Grant H. Garcia

Arthroscopic Remplissage With Bankart Repair for the Treatment of Glenohumeral Instability With Hill-Sachs Defects

PURPOSE To determine whether arthroscopic remplissage with Bankart repair is an effective treatment strategy for patients with Bankart lesions and large Hill-Sachs defects. METHODS Between 2006 and 2008, 20 patients underwent arthroscopic Bankart repair with remplissage for the treatment of recurrent anterior glenohumeral instability and large Hill-Sachs defects. Preoperative imaging in all patients identified avulsion of the anterior inferior glenohumeral ligament with an associated Hill-Sachs defect that involved greater than 25% of the humeral head. Patients were followed up postoperatively with the Western Ontario Shoulder Instability score, the American Shoulder and Elbow Surgeons score, and the Penn Shoulder Score. Recurrent subluxation or dislocation was documented. RESULTS There were 15 male patients and 5 female patients. The mean age of the patients was 27.3 years. The mean length of follow-up in this series was 29.2 months (range, 24.3 to 37.7 months). At final follow-up, 3 patients reported recurrence of instability, which spontaneously reduced in all cases. The mean American Shoulder and Elbow Surgeons score was 92.5 (pain, 47.3; function, 45.3). The mean Penn score was 90 of 100 (pain, 27.3 of 30; satisfaction, 8.5 of 10; function, 54.3 of 60). The mean total Western Ontario Shoulder Instability score was 72.74% (mean physical symptom score, 77.10%; mean sports and recreation score, 70.25%; mean lifestyle score, 75%; mean emotions score, 58.50%). CONCLUSIONS Using an all-arthroscopic remplissage technique with Bankart repair, we were able to restore function, diminish pain, and yield satisfaction in 85% of the patients in this study. Our results compare favorably with historic controls with similar pathology at early- to intermediate-term follow-up in terms of recurrence. LEVEL OF EVIDENCE Level IV, therapeutic case series.

The Evaluation of Arthroscopic Remplissage by High-Resolution Magnetic Resonance Imaging

Background: Arthroscopic remplissage is a novel procedure recently advocated for the treatment of large Hill-Sachs lesions with recurrent anterior glenohumeral instability. We have shown previously that infraspinatus tenodesis and Bankart repair reduce the risk of recurrent instability in high-risk patients. The ability to perform this procedure arthroscopically and without the need for bone grafting or an open approach makes this an appealing alternative to more traditional techniques. Purpose: To evaluate and characterize the postoperative appearance of the remplissage procedure on high-resolution magnetic resonance imaging (MRI) and to correlate these findings to clinical outcome (Western Ontario Shoulder Instability [WOSI] score, range of motion). Study Design: Case series; Level of evidence, 4. Methods: In patients who had undergone arthroscopic remplissage for recurrent glenohumeral instability with large Hill-Sachs defects, images were acquired with a 3-T protocol (and reviewed by 2 musculoskeletal radiologists) with the shoulder in the abduction-external rotation (ABER) and neutral positions at the time of the latest clinical examination. Measured parameters included signal intensity of tissue within the prior defect, signal intensity of the residual infraspinatus, degree of fatty infiltrate and muscle atrophy as a percentage of fat signal versus muscle signal (Goutallier grade), presence of marrow edema, and number of anchors in the defect. Functional scores were obtained with the WOSI questionnaire, and comprehensive range of motion data were recorded with a goniometer. Results: In 11 patients with an average clinical follow-up of 18.0 months (range, 8.8-27.2 months), the average size of the Hill-Sachs deformity was 334.3 mm3 (range, 93.6-825.1 mm3). The percentage of the deformity filled in with tendon was 75% to 100%, and the degree of atrophy was 0% to 25% for all patients studied. No defects were left unfilled. Two patients had granulation tissue filling the lesion, and 3 patients had fibrous tissue, while the rest of the patients had the MRI appearance of both granulation and fibrous tissue. Four of 9 patients had tendinopathy or partial tears of the residual infraspinatus tendon insertion, and 1 patient demonstrated residual bone marrow edema. The average number of anchors used was 1.4 (range, 1-3). The average WOSI score was 74.3% (range, 41.6%-99.2%), with an average external rotation loss of 5.8° (range, 0°-22°). One patient had recurrence of instability. Conclusion: Our data suggest that there is evidence of tendon incorporation and fill into the Hill-Sachs defect following arthroscopic remplissage at 8 months and beyond. Although MRI findings did not correlate with the clinical findings, patients were satisfied with the procedure and demonstrated minimal loss of external rotation (average, 5.8°) at early follow-up.

