Adam P. Schumaier

Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient

Introduction: Proximal humerus fractures are common in the elderly. The evaluation and management of these injuries is often controversial. The purpose of this study is to review recent evidence and provide updated recommendations for treating proximal humerus fractures in the elderly. Methods: A literature review of peer-reviewed publications related to the evaluation and management of proximal humerus fractures in the elderly was performed. There was a focus on randomized controlled trials and systematic reviews published within the last 5 years. Results: The incidence of proximal humerus fractures is increasing. It is a common osteoporotic fracture. Bone density is a predictor of reduction quality and can be readily assessed with anteroposterior views of the shoulder. Social independence is a predictor of outcome, whereas age is not. Many fractures are minimally displaced and respond acceptably to nonoperative management. Displaced and severe fractures are most frequently treated operatively with intramedullary nails, locking plates, percutaneous techniques, or arthroplasty. Discussion: Evidence from randomized controlled trials and systematic reviews is insufficient to recommend a treatment; however, most techniques have acceptable or good outcomes. Evaluation should include an assessment of the patient’s bone quality, social independence, and surgical risk factors. With internal fixation, special attention should be paid to medial comminution, varus angulation, and restoration of the calcar. With arthroplasty, attention should be paid to anatomic restoration of the tuberosities and proper placement of the prosthesis. Conclusion: A majority of minimally displaced fractures can be treated conservatively with early physical therapy. Treatment for displaced fractures should consider the patient’s level of independence, bone quality, and surgical risk factors. Fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options. There is no clear evidence-based treatment of choice, and the surgeon should consider their comfort level with various procedures during the decision-making process.

Correlation of Patient-Reported Outcome Measurement Information System Physical Function Upper Extremity Computer Adaptive Testing, With the American Shoulder and Elbow Surgeons Shoulder Assessment Form and Simple Shoulder Test in Patients With Shoulder Pain

PURPOSEnTo evaluate the Patient-Reported Outcome Measurement Information System Physical Function Upper Extremity Computer Adaptive Testing (PROMIS PFUE CAT) measurement tool against the already validated American Shoulder and Elbow Surgeons Shoulder Assessment Form (ASES) and the Simple Shoulder Test (SST) in patients presenting with shoulder pain and determine the responder burden for each of the 3 surveys.nnnMETHODSnNinety patients presenting with shoulder pain were asked to fill out the ASES, SST, and PROMIS PFUE CAT. The time for completion of each survey was measured to determine responder burden, and the Pearson correlation between the 3 instruments was defined as excellent (r > 0.7), excellent-good (0.61 ≤ r ≤ 0.7), good (0.31 ≤ r ≤ 0.6), and poor (0.2 ≤ r ≤ 0.3).nnnRESULTSnThe PROMIS PFUE CAT showed an excellent correlation with the SST (rxa0= 0.82, P < .001) and ASES (rxa0= 0.72, Pxa0<xa0.001). The average time to complete SST, ASES, and PROMIS PFUE CAT was 92.8 ± 35.8, 142.3 ± 60.1, and 61.3xa0±xa028.8xa0seconds, respectively. The time to complete the PROMIS PFUE CAT was significantly less than both the SST (Pxa0<xa0.001) and ASES (P < .001).nnnCONCLUSIONSnThe PROMIS PFUE CAT showed an excellent correlation with the previously validated ASES and SST in patients with shoulder pain. The time saving of the PROMIS PFUE CAT was found to be smaller than that of the ASES and SST but shows that moving forward, using the PROMIS PFUE CAT would not place any additional burden on the patient filling out the survey. The lack of ceiling or floor effects with the PROMIS PFUE CAT indicates its ability to differentiate both high and low functioning patients. All of these findings indicate that the PROMIS PFUE CAT is an adequate tool for the evaluation of patients with shoulder pain and should be used in these patients going forward.nnnLEVEL OF EVIDENCEnLevel II, diagnostic study.

