Quantitative videographic analysis of intraoperative total shoulder arthroplasty is predictive of radiographic implant loosening

Background

It is believed that both patient and surgeon factors contribute to premature implant loosening. This video study was designed to answer the following questions: Can orthopedic surgeons reliably differentiate between procedures done well and those that will lead to early glenoid failure? Do the difficulty of the operation and the surgeon's performance predict a patient's outcome? Does the presence of a Walch B2 glenoid result in surgery that is evidently more difficult and performed in such a way to suggest early glenoid component failure?

Methods

Eleven upper extremity surgeons blindly graded a set of intraoperative videos of 15 total shoulder arthroplasty patients (grouped by outcome at 2 years). Evaluation questionnaires consisted of questions about the perceived difficulty and the surgeon's performance. Total and partial patient scores were calculated for each video. Higher calculated score would indicate worse postsurgical outcome.

Results

The loosening group had a significantly higher total score (P = .0057). Also, patients with B2 glenoids scored significantly higher than patients with other wear type. The analysis of overall procedure performance indicated difference between outcome groups (P = .0063).

Conclusion

Our results indicate that surgeons could review surgical videos and differentiate the cases that were difficult or those that were more likely to lead to loosening of the glenoid component. The presence of a B2 glenoid was predictive of difficult surgery. The results of this study should serve as a starting point for surgeons interested in critically evaluating performance and also for those interested in finding ways to maximize patient outcomes after total shoulder arthroplasty.

No relationship between mild limb length discrepancy and spine, hip or knee degenerative disease in a large cadaveric collection

BACKGROUND

Although asymptomatic mild limb length discrepancy (LLD) in children is generally treated non-operatively, there is limited high quality follow up data to support this recommendation.

HYPOTHESIS

We hypothesized that there would be no association between LLD and arthritic changes with mild limb length discrepancy.

MATERIALS AND METHODS

We studied 576 well-preserved cadaveric skeletons ranging from 40 to 79 years of age. Limb length discrepancy was based on combined femoral and tibial lengths measured using digital calipers. Degenerative disease was hand graded in the spine, hips and knees using a previously described classification system. Power was set at 90%.

RESULTS

Average age was 56±10 years and average LLD was 4.8±4.0mm. Multiple regression analysis did not demonstrate any correlation between LLD and degenerative disease. After screening to find 26 additional specimens with LLD 10mm or greater, and assessing a potentially quadratic relationship, we still did not find any detrimental effects of LLD.

DISCUSSION

Our data support the general clinical recommendation of observation for mild asymptomatic LLD. These results do not apply to larger LLD nor LLD associated with other deformities or clinical symptoms.

LEVEL OF EVIDENCE

Not applicable, anatomic basic science study.

Bone Graft Augmentation for Severe Glenoid Bone Loss in Primary Reverse Total Shoulder Arthroplasty: Outcomes and Evaluation of Host Bone Contact by 2D-3D Image Registration

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.

The influence of patient- and surgeon-specific factors on operative duration and early postoperative outcomes in shoulder arthroplasty

BACKGROUND

Increased operative duration has been shown to have demonstrable effects on the outcomes and complications in multiple areas of orthopedic surgery. We sought to determine if patient- and surgeon-specific factors correlated to operative duration in shoulder arthroplasty. Our hypothesis was that increased surgeon and trainee volume would decrease operative times and that more complex pathology would increase operative duration.

METHODS

A retrospective review of primary and revision total and reverse shoulder arthroplasties performed at a single institution from 2012 through 2015 was performed evaluating the correlation between specific patient and surgeon factors and operative duration. The influence of operative duration on postoperative length of stay and risk of readmission within 30 days was also analyzed.

RESULTS

For surgeon-specific factors, high surgeon volume (>30 shoulder arthroplasties/year) was associated with shorter operative duration (105.9 vs. 128.3 minutes; P < .001). Progression through the fellowship academic year was found to be associated with decreased surgical times (100.7 vs. 116.5 minutes; P < .0001). Certain complex pathologic processes (reverse shoulder arthroplasty for sequelae of prior fracture, total shoulder arthroplasty for dysplastic glenoid morphology, revision surgery) showed increased operative times. Patients with postoperative readmission had a longer mean operative time (163 vs. 107.1 minutes).