Outcomes of the Remplissage Procedure and Its Effects on Return to Sports: Average Five-Year Follow Up

Background: Short-term outcomes for patients with large, engaging Hill-Sachs lesions who underwent remplissage have demonstrated good results. However, limited data are available for longer term outcomes. Purpose: To evaluate the long-term outcomes of remplissage and determine the long-term rate of return to specific sports postoperatively. Study Design: Case series; Level of evidence, 4. Methods: This was a retrospective review of patients treated with the remplissage procedure from 2007 to 2013. All underwent preoperative magnetic resonance imaging demonstrating large Hill-Sachs lesions by the Rowe criteria and glenoid bone loss <20%. All Hill-Sachs lesions were “off track” by an arthroscopic examination and preoperative imaging. At final follow-up, patients underwent a range of motion evaluation and were administered a detailed outcome survey, which included Western Ontario Shoulder Instability Index (WOSI) and American Shoulder and Elbow Surgeons (ASES) scores as well as questions regarding sports, employment, physical activities, and dislocation events. Results: A total of 50 patients (51 shoulders) were included in the study. The average patient age at surgery was 29.8 years (range, 15.0-72.4 years), and the average follow-up time was 60.7 months (range, 25.5-97.6 months); 20.0% of patients underwent previous surgery on their shoulder. The average postoperative WOSI score was 79.5%, and the average ASES score was 89.3. Six shoulders had dislocation events (11.8%) postoperatively: 3 were traumatic, and 3 were atraumatic. Increased preoperative dislocations led to a greater risk of a postoperative dislocation (P < .001). There was also a trend toward higher postoperative dislocation rates in patients who underwent revision (P = .062). The average loss of external rotation was 5.26° (P = .13). The rate of return to ≥1 sports was 95.5% of patients at an average of 7.0 months postoperatively; 81.0% returned to their previous intensity and level of sport. Of patients who played a throwing sport, 65.5% (n = 19) stated that they had problems throwing, and 58.6% (n = 17) felt that they could not normally wind up throwing a ball. Direct rates of return to overhead sports were volleyball, 100%; basketball, 69%; baseball, 50%; and football, 50%. Conclusion: The redislocation rate after remplissage was 11.8% at an average of 5 years, with 95.5% of patients returning to full sports at an average of 7 months. For throwing sports, 65.5% of patients complained of decreased range of motion during throwing. The results should be considered preoperatively in candidates for remplissage who are engaged in throwing sports.

Progress Report: The Prevalence of Required Medical School Instruction in Musculoskeletal Medicine at Decade's End

