Ilya Voloshin

Complications of total elbow replacement: A systematic review

Total elbow arthroplasty (TEA) is becoming an increasingly popular reconstructive procedure. Improved surgical techniques, newer implant designs, and improving clinical results have each contributed to the rise in prevalence of this surgical intervention. Themost common indication remains rheumatoid arthritis (RA). However, with the advent of semiconstrained prostheses, the indications have expanded to include post-traumatic sequelae such as instability and arthritis, as well as acute comminuted distal humerus fractures in the elderly. The rate of complications following TEA, ranging from 20% to 45%, is higher than in other large joint replacements. In their review of the literature, Gschwend et al reported a complication rate of 43% including aseptic loosening, infections, ulnar nerve complications, instability, disassembly, dislocation, subluxation, intraoperative fractures, fractures of the prosthesis, and ectopic bone formation. In order to reduce these complications, a variety of technical advances have been made within the last decade in the areas of prosthetic design and surgical technique. Fully constrained prostheses have fallen out of favor due to their high rates of aseptic loosening. They have been largely replaced by linked and unlinked components. The linked prostheses are semi-constrained and utilize ‘‘sloppy hinges,’’ which both decrease the rate of aseptic

Arthroscopic Versus Mini-open Rotator Cuff Repair A Comprehensive Review and Meta-analysis

Background Controversy remains regarding the results of all arthroscopic rotator cuff repairs compared with the mini-open approach. The purpose of this study was to perform a comprehensive literature search and meta-analysis of clinical trials comparing the results of arthroscopic rotator cuff repairs and mini-open rotator cuff repairs. Hypothesis There is no difference between the clinical results obtained from all arthroscopic rotator cuff repairs compared with mini-open repairs. Study Design Meta-analysis. Methods A computerized search of articles published between 1966 and July 2006 was performed using MEDLINE and PubMed. Additionally, a search of abstracts from 4 major annual meetings each held between 2000 and 2005 was performed to identify Level I to III studies comparing the results of arthroscopic rotator cuff repair and mini-open repair. Studies that included follow-up of an average of over 2 years and a minimum of 1 year and included the use of 1 of 4 validated functional outcome scores used to study shoulder injuries were included in the present meta-analysis. All outcome scores were converted to a 100-point scale to allow for outcome comparison. Results Five studies that met the inclusion criteria were identified. There was no difference in functional outcome scores or complications between the arthroscopic and mini-open repair groups. Conclusion Based on current literature, there was no difference in outcomes between the arthroscopic and mini-open rotator cuff repair techniques.

Pediatric tibial eminence fractures: evaluation and management.

Abstract Tibial eminence fractures result from both contact and noncontact injuries. Skeletally immature persons are especially at risk. In adults, isolated fractures of the tibial eminence are usually associated with higher‐energy mechanisms. The incidence of concomitant intra‐articular injuries with tibial eminence fracture is high; MRI is useful in evaluating this injury. Nondisplaced fractures are amenable to nonsurgical management. Displaced fractures are managed with arthroscopic reduction and fixation with either sutures or screws. Although most fractures heal successfully, residual laxity usually persists because of prefracture anterior cruciate ligament midsubstance attenuation. This does not typically manifest in subjective instability, and reconstruction of the anterior cruciate ligament is rarely required. Patient factors, surgeon experience, and fracture pattern must be carefully considered before undertaking surgical repair.

Arthroscopic distal clavicle resection in athletes : A prospective comparison of the direct and indirect approach

