Ofir Uri

Clinical outcome after reconstruction for sternoclavicular joint instability using a sternocleidomastoid tendon graft.

BACKGROUND Anterior instability of the sternoclavicular joint is uncommon and usually follows a benign course, although symptomatic patients may require surgical intervention. The optimal treatment for symptomatic instability of the sternoclavicular joint remains unclear. The aim of this study was to evaluate the clinical outcome after reconstruction of the sternoclavicular joint with use of a sternocleidomastoid tendon graft to treat chronic debilitating anterior instability of the sternoclavicular joint. METHODS Thirty-two patients underwent surgical reconstruction of the sternoclavicular joint for chronic debilitating anterior instability using the tendon of the sternal head of the ipsilateral sternocleidomastoid muscle and were followed for a mean of forty-four months. The etiology of instability was posttraumatic in fourteen patients, generalized hyperlaxity in seven patients, and degenerative instability in eleven patients. Outcome measures included the Oxford instability shoulder score, subjective shoulder value, pain rating, and postoperative grading of sternoclavicular joint stability. RESULTS Clinical scores and pain rating were similar for the three groups before surgery and improved significantly in all of the groups to the same extent after the surgery. At the time of the latest follow-up, eleven of fourteen patients in the posttraumatic group, six of seven patients in the generalized hyperlaxity group, and eight of eleven patients in the degenerative group reported the sternoclavicular joint as stable with no functional limitation. Two patients reported that the joint remained unstable. No other complications occurred. CONCLUSIONS Sternoclavicular joint reconstruction using a sternocleidomastoid tendon graft is safe and offers reliable pain relief and functional improvement for patients with chronic debilitating anterior instability of the sternoclavicular joint.

No gender-related bias in acute musculoskeletal pain management in the emergency department.

Introduction Patients’ gender remains a contributor for bias in pain management. Implementation of standardised analgesic protocols has been shown to minimise bias in analgesic care. The purpose of this study was to assess whether gender-related bias in pain management exists in our emergency department (ED) setting, where a standardised pain management protocol based on patients’ subjective pain rating is routinely used. Methods Pain management measures (ie, analgesia administration, waiting time for analgesia, pain relief and patients’ satisfaction) were prospectively assessed in 328 patients (150 women and 178 men, average age 36±18 years) who were treated in our ED for acute musculoskeletal pain. Results Patients’ subjective pain rating on arrival were similar for men and women (59±24 mm vs 61±26 mm, respectively; p=0.47). Interestingly, physicians using the same scale assessed the womens pain level to be higher than that of men (75±25 mm vs 63±22 mm, respectively; p<0.001) and higher than that of womens subjective pain rating (75±25 mm vs 61±26 mm respectively; p<0.001). Nevertheless, the rates of analgesia administration, waiting time for analgesia, pain relief and patient satisfaction were similar for both genders. Physicians’ own gender did not affect analgesic care. Conclusions Our findings suggest that a standardised pain management protocol based on patients’ subjective pain rating may reduce gender-related bias in acute musculoskeletal pain management.

A reverse shoulder arthroplasty with increased offset for the treatment of cuff-deficient shoulders with glenohumeral arthritis

Inherent disadvantages of reverse shoulder arthroplasty designs based on the Grammont concept have raised a renewed interest in less-medialised designs and techniques. The aim of this study was to evaluate the outcome of reverse shoulder arthroplasty (RSA) with the fully-constrained, less-medialised, Bayley-Walker prosthesis performed for the treatment of rotator-cuff-deficient shoulders with glenohumeral arthritis. A total of 97 arthroplasties in 92 patients (53 women and 44 men, mean age 67 years (standard deviation (sd) 10, (49 to 85)) were retrospectively reviewed at a mean follow-up of 50 months ((sd 25) (24 to 96)). The mean Oxford shoulder score and subjective shoulder value improved from 47 (sd 9) and 24 points (sd 18) respectively before surgery to 28 (sd 11) and 61 (sd 24) points after surgery (p < 0.001). The mean pain at rest decreased from 5.3 (sd 2.8) to 1.5 (sd 2.3) (p < 0.001). The mean active forward elevation and external rotation increased from 42(°)(sd 30) and 9(°) (sd 15) respectively pre-operatively to 78(°) (sd 39) and 24(°) (sd 17) post-operatively (p < 0.001). A total of 20 patients required further surgery for complications; 13 required revision of components. No patient developed scapular notching. The Bayley-Walker prosthesis provides reliable pain relief and reasonable functional improvement for patients with symptomatic cuff-deficient shoulders. Compared with other designs of RSA, it offers a modest improvement in forward elevation, but restores external rotation to some extent and prevents scapular notching. A longer follow-up is required to assess the survival of the prosthesis and the clinical performance over time.

