Joseph W. Galvin

Management of complications after total shoulder arthroplasty

The outcomes of total shoulder arthroplasty (TSA) for painful arthritis of the glenohumeral joint are excellent with significant improvement in pain and function. Increased use of total shoulder arthroplasty over the past decade has led to identification of common complications. Although the complication rate is low, accurate and timely diagnosis, appropriate management, and implementation of methods for prevention are critical to a successful long-term outcome. The most common complications include infection, glenoid and humeral component loosening, rotator cuff tear, periprosthetic fracture, and neurologic injury. The purpose of this review is to outline the best practices for diagnosing, managing, and preventing these complications.

The Epidemiology and Natural History of Anterior Shoulder Instability

Purpose of ReviewThe purpose of this review is to outline the natural history and best clinical practices for nonoperative management of anterior shoulder instability.Recent FindingsRecent studies continue to demonstrate a role for nonoperative treatment in the successful long-term management of anterior glenohumeral instability. The success of different positions of shoulder immobilization is reviewed as well.SummaryThere are specific patients who may be best treated with nonoperative means after anterior glenohumeral instability. There are also patients who are not good nonoperative candidates based on a number of factors that are outlined in this review. There continues to be no definitive literature regarding the return to play of in-season athletes. Successful management requires a thorough understanding of the epidemiology, pathoanatomy, history, physical examination, diagnostic imaging modalities, and natural history of operative and nonoperative treatment.

Arthroscopic treatment of posterior shoulder instability in patients with and without glenoid dysplasia: a comparative outcomes analysis

BACKGROUND The purpose of this study was to evaluate the influence of glenoid dysplasia on outcomes after isolated arthroscopic posterior labral repair in a young military population. METHODS Thirty-seven male patients who underwent arthroscopic posterior labral repair for symptomatic posterior shoulder instability were evaluated at a mean duration of 3.1 years. A comparative analysis was performed for those with glenoid dysplasia and without dysplasia. Additional factors analyzed included military occupational specialty (MOS), preoperative mental health clinical encounters and mental health medication use, and radiographic characteristics (version, posterior humeral head subluxation, and posterior capsular area) on a preoperative standard shoulder magnetic resonance arthrogram. The groups were analyzed with regard to shoulder outcome scores (subjective shoulder value [SSV], American Shoulder and Elbow Surgeons [ASES] rating scale, Western Ontario Shoulder Instability Index [WOSI]), need for revision surgery, and medical separation from the military. RESULTS Of 37 patients, 3 (8.1%) underwent revision surgery and 6 (16%) underwent medical separation. Overall outcome assessment demonstrated a mean SSV of 67.9 (range, 25-100) ± 22.1, mean ASES of 65.6 (range, 15-100) ±  22, and mean WOSI of 822.6 (range, 5-1854) ± 538. There were no significant differences in clinical outcome scores between the glenoid dysplasia and no dysplasia groups (SSV, P = .55; ASES, P = .57; WOSI, P = .56). MOS (P = .02) and a history of mental health encounters (P = .04) were significantly associated with diminished outcomes. CONCLUSIONS The presence or absence of glenoid dysplasia did not influence the outcome after arthroscopic posterior labral repair in a young military population. However, a history of mental health clinical encounters and an infantry MOS were significantly associated with poorer clinical outcomes.

Return to Duty Rates Following Meniscal Repair Surgery in an Active Duty Military Population

Meniscal injury is a common knee injury in a young athletic population. Maintaining the integrity of the meniscus is critical to reducing contact pressures on the tibiofemoral articulation. The purpose of this study is to analyze the outcomes of meniscal repair in a young military population. We conducted a retrospective review of all meniscal repairs performed on active duty Army personnel at a Military Medical Center from January 2002 to December 2012. One hundred seventy-eight active duty patients, mean age 28 (19-48) years underwent 178 meniscal repairs. Postoperatively, 33 (18.5%) patients were medically separated from the military at an average time of 29 months. Fifty (28%) patients required a permanent duty restricting profile. Ninety-five (53.5%) patients required no profile after meniscal repair at an average follow-up of 5 (1.5-12.3) years. Meniscal repair in this young military population allowed 81.5% of patients to return to duty; however, 34% of those required a permanent duty restricting profile. Approximately 20% of patients required medical separation from the military after meniscal repair. Older age was significantly associated with the ability to remain on active duty (p = 0.01).

