E. Scott Paxton

Use of reverse total shoulder arthroplasty in the Medicare population

BACKGROUNDnReverse shoulder arthroplasty (RSA) has been Food and Drug Administration approved in the United States since 2004 but did not obtain a unique code until 2010. Therefore, the use of this popular procedure has yet to be reported. The purpose of this study was to examine the use and reimbursement of RSA compared with total shoulder arthroplasty (TSA) and shoulder hemiarthroplasty (SHA).nnnMETHODSnWe analyzed the 100% sample of the 2011 Medicare Part A claims data for patients aged 65 years or older. Patient demographic characteristics, diagnoses, provider information, reimbursements, and lengths of stay were extracted from the claims data.nnnRESULTSnIn 2011, a total of 31,002 shoulder arthroplasty procedures were performed; 37% were RSAs, 42% were TSAs, and 21% were SHAs. Osteoarthritis was the primary diagnosis code in 91% of TSAs, 37% of SHAs, and 45% of RSAs. A primary diagnosis of osteoarthritis with no secondary code for rotator cuff tear was found in 22% of patients undergoing RSA. The mean length of stay for RSA (2.6 days; SD, 2.1 days) was longer than that for TSA (2.1 days; SD, 1.5 days) and shorter than that for SHA (3.5 days; SD, 3.6 days) (P < .001). Lower-volume surgeons (<10 arthroplasties per year) performed most shoulder arthroplasties: 57% of RSAs, 65% of TSAs, and 97% of SHAs. Seventy percent of RSAs were implanted by surgeons who performed more RSAs than TSAs and SHAs combined.nnnCONCLUSIONSnRSA is performed with similar frequency to TSA and almost twice as much as SHA in the Medicare population. Lower-volume surgeons perform most RSAs, and a majority of surgeons perform more RSAs than all anatomic shoulder arthroplasties combined.

Shoulder arthroplasty options in young (<50 years old) patients: review of current concepts

BACKGROUNDnProsthetic shoulder arthroplasty provides excellent pain relief and functional restoration for patients with glenohumeral arthritis, but concerns of survivorship have limited its use in younger patients.nnnDISCUSSIONnDespite general reports of high long-term survivorship, implant failure and functional deterioration after total shoulder arthroplasty are major concerns in the management of younger patients. In addition to having a longer life expectancy, younger patients also tend to be more active and can be expected to place greater demands on their shoulder arthroplasty.nnnCONCLUSIONnAlternative strategies have been developed and used for shoulder arthroplasty in younger patients. This manuscript reviews current concepts of shoulder arthroplasty in young patients.

Leukocyte esterase in the diagnosis of shoulder periprosthetic joint infection.

BACKGROUNDnShoulder periprosthetic joint infection (PJI) is difficult to diagnose with traditional methods. Leukocyte esterase (LE) has recently proven to be reliable in knee arthroplasty; however, its value in the shoulder has not been explored. We hypothesized that LE would display high sensitivity and specificity in shoulder PJI.nnnMETHODSnTwo groups were prospectively evaluated: 45 primary and 40 revision shoulder arthroplasties. Synovial fluid and soft tissue cultures were obtained at surgery. Synovial fluid was evaluated with LE test strips. Any aspiration that contained erythrocytes was centrifuged and retested. Shoulder PJI was defined by modified Musculoskeletal Infection Society (MSIS) criteria.nnnRESULTSnOf 5 primaries with positive tissue cultures (11%), only 1 was positive for LE. Of 16 revisions with positive cultures (40%), 4 had positive LE results. Among all patients with bacterial isolates, 6 aspirates were not interpretable (29%), despite centrifugation. LE had sensitivity of 25% and specificity of 75% to predict positive cultures in revisions. Ten revision patients met modified MSIS criteria for PJI. The sensitivity of LE in these patients was 30%, and the specificity was 67% (positive predictive value, 43%; negative predictive value, 83%). If bloody aspirates were considered positive, LE sensitivity in MSIS PJI increased to 60%, but the positive predictive value fell to 37.5%.nnnCONCLUSIONnLE is an unreliable diagnostic measure in shoulder PJI. The presence of erythrocytes within aspirates further decreased its accuracy. We conclude that LE should not be used for the routine identification of shoulder PJI.

