Mark D. Lazarus

Eccentric reaming in total shoulder arthroplasty: a cadaveric study.

Posterior glenoid bone loss often is seen in association with glenohumeral osteoarthritis. Many different techniques have been proposed to account for this bone loss during total shoulder arthroplasty, the most popular being eccentric anterior reaming. However, the amount of correction that can be achieved has not been been well quantified. The purpose of this study was to define the amount of eccentric posterior glenoid wear that can be corrected by anterior glenoid reaming. Eight cadaveric scapulae were studied. Simulations of posterior glenoid wear in 5 degrees increments were performed on each scapula. The specimens were then eccentrically reamed to correct the deformity. Anteroposterior width, superior-inferior height, and the best-fit pegged glenoid prosthesis size were measured. Anterior reaming to correct a 10 degrees posterior defect resulted in a decrease in anteroposterior glenoid diameter from 26.7+/-2.5 mm to 23.8+/-3.1 mm (P=.006). In 4 of 8 specimens, placing a glenoid prosthesis was not possible after correcting a 15 degrees deformity because of inadequate bony support (N=2), peg penetration (N=1) or both (N=1). A 20 degrees deformity was correctable in 2 of 8 specimens and only after downsizing the glenoid component. Anterior glenoid reaming to correct eccentric posterior wear of >10 degrees results in significant narrowing of the anteroposterior glenoid width. A 15 degrees deformity has only a 50% chance of successful correction by anterior, eccentric reaming. Orthopedic surgeons need to be cognizant of this in their preoperative planning for total shoulder arthroplasty.

Reverse shoulder arthroplasty for proximal humeral fractures: update on indications, technique, and results

The introduction of the reverse shoulder arthroplasty has provided shoulder surgeons with more options for the treatment of complex proximal humeral fractures in the elderly. Early reported results suggest that the average functional outcome may be better than hemiarthroplasty in certain patients and specific clinical scenarios. In addition, these results seem to be reached more quickly with less dependence on rehabilitation. The reverse prosthesis may be particularly useful in patients aged older than 70 years, especially those with severely comminuted fractures in osteopenic bone. These factors likely have a negative impact on the results of hemiarthroplasty and internal fixation. Despite the potential benefits of reverse arthroplasty for fracture, there is a significant learning curve with the use of this prosthesis, and it has its own set of complications. The surgeon must show appropriate judgment when selecting a reverse arthroplasty in the setting of a proximal humeral fracture and, furthermore, be well acquainted with the surgical technique and prosthetic options at the time of surgery. Although the longevity of this prosthesis remains unknown, midterm outcomes are promising.

Complications of open anterior stabilization of the shoulder.

&NA; Complications of surgery for glenohumeral instability are relatively uncommon. When they occur, salvaging failures and obtaining a stable joint can be awesome challenges. Accurate recognition of the cause of the instability and application of the appropriate surgical technique are critical. Deficiencies of the glenoid concavity, the anterior capsule, or the subscapularis may be present and require correction. Overtightening a shoulder and eliminating its normal laxity should be avoided. Loose or malpositioned hardware about the glenohumeral joint must be recognized as soon as possible and removed. The goal of treatment is to correct the deficient stabilizing mechanisms without altering normal glenohumeral function.

Clinical outcomes in patients undergoing revision rotator cuff repair with extracellular matrix augmentation.

Outcomes following revision surgery for failed rotator cuff repairs are far less predictable than and are associated with decreased patient satisfaction compared with primary repairs. Extracellular matrix augmentation (ECM) may improve the biologic potential for healing during revision repair. The authors examined clinical outcomes and healing rates based on postoperative imaging of patients who underwent revision open rotator cuff repair with an ECM patch for symptomatic recurrent rotator cuff tear. Twenty-four (77%) of 31 patients with a mean follow-up of 50 months (range, 30-112 months) completed post-revision surgery outcome questionnaires at a mean of 5.3 years after revision surgery, and 16 patients (67%) underwent a physical examination and repeat imaging (ultrasound or magnetic resonance imaging) at a mean of 4.2 years after revision surgery. Ten (63%) of those 16 patients were found to have failed revision rotator cuff repair on imaging, with American Shoulder and Elbow Surgeons (ASES) outcome measures that were significantly (P=.04) better in patients with confirmed intact repairs than those with confirmed failed revision repair. Outcome measures for all patients (n=24) included a mean ASES score of 67.2 (SD, 27.9) and a mean Single Assessment Numeric Evaluation (SANE) score of 66.9 (SD, 26.0). Based on these scores, excellent results were achieved in 24% of patients, good in 13%, fair in 21%, and poor in 42%. Results of this investigation demonstrated that augmentation of revision rotator cuff repair with an ECM patch through an open approach showed no significant improvement in outcomes when compared to historical reports without augmentation.

Leukocyte esterase in the diagnosis of shoulder periprosthetic joint infection.

