Brent Mollon

Disproportionate trends in ulnar collateral ligament reconstruction: projections through 2025 and a literature review

BACKGROUND Medial ulnar collateral ligament (UCL) injuries of the elbow that require surgical management are uncommon. There is growing evidence, however, suggesting that the incidence of UCL reconstruction (UCLR) procedures is rapidly increasing. We sought to quantify the incidence of age-related trends for UCLR from 2003 to 2014 and subsequently to project future trends through 2025. We hypothesized that as the total number of UCLRs performed increased, a disproportionate incidence among younger patients would be observed. METHODS New York States Statewide Planning and Research Cooperative System database was queried from 2003 to 2014 to identify individuals between 10 and 40 years old undergoing UCLR. Poisson regression was used to develop future projections for UCLR and New York State population through 2025, and incidence estimates per 100,000 people were calculated. RESULTS In New York State between 2003 and 2014, there were 890 patients who underwent UCLR, with average annual incidence per 100,000 people equaling 6.3 ± 2.8 for ages 15 to 19 years, significantly greater than for all other age groups (P < .001). Projections from 2015 through 2025 suggest that incidence in 15- to 19-year-olds and 20- to 24-year-olds will continue to rapidly increase while rates for other age groups will remain relatively stable. CONCLUSIONS The number of UCLRs performed between 2003 and 2014 increased by 343%, and a disproportionate trend in average annual incidence for patients between 15 and 19 years old was observed. As our review of the literature questioned outcomes in adolescent athletes after UCLR, continued attempts at preventing these injuries in the young throwing athlete remain paramount.

Impact of scapular notching on clinical outcomes after reverse total shoulder arthroplasty: an analysis of 476 shoulders

BACKGROUND Scapular notching is a complication unique to reverse total shoulder arthroplasty (rTSA), although its clinical implications are unclear and remains controversial. METHODS We retrospectively reviewed rTSA patients of a single implant design in 476 shoulders with a minimum 2-year clinical and radiographic follow-up. Clinical measures included active range of motion and American Shoulder and Elbow Surgeons scores, in addition to one or more of the Constant score, Shoulder Pain and Disability Index, Simple Shoulder Test (SST), and University of California, Los Angeles Shoulder Rating Scale. Complications and rates of humeral radiolucencies were also recorded. RESULTS Scapular notching was observed in 10.1% (48 of 476) of rTSAs and was associated with a longer clinical follow-up, lower body weight, lower body mass index, and when the operative side was the nondominant extremity. Patients with scapular notching had significantly lower postoperative scores on the Shoulder Pain and Disability Index, Constant, Simple Shoulder Test, and University of California, Los Angeles, Shoulder Rating Scale compared with patients without scapular notching. Patients with scapular notching also had significantly lower active abduction, significantly less strength, and trended toward significantly less active forward flexion (P = .0527). Finally, patients with scapular notching had a significantly higher complication rate and trended toward a significantly higher rate of humeral radiolucent lines (P = .0896) than patients without scapular notching. CONCLUSIONS This large-scale outcome study demonstrates that patients with scapular notching have significantly poorer clinical outcomes, significantly less strength and active range of motion, and a significantly higher complication rate than patients without scapular notching. Longer-term follow-up is necessary to confirm that these statistical observations in the short-term will result in greater clinically meaningful differences over time.

Impact of glenosphere size on clinical outcomes after reverse total shoulder arthroplasty: an analysis of 297 shoulders

BACKGROUND Although increasing glenosphere diameter has been found to increase passive range of motion (ROM) in simulated models of reverse total shoulder arthroplasty (rTSA), the clinical implications of glenosphere size are unclear. The purpose of our study was to determine the impact that glenosphere size had on short-term and midterm clinical outcomes, specifically American Shoulder and Elbow Surgeons (ASES) scores and ROM. METHODS Prospectively collected data comparing patients receiving an rTSA with either a 38- or 42-mm glenosphere after a minimum 2-year follow-up were obtained. Clinical outcome measures included active ROM and ASES scores. RESULTS We included 297 primary rTSAs in 290 patients: a 38-mm-diameter glenosphere was used in 160 shoulders and a 42-mm-diameter glenosphere in 137 shoulders. Of the patients, 191 were women and 99 were men. The mean age at the time of surgery was 72 years (range, 50-88 years). At last follow-up, improvements in active forward elevation (aFE) and active external rotation (aER) were significantly greater in shoulders with a 42-mm glenosphere (+59° vs +44° for aFE and +24° vs +18° for aER). Female shoulders treated with a 42-mm glenosphere had significantly greater improvements in aFE, aER, and functional scores. Male shoulders treated with a 38-mm glenosphere had significantly greater improvements in pain levels and ASES scores but less improvement in aFE. Complications and rates of scapular notching were similar between glenosphere sizes. CONCLUSIONS Patients treated with 42-mm glenospheres had greater improvements in aFE and aER when compared with 38-mm glenospheres. Our results suggest a potential association among gender, glenosphere size, and improvement in clinical outcome scores. LEVEL OF EVIDENCE Level III; Retrospective Cohort Design; Treatment Study.