CONCLUSIONS

Increased surgeon and trainee volumes were associated with decreased operative duration in shoulder arthroplasty. Patients with more complex pathology were more likely to have increased surgical times. Postoperative readmission within 30 days was associated with increased operative duration. Consideration of patient selection by surgeons to minimize operative times may reduce readmissions.

Medialized Versus Lateralized Center of Rotation in Reverse Shoulder Arthroplasty

Reverse shoulder arthroplasty may be performed using components that medialize or lateralize the center of rotation. The purpose of this prospective study was to directly compare 2 reverse shoulder arthroplasty designs. Two treatment groups and 1 control group were identified. Group I comprised 9 patients using a medialized Grammont-style (GRM) prosthesis with a neck-shaft angle of 155°. Group II comprised 9 patients using a lateralized (LAT) prosthesis with a neck-shaft angle of 135°. Pre- and postoperative assessment of range of motion, American Shoulder and Elbow Surgeons score, and visual analog scale pain score were performed. Radiographic measurements of lateral humeral offset and acromiohumeral distance were compared. The GRM prosthesis achieved greater forward flexion (143.9° vs 115.6°; P=.05), whereas the LAT achieved greater external rotation (35.0° vs 28.3°; P=.07). The lateral humeral offset was greater for the LAT prosthesis compared with the GRM prosthesis, but this distance was not significantly different from that found in the control group. The acromiohumeral distance was significantly greater in the GRM prosthesis group compared with both the LAT and the control groups. The results of this study confirm that different reverse shoulder arthroplasty designs produce radiographically different anatomy. Whereas the GRM prosthesis significantly alters the anatomy of the shoulder, the LAT design can preserve some anatomic relationships found in the normal shoulder. The clinical outcomes indicate that this may have an effect on range of motion, with traditional designs achieving greater forward flexion and lateralized designs achieving greater external rotation.

Neer Award 2015: A randomized, prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic agent that has been shown to significantly reduce blood loss and transfusion requirements after total knee and hip arthroplasty. The purpose of this study was to evaluate the effect of TXA on postoperative blood loss after shoulder arthroplasty.

METHODS

A total of 111 patients (62 women; average age, 67 years) who underwent shoulder arthroplasty were prospectively randomized in double-blinded fashion to receive either 100 mL of normal saline or 100 mL of normal saline with 2 g TXA by topical application into the wound at the completion of the case. All patients received a postoperative drain. Drain output representing postoperative blood loss, transfusion requirements, and change in hemoglobin level were recorded. All postoperative complications were noted.

RESULTS

The average blood loss recorded after surgery was 170 mL in the placebo group and 108 mL in the TXA group (P = .017). The average change in hemoglobin level was 2.6 g/dL in the placebo group and 1.7 g/dL in the TXA group (P < .001). There were no transfusion requirements or postoperative complications noted in either group.

DISCUSSION

In this cohort of patients, those treated with TXA experienced a significantly lower amount of postoperative blood loss and a significantly smaller change in hemoglobin level compared with those treated with placebo. Further work is required to determine the effectiveness and clinical significance of TXA in reducing transfusion requirements in shoulder arthroplasty and, more specifically, shoulder arthroplasty performed for complicated patients or for trauma and fracture patients.

Patients Undergoing Total Shoulder Arthroplasty on the Dominant Extremity Attain Greater Postoperative ROM

BACKGROUND

Total shoulder arthroplasty (TSA) provides excellent functional outcomes and pain relief in appropriately selected patients. Although it is known to affect other shoulder conditions, the role of hand dominance after TSA has not been reported, to our knowledge.

QUESTIONS/PURPOSES

We asked: (1) Does TSA of the dominant arm result in greater postoperative ROM compared with TSA of the nondominant arm? (2) Does hand dominance affect validated outcome scores after TSA?