Background The clinical success of arthroscopic distal clavicle resection for athletes has been well documented. There are, however, no published studies that prospectively compare the recovery rates in athletes as well as the outcomes of the indirect versus direct approaches. Hypothesis Both procedures are equally successful; however, the direct approach affords faster return to sports. Study Design Randomized controlled clinical trial; Level of evidence, 2. Methods Thirty-eight consecutive athletes with osteolysis of the distal clavicle or isolated posttraumatic arthrosis of the acromioclavicular joint without instability underwent arthroscopic distal clavicle resection. The patients were randomized into 2 groups: a direct superior approach and an indirect subacromial approach. American Shoulder and Elbow Surgeons and Athletic Shoulder Scoring System scores were measurable outcomes. Results Thirty-four athletes were available for a minimum 2-year follow-up. The 2 groups were similar, including preoperative American Shoulder and Elbow Surgeons and Athletic Shoulder Scoring System scores. Both groups demonstrated significant improvement in both scores at final follow-up when compared with preoperative scores (P < .001). The direct group demonstrated higher American Shoulder and Elbow Surgeons (82 vs 64) and Athletic Shoulder Scoring System (74 vs 56) scores at week 2 (P < .001) and week 6 (American Shoulder and Elbow Surgeons, 88 vs 77; Athletic Shoulder Scoring System, 87 vs 73) (P < .001). At final follow-up, both groups demonstrated excellent clinical outcomes, even though there was a statistical difference in scores, with the direct group scoring better (American Shoulder and Elbow Surgeons, 95.7 vs 91.2; Athletic Shoulder Scoring System -94.9 vs 88.3). The direct group demonstrated faster return to sports (mean, 21 days) than the indirect group (mean, 42 days) (P < .001). Radiographic analysis demonstrated an equivalent resection. One patient in each group had a clinically insignificant increase in coracoclavicular distance. Conclusions Both the direct superior approach and the indirect subacromial approach to the arthroscopic distal clavicle resection result in successful clinical outcome with clinically insignificant difference at final follow-up. Athletes treated with the direct superior approach improved faster clinically and returned to sports earlier.

Analysis of subscapularis integrity and function after lesser tuberosity osteotomy versus subscapularis tenotomy in total shoulder arthroplasty using ultrasound and validated clinical outcome measures

BACKGROUND The optimal method-subscapularis peel (SP) or lesser tuberosity osteotomy (LTO)-for takedown of the subscapularis during total shoulder arthroplasty (TSA) is controversial. This study compares the functional outcomes in a 2-surgeon cohort using the 2 techniques. METHODS Patients who underwent TSA with a minimum 1 year of follow-up were evaluated. Physical and ultrasound examinations of the operative shoulder were performed. Radiographs were evaluated for osteotomy healing. Patients completed the Western Ontario Osteoarthritis of the Shoulder (WOOS) index, Disability of the Arm, Shoulder, and Hand (DASH), and Constant Scores. RESULTS Subscapularis tenotomy (n = 32) and LTO (n = 28) patients were similar in age, hand dominance, and sex. Follow-up duration for subscapularis tenotomy and LTO patients differed (31.7 vs 22.1 months, P = .003). SP patients demonstrated increased external rotation (69° ± 12° vs 60° ± 11°). Belly press and bear hug resistance were not significantly different. WOOS (P = .13), DASH (P = .71), and Constant Scores (P = .80) were not significantly different. After controlling for follow-up imbalance, the WOOS score difference was statistically significant (91.5 ± 10.2 for LTO vs 82.1 ± 18.9 for SP, P = .05) but not clinically significant. By ultrasonography assessment, 4 subscapularis tendons were abnormal in the SP group (3 attenuated, 1 ruptured), and all tendons were normal in the LTO group. Patients with an abnormal ultrasound result had significantly inferior WOOS (88 ± 15 vs 65 ± 18) and DASH (11.5 ± 11.4 vs 25.9 ± 11.2) scores. Belly press resistance was significantly decreased, bear hug resistance trended lower, and external rotation was increased in the abnormal ultrasound group. CONCLUSIONS Abnormal subscapularis tendons identified by ultrasonography only in the SP group correlate with clinically significant inferior functional outcome scores.