Two-stage revision for infected shoulder arthroplasty

BACKGROUND Periprosthetic shoulder infections (PSIs) are challenging to treat and often result in significant patient morbidity. Without a standardized treatment protocol, PSIs are often managed similarly to periprosthetic hip and knee infections. Because 2-stage revision is the gold standard for treating periprosthetic hip and knee infections, we performed a case series and literature review to determine its effectiveness in PSIs. METHODS We identified 19 patients (14 men) from our institution who were treated with a 2-stage revision after presenting with a PSI. Mean patient age was 63 ± 9 years, and average body mass index was 30.8 ± 5.8. The average time from the index arthroplasty to treatment was 40 months, 8 of 13 positive cultures were Propionibacterium acnes, and 9 of 19 patients had multiple shoulder operations before presenting with infection. Minimum follow-up for all patients was 2 years. RESULTS After a mean follow-up of 63 months (range, 25-184 months), 15 of 19 patients in our study were successfully treated for PSI. Average postoperative American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment score was 69 (range, 32-98) and average postoperative forward elevation was significantly increased from 58° to 119° (P < .001). The incidence of recurrent infection was 26%. The rate of noninfection complications was 16%, for a total complication rate of 42%. CONCLUSION In patients with PSIs, especially those with intractable, chronic infections, a 2-stage revision represents a viable treatment option for eradicating infection and restoring function. However, it is important to recognize the risk of recurrent infection and postoperative complications in this challenging patient population.

Definitive Treatment of Infected Shoulder Arthroplasty With a Cement Spacer

Infection in the setting of shoulder arthroplasty can result in significant pain, loss of function, and the need for additional surgery. As the use of shoulder arthroplasty increases, the medical and economic burdens of periprosthetic joint infection increase as well. The ideal management of infected shoulder prostheses has not been established. This report describes 9 patients from a single institution who had an infected shoulder arthroplasty that was definitively managed with a cement spacer. All patients had a minimum of 2 years of follow-up. Of the 9 patients in this study, 6 were men. Mean age was 73±9 years. Of the study patients, 1 had diabetes, 2 presented with Parkinsons disease, and 5 had a history of tobacco use. Average body mass index was 27.9±7 kg/m(2). After mean follow-up of 4 years, none of the patients had clinical or radiographic evidence of infection. Functional outcomes, as measured by American Shoulder and Elbow Surgeons scores, were good or fair in 89% of patients, and the average American Shoulder and Elbow Surgeons score was 57. A review of recent literature suggested that the current findings were similar to those in studies reporting 1- or 2-stage revision procedures. Although cement spacers are typically used as part of a 2-stage revision procedure, the current findings suggest that cement spacers can be used effectively to eradicate infection and allow for acceptable functional recovery and range of motion in patients who have severe medical comorbidities and cannot tolerate additional surgery. [Orthopedics. 2016; 39(5):e924-e930.].

Arthroscopic Rotator Cuff Repair: Double-Row Transosseous Equivalent Suture Bridge Technique

Following a failed course of conservative management, arthroscopic rotator cuff repair (ARCR) has become the gold standard treatment for patients presenting with symptomatic rotator cuff (RC) tears. Traditionally, the single-row repair technique was used. Although most patients enjoy good to excellent clinical outcomes, structural healing to bone remains problematic. As a result, orthopaedic surgeons have sought to improve outcomes with various technological and technical advancements. One such possible advancement is the double-row technique. We present a method for repairing an RC tear using double-row suture anchors in a transosseous equivalent suture bridge technique. The double-row technique is believed to more effectively re-create the anatomic footprint of the tendon, as well as increase tendon to bone surface area, and apposition for healing. However, it requires longer operating times and is costlier. This report highlights this technique for ARCR in an adult by using a double-row transosseous equivalent suture bridge.

