Kevin T. Hug

Dermal Tissue Allograft for the Repair of Massive Irreparable Rotator Cuff Tears

Background: Massive irreparable rotator cuff tears in patients without advanced glenohumeral arthritis can pose a challenge to surgeons. Numerous management strategies have been utilized, and studies have shown varied results with regard to shoulder pain, range of motion, strength, and overall function. Hypothesis: Patients undergoing repair of massive irreparable rotator cuff tears through a mini-open approach with the use of human dermal tissue matrix allograft would demonstrate an improvement in pain, range of motion, strength, and subjective functional outcomes. Study Design: Case series; Level of evidence, 4. Methods: We performed a prospective observational study of 24 patients who underwent interposition repair of massive rotator cuff tears using human dermal allograft. All patients were evaluated preoperatively and postoperatively by the treating surgeon. Data were collected preoperatively and postoperatively for an average 3-year follow-up period (range, 29-40 months). Active range of motion as well as supraspinatus and infraspinatus strength was assessed. Subjective outcome measures included pain level (visual analog scale of 0-10, with 10 = severe pain), American Shoulder and Elbow Score (ASES), and Short-Form 12 (SF-12) score. Imaging evaluation to assess for repair integrity was performed using static and dynamic ultrasonography at final follow-up. Results: Mean pain level decreased from 5.4 to 0.9 (P = .0002). Mean active forward flexion and external rotation motion improved from 111.7° to 157.3° (P = .0002) and from 46.2° to 65.1° (P = .001), respectively. Mean shoulder abduction improved from 105.0° to 151.7° (P = .0001). Supraspinatus and infraspinatus strength improved from 7.2 to 9.4 (P = .0003) and from 7.8 to 9.3 (P = .002), respectively. Mean ASES improved from 66.6 to 88.7 (P = .0003). Mean SF-12 scores improved from 48.8 to 56.8 (P = .03). One partial graft retear occurred because of patient noncompliance during postoperative rehabilitation. However, this patient still demonstrated improvement in pain, motion, and subjective outcomes at final follow-up. Ultrasonography demonstrated “fully intact” repairs in 76% of patients. All remaining patients had “partially intact” repairs. There were no complete tears. Conclusion: In our series of carefully selected candidates, all patients demonstrated a significant improvement in pain, range of motion, and strength. Subjective outcome measures, including mean ASES and SF-12 scores, also demonstrated significant improvement at an average 3-year follow-up.

Massive or 2-Tendon Rotator Cuff Tears in Active Patients With Minimal Glenohumeral Arthritis Clinical and Radiographic Outcomes of Reconstruction Using Dermal Tissue Matrix Xenograft

Background: The management of irreparable massive or full-thickness 2-tendon rotator cuff tears in active patients with minimal glenohumeral arthritis remains a difficult challenge for the treating surgeon. Many different treatment options, with varied success, have been proposed. Hypotheses: (1) Patients undergoing reconstruction of irreparable massive or full-thickness 2-tendon rotator cuff tears by dermal tissue matrix xenograft would demonstrate improvements in pain, range of motion, strength, and subjective functional outcomes. (2) Postoperative ultrasonography would demonstrate intact repairs at a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: Twenty-six patients (27 shoulders) underwent reconstruction of irreparable massive or full-thickness 2-tendon rotator cuff tears by dermal tissue matrix xenograft. Pain level (scale 0-10, 10 = severe pain), active range of motion, and supraspinatus and external rotation strength were assessed. Subjective outcome measures included American Shoulder and Elbow Score (ASES) and Short Form-12 (SF-12) score. Clinical and radiographic analyses were performed at an average 32-month follow-up period (minimum 2-year follow-up). Ultrasound imaging (static and dynamic) of the operative shoulder was performed at final follow-up to assess the integrity of the construct. Results: Mean patient age was 60 years. Mean pain level decreased from 5.1 to 0.4 (P = .002). Mean active forward flexion and abduction improved from 138.8° to 167.3° (P = .024) and 117.9° to 149.3° (P = .001), respectively. Supraspinatus and external rotation strength improved from 7.2 to 9.4 (P = .001) and 7.4 to 9.5 (P = .001), respectively. Mean ASES improved from 62.7 to 91.8 (P = .0007), and mean SF-12 scores improved from 48.4 to 56.6 (P = .044). Twenty-one patients (22 shoulders) returned for a dynamic and static ultrasound of the operative shoulder at a minimum 2-year follow-up. Sixteen patients (73%) demonstrated a fully intact tendon-graft reconstruction, 5 patients (22%) had a partially intact reconstruction, and 1(5%) had a complete tear at the graft-bone interface caused by suture anchor pullout as a result of a fall. There were no cases of infection or tissue rejection. Conclusion: Active patients with massive or 2-tendon rotator cuff tears with minimal glenohumeral arthritis continue to be a subset of the population for whom there is no current standard of care. Results suggest that the use of porcine xenograft may be an effective means by which to treat these patients.