Arthroscopic Versus Open Acromioplasty A Meta-Analysis

Background To address persisting controversy in the literature concerning the efficacy of arthroscopic compared to open acromioplasty, a meta-analysis was performed to evaluate the treatment effect after both approaches. Hypothesis The final clinical outcomes will be the same after both open and arthroscopic acromioplasty. However, the arthroscopic technique results in faster recovery and less postoperative morbidity as reflected by faster return to work and decreased hospital stays. Study Design Meta-analysis; Level of evidence, 3. Methods We performed our search of published English language literature using PubMed. We also searched the proceedings from 4 major orthopaedic meetings convened from 2000 to 2007. Furthermore, the reference sections of all relevant articles were reviewed for pertinent studies and presentations. Nine studies met the inclusion criteria that directly compared arthroscopic versus open acromioplasty with minimum follow-up of 1 year. The analysis focused on 1-year clinical outcome and included comparison of the objective 100-point score, hospital stay, time until return to work, operative time, and complications. Results No significant differences were found in clinical outcomes or complications for the 2 groups. However, open acromioplasty was associated with longer hospital stays (2.3 days, P = .05) and a greater length in time until return to work (65.1 days) compared with the arthroscopic technique (48.6 days) (P < .05). Conclusion Arthroscopic and open acromioplasty have equivalent ultimate clinical outcomes, operative times, and low complication rates. However, arthroscopic acromioplasty results in faster return to work and fewer hospital inpatient days compared with the open technique.

Arthroscopic Evaluation of Radiofrequency Chondroplasty of the Knee

Background Considerable debate exists over the use of radiofrequency-based chondroplasty to treat partial-thickness chondral defects of the knee. This study used second-look arthroscopy to evaluate cartilage defects previously treated with bipolar radiofrequency—based chondroplasty. Hypothesis Partial-thickness articular cartilage lesions treated with bipolar radiofrequency—based chondroplasty will show no progressive deterioration. Study Design Case series; Level of evidence, 4. Methods One hundred ninety-three consecutive patients underwent bipolar radiofrequency—based chondroplasty over 38 months; 15 (25 defects treated with bipolar radiofrequency—based chondroplasty) underwent repeat arthroscopy for recurrent or new injuries. Time from the initial to repeat arthroscopy ranged from 0.7 to 32.7 months. At both procedures, the location, size, grade, and stability of lesions were evaluated, recorded, and photographed arthroscopically. Results At the initial procedure, 25 lesions treated using bipolar radiofrequency—based chondroplasty ranged from 9 to 625 mm2 (mean, 170.2 ± 131.2 mm2; median, 120 mm2); at second look, lesion size was 9 to 300 mm2 (mean, 107.7 ± 106.7 mm2; median, 100 mm2). At second look, 3 (12%) demonstrated unstable borders with damage in the surrounding cartilage that appeared to be progressive. Eight (32%) lesions were unchanged in size. Eight (32%) demonstrated partial filling with stable repair tissue, and 6 (24%) demonstrated complete filling with stable repair tissue. Lesions in the tibiofemoral compartments showed better response to radiofrequency chondroplasty than did those within the patellofemoral joint (P < .05). Conclusion Only 3 of 25 lesions demonstrated progression. More than 50% showed partial or complete filling of the defect. Bipolar radiofrequency chondroplasty is an effective way to treat partial-thickness cartilage lesions; however, long-term effects of this treatment on cartilage remain unknown.

Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent

BACKGROUND Total shoulder arthroplasty (TSA) results in superior clinical outcomes to hemiarthroplasty (HA); however, TSA is a more technical and invasive procedure. This study retrospectively compares perioperative complications after HA and TSA using the National Surgical Quality Improvement Program (NSQIP) database. METHODS The NSQIP user file was queried for HA and TSA cases from the years 2005 through 2010. Major complications were defined as life-threatening or debilitating. All complications occurred within 30 days of the initial procedure. We performed multivariate analysis to compare complication rates between the two procedures, controlling for patient comorbidities. RESULTS The database returned 1,718 patients (HA in 30.4% [n = 523] and TSA in 69.6% [n = 1,195]). The major complication rates in the HA group (5.2%, n = 29) and TSA group (5.1%, n = 61) were similar (P = .706). Rates of blood transfusions for postoperative bleeding in patients undergoing HA (2.3%, n = 12) and TSA (2.9%, n = 35) were indistinguishable (P = .458). Venous thromboembolism was a rare complication, occurring in 0.4% of patients in each group (2 HA patients and 5 TSA patients, P > .999). On multivariate analysis, the operative procedure was not associated with major complications (P = .349); however, emergency case, pulmonary comorbidity, anemia with a hematocrit level lower than 36%, and wound class of III or IV increased the risk of a major complication (P < .05 for all). CONCLUSION Multivariate analysis of patients undergoing TSA or HA in the NSQIP database suggests that patient factors-not the procedure being performed-are significant predictors of major complications. Controlling for patient comorbidities, we found no increased risk of perioperative major complications in patients undergoing TSA compared with HA.