BACKGROUND Shoulder periprosthetic joint infection (PJI) is difficult to diagnose with traditional methods. Leukocyte esterase (LE) has recently proven to be reliable in knee arthroplasty; however, its value in the shoulder has not been explored. We hypothesized that LE would display high sensitivity and specificity in shoulder PJI. METHODS Two groups were prospectively evaluated: 45 primary and 40 revision shoulder arthroplasties. Synovial fluid and soft tissue cultures were obtained at surgery. Synovial fluid was evaluated with LE test strips. Any aspiration that contained erythrocytes was centrifuged and retested. Shoulder PJI was defined by modified Musculoskeletal Infection Society (MSIS) criteria. RESULTS Of 5 primaries with positive tissue cultures (11%), only 1 was positive for LE. Of 16 revisions with positive cultures (40%), 4 had positive LE results. Among all patients with bacterial isolates, 6 aspirates were not interpretable (29%), despite centrifugation. LE had sensitivity of 25% and specificity of 75% to predict positive cultures in revisions. Ten revision patients met modified MSIS criteria for PJI. The sensitivity of LE in these patients was 30%, and the specificity was 67% (positive predictive value, 43%; negative predictive value, 83%). If bloody aspirates were considered positive, LE sensitivity in MSIS PJI increased to 60%, but the positive predictive value fell to 37.5%. CONCLUSION LE is an unreliable diagnostic measure in shoulder PJI. The presence of erythrocytes within aspirates further decreased its accuracy. We conclude that LE should not be used for the routine identification of shoulder PJI.

Shoulder Instability in Older Patients

Glenohumeral instability has a bimodal age distribution, with most affected patients younger than 40 years, but with a second peak in older patients. Glenohumeral dislocations in older patients often present with complex injury patterns, including rotator cuff tears, fractures, and neurovascular injuries. Glenohumeral instability in patients older than 40 years requires a different approach to treatment. An algorithmic approach aids the surgeon in the stepwise decision-making process necessary to treat this injury pattern.

Repair of Pectoralis Major Ruptures: Single-surgeon Case Series

Rupture of the pectoralis major is an uncommon injury that can lead to pain, loss of strength, and cosmetic deformity. The purpose of this study was to analyze the outcome of pectoralis major repairs by a single surgeon. Twenty-four patients who underwent pectoralis major repair by the senior author (M.D.L.) between May 2005 and March 2011 were retrospectively identified. Patients were assessed at least 6 months postoperatively with the use of various questionnaires, including the Penn Shoulder Score, American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, and Single Assessment Numeric Evaluation (SANE). All patients were men with an injury to the sternal head of the pectoralis. Most (16/24; 67%) patients sustained the injury while bench or incline bench pressing. Nineteen (79%) patients were successfully contacted for follow-up. Of these, an average preinjury bench press of 318 lb (range, 145-525 lb) was restored to an average of 264 lb (range, 100-500 lb) at follow-up. Average preoperative Penn Shoulder Score was 60 points (range, 33-77 points), improving to 94 points (range, 64-100 points) at last follow-up (P=.011). Average postoperative ASES and SANE scores were 96 points (range, 60-100 points) and 93 points (range, 50-100 points), respectively. All but 1 patient were rated excellent (14/19; 74%) or good (4/19; 21%) by the Bak criteria. Operative treatment of pectoralis major rupture yields high patient satisfaction and allows predictable return of comfort, range of motion, cosmesis, and overall limb strength, with a slightly less predictable return of maximum bench press strength.

Length of stay after shoulder arthroplasty—the effect of an orthopedic specialty hospital

BACKGROUND One potential avenue for the realization of health care savings is reduction in hospital length of stay (LOS). Initiatives to reduce LOS may also reduce infection and improve patient satisfaction. We compare LOS after shoulder arthroplasty at an orthopedic specialty hospital (OSH) and a tertiary referral center (TRC). METHODS A single institutional database was used to retrospectively identify all primary shoulder arthroplasties performed between January 1, 2013, and July 1, 2015, at the OSH and TRC. Manually matched cohorts from the OSH and TRC were compared for LOS and readmission rate. RESULTS There were 136 primary shoulder arthroplasties performed at the OSH matched with 136 at the TRC during the same study period. OSH and TRC patients were similar in age (P = .949), body mass index (P = .967), Charlson Comorbidity Index (P = 1.000), gender (both 52.21% male), procedure (69.12% total shoulder arthroplasty, 7.35% hemiarthroplasty, and 23.53% reverse shoulder arthroplasty), insurance status (P = .714), and discharge destination (P = .287). Despite equivalent patient characteristics, average LOS at the OSH was 1.31 ± 0.48 days compared with 1.85 ± 0.57 days at the TRC (t = 8.41, P < .0001). Of the 136 OSH patients, 3 (2.2%) required transfer to a TRC. Readmission rates for the OSH patients (2/136, 1.5%) and TRC patients (1/136, 0.7%) were similar (z = 0.585, P = .559). CONCLUSION LOS at the OSH was significantly shorter than at the TRC for a strictly matched cohort of patients. This may be a result of fast-track rehabilitation and strict disposition protocols at the OSH. With rising shoulder arthroplasty demand, utilization of an OSH may be a safe avenue to delivery of more efficient and effective orthopedic care.

