Bradford O. Parsons

Transfusion after shoulder arthroplasty: An analysis of rates and risk factors

HYPOTHESIS Advancing age, lower preoperative hemoglobin levels, and more complex procedures are risk factors in transfusion requirements following shoulder arthroplasty. MATERIALS AND METHODS We retrospectively reviewed the records of 196 consecutive shoulder arthroplasties performed by a single surgeon (including 113 primary noncomplex total shoulder arthroplasties, 27 primary noncomplex hemiarthroplasties, 37 revision or complex arthroplasties, and 19 reverse shoulder arthroplasties). Logistic regression analysis was used to determine which clinical variables were associated with the need for postoperative transfusion. RESULTS The overall transfusion rate was 43% (84/196). The presence of preoperative anemia (males <13 g/dl, females <12 g/dl), decreasing preoperative hemoglobin levels, female gender, increasing age, and implantation of a reverse shoulder arthroplasty were independent risk factors for postoperative transfusion. Operative time, estimated blood loss, anesthesia type, preoperative use of anticoagulants and body mass index (BMI) were not found to be predictive of transfusion. DISCUSSION Our results corroborate the few existing studies regarding the effects of lower preoperative hemoglobin levels on transfusion risk following shoulder arthroplasty. In contrast to these studies, however, we found increasing age and the implantation of a reverse shoulder arthroplasty to be independent predictors for transfusion. CONCLUSION The results of the present study support close postoperative monitoring of older, female patients (>65 years), patients with preoperative anemia (males <13 g/dl, females <12 g/dl), and those undergoing reverse shoulder replacement. These patients should be educated before surgery of the potential need for postoperative blood transfusion. LEVEL OF EVIDENCE Level 4; Retrospective case series, no control group.

Arthroscopically-assisted treatment of pediatric lateral humeral condyle fractures.

Background: Pediatric lateral humeral condyle fractures are common injuries. Current treatment recommendations include nonoperative treatment for nondisplaced Milch type 1 fractures; however, truly nondisplaced fractures may be rare. Although closed reduction and percutaneous pinning under arthrographic visualization are most commonly used, anatomical reconstitution of the articular surface may require a lateral Kocher approach. This approach may compromise the vascularity of the distal fragment. To avoid this catastrophic complication while still obtaining anatomical articular surface reduction, we have investigated a new technique in which the lateral condyle fracture is reduced arthroscopically, allowing visualization of the articular surface without the soft tissue dissection required with open approaches. The fracture is then percutaneously pinned and immobilized as previously recommended. Methods: Six skeletally immature patients with lateral humeral condyle fractures underwent arthroscopic reduction and percutaneous pinning. The mean age of the patients was 48 months (range, 21-69 months). There were 2 girls and 4 boys. Surgery was performed on 4 left and 2 right elbows. The mean follow-up was 32 weeks (range, 21-44 weeks). Postoperatively, all patients were placed in a long arm cast for 4 weeks. Pins and casts were removed at 4 weeks, and motion was begun. Elbow radiographs were evaluated for fracture healing, articular congruity, malunion, growth disturbance, and presence of avascular necrosis. Range of motion, function, pain, and cosmetic deformity were recorded. Results: All patients had full active and passive range of motion. There was no difference in range of motion compared with the contralateral side (P < 0.05). All fractures healed radiographically by 4 weeks. There were no cases of nonunion or malunion. No patients developed cubitus varus. One patient developed radiolucency of the capitellum. There were no other complications. Conclusions: Arthroscopic reduction and percutaneous fixation of pediatric lateral humeral condyle fractures may offer a safe and effective alternative to open treatment with decreased soft tissue stripping and a possibly decreased risk of malunion or avascular necrosis. Level of Evidence: Level IV.

Reliability and reproducibility of radiographs of greater tuberosity displacement. A cadaveric study.

BACKGROUND Classification of fractures of the greater tuberosity has shown poor reliability, in part as a result of an inability to assess fracture displacement accurately. We used fluoroscopic images of prepositioned osteotomized greater tuberosity fragments in cadavers to determine the accuracy of radiographic interpretation, the interobserver reliability, and the effect that radiographs might have on surgical decision-making. METHODS Twelve osteotomies of the greater tuberosity (three each with 2, 5, 10, and 15 mm of displacement) were created in whole-body cadavers. Six fluoroscopic images (anteroposterior views in external and internal rotation, anteroposterior views in neutral rotation with 15 degrees of cephalic and 15 degrees of caudal tilt, a lateral outlet view, and an axillary view) were made after each osteotomy. Four experienced orthopaedic surgeons measured displacement in millimeters on seventy-two randomized images. Four views in sequence (the anteroposterior view in internal rotation and the outlet view together, then the axillary view, and then the anteroposterior view in external rotation) of each osteotomy pattern were then viewed, and each surgeon was asked whether surgery would be indicated on the basis of each set of images. RESULTS No one fluoroscopic view was significantly more accurate than another. There was a trend toward increased accuracy of imaging of minimally displaced (</=5 mm) tuberosity fragments with the anteroposterior view in external rotation. When viewed sequentially, the anteroposterior view in external rotation, evaluated last, altered treatment in nine of forty-eight situations. There was substantial agreement (kappa = 0.71) among the surgeons with respect to their recommendations for treatment of the displaced greater tuberosities after they had inspected the four images. CONCLUSIONS AND CLINICAL RELEVANCE To our knowledge, we are the first to examine the accuracy and reliability of interpreting images of known displacements of the greater tuberosity. Multiple radiographic views are needed to evaluate displacement of the greater tuberosity appropriately. The anteroposterior view in external rotation can profile the greater tuberosity and help demonstrate small displacements. Treatment decisions should be consistent between surgeons when multiple views are used.