Hip-inspired implant for revision of failed reverse shoulder arthroplasty with severe glenoid bone loss Improved clinical outcome in 11 patients at 3-year follow-up

Background and purpose — Glenoid reconstruction and inverted glenoid re-implantation is strongly advocated in revisions of failed reverse shoulder arthroplasty (RSA). Nevertheless, severe glenoid deficiency may preclude glenoid reconstruction and may dictate less favorable solutions, such as conversion to hemiarthropasty or resection arthropasty. The CAD/CAM shoulder (Stanmore Implants, Elstree, UK), a hip arthroplasty-inspired implant, may facilitate glenoid component fixation in these challenging revisions where glenoid reconstruction is not feasible. We questioned (1) whether revision arthroplasty with the CAD/CAM shoulder would alleviate pain and improve shoulder function in patients with failed RSA, not amenable to glenoid reconstruction, (2) whether the CAD/CAM hip-inspired glenoid shell would enable secure and durable glenoid component fixation in these challenging revisions. Patients and methods — 11 patients with failed RSAs and unreconstructable glenoids underwent revision with the CAD/CAM shoulder and were followed-up for mean 35 (28–42) months. Clinical outcomes included the Oxford shoulder score, subjective shoulder value, pain rating, physical examination, and shoulder radiographs. Results — The average Oxford shoulder score and subjective shoulder value improved statistically significantly after the revision from 50 to 33 points and from 17% to 48% respectively. Pain rating at rest and during activity improved significantly from 5.3 to 2.3 and from 8.1 to 3.8 respectively. Active forward flexion increased from 25 to 54 degrees and external rotation increased from 9 to 21 degrees. 4 patients required reoperation for postoperative complications. No cases of glenoid loosening occurred. Interpretation — The CAD/CAM shoulder offers an alternative solution for the treatment of failed RSA that is not amenable to glenoid reconstruction.

Increased-offset reverse shoulder arthroplasty for the treatment of failed post-traumatic humeral head replacement.

BACKGROUND Late complications after humeral head replacement (HHR) for comminuted proximal humeral fractures are common and may necessitate revision surgery. This study evaluated the outcome of revision surgery of failed post-traumatic HHR with a less medialized reverse shoulder prosthesis. METHODS Thirty-three patients with failed post-traumatic HHR due to rotator-cuff insufficiency and glenoid erosion, but with sufficient preservation of the glenoid bone stock to permit primary stability of an inverted glenoid implant, underwent revision using the Bayley-Walker reverse shoulder prosthesis (Stanmore Implants, Elstree, UK) and were monitored up for a mean of 31 months. Outcome measures included the Oxford Shoulder Score, subjective shoulder value, pain rating, active range of motion, and shoulder radiographs. RESULTS The average postrevision Oxford Shoulder Score and subjective shoulder value improved from 50 ± 6 to 29 ± 11 and from 23 ± 19 to 51 ± 23, respectively (P < .001). Pain level decreased from 6.2 ± 2.1 to 1.4 ± 2.0 (P < .001). Active forward flexion increased from 34° ± 22° to 63° ± 30° and external rotation from 11° ± 14° to 20° ± 16°(P < .01). More patients were able to use their affected arm to reach a functional triangle consisting the mouth, opposite armpit, and ipsilateral buttock after revision (24% vs 73%; P < .001). Seven patients (21%) had postrevision complications. No glenoid loosening or scapular notching occurred. CONCLUSION Revision of failed post-traumatic HHR with the Bayley-Walker shoulder offers reliable pain relief and improvement in shoulder function with a complication rate similar to other reverse prostheses. Nevertheless, revision shoulder arthroplasty remains challenging with a high rate of complications.