METHODS

We performed a review of all patients who underwent primary TSAs between 2008 and 2011 with a minimum of 12 months followup. During that time, one surgeon performed 156 primary TSAs. One hundred twenty-seven patients met the minimum followup requirement for this analysis (81%), whereas 29 (19%) were lost to followup. Seven patients were excluded for surgical indications other than glenohumeral osteoarthritis. A total of 58 patients underwent TSA of the dominant upper extremity and 62 underwent TSA of the nondominant upper extremity. Patient demographics, preoperative and postoperative ROM, and preoperative and postoperative outcome scores, were collected from the medical records. Student's t-tests and chi-square tests were used for analysis. Demographics and preoperative ROM did not differ between patients undergoing TSA on the dominant or the nondominant upper extremity.

RESULTS

Dominant-arm TSAs showed greater postoperative forward elevation and external rotation. Postoperative active forward elevation in the dominant group was 151° versus 141° in the nondominant group (mean difference, 10°; 95% CI, 1°-18°; p = 0.033). Postoperative active external rotation was 61° in the dominant group, versus 51° in the nondominant group (mean difference, 10°; 95% CI, 5°-15°; p < 0.001). Active internal rotation did not differ (dominant, 52°, nondominant, 50°; mean difference, 2°; 95% CI, -3° to 7°; p = 0.419). There were no differences in postoperative VAS (dominant, 0.9, nondominant, 1.4; mean difference, 0.5; 95% CI, -0.1 to 1.1; p = 0.129), simple shoulder test (dominant, 9.8, nondominant, 9.2; mean difference, 0.5; 95% CI, -0.5 to 1.5; p = 0.278), and American Shoulder and Elbow Surgeons scores (dominant, 84, nondominant, 80; mean difference, 4; 95% CI, -2 to 10; p = 0.211).

CONCLUSIONS

Patients who underwent TSA of their dominant upper extremity had greater postoperative active forward elevation and active external rotation compared with patients who had TSA of their nondominant upper extremity. This average difference of 10° active forward elevation and active external rotation could be useful for preoperative and postoperative counseling of patients. Regardless of hand dominance, similar functional outcomes were achieved.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Radiostereometric and Radiographic Analysis of Glenoid Component Motion After Total Shoulder Arthroplasty

Aseptic glenoid component loosening is a common cause of total shoulder arthroplasty (TSA) failure, but early detection is difficult because pain often appears late and radiolucent lines are of uncertain significance. This study sought to answer the following questions: (1) What types of glenoid component motion may be observed during the first 3 years following implantation?; (2) Is the appearance of radiolucent lines around the glenoid component a reliable indicator of component motion?; and (3) Are clinical outcomes correlated with early glenoid component motion within the first 3 years after TSA? Eleven patients (mean age, 60.6 years) underwent TSA using a cemented, all-polyethylene glenoid component with tantalum bead implantation. Clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score, visual analog scale [VAS] pain score, and range of motion) were compared pre- and postoperatively, and radiolucencies were graded according to the criteria of Lazarus et al. Patients were evaluated using radiostereometric analysis at 6 months and 1, 2, and 3 years postoperatively to measure component micromotion in translation and rotation. At a mean follow-up of 50.2 months, mean ASES score had improved from 30.3 to 81.3 (P<.001), mean VAS pain score had improved from 8 to 1 (P<.001), active forward flexion had improved from 109° to 155° (P=.001), active external rotation had improved from 28° to 54° (P=.003), and internal rotation had improved from the level of the sacrum to L3 (P=.002). Radiolucencies were detected around none of the components at 1 year, 6 components at 2 years, and 5 components at 3 years, and these radiolucencies were mostly found around components that experienced high levels of rotational motion.

