Matthew B. Burn

Early Corrosion-related Failure of the Rejuvenate Modular Total Hip Replacement

BACKGROUND The Rejuvenate modular-neck stem implant (Stryker Orthopaedics, Mahwah, New Jersey) was recently recalled due to corrosion at the femoral neck-stem junction. The purpose of this study was to investigate the rate of corrosion-related failure and survivorship of this implant and analyze the correlation of implant and patient factors with serum metal ion levels and revisions. METHODS From June 2009 to July 2012, 123 Rejuvenate total hip arthroplasty stems (ninety-seven modular and twenty-six non-modular) were implanted in 104 patients by a single surgeon. Serum cobalt (Co) and chromium (Cr) levels (micrograms per liter [μg/L]) were measured postoperatively for all patients. Patients with persistent hip pain or elevated metal ion levels underwent magnetic resonance imaging for assessment of osteolysis or adverse local tissue reactions. Correlation of implant factors (stem size, head size, head length, and femoral head-neck offset) and patient factors (age, sex, and body mass index) with serum metal ion levels and revisions were analyzed with use of logistic regression models. RESULTS The mean duration of follow-up (and standard deviation) was 2.7 ± 0.6 years. The mean Co and Cr levels were 5.4 ± 5.7 μg/L (range, 0.2 to 31 μg/L) and 2.1 ± 1.5 μg/L (range, 0.1 to 4.3 μg/L), respectively. The differences in Co and Cr levels between the two groups (modular and non-modular) were significant: 48% of the total hip arthroplasties in the modular group resulted in elevated metal ion levels (Co >4.0 μg/L and Cr >2.0 μg/L; p < 0.05). The metal ion levels in the non-modular group were normal. In the modular group, higher metal ion levels were significantly correlated with younger age and a higher femoral head-neck offset (p = 0.04). Pain and high Co serum levels were significant predictors of revision surgery (p = 0.006). The rate of revision at the time of this study was 28% in the modular group, with the majority of the revisions performed in the second year after surgery; the Kaplan-Meier survivorship was 40% at four years. CONCLUSIONS The short-term high rate of corrosion-related revision with Rejuvenate modular-neck stems is striking.

Prevalence of Scapular Dyskinesis in Overhead and Nonoverhead Athletes: A Systematic Review

Background: Scapular dyskinesis, or abnormal dynamic scapular control, is a condition that is commonly associated with shoulder pathology but is also present in asymptomatic individuals. Literature varies on whether it represents a cause or symptom of shoulder pathology, but it is believed to be a risk factor for further injury. Clinical identification focuses on visual observation and examination maneuvers. Treatment of altered scapular motion has been shown to improve shoulder symptoms. It is thought to be more common in overhead athletes due to their reliance on unilateral upper extremity function but the incidence within nonoverhead athletes is unknown. Hypothesis: Overhead athletes will have a greater prevalence of scapular dyskinesis when compared with nonoverhead athletes. Study Design: Systematic review; Level of evidence, 3. Methods: After PROSPERO registration, a systematic review was performed using PRISMA guidelines through the PubMed database looking for studies published before October 2014. All studies containing the search terms scapular, scapulothoracic, dyskinesis, dyskinesia, shoulder athlete, or overhead athlete were included. Studies that did not include prevalence data for scapular dyskinesis were excluded. Study methodological quality was evaluated using the modified Coleman methodology score. Descriptive statistics and 2-proportion 2-tailed z-tests were used to compare the reported prevalence of scapular dyskinesis between overhead and nonoverhead athletes. Results: Twelve studies were analyzed including 1401 athletes (1257 overhead and 144 nonoverhead; mean age, 24.4 ± 7.1 years; 78% men). All the studies were evidence level 2 (33%) or level 3 (67%). The reported prevalence of scapular dyskinesis was significantly (P < .0001) higher in overhead athletes (61%) compared with nonoverhead athletes (33%). Conclusion: Scapular dyskinesis was found to have a greater reported prevalence (61%) in overhead athletes compared with nonoverhead athletes (33%). Clinical Relevance: Prevalence data for scapular dyskinesis are scarce within the literature. Information on the reported prevalence, laterality, and association with the dominant extremity will allow for better allocation of diagnostic and therapeutic interventions. Recognition and treatment will help athletes to optimize functional performance and decrease the risk of further shoulder injury.

