Gasbarro Gregory, Crasto Jared A, Rocha Jorge, Henry Sarah, Kano Daiji, Tarkin Ivan S
Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
Geriatr Orthop Surg Rehabil. 2019 Jun 10;10:2151459319855318. doi: 10.1177/2151459319855318. eCollection 2019.
Preoperative axillary nerve palsy is a contraindication to reverse total shoulder arthroplasty (rTSA) due to the theoretical risk of higher dislocation rates and poor functional outcomes. Treatment of fracture-dislocations of the proximal humerus with rTSA is particularly challenging, as these injuries commonly present with concomitant neurologic and soft tissue injury. The aim of the current study was to determine the efficacy of rTSA for this fracture pattern in geriatric patients presenting with occult or profound neurologic injury.
A retrospective case series of all shoulder arthroplasty procedures for proximal humerus fractures from February 2006 to February 2018 was performed. Inclusion criteria were patients aged greater than 65 years at the time of surgery, fracture-dislocations of the proximal humerus, and treatment with rTSA. Patients with preoperative nerve injuries were compared to patients without overt neurologic dysfunction. Forward elevation, Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), Visual Analog Scale (VAS), and Subjective Shoulder Value (SSV) were obtained at final follow-up.
Forty-six rTSA for acute fracture were performed during the study period, 16 patients met the inclusion criteria and 5 (31%) presented with overt preoperative nerve injuries. At mean 3.1 years follow up, there were no postoperative complications including dislocations and final forward elevation was similar between study groups. Patients with overt nerve palsy had higher QuickDASH and VAS scores with lower SSV and self-rated satisfaction.
In the majority of patients with or without overt nerve injury, rTSA reliably restored overhead function and led to good or excellent patient-rated treatment outcomes. Overt nerve palsy did not lead to higher complication rates, including dislocation. Despite greater disability and less satisfaction, complete or partial nerve recovery can be expected in the majority of patients.
Nerve injury following proximal humeral fracture dislocation may not be an absolute contraindication to rTSA.
术前腋神经麻痹是反向全肩关节置换术（rTSA）的禁忌证，因为理论上存在更高脱位率和功能预后不良的风险。用rTSA治疗肱骨近端骨折脱位尤其具有挑战性，因为这些损伤通常伴有神经和软组织损伤。本研究的目的是确定rTSA治疗老年隐匿性或严重神经损伤患者这种骨折类型的疗效。
对2006年2月至2018年2月期间所有肱骨近端骨折的肩关节置换手术进行回顾性病例系列研究。纳入标准为手术时年龄大于65岁、肱骨近端骨折脱位且接受rTSA治疗的患者。将术前有神经损伤的患者与无明显神经功能障碍的患者进行比较。在末次随访时获得前屈、上肢、肩部和手部快速残疾评定量表（QuickDASH）、视觉模拟评分法（VAS）和主观肩关节评分（SSV）。
在研究期间进行了46例急性骨折的rTSA手术，16例患者符合纳入标准，其中5例（31%）术前有明显神经损伤。平均随访3.1年，术后无并发症，包括脱位，研究组间最终前屈相似。有明显神经麻痹的患者QuickDASH和VAS评分较高，SSV和自我评定满意度较低。
在大多数有或无明显神经损伤的患者中，rTSA可靠地恢复了上举功能，并取得了良好或优异的患者评定治疗效果。明显的神经麻痹并未导致更高的并发症发生率，包括脱位。尽管残疾程度更高且满意度更低，但大多数患者有望实现完全或部分神经恢复。
肱骨近端骨折脱位后的神经损伤可能不是rTSA的绝对禁忌证。