BackgroundIn a 2003 report, required courses in musculoskeletal medicine were found in only 65 of the 122 medical schools in the United States. Since then, national efforts to promote musculoskeletal medicine education were led by the US Bone and Joint Decade, the American Medical Association, the Association of American Medical Colleges, the American Academy of Orthopaedic Surgeons, and the National Board of Medical Examiners, among others. Whether these efforts resulted in any changes in curricula is unclear.Questions/purposesWe assessed the change, if any, in the prevalence of required instruction in musculoskeletal medicine, which might be attributed to these reform efforts.MethodsCurriculum requirements were ascertained by an email survey sent to all 127 medical schools in the United States and from the schools’ websites. The presence of a preclinical course or block dedicated to musculoskeletal medicine was noted. Likewise, the requirement for a clerkship in a musculoskeletal discipline (comprising orthopaedic surgery, rheumatology, or physical medicine) was recorded.ResultsOne hundred of the 127 medical schools in the United States had required preclinical courses in musculoskeletal medicine. Among the schools without such a course, six had a required musculoskeletal clerkship. Thus, 106 schools had some requirement, with only 21 (17%) lacking required instruction in musculoskeletal medicine. This rate compares favorably with the 47% rate (57 of the 122 schools) reported previously.ConclusionThe prevalence of required instruction in musculoskeletal medicine is greater compared with the prevalence reported in previous studies. Musculoskeletal medicine appears to have attained a more prominent place in the curriculum at most schools.

Outcomes in revision Tommy John surgery in Major League Baseball pitchers

BACKGROUND With the recent rise in the number of Tommy John surgeries, a proportionate rise in revisions is expected. However, much is unknown regarding the current revision rate of Tommy John surgery, return to play, and change in performance in Major League Baseball (MLB) pitchers. METHODS Publicly available databases were used to obtain a list of all MLB pitchers who underwent primary and revision Tommy John surgery. Pitching performance preoperatively and postoperatively for pitchers who returned to 1 or more MLB games after revision surgery was compared with controls matched for age and position. RESULTS Since 1999, 235 MLB pitchers have undergone Tommy John surgeries; 31 pitchers (13.2%) underwent revision surgery, and 37% underwent revision within 3 years of the index procedure. Twenty-six revisions had more than 2 years of follow-up; 17 pitchers (65.4%) returned to pitch at least 1 major league game, whereas only 11 (42.3%) returned to pitch 10 or more games. Of those who returned to MLB competition, the average length of recovery was 20.76 months. Compared with controls matched for age and position, MLB pitchers undergoing revision surgery had a statistically shorter career after revision surgery (4.9 vs 2.6 seasons, P = .002), pitched fewer innings, and had fewer total pitches per season. CONCLUSIONS The rate of revision Tommy John surgery is substantially higher than previously reported. For MLB pitchers, return to play after revision surgery is much lower than after primary reconstruction. The overall durability of MLB pitchers after revision ulnar collateral ligament reconstruction decreases significantly compared with controls matched for age and matched controls.

Patient Activity Levels After Reverse Total Shoulder Arthroplasty What Are Patients Doing

Objectives: Indications for reverse total shoulder arthroplasty (RTSA) are expanding, resulting in younger patients who wish to remain active following the procedure. Little information, however, is available to help manage expectations of both physicians and patients for return to sporting activities. The purpose of this study was to determine the rate of return of sports activities, assess average time to return to sports for patients having undergone RTSA. Methods: A prospectively collected registry was queried for consecutive patients who underwent RTSA at our institution between 2007 and 2013. Patients with a minimum of 1-year follow-up were included. Patients without preoperative sporting activity were excluded. All patients were asked to complete a questionnaire regarding their physical fitness, sporting activities. The questionnaire was designed in accordance with previously published activity assessments for total joint arthroplasty. Each patient also completed an ASES and VAS assessment. Results: 76 patients played a sport preoperatively and met inclusion/exclusion criteria. The average follow-up was 31.6 months (12-65 mons) and average age was 74.84 years (49.9 - 92.6 yrs). Preoperative diagnoses were cuff tear arthropathy (55.2%), osteoarthritis (30.9%), proximal humerus fracture (17.1%), and rheumatoid arthritis (5.2%). 73% of the cohort had undergone prior ipsilateral shoulder surgery. Average VAS pain scores improved from 6.57 to 0.63 (p<0.001). Average ASES scores improved from 34.30 to 81.45 (p<0.001). 85.5% of patients who participated in sports preoperatively returned to at least one sport following RTSA. Average time to full return to sport was 5.3 months. Walking had the highest direct rate of return (85.7%), followed by fitness sports (81.5%), swimming (66.7%), running (57.1%), cycling (50.0%) and golf (50%). Age less than 70 years had significant improvement in rate of return to sports (p<0.002). 41.1% reported improved physical fitness following RTSA. 88.2% felt their sports outcome was good to excellent and 93.4% felt their surgical outcome was good to excellent. The two most commonly reported reasons for not returning to a sport were pain (13.1%) and lack of interest (9.2%). For all types of sports and rates of return see fig 1. Conclusion: Patients undergoing RTSA had an 85% rate of return to one or more sporting activities at an average of 5.3 months following surgery. Non-contact high demand activities (swimming, skiing, golf, and tennis) had lower return rates than lower demand activities. Age greater than 70 years old was a significant predictor of decreased return to activities. This is the only study to document both preoperative and postoperative sports and activities of daily living following RTSA. The present study offers valuable information to help manage patient and surgeon expectations.

