Brachial Plexus: Traumatic Nerve Injuries

The brachial plexus are nerves that conduct signals to the shoulder, elbow, and hand muscles and provide feeling in the arm. If these nerves become injured you can lose function, sensation, and experience pain. Some injuries to the brachial plexus are minor and brief, while others are severe and can cause permanent disability. These injuries often occur after a traumatic event, such as a sports injury, an automobile accident, or from complications at birth.

Brachial plexus injuries involve the C5, C6, C7, C8, and T1 nerves that originate from the spinal cord in the neck. As these nerves leave the neck, they form the brachial plexus, which weaves together then branches as they pass under the clavicle (collarbone) toward the shoulder. Depending on the extent of the injury and which nerve is damaged, brachial plexus injuries are sometimes called Erb’s palsy, Klumpke palsy, Parsonage-Turner syndrome (brachial plexus neuritis), and burners and stingers. Most brachial plexus injuries are minor and you will recover within a few weeks with limited treatment; however, other injuries can require rehabilitation or surgery and take longer to heal.

Causes

Often, brachial plexus injuries occur during high-speed automobile accidents, blunt trauma from a fall, or from the violence of a stab or gunshot wound. Difficult births are a major cause of brachial plexus nerve injuries in newborns. The nerve injuries can also result from medical conditions such as inflammation, compression from a growth or tumor, and nerve disease.

The damage occurs when 1 or more nerves are pulled, stretched, compressed, or torn. The nerve injury can be an avulsion (pulled away from the spinal cord), a stretch (pulled but not torn), or a rupture (stretched with a partial or complete tear). Often, the nerves closer to the neck are damaged when the shoulder is forced down and the nerves closer to the armpit are more likely damaged when your arm is forced upward or above your head. In addition, athletes in contact sports can sustain transient brachial plexus injuries known as “burners and stingers” after sustaining a blow to the neck and shoulder girdle region. The injury occurs when the arm is forcibly pulled or stretched downward and the head is pushed to the opposite side. Interestingly, brachial plexus insult can also occur in an idiopathic (unknown cause) fashion after inflammation of the nerves.

Symptoms

For most brachial plexus injuries, only one side is usually affected and depending on the severity and location, the signs and symptoms vary. For example, the minor damage caused by a burner or stinger can produce an electric shock or burning sensation shooting down the arm and numbness and weakness in the limb. The symptoms can last a few seconds or they can last for days. Traumatic brachial plexus injuries can present with partial or complete motor and sensory paralysis of the arm, shooting pains in the affected arm and an inability to use all or selected muscles on the affected side. These injuries can be transient and slowly resolve over time or can persist for longer periods leading to permanent damage. If you experience a serious injury, such as an avulsion, you may become unable to use certain muscles in your shoulder, arm, or hand. You may experience severe pain or lose feeling and the ability to move the limb. Acute injuries to the brachial plexus often warrant close follow-up with a medical professional.

You should seek medical advice and treatment if a brachial plexus injury is suspected, especially when symptoms persist without improvement. Additionally, you should see a doctor if you have recurrent burners and stingers, weakness in your hand or arm, or experience neck pain.

Screening and diagnosis

A thorough health history and physical exam are of paramount importance in screening patients for potential brachial plexus injuries. Your physician may first order chest, spine, or shoulder x-rays to rule out a fracture or dislocation that can cause entrapment (compression of the nerve) of the brachial plexus. Performing a computerized tomography with myelography (a CT scan using dye) a few weeks after the initial injury is the current gold standard to identify the nerve injury level. Other imaging modalities that can be useful include magnetic resonance imaging (MRI), electromyography (EMG), nerve conduction velocity (NCV), and other nerve studies based on the discretion of the healthcare provider. If your physician suspects an infectious cause, he or she will include laboratory work in the screening process.

Treatment

The mainstay treatment for brachial plexus injuries remains nonsurgical management with close observation for symptom resolution. The physician conducts frequent and thorough exams over the first 3 to 6 months and performs additional testing as needed to evaluate the recovery. Partial brachial plexus injuries with a halt in neurologic resolution can require surgery. If your physician suspects an inflammatory process, a course of pain control, physical therapy, and oral corticosteroids may be necessary.