Single-blind vs Double-blind Peer Review in the Setting of Author Prestige

Methods | This study was approved by the University of Washington institutional review board and conducted at Clinical Orthopaedics and Related Research (CORR), an orthopedic journal (2015 impact factor, 3.127; acceptance rate, 20%) that allows authors to select single-blind or double-blind peer review. Potential reviewers (based on expertise) were identified from the journal’s database, informed that a study on peer review would occur in the coming year, and allowed to opt out. To avoid influencing behavior, the details and timing of the study were not described and the trial was registered after completion. The protocol appears in the Supplement. Between June 2014 and August 2015, reviewers were randomized via random number table (1:1 ratio in blocks of 8) to receive single-blind or double-blind versions of an otherwise identical fabricated manuscript, which was putatively written by 2 past presidents of the American Academy of Orthopaedic Surgeons from prominent institutions. The manuscript described a prospective study on a nonclinical topic of broad interest (team training to improve communication and safety in the operating room). Five subtle errors were included, ranging from numerical mistakes to an error in the conclusion, to determine differences in how critically the manuscript was examined. The primary outcome was recommendation of acceptance or rejection. Grades of “accept” and “reject” were taken at face value and, for grades of “major revision” and “minor revision,” reviewers’ comments were analyzed for language recommending rejection by researchers blinded to group allocation. Secondary outcomes were the number of intentionally placed errors detected and quality scores for the Methods. Post hoc, scores for the other categories usually solicited by CORR were compared. Based on 80% power and an α of .05, 98 reviewers were needed to detect a 20% difference in acceptance rates. Statistical analysis used χ2, Fisher exact, student t, and negative binomial testing, and multivariable logistic regression (SAS [SAS Institute], version 9). Significance was defined as a 2-sided P value of less than .05.

Role of diabetes type in perioperative outcomes after hip and knee arthroplasty in the United States.

The objective of this study was to determine whether the type of diabetes mellitus (DM) affected the incidence of immediate perioperative complications following joint replacement. From 1988 to 2003, the Nationwide Inpatient Sample recognized 65,769 patients with DM who underwent total hip and knee arthroplasty in the United States. Bivariate and multivariate analyses compared patients with type 1 (n = 8728) and type 2 (n = 57,041) DM regarding common perioperative complications, mortality, and hospital course alterations. Type 1 DM patients had increased length of stays and inflation-adjusted costs after surgery (p < .001). Type 1 patients also had significant increases in the incidence of myocardial infarction, pneumonia, urinary tract infection, postoperative hemorrhage, wound infection, and death (p < .02). Perhaps because of the differences in the duration of disease and their underlying pathologies, patients with type 1 diabetes carry more significant overall perioperative risks and require more health care resources compared with patients with type 2 diabetes following hip and knee arthroplasty.

