• Clinics in Shoulder and Elbow
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• v.22 no.1
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• pp.50-57
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• 2019

Rotator cuff tear is a common cause of shoulder pain and disability in adults. Due to the various nature of progression of rotator cuff tears and the complex biomechanics of the shoulder joint, repair and treatment of large-to-massive tears are challenging for many surgeons. Despite the recent popularity of reverse total shoulder arthroplasty as a treatment option for large-to-massive irreparable rotator cuff tears, biological and mechanical repair augmentation has also shown promise as a viable treatment option. The purpose of this study was to briefly summarize and review current studies on the assessment and arthroscopic treatment of large-to-massive rotator cuff tears, whether repairable or irreparable, to aid in developing a consensus on future treatment directions.

• Clinics in Shoulder and Elbow
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• v.23 no.2
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• pp.105-108
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• 2020

Stress fractures of the acromion and scapular spine are well-known complications following reverse total shoulder arthroplasty. However, these fractures in patients with massive rotator cuff tear or cuff tear arthropathy are extremely rare, and the pathogenesis, clinical features, diagnosis, and treatment of these fractures are poorly understood. We report a case of bilateral stress fracture of the posterior angle of the acromion in a patient with massive rotator cuff tear and discuss the pathogenesis, clinical manifestation, and treatment with a review of the literature.

• Clinics in Shoulder and Elbow
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• v.16 no.2
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• pp.73-83
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• 2013

Purpose: The goal of this study is to evaluate the minimum three-year follow-up results of reverse total shoulder arthroplasty (RTSA) for glenohumeral (GH) arthritic and pseudoparalytic patients with severe rotator cuff deficiency. Materials and Methods: We evaluated 13 patients (three males and 10 females) who underwent RTSA from July 2007 to July 2010. The average follow-up duration was 54.2 months (range, 37~74 months). Clinical results were evaluated using the Visual Analog Scale (VAS) for pain, active Range of Motion (ROM): active forward flexion (aFF); active external rotation at the side (aERs); active internal rotation to the back (aIRb), American Shoulder and Elbow Surgeons (ASES) score, Korean Shoulder Score (KSS), and intraoperative and postoperative complications. Results: VAS score improved from 7.5(6~10) points to 1.5(0~4), and ROM of active forward elevation improved from $42.7(10{\sim}100)^{\circ}$ to $129.1(110{\sim}180)^{\circ}$. In addition, ASES score improved from preoperative 32.9 (11.7~46.7) points to 80.2(58.3~95.0) postoperatively, and KSS score improved from 36.8(24~47) points to 78.4 (61~92). Twelve out of 13 cases showed various degrees of scapular notching at the last follow-up. There was one case of intraoperative anterior glenoid fracture and two cases of temporary nerve injury. Revision surgery was performed in two cases for treatment of delayed postoperative deep infection. Conclusion: According to minimum three-year follow-up results, RTSA may be an effective treatment option for glenohumeral (GH) arthritic and pseudoparalytic patients. However, considering the possibility of complications related to delayed deep infection or surgeon's technique, RTSA should be judiciously and carefully indicated by expert surgeons.

• Journal of the Korean Orthopaedic Association
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• v.54 no.5
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• pp.418-426
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• 2019

Purpose: This study analyzed the features of humeral head decentralization in large to massive rotator cuff tears with a shoulder dislocation in the elderly. Moreover, shoulder instability and treatment were reviewed. Materials and Methods: From May 2005 to February 2017, Group A containing 45 cases (45 patients) over 65 years old accompanied by a large or massive rotator cuff tear with a shoulder dislocation and Group B containing 45 cases (45 patients) without a shoulder dislocation were enrolled. The mean ages in Groups A and B were 73.2 and 72.1 years old, and the mean follow-up periods were 30.7 and 31.3 months, respectively. Twenty-one cases (46.7%) in Group A underwent rotator cuff repair, and 8 cases (17.8%) underwent concomitant rotator cuff repair with Bankart repair. Sixteen cases (35.6%) underwent reverse total shoulder arthroplasty for cuff tear arthropathy. 45 cases (100%) in Group B underwent rotator cuff repair. The off-the center and head elevation were measured in the preoperative magnetic resonance imaging (MRI) of Groups A and B. The preoperative and postoperative visual analogue scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, and University of California Los Angeles (UCLA) score in Groups A and B were compared. Results: In Groups A and B, the mean off-the centers were posterior 7.41 mm and posterior 2.02 mm (p=0.03), and the mean head elevations were superior 6.66 mm and superior 2.44 mm (p=0.02), respectively. The mean ASES scores of Groups A and B were 32.8 and 33.4 before surgery, and 77.1 (p=0.02) and 78.1 (p=0.02) after surgery (p=0.18), respectively. The mean UCLA scores of Groups A and B were 13.1 and 12.8 before surgery, and 28.9 (p=0.02) and 29.5 (p=0.01) after surgery (p=0.15), respectively. Conclusion: Patients over 65 years old with a shoulder dislocation in large to massive rotator cuff tears had higher off-the center and head elevation on the preoperative MRI than those without a shoulder dislocation. This measurement can help predict preceding shoulder instability. Early rotator cuff repairs should be performed and other treatments, such as Bankart repair and reverse total shoulder arthroplasty, should also be considered.