Important Differences Exist in Posterior Condylar Offsets in an Osteological Collection of 1,058 Femurs

Posterior condylar offset (PCO) has important implications in total knee arthroplasty (TKA) function and design. In an osteological study of 1,058 femurs, we measured PCO using two separate techniques with a 3D digitizer. Measurements were standardized for the size of the femur. The medial PCO was greater than lateral PCO (32.6mm vs. 31.2mm, P<0.0001). In 53% of individuals, the medial PCO differed between sides by more than 2mm. Age did not affect standardized medial or lateral PCO. Compared with African-Americans, Caucasians had a larger standardized medial (1.3mm vs. 1.2mm, P=0.006) and lateral (1.1mm vs. 1.0mm, P=0.004) PCOs. The standardized medial (1.2mm vs. 1.3mm, P=0.073), and lateral (1.1mm vs. 1.1mm, P=0.098), PCO did not differ between men and women, respectively.

Scapular neck length and implications for reverse total shoulder arthroplasty: An anatomic study of 442 cadaveric specimens

Purpose:

Reverse total shoulder arthroplasty (RTSA) may be used to treat a variety of pathologic shoulder conditions, but complications such as scapular notching continue raise concerns. Variable anatomy surrounding the glenoid may have implications for future RTSA design, but at present the anatomy of the scapular neck in the human population has not been clearly defined.

Materials and Methods:

442 human scapulae from the Hamann-Todd Osteological Collection were measured for scapular neck length (SNL) and scapular neck angle (SNA). SNL was defined as the distance from the most lateral portion of the infraglenoid tubercle to the most inferolateral portion of the glenoid fossa. The SNA was measured according to Gerber et al. previously. The mean, standard deviation and ranges for SNL and SNA were calculated and compared based on sex and race, and interobserver variability was calculated.

Results:

The mean SNL was 1.06 cm ± 0.33 cm (0.37-2.43 cm). Males demonstrated a larger SNL (1.08 cm ± 0.33 cm) than females (1.01 cm ± 0.32 cm) (P < 0.12), and Caucasians (1.09 cm ± 0.33 cm) demonstrated a significantly larger SNL than African-Americans (1.00 cm ± 0.32) (P < 0.01). The mean SNA was 106.7° ± 11.0° (76.9-139.4°). No significant correlation was found between SNL and SNA (Pearson Correlation Coefficient = 0.018) (P < 0.702).

Conclusion:

Scapular neck length and SNA vary widely within the population but there appears to be a tendency towards increased SNL in males and Caucasians.

Clinical Relevance:

The anatomy of the scapular neck may have significant implications for RTSA design, surgical planning, and reduction of associated complications.

Tendinopathy of the long head of the biceps tendon: histopathologic analysis of the extra-articular biceps tendon and tenosynovium

BACKGROUND

Bicipital tendinitis is a common cause of anterior shoulder pain, but there is no evidence that acute inflammation of the extra-articular long head of the biceps (LHB) tendon is the root cause of this condition. We evaluated the histologic findings of the extra-articular portion of the LHB tendon and synovial sheath in order to compare those findings to known histologic changes seen in other tendinopathies.

METHODS

Twenty-six consecutive patients (mean age 45.4±13.7 years) underwent an open subpectoral biceps tenodesis for anterior shoulder pain localized to the bicipital groove. Excised tendons were sent for histologic analysis. Specimens were graded using a semiquantitative scoring system to evaluate tenocyte morphology, the presence of ground substance, collagen bundle characteristics, and vascular changes.

RESULTS

Chronic inflammation was noted in only two of 26 specimens, and no specimen demonstrated acute inflammation. Tenocyte enlargement and proliferation, characterized by increased roundness and size of the cell and nucleus with proteoglycan matrix expansion and myxoid degenerative changes, was found in all 26 specimens. Abundant ground substance, collagen bundle changes, and increased vascularization were visualized in all samples.

CONCLUSION

Anterior shoulder pain attributed to the biceps tendon does not appear to be due to an inflammatory process in most cases. The histologic findings of the extra-articular portion of the LHB tendon and synovial sheath are similar to the pathologic findings in de Quervain tenosynovitis at the wrist, and may be due to a chronic degenerative process similar to this and other tendinopathies of the body.