Patients with open injuries, progressive neurologic deficits, and penetrating injuries such as gunshot wounds, often require immediate surgical treatment. For patients with a total plexus injury, surgery will likely take place around 4 to 6 weeks after the initial injury. New advances in nerve surgery are helping to restore movement and function in the shoulder, elbow, and hand, which once was impossible. There are many surgical techniques available depending on the specific injury encountered. Some of these include direct nerve repair, nerve grafting, nerve transfers, muscle or tendon (tissue connecting muscle to bone) transfers, osteotomies (bone surgery), and arthrodesis (fusion of a joint). Reconstruction procedures can take up to 3 years before full recovery occurs, especially since nerve regeneration occurs at a slow rate of approximately 1 mm/day. When comparing injuries of the upper (C5, C6) and lower (C8, T1) brachial plexus, the upper plexus tend to have better outcomes as hand function remains preserved.

Be patient

Nerves heal and regenerate slowly, so you must be patient. Your doctor may prescribe a rehabilitation program to follow to keep your muscles strong and healthy while the nerve heals. Outcomes after sustaining brachial plexus injuries are dependent on the extent and level of your injury. However, given enough time, many brachial plexus injuries heal without lasting damage.

Author: Devin W. Collins, DO

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 4, Fall 2018.

 

Medal of Honor recipient Al Lynch Reception and Presentation

Please join Hughston on May 2nd at the National Infantry Museum for a Meet-the-author, Book Signing, and Presentation by Medal of Honor recipient Al Lynch. We look forward to seeing you out there!

 

Tennessee Physicians Carry on the Hughston Legacy

Our physicians at Hughston Clinic Orthopaedics are continuing Dr. Hughston’s vision of exceptional orthopaedic care and legacy of sports medicine. Featured on Nashville Medical News Blog, an article written by the Hughston Foundation’s Dennise Brogdon gives us insight into Dr. Hughston’s history and vision.

“In Columbus, Ga., and in orthopaedics, Jack C. Hughston, MD, is a well-known pioneer in the field of sports medicine. In Tennessee his notoriety is not as well known. However, Hughston orthopaedic physicians are carrying on his legacy through their local clinics and sports medicine programs. Dr. Hughston established The Hughston Clinic in Columbus in 1949. Now, 70 years later, the practice continues to grow with clinics in 6 states, specialized trauma services in major hospitals, and over 50 board-certified, specialty-trained physicians.”

Read the full article here: nashvillemedicalnews.blog/2019/03/22/tennessee-physicians-carry-on-the-hughston-legacy/

Jack Hughston Memorial Hospital Recognized as a CMS 5-Star Rated Hopsital

Jack Hughston Memorial Hospital is among only 293 hospitals in the nation that were recognized as 5-star hospitals by CMS, last week. This rating is based on the following categories:

  • Timely and effective care
  • Complications and deaths
  • Unplanned hospital visits
  • Use of medical imaging
  • HCAHPS
  • Payment and value of care

CMS assesses various metrics for each of the categories, for over 4,500 hospitals, to determine and assign the star rating. The overall hospital rating, which ranges from 1 to 5 stars, shows how well each hospital performed, on average, compared to other hospitals in the U.S. Our 5-star rating shows we are, indeed, striving for “Excellence Always”!

For detailed information about our rating, visit Hospital Compare https://www.medicare.gov/hospitalcompare/search.html

 

Read press releases here:

MEDHOST Customers Get Recognized by CMS as Five-Star Hospitals

Raymond Long, MD Wins Research Award

Raymond Long, MD presented his research “The Posterolateral Approach for Fixation of Posterior Malleolar Fractures” at the Orthopaedic Trauma Association’s national meeting held in Vancouver, BC, Canada. Dr. Long’s research video was selected as a top-three finalist from a host of submissions.

https://vimeopro.com/orthotraumaassn/2015-surgical-technique-videos/video/246505092

Liposomal Bupivacaine

A New Option For Managing Pain After Surgery

The use of opioid pain medicine, also referred to as narcotic medicine, has received much attention lately with the epidemic of patient addiction and the concern of over prescribing medications. The problem often begins with chronic pain or after a patient undergoes surgery. For the patient’s comfort, the physician typically prescribes narcotic pain medicine in a large dosage and prolonged duration of time to help ease the pain. This increases the likelihood of patient addiction, which can further lead to chronic dependency and in some instances, progression to street opioid use, such as heroin (a drug produced from morphine and sold illegally). The Center for Behavioral Health Statistics and Quality reports that 4 out of 5 new heroin users start out by misusing opioid pain medications.