Higher critical shoulder angle increases the risk of retear after rotator cuff repair.

BACKGROUND No evaluation has been done on the relationship of the critical shoulder angle (CSA) with retear after rotator cuff repair. Our purpose was to evaluate whether a higher CSA is associated with retear after rotator cuff repair. METHODS This was a retrospective review of 76 patients who had undergone rotator cuff repair with postoperative ultrasound examination. Ultrasound findings were graded no retear (NT), partial-thickness (PT) retear, or full-thickness (FT) retear. Preoperative radiographs were used to measure CSA, glenoid inclination, lateral acromion angle, and acromion index. RESULTS Average age was 61.9 years (45.3-74.9 years). On ultrasound examination, 57 shoulders (74.0%) had NT, 11 (14.2%) had PT retears, and 8 (10.3%) had FT retears. There was no significant difference in retear rate by age, gender, or tension of repair. Average CSA was significantly lower for the NT group at 34.3° ± 2.9° than for the FT group at 38.6° ± 3.5° (P < .01). If CSA was >38°, the odds ratio of having an FT retear was 14.8 (P < .01). In addition, higher CSA inversely correlated with postoperative American Shoulder and Elbow Surgeons scores (P < .03). Average glenoid inclination was significantly lower in the NT group at 12.3° ± 2.7° compared with 17.3° ± 2.6° in the FT group (P < .01). If glenoid inclination was >14, the odds ratio of having a FT retear was 15.0 (P < .01). CONCLUSION At short-term follow-up, higher CSA significantly increased the risk of an FT retear after rotator cuff repair. Also, increasing CSA correlated with worse postoperative American Shoulder and Elbow Surgeons scores. This radiographic marker may help manage expectations for rotator cuff tear patients.

Malnutrition: a marker for increased complications, mortality, and length of stay after total shoulder arthroplasty.

BACKGROUND Malnutrition is an established risk factor for postoperative complications. The purpose of this investigation was to determine the overall prevalence of malnutrition in total shoulder arthroplasty (TSA) patients, the differences in prevalence across obesity subgroups, and the overall complication risk of malnourished patients compared with normal patients. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried for TSA cases from 2005 to 2013 for this retrospective cohort study. Malnutrition was defined as preoperative albumin concentration of <3.5 g/dL. Rates of postoperative complications were compared between normal and malnourished patients. RESULTS We identified 4,655 TSA cases, with preoperative albumin measurements available for 1681 patients (36.1%). Propensity score adjustment successfully reduced selection bias, with adjusted P values of >.05 for demographics, body mass index, and modified Charlson Comorbidity Index. Of the cohort with albumin measurements, 7.6% of patients were malnourished according to our criteria. Bivariate analysis showed malnourished patients had higher rates of pulmonary complications, anemia requiring transfusion, extended length of stay (LOS), and death (all P < .05). Propensity-adjusted multivariable logistic regression demonstrated that malnutrition was significantly associated (all P < .05) with postoperative transfusion (odds ratio, 2.49), extended LOS (odds ratio, 1.69), and death (odds ratio, 18.09). CONCLUSION The overall prevalence of malnutrition was 7.6%. Malnourished patients were at a significantly increased risk for blood transfusion, longer hospital LOS, and death within 30 days of surgery. Multivariable analysis showed TSA patients with preoperative albumin levels of <3.5 g/dL are at much higher risk for morbidity and death after surgery than patients with albumin levels within normal reference ranges.