Shoulder Instability in Older Patients

Glenohumeral instability has a bimodal age distribution, with most affected patients younger than 40 years, but with a second peak in older patients. Glenohumeral dislocations in older patients often present with complex injury patterns, including rotator cuff tears, fractures, and neurovascular injuries. Glenohumeral instability in patients older than 40 years requires a different approach to treatment. An algorithmic approach aids the surgeon in the stepwise decision-making process necessary to treat this injury pattern.

Factors affecting hospital charges after total shoulder arthroplasty: an evaluation of the National Inpatient Sample database

BACKGROUNDnThe number of total shoulder arthroplasties (TSA) performed in the United States increases yearly. At the same time, cost containment in health care continues to be a major concern. Therefore, it is imperative to identify specific variables that affect the cost of shoulder arthroplasty.nnnMETHODSnThe U.S. National Inpatient Sample database was queried (1993-2010) to evaluate total hospital charges for shoulder arthroplasty. Etiology of arthritis, multiple medical comorbidities, and patient and hospital demographics were evaluated for their effect on total inpatient hospital charges by a multivariate analysis.nnnRESULTSnHospital charges for TSA increased from 1993 to 2010. Gender, race, and obesity were not associated with these differences in hospital charges. Post-traumatic and rheumatoid arthritis resulted in increased hospital charges; however, osteoarthritis resulted in decreased charges from the baseline. Multiple comorbidities (diabetes, lung disease, heart disease, and kidney disease) resulted in increased hospital charges after TSA. Regionally, the western and southern United States had the highest total charges above baseline. Larger hospitals and private urban hospitals also showed charges above baseline.nnnCONCLUSIONSnThe factors related to increased hospital charges after TSA are multifactorial and include medical comorbidities, patient demographics, and regionalization. As the future of health care continues to evolve, it is important for practitioners, legislators, insurance administrators, and hospitals to recognize factors that increase costs.

Agreement Among ASES Members on the AAOS Clinical Practice Guidelines

The American Academy of Orthopaedic Surgeons (AAOS) has recently developed several clinical practice guidelines (CPG) involving upper extremity conditions. The purpose of the current study was to evaluate the practice patterns of members of the American Shoulder and Elbow Society (ASES) with regard to the CPGs. An e-mail survey was sent to the 340 members of the ASES. The survey contained 40 questions involving the subject matter of the 2 existing AAOS CPGs pertaining specifically to the shoulder: Optimizing the Management of Rotator Cuff Problems and the Treatment of Glenohumeral Joint Arthritis. Overall, 98 responses were obtained, for a response rate of 29%. Only 19 of 47 CPGs were not inconclusive and a recommendation was actually made. A majority (more than 50%) of surgeons agreed with 17 (90%) of 19 of these AAOS recommendations. A strong majority (more than 80%) adhered to 13 (68%) of 19 recommendations. There were 4 consensus recommendations, and more than 50% agreed with all of them. Of the 5 moderate recommendations, more than 50% agreed with 4 of them. There were 10 weak recommendations, and more than 50% of surgeons agreed with 9 of them. There was more than 80% agreement on 18 of 28 inconclusive recommendations. Although the AAOS CPGs are not meant to be fixed protocols, they are intended to unify treatment and/or diagnosis of common problems based on the best evidence available. Despite the majority of the AAOS CPG recommendations for rotator cuff problems and glenohumeral arthritis being inconclusive, most surgeons agree with most of the CPG recommendations.