Intermediate Outcomes Following Percutaneous Fixation of Proximal Humeral Fractures

BACKGROUND Mini-open reduction and percutaneous fixation of proximal humeral fractures historically results in good outcomes and a low prevalence of osteonecrosis reported with short-term follow-up. The purpose of this study was to determine the midterm results of our multicenter case series of proximal humeral fractures treated with percutaneous fixation. METHODS Between 1999 and 2006, thirty-nine patients were treated with percutaneous reduction and fixation for proximal humeral fractures at three tertiary shoulder referral centers. Twenty-seven of these patients were available for intermediate follow-up at a minimum of three years (mean, eighty-four months; range, thirty-seven to 128 months) after surgery; the follow-up examination included use of subjective outcome measures and radiographic analysis to identify osteonecrosis and posttraumatic osteoarthritis on radiographs. RESULTS Osteonecrosis was detected in seven (26%) of the total group of twenty-seven patients at a mean of fifty months (range, eleven to 101 months) after the date of percutaneous fixation. Osteonecrosis was observed in five (50%) of the ten patients who had four-part fractures, two (17%) of the twelve patients who had three-part fractures, and none (0%) of the five patients who had two-part fractures. Posttraumatic osteoarthritis, including osteonecrosis, was present on radiographs in ten (37%) of the total group of twenty-seven patients. Posttraumatic osteoarthritis was observed in six (60%) of the ten patients who had four-part fractures, four (33%) of the twelve patients who had three-part fractures, and none (0%) of the five patients who had two-part fractures. CONCLUSIONS Intermediate follow-up of patients with percutaneously treated proximal humeral fractures demonstrates an increased prevalence of osteonecrosis and posttraumatic osteoarthritis over time, with some patients with these complications presenting as late as eight years postoperatively. Development of osteonecrosis did not have a universally negative impact on subjective outcome scores.

What's new in shoulder and elbow surgery.

This annual update on shoulder and elbow surgery is based on a review of presentations at meetings of the Arthroscopy Association of North America (Specialty Day, March 25, 2006, Chicago, Illinois; Twenty-fifth Annual Meeting, May 18 to 21, 2006, Hollywood, Florida), the American Shoulder and Elbow Surgeons (Twenty-second Open Meeting, Specialty Day, March 25, 2006, Chicago, Illinois; Twenty-third Closed Meeting, September 13 to 15, 2006, Chicago, Illinois), The American Orthopaedic Society for Sports Medicine (Specialty Day, March 25, 2006, Chicago, Illinois), the American Academy of Orthopaedic Surgeons (Seventy-third Annual Meeting, March 22 to 25, 2006, Chicago, Illinois), and the Orthopaedic Research Society (Fifty-second Annual Meeting, March 19 to 22, 2006, Chicago, Illinois). ### Rotator Cuff #### Basic Science Park proposed a transosseous equivalent rotator cuff repair technique and performed a biomechanical study to evaluate footprint contact pressure in a variety of repair configurations. A “suture-bridging” technique utilizing medial anchors with suture limbs traversing over the cuff to a lateral interference screw attachment was compared with a double-row anchor repair. A four-limb suture bridge (two medial anchors with four limbs over the cuff laterally) established a significantly higher mean contact pressure area (72.3%) compared with a two-limb suture bridge (57.3%) and a double-row repair (35.1%) (p < 0.05). The authors concluded that increasing footprint contact pressure may aid in rotator cuff healing. #### Impingement Milano investigated the influence of acromioplasty on outcome following arthroscopic rotator cuff repair. Eighty patients were prospectively randomized into two groups, with half undergoing rotator cuff repair with acromioplasty and half undergoing rotator cuff repair without acromioplasty. The outcome measures that were evaluated were the Constant score and the Quick-DASH and Work-DASH self-administered questionnaires. Comparison between the two groups failed to demonstrate a significant difference at two years of follow-up. The authors concluded that acromioplasty does not affect the outcome of arthroscopic rotator cuff repair. …

Hemiarthroplasty versus reverse shoulder arthroplasty for treatment of proximal humeral fractures: a meta-analysis