Acromial stress fractures: correlation with acromioclavicular osteoarthritis and acromiohumeral distance

Fractures around the acromion are a known complication of reverse total shoulder arthroplasty. The literature provides limited data on the risk factors associated with this complication as well as the ultimate outcomes after nonoperative treatment. The goal of this study was to report clinical outcomes in patients with acromial fractures after nonoperatively treated reverse total shoulder arthroplasty. The authors performed a retrospective review of 125 patients undergoing reverse total shoulder arthroplasty that included several acromial stress fractures in the postoperative period. They prospectively compared radiographic data, including acromiohumeral distance, the presence of acromioclavicular joint arthritis, clinical measures of motion, visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, and Single Assessment Numeric Evaluation (SANE) score, in 2 groups based on the presence or absence of fracture in the postoperative period. Fourteen patients (11.2%) had an acromial fracture after reverse total shoulder arthroplasty at an average of 5.1 months postoperatively. Patients who had fractures had worse postoperative forward elevation before fracture (116.6 vs 143.5; P=.02) and greater pain relief after reverse shoulder replacement, before fracture (P=.04). No significant difference was found between groups when the degree of arm lengthening was compared (27.6 vs 26.2 mm), and no difference was found in the prevalence of degenerative acromioclavicular joint changes identified preoperatively (66.4% vs 77.3%). After conservative management, most patients who had an acromial fracture returned to a functional level that was comparable to that achieved before fracture.

Correlation of pelvic incidence with cam and pincer lesions

BACKGROUND

The sacropelvic parameter of pelvic incidence (PI) is a position-independent anatomic parameter that regulates lumbar lordosis and pelvic orientation. While it has been extensively studied in relation to spine pathology, only a single study has correlated PI with femoroacetabular impingement (FAI).

HYPOTHESIS

Decreased PI would be associated with an increased prevalence of cam and pincer lesions.

STUDY DESIGN

Controlled laboratory study.

METHODS

Measurements of the acetabulum, proximal femur, and sacropelvis were made bilaterally on 40 cadaveric specimens, for a total of 80 hips. Twenty specimens had the presence of bilateral cam deformities (alpha angle >55°), and 20 age- and sex-matched specimens had bilateral normal hips. Pincer lesions were defined as an anteversion <15°. Pelvic incidence and acetabular version were measured using standardized lateral photographs and a goniometer, respectively. Independent-samples t tests were performed to evaluate for differences in measured parameters between groups.

RESULTS

The mean PI was 43.1° ± 8.6° for hips with a cam lesion and 47.7° ± 9.3° for normal hips, demonstrating a significant association between decreased PI and the presence of a cam lesion (P = .02). The mean version of acetabula with pincer lesions (n = 28) was 11.4° ± 2.5°, and the mean version of normal acetabula (n = 52) was 20.1° ± 3.8°. The mean PI of hips with pincer lesions was 42.5° ± 8.5°, significantly less than that of normal hips, 47.0° ± 9.2° (P = .04).

CONCLUSION

This study supports a recent study that suggested patients with pincer impingement have a smaller PI than the healthy population, and it is the first to demonstrate a significant association between decreased PI and cam-type femoral deformity. Based on results of this study, further clinical study of the effects of pelvic geometry on FAI is warranted.

CLINICAL RELEVANCE

While the study results do not prove a causal relationship, it is theorized that the restriction of range of motion and biomechanical adaptations of the pelvis around the hip joints resulting from a smaller PI may affect hip development and FAI. The influence of mechanical factors beyond the hip joint in the development of FAI should be considered by clinicians.

Biologic resurfacing of the glenoid with humeral head resurfacing for glenohumeral arthritis in the young patient

BACKGROUND

Resurfacing of the glenoid with an interposition soft tissue graft in conjunction with humeral head arthroplasty has been proposed as an option to improve glenohumeral arthritis in young patients while avoiding the potential complications associated with total shoulder arthroplasty. There currently exist minimal outcomes data for this procedure, and the results have not been consistent. The purpose of this study was to report on the outcomes in our cohort of patients aged younger than 55 years.

