Brett P. Wiater

Clinical and radiographic results of cementless reverse total shoulder arthroplasty: a comparative study with 2 to 5 years of follow-up

BACKGROUNDnMost studies of reverse total shoulder arthroplasty (RTSA) involve cemented humeral stems. To our knowledge, this is the first study to compare the results of cementless RTSA, using a porous-coated stem designed for uncemented fixation, with cemented RTSA.nnnMETHODSnA prospective database of patients undergoing RTSA was retrospectively reviewed for patients with a diagnosis of cuff tear arthropathy or severe rotator cuff deficiency with minimum 2-year follow-up. Of these, 37 patients had cemented RTSA and 64 patients had cementless RTSA. Outcome measures included Constant-Murley scores, American Shoulder and Elbow Surgeons scores, visual analog pain scale scores, range of motion, patient satisfaction, and radiographic evidence of complication.nnnRESULTSnCompared with preoperative values, both cohorts demonstrated significant improvements (Pxa0<xa0.01) in all functional scores, active forward elevation, and active internal rotation. There was no significant difference (Pxa0>xa0.05) in comparing the changes in these values after surgery between the cemented and cementless cohorts. On radiographic evaluation, there was no evidence of loosening or humeral components at risk of loosening in either group. There was no significant difference (Pxa0=xa01.0) in the incidence of humeral component radiolucent lines between the cemented and uncemented cohorts. There was no significant difference (Pxa0=xa0.30) in the incidence of scapular notching between the cemented (nxa0=xa08) and uncemented (nxa0=xa010) cohorts.nnnCONCLUSIONnCementless fixation of a porous-coated RTSA humeral stem provides clinical and radiographic outcomes equivalent to those of cemented stems at minimum 2-year follow-up. With advantages such as simplified operative technique, no cement-related complications, greater ease of revision, and long-lasting biologic fixation, uncemented fixation may provide several benefits over cemented fixation.

The evaluation of the failed shoulder arthroplasty

As the incidence of shoulder arthroplasty continues to rise, the orthopedic shoulder surgeon will be increasingly faced with the difficult problem of evaluating a failed shoulder arthroplasty. The patient is usually dissatisfied with the outcome of the previous arthroplasty as a result of pain, but may complain of poor function due to limited range of motion or instability. A thorough and systematic approach is necessary so that the most appropriate treatment pathway can be initiated. A comprehensive history and physical examination are the first steps in the evaluation. Diagnostic studies are numerous and include laboratory values, plain radiography, computed tomography, ultrasound imaging, joint aspiration, nuclear scans, and electromyography. Common causes of early pain after shoulder arthroplasty include technical issues related to the surgery, such as malposition or improper sizing of the prosthesis, periprosthetic infection, neurologic injury, and complex regional pain syndrome. Pain presenting after a symptom-free interval may be related to chronic periprosthetic infection, component wear and loosening, glenoid erosion, rotator cuff degeneration, and fracture. Poor range of motion may result from inadequate postoperative rehabilitation, implant-related factors, and heterotopic ossification. Instability is generally caused by rotator cuff deficiency and implant-related factors. Unfortunately, determining the cause of a failed shoulder arthroplasty can be difficult, and in many situations, the source of pain and disability is multifactorial.

Early outcomes of staged bilateral reverse total shoulder arthroplasty: A case–control study

Some surgeons are reluctant to perform a reverse total shoulder arthroplasty (RTSA) on both shoulders because of concerns regarding difficulty with activities of daily living post-operatively as a result of limited rotation of the shoulders. Nevertheless, we hypothesised that outcomes and patient satisfaction following bilateral RTSA would be comparable to those following unilateral RTSA. A single-surgeon RTSA registry was reviewed for patients who underwent bilateral staged RTSA with a minimum follow-up of two years. A unilateral RTSA matched control was selected for each shoulder in those patients undergoing bilateral procedures. The Constant-Murley score (CMS), American Shoulder and Elbow Surgeons (ASES) score, Subjective Shoulder Values (SSV), visual analogue scale (VAS) for pain, range of movement and strength were measured pre- and post-operatively. The mean CMS, ASES, SSV, VAS scores, strength and active forward elevation were significantly improved (all p < 0.01) following each operation in those undergoing bilateral procedures. The mean active external rotation (p = 0.63 and p = 0.19) and internal rotation (p = 0.77 and p = 0.24) were not significantly improved. The improvement in the mean ASES score after the first RTSA was greater than the improvement in its control group (p = 0.0039). The improvement in the mean CMS, ASES scores and active forward elevation was significantly less after the second RTSA than in its control group (p = 0.0244, p = 0.0183, and p = 0.0280, respectively). Pain relief and function significantly improved after each RTSA in those undergoing a bilateral procedure. Bilateral RTSA is thus a reasonable form of treatment for patients with severe bilateral rotator cuff deficiency, although inferior results may be seen after the second procedure compared with the first.

