Justin W. Griffin

Peripheral nerve repair and reconstruction.

When possible, direct repair remains the current standard of care for the repair of peripheral nerve lacerations. In large nerve gaps, in which direct repair is not possible, grafting remains the most viable option. Nerve scaffolds include autologous conduits, artificial nonbioabsorbable conduits, and bioabsorbable conduits and are options for repair of digital nerve gaps that are <3 cm in length. Experimental studies suggest that the use of allografts may be an option for repairing larger sensory nerve gaps without associated donor-site morbidity.

Nerve conduits for nerve repair or reconstruction.

Advances in treating peripheral nerve lesions have resulted from research in nerve regeneration and the use biomaterials as well as synthetic materials. When direct tensionless repair of peripheral nerve lesions is not possible, nerve conduits may be used to bridge digital sensory nerve gaps of ≤3 cm. Nerve autograft is the benchmark for larger, longer, mixed, or motor nerve defects. Biologic, autogenous conduits-typically veins or, rarely, arteries-have demonstrated their utility in nerve gaps <3 cm in length. Three types of bioabsorbable conduit have been approved by the US Food and Drug Administration, constructed of collagen, polyglycolic acid, or caprolactone. Caprolactone conduits have been found to be equivalent in results to autograft. Collagen conduits are next best, and polyglycolic acid conduits are functionally inferior. Further research and prospective, multicenter, large-scale trials are needed to help establish the role of synthetic, bioabsorbable conduits in peripheral nerve reconstruction.

Morbid obesity in total shoulder arthroplasty: risk, outcomes, and cost analysis

BACKGROUND A rate of obesity in the US population and the rate of total shoulder arthroplasty (TSA) has increased over the past decade. Little information exists concerning the number of morbidly obese patients undergoing TSA or how these patients compare with their non-obese counterparts. The goal of this study was to determine whether morbidly obese patients exhibit greater rates of postoperative in-hospital complications, mortality, or utilization of resources. METHODS We used the Nationwide Inpatient Sample to analyze 31,924 patients undergoing TSA between 1998 and 2008. Multivariate analysis with logistic regression modeling was used to compare patients based on body mass index for various outcomes. RESULTS Among morbidly obese patients, predictors of death included age (odds ratio, 1.06; 95% confidence interval, 1.01-1.11) and Deyo score. A comparison of hospital costs among patients showed that increased patient body mass index led to increased hospital charges independent of physician charges (

Validation of an innovative method of shoulder range-of-motion measurement using a smartphone clinometer application

38,103.88 in morbidly obese patients vs

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: A Comparison of Restoration of Length-Tension and Mechanical Strength Between Techniques

33,521.66 in non-obese patients, P = .0001). An increased length of stay was observed in morbidly obese patients (2.84 days vs 2.52 days in obese patients and 2.56 days in non-obese patients, P = .003). Respiratory dysfunction occurred more commonly in morbidly obese patients than in non-obese patients (1.2% vs 0.7%; odds ratio, 1.61; P < .01). CONCLUSIONS Obese patients tend to have longer hospital stays, an increased risk of postoperative respiratory complications, and higher costs. Although there was a trend toward an increased early postoperative mortality rate, obesity was not associated with an increased incidence of most complications. These findings should be supplemented with further research to assist patient counseling and risk adjustment for obese patients undergoing TSA.

Obesity is associated with increased postoperative complications after operative management of proximal humerus fractures

BACKGROUND An accurate and reliable measurement of shoulder range of motion (ROM) is important in the evaluation of the shoulder. A smartphone digital clinometer application is a potentially simpler method for measuring shoulder ROM. The goal of this study was to establish the reliability and validity of shoulder ROM measurements among varying health care providers using a smartphone clinometer application in healthy and symptomatic adults. METHODS An attending surgeon, fellow, resident, physician assistant, and student served as examiners. Bilateral shoulders of 24 healthy subjects were included. Fifteen postoperative patients served as the symptomatic cohort. Examiners measured ROM of each shoulder, first using visual estimation and then using a goniometer and smartphone clinometer in a randomized fashion. RESULTS The interobserver reliability among examiners showed significant correlation, with average intraclass correlation coefficient [ICC(2,1)] values of 0.61 (estimation), 0.69 (goniometer), and 0.80 (smartphone). All 5 examiners had substantial agreement with the gold standard in healthy subjects, with average ICC(2,1) values ranging from 0.62 to 0.79. The interobserver reliability in symptomatic patients showed significant correlation, with average ICC(2,1) values of 0.72 (estimation), 0.79 (goniometer), and 0.89 (smartphone). Examiners had excellent agreement with the gold standard in symptomatic patients, with an average ICC(2,1) value of 0.98. CONCLUSION The smartphone clinometer has excellent agreement with a goniometer-based gold standard for measurement of shoulder ROM in both healthy and symptomatic subjects. There is good correlation among different skill levels of providers for measurements obtained using the smartphone. A smartphone-based clinometer is a good resource for shoulder ROM measurement in both healthy subjects and symptomatic patients.

