James Shaha

Clinical Validation of the Glenoid Track Concept in Anterior Glenohumeral Instability.

BACKGROUNDnGlenoid and humeral bone loss are well-described risk factors for failure of arthroscopic shoulder stabilization. Recently, consideration of the interactions of these types of bone loss (bipolar bone loss) has been used to determine if a lesion is on-track or off-track. The purpose of this study was to study the relationship of the glenoid track to the outcomes of arthroscopic Bankart reconstructions.nnnMETHODSnOver a 2-year period, 57 shoulders that were treated with an isolated, primary arthroscopic Bankart reconstruction performed at a single facility were included in this study. The mean patient age was 25.5 years (range, 20 to 42 years) at the time of the surgical procedure, and the mean follow-up was 48.3 months (range, 23 to 58 months). Preoperative magnetic resonance imaging was used to determine glenoid bone loss and Hill-Sachs lesion size and location and to measure the glenoid track to classify the shoulders as on-track or off-track. Outcomes were assessed according to shoulder stability on examination and subjective outcome.nnnRESULTSnThere were 10 recurrences (18%). Of the 49 on-track patients, 4 (8%) had treatment that failed compared with 6 (75%) of 8 off-track patients (p = 0.0001). Six (60%) of 10 patients with recurrence of instability were off-track compared with 2 (4%) of 47 patients in the stable group (p = 0.0001). The positive predictive value of an off-track measurement was 75% compared with 44% for the predictive value of glenoid bone loss of >20%.nnnCONCLUSIONSnThe application of the glenoid track concept to our cohort was superior to using glenoid bone loss alone with regard to predicting postoperative stability. This method of assessment is encouraged as a routine part of the preoperative evaluation of all patients under consideration for arthroscopic anterior stabilization.nnnLEVEL OF EVIDENCEnTherapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pathology of borderline HER-2/neu breast carcinoma: a biologically distinct phenotype.

SummaryPurposeThe significance of HER-2/neu results obtained by immunohistochemical analyses (IHC) which are neither negative nor strongly positive is controversial. The incidence of fluorescence in situ hybridization (FISH) positivity in these tumors is small and the implication is that these borderline results represent laboratory misclassification. We analyzed the tumor characteristics of these HER-2/neu borderline tumors to determine if they represent a unique tumor type.MethodsHER-2/neu status was determined by image analysis (IA) of IHC sections in 669 cases of invasive breast cancer. Borderline cases were reflexed to FISH to determine gene status. HER-2/neu results were compared to tumor morphology and other tumor markers.ResultsHER-2/neu was negative, borderline and positive in 69.5, 15.8, and 14.6% of cases, respectively. HER-2/neu amplification was present in 17.3% of borderline cases. The borderline group is significantly different from the HER-2/neu positive group for all parameters studied except Ki-67. Compared to the HER-2/neu negative group, the borderline group showed a significantly higher HER-2/neu gene copy number and a trend towards lower progesterone receptor expression (p=0.058). Compared to the HER-2/neu negative group, the HER-2/neu borderline/FISH-negative group showed significantly lower PR expression. Compared to the HER-2/neu positive group, the HER-2/neu borderline/FISH positive group showed significant differences with multiple parameters.ConclusionBorderline HER-2/neu tumors are a unique tumor type and do not represent laboratory imprecision. Hormone receptor alterations are associated with early changes in HER-2/neu expression. While IA is capable of detecting these changes, current FISH methodology is not.

Preoperative Resilience Strongest Predictor of Postoperative Outcome Following an Arthroscopic Bankart Repair

Objectives: Resilience, which is a psychometric property related to “hardiness” or the ability to respond to challenging situations, is a recognized predictor in many outcomes’ domains. This has been studied extensively in stressful situations such as military returning from deployment, serious disease, and traumatic injury. To date however, no study has assessed the role of patient resiliency with respect to surgical outcome. The purpose of this study was to assess the role of preoperative resiliency as calculated by the Brief Resiliency Score (BRS) on relevant surgical outcomes, including the time required to return to full unrestricted activity following an arthroscopic Bankart repair. In addition the correlation between pre-operative BRS with post-operative BRS, post-operative Western Ontario Instability Index (WOSI), American Shoulder and Elbow (ASES) and Single Assessment Numeric Evaluation (SANE) scores was also assessed. Methods: This is a retrospective review of prospectively gathered data on 25 consecutive active duty military patients undergoing an arthroscopic Bankart repair for instability. The mean follow-up was 24.3 months (range, 23-27) as the primary outcome was return to unrestricted duty which occurs within the first year post-intervention. There were 24 males and 1 female. All patients were on unrestricted active military duty prior to injuring the operative shoulder. All patients completed BRS, WOSI, ASES, and SANE questionnaires prior to operative intervention. They then completed the same questionnaires at the most recent follow-up as well as an additional questionnaire on military duty status (unrestricted duty, limited duty, medical separation from the military). Patients were divided into low resiliency and high resiliency groups based on a score of <4.0 for low and ≥4.0 for high in the BRS, and their outcomes were compared. Results: All patients had been cleared for return to full-duty or were undergoing a medical separation at final follow-up. There were no differences between groups in demographics, glenoid bone loss, or glenoid track status. Pre-operative BRS was significantly correlated with time to return to full duty, need for medical separation from the military, post-operative WOSI, SANE and ASES scores and change between pre- and post-operative WOSI, ASES and SANE scores. Those patients with high resiliency returned to full duty significantly faster than the low resiliency group (4.4 v 6.7 months, p<0.01), had better post-operative WOSI (86.4% v 48.9%, p<0.01), SANE (92 v 72, p=0.03), ASES scores (91.5 v 67.6, p=0.03) and were 5 times less likely to be medically separated from the military (7.7% v 38.5%, p<0.01). Also, patients with high resiliency had significantly greater improvement comparing pre-operative to post-operative WOSI (44.8% v 20.3%, p=0.04), ASES (22.0 v 7.5, p=0.04) and SANE scores (2.5 v 1.3, p=0.01). There were no patients with a change between pre- and post-operative resiliency classification. Conclusion: Preoperative resiliency was highly predictive of the time required to return to full, unrestricted military duty. It was also predictive of post-operative subjective and objective outcomes as well as overall improvement between pre- and post-operative outcomes scores. Highly resilient patients were able to return to duty 2 months faster with significantly fewer requiring medical separation from the military than those lacking resiliency.