The opioid epidemic has created a public health crisis, increased medical costs, and formed an ethical predicament for physicians. To overcome these problems, physicians are researching new ways to reduce pain while also reducing the use of opioids. Liposomal bupivacaine is a new treatment surgeons use to manage postoperative pain, which greatly decreases, and in some cases eliminates, the use of narcotic pain medicine.

Bupivacaine is a medicine that has been around for many years. Physicians inject it into a specific area or next to a nerve to decrease the feeling to that area, making it numb, and therefore painless. On its own,bupivacaine will only last 2 to 4 hours. Therefore, physicians combine it with a medicine called epinephrine, which narrows the small blood vessels around the area so the medicine can last longer. Combined with epinephrine, the bupivacaine can help ease a patient’s pain for 3 to 7 hours.
In the latest advancement, the bupivacaine is placed into liposomes. A liposome is a spherical vesicle that acts as a delivery device in our bodies, such as transporting nutrients and medications. In this setting, the bupivacaine slowly releases into the body and provides approximately 72 hours or 3 days of pain relief. This increase of time helps the patient past the initial surge of postoperative pain.

In December 2015, the FDA approved liposomal bupivacaine for “local surgical infiltration”. This means that the surgeon can inject the medication into the tissues surrounding the surgical incision during surgery. Today, surgeons use liposomal bupivacaine in conjunction with various orthopedic surgeries to include hip and knee replacements, shoulder, and spine surgery. Hip and knee replacements are 2 of the 7 most common surgeries that carry an increased risk of chronic opioid use. Recent studies on the use of liposomal bupivacaine used in hip and knee surgery show that patients have a decreased length of stay at the hospital, and initially walk better after surgery.

Patients, as well as their physicians, are concerned about the side effects of opioids, the risk of addiction, and prefer a pain management plan that decreases opioid use. Liposomal bupivacaine can help control postoperative pain and greatly reduce the use of opioids after surgery.

Author: Roman Ashmyan, DO

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 4, Fall 2018.

Hip Arthroscopy

Hip arthroscopy has gained in popularity over the past 20 years due to the minimally

invasive nature of the surgery and the ability to address different types of disease or injury. Surgeons primarily use arthroscopic surgery (tiny camera and instruments inserted into the joint) to remove loose bodies, which are small pieces of cartilage (tissue that covers the ends of bones) that have broken off and then move around inside the hip joint. Surgeons also use this surgery to treat labral tears, injuries to the cartilage of both the femoral head (ball) and acetabulum (socket), and femoroacetabular impingement (Fig.1).

The hip joint is a ball-and-socket joint that connects the femur to the pelvis (Fig. 2). There are different elements in and around the hip joint that can be a source of pain, such as damaged cartilage and ligament (tissue connecting 2 bones) tears. When the physician evaluates a patient, it is critical to determine whether symptoms are intra-articular (coming from within the joint itself), or extra-articular (around the joint). For conditions that arise within the joint, hip arthroscopy can be a possible solution to address these problems.

Diagnosing hip pain.

Your physician will complete a thorough physical exam, record your health history, and order x-rays to determine the cause of your hip pain. X-rays are a good tool for evaluating the bony structures around the hip joint. Most patients with suspected intra-articular disease who do not have obvious arthritis on x-rays will also undergo a magnetic resonance imaging (MRI) scan. A MRI is especially useful to evaluate the soft tissue structures around the hip, such as the cartilage, labrum, and tendons, which may be injured.

Nonsurgical treatment

If you have no mechanical symptoms, such as catching, popping, or a clicking sensation in your hip, your physician often begins with nonsurgical treatment. Nonoperative treatments can include resting the joint if you are involved in regular exercise or athletic activity, anti-inflammatory medications, physical therapy, and steroid injections.
If these treatments fail to alleviate your pain and you continue to have difficulty either walking or standing, your physician may recommend hip arthroscopy.

