Bradley Schoch

Optimizing follow-up after anatomic total shoulder arthroplasty

BACKGROUNDnWith increases in both total shoulder arthroplasty (TSA) volumes and patient life expectancies, the number of patients requiring follow-up after shoulder arthroplasty continues to grow exponentially. The purpose of this study is to establish a data-based follow-up schedule minimizing unnecessary patient and health care system costs without sacrificing patient care.nnnMETHODSnBetween January 1975 and January 2013, 2786 consecutive anatomic TSAs were performed at our institution. All shoulders undergoing reoperation/revision were reviewed to identify the common modes of failure and times to failure.nnnRESULTSnA total of 208 shoulders (7.5%) required reoperation. Early failure mechanisms included instability, rotator cuff tears, and infection, with 63% of these reoperations occurring within 2 years. Later failures included mechanical failures (including component loosening) and periprosthetic fractures, with no identifiable peak occurrence. After 2 years, TSA failed at an average rate 1.1% per year.nnnCONCLUSIONSnTSA failure after 2 years is uncommon and triggers surgical intervention in approximately 1% of patients per year. Routine in-person surveillance of all patients on a scheduled basis may not be necessary and would increase patient and other health care costs. We recommend in-person visits to assess healing, direct rehabilitation, and manage soft tissue or infectious issues until 2 years, with planned, periodic patient contact by mail and radiographic evaluation of patients with poor or worsening outcomes thereafter, unless patient concerns arise or a newer implant design warrants closer clinical assessment.

Revisions for aseptic glenoid component loosening after anatomic shoulder arthroplasty

BACKGROUNDnGlenoid component loosening is a common indication for revision shoulder arthroplasty. The objective of this study is to assess the longer-term outcomes of patients undergoing revision specifically for aseptic loosening.nnnMATERIALS AND METHODSnBetween 1985 and 2005, 34 revision shoulder arthroplasties were performed for aseptic glenoid loosening. Three patients were lost to follow-up. Treatment included component reimplantation in 20 shoulders (group I) or component removal with bone grafting in 11 shoulders (group II). We identified 9 cases of instability with or without rotator cuff tearing prior to revision. The mean follow-up period was 8.3 years.nnnRESULTSnThe rate of survival free of reoperation at 10 years was 78.9% in group I and 83.9% in group II (Pu2009=u2009.5). Pain relief occurred in 26 of 31 shoulders, with no difference between groups (Pu2009>u2009.99). Active elevation and external rotation improved in both groups (Pu2009=u2009.8). Five shoulders in group I had radiographically loose glenoids, with two requiring reoperation. Nine shoulders in group II had medial glenoid erosion, with two requiring reoperation for pain. There was a trend toward reoperation in those with preoperative instability (5 of 8 re-revisions).nnnDISCUSSION AND CONCLUSIONnGlenoid revision surgery in the absence of infection provides satisfactory results, especially when instability is not coexisting. When glenoid bone stock permits, reimplantation of a new glenoid component in an active patient with an intact rotator cuff and no instability is reasonable. When the remaining glenoid bone will not support a new component, conversion to a hemiarthroplasty is also reasonable.

Humeral shaft fractures: national trends in management

BackgroundThe incidence of humeral shaft fractures has been increasing over time. This represents a growing public health concern in a climate of cost containment. The purpose of this study is to analyze national trends in surgical management of humeral shaft fractures and determine factors predictive of surgical intervention.Materials and methodsHumeral shaft fractures were identified by the International Classification of Diseases, Ninth Revision, Clinical Modification codes 812.21 and 812.31 in the United States Nationwide Inpatient Sample from 2002 to 2011. Open reduction and internal fixation (ORIF) was identified by code 79.31 (ORIF, humerus). Other case codes analyzed were 79.01 (closed reduction without internal fixation), 79.11 (closed reduction with internal fixation), and 79.21 (open reduction without internal fixation). Multivariate regression analysis was utilized to determine predictive factors for utilization of ORIF.Results27,908 humeral shaft fractures were identified. Utilization of ORIF increased from 47.2% of humeral shaft fractures in 2002 to 60.3% in 2011. Demographically, patients who underwent ORIF were younger (51.5 versus 59.7xa0years, pxa0<xa00.001; odds ratio 0.87 per decade of age). There were modest increases in ORIF usage with private insurance, open fracture, and hospital size, which persisted with multivariate regression analysis. Surprisingly, there was a tendency to shift from a slight increase in ORIF for males with the bivariate case to a slight preference for females in the multivariate case.ConclusionUtilization of ORIF for humeral shaft fractures has been steadily increasing with time. Surgical intervention was more common with younger patients, female gender, private insurance, and larger hospital size. The increasing incidence of surgical management for humeral shaft fractures may represent a public health burden given the historical success of non-operative management.Level of evidenceIV.