Relevant Anatomic Landmarks and Measurements for Biceps Tenodesis

Background: Biceps tenodesis around the pectoralis major insertion may alter resting tension on the biceps, leading to unfavorable clinical outcomes. Hypothesis: The anatomic relationship between the musculotendinous junction (MTJ) of the biceps and the pectoralis major tendon will provide guidelines for anatomic location to perform biceps tenodesis with the goal of re-establishing biceps tension. Study Design: Descriptive laboratory study. Methods: Cadaveric dissections were performed that reflected the pectoralis major tendon and exposed the long head of the biceps tendon (LHBT). Calipers were used to measure the longitudinal width of the pectoralis major tendon at the humerus, 2 cm away from the humerus, and at its proximal expansion on the humerus. The distance from the proximal extent of the pectoralis major tendon footprint to the beginning of the MTJ of the biceps and the length of the MTJ of the biceps were recorded. The location of the distal end of the MTJ of the biceps relevant to the inferior border of the pectoralis major tendon was calculated. Results: The average longitudinal width of the pectoralis major tendon at its humeral insertion was 76.8 mm, the width 2 cm away from the humerus averaged 37.3 mm, and the proximal expansion averaged 13.3 mm. The MTJ of the biceps began an average of 32.4 mm distal from the proximal aspect of the pectoralis major footprint and extended for an average of 78.1 mm. The MTJ of the LHBT was calculated to extend 3.3 cm distal to the inferior border of the pectoralis major footprint. Conclusion: The MTJ of the biceps begins further proximal than may be appreciated intraoperatively. Knowledge of the anatomic relationships between the LHBT, its MTJ, and the pectoralis major tendon provides helpful guidelines for the biceps tenodesis site. The final resting spot of the most distal aspect of the MTJ of the LHBT after tenodesis should be approximately 3 cm distal to the inferior edge of the pectoralis major tendon footprint on the humerus.

Addition of a Suture Anchor for Coracoclavicular Fixation to a Superior Locking Plate Improves Stability of Type IIB Distal Clavicle Fractures

PURPOSE The purpose of this study was to determine the effect of coracoclavicular (CC) fixation on biomechanical stability in type IIB distal clavicle fractures fixed with plate and screws. METHODS Twelve fresh-frozen matched cadaveric specimens were used to create type IIB distal clavicle fractures. Dual-energy x-ray absorptiometry (DEXA) scans ensured similar bone quality. Group 1 (6 specimens) was stabilized with a superior precontoured distal clavicle locking plate and supplemental suture anchor CC fixation. Group 2 (6 specimens) followed the same construct without CC fixation. Each specimen was cyclically loaded in the coronal plane at 40 to 80 N for 17,500 cycles. Load-to-failure testing was performed on the specimens that did not fail cyclic loading. Outcome measures included mode of failure and the number of cycles or load required to create 10 mm of displacement in the construct. RESULTS All specimens (12 of 12) completed cyclic testing without failure and underwent load-to-failure testing. Group 1 specimens failed at a mean of 808.5 N (range, 635.4 to 952.3 N), whereas group 2 specimens failed at a mean of 401.3 N (range, 283.6 to 656.0 N) (P = .005). Group 1 specimens failed by anchor pullout without coracoid fracture (4 of 6) and distal clavicle fracture fragment fragmentation (1 of 6); one specimen did not fail at the maximal load the materials testing machine was capable of exerting (1,000 N). Group 2 specimens failed by distal clavicle fracture fragment fragmentation (3 of 6) and acromioclavicular (AC) joint displacement (1 of 6); 2 specimens did not fail at the maximal load of the materials testing machine. CONCLUSIONS During cyclic loading, type IIB distal clavicle fractures with and without CC fixation remain stable. CC fixation adds stability to type IIB distal clavicle fractures fixed with plate and screws when loaded to failure. CLINICAL RELEVANCE CC fixation for distal clavicle fractures is a useful adjunct to plate-and-screw fixation to augment stability of the fracture.