Comparison of arthroscopic osteochondral substitute grafting and remplissage for engaging Hill-Sachs lesions.

The optimum management for recurrent glenohumeral instability with significant humeral head defects remains controversial. The purpose of this study was to compare outcomes and recurrence rates between patients who underwent osteochondral substitute grafting and patients who underwent remplissage to treat recurrent shoulder instability from an engaging Hill-Sachs defect with a Bankart lesion. Twenty consecutive patients who underwent remplissage and 19 consecutive patients who underwent osteochondral substitute grafting with Bankart repair were studied. Mean follow-up was 29.6 months for the remplissage group and 32.1 months for the osteochondral substitute grafting group. All patients had an engaging Hill-Sachs lesion, and indications for surgery were identical between groups. Three postoperative recurrences occurred in the remplissage group and 6 occurred in the osteochondral substitute grafting group (P=.18). Nineteen patients in the remplissage group and 7 patients in the osteochondral substitute grafting group had a large humeral head defect. Patients in the remplissage group had better Western Ontario Shoulder Instability Index [WOSI] scores than those in the osteochondral substitute grafting group for large lesions (74.7 vs 50.4, respectively), although they were not statistically significant (P=.077). After controlling for age, sex, lesion size, and follow-up differences, the remplissage group reported significantly better WOSI scores (P=.016). This study demonstrated a potential advantage of remplissage compared with osteochondral synthetic grafting in patients who experienced recurrent anterior shoulder instability, particularly in shoulders with a large humeral head defect.

Sports after shoulder arthroplasty: a comparative analysis of hemiarthroplasty and reverse total shoulder replacement

BACKGROUND Traditionally, fewer postoperative sport restrictions are imposed on hemiarthroplasty (HHA) patients on than reverse total shoulder arthroplasty (RTSA) patients. However, functional outcomes have been shown to be superior in RTSA. No direct comparison of RTSA vs HHA has been done on rates of return to sports in patients with glenohumeral arthritis and rotator cuff dysfunction, proximal humeral fractures, or rheumatoid arthritis. METHODS This is a retrospective review of consecutive RTSA and HHA patients collected from our institutions shoulder arthroplasty registry. All patients playing sports preoperatively with minimum 1-year follow-up were included. Final follow-up included an additional patient-reported questionnaire with questions regarding physical fitness and sport activities. RESULTS The study included 102 RTSA and 71 HHA patients. Average age at surgery was 72.3 years for RTSA compared with 65.6 years for HHA (P < .001). Patients undergoing RTSA had improved visual analog scale scores compared with HHA (-5.6 vs -4.2, P = .007), returned to sports after RTSA at a significantly higher rate (85.9% vs 66.7%, P = .02), and were more likely to be satisfied with their ability to play sports (P = .013). HHA patients were also more likely to have postoperative complaints than RTSA patients (63% vs 29%, P < .0001). No sports-related complications occurred. Female sex, age <70 years, surgery on the dominant extremity, and a preoperative diagnosis of arthritis with rotator cuff dysfunction predicted a higher likelihood of return to sports for patients undergoing RTSA compared with HHA. CONCLUSIONS Despite traditional sport restrictions placed on RTSA, patients undergoing RTSA can return to sports at rates higher than those undergoing HHA, with fewer postoperative complaints.