Arthroscopic Management of SLAP Lesions With Concomitant Spinoglenoid Notch Ganglion Cysts: A Systematic Review Comparing Repair Alone to Repair With Decompression

PURPOSEnTo determine if cyst management is necessary in the setting of SLAP lesions with concomitant paralabral ganglion cysts.nnnMETHODSnWe performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, including all studies that met inclusion criteria from January 1975 to July 2015. We included patients with a SLAP II-VII lesion and a concomitant paralabral ganglion cyst who underwent arthroscopic labral repair with or without cyst decompression. Patients with follow-up of less than 3xa0months, a SLAP I lesion, or who underwent concomitant cuff repair were excluded. The Methodological Index for Non-randomized Studies (MINORS) scoring system was used to quantify the potential bias in each study. Outcome measures reported were provided in a table format and a subjective analysis was performed.nnnRESULTSnNineteen studies were included yielding a total of 160 patients: 66 patients treated with repair alone [R] and 94 patients with additional cyst decompression or excision [R+D]. The VAS, Rowe, and Constant scores were excellent and similar in both groups. The mean VAS was 0.6 in [R] and ranged between 0 and 2 in [R+D] (0.5, 0, 2, 0.2). The mean Rowe scores were 94xa0and 98 in [R] and 95 in [R+D]. The mean Constant scores were 97 in [R] and ranged between 87 and 98 in [R+D] (98, 87, 92, 94). In total, 5 of 90 patients were unable to return to work and 2 of 45 were unable to return to sport. All 15 patients who had follow-up electromyographies displayed resolution, and in the 115 patients with follow-up MRIs, 12 did not have complete resolution of the cyst.nnnCONCLUSIONSnDespite the lack of high-quality evidence, the studies subjectively analyzed in this review suggest that both groups have excellent results. The results do not show any advantages from performing decompression.nnnLEVEL OF EVIDENCEnLevel IV, systematic review of Level II and Level IV studies.

Management of Cervical Instability as a Complication of Neurofibromatosis Type 1 in Children: A Historical Perspective With a 40-Year Experience

STUDY DESIGNnLiterature review with supplementary case examples.nnnOBJECTIVESnThe objective of this article was to review neurofibromatosis type 1 (NF1) and the associated spinal pathology with a focus on the disorders manifestations in the immature cervical spine. NF1 is one of the most common inheritable genetic disorders. The disorder is associated with spinal deformities, long bone dysplasia, and osteoporosis. The manifestations of NF1 in the cervical spine commonly include instability secondary to kyphosis, neurofibromas, and dural ectasia.nnnMETHODSnLiterature relevant to the evaluation and management of NF1 in the cervical spine was reviewed using the PubMed/NCBI database with a focus on recent clinical studies. The review was supplemented with a historical perspective and patient cases.nnnRESULTSnThe prevalence of NF1 cervical spine lesions is difficult to define because many patients may be asymptomatic. Symptoms of cervical kyphosis can include pain or nerve deficits but some have a surprisingly high tolerance for deformity and may have frank dislocation of one vertebral body over another (spondyloptosis) with few associated symptoms. Cervical radiographs should be obtained in patients requiring traction, surgery, or intubation, and those with neck pain or symptoms that suggest spinal neurofibromas. Patients with progressive symptoms should be offered surgery. Careful planning is required because many patients will have small, dysplastic vertebral bodies, thin posterior elements, plexiform neurofibromas, or dural ectasia. The decision to use preoperative traction will vary from patient to patient. Combined anterior-posterior fusion is recommended for most cases of severe symptomatic kyphosis, and the fusion should extend from parallel to parallel vertebrae (or six or more levels). Anterior or posterior fusion alone may be an alternative for skeletally mature patients with smaller, flexible curves.nnnCONCLUSIONSnSpinal deformity is the most common musculoskeletal manifestation of NF1. Cervical lesions are frequently asymptomatic, but patients with thoracolumbar scoliosis, dystrophic features, or a history of laminectomy should have the cervical spine carefully evaluated. For severe and progressive kyphotic deformities, most authors recommend a period of traction followed by a combined anterior-posterior fusion that is instrumented from parallel to parallel vertebra (or six or more levels). Close follow-up is very important because complications and progression are frequent.STUDY DESIGNnLiterature review with supplementary case examples.nnnOBJECTIVESnThe objective of this article was to review neurofibromatosis type 1 (NF1) and the associated spinal pathology with a focus on the disorders manifestations in the immature cervical spine.nnnSUMMARY OF BACKGROUND DATAnNF1 is one of the most common inheritable genetic disorders. The disorder is associated with spinal deformities, long bone dysplasia, and osteoporosis. The manifestations of NF1 in the cervical spine commonly include instability secondary to kyphosis, neurofibromas, and dural ectasia.nnnMETHODSnLiterature relevant to the evaluation and management of NF1 in the cervical spine was reviewed using the PubMed/NCBI database with a focus on recent clinical studies. The review was supplemented with a historical perspective and patient cases.nnnRESULTSnThe prevalence of NF1 cervical spine lesions is difficult to define because many patients may be asymptomatic. Symptoms of cervical kyphosis can include pain or nerve deficits but some have a surprisingly high tolerance for deformity and may have frank dislocation of one vertebral body over another (spondyloptosis) with few associated symptoms. Cervical radiographs should be obtained in patients requiring traction, surgery, or intubation, and those with neck pain or symptoms that suggest spinal neurofibromas. Patients with progressive symptoms should be offered surgery. Careful planning is required because many patients will have small, dysplastic vertebral bodies, thin posterior elements, plexiform neurofibromas, or dural ectasia. The decision to use preoperative traction will vary from patient to patient. Combined anterior-posterior fusion is recommended for most cases of severe symptomatic kyphosis, and the fusion should extend from parallel to parallel vertebrae (or six or more levels). Anterior or posterior fusion alone may be an alternative for skeletally mature patients with smaller, flexible curves.nnnCONCLUSIONSnSpinal deformity is the most common musculoskeletal manifestation of NF1. Cervical lesions are frequently asymptomatic, but patients with thoracolumbar scoliosis, dystrophic features, or a history of laminectomy should have the cervical spine carefully evaluated. For severe and progressive kyphotic deformities, most authors recommend a period of traction followed by a combined anterior-posterior fusion that is instrumented from parallel to parallel vertebra (or six or more levels). Close follow-up is very important because complications and progression are frequent.