Economic evaluation of access to musculoskeletal care: the case of waiting for total knee arthroplasty

BackgroundThe projected demand for total knee arthroplasty is staggering. At its root, the solution involves increasing supply or decreasing demand. Other developed nations have used rationing and wait times to distribute this service. However, economic impact and cost-effectiveness of waiting for TKA is unknown.MethodsA Markov decision model was constructed for a cost-utility analysis of three treatment strategies for end-stage knee osteoarthritis: 1) TKA without delay, 2) a waiting period with no non-operative treatment and 3) a non-operative treatment bridge during that waiting period in a cohort of 60 year-old patients. Outcome probabilities and effectiveness were derived from the literature. Costs were estimated from the societal perspective with national average Medicare reimbursement. Effectiveness was expressed in quality-adjusted life years (QALYs) gained. Principal outcome measures were average incremental costs, effectiveness, and quality-adjusted life years; and net health benefits.ResultsIn the base case, a 2-year wait-time both with and without a non-operative treatment bridge resulted in a lower number of average QALYs gained (11.57 (no bridge) and 11.95 (bridge) vs. 12.14 (no delay). The average cost was

In Brief: Classifications in Brief: Brooker Classification of Heterotopic Ossification After Total Hip Arthroplasty

1,660 higher for TKA without delay than wait-time with no bridge, but

Total Knee Arthroplasty in Osteopetrosis Using Patient-Specific Instrumentation

1,810 less than wait-time with non-operative bridge. The incremental cost-effectiveness ratio comparing wait-time with no bridge to TKA without delay was

Creation of a Femoral Cortical Window to Facilitate Total Hip Arthroplasty in Patients with Sickle Cell Hemoglobinopathies

2,901/QALY. When comparing TKA without delay to waiting with non-operative bridge, TKA without delay produced greater utility at a lower cost to society.ConclusionsTKA without delay is the preferred cost-effective treatment strategy when compared to a waiting for TKA without non-operative bridge. TKA without delay is cost saving when a non-operative bridge is used during the waiting period. As it is unlikely that patients waiting for TKA would not receive non-operative treatment, TKA without delay may be an overall cost-saving health care delivery strategy. Policies aimed at increasing the supply of TKA should be considered as savings exist that could indirectly fund those strategies.

Intra-abdominal migration of a k-wire during revision total hip arthroplasty

THA is a frequently performed surgery for the treatment of patients with osteoarthritis, rheumatoid arthritis, avascular necrosis, developmental dysplasia, and many other forms of hip pathology. Heterotopic ossification (HO) is a common complication after THA with a frequency of 26% to 41% reported in recent studies [2, 20, 21]. The majority of HO is not clinically important, but severe HO may lead to decreased hip ROM [12] and increased pain [7]. Multiple different classification schemes have been proposed to describe the degree of HO after THA, including those by Brooker et al. [3], Hamblen et al. [9], DeLee et al. [5], and Kjaersgaard-Andersen et al. [11] as well as by Arcq [1] within the German literature. All of the classification systems use plain radiographs in at least the AP plane, but some make use of other radiographic views as well. The Brooker classification system was one of the earliest systems described and remains very widely used in contemporary literature. Some groups have suggested modifications or additions to the Brooker system with the goal of improving consistency and predictability [6, 19, 23], whereas others have focused on simplifying the Brooker system to improve communication and reproducibility [22]. Although these authors have argued that their revisions demonstrate an improvement over the Brooker classification, the original Brooker classification remains a commonly used system for classifying HO after THA.

Risk factors associated with periprosthetic joint infection after total elbow arthroplasty

Osteopetrosis is an uncommon endocrine disease characterized by defective osteoclast resorption of bones. This causes a hard, sclerotic, and brittle bone throughout the skeleton. Fractures and unforgiving subchondral bone are common in this condition, both of which can lead to osteoarthritis. Total knee arthroplasty is often the treatment of choice but presents challenges due to the hard and sclerotic bone present throughout the metaphysis and diaphysis of the femur and the tibia. We present a case of knee osteoarthritis in a patient with osteopetrosis who underwent total knee arthroplasty using patient-specific instrumentation. This technique eliminates intramedullary alignment and minimizes drilling, reaming, and saw passes, making it attractive in the setting of diseases such as osteopetrosis to decrease operative time and potential complications.