Glenoid Dysplasia: Pathophysiology, Diagnosis, and Management.

➤Subtle forms of glenoid dysplasia may be more common than previously thought and likely predispose some patients to symptomatic posterior shoulder instability. Severe glenoid dysplasia is a rare condition with characteristic radiographic findings involving the posteroinferior aspect of the glenoid that often remains asymptomatic.➤Instability symptoms related to glenoid dysplasia may develop over time with increased activities or trauma. Physical therapy focusing on rotator cuff strengthening and proprioceptive control should be the initial management.➤Magnetic resonance imaging and computed tomographic arthrograms are useful for detecting subtle glenoid dysplasia by revealing the presence of an abnormally thickened or hypertrophic posterior part of the labrum, increased capsular volume, glenoid retroversion, and posteroinferior glenoid deficiency.➤Open and arthroscopic labral repair and capsulorrhaphy procedures have been described for symptomatic posterior shoulder instability. Glenoid retroversion of >10° may be a risk factor for failure following soft-tissue-only procedures for symptomatic glenoid dysplasia.➤Osseous procedures are categorized as either glenoid reorientation (osteotomy) or glenoid augmentation (bone graft), and no predictable results have been demonstrated for any surgical strategy. Glenoid osteotomies have been described for increased retroversion, with successful results, although others have noted substantial complications and poor outcomes.➤In severe glenoid dysplasia, the combination of bone deficiency and retroversion makes glenoid osteotomy extremely challenging. Bone grafts placed in a lateralized position to create a blocking effect may increase the risk of the development of arthritis, while newer techniques that place the graft in a congruent position may decrease this risk.

Critical Findings on Magnetic Resonance Arthrograms in Posterior Shoulder Instability Compared With an Age-Matched Controlled Cohort

Background: Posterior shoulder instability is less common and potentially more difficult to diagnose clinically and radiographically compared with anterior shoulder instability. Radiographic findings including posterior labral tears, increased retroversion, presence of glenoid dysplasia, and increased capsular area are associated with symptomatic recurrent posterior shoulder instability. Purpose: This study aimed to determine the prevalence and severity of associated radiographic parameters found on magnetic resonance arthrograms (MRAs) in patients with arthroscopically confirmed isolated posterior labral tears and symptomatic recurrent posterior shoulder instability, compared with an age-matched cohort of patients without posterior instability or labral injury confirmed with shoulder arthroscopy. Study Design: Cross-sectional study, Level of evidence, 3. Methods: Patients who received a preoperative standard shoulder MRA at an academic institution over a 5-year period and had symptomatic posterior instability and received a repair of an arthroscopically confirmed posterior labral tear (n = 63) were identified. These patients were compared with an age-matched control group of patients without posterior instability (n = 49) who underwent an isolated arthroscopic distal clavicle resection that included an arthroscopic glenohumeral joint evaluation. Glenoid version, posterior humeral head subluxation, glenoid dysplasia, and linear and capsular area measurements were evaluated between the 2 groups. Interobserver reliability for continuous and categorical variables was assessed for all measurements. Results: Multivariate logistic regression revealed that the presence of increased glenoid retroversion (P = .0018), glenoid dysplasia (P = .03), and increased axial posterior capsular cross-sectional area (P = .05) were significantly associated with posterior labral tears and symptomatic posterior shoulder instability compared with the age-matched control group. Posterior humeral head subluxation was found to be a statistically significant variable with univariate analysis (P = .001) for posterior shoulder instability but not with multivariate logistic regression (P = .53). Interobserver reliability was good to very good for all measurements (intraclass correlation coefficient [ICC] = 0.74-0.85; κ = 0.64) but was moderate for total capsular area and sagittal capsular area measurements (ICC = 0.43-0.56). Conclusion: The presence of increased glenoid retroversion, glenoid dysplasia, and increased posterior capsular area on MRA are significantly associated with posterior labral tears and symptomatic posterior shoulder instability. Identification of these critical radiographic variables on magnetic resonance arthrography assists in the accurate diagnosis and management of clinically significant posterior shoulder instability.