Subtotal Scapulectomy With Scapulothoracic Fusion and Local Tendon Transfer for Management of Chondrosarcoma.

Scapulectomy can dramatically alter glenohumeral function and the ability of patients to conduct activities of daily living. In oncologic cases, treatment of the tumor can compromise local musculature, making successful reconstruction difficult to achieve. Depending on the resection level, local musculature may be inadequate to restore shoulder range of motion and/or glenohumeral stability. Surgeons have attempted to address these issues via soft-tissue repairs, allograft replacement, and prosthetic replacement, with variable success. Outcomes are better when a greater portion of the scapula is preserved, thus saving functional rotator cuff muscle bellies. However, preservation of significant rotator cuff musculature is not routinely possible. To our knowledge, no authors in the English-language orthopaedic literature have reported on local tendon transfers as a technique to augment and reconstruct the rotator cuff in a patient with previous scapulectomy.

Orthopedic complications of linear morphea: Implications for early interdisciplinary care

Linear morphea of the limb primarily affects children, and extracutaneous manifestations are common. Orthopedic surgeons are often essential in the care of patients with linear morphea, yet there are few reports outlining specific orthopedic complications in this population. We sought to improve the understanding of orthopedic complications in linear morphea of the limb. Between 1999 and 2014, 51 children were evaluated for linear morphea of an extremity. Twenty‐six (51%) had documented orthopedic manifestations. Outcome measures included limb length discrepancy, angular malalignment, limb atrophy, and orthopedic surgical intervention. Joint contractures were most common, affecting 88% of patients, followed by limb atrophy, angular deformity, and limb length discrepancy; 14% required surgical intervention. Despite the use of systemic immunosuppressive therapy in many patients, approximately half of patients with linear morphea of an extremity have orthopedic disease. Early orthopedist involvement is crucial to improve limb alignment and preserve function.

Total elbow arthroplasty for primary osteoarthritis

BACKGROUNDnPrimary osteoarthritis of the elbow is a less common indication for total elbow arthroplasty (TEA). Higher complication rates in younger, active patients may offset short-term improvements in pain and function. The purpose of this study was to determine pain relief, functional outcomes, complications, and survival of TEA in this population.nnnMETHODSnBetween 1984 and 2011, 20 consecutive TEAs were performed for primary elbow osteoarthritis. Two patients died before the 2-year follow-up. Mean age at surgery was 68 years (range, 51-85 years). Outcome measures included pain, motion, Mayo Elbow Performance Score, satisfaction, complications, and reoperations. Mean follow-up was 8.9 years (range, 2-20 years).nnnRESULTSnThree elbows sustained mechanical failures. Complications included intraoperative fracture (n = 2), wound irrigation and débridement (n = 1), bony ankylosis (n = 1), humeral loosening (n = 1), humeral component fracture (n = 1), and mechanical failure of a radial head component (n = 1). Fifteen elbows without mechanical failure were examined clinically. Pain improved from 3.6 to 1.5 (Pu2009<u2009.001). Range of motion remained clinically unchanged (Pu2009>u2009.05), with preoperative flexion contractures not improving. Mayo Elbow Performance Scores were available for 13 elbows without mechanical failure, averaging 81.5 points (range, 60-100 points); these were graded as excellent (n = 5), good (n = 2), and fair (n = 6). Subjectively, all patients without mechanical failure were satisfied.nnnCONCLUSIONnTEA represents a reliable surgical option for pain relief in patients with primary osteoarthritis. However, restoration of extension is not always obtained, indicating that more aggressive soft tissue releases or bony resection should be considered. Complications occurred in a large number of elbows, but mechanical failure was low considering the nature of this population and the length of follow-up.

Managing Glenoid Bone Deficiency—The Augment Experience in Anatomic and Reverse Shoulder Arthroplasty

Glenoid bone deficiency in the setting of shoulder replacement surgery is far more common than originally reported. The frequency and severity of the glenoid defects are noted to be more common and severe with the advent of computer-assisted surgery. The results of an anatomic total shoulder arthroplasty (aTSA) with glenoid deficiency have been reported to be inferior to aTSA patients without a glenoid deficiency. Options for treating the glenoid deficiency include eccentric reaming, bone grafting, and the use of augmented glenoid components. The purpose of this article is to present the indications, technique, and results of augmented glenoids for both aTSA and reverse TSA (RTSA). Augments for both aTSA and RTSA are viable options. They preserve subchondral bone at the same time as optimizing the joint line without the need for bone grafts. Complications, revisions and results are as good as compared to shoulder arthroplasties without glenoid wear.