Arthroscopic treatment

Your physician will discuss arthroscopic surgery with you if nonsurgical treatments have failed and your symptoms disrupt your normal day-to-day activities. Surgeons perform hip arthroscopy under general anesthesia and routinely use a special table to allow distraction (a gentle separation) of the ball from the socket to access to the intra-articular structures. Two common hip injuries treated arthroscopically are femoroacetabular impingement and labral tears (Fig. 3).

Femoroacetabular impingement

Femoroacetabular impingement (FAI) is a disorder of the hip in which the femoral head and neck rubs or “impinges” on the acetabulum. There are 2 types of FAI: cam impingement refers to a femoral-based disorder and is often seen in young athletic males and pincer impingement refers to an acetabular or socket-based disorder usually seen in active, middle-aged women. For both of these impingements, pain results from the proximal, or top of the femur abutting the acetabulum during range of motion, especially while bending. Patients often present with symptoms that include activity-related groin pain, difficulty sitting, and mechanical symptoms that includes a catching, clicking, or popping sensation during movement. If your physician suspects FAI, he or she will order x-rays to determine the shape and contour of the femoral head and neck as well as look for any abnormalities of the acetabulum. Your physician will also order a MRI to evaluate further the soft tissue structures in and around the hip.
At the time of arthroscopic surgery, the surgeon introduces the arthroscope into the hip joint to perform an initial diagnostic examination. Once inside the joint, the surgeon will look for disease or damage, such as cartilage defects of the femoral head and socket, loose bodies, and tears of the labrum.

Labral tears

The labrum is a horseshoe shaped structure that lines the outer rim of the hip socket. It is made of fibrocartilage and dense connective tissue. Sometimes when femoroacetabular impingement occurs, the labrum is torn. This tear can lead to pain during movement and you may experience catching, snapping, or locking. You may also feel a vague pain in your groin. If your doctor suspects a labral tear, as with FAI, you will undergo a MRI of the hip for further evaluation to confirm the diagnosis.

There are 2 main treatments of labral tears in regards to hip arthroscopy, labral debridement and labral repair. Labral tears not amenable to fixation are usually debrided, or trimmed back, to a stable base to the point that the unstable piece of torn labrum no longer causes symptoms. Your surgeon will remove any inflamed tissue in the hip joint and address any other underlying problems during surgery as well. This usually involves shaving some bone off the femoral head-neck junction as well as the hip socket so the bones do not rub against one another.

A labral repair often involves attaching the labrum back to its original site with the use of specialized anchors and sutures. Postoperatively, patients use crutches to aid in walking and are restricted to limited weightbearing and limited hip bending for approximately 4 to 6 weeks while the labrum heals.

Complications

Hip arthroscopy for either FAI or labral tears is not without complications, although the complication rate is low. Complications reported with hip arthroscopy occur at a rate between 1.3% and 6.4%. Most complications are minor and are often self-limiting, but there are several major complications that have been described in hip arthroscopy that the patient should be aware of. These include traction neurapraxia, where there is a temporary loss of motor and sensory function of nerves surrounding the hip. This occurs when traction is placed on the operative leg to help distract the hip joint in order to gain access for the arthroscope. This often resolves soon after surgery and most patients have a complete recovery. Damage to major nerves and blood vessel structures around the hip joint can also occur. Additionally, damage from instrumentation can happen; but with proper positioning and technique, the incidence of this complication is low.

On the mend

After surgery, you will be given instructions to follow for the weeks and months following surgery, including returning to see your physician for follow-up to see how you are progressing. Some of these instructions will include how to care for your portal sites and when you can shower or submerge the incisions in water. Additionally, you will be give crutches to use. Depending on the extent and type of repair, you may be on crutches for days, weeks, or months. When the hip has begun healing and the time is appropriate, your physician will refer you to rehabilitation. You should follow your rehabilitation program as instructed at the physical therapist’s office and at home. Physical therapy is a part of your treatment; therefore, you should adhere to the rehabilitation regime to achieve your best possible range of motion and functional outcome.

Hip arthroscopy can be an effective procedure and the risk of complications is low, although they do occur. Most patients are pleased with their outcomes and have resolution of symptoms, which allows them to get back to a more active lifestyle.

