BACKGROUND:Preoperative planning software enables virtual implantation of reverse total shoulder arthroplasty (rTSA) and assessment of impingement-free range of motion (ROM). Recent studies have shown that scapular resting position varies significantly among individuals and impacts impingement-free ROM. The resting position of the arm also varies between individuals, yet its impact on simulated outcomes and whether this parameter should be integrated into planning programs remains unclear. The objective of this study was to assess the effect of the resting arm position in the coronal plane on simulated impingement-free ROM and on implant positioning metrics, specifically the lateralization shoulder angle (LSA) and distalization shoulder angle (DSA) in rTSA planning. METHODS:A prospective computational modeling study was conducted using a commercially available three-dimensional planning software (Imascap, Plouzané, France). Thirty computed tomography scans of patients with primary osteoarthritis or cuff tear arthropathy were planned independently by 9 experienced surgeons. The resting abduction angle (RAA) was implemented as proxy for the resting arm position in the coronal plane and determined by the humeral diaphyseal axis and vertical scapular axis. Each plan was simulated with 10 distinct resting arm positions (between -5° and 40° of abduction), resulting in 2,700 virtual cases. Impingement-free ROM, LSA, and DSA were evaluated for each resting arm position. One-way analysis of variance and Pearson correlation analyses were conducted to determine the relationship between RAA and key planning outcomes. RESULTS:RAA significantly influenced simulated ROM parameters across all tested arm positions (P < .0001). Increasing RAA, resulted in greater adduction (R2 = 0.72, P < .0001), internal (R2 = 0.23, P < .0001), and external rotation (R2 = 0.23, P < .0001), while inversely affecting abduction (R2 = 0.44, P < .0001), forward flexion (R2 = 0.26, P < .0001), and extension (R2 = 0.31, P < .0001). Significant differences were found in LSA and DSA values across the different simulated resting arm positions (P < .0001). LSA showed a weak positive correlation with RAA (R2 = 0.34, P < .0001), whereas DSA exhibited a strong inverse relationship (R2 = 0.63, P < .0001), indicating that a more abducted resting arm position led to higher LSA and lower DSA values without altering implant position. CONCLUSION:The resting arm position significantly affects virtual impingement-free ROM in Imascap planning software, highlighting the importance of incorporating humeral position into rTSA preoperative planning. Additionally, because LSA and DSA measurements are substantially influenced by the arm position despite an unchanged implant configuration, consideration of humeral orientation may be necessary when interpreting these metrics.
Background:Atlantoaxial dislocation (AAD) is a rare but potentially life-threatening condition characterized by an abnormal alignment between the atlas and axis. Traumatic AAD are commonly associated with severe ligamentous injury and may result in spinal cord compression or neurological deficits. Posterior atlantoaxial dislocation with an intact odontoid process and without associated fracture is extremely uncommon and has rarely been reported in literature. Objective:To report a rare case of traumatic posterior atlantoaxial dislocation with an intact odontoid process and describe its management strategy, including emergency reduction and posterior C1-C2 fixation using a C2 laminar screw. Methods:A 51-year-old man was admitted after a traffic accident with severe polytrauma including traumatic brain injury, multiple rib fractures, bilateral hemopneumothorax, splenic injury, and fractures of the left tibia and fibula. Cervical computed tomography revealed a posterior atlantoaxial dislocation without odontoid fracture. Emergency skull traction was performed under general anesthesia with a gradual increase in traction weight from 5 to 10 kg under fluoroscopic guidance. Posterior C1-C2 fixation was subsequently performed because of the redislocation observed on follow-up imaging. Because of a narrow left C2 pedicle and a high-riding vertebral artery, a C2 laminar screw was used as an alternative fixation technique. Results:Intraoperative fluoroscopy and postoperative imaging confirmed a satisfactory reduction and stable fixation of the atlantoaxial complex. However, despite intensive treatment, the patient died 10 days postoperatively due to multiple organ failure secondary to severe polytrauma rather than complications related to the spinal procedure. Conclusion:Emergency skull traction may achieve temporary reduction in traumatic atlantoaxial dislocation; however, surgical stabilization is often required in cases with significant instability. C2 laminar screw fixation is a safe and effective alternative when pedicle screw placement is limited by anatomical variations.