The Glenoid Component in Anatomic Shoulder Arthroplasty

Ideal management of the glenoid in anatomic shoulder arthroplasty remains controversial. Glenoid component loosening remains a common source of clinical concern and, in young, active patients, implantation of a glenoid prosthesis is often avoided. Efforts to decrease glenoid loosening have resulted in changes to prosthetic design and implantation techniques. Currently, a wide variety of glenoid component options are available, including metal-backed or all-polyethylene, bone ingrowth or ongrowth, inset, and augmented designs. Additionally, several alternatives are available for the young, active patient, including hemiarthroplasty, nonprosthetic resurfacing, and tissue interposition. Many recent clinical and biomechanical studies have examined these implant options. A thorough knowledge of glenoid anatomy, pathology, implant options, indications, and principles of implantation is necessary to optimize the outcome following anatomic shoulder arthroplasty.

Preoperative Deltoid Size and Fatty Infiltration of the Deltoid and Rotator Cuff Correlate to Outcomes After Reverse Total Shoulder Arthroplasty

BackgroundReverse total shoulder arthroplasty (RTSA) allows the deltoid to substitute for the nonfunctioning rotator cuff. To date, it is unknown whether preoperative deltoid and rotator cuff parameters correlate with clinical outcomes.Questions/purposesWe asked whether associations exist between 2-year postoperative results (ROM, strength, and outcomes scores) and preoperative (1) deltoid size; (2) fatty infiltration of the deltoid; and/or (3) fatty infiltration of the rotator cuff.MethodsA prospective RTSA registry was reviewed for patients with cuff tear arthropathy or massive rotator cuff tears, minimum 2-year followup, and preoperative shoulder MRI. Final analysis included 30 patients (average age, 71xa0±xa010xa0years; eight males, 22 females). Only a small proportion of patients who received an RTSA at our center met inclusion and minimum followup requirements (30 of 222; 14%); however, these patients were found to be similar at baseline to the overall group of patients who underwent surgery in terms of age, gender, and preoperative outcomes scores. The cross-sectional area of the anterior, middle, and posterior deltoid was measured on axial proton density-weighted MRI. Fatty infiltration of the deltoid, supraspinatus, infraspinatus, teres minor, and subscapularis were quantitatively assessed on sagittal T1-weighted MR images. Patients were followed for Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) scores, subjective shoulder value, pain, ROM, and strength. Correlations of muscle parameters with all outcomes measures were calculated.ResultsPreoperative deltoid size correlated positively with postoperative Constant-Murley score (67.27xa0±xa013.07) (ρxa0=xa00.432, pxa0=xa00.017), ASES (82.64xa0±xa014.25) (ρxa0=xa00.377; pxa0=xa00.40), subjective shoulder value (82.67xa0±xa017.89) (ρxa0=xa00.427; pxa0=xa00.019), and strength (3.72 poundsxa0±xa02.99 pounds) (ρxa0=xa00.454; pxa0=xa00.015). Quantitative deltoid fatty infiltration (7.91%xa0±xa04.32%) correlated with decreased postoperative ASES scores (ρxa0=xa0−0.401; pxa0=xa00.047). Quantitative fatty infiltration of the infraspinatus (30.47%xa0±xa015.01%) correlated with decreased postoperative external rotation (34.13°xa0±xa016.80°) (ρxa0=xa0−0.494; pxa0=xa00.037).ConclusionsLarger preoperative deltoid size correlates with improved validated outcomes scores, whereas fatty infiltration of the deltoid and infraspinatus may have deleterious effects on validated outcomes scores and ROM after RTSA. The current study is a preliminary exploration of this topic; future studies should include prospective enrollment and standardized MRI with a multivariate statistical approach. Quantitative information attained from preoperative imaging not only holds diagnostic value, but, should future studies confirm our findings, also might provide prognostic value. This information may prove beneficial in preoperative patient counseling and might aid preoperative and postoperative decision-making by identifying subpopulations of patients who may benefit by therapy aimed at improving muscle properties.Level of EvidenceLevel III, prognostic study.

