Okechukwu A. Anakwenze

Current review of adhesive capsulitis

Adhesive capsulitis, also known as frozen shoulder, is a common condition involving scapulohumeral pain and loss of motion. This condition was termed ‘‘peri-arthritis scapulohumerale’’ by Duplay in 1896. Codman, in 1934, characterized the diagnosis of ‘‘frozen shoulder’’ as a condition characterized by pain and reduced range of motion in the affected shoulder. Neviaser, in the prearthroscopic era, subsequently used the term ‘‘adhesive capsulitis’’ to describe the findings of chronic inflammation and fibrosis of the joint capsule, although arthroscopic examination would support the term ‘‘fibrotic capsulitis’’ with the absence of adhesions. The current consensus definition of the American Shoulder and Elbow Surgeons is ‘‘a condition of uncertain etiology characterized by significant restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder.’’ Despite the large number of patients affected by this condition, our understanding of the condition is limited. In the past, the term ‘‘frozen shoulder’’ has often been used to describe other shoulder conditions such as subacromial bursitis and calcific tendonitis. Neviaser and Neviaser described the term ‘‘frozen shoulder’’ as a ‘‘waste-can diagnosis,’’ because it was often overused and misapplied to patients with a stiff and painful shoulder. Conditions such as calcific tendonitis, bicipital tenosynovitis, glenohumeral and acromioclavicular arthritis, and tears of the rotator cuff can lead to a stiff and painful shoulder, causing apparent limitation of active range of motion, but they lack true

Sagittal Cervical Alignment After Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion : Results of a Prospective, Randomized, Controlled Trial

Study Design. Radiographic results of a multicenter, prospective randomized study comparing 1-level cervical total disc replacement (TDR-C) with anterior cervical discectomy and fusion (ACDF). Objective. To evaluate the effect on device-level lordosis, cranial and caudal adjacent level lordosis, and overall cervical sagittal alignment (C2–C6) after TDR-C or ACDF. Summary of Background Data. Cervical total disc replacement (TDR-C) has emerged as a promising alternative to ACDF in a select group of patients. The maintenance and/or improvement of sagittal balance is essential in preserving functionality after reconstructive spinal procedures. Recent studies have documented changes in spinal alignment after TDR-C, however, no studies have compared these changes to those noted in matched group of patients that have undergone ACDF. Methods. Radiographic data were obtained from the randomized group of a multicenter, randomized, prospective, controlled study comparing TDR-C (ProDisc-C, Synthes Spine, West Chester, PA) with ACDF in the treatment of 1-level cervical disc disease. Complete radiographic data were available for 89 TDR-C patients (average age: 42.2 years) and 91 ACDF patients (average age: 41.7 years). Cervical lordosis at the device level, cranial and caudal adjacent levels, and total cervical lordosis (C2–C6) were independently measured before surgery and 2 years after surgery using custom image stabilization software (Quantitative Motion Analysis, Medical Metrics, Inc, Houston, TX). Results. C5–C6 was the most common operative level (TDR-C: 54%; ACDF: 55%). At 2 years after surgery, the TDR-C group experienced statistically significant changes in lordosis of 3.0° (P < 0.001), 0.90° (P = 0.006), and −1.9° (P < 0.001) at the operative, cranial, and caudal adj-acent levels, respectively. ACDF experienced changes in lordosis of 4.2° (P < 0.001), 1.0° (P = 0.001), and −1.5° (P = 0.001), respectively. The between-group differences were significant at the operative level (P = 0.03) and the caudal adjacent level (P = 0.05). Total cervical lordosis increased in both TDR-C and ACDF by 3.1° and 3.8°, respectively (P = 0.49). Conclusion. In both TDR-C and ACDF, lordosis increased at the device-level, cranial adjacent level, and in total cervical lordosis, while lordosis decreased at the caudal adjacent level. Although ACDF facilitated a greater increase in device level lordosis (+1.25°) and less loss of lordosis at the caudal adjacent level compared with TDR-C (−0.39°), the clinical relevance of the small differences remain unknown.

Segmental contribution toward total cervical range of motion: a comparison of cervical disc arthroplasty and fusion.

Study Design. Prospective radiographic evaluation of patients that underwent cervical total disc replacement (TDR-C) or anterior cervical discectomy and fusion (ACDF) for one-level cervical disc disease. Objective. To evaluate the following: (1) total cervical range of motion (ROM) from C2 to C7, and (2) the relative contribution to total cervical ROM from the operative level and each adjacent level after one-level TDR-C or ACDF. Summary of Background Data. The development of symptomatic adjacent segment disease after ACDF has served as the impetus for the development of motion-preserving alternatives, most notably cervical disc arthroplasty. While previous reports have evaluated device-level and total cervical motion, no study has comprehensively quantified the relative contribution made from each of the adjacent levels to total cervical ROM in TDR-C and ACDF. Methods. Radiographic review of 187 randomized patients from a multicenter, prospective, randomized trial comparing TDR-C with ACDF for one-level cervical disc disease. There were 93 TDR-C and 94 ACDF patients included. ROM measurements were performed independently using quantitative motion analysis, a custom digitized image stabilization software program, to evaluate total cervical ROM and relative contribution to total ROM from each level from C2 to C7 preoperatively and at 24 months. Results. The most common operative level was C5/C6 (57%) followed by C6/C7 (34%). At 2 years, the TDR-C group underwent a statistically greater improvement in total cervical ROM (+5.9°) compared with ACDF (–0.8°, P = 0.001). In TDR-C, the relative contributions to total cervical ROM from the operative level and each caudal and cranial adjacent level were statistically equivalent from baseline to 24 months. In contrast, ACDF patients had significantly reduced contribution to total cervical ROM from the operative level (by 15%, P < 0.001), and significantly elevated contribution from the caudal adjacent level (by 5.9%, P < 0.001), first cranial adjacent level (by 3.3%, P < 0.001), second cranial adjacent level (by 5.3%, P < 0.001), and third cranial adjacent level (by 3.0%, P < 0.001). Conclusion. Compensation for the loss of motion at the operative level in ACDF is seen throughout the unfused cervical spine. Cervical disc arthroplasty, however, increases total cervical ROM compared with ACDF and maintains a physiologic distribution of ROM throughout the cervical spine at 2 years, potentially lowering the risk for adjacent segment breakdown.

Segmental contribution toward total lumbar range of motion in disc replacement and fusions: a comparison of operative and adjacent levels.

Study Design. Radiographic results from a prospective, randomized, multicenter trial assessing patients who underwent lumbar total disc replacement (TDR) or circumferential arthrodesis for 1-level degenerative disc disease. Objective. To quantify the relative segmental contribution to total lumbar range of motion (ROM) at the operative level at each adjacent level in lumbar TDR and arthrodesis. Summary of Background Data. Although previous studies have evaluated ROM in TDR and fusion, no study has quantified or compared the relative segmental contribution to total lumbar ROM. Further, no study to the best of our knowledge has evaluated the kinematic profile of the more cranial adjacent segments (i.e., the second or third adjacent levels) following implantation of either TDR or fusion. Methods. Radiographic data collected from all randomized 1-level degenerative disc disease patients operated at L4/5 or L5/S1 that participated in the multicenter, prospective, randomized IDE study comparing ProDisc-L with circumferential lumbar arthrodesis were evaluated before surgery and at 24 months. Radiographic measurements were performed independently using custom digitized image stabilization