Treatments of Choice for Isolated, Full-Thickness Tears of the Posterior Cruciate Ligament: A Nationwide Survey of Orthopaedic Surgeons

The ideal treatment for isolated, full-thickness tears of the posterior cruciate ligament (PCL) is uncertain. The purpose of this study was to determine how the majority of orthopaedic surgeons treat isolated, full-thickness tears of the PCL. In July 2017, a 17-question multiple-choice survey regarding the treatment of isolated, full-thickness tears of the PCL was emailed to 3,500 orthopaedic sports medicine surgeons with membership in the American Orthopaedic Society for Sports Medicine. Responders answered multiple-choice questions related to indications, technique, graft choice, bracing, and weight-bearing status following reconstruction. Answer choices were then analyzed against surgeon-specific variables. The survey was completed by 663 orthopaedic surgeons. Of the responders, 93% were fellowship trained in sports medicine with an average practice duration of 13 years. The total number of PCLs reconstructed per surgeon was low, 11.6. On average, surgeons estimate they reconstruct the PCL in only 22% of patients with full-thickness tears. The two most common surgical indications were functional limitations and failure of physical therapy. The reconstruction of choice involves a transtibial approach (63%) with a single bundle (87%) allograft (83%) of the Achilles tendon (51%). The postoperative brace is typically locked in extension (66%), and weight-bearing is delayed for 3.8 weeks. Of the surgeons with the fewest years of experience, 39% use all-inside, 89% use allograft, and 24% use dynamic bracing. Compared with surgeons with the most years of experience, only 16% use all-inside (pu2009<u20090.01), 57% use allograft (pu2009<u20090.01), and 11% use dynamic bracing (pu2009=u20090.01). Isolated, full-thickness tears of the PCL are rare injuries that are infrequently reconstructed. The most common indications for reconstruction are functional limitations and failure of conservative management. Most surgeons treatment of choice for reconstruction involves a transtibial approach with a single bundle Achilles allograft and a postoperative brace locked in extension. On average, weight-bearing is prolonged for 3.8 weeks. The all-inside technique, allograft, and dynamic bracing are becoming more popular.

