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Background:The treatment of patients with severe glenoid bone loss using reverse total shoulder arthroplasty (RSA) is challenging because of the difficulty in obtaining glenoid fixation. The outcomes following primary RSA with structural bone-grafting for severe glenoid bone loss and the amount of native bone support necessary to achieve clinical improvement are unclear.Methods:We reviewed functional outcomes (American Shoulder and Elbow Surgeons [ASES] score, Simple Shoulder Test [SST], visual analog scale [VAS] for pain and function, patient satisfaction, and range of motion) for 57 patients who were treated with a primary RSA and glenoid bone-grafting for severe glenoid bone loss. Three glenoids were classified as type A2; 2, as type B2; and 2, as type C, according to the Walch classification; 16 glenoids, as grade E1; and 19, as grade E3, according to the Sirveaux classification; 9 glenoids, as grade 3, according to the Levigne classification; and 6 were unable to be classified. For the 44 patients with adequate preoperative computed tomographic (CT) data and postoperative radiographs, we evaluated native bone contact under the glenoid baseplate by matching the projected shape of the implant and scapula from the postoperative radiographs with a generated 3-dimensional (3D) model of the preoperative scapula. We then analyzed functional outcomes in relation to native bone support of the baseplate.Results:At a mean of 46 months (minimum, 24 months), the patients demonstrated significant improvements in function, motion, and pain (change in the ASES total score = 38.6, change in SST = 5.4, change in forward elevation = 72.4°, change in abduction = 67.7°, change in external rotation = 24.3°, and change in VAS pain score = −4.6; p < 0.001 for all). On the basis of the generated 3D model, the baseplate contact to host bone was a mean (and standard deviation) of 17% ± 12% (range, 0% to 50%). There was no significant correlation between host bone coverage and change in the ASES score (p = 0.51) for the 44 patients included in this analysis. There were 4 major complications (7%) in the study group but no glenoid baseplate failures.Conclusions:Glenoid bone-grafting in a primary RSA in a shoulder with severe bone loss produces good functional outcomes that do not correlate with the degree of native bone contact under the baseplate. We had observed no glenoid component failures at the time of writing.Level of Evidence:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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Background Cyanoacrylate-based, microbial sealant is an adhesive skin barrier designed to prevent bacterial contamination in surgical wounds. This type of adhesive barrier could have use in decreasing the incidence of positive cultures and subsequent infection in shoulder arthroplasty. Questions/purposes We therefore evaluated whether cyanoacrylate microbial sealant reduced the positive intraoperative culture rates in revision shoulder arthroplasty. Methods We retrospectively reviewed 55 patients who underwent revision shoulder arthroplasties. Intraoperative aerobic and anaerobic deep tissue culture results taken during the revisions were compared. Cultures were taken of the deep synovial tissue lining the prosthesis. Patients were divided into two groups: those who underwent standard preparations with adhesive, iodine-barrier drapes (Group SP) and those who had placement of cyanoacrylate microbial sealant in addition to the standard prep (Group MS). Results The prevalence of cases with positive cultures was 18% (seven of 40) in Group SP compared with 7% (one of 15) in Group MS. The prevalence of positive, anaerobic Propionibacterium acnes cultures was 13% in Group SP compared with 7% in Group MS. The prevalence of infections confirmed at revision surgery was 8% in Group SP versus 0% in Group MS. Conclusions Our observations suggest application of a cyanoacrylate microbial sealant may reduce the prevalence of positive cultures and thereby subsequent infections in revision shoulder arthroplasties.

The response of tissue to trauma is difficult to define. The zone of injury is an area surrounding a wound that, though traumatized, may not appear nonviable at initial debridement. Because of this, a policy of repeated debridements has been followed to monitor tissues for viability before final tissue coverage. Appreciation of the zone of injury has led to a controversy in the literature about how to define and approach the management of traumatic injuries requiring free-tissue coverage. This review examines the current literature with regard to the definition of the zone of injury, and seeks to establish a consensus statement about the application of free flaps to traumatized wounds. We have investigated the literature supporting the use of free flaps relying on proximally or distally based recipient vessels. Critical appraisal of this literature includes study design, determination of the power of the study, subject classification, inclusion and exclusion criteria, follow-up, and outcomes (free flap success). There has been little attempt in the literature to fully and objectively define the zone of injury. All studies to date have been observational alone. Although it would be impossible to rid a definition of the zone of injury of subjectivity entirely, a more objective, reproducible definition is vitally needed. Without a clear definition of what the zone of injury is, there can only be anecdotal, technique reports of the placement of free flap anastomoses. In this time of rising costs and lower reimbursements, this is one area that could provide vital information to improve care for patients, lessen costs, and further medical knowledge.