Intravenous tranexamic acid reduces total blood loss in reverse total shoulder arthroplasty: a prospective, double-blinded, randomized, controlled trial

BACKGROUNDnPatients undergoing reverse total shoulder arthroplasty (RTSA) are at risk of significant perioperative blood loss. To date, few studies have examined the effectiveness of tranexamic acid (TXA) to reduce blood loss in the setting of RTSA.nnnMETHODSnIn a prospective, double-blinded, single-surgeon trial, we analyzed 102 patients undergoing primary RTSA who were randomized to receive intravenous TXA (nu2009=u200953) or placebo (nu2009=u200949). Calculated total blood loss, drain output, and hemoglobin (Hb) drop were measured. Postoperative transfusions were recorded. Complications were assessed out to 6 weeks postoperatively.nnnRESULTSnTotal blood loss was less for the TXA group (1122.4u2009u2009±u2009411.6 mL) than the placebo group (1472.6u2009±u2009475.4 mL, Pu2009<u2009.001). Total drain output was less for the TXA group (221.4u2009±u2009126.2 mL) than the placebo group (371.9u2009±u2009166.3 mLu2009, Pu2009<u2009.001). Total Hb loss was less in the TXA group (154.57u2009±u200960.29 g) compared with the placebo group (200.1u2009±u200965.5 g, Pu2009=u2009.001). Transfusion rates differed significantly at postoperative day 1; however, overall transfusion rates did not vary significantly. Seven patients (14.3%) and 12 units were transfused in the placebo group compared with 3 patients (5.7%) and 3 units in the TXA group.nnnDISCUSSIONnIn this cohort of patients undergoing primary RTSA, TXA was effective in reducing total drain output, total Hb loss, and total blood loss compared with a placebo control.

Elucidating trends in revision reverse total shoulder arthroplasty procedures: a retrieval study evaluating clinical, radiographic, and functional outcomes data

BACKGROUNDnThe purpose of this study was to explore relationships between damage modes in explanted reverse total shoulder arthroplasty (RTSA) components, patient and radiographic risk factors, and functional data to elucidate trends in RTSA failure.nnnMETHODSnFifty RTSA systems, retrieved from 44 patients, with 50 polyethylene (PE) liners, 30 glenospheres, 21 glenoid baseplates, 13 modular humeral metaphases, and 17 humeral stems, were examined for damage modes, including abrasion, burnishing, dishing, embedding, scratching, and pitting. PE liners were also analyzed for delamination and edge deformation. Charts were reviewed for patient, surgical, and functional data. Pre-revision radiographs were analyzed for scapular notching and loosening.nnnRESULTSnAverage term of implantation was 20 months (range, 0-81 months). Metallic components exhibited abrasion, burnishing, dishing, pitting, and scratching. PE liners displayed all damage modes. Damage was exhibited on 93% of glenospheres and 100% of PE liners. Of 29 aseptic shoulders, 13 showed evidence of scapular notching and 5 of humeral loosening. There was a moderate correlation between radiographically observed implant failure or dissociation and PE embedding (r = 0.496; P < .001). There were weak and moderate correlations between scapular notching severity and PE dishing (r = 0.496; P = .006), embedding (r = 0.468; P = .010), and delamination (r = 0.384; P = .040).nnnCONCLUSIONSnTo date, this is the largest series of retrieved RTSA components and the first to relate damage modes to radiographic and clinical data. Most damage was observed on the PE liners, on both the articular surface and rim, and glenosphere components. Correlation of retrieval findings with radiographic and clinical data may help establish predictors of prostheses at risk for failure.

