Anastasios Papadonikolakis

Avoiding Catastrophic Complications of Stroke and Death Related to Shoulder Surgery in the Sitting Position

The beach-chair position in shoulder surgery provides advantages to the surgeon and anesthesiologist. However, cautious interpretation of the patients blood pressure is essential, especially when the blood pressure cuff is placed at the calf. The calf pressure should be interpreted relative to the heart-level pressure to avoid iatrogenic cerebral hypoperfusion related to hypotensive anesthesia. Possible complications of cerebral hypoperfusion are permanent neurologic impairment, stroke, and death.

Failure of the glenoid component in anatomic total shoulder arthroplasty: a systematic review of the English-language literature between 2006 and 2012.

BACKGROUND Although glenoid component failure is one of the most common complications of anatomic total shoulder arthroplasty, substantial evidence from the recent published literature is lacking regarding the temporal trend in the rate of this complication and the risk factors for its occurrence. METHODS We conducted a systematic review and identified twenty-seven articles presenting data on glenoid component failure rates that met the inclusion criteria. These articles represented data from 3853 total shoulder arthroplasties performed from 1976 to 2007. RESULTS Asymptomatic radiolucent lines occurred at a rate of 7.3% per year after the primary shoulder replacement. Symptomatic glenoid loosening occurred at 1.2% per year, and surgical revision occurred at 0.8% per year. There was no significant evidence that the rate of symptomatic loosening has diminished over time. Keeled components had greater rates of asymptomatic radiolucent lines compared with pegged components in side-by-side comparison studies. However, as a result of wide variability in outcomes reporting, only sex, Walch class, and diagnosis were significantly associated with the risk of glenoid component failure in the overall analysis. CONCLUSIONS This is the first systematic review of the published evidence on glenoid component failure. Although the authors of individual articles proposed various risk factors for glenoid component failure, many of these relationships were not significant in the present study. A consistent methodological approach to future investigations is likely to improve the quality of the evidence on which patients, techniques, and prostheses are selected for total shoulder arthroplasty.

Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder

BACKGROUND Acromioplasty for impingement syndrome of the shoulder is one of the most common orthopaedic surgical procedures. The rate with which this procedure is performed has increased dramatically. This investigation sought high levels of evidence in the published literature related to five hypotheses pertinent to the concept of the impingement syndrome and the rationale supporting acromioplasty in its treatment. METHODS We conducted a systematic review of articles relevant to the following hypotheses: (1) clinical signs and tests can reliably differentiate the so-called impingement syndrome from other conditions, (2) clinically common forms of rotator cuff abnormality are caused by contact with the coracoacromial arch, (3) contact between the coracoacromial arch and the rotator cuff does not occur in normal shoulders, (4) spurs seen on the anterior aspect of the acromion extend beyond the coracoacromial ligament and encroach on the underlying rotator cuff, and (5) successful treatment of the impingement syndrome requires surgical alteration of the acromion and/or coracoacromial arch. Three of the authors independently reviewed each article and determined the type of study, the level of evidence, and whether it supported the concept of the impingement syndrome. Articles with level-III or IV evidence were excluded from the final analysis. RESULTS These hypotheses were not supported by high levels of evidence. CONCLUSIONS The concept of impingement syndrome was originally introduced to cover the full range of rotator cuff disorders, as it was recognized that rotator cuff tendinosis, partial tears, and complete tears could not be reliably differentiated by clinical signs alone. The current availability of sonography, magnetic resonance imaging, and arthroscopy now enable these conditions to be accurately differentiated. Nonoperative and operative treatments are currently being used for the different rotator cuff abnormalities. Future clinical investigations can now focus on the indications for and the outcome of treatments for the specific rotator cuff diagnoses. It may be time to replace the nonspecific diagnosis of so-called impingement syndrome by using modern methods to differentiate tendinosis, partial tears, and complete tears of the rotator cuff.