Outcomes of the Bridle Procedure for the Treatment of Foot Drop

Background: The purpose of this study was to determine the clinical outcomes and objective measures of function that can be expected for patients following the Bridle procedure (modification of the posterior tibial tendon transfer) for the treatment of foot drop. Methods: Nineteen patients treated with a Bridle procedure and 10 matched controls were evaluated. The Bridle group had preoperative and 2-year postoperative radiographic foot alignment measurements and completion of the Foot and Ankle Ability Measure. At follow-up, both groups were tested for standing balance (star excursion test) and for ankle plantarflexion and dorsiflexion isokinetic strength, and the American Orthopaedic Foot & Ankle Society and Stanmore outcome measures were collected only on the Bridle patients. Results: There was no change in radiographic foot alignment from pre- to postoperative measurement. Foot and Ankle Ability Measure subscales of activities of daily living and sport, American Orthopaedic Foot & Ankle Society, and Stanmore scores were all reduced in Bridle patients as compared with controls. Single-limb standing-balance reaching distance in the anterolateral and posterolateral directions were reduced in Bridle participants as compared with controls (P < .03). Isokinetic ankle dorsiflexion and plantarflexion strength was lower in Bridle participants (2 ± 4 ft·lb, 44 ± 16 ft·lb) as compared with controls (18 ± 13 ft·lb, 65 ± 27 ft·lb, P < .02, respectively). All Bridle participants reported excellent to good outcomes and would repeat the operation. No patient wore an ankle-foot orthosis for everyday activities. Conclusion: The Bridle procedure was a successful surgery that did not restore normal strength and balance to the foot and ankle but allowed individuals with foot drop and a functional tibialis posterior muscle to have significantly improved outcomes and discontinue the use of an ankle-foot orthosis. In addition, there was no indication that loss of the normal function of the tibialis posterior muscle resulted in change in foot alignment 2 years after surgery. Level of Evidence: Level III, retrospective comparative series.

Arthroscopic repair of an avulsed latissimus dorsi tendon transfer for massive, irreparable rotator cuff tear: a report of two cases

Department of Orthopedic Surgery, The Summit Medical Group, Berkeley Heights, NJ, USA Department of Orthopedic Surgery, Brown University, Rhode Island Hospital, Providence, RI, USA Department of Orthopedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, PA, USA Department of Orthopedic Surgery, St. Paul’s Hospital, The Catholic University of Korea, Seoul, South Korea

Transolecranon fracture dislocations

Although olecranon fractures account for approximately 10 % of all elbow fractures, transolecranon fracture-dislocations are much less common and may be misdiagnosed. An axial load of the humerus into the greater sigmoid notch leads to fracture of the olecranon and proximal ulna and causes an anterior dislocation of the radiocapitellar joint. Surgical intervention is almost always performed to restore elbow joint anatomy. Articular reconstruction combined with stable axial fixation utilizing a dorsally applied plate on the olecranon and proximal ulna is the optimal repair construct. Outcomes of treatment of these injuries are typically very good as long as initial stable fixation allowing early motion is achieved. The goal of this chapter is to discuss the evaluation and management of transolecranon fracture-dislocations with particular focus on highlighting points and pearls that can optimize the outcome of treatment.

An Evidence-Based Approach to Differentiating the Cause of Shoulder and Cervical Spine Pain

Differentiating the cause of pain and dysfunction due to cervical spine and shoulder pathology presents a difficult clinical challenge in many patients. Furthermore, the anatomic region reported to be painful may mislead the practitioner. Successfully treating these patients requires a careful and complete history and physical examination with appropriate provocative maneuvers. An evidence-based selection of clinical testing also is essential and should be tailored to the most likely underlying cause. When advanced imaging does not reveal a conclusive source of pathology, electromyography and selective injections have been shown to be useful adjuncts, although the sensitivity, specificity, and risk-reward ratio of each test must be considered. This review provides an evidence-based review of common causes of shoulder and neck pain and guidelines for assistance in determining the pain generator in ambiguous cases.