The impact of rotator cuff deficiency on structure, mechanical properties, and gene expression profiles of the long head of the biceps tendon (LHBT): Implications for management of the LHBT during primary shoulder arthroplasty

The long head of the biceps tendon (LHBT) occupies a unique proximal intra‐articular and distal extra‐articular position within the human shoulder. In the presence of a rotator cuff (RC) tear, the LHBT is recruited into an accelerated role undergoing potential mechanical and biochemical degeneration. Intra‐articular sections of the LHBT were harvested during primary shoulder arthroplasty from patients with an intact or deficient RC. LHBTs were stained (H&E, Alcian Blue) and subjected to histologic analysis using the semiquantitative Bonar scale and measurement of collagen orientation. LHBTs (nu2009=u200912 per group) were also subjected to gene‐expression analyses via an RT2‐PCR Profiler Array quantifying 84 genes associated with cell‐cell and cell‐matrix interactions. LHBTs (nu2009=u200918 per group) were biomechanically tested with both stress‐relaxation and load‐to‐failure protocols and subsequently modeled with the Quasilinear Viscoelastic (QLV) and Structural‐Based Elastic (SBE) models. While no histologic differences were observed, significant differences in mechanical testing, and viscoelastic modeling parameters were found. PCR arrays identified five genes that were differentially expressed between RC‐intact and RC‐deficient LHBT groups. LHBTs display signs of pathology regardless of RC status in the arthroplasty population, which may be secondary to both glenohumeral joint arthritis and the additional mechanical role of the LHBT in this population.

Video Recording With a GoPro in Hand and Upper Extremity Surgery

Video recordings of surgical procedures are an excellent tool for presentations, analyzing self-performance, illustrating publications, and educating surgeons and patients. Recording the surgeons perspective with high-resolution video in the operating room or clinic has become readily available and advances in software improve the ease of editing these videos. A GoPro HERO 4 Silver or Black was mounted on a head strap and worn over the surgical scrub cap, above the loupes of the operating surgeon. Five live surgical cases were recorded with the camera. The videos were uploaded to a computer and subsequently edited with iMovie or the GoPro software. The optimal settings for both the Silver and Black editions, when operating room lights are used, were determined to be a narrow view, 1080p, 60 frames per second (fps), spot meter on, protune on with auto white balance, exposure compensation at -0.5, and without a polarizing lens. When the operating room lights were not used, it wasxa0determined that the standard settings for a GoPro camera were ideal for positioning andxa0editing (4K, 15 frames per second, spot meter and protune off). The GoPro HERO 4 provides high-quality, the surgeon perspective, and a cost-effective video recording of upper extremity surgical procedures. Challenges include finding the optimal settings for each surgical procedure and the length of recording due to battery life limitations.

Outcomes Following Low-Profile Mesh Plate Osteosynthesis of Patella Fractures

Abstract Treatment of patella fractures is fraught with complications and historically poor functional outcomes. A fixation method that allows for early mobilization and decreases symptomatic hardware rates will improve knee range of motion, postoperative functional status, and reoperation rates. The purpose of this study was to evaluate the functional outcomes after locked plate osteosynthesis of patella fractures at a Level 1 trauma center. A retrospective case series was conducted of patients who underwent open reduction internal fixation (ORIF) of a patella fracture using a locked mesh plating technique coupled with neutralization of forces on the distal pole of the patella. Twelve patients were evaluated at a mean follow‐up of 19 months (range, 6‐30) with physical exam, functional outcomes, and radiographs. There were 9 women and 3 men with an average age of 66.1 years (range, 53‐75). Radiographic bony union was achieved in all patients by 3‐month follow‐up. Visual Analog Pain Score averaged 1.7 (median, 1.0; range, 0‐8), the mean Knee Outcome Score ‐ Activities of Daily Living Scale was 83.9 (median, 92.1; range, 45.7‐100.0), the mean Short Form Musculoskeletal Function Assessment (SMFA) Function Index was 9.9 (median, 3.7; range, 0.7‐41.2), and the mean SMFA Bother Index was 11.1 (median, 3.1; range, 0‐62.5). The SF‐36 Physical Component Score mean was 48.4 ± 8.5 and the SF‐36 Mental Component Score mean was 54.1 ± 9.6. No complications developed and there were no reoperations for nonunion, infection, or symptomatic hardware. This study demonstrates that locked plate osteosynthesis for operative patella fractures can reliably achieve bony union with potentially superior functional outcomes as compared with traditional methods. Further studies are needed to evaluate plate fixation for patella fractures, but early results are promising.