Published Evidence Demonstrating the Causation of Glenohumeral Chondrolysis by Postoperative Infusion of Local Anesthetic Via a Pain Pump

BACKGROUND Glenohumeral chondrolysis is the irreversible destruction of previously normal articular cartilage, occurring most commonly after shoulder surgery in young individuals. The reported incidence of this complication has risen rapidly since the early 2000s. As chondrolysis cannot be reversed, its occurrence can only be prevented by establishing and avoiding its causes. METHODS We analyzed all published cases of glenohumeral chondrolysis, including the relevant published laboratory data, to consolidate the available evidence on the causation of this complication by the postoperative intra-articular infusion of local anesthetic via a pain pump. RESULTS Analysis of the published evidence demonstrated a causal relationship between the infusion of local anesthetic and the development of glenohumeral chondrolysis. The risk of this complication in shoulders receiving intra-articular infusions via a pain pump was significantly greater with higher doses of local anesthetic: twenty of forty-eight shoulders receiving high-flow infusions developed chondrolysis, whereas only two of twenty-five shoulders receiving low-flow infusions developed this complication (p = 0.0029). Eleven of twenty-two shoulders receiving 0.5% bupivacaine developed chondrolysis, whereas none of six shoulders receiving 0.25% bupivacaine developed this complication (p = 0.05). Of twenty-two shoulders infused with 0.5% bupivacaine, the eleven that developed chondrolysis had a mean pain pump delivery volume of 377 mL, whereas the eleven that did not develop chondrolysis had a mean volume of 187 mL (p = 0.003). Among shoulders in which an intra-articular pain pump was used, the risk of chondrolysis was significantly greater when suture anchors were placed in the glenoid for labral repair (p < 0.001). CONCLUSIONS The published evidence indicates that the preponderance of cases of glenohumeral chondrolysis can be prevented by the avoidance of the intra-articular infusion of local anesthetic via a pain pump.

Reconstruction of Essex-Lopresti Injury of the Forearm: Technical Note

Longitudinal instability of the forearm resulting from an Essex-Lopresti injury is a surgical challenge, and no technique has yet met universal success. A new technique is presented here consisting of reconstruction of the radial head, leveling of the distal radioulnar joint, reconstruction of the central band of the interosseous membrane by using a pronator teres rerouting technique, and finally repair of the triangular fibrocartilage complex. It is hoped that by addressing all of the contributing longitudinal stabilizing structures, the longitudinal instability of the forearm will be controlled. The technique is challenging and requires much surgical experience.

Release of the medial collateral ligament to improve flexion in post-traumatic elbow stiffness

Contracture of the collateral ligaments is considered to be an important factor in post-traumatic stiffness of the elbow. We reviewed the results of isolated release of the medial collateral ligament in a series of 14 patients with post-traumatic loss of elbow flexion treated between 1998 and 2002. There were nine women and five men with a mean age of 45 years (17 to 76). They were reviewed at a mean follow-up of 25 months (9 to 48). The operation was performed through a longitudinal posteromedial incision centred over the ulnar nerve. After decompression of the ulnar nerve, release of the medial collateral ligament was done sequentially starting with the posterior bundle and the transverse component of the ligament, with measurement of the arc of movement after each step. If full flexion was not achieved the posterior half of the anterior bundle of the medial collateral ligament was released. At the latest follow-up, the mean flexion of the elbow improved significantly from 96 degrees (85 degrees to 115 degrees ) pre-operatively to 130 degrees (110 degrees to 150 degrees ) at final follow-up (p = 0.001). The mean extension improved significantly from 43 degrees (5 degrees to 90 degrees ) pre-operatively to 22 degrees (5 degrees to 40 degrees ) at final follow-up (p = 0.003). There was a significant improvement in the functional outcome. The mean Broberg and Morrey score increased from a mean of 54 points (29.5 to 85) pre-operatively to 87 points (57 to 99) at final follow-up (p < 0.001). All the patients had normal elbow stability. Our results indicate that partial surgical release of the medial collateral ligament is associated with improved range of movement of the elbow in patients with post-traumatic stiffness, but was less effective in controlling pain.

Metal-backed Glenoid Components Have a Higher Rate of Failure and Fail by Different Modes in Comparison with All-polyethylene Components: A Systematic Review