Do Safe Radiographic Sacral Screw Pathways Exist in a Pediatric Patient Population and Do They Change With Age

Objectives: Iliosacral screw pathways in the first (S1) and second (S2) sacral segments are commonly used for adult pelvic ring stabilization. We hypothesize that radiographically “safe” pathways exist in pediatric patients. Setting: Academic level I Trauma Center. Patients: All patients between ages 2 and 16 years with a computed tomography scan including the pelvis obtained over a 6-week period (174 children, mean age 10.8 ± 3.9 years; 90 boys, 84 girls). Intervention: The width and height at the “constriction point” in 3 safe screw pathways were measured bilaterally by 3 orthopaedists (resident, trauma fellow, trauma attending). Pathways corresponding to: (1) an “iliosacral” screw at S1, a “trans-sacral trans-iliac” (TSTI) screw at S1, and a TSTI screw at S2. Main Outcome Measurements: (1) Mean width and height of pathways, (2) interrater reliability coefficient, (3) availability of pathways greater than 7 mm, (4) growth of pathways with age, (5) sacral morphology. Results: The interrater reliability coefficient was above 0.917 for all measurements. Radiographically safe pathways were available for 99%, 51%, and 89% of children for iliosacral screws at S1 (width 16.4 ± 2.8 mm, height 15.1 ± 3.3 mm), TSTI screws at S1 (width 7.2 ± 4.9 mm, height 8.3 ± 5.6 mm), and TSTI at S2 (width 9.3 ± 2.2 mm, height 11.5 ± 2.7 mm), respectively. Conclusions: Contrary to our hypothesis, almost all children aged 2–16 had a radiographically safe screw pathway for an iliosacral screw at S1, and most of the children had an available pathway for a TSTI screw at S2. However, only 51% had a pathway for a TSTI screw at S1.

Performance and Return to Sport After Tommy John Surgery Among Major League Baseball Position Players

Background: The anterior bundle of the medial ulnar collateral ligament (UCL) is the primary restraint to valgus stress at the elbow and is often injured among overhead throwing athletes. Despite prevention strategies, injuries to the elbow UCL are on the rise. Purpose: To determine (1) the return-to-sport (RTS) rate of Major League Baseball (MLB) position players after elbow medial UCL reconstruction, (2) postoperative career length and games per season, (3) pre- and postoperative performance, (4) postoperative performance versus matched control players, and (5) whether position players changed positions after UCL reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: MLB players who underwent elbow UCL reconstruction were identified (cases). Demographic and performance data were collected for each player. Matched controls were identified. RTS in MLB was defined as playing in at least 1 MLB game after UCL reconstruction. Comparisons between case and control groups and pre- and postoperative time points were made via paired samples Student t tests. Results: Thirty-three players (34 surgical procedures) were identified with a mean ± SD age of 30.2 ± 4.2 years and a mean experience in the MLB of 6.3 ± 3.9 years at the time of surgery. Twenty-eight players (84.8%) were able to RTS in MLB at a mean 336.9 ± 121.8 days. However, players ≥30 years old demonstrated a significantly lower RTS rate (53.3%) than players <30 years old (89.4%; P < .05). Catchers had a significantly shorter postoperative career length (2.8 ± 1.8 years) versus matched controls (6.1 ± 1.9 years; P < .05). Outfielders had a significantly lower wins above replacement postoperatively (0.8 ± 0.7) versus preoperatively (1.5 ± 1.1; P < .05). There were no performance differences between cases and matched controls. Twelve players (48%) returned to a different position postoperatively. Conclusion: The RTS rate for MLB position players after elbow UCL reconstruction is similar to that of pitchers. Catchers had a significantly shorter career length than that of matched controls. Outfielders performed worse postoperatively versus preoperatively. There is a high rate of position change after Tommy John surgery for infielders and outfielders.