Hemiarthroplasty Is an Option for Patients Older Than 70 Years With Glenohumeral Osteoarthritis

Hemiarthroplasty (HA) of the shoulder has several potential advantages over total shoulder arthroplasty (TSA), particularly in the elderly population. This study reviewed long-term results of HA and TSA in patients older than 70 years with glenohumeral osteoarthritis. During a 30-year period, 403 shoulders had undergone HA (n=74) or TSA (n=329) for glenohumeral osteoarthritis. Outcome measures included pain, range of motion, and postoperative modified Neer ratings. All patients were included in the mortality and revision analyses. A total of 289 shoulders (44 HAs and 245 TSAs; mean patient age, 75 years) with a minimum of 5 years of follow-up or follow-up until revision were included. Both groups showed significant improvements in pain, abduction, and external rotation. No significant differences were detected between groups in postoperative pain, range of motion, or modified Neer ratings. Operative time was significantly lower in the HA group. There was no statistically significant difference detected in implant revision-free survival between TSA and HA (hazard ratio, 3.09) or in overall survival hazard ratio. At long-term follow-up, both HAs and TSAs provided good function in the elderly population. Patients who underwent TSA and patients who underwent HA had similar results, but the latter had a shorter operative time and lower revision rate. Hemiarthroplasty is a reasonable option for patients older than 70 years with end-stage glenohumeral osteoarthritis. [Orthopedics. 2018; 41(4):222-228.].

Outcomes of distal humerus fractures: What are we measuring?

INTRODUCTIONnWe evaluate the most common outcome measures used in distal humerus fracture studies in order to suggest standardization for future research.nnnMATERIALS AND METHODSnA systematic review identified articles assessing the outcomes of acute distal humerus fractures from 2006 to 2016 from PubMed and Web of Science databases. The inclusion criterion was studies reporting on the outcomes of treatment of acute distal humerus fractures. Review articles, meta-analyses, studies with<5 patients, technique articles, biomechanical studies, and those focusing on one complication/outcome were excluded. Patient demographics and all outcome measures were reviewed. Journal and demographic factors were then compared.nnnRESULTSnOne-hundred-nine of 2158 articles met inclusion criteria. The median number of fractures per study was 35. Mean patient age was 55.0 years. Average follow-up was 35 months. Range-of-motion and strength measurements were reported in 90% and 17% of studies, respectively. Twenty patient-reported outcome instruments were used. The most commonly reported measures were MEPS, DASH, VAS pain, and Quick DASH scores. An average of 1.9 outcome measures were reported per study. A journal impact factor of≥1.5 was associated with more reported outcome measures. Articles including elbow arthroplasty were associated with higher impact factor journals, more outcome measures, and longer follow-up. Level of evidence was not associated with the number of reported outcome measures.nnnDISCUSSIONnThe current distal humerus fracture literature inconsistently reports outcome measures. More outcome measures were reported in higher impact journals. Future distal humerus fracture studies should include MEPS, DASH or Quick DASH, and VAS Pain scores to allow for appropriate cross-study comparison.nnnLEVEL OF EVIDENCEnIV, Systematic review.

Culture positivity in primary total shoulder arthroplasty

BACKGROUNDnThe clinical significance of positive cultures in shoulder surgery remains unclear. This study determined the rate and characteristics of positive intraoperative cultures in a cohort of patients undergoing primary shoulder arthroplasty.nnnMETHODSnFrom February 2015 to March 2016, 94 patients, without prior surgery, underwent primary shoulder arthroplasty. Before surgery, all shoulders were prospectively enrolled and consented to obtain standardized intraoperative cultures. All patients received standard preoperative antibiotic prophylaxis. Standardized fluid and tissue locations were sampled and sent for aerobic and anaerobic cultures and held for 13 days. Patients and surgeon were blinded to the culture results.nnnRESULTSnAverage age at surgery was 70.5 years (range, 50-91 years), and 41 patients (47%) were male. At least 1 positive culture was found in 33 shoulders (38%), with 17 patients (19%) having ≥2 positive cultures. Cutibacterium (formerly Propionibacterium) acnes was the most common organism (67%), followed by coagulase-negative Staphylococcus (21%), Staphylococcus aureus (3%), and other organisms (18%). The rate of positive culture was higher in men (51%) than in women (26%, Pu2009=u2009.016). Cutibacterium acnes was more common in men with positive cultures (95% vs. 17%, Pu2009<u2009.001) and coagulase-negative Staphylococcus and Staphylococcus epidermidis were more common in women with positive cultures (42% vs. 10%, Pu2009=u2009.071).nnnCONCLUSIONnPositive deep tissue cultures develop in a high percentage of patients undergoing primary shoulder arthroplasty despite antibiotic prophylaxis. The long-term clinical implication of this finding requires further study, especially with regard to the risk of late failures of shoulder arthroplasty.