METHODS

A multicenter review of 16 patients who had undergone humeral head arthroplasty with soft tissue interposition grafting of the glenoid was performed. All patients had a minimum follow-up time of 24 months, unless revision surgery was required because of failure of the procedure.

RESULTS

At a mean follow-up of 60 months, the patients showed improvement in the visual analog scale score for pain from 8.1 to 5.8 (P < .05), and the American Shoulder and Elbow Surgeons score improved from 23.2 to 57.7 (P < .05). Forward elevation improved from 128° to 134° (P = .33), and external rotation improved from 28° to 32° (P = .5). Internal rotation showed no improvement. Conversion to a total shoulder arthroplasty was performed in 7 patients (44%) at a mean of 36 months.

CONCLUSIONS

The optimal management for the young patient with arthritis has not yet been established. Because of the limited improvement in patient outcomes and the relatively high revision rate, biologic resurfacing of the glenoid with humeral head resurfacing is no longer our primary treatment option for young patients and should be used with caution.

Diagnostic accuracy in detecting tears in the proximal biceps tendon using standard nonenhancing shoulder MRI

BACKGROUND

There is a paucity of data in the literature evaluating the performance of noncontrast MRI in the diagnosis of partial and complete tears of the proximal portion of the long head of the biceps (LHB) tendon. The objective of this study was to evaluate the accuracy of noncontrast magnetic resonance imaging (MRI) compared to arthroscopy for the diagnosis of pathology involving the intra-articular portion of the LHB tendon.

METHODS

We conducted a retrospective review of 66 patients (mean age 57.8 years, range 43-70 years) who underwent shoulder arthroscopy and evaluation of the LHB tendon after having had a noncontrast MRI of the shoulder. Biceps pathology was classified by both MRI and direct arthroscopic visualization as either normal, partial tearing, or complete rupture, and arthroscopy was considered to be the gold standard. We then determined the sensitivity, specificity, and positive- and negative-predictive values of MRI for the detection of partial and complete LHB tears.

RESULTS

MRI identified 29/66 (43.9%) of patients as having a pathologic lesion of the LHB tendon (19 partial and ten complete tears) while diagnostic arthroscopy identified tears in 59/66 patients (89.4%; 50 partial and 16 complete). The sensitivity and specificity of MRI for detecting partial tearing of the LHB were 27.7% and 84.2%, respectively (positive predictive value =81.2%, negative predictive value =32.0%). The sensitivity and specificity of MRI for complete tears of the LHB were 56.3% and 98.0%, respectively (positive predictive value =90.0%, negative predictive value =87.5%).

CONCLUSION

Standard noncontrast MRI of the shoulder is limited in detecting partial tears and complete ruptures of the intra-articular LHB tendon. Surgeons may encounter pathologic lesions of the LHB tendon during arthroscopy that are not visualized on preoperative MRI.

Early follow-up of reverse total shoulder arthroplasty in patients sixty years of age or younger

BACKGROUND

Reverse shoulder arthroplasty (RSA) is an accepted treatment that provides reproducible results in the treatment of shoulder arthritis and rotator cuff deficiency. Concerns over the longevity of the prosthesis have resulted in this procedure being reserved for the elderly. There are limited data in the literature with regard to outcomes in younger patients. We report on the early outcomes of RSA in a group of patients who were sixty years or younger and who were followed for a minimum of two years.

METHODS

A retrospective multicenter review of sixty-six patients (sixty-seven RSAs) with a mean age of 52.2 years was performed. The indications included rotator cuff insufficiency (twenty-nine), massive rotator cuff disorder with osteoarthritis (eleven), failed primary shoulder arthroplasty (nine), rheumatoid arthritis (six), posttraumatic arthritis (four), and other diagnoses (eight). Forty-five shoulders (67%) had at least one prior surgical intervention, and thirty-one shoulders (46%) had multiple prior surgical procedures.