Physician Rating Scales Do Not Accurately Rate Physicians

The purpose of this study was to determine the proportion of questions used by online physician rating scales to directly rate physicians themselves. A systematic review was performed of online, patient-reported physician rating scales. Fourteen websites were identified containing patient-reported physician rating scales, with the most common questions pertaining to office staff courtesy, wait time, overall rating (entered, not calculated), trust/confidence in physician, and time spent with patient. Overall, 28% directly rated the physician, 48% rated both the physician and the office, and 24% rated the office alone. There is great variation in the questions used, and most fail to directly rate physicians themselves. [Orthopedics. 2018; 41(4):e445-e456.].

Open, Arthroscopic, and Percutaneous Surgical Treatment of Lateral Epicondylitis: A Systematic Review

Background: Approximately 10% of patients with lateral epicondylitis go on to have surgical treatment; however, multiple surgical treatment options exist. The purpose of this study was to review the literature for the clinical outcomes of open, arthroscopic, and percutaneous treatment of lateral epicondylitis. The authors hypothesized that the clinical outcome of all 3 analyzed surgical treatments would be equivalent. Methods: A systematic review was performed using PubMed, Cochrane Central Register of Controlled Trials, and Google Scholar in July 2016 to compare the functional outcome, pain, grip strength, patient satisfaction, and return to work at 1-year follow-up for open, arthroscopic, and percutaneous treatment of lateral epicondylitis. Results: Six studies (2 Level I and 4 Level II) including 179 elbows (83 treated open, 14 arthroscopic, 82 percutaneous) were analyzed. Three outcome measures (Disabilities of the Arm, Shoulder, and Hand [DASH] score, visual analog scale [VAS], and patient satisfaction) were reported for more than one category of surgical technique. Of these, the authors noted no clinically significant differences between the techniques. Conclusions: This is the first systematic review looking at high-level evidence to compare open, percutaneous, and arthroscopic techniques for treating lateral epicondylitis. There are no clinically significant differences between the 3 surgical techniques (open, arthroscopic, and percutaneous) in terms of functional outcome (DASH), pain intensity (VAS), and patient satisfaction at 1-year follow-up.

Is digital photography an accurate and precise method for measuring range of motion of the hip and knee

BackgroundAccurate measurements of knee and hip motion are required for management of musculoskeletal pathology. The purpose of this investigation was to compare three techniques for measuring motion at the hip and knee. The authors hypothesized that digital photography would be equivalent in accuracy and show higher precision compared to the other two techniques.MethodsUsing infrared motion capture analysis as the reference standard, hip flexion/abduction/internal rotation/external rotation and knee flexion/extension were measured using visual estimation, goniometry, and photography on 10 fresh frozen cadavers. These measurements were performed by three physical therapists and three orthopaedic surgeons. Accuracy was defined by the difference from the reference standard, while precision was defined by the proportion of measurements within either 5° or 10°. Analysis of variance (ANOVA), t-tests, and chi-squared tests were used.ResultsAlthough two statistically significant differences were found in measurement accuracy between the three techniques, neither of these differences met clinical significance (difference of 1.4° for hip abduction and 1.7° for the knee extension). Precision of measurements was significantly higher for digital photography than: (i) visual estimation for hip abduction and knee extension, and (ii) goniometry for knee extension only.ConclusionsThere was no clinically significant difference in measurement accuracy between the three techniques for hip and knee motion. Digital photography only showed higher precision for two joint motions (hip abduction and knee extension). Overall digital photography shows equivalent accuracy and near-equivalent precision to visual estimation and goniometry.