BACKGROUND We performed a meta-analysis of studies with at least Level IV evidence to compare outcomes between hemiarthroplasty and reverse shoulder arthroplasty for the treatment of proximal humeral fractures. METHODS Three electronic databases (PubMed, Cochrane, and EMBASE) were searched. The quality of each study was investigated, and data on radiographic and functional outcomes were extracted and analyzed. RESULTS The analysis included 1 Level I study, 1 Level II study, 3 Level III studies, and 2 Level IV studies. Reverse shoulder arthroplasty was more favorable than hemiarthroplasty in forward elevation (P < .001), abduction (P < .001), tuberosity healing (P = .002), Constant score (P < .001), American Shoulder and Elbow Surgeons score (P < .001), and Disabilities of the Arm, Shoulder and Hand score (P = .001). Only external rotation (P = .85) was not in favor of reverse shoulder arthroplasty. CONCLUSIONS The available literature suggests that reverse shoulder arthroplasty performed to address complex proximal humeral fractures might result in more favorable clinical outcomes than hemiarthroplasty performed for the same indication.

Early clinical results following staged bilateral primary total shoulder arthroplasty

BACKGROUND The advantages of performing either a single- or 2-staged joint replacement has been reviewed extensively in the hip and knee arthroplasty literature, but far less data exist regarding total shoulder replacements. In the appropriate clinical setting, bilateral total shoulder arthroplasty yields excellent functional results with a low complication profile. MATERIALS AND METHODS We evaluated retrospectively the records of 13 consecutive patients (26 shoulders) who underwent staged bilateral primary total shoulder replacements by a single surgeon, with a minimum follow-up of 12 months for each side (range, 12.0-61.5). The interval between replacements averaged 7.4 months (range, 0.5-26.0). RESULTS The mean unadjusted baseline Constant score for the first versus the second side was not significant (35 vs 41, P = .3). These scores improved to 73 and 72 by final follow-up (both P < .0001). Mean pain scores on the visual analog scale (VAS) improved from 6.9 to 0.9 (P < .0001). We found no difference in the estimated blood loss (EBL), operative time, or hospital length of stay (LOS) between the sides. Significantly higher mean scores were demonstrated in all components of the SF-36 questionnaire over a normalized cohort of U.S. age-matched males and females by final follow-up. All patients were satisfied with both procedures. CONCLUSION Staged, bilateral total shoulder arthroplasty results in excellent functional outcomes and high satisfaction in subjective patient assessment. We currently recommend a minimum of 6 weeks between replacements to allow for appropriate tissue healing and rehabilitation. LEVEL OF EVIDENCE 4.

Heterotopic ossification formation after fracture-dislocations of the elbow.

BACKGROUND Heterotopic ossification (HO) is a serious complication of traumatic elbow injuries, particularly fracture-dislocations. Limited data exist in the literature regarding the risk factors associated with HO formation in these injuries. The purpose of this study was to review the incidence of HO after fracture-dislocation of the elbow and to identify potential risk factors associated with its formation. METHODS Twenty-seven patients (28 elbows) were surgically treated for elbow fracture-dislocations during 8 years, with an average follow-up of 14 months. Records were reviewed with attention paid to several factors: demographic data, comorbidities, time interval from injury to surgical intervention, number of closed reductions attempted before surgery, surgical approach, management of the radial head, treatment of the anterior capsular injury, and coronoid fixation. RESULTS Of the 28 elbows, 12 (43%) developed HO postoperatively; 9 of 28 elbows underwent multiple attempted closed reductions before definitive surgical stabilization, with HO formation in 7 of the 9 (77%). Time to surgery, age, gender, radial head fixation or replacement, coronoid open reduction and internal fixation, capsular repair, and medical comorbidities were not found to influence HO formation, although the performance of multiple reductions was identified as a risk factor. DISCUSSION HO developed in 77% of patients with multiple attempted closed reductions. We found a 43% incidence of HO in patients surgically treated for elbow fracture-dislocations. Neither time to surgery after the injury nor demographic or other factors relating to the manner in which associated osseous or soft tissue injuries were managed influenced the formation of HO.

Acute elbow dislocations in athletes.

Elbow dislocation in the athletic population is not an uncommon injury. The literature does not clearly establish treatment guidelines, with treatment being extrapolated from the experience in the general population. A short period of immobilization with early range of motion exercises limits disability and allows return to sports participation within 6 weeks.

Arthroscopic Management of Elbow Fractures.

Several types of elbow fractures are amenable to arthroscopic or arthroscopic-assisted fracture fixation, including fractures of the coronoid, radial head, lateral condyle, and capitellum. Other posttraumatic conditions may be treated arthroscopically, such as arthrofibrosis or delayed radial head excision. Arthroscopy can be used for assessment of stability or intra-articular fracture displacement. The safest portals are the midlateral (soft spot portal), proximal anteromedial, and proximal anterolateral. Although circumstances may vary according to the injury pattern, a proximal anteromedial portal is usually established first. Arthroscopy enables a less invasive surgical exposure that facilitates visualization of the fracture fragments in select scenarios.