RESULTS

At a mean follow-up time of 36.5 months, mean active forward elevation of the arm as measured at the shoulder improved from 54.6° to 134.0° and average active external rotation improved from 10.0° to 19.6°. A total of 81% of patients were either very satisfied or satisfied. The mean American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) score for pain improved from 40.0 to 72.4 and 7.5 to 3.0, respectively. The ability to achieve postoperative forward arm elevation of at least 100° was the only significant predictor of overall patient satisfaction (p < 0.05) that was identified in this group. There was a 15% complication rate postoperatively, and twenty-nine shoulders (43%) had evidence of scapular notching at the time of the latest follow-up.

CONCLUSIONS

RSA as a reconstructive procedure improved function at the time of short-term follow-up in our young patients with glenohumeral arthritis and rotator cuff deficiency. Objective outcomes in our patient cohort were similar to those in previously reported studies. However, overall satisfaction was much lower in this patient population (81%) compared with that in the older patient population as reported in the literature (90% to 96%).

Orthopaedic surgeons frequently underestimate the cost of orthopaedic implants

BACKGROUND

A poor understanding of cost among healthcare providers may contribute to high healthcare expenditures. Currently, it is unclear whether and how much surgeons know about the costs of implantable medical devices (IMDs).

QUESTIONS/PURPOSES

We (1) determined the level of comfort with orthopaedic IMD costs among orthopaedic residents and attending surgeons, (2) quantified how accurately surgeons understand the costs of orthopaedic IMDs, and (3) identified which constructs yield the most accurate cost estimations among residents and attending surgeons.

METHODS

A questionnaire was presented to 60 residents and 37 attending orthopaedic surgeons from two large academic medical centers. Respondents estimated the cost of 13 commonly used orthopaedic devices. Fifty-one surgeons participated (36 residents, 15 attending surgeons), for an overall response rate of 53%. Cost estimates were compared against the actual material costs, and we recorded the percentage error for each estimate.

RESULTS

More than ½ of the respondents rated their knowledge of IMD cost as poor. The mean percentage error in estimation for all respondents was 69% (range, 29%-289%). Overall, 67% of responses were underestimations and 33% were overestimations. Residents demonstrated a mean percentage error of 73% (range, 29%-289%) while attending surgeons had a mean percentage error of 59% (range, 49%-79%). Residents and attending surgeons demonstrated differences in accuracy within groups and between groups based on the IMD being estimated.

CONCLUSIONS

We found the knowledge of orthopaedic IMD costs among the orthopaedic residents and attending surgeons surveyed was poor. Further investigation of how physicians conceptualize material costs will be important to healthcare cost control.

The shape of the proximal femur influences acetabular wear patterns over time

BACKGROUND

Femoroacetabular impingement has been proposed as a cause of early osteoarthritis, but it is not known how this develops over time or whether the shape of the proximal femur influences this risk.

QUESTIONS/PURPOSES

(1) Which areas of the acetabulum are worn more frequently by individuals with a cam deformity of the proximal femur? (2) Do observed acetabular wear patterns differ based on the etiology of the cam deformity? (3) Do wear patterns of individuals with a cam deformity differ based on an individual's age?

METHODS

We examined 645 corresponding femora and acetabuli from the Hamann-Todd Osteological Collection and determined the offset and alpha angle using photographs; 370 specimens met inclusion criteria and were examined for signs of wear and the locations of wear were recorded. Specimens were separated into eight subgroups based on age either younger than 40 years or older than 60 years, alpha angle greater or less than 55°, and degree of anterior head-neck offset. We compared the prevalence of wear between groups in each location.

RESULTS

Individuals with abnormal geometry of the proximal femur demonstrated different wear patterns from individuals with normal geometry. There were few differences in wear patterns identified based on the etiology of the femoral deformity. Abnormal femoral geometry was associated with more frequent wear primarily at the anterosuperior acetabulum for individuals younger than 40 years of age and globally for individuals older than 60 years of age.