Sleep disturbances are common among patients with shoulder pathology and are often associated with poor postoperative outcomes, diminished quality of life, and increased healthcare use. Shoulder arthroplasty (SA) is a well-established treatment for functional limitations and pain due to glenohumeral osteoarthritis, with relief from nighttime pain and improved sleep quality frequently influencing patients’ decisions to undergo surgery. While prior studies have documented the link between sleep disturbances and functional outcomes in shoulder surgery, the role of sleep in overall recovery remains unclear. This study evaluates the relationship between sleep comfort and recovery in patients undergoing primary and revision reverse shoulder arthroplasty (RSA). A retrospective review of patients who underwent RSA by a single fellowship-trained orthopaedic surgeon from 2015-2020 was conducted. Patients were separated into two groups: 1) pRSA and 2) rRSA. Demographic variables, composite ASES scores, and individual responses to the sleep component of the ASES score were collected at 3, 6, 12, and 24 months postoperatively. Patients rated their ability to comfortably sleep on a 0-3 scale (0=“unable”, 1=“very difficult”, 2=“slightly difficult”, 3=“normal”). If a score of 0-2 was obtained, patients were considered to have “difficulty” sleeping. Utilizing the ASES score, patients were deemed “recovered” if they obtained a postoperative score of 70 or greater based on previously defined methods.22,23 Patients were further grouped into “not recovered” and “recovered” groups and statistically compared to their sleep scores using a chi-square analysis. A total of 476 RSA patients (pRSA=386, rRSA=90) were included in the final analysis. Patients who underwent pRSA had a mean age of 73 years, BMI of 29.2 kg/m² and consisted of 37% males. Patients who underwent rRSA had a mean age of 68 years, BMI of 29.7 kg/m² and consisted of 51.7% males. Most patients that recovered indicated “no difficulty” sleeping by 3 months (pRSA group = 61.1%, rRSA group = 63.6%) and this incrementally improved up to one year for both pRSA and rRSA patients (6 months (RSA group = 69.1%, rRSA group = 73.3%), 12 months (RSA group = 69.4%, rRSA group = 75%). The recovered patients demonstrated significantly higher rates of “no difficulty” sleeping when compared to their respective “not recovered” patients at each time point (p < 0.001). This study demonstrates a significant association between normal sleep restoration and recovery after RSA, with most patients achieving improved sleep by 3 months postoperatively. Sleep quality continued to improve through 12 months but plateaued thereafter, indicating a stabilization of recovery. These findings highlight the importance of sleep as a key indicator of recovery and suggest that surgeons can use sleep quality as a simple metric for assessing patient progress.
Background: Posterior cruciate ligament (PCL) injury is a relatively common musculoskeletal condition. However, there is currently a lack of consensus on decision-making, treatment and postoperative management for such injuries. Objectives: To use the modified Delphi method to reach expert consensus on the management of PCL injury. Methods: A literature search of PubMed, Cochrane Library, Embase, and Web of Science for articles up to 17 October 2024, to support the development of recommendation statements. An Expert Panel of 90 experienced clinicians from orthopaedics and sports medicine participated in a two-round Delphi process. Each statement was evaluated in two parts: the first part assessed content appropriateness (score of 7-9 indicating appropriateness and 4-6 indicating possible appropriateness), while the second part assessed agreement (score of 5-9 indicating agreement). Results: The panel members developed 11 statements using the Delphi process, addressing the following topics: (1) clinical decision-making, (2) treatment, and (3) postoperative management about PCL injuries. The final consensus was reached on 11 statements and we eventually translated these statements into a corresponding table of expert recommendations. Conclusion: Consensus was reached on 11 statements regarding three aspects of PCL injury management. These findings provide a foundation for developing evidence-based guidelines that can enhance clinical decision-making, improve treatment strategies, and optimize postoperative care for patients with PCL injuries.
Introduction: Pelvic mobility is calculated as the change (∆) in either pelvic tilt (PT) or sacral slope (SS) between extreme positions, and can be considered insufficient (stiff) if ∆SS or ∆PT 30° in the arthritic population. Furthermore, it is postulated that pelvic mobility is correlated to pelvic incidence (PI) in non-arthritic patients with femoroacetabular impingement (FAI). Moreover, it is suggested that symptoms of FAI depend on pelvic mobility, as the same cam lesion could be symptomatic in hip users (PI<40°), but asymptomatic in spine users (PI≥40°). This study aims to assess pelvic mobility’s repeatability (∆SS and ∆PT) and its association with PI in non-arthritic hip pain patients with a positive impingement test. Methods: The cohort comprised 82 patients aged 31.8±7.4, with hip pain and positive impingement test. Stereo- radiographic images were acquired in three positions (neutral standing, neutral sitting, and flexed- forward sitting). PI, pelvic tilt (PT), and sacral slope (SS) were measured. Repeatability was evaluated. Pelvic mobility was calculated as ΔPT and ΔSS from i) standing to sitting, ii) neutral to flexed-forward- sitting, and iii) maximum to minimum values. Correlations of PI with PT, SS, ΔPT, and ΔSS were assessed. Results: Repeatability was excellent for all pelvic mobility measurements (intraclass correlation coefficients, ICC >0.97). ΔPT was 25.9±8.3º from standing to sitting, 14.4±11.2º from standing to flexed-forward-sitting, and 37.8±13.7º from maximum to minimum values. ΔSS was 24.0±7.6º from standing to sitting,14.2±11.6º from standing to flexed-forward-sitting, and 35.9±13.7º from maximum to minimum values. PI was strongly correlated with PT in standing (r=0.7) and SS in standing (r=0.7), and moderately correlated with PT in sitting (r=0.6) and SS in sitting (r=0.5), but was not correlated with neither ΔPT nor ΔSS (r <0.3). Conclusions: Pelvic mobility, calculated as ΔPT and ΔSS, has excellent repeatability, and is not correlated with PI in non-arthritic patients with hip pain. Therefore, PI should not be considered for diagnosis and treatment of painful hips with positive impingement test, nor to distinguish hip users from spine users.