Posterior shoulder instability following anatomic total shoulder arthroplasty: A case report and review of management

We report a case of posterior shoulder instability following anatomic total shoulder arthroplasty (TSA). In addition, we present guidelines to aid in the management of posterior instability after TSA. A 50-year-old male underwent anatomic TSA for glenohumeral osteoarthritis. Postoperatively, the patient developed posterior instability secondary to glenoid retroversion. He did not improve despite conservative treatment. He underwent an arthroscopic posterior bone block procedure, 4-month after his index arthroplasty. At 14-month follow-up, the patient had regained near full motion and strength, and radiographs demonstrated osseous integration with no evidence of component loosening. Posterior instability following TSA is a relatively rare complication and challenging to manage. The posterior, arthroscopic iliac crest bone block grafting procedure represents a treatment option for posterior instability in the setting of a stable glenoid prosthesis following TSA.

Pseudarthrosis of the clavicle.

A 21-year-old active duty soldier presented with right shoulder pain and prominence over his right clavicle, with no history of trauma. He recalled that the deformity had been present for a long time, but only recently became painful. The onset of shoulder pain coincided with the beginning of his military service and the requirement to wear over-the-shoulder equipment such as back packs and load-bearing equipment. Physical examination revealed a prominence over the right midshaft clavicle with tenderness to palpation, full active range of motion of the shoulder, and that he was neurovascularly intact.

Snapping Biceps Femoris Tendon

A 23-year-old male active duty soldier presented with a biceps femoris tendon snapping over the fibular head with flexion of the knee beyond 90°. Surgical release of anomalous anterolateral tibial and lateral fibular insertions provided relief of snapping with no other repair or reconstruction required. The soldier quickly returned to full running and active duty. Snapping biceps femoris tendon is a rare but potential cause of pain and dysfunction in the lateral knee. The possible anatomical variations and the cause of snapping must be considered when determining the operative approaches to this condition.

Trends in Surgical Management of Anterior Shoulder Instability: Increased Utilization of Bone Augmentation Techniques†

Purpose The purpose of this study is to evaluate the trends in surgical management for anterior shoulder instability in the U.S. Military. Methods A retrospective analysis of military service members undergoing arthroscopic or open shoulder stabilization from 2012 to 2015 within the U.S. Military Health System was conducted. Demographic and surgical variables were extracted from the medical record. Chi-square and linear regression analysis were performed to identify temporal trends by surgical procedures and concomitant surgery. Associations between demographic variables and surgical procedure were evaluated using logistic regression analysis with odds ratios and 95% confidence intervals. Results Eight thousand five hundred and eighty nine surgeries were performed for anterior shoulder instability. The arthroscopic Bankart procedure remained the dominant surgical procedure over time (n = 8177, 95.2%), whereas the open Bankart procedure (n = 172, 2.0%) demonstrated a diminishing trend, which was significant on univariate analysis (p = 0.0009), but not statistically significant on linear regression (p = 0.12). Additionally, there was a significant trend toward increased utilization of the Latarjet procedure over the period studied (n = 33, 1.7% - n = 81, 3.56%) (p = 0.009). During the same time period, concomitant superior labrum anterior/posterior repairs decreased (n = 980, 11.4%; p = 0.0045), whereas rates of biceps tenodesis (n = 741, 8.6%; p = 0.05) increased significantly. When analyzing patient age as a continuous variable, increasing age was associated with a significantly higher likelihood of arthroscopic treatment (odds ratio 1.02, 95% confidence interval 1.00-1.03, p = 0.05). Conclusion The rate of performing an arthroscopic Bankart repair has remained relatively stable as the dominant surgical procedure for shoulder instability in the military patient population. There was a significant trend of increased use of the Latarjet procedure, which likely reflects the recognition of bone loss through use of preoperative advanced imaging and computed tomography with three-dimensional reconstructions. Additionally, there was a significant decrease in adjacent superior labrum anterior/posterior repairs over the study period, followed by a corresponding rise in biceps tenodesis. Level of evidence: level IV.