Obstructive sleep apnea as a risk factor after shoulder arthroplasty

Objectives: The approach to biceps tenodesis remains controversial, as the procedure can be performed open or arthroscopically. Little data exists directly comparing the arthroscopic suprapectoral and open subpectoral techniques, particularly in terms of location, restoration of the long head biceps length-tension relationship, and the mechanical strength of the tenodesis. The purpose of this study was to (1) determine the in-vivo tenodesis location using arthroscopic suprapectoral (ASPBT) and open subpectoral techniques (OSPBT) for long head biceps tenodesis and compare this to the location achieved in a separate clinical cohort, (2) evaluate the in-vivo restoration of the long head biceps length-tension relationship for both ASPBT and OSPBT techniques and (3) assess how location in the proximal humerus (suprapectoral or subpectoral) and method of fixation affects pull-out strength for biceps tenodesis using an interference screw implant. Our null hypothesis was that no difference existed between ASPBT and OSPBT with regards to location, restoration of the length-tension relationship, and pull-out strength. Methods: 18 matched cadaveric shoulder specimens were randomized to either open subpectoral or arthroscopic suprapectoral tenodesis groups (9 open, 9 arthroscopic.) Tenodesis was performed by two sports fellowship-trained surgeons using identical clinical techniques. Prior to surgery, a metallic bead was sutured in place, 1 cm distal to the musculotendinous junction of the long head of the biceps, and a pre-operative fluoroscopic image was obtained. Post-operatively, an additional fluoroscopic image was obtained to evaluate the location of the tenodesis and the metallic bead, which was compared to the pre-operative image to determine tensioning (Fig 1). Biomechanical testing was then performed using a MTS machine with 2.5kN load cell. Constructs were cycled for 100 cycles, then load to failure testing was performed. Results: The average tenodesis location in the ASPBT group of cadaveric specimens was 4.68 cm ± 0.97 cm distal to the top of the humerus, compared with 7.46 cm ± 1.7 cm (p < 0.0001) in the OSPBT group. This was very similar to the location observed in a separate clinical cohort. The ASPBT technique resulted in an average of 2.15 ± 0.62 cm of biceps over-tensioning compared with 0.78 ± 0.35 cm (p < 0.001) in the OSPBT group. The average load to failure in the ASPBT group was 138.8 ± 29.1 N compared to 197 ± 38.6 N (p = 0.002) in the OSPBT group. Implant pullout was significantly more frequent in the ASPBT (7/9) compared to the OSPBT (1/9) group. Conclusion: This study revealed several notable differences between the arthroscopic suprapectoral and open subpectoral biceps tenodesis techniques. The described ASPBT technique using an interference screw implant results in a more proximal tenodesis location, has the tendency to over-tension the biceps and has a significantly decreased ultimate load to failure compared with an open subpectoral technique in matched cadaver specimens. Modification of currently published arthroscopic suprapectoral techniques is necessary to improve restoration of the physiologic length-tension relationship of the biceps. Improved implants are likely necessary to achieve equivalent construct strength to the open subpectoral technique, although the clinical ramifications of this strength discrepancy have not been established.

Management of failed metal-on-metal total hip arthroplasty

BACKGROUND Obesity has become a significant public health concern in the United States. The goal of this study was to assess the effect of obesity on postoperative complications after operative management of proximal humerus fractures by use of a national database. METHODS Patients who underwent operative management of a proximal humerus fracture were identified in a national database by Current Procedural Terminology codes for procedures in patients with International Classification of Diseases, Ninth Revision (ICD-9) codes for proximal humerus fracture, including (1) open reduction and internal fixation, (2) intramedullary nailing, (3) hemiarthroplasty, and (4) total shoulder arthroplasty. These groups were then divided into obese and nonobese cohorts by use of ICD-9 codes for obesity, morbid obesity, or body mass index >30. Each cohort was then assessed for local and systemic complications within 90 days and mortality within 2 years postoperatively. Odds ratios and 95% confidence intervals were calculated. RESULTS From 2005 to 2011, 20,319 patients who underwent operative management of proximal humerus fractures were identified, including 14,833 (73.0%) open reduction and internal fixation, 1368 (9.2%) intramedullary nail, 3391 (16.7%) hemiarthroplasty, and 727 (3.6%) shoulder arthroplasty. Overall, 3794 patients (18.7%) were coded as obese, morbidly obese, or body mass index >30. In each operative group, obesity was associated with a substantial increase in local and systemic complications. CONCLUSIONS Obesity and its resultant medical comorbidities are associated with increased rates of postoperative complications after operative management of proximal humerus fractures. Obese patients for whom operative management of proximal humerus fractures is planned should be counseled preoperatively about their increased risk for postoperative complications.

Outpatient total shoulder arthroplasty: a population-based study comparing adverse event and readmission rates to inpatient total shoulder arthroplasty

BACKGROUND Obstructive sleep apnea (OSA) has been identified as an important risk factor in perioperative orthopaedic surgery outcomes despite limited evidence. Screening systems are being instituted in increasing frequency to prevent morbidity and mortality. Our objective was to determine if patients with OSA have a higher likelihood of postoperative in-hospital complications, length of stay, or increased costs after shoulder arthroplasty. METHODS We utilized the Nationwide Inpatient Sample (NIS) to analyze 22988 patients undergoing TSA or hemiarthroplasty. Of these patients, 1983 (5.9%) were diagnosed with OSA. Multivariate analysis with logistic regression modeling was used to compare patients with and without OSA for various outcomes. RESULTS Patients with obstructive sleep apnea had overall similar in-hospital mortality and complications including PE compared with those without OSA. OSA was not associated with increased postoperative charges (

The timing of elective shoulder surgery after shoulder injection affects postoperative infection risk in Medicare patients.

39,741 in patients with OSA vs.