BACKGROUND Glenoid component failure is a common and serious complication of total shoulder arthroplasty. The purpose of this study was to evaluate published evidence on whether metal backing lessens the rate of glenoid component failure. METHODS A comprehensive systematic review yielded twenty-one studies on radiolucency, radiographic failure, and revision after arthroplasty with metal-backed glenoid components and twenty-three studies with all-polyethylene components. Our analysis included data on 1571 metal-backed and 3035 all-polyethylene components. The mean duration of follow-up was 5.8 years in the studies with metal-backed components and 7.3 years with all-polyethylene components. RESULTS All-polyethylene components had a 42.5% rate of radiolucency compared with 34.9% for metal-backed components (p = 0.0026) and a 21.1% rate of radiographic loosening or failure compared with 16.8% for metal-backed components (p = 0.0005). However, the rate of revision was more than three times higher with metal-backed components (14.0%) than with all-polyethylene components (3.8%, p < 0.0001). Although 77% of the revisions of all-polyethylene components were for loosening, 62% of the revisions of metal-backed components were for other reasons, such as component fracture, screw breakage, component dissociation, polyethylene wear, metal wear, and rotator cuff tear (p < 0.0001). CONCLUSIONS The published evidence indicates that metal-backed glenoid components require revision at a significantly higher rate and for different reasons in comparison with all-polyethylene components. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary fibular and impaction allografting in revision total elbow arthroplasty with endosteal deficiency.

One of the many reasons for failed revision elbow replacement is loss of the normally irregular shape of the endosteal surface leading to reduced ability to provide rotational control of the humeral or ulnar component within the intramedullary canal. The endosteal bone loss of the distal humerus or proximal ulna compromises the rotational stability of the stem in the intramedullary canal. In these cases, impaction cancellous allografting techniques, similar to the ones used in revision total hip arthroplasties, are commonly used to address the osseous deficiency, but these methods are not optimal for providing rotational control of the prosthetic stem. We describe a technique of restoring the irregular shape of the endosteal bone using intramedullary fibular allografting to enhance the rotational control of the prosthetic stem within the intramedullary bone canal.

Arthroscopic Reduction and Fixation of Transverse Intra-articular Glenoid Fractures With Scapular Extension

The most common procedure to address transverse glenoid fractures that are characterized by intra-articular step-off or gapping is open reduction and internal fixation. Disadvantages of open surgery are delay in regaining full range of motion, increased approach morbidity, neurovascular complications, and the need for capsulotomy, which delays healing and increases the risk of stiffness. An arthroscopically assisted fracture fixation, as described in this article, is characterized by better visualization of the glenoid articular surface and reduction of the intra-articular fragments under direct vision, which diminishes the chances of residual step-off after fixation. Furthermore, arthroscopic fixation provides the advantages of minimal surgical trauma, which speeds up the recovery time, decreased morbidity as there is less blood loss compared with the open technique, lower chance of neurologic injury as there is less dissection around the spinoglenoid or suprascapular notch, less trauma to the joint capsule, and lower chances of stiffness and capsulorrhaphy arthropathy.

Arthroscopic debridement for osteochondral injury of the elbow trochlea: A case report with a long-term follow-up

Q1 Osteochondral injury of the elbow is a rare lesion of the articular surface of the immature joint. A number of cases involving the humeral trochlea of adolescent throwing athletes have been reported in the English-language literature. 6 In the last decade, elbow arthroscopy has evolved to become an accepted technique for the treatment of elbow osteochondral lesions. 8 This is the first report in the literature of the use of arthroscopic debridement for the treatment of a rare osteochondral defect located to the humeral trochlea. Case report A right handedominant 15-year-old female athlete presented with complaints of left elbow pain and limited range of motion (ROM). There was no precedent history of elbow trauma. The patient was a competitive athlete in basketball and swimming. The initial examination by a local orthopaedic surgeon showed a minor elbow extension loss, and an initial diagnosis of triceps tendinitis was made. The diagnosis was based on normal elbow radiographs and a clinical finding of tenderness at the triceps insertion. The orthopaedic surgeon recommended rest and prescribed nonsteroidal anti-inflammatory drugs. However, during the course of the subsequent year, the patient remained active in sporting activities. Despite conservative measures, elbow pain and stiffness persisted, and the athlete was referred to our institution for further evaluation. According to her report, the duration of her symptoms was 1 year. Subsequent physical examination showed limited left elbow ROM from e35 ! of extension to 140 ! of flexion, with full forearm pronation and supination. There was no evidence of elbow swelling or instability. Plain radiographs of the left elbow were again normal (Fig. 1). However, magnetic resonance imaging (MRI) showed a high-signal focus on the posterior-superior surface of the humeral trochlea. The radiologic finding was consistent with an osteochondral lesion. Adjacent to the lesion, another high-signal focus indicated posterior synovial hypertrophy. The triceps tendon itself appeared normal (Fig. 2). On the basis of worsening symptoms, progressive loss of ROM, and MRI findings, a decision for surgical management was made. Q2