Impact of Race and Gender on Utilization Rate of Total Shoulder Arthroplasty

Marked underutilization rates of total joint arthroplasty in minorities compared with nonminorities exist, with a paucity of literature surrounding inequities related to total shoulder arthroplasty (TSA). Using the Statewide Planning and Research Cooperative System database, patients who underwent elective TSA in New York State (NYS) were identified and characterized by age, race, gender, medical comorbidities, and payor status. Patients were stratified into 4 separate 5-year periods from 1990 to 2009. Comorbidity severity was defined using the Elixhauser criteria. A total of 10,538 elective TSAs were identified, with half of the procedures occurring in the most recent time quartile. Whites accounted for 70% of the procedures, whereas blacks accounted for 5%. During the 20-year period, the age-adjusted incidence of TSA in white men and women increased by 417% and 421%, respectively, whereas the incidence for black men and women increased by 378% and 329%, respectively. Black men had the lowest utilization rate among all subgroups, and overall disparity between races continued to widen over time. Blacks had significantly more comorbid conditions (P<.001) than whites when undergoing TSA. Blacks were more likely to have Medicaid insurance and less participation in Medicare (P<.001). Racial and gender disparities clearly exist in TSA utilization rates in NYS and may be worsening. Although reasons for these disparities are likely multifactorial, a deeper understanding of the factors involved in patient selection and access to care is necessary to appropriately address these disparities and effect change at a system-wide patient and provider level. [Orthopedics. 2016; 39(3):e538-e544.].

Risk factors for recurrent instability or revision surgery following arthroscopic Bankart repair

Aims The factors that predispose to recurrent instability and revision stabilization procedures after arthroscopic Bankart repair for anterior glenohumeral instability remain unclear. We sought to determine the rate and risk factors associated with ongoing instability in patients undergoing arthroscopic Bankart repair for instability of the shoulder. Materials and Methods We used the Statewide Planning and Research Cooperative System (SPARCS) database to identify patients with a diagnosis of anterior instability of the shoulder undergoing arthroscopic Bankart repair between 2003 and 2011. Patients were followed for a minimum of three years. Baseline demographics and subsequent further surgery to the ipsilateral shoulder were analyzed. Multivariate analysis was used to identify independent risk factors for recurrent instability. Results A total of 5719 patients were analyzed. Their mean age was 24.9 years (SD 9.3); 4013 (70.2%) were male. A total of 461 (8.1%) underwent a further procedure involving the ipsilateral shoulder at a mean of 31.5 months (SD 23.8) postoperatively; 117 (2.1%) had a closed reduction and 344 (6.0%) had further surgery. Revision arthroscopic Bankart repair was the most common subsequent surgical procedure (223; 65.4%). Independent risk factors for recurrent instability were: age < 19 years (odds ratio 1.86), Caucasian ethnicity (hazard ratio 1.42), bilateral instability of the shoulder (hazard ratio 2.17), and a history of closed reduction(s) prior to the initial repair (hazard ratio 2.45). Revision arthroscopic Bankart repair was associated with significantly higher rates of ongoing persistent instability than revision open stabilization (12.4% vs 5.1%, p = 0.041). Conclusion The incidence of a further procedure being required in patients undergoing arthroscopic Bankart repair for anterior glenohumeral instability was 8.1%. Younger age, Caucasian race, bilateral instability, and closed reduction prior to the initial repair were independent risk factors for recurrent instability, while subsequent revision arthroscopic Bankart repair had significantly higher rates of persistent instability than subsequent open revision procedures.

Comparison of general versus isolated regional anesthesia in total shoulder arthroplasty: A retrospective propensity-matched cohort analysis

BACKGROUND Intraoperative anesthetic typically consists of either general anesthesia (GA) or isolated regional anesthesia (RA). METHODS A retrospective propensity-matched cohort analysis on patients undergoing TSA was performed to determine differences between GA and RA in regard to patient population, complications, LOS and hospital readmission. RESULTS 4158 patients underwent TSA with GA or isolated RA. Propensity-matching resulted in 912 patients in each cohort. RA had lower overall in-hospital complications and greater homebound discharge disposition with lower 90-day readmission rates than GA. CONCLUSION After TSA, isolated RA was associated with lower in-hospital complications, readmission rates and odds of hospital readmission than GA.

Cryopreserved bone allograft for the treatment of shoulder instability with glenoid defect

The purpose of this study was to examine outcomes after cryopreserved tri-cortical iliac crest allograft reconstruction for glenoid bone loss in patients with shoulder instability. 10 patients completed the required assessments at a mean follow up of 4.5 years. At final follow up, mean ASES was 92 ± 12, mean WOSI was 315 ± 319, with good range of motion. None of the final radiographs demonstrated graft resorption or failure of hardware. The data demonstrated that patients who were treated with glenoid bone grafting with cryopreserved tri-cortical iliac crest allograft can expect good range of motion and functional capacity.