Readability assessment of American Shoulder and Elbow Surgeons patient brochures with suggestions for improvement

Background Many Americans have limited literacy skills, and the National Institutes of Health (NIH) suggests patient educational material be written below the 8th grade level. Many orthopedic organizations provide print material for patients, but whether these documents are written at an appropriate reading level is not clear. This study assessed the readability of patient education brochures provided by the American Shoulder and Elbow Surgeons (ASES). Materials and Methods In May 2017, 6 ASES patient education brochures were analyzed using readability software. The reading level was calculated for each brochure using 9 different tests. The mean reading level for each article was compared with the NIH-recommended 8th grade level using 2-tailed, 1-sample t tests assuming unequal variances. Results For each of the 9 tests, the mean reading level was higher than the NIH-recommended 8th grade (test, grade level): Automated Readability Index, 14.1 (Pu2009<u2009.05); Coleman-Liau, 14.2 (Pu2009<u2009.05); New Dale-Chall, 13.2 (Pu2009<u2009.05); Flesch-Kincaid, 13.7 (Pu2009<u2009.05); FORCAST, 11.8 (Pu2009<u2009.05); Fry, 15.8 (Pu2009<u2009.05); Gunning Fog, 16.5 (Pu2009<u2009.05); Raygor Estimate, 15.4 (Pu2009<u2009.05); and Simple Measure of Gobbledygook (SMOG), 15.1 (Pu2009<u2009.05). Conclusions The ASES patient education brochures are written well above the NIH-recommended 8th grade reading level. These findings are similar to other investigations concerning orthopedic patient education material. Supplementary brochures and websites could be a useful source of information, particularly for patients who are deterred from asking questions in the office. Printed material designed for patient education should be edited to a more reasonable reading level. Further review of patient education materials is warranted.

Terminal position of a tibial intramedullary nail: a computed tomography (CT) based study

PurposeThe purpose of this study is to characterize the distal anatomic end-point of a tibial intramedullary nail placed using modern surgical techniques. The goal is to improve reduction of distal tibia fractures.MethodsAn intramedullary nail was placed in 14 skeletally mature legs. This included 8 patients with mid-shaft tibial fractures and 6 intact cadaveric legs. Each nail was a titanium cannulated tibial nail, size 10- or 11-mm. The nails were placed using a suprapatellar or transpatellar approach with an ideal starting point. All legs received post-nail insertion CT scans and fluoroscopy. The main outcome measure was the terminal location of the nail just proximal to the distal tibial physeal scar, as seen on axial CT and fluoroscopic views of the ankle (mortise and lateral). The end-point was measured as the (1) ratio of medial–lateral tibial width (ML ratio) and (2) ratio of anterior–posterior tibial width (AP ratio). Two-tailed Welch’s t tests were used to compare the actual, observed position of the nail to the hypothesized center–center position (H0u2009=u2009ML and AP ratio of 0.5).ResultsAll enrolled patients (nu2009=u20098) and cadaveric legs were included (nu2009=u20096). On axial CT, the average distance from the medial tibial cortex to the nail center as a ratio of medial–lateral tibial width was 0.63, 95% CI 0.60–0.67, pu2009<u20090.001 (Patientu2009=u20090.60, 95% CI 0.55–0.64, pu2009=u20090.001) (Cadaveru2009=u20090.68, 95% CI 0.64–0.73, pu2009<u20090.001). On fluoroscopic mortise views, the distance from the medial cortex to the nail center as ratio of medial–lateral tibial width was 0.64, 95% CI 0.60–0.67, pu2009<u20090.001 (Patientu2009=u20090.61, 95% CI 0.56–0.65, pu2009<u20090.001) (Cadaveru2009=u20090.67, 95% CI 0.63–0.72, pu2009<u20090.001). The AP ratio was not significantly different from 0.5 on either axial CT or fluoroscopic mortise views (pu2009>u20090.05).ConclusionThe distal end-point of a tibial intramedullary nail is lateral (ML plane) and center (AP plane) in both cadaveric legs and patients with midshaft tibia fractures. These results suggest that the treatment of distal tibia fractures with intramedullary nails may be improved by positioning the nail slightly lateral in the distal segment.Level of evidenceDiagnostic level I.