CONCLUSION

Femoral geometry appears to influence the pattern of acetabular wear occurring over time.

Resection arthroplasty for failed shoulder arthroplasty

BACKGROUND

As shoulder arthroplasty becomes more common, the number of failed arthroplasties requiring revision is expected to increase. When revision arthroplasty is not feasible, resection arthroplasty has been used in an attempt to restore function and relieve pain. Although outcomes data for resection arthroplasty exist, studies comparing the outcomes after the removal of different primary shoulder arthroplasties have been limited.

MATERIALS AND METHODS

This was a retrospective multicenter review of 26 patients who underwent resection arthroplasty for failure of a primary arthroplasty at a mean follow-up of 41.8 months (range, 12-130 months). Resection arthroplasty was performed for 6 failed total shoulder arthroplasties (TSAs), 7 failed hemiarthroplasties, and 13 failed reverse TSAs.

RESULTS

Patients who underwent resection arthroplasty demonstrated significant improvement in visual analog scale pain score (6 ± 4 preoperatively to 3 ± 2 postoperatively). Mean active forward flexion and mean active external rotation decreased, but this difference was not significant. Subgroup analysis revealed that postoperative mean active forward flexion was significantly greater in patients undergoing resection arthroplasty after failed TSA than after reverse TSA (P = .01).

CONCLUSIONS

Resection arthroplasty is effective in relieving pain, but patients have poor postoperative function. Patients with resection arthroplasty for failed reverse shoulder arthroplasty have worse function than those with failed hemiarthroplasty or TSA. Surgeons should be aware of this when assessing postoperative function. There is no difference in functional outcome between hemiarthroplasty and TSA.

Pectoralis major tendon transfer for the treatment of scapular winging due to long thoracic nerve palsy

BACKGROUND

Painful scapular winging due to chronic long thoracic nerve (LTN) palsy is a relatively rare disorder that can be difficult to treat. Pectoralis major tendon (PMT) transfer has been shown to be effective in relieving pain, improving cosmesis, and restoring function. However, the available body of literature consists of few, small-cohort studies, and more outcomes data are needed.

MATERIALS AND METHODS

Outcomes of 26 consecutive patients with electromyelogram-confirmed LTN palsy who underwent direct (n = 4) or indirect transfer (n = 22) of the PMT for dynamic stabilization of the scapula were reviewed. All patients were followed up clinically for an average of 21.8 months (range, 3-62 months) with evaluations of active forward flexion, active external rotation, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and observation of scapular winging.

RESULTS

Preoperative to postoperative results included increases in the mean active forward flexion from 112° to 149° (P < .001) an in mean active external rotation from 53.8° to 62.8° (P = .045), an improvement in the mean ASES score from 28 to 67.0 (P < .001), and an improvement in the mean VAS pain score from 7.7 to 3.0 (P < .001). Recurrent scapular winging occurred in 5 patients. There was no difference in outcome by length of follow-up.

CONCLUSIONS

PMT transfer is an effective treatment for painful scapular winging resulting from LTN palsy. This is the largest reported series of consecutive patients treated with PMT transfer for the correction of scapular winging.

All-arthroscopic biologic total shoulder resurfacing

The treatment of advanced, bipolar glenohumeral osteoarthritis in the young patient is particularly challenging because of the expected failure of a traditional shoulder arthroplasty within the patient's lifetime. We have had early success performing osteochondral allograft resurfacing of the humeral head articular surface and glenoid articular surface, and we describe a new all-arthroscopic technique for performing this procedure. In the context of our new procedure, we have reviewed the available literature on the topic of biologic resurfacing with osteochondral allograft and have provided an overview of the relevant findings. Although only short-term follow-up data are available, our results in young patients have been promising in terms of regained motion, minimal pain, and accelerated rehabilitation. We believe that this new arthroscopic biologic shoulder resurfacing technique has the potential to be superior to other available treatments for this patient population because it preserves bone stock, limits damage to surrounding structures, and allows for early rehabilitation. Although longer-term follow-up is needed, early results have been greatly encouraging.