes on the glenoid bone. Others use packing of the peg holes with a sponge embedded in epinephrine solution. The theory behind the packing is that the epinephrine causes vasoconstriction and minimizes bleeding in the glenoid peg holes allowing the pressurized cement to achieve a better incorporation with the bone at the cement-bone interface.

I personally use an epinephrine solution and a sponge technique for glenoid component bone peg hole preparation. These radiographs below are the x-rays of the first shoulder replacement that I performed after finishing my fellowship. No lucent lines are seen. For further reading I recommend the following study:
http://www.ncbi.nlm.nih.gov/pubmed/22960147

The Doctor the NFL Tried to Silence

League physicians sought to discredit Bennet Omalu’s autopsy study showing widespread brain damage in former Steelers star Mike Webster.

More info:

http://www.wsj.com/articles/the-doctor-the-nfl-tried-to-silence-1448399061

Zion receives bilateral hand transplant. We can learn from this young man and the surgical team who treated him

The field of reconstructive microsurgery is an exciting one. Unfortunately, in the western societies there is very little support for the microsurgeons because poor nerve function and scar tissue formation are the biggest enemies of replantation surgery. Long hours in the operating room, extensive use of resources and high cost are obstacles to the great field of reconstructive surgery. James Urbaniak and Panayotis N Soucacos say: "there is no end to the world of microsurgery". However, how to make a replant, such as a hand or finger or arm, functional remains a big challenge. I think that supporting efforts like the efforts of Dr Scott Levin who was the lead physician of the team that performed the bilateral hand transplantation in Philadelphia is of great importance. I see two exciting scenarios for the future of such surgeries. Tissue engineering or advances in the understanding of graft rejection will make this transplantation surgeries a viable solution to many amputees especially the young children who have a great potential for nerve recovery after end to end nerve repair. We are all excited for what is coming in the near future

SLAP tears and paralabral cysts

Paralabral cysts associated with SLAP lesions are frequent findings on MRI of the shoulder. They can be addressed either with direct decompression or by a repair of the SLAP lesion alone. If there is no history of trauma or the patient is older then clinical followup without surgery is the approach of choice. If they produce pain or weakness and are associated with traumatic labral tears then decompression and repair of the SLAP tear is the debridement of choice. Below please see a case that was approached with decompression using percutaneous arthroscopic technique and an 18G spinal needle. Repair of the SLAP lesion is necessary in these cases for the treatment of pain and avoidance of recurrence of the cyst.

Deja vu. 2011 and 2015

In 2011, we published a study highlighting the need to reconsider using the term of "shoulder impingement" Link

 In August of 2015 the JBJS published a commentary about the classic article published by Charles Neer on acromioplasty. Link

We are glad that the leadership of the Journal of Bone and Joint Surgery adopts our suggestion to stop using the term.

Attached please see the last paragraph from the "Classics documentary"

Neer’s hypothesis that impingement caused most rotator cuff tears does not appear to have withstood the test of time, however. Arthroscopy and magnetic resonance imaging arthrography have elucidated many other conditions that cause shoulder pain that were previously misdiagnosed as impingement. Consequently, the liberal use of acromioplasty to treat “impingement” is being replaced by a trend toward making an anatomic diagnosis, such as a partial or complete tear of the rotator cuff, and performing aggressive rehabilitation prior to corrective surgery.