Type 2 retear after arthroscopic single-row, double-row and suture bridge rotator cuff repair: a systematic review

Aim/PurposeTo provide a systematic review of the literature on patterns of retear after single-row (SR), double-row (DR) and suture bridge (SB) techniques.MethodsThe PubMed and MEDLINE databases were searched for published articles reporting both repair technique and retear pattern. Studies in languages other than English, those reporting open rotator cuff repair as the index procedure, as well as animal and cadaveric studies and those which did not describe patterns of retear, were excluded. MINORS scoring system was used to quantify potential bias in each study. Retears were classified into type 1 (failure at the tendon–bone interface) and type 2 (medial cuff failure). For all studies included, number and type of retears after different repair techniques were reported and analyzed.ResultsFourteen studies were included yielding a total of 260 rotator cuff retears. Repair technique had a significant impact on the estimated incidence rate of type 2 retear (pxa0=xa0.001). The estimated incidence rate of type 2 retear was 24% with SR (95% CI 14–38%), 43% with DR (95% CI 22–66%), 62% with SB (95% CI 54–70%) and 38% with SB (95% CI 23–57%).ConclusionDespite the lack of high-quality evidence, this study suggests that DR and SB techniques increase the risk of medial cuff failure. Modifications in surgical techniques in both DR and SB repairs can help decrease that risk.Level of evidenceLevel IV, systematic review of investigations including level IV.

Spondylocostal Dysostosis: A Literature Review and Case Report with Long-Term Follow-Up of a Conservatively Managed Patient

Introduction Patients with spondylocostal dysostosis (SCD) have congenital spine and rib deformities associated with frequently severe thoracic insufficiency and respiratory compromise. The literature is largely composed of case reports and small cohorts, and there is little information regarding adults with this condition. In this report, we describe the natural history of a conservatively treated patient and include quality-of-life issues such as childbearing, athletic participation, and occupational selection. Case Presentation We present a patient with SCD who was conservatively treated by a single physician from birth for 31 years. Our patient was capable of a reasonably good quality of life through adulthood, including participation in gymnastics and employment. At age 18, she became pregnant and subsequently terminated the pregnancy due to obstetrical concerns for compromised respiration. She has had intermittent respiratory complaints and occasionally experiences dyspnea with exertion, but this only has limited her during certain activities in the past three years. Currently, she takes naproxen for chronic back pain with periodic exacerbations. Discussion Other cases in the literature have described adult SCD patients who have received nonoperative treatment and achieved a wide range of functional outcomes. This provides some limited evidence to suggest that select patients with SCD may be treated conservatively and achieve a reasonable quality of life. However, close clinical follow-up with these patients is recommended, particularly early on, considering the high rates of infant morbidity and mortality. Chest physiotherapy and early pulmonary care have been associated with favorable outcomes in infancy. Surgery to increase thoracic volume and correct scoliosis has been shown in some cases to improve respiratory function. Treatment depends on the degree of thoracic insufficiency and quality of life. The natural history of SCD remains largely unknown, but some patients are capable of relatively favorable life spans, employment, and participation in athletics.

Long-Term Follow-Up of Adamantinoma of the Tibia Complicated by Metastases and a Second Unrelated Primary Cancer: A Case Report and Literature Review

Adamantinoma is a rare, low-grade malignant tumor of the bone which grows slowly and typically occurs in the diaphysis of long bones, particularly in the tibia. Adamantinomas have the potential for local recurrence and may metastasize to the lungs, lymph nodes, or bone. We report a case of a 14-year-old female with a tibial adamantinoma who underwent wide resection with limb salvage and has subsequently been followed up for 18 years. The patient went on to have both a local soft tissue recurrence 5 years after the resection and metastases to both an inguinal lymph node and the right lower lobe of the lung 8 years after that recurrence, all of which have been treated successfully with marginal resections. Unique to this case, the patient was also incidentally found to have chromophobe-type renal cell carcinoma when undergoing a partial nephrectomy to resect a presumed metastasis of her adamantinoma. Genetic testing has not revealed any known genetic predisposition to cancer.