Outcomes of Arthroscopic Repair of Panlabral Tears of the Glenohumeral Joint

Background: Combined lesions of the glenoid labrum involving tears of the anterior, posterior, and superior labrum have been infrequently reported in the literature. Purpose: To evaluate the clinical outcomes of arthroscopic repair of these lesions in a general population using validated scoring instruments, presence of complications, and need for revision surgery. Study Design: Case series; Level of evidence, 4. Methods: Fifty-eight patients who had arthroscopic labral repair of tears involving the anterior, posterior, and superior labrum (defined as a panlabral repair) were identified at our institution by retrospective review. All patients underwent arthroscopic labral repair with suture anchor fixation by a uniform approach and with a standardized postoperative protocol. Forty-four patients had a minimum 16-month postoperative follow-up. Outcomes were assessed postoperatively by the American Shoulder and Elbow Surgeons (ASES) score and the Penn Shoulder score. Complications were also documented, including need for revision surgery. Results: The mean age at the time of surgery was 32 years (range, 15-55 years) in the 44 patients. Presenting shoulder complaints included pain alone (40%), instability alone (14%), or pain and instability (45%). Mean number of anchors per repair was 7.9 (range, 5-12). Mean follow-up was 42 months (range, 16-78 months). Mean ± standard deviation ASES score at final follow-up was 90.1 ± 17.7 (range, 22-100), and mean Penn Shoulder score was 90.2 ± 15.3 (range, 38-100). Three of the 4 patients with outcome scores of 70 or less at final follow-up had undergone prior surgery. Thirteen postoperative complications (30%) occurred, with 3 (7%) requiring a second surgery. Five patients (11%) had an instability event following panlabral repair, but only 1 of these patients (2%) required revision surgery for a recurrent labral tear. Conclusion: Combined tears of the anterior, posterior, and superior glenoid labrum represent a small but significant portion of labral injuries. Arthroscopic repair of these injuries can be performed with good postoperative outcomes and a low rate of recurrent labral injury.

Economic Decision Model Suggests Total Shoulder Arthroplasty is Superior to Hemiarthroplasty in Young Patients with End-stage Shoulder Arthritis

BackgroundYoung patients with severe glenohumeral arthritis pose a challenging management problem for shoulder surgeons. Two controversial treatment options are total shoulder arthroplasty (TSA) and hemiarthroplasty. This study aims to characterize costs, as expressed by reimbursements for episodes of acute care, and outcomes associated with each treatment.Questions/purposesWe asked: for patients 30 to 50 years old with severe end-stage glenohumeral arthritis refractory to conservative management, (1) are more years of patient-derived satisfactory outcome by the Neer criteria and quality-adjusted life-years (QALYs) achieved using a TSA or a hemiarthroplasty; (2) does a TSA or a hemiarthroplasty result in a greater number of revision procedures; and (3) does a TSA or a hemiarthroplasty result in greater associated costs to society?MethodsThe incidence of glenohumeral arthritis among 30- to 50-year-old patients, outcomes, reoperation probabilities, and associated costs from TSA and hemiarthroplasty were derived from the literature. A Markov chain decision tree model was developed from these estimates with number of revisions, cost of management for patients to 70 years old as defined by reimbursement for acute-care episodes, years with “satisfactory” or “excellent” outcome by the modified Neer criteria, and QALYs gained as principle outcome measures. A Monte Carlo simulation was conducted with a cohort representing the at-risk population for shoulder arthritis between 30 and 50 years old in the United States.ResultsDuring the lifetime of a cohort of 5279 patients, hemiarthroplasty as the initial treatment resulted in 59,574 patient years of satisfactory or excellent results (11.29 per patient) and average QALYs gained of 6.55, whereas TSA as the initial treatment resulted in 85,969 patient years of satisfactory or excellent results (16.29 per patient) and average QALYs gained of 7.96. During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as the initial treatment led to 2090 lifetime revisions (0.4 per patient), whereas a TSA as the initial treatment led to 1605 lifetime revisions (0.3 per patient). During the lifetime of a cohort of 5279 patients, a hemiarthroplasty as initial treatment resulted in USD 132,500,000 associated direct reimbursements (USD 25,000 per patient), whereas a TSA as initial treatment resulted in USD 125,500,000 associated direct reimbursements (USD 23,700 per patient).ConclusionsTreatment of end-stage glenohumeral arthritis refractory to conservative treatment in patients 30 to 50 years old in the United States with TSA, instead of hemiarthroplasty, would result in greater cost savings, avoid a substantial number of revision procedures, and result in greater years of satisfactory or excellent patient outcomes and greater QALYs gained. On a population level, TSA is the cost-effective treatment for glenohumeral arthritis in patients 30 to 50 years old.Level of EvidenceLevel II, economic and decision analysis study.