Local implantation of autologous adipose-derived stem cells increases femoral strength and bone density in osteoporotic rats: A randomized controlled animal study

Background: Deficient osteogenic capacity of bone marrow stem cells plays a critical role in the pathophysiology of osteoporosis. Adipose-derived stem cells (ADSCs) have emerged as a promising source of skeletal progenitor cells. The capacity of ADSCs to undergo osteogenic differentiation and induce mineralized tissue formation may be beneficial in the treatment of osteoporosis. We question whether administration of autologous ADSCs into the proximal femur of osteoporotic rats will induce osteogenesis and enhance bone quality and strength. Materials and Methods: Thirty ovariectomized female rats were randomly assigned to one of the two treatment groups: (1) percutanous implantation of autogenous ADSCs-seeded scaffold into the proximal femur and (2) percutanous implantation of non-seeded scaffold. The contralateral untreated femur served as control. The effect of treatment on bone characteristics was assessed at 12-week follow-up by micro-computed tomography analysis, mechanical testing, and histological analysis. Results: The mean cortical thickness, total bone volume density, and bone load to failure in femora injected with autologous ADSCs-seeded scaffold was significantly higher compared to femora injected with non-seeded scaffold and compared to the untreated control femora (p < 0.01). Histological examination of the injected specimens revealed complete osseo-integration of the scaffolds with direct conversion of the ADSCs into osteoblasts and no inflammatory response. Conclusions: Autogenous ADSCs implantation into the proximal femur of rats with ovariectomy-related osteoporosis promoted bone regeneration and increased bone strength at short-term follow-up. These findings highlight the potential benefit of autogenous ADSCs in the treatment of osteoporosis. Level of Evidence: Level I, randomized controlled trial, animal study.

Primary shoulder arthroplasty using a custom-made hip-inspired implant for the treatment of advanced glenohumeral arthritis in the presence of severe glenoid bone loss

BACKGROUND Total shoulder arthroplasty for end-stage glenohumeral arthritis with severe glenoid bone loss poses a unique challenge for shoulder surgeons. Current surgical solutions are limited and associated with high complication rates. We hypothesized that a custom-made computer-aided design-computer-aided manufacturing (CAD-CAM) total shoulder replacement (TSR; Stanmore Implants Worldwide, Elstree, UK) resembling a total hip prosthesis could offer a reliable alternative for this challenging subset of patients. METHODS Thirty-seven patients with rotator cuff-deficient end-stage glenohumeral arthritis and severe glenoid bone loss (assessed as not amenable to treatment with standard anatomic or reverse total shoulder implants) were treated with the CAD-CAM TSR between 2006 and 2013. Clinical data were collected prospectively and analyzed at a mean follow-up of 5 years. RESULTS Postoperatively, the pain level with activity decreased from 9.2 ± 1.7 to 2.4 ± 2.9 (P < .001). The Oxford Shoulder Score improved from 11 ± 8 points to 27 ± 11 points (P < .001), and the Subjective Shoulder Value (on a 0%-100% scale) improved from 23% ± 14% to 60% ± 24% (P < .001). Active forward elevation improved from 39° ± 23° to 63° ± 38° (P < .001), and external rotation improved from 6° ± 16° to 15° ± 17° (P = .001). Component revision was required in 6 of 37 patients (16%) (glenoid loosening in 1, humeral stem loosening in 3, periprosthetic fracture in 1, and prosthesis dislocation in 1). CONCLUSION The CAD-CAM TSR offers a reliable alternative for the treatment of end-stage glenohumeral arthritis with severe glenoid deficiency not amenable to standard anatomic or reverse total shoulder implants, with maintenance of significant pain relief and clinical-functional improvement at 5-year postoperative follow-up.