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Shoulder Arthroplasty for Proximal Humeral Nonunions

Shoulder Arthroplasty for Proximal Humeral Nonunions

Shoulder fractures are common injuries among the elderly, but the management of these fractures can be challenging for physicians. Treatment options include nonoperative modalities, osteosynthesis, and arthroplasty, but patients can still suffer from substantial pain and functional impairment even after receiving these interventions. Nonunions have been frequently linked to bone loss, poor bone quality, and soft-tissue contractures. “In previous studies, surgeons have had difficulty achieving fracture union with internal fixation and bone-grafting treatments in patients with proximal humeral fracture nonunions,” explains Thomas R. Duquin, MD. “As an alternative, unconstrained shoulder arthroplasty has been advocated for treating these nonunions. Unfortunately, research has documented high rates of unsatisfactory results with arthroplasty, especially with regard to functional outcomes.” Study Results on Proximal Humeral Nonunions In the Journal of Bone and Joint Surgery, Dr. Duquin and colleagues recently had a study published that reviewed the results and complications of conventional anatomic shoulder arthroplasty for proximal humeral nonunions. The study also identified factors associated with success or failure. From 1976 to 2007, 67 patients who underwent unconstrained shoulder arthroplasty for proximal humeral nonunions were followed for more than 2 years. The study included 49 women and 18 men with an average age of 64 and a mean duration of 9 years follow-up. Fracture type was assessed according to the Neer rating classification. There were two-part fractures in 36 patients, three-part fractures in 16 patients, and four-part fractures in 15 patients. Hemiarthroplasty was performed in 54 individuals, and total shoulder arthroplasty was done in 13. According to findings, there were 33 excellent or satisfactory results based on a modified Neer rating classification (Figure 1). “For...

Comparing Treatments in Vertebral Fractures

Percutaneous therapy for treating patients with bony malignancy and vertebral fractures appears to significantly reduce costs and lengths of stay when compared with surgery. A retrospective review demonstrated that overall costs were $13,565 less and inpatient stays were 4.1 days shorter with percutaneous therapy when compared with surgery. Abstract: Journal of Vascular and Interventional Radiology, November...

Managing Common Diabetes Comorbidities: Going Beyond Standard Care

This Physician’s Weekly feature covering the management of common diabetes comorbidities was completed in cooperation with the experts at the American Diabetes Association. Throughout the medical literature, it has been well documented that patients with type 2 diabetes are at increased risk for developing cardiovascular disorders, including coronary artery disease and stroke. The constellation of symptoms that includes insulin resistance and obesity greatly increases the likelihood of additional comorbidities emerging. “In addition to the commonly appreciated comorbidities of obesity, hypertension, and dyslipidemia,” says Medha N. Munshi, MD, “diabetes is also associated with other diseases or conditions at rates higher than those of people without diabetes.” In keeping with patient-centered approaches to care, physicians should be aware of the wide spectrum of comorbidities their patients face when managing them throughout their disease course. When the risk for these comorbidities is elevated, patients should be treated accordingly. The American Diabetes Association reports that some of the more common comorbidities outside the realm of obesity, hypertension, and dyslipidemia include obstructive sleep apnea (OSA), fatty liver disease, cancer, and fractures (Table 1). “Clinicians should consider these other comorbidities during their care of patients with diabetes to optimize outcomes,” says Dr. Munshi. Obstructive Sleep Apnea OSA is the most common form of sleep-disordered breathing in patients with type 2 diabetes, accounting for over 80% of cases. In people with diabetes, the prevalence of OSA has been documented to be as high as 23% and the prevalence of some form of sleep disordered breathing may be as high as 58%. “Treating sleep apnea can significantly improve quality of life and blood pressure control,” Dr. Munshi...
New Guidelines on Osteoporosis in Men

New Guidelines on Osteoporosis in Men

This week, the Endocrine Society issued guidelines on managing osteoporosis in men. Published in the June 1, 2012 issue of Journal of Clinical Endocrinology & Metabolism, the guidelines recommend the following: Men at increased risk for osteoporosis should be tested by measurement of bone mineral density (BMD). Men at high risk for osteoporosis should be screened with dual-energy x-ray absorptiometry (DXA). This includes those aged 70 and older and younger men with risk factors. Risk factors for osteoporosis in younger men (aged 50-69) include: – History of fracture after age 50 – low body weight – Diseases such as delayed puberty, hypogonadism, hyperparathyroidism, hyperthyroidism, or COPD – Drugs such as glucocorticoids or GnRH agonists – Life choices such as alcohol abuse or smoking Measure forearm DXA (1/3 or 33% radius) when spine or hip BMD cannot be interpreted and for men with hyperparathyroidism or receiving androgen-deprivation therapy for prostate cancer. FRAX, Garvan, or other fracture risk calculators can improve the assessment of fracture risk and the selection of patients for treatment. Men with low levels of vitamin D (less than 30 ng/mL) should take vitamin D supplements. Those with or at risk for osteoporosis should consume 1,000 to 1,200 mg of calcium every day, ideally from dietary sources. Men aged 50 and older with prior spine or hip fracture, low bone mineral density, or other clinical risk factors (eg, those receiving long-term glucocorticoid therapy in pharmacological doses) should receive drug therapy. Those receiving treatment should have their bone mineral density assessed by DXA at the spine and hip every 1 to 2 years. Pharmacological therapy is recommended for all...

Heart Failure & Osteoporotic Fracture Risk

Canadian research suggests that heart failure (HF) appears to be associated with a 30% increase in major fractures, regardless of patients’ traditional risk factors and bone mineral density levels. Among patients with HF, 10% had incident major fractures, compared with 5% among those without HF.   Abstract: Journal of Clinical Endocrinology & Metabolism, April...
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