Author: Garland J. Gudger, Jr., MD

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 4, Fall 2018.

 

Sports Broadcasting Hall of Famer Dick Vitale Cheers On Auburn University Hughston Style

Prior to the 2018 Auburn V. Kentucky men’s basketball game, Dick Vitale tweeted a video from the Auburn Arena. Do you see what we see? That’s one, big Hughston-style celebration!

 

Pelvic Fractures

The forces required to fracture the pelvis of a person with normal bone structure are nothing short of massive. These types of forces are generally the result of high energy blunt trauma that occurs in extreme situations such as motor vehicle accidents or falls from heights. Approximately 8 to 10% of patients who sustain a blunt force and are treated at a Level 1 trauma center have a pelvic fracture. Because of the forces involved, pelvic fractures are often associated with trauma to organs and vessels inside as well as outside the bony pelvis. Due to the extensive blood supply to the region, they are also associated with hemorrhage (bleeding). For these reasons, pelvic fractures should never be considered in isolation, but rather in the context of a polytrauma or multiply injured patient. Furthermore, despite modern treatment techniques and advances in trauma care, acute pelvic fractures can be fatal. Fatality usually results from trauma to organs or surrounding blood vessels and nerves. Pelvic fractures can carry mortality rates as high as 50% if they are open (caused a break in the skin) and up to 20% if they are unstable. Fortunately, pelvic fractures represent only about 3% of the total number of skeletal injuries sustained in the US each year.

Anatomy of the pelvis

The pelvis supports and stabilizes both legs and the trunk of the body. The word pelvis is Latin for “basin,” and the bones of the pelvis form a basin or bowl-like structure called the pelvic ring. The enclosed space, which houses and protects the reproductive organs and rectum, is known as the pelvic cavity. This cavity is typically wider in women to accommodate pregnancy and childbirth. The large bone on either side of the pelvic ring is innominate or nameless. Each of these paired bones is formed by the fusion of 3 smaller bones —the ilium, ischium, and pubis—and connects to the sacrum (the bone in the lower back formed by 5 fused lower vertebrae) (Fig. 1) and the coccyx or tailbone (formed by a fusion of the last 4 vertebrae) (Fig. 2). The ilium is the broad upper portion of the bone where we place our hands on our hips. The ischium makes up the inferior or lower portion of the posterior pelvis; it is the bone on which we sit. At the anterior or front portion of each innominate bone is the pubis bone. Between the left and right pubis bone is a fibrocartilaginous disc that helps to make up the joint called the pubic symphysis (Fig. 1). This joint, together with the posterior sacroiliac complex (area where the pelvis joins the sacrum), stabilizes the pelvic ring. The anterior structure of the pelvis contributes approximately 40% of its overall rigidity, and the posterior approximately 60%. The posterior portion is thus more important than the anterior to pelvic-ring stability, which makes it also more important to pelvic fracture classification.

Diagnosis and classification

Imaging studies are needed to accurately diagnose and classify a pelvic fracture. These can include x-rays with multiple views and stress views taken while the examiner manipulates the pelvis. A CT (computerized tomography) scan featuring multiple images of the pelvis can also be done for full assessment of the fracture pattern. A careful inspection of the entire structure must be made because following a trauma, a patient often has more than just a pelvic fracture.

Fractures of the pelvis are generally classified in 1 of 2 ways. The first is based on the stability of the pelvis and includes 3 subdivisions: 1) stable; 2) partially stable; and 3) unstable. The second, referred to as the Young-Burgess classification, is based on the mechanism of injury or the direction of the injuring force applied to the pelvis. It includes 4 subdivisions: 1) lateral compression (force is applied from the side of the pelvis); 2) anterior to posterior (force is applied from front to back ); 3) vertical sheer (part of the pelvis shifts upward or downward in relation to the remaining structure); and 4) a combined mechanism.