• Clinics in Shoulder and Elbow
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• v.21 no.4
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• pp.220-226
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• 2018

Background: This study introduces a surgical technique with good clinical outcome useful in the treatment of osteoporotic displaced 3- or 4-part proximal humeral fractures. Methods: From May 2014 to February 2016, 16 patients with displaced 3- or 4-part proximal humeral fractures were treated by application of a locking plate with an endosteal strut allograft via a deltoid splitting approach with a minimum follow-up of 12 months. The allograft was inserted through a fractured gap of the greater tuberosity to support the humeral head and then fixed by a locking plate with meticulous soft tissue dissection to protect the axillary nerve. Surgical outcomes were evaluated by the American Shoulder and Elbow Surgeons (ASES) and visual analogue scale (VAS) scores, radiological imaging, and clinical examination. Fixation failure on radiographs was defined as a >$5^{\circ}$ loss of neck shaft angle (NSA) compared to that on an immediate postoperative radiograph. Avascular necrosis (AVN) of the humeral head was also evaluated. Results: In all cases, complete union was achieved. The ASES and VAS scores were improved to $85.4{\pm}2.1$ and $3.2{\pm}1.3$, respectively. Twelve patients (75.0%) had greater than a $5^{\circ}$ change in NSA; the average NSA change was $3.8^{\circ}$. Five patients (31.3%) had unsatisfactory ranges of motion exhibiting a <$100^{\circ}$ active forward flexion. No axillary nerve injuries or AVN were observed at the last follow-up. One patient was converted to reverse total arthroplasty due to severe pain and functional deficit. Conclusions: Minimally invasive fixation via a locking compression plate and an endosteal fibula strut allograft in Neer classification 3-or 4-part fractures with severe osteoporosis in elderly patients can achieve good clinical results.

• Journal of the Korean Orthopaedic Association
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• v.56 no.5
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• pp.391-397
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• 2021

Purpose: Tranexamic acid (TXA) can reduce perioperative blood loss and the frequency of blood transfusions in lower extremity surgery. On the other hand, the effects of TXA on reverse total shoulder arthroplasty (rTSA) remain undetermined. This study evaluated the efficacy of TXA on perioperative blood loss, transfusion requirements, and the change in the hemotologic index. Materials and Methods: This study evaluated patients who underwent rTSA from September 2009 to July 2020. The patients were classified into two groups. The TXA group were administered TXA intravenously and topical TXA during surgery. The non-TXA group was not administered TXA. The quantity of hemovac drainage, which represented the postoperative blood loss, transfusion requirements, and postoperative change in hemoglobin and hematocrit level, were recorded. Results: The TXA and non-TXA groups consisted of 93 and 84 patients, respectively. The preoperative demographics showed no significant differences in age (72.0±7.0 vs. 71.5±5.8, p=0.656), sex (male:female, 28:65 vs. 23:61, p=0.689) and the prevalence of hypertension and diabetes (hypertension:diabetes:both, 36:3:13 vs. 32:3:8, p=0.806) between the two groups. There were significant differences in the requirements of transfusion (0 vs. 9, p=0.001), hemovac drainage at the 1^st (98.8±61.2 ml vs. 162.7±98.8 ml, p<0.001), the 2^nd postoperative day (73.8±48.4 ml vs. 91.5±54.5 ml, p=0.024), hemoglobin level at the 1^st (11.7±1.2 g/dl vs. 11.2±1.4 g/dl, p=0.048), 3^rd (10.9±1.2 g/dl vs. 10.2±1.2 g/dl, p<0.001), and 6^th (11.2±1.3 g/dl vs. 10.7±1.3 g/dl, p=0.020) postoperative day, and the hematocrit level at the 1^st (35.0%±3.6% vs. 32.5%±3.8%, p=0.001), 3^rd (32.3%±5.0% vs. 29.8%±3.6%, p<0.001), and 6^th (33.5%±3.8% vs. 31.5%±3.7%, p<0.001) postoperative day between the two groups. Conclusion: Intravenous and topical intra-articular TXA can reduce the transfusion requirement and blood loss in rTSA.

• Journal of the Korean Orthopaedic Association
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• v.53 no.6
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• pp.505-512
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• 2018

Purpose: Many reconstruction methods have been attempted after an en-bloc resection of the proximal humerus. In particular, the introduction of reverse shoulder arthroplasty (RSA) has made a breakthrough in the functional recovery of the shoulder. Nevertheless, RSA has limitations when the humeral bone stock loss is significant. In addition, it is unclear if RSA is effective in patients showing failure with non-operative treatment of a proximal humeral tumor. Materials and Methods: A reconstruction was performed using an overlapping allograft-RSA composite for 11 patients with a failed proximal humeral construct. Delayed RSA was performed on 6 patients with failed non-operative treatment. The pre- and postoperative Musculoskeletal Tumor Society (MSTS) score and the complications were addressed. Results: Overlapping allograft-RSA composite afforded a stable construct in 11 failed proximal humeral reconstructions and the patient's chief complaints were resolved. The mean time to the union of overlapped allograft-host junction was 5.5 months. Average preoperative MSTS score of 20.3 point increased to 25.7 point, postoperatively. Four of the six patients who had RSA within 4 years from the index operation showed arm elevation of more than $90^{\circ}$ whereas the remaining 5 patients showed some disability. The complications include one case each of dislocation and aseptic infection, which were resolved by changing the polyethylene liner and scar revision, respectively. None of the 6 patients who underwent delayed RSA after the failure of non-operative treatment showed arm elevation more than $90^{\circ}$. Conclusion: An overlapping allograft-RSA composite is a simple and reliable reconstructive modality in patients with massive bone loss. In patients with metastatic cancer necessitating a surgical resection at presentation, early conversion to RSA is recommended to secure functional recovery.