Management

The initial management of an unstable pelvic fracture often involves applying a sheet or pelvic binder around the patient’s pelvis to compress the area and halt any ongoing bleeding from the fracture. Once the fracture patient has been resuscitated and stabilized and the injury accurately diagnosed and classified, the goal then becomes definitive treatment. The unstable pelvis must be treated early on, not only to mobilize the patient and control pain, but also to control blood clots and chronic instability or deformity. Current pelvic fracture management employs a substantial amount of percutaneous reduction and fixation. This involves making small incisions through the skin to get the fractured bones back into the correct alignment and then fixing them in place with screws applied though these incisions. The introduction of these modern techniques and treatment options has resulted in fewer pelvic reconstructive surgeries involving large open incisions, though they are still sometimes necessary to stabilize the pelvis.

Rehabilitation

The type and amount of rehabilitation the patient needs largely depend on the particular fracture pattern and the fixation obtained during surgery. For stable injuries, immediate weight bearing as tolerated is often recommended, whereas for an unstable pelvic fracture, full weight bearing is often halted for at least 8 to 12 weeks after surgical treatment.

Residual problems

Following severe pelvic fractures, almost all patients continue to experience some degree of pelvic pain. In addition, limitations in sexual and excretory (elimination) function as well as nerve injury are common. Patients should therefore be counseled appropriately. While women who have sustained pelvic injury may still be able to give birth vaginally, the rate of cesarean, or C-section, delivery is higher than for women who have never sustained such injuries.

Toward better outcomes

As pelvic fractures can be fatal and often occur in tandem with other types of traumatic injuries, they should not be considered in isolation but in the context of a polytrauma patient. Consequently, although pelvic injury classification based on overall pelvic stability and the direction of the injuring force has become more standardized, it remains only a general guide to treatment. Over the past 30 years, major advances in the ability to evaluate and treat pelvic ring disruptions have led to more individualized treatment and improved outcomes.

Author: Aaron D. Schrayer, MD Lewisville, Texas

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 1,Winter 2017.

Reverse Total Shoulder Arthroplasty Explained

Today, there are 2 radically different kinds of total shoulder arthroplasties or replacements for individuals who suffer from severe shoulder joint pain due to arthritis or injury. While traditional shoulder arthroplasty has concentrated on replacing normal joint anatomy with plastic or metal components, the reverse total shoulder arthroplasty (RTSA) involves not only replacing joint components, but also repositioning them and altering the normal biomechanics of the shoulder. In cases where patients have sustained major muscle or tendon damage, making conventional replacement constructs more likely to fail, RTSA has become a viable solution for shoulder pain and disability. To understand how an RTSA works, a patient should first understand basic shoulder anatomy.

Shoulder anatomy

The glenohumeral, or shoulder, joint is classified as a ball-and-socket joint. It is formed by the articulation of the head (ball) of the humerus, or upper arm bone, with the glenoid cavity (socket) of the scapula (shoulder blade) (Fig.1). Since the cavity is shallow, there is little contact between the bones, but the glenoid labrum, a ring of cartilaginous fiber that lines its circumference, deepens the cavity by about 50%, allowing for more surface contact and a better fit. Nevertheless, the joint capsule, or envelope of fibrous connective tissue that attaches to the bones of the joints to seal the joint space and to help provide stability, is very loose. This makes the glenohumeral joint the most mobile of the body, capable of flexion (bending), extension (straightening), adduction (pulling toward the body), abduction (pulling away from the body) medial and lateral rotation (turning toward or away from the midline of the body), and circumduction (moving in a circle). The capsule consists of a number of tendons (tissues that connect muscle to bone) along with bursae, or small fluid-filled sacs, strategically located to aid movement and prevent friction. Because it lacks strong ligaments (tissues that connect bone to bone) to support it, the glenohumeral joint is also known as a muscle-dependent joint. It is primarily stabilized by the biceps brachii, or muscle on the anterior (front) side of the upper arm, and the tendons of what are called the rotator cuff muscles. These include the supraspinatus, subscapularis (Fig. 2), infraspinatus, and teres minor muscles (Fig. 3). Each of these muscles originates from the scapula and has a tendon that attaches to the head of the humerus. Together they form “a cuff” around the shoulder joint, called the rotator cuff, which provides stability. This cuff is also important to shoulder movement and is frequently injured from playing sports or doing other activities involving repetitive arm and shoulder motion.

Variations on shoulder arthroplasty

In traditional shoulder replacements, a plastic cup is used for the glenoid cavity of the scapula and a metal ball for the head of the humerus (Fig. 4). Outcomes from this procedure are generally good, but when a patient with shoulder arthritis also has a massive rotator cuff tear, conventional anatomic total shoulder replacements have higher complication rates. This is because, without an intact rotator cuff to stabilize the glenohumeral joint, its centers of force shift upward, causing the arthroplasty to loosen and fail.1 The problem with patients who also have rotator cuff injuries was recognized decades ago when it led to the development of the RTSA. This new type of prosthesis or implant reversed the normal anatomic configuration of the shoulder by placing the ball component of the implant in the glenoid socket of the scapula and the socket component in the humerus. In the 1970s, early designs of this arthroplasty often failed because the implant would loosen, break, or otherwise become unstable. Over time, the prostheses were designed to use the deltoid muscle (the rounded muscle on top of the shoulder) as a lever to compensate for the deficient rotator cuff. However, the early versions of this new design also frequently failed as the replacement constructs proved to be too constraining.

The Grammont arthroplasty

In 1985, French orthopaedist Paul Grammont advanced the design for RTSA when he came up with the idea of altering the normal biomechanics of the shoulder joint. Over the next 20 years, engineering of the Grammont RTSA evolved to provide a viable solution for patients with arthropathy (joint pain) and rotator cuff deficiency (Fig. 4). The construct functioned by converting the forces acting on the joint and, as in the previous designs, using the deltoid muscle in the absence of an intact rotator cuff as a lever so the patient could lift his or her arm. As it gave the glenohumeral articulation a larger contact surface area, the implant was more stable than earlier models and was able to prevent the humerus from shifting upward in patients with rotator cuff deficiency. Lastly, patients who were having pain from shoulder arthritis could get relief from the resurfacing provided by the stable implant. While various manufacturers have since produced prostheses that feature their own specific modifications, all of these are based on Grammont’s original design. Additionally, even though the procedure is still largely used in cases of arthropathy and rotator cuff deficiency or as revision surgery when traditional arthroplasty fails, indications for RTSA have now expanded to include some fractures of the humerus.

Outcomes and complications

RTSA offers new hope to patients suffering with shoulder pain and disability. According to doctors at Rush University Medical Center in Chicago, having this type of surgery substantially reduced shoulder pain in 9 out of 10 patients and led to a stabilized shoulder in at least 75% of cases. Despite these statistics and advancements in prosthesis design, outcomes for RTSA can vary widely and the procedure is associated with high complication rates ranging from 19 to 68% of cases.2 For example, scapular notching or erosion caused by the humerus or the humeral prosthesis impinging on the inferior or lower neck of the scapula, is unique to reverse total shoulder surgery. Other common problems include instability and dislocation of the prosthesis. These complications have been attributed to poor soft tissue tension, implant misplacement, an improperly-sized implant, mechanical impingement, bone loss, and neurologic dysfunction. For instance, acromial (pertaining to the protruding bone on the top of the shoulder) and scapular fractures have been reported after surgery and attributed to minor postoperative injuries. Fractures can also occur during surgery through a variety of mechanisms including bone preparation and placing instrumentation in bone that is already weak and porous. Moreover, nerve injury can result from over-lengthening the arm with the implants and overstretching nerves. Additionally, the unavoidable dead space (opening in the tissues created by the procedure itself, which allows the accumulation of blood or serum) can permit a hematoma, a solid swelling of clotted blood within the tissues, to develop. As with other joint arthroplasties, infection associated with hematomas, dead space, revision surgeries, a breach in sterile technique, or a compromised immune system, can occur. Given these possible complications, RTSA should be recommended only for select patients and performed only by experienced surgeons. Even after a successful reverse total shoulder procedure, some patients may continue to experience limitations in joint mechanics and function.

A good option for a bad shoulder

Historically, shoulder pain and arthritis have been difficult to treat in patients with a rotator cuff deficiency or following failed conventional shoulder replacement surgery. Although there can be complications, reverse total shoulder surgery addresses the problems involved directly and, to-date, offers the best treatment option available for many patients with damaged rotator cuffs.

Author: David A. Lalli, DO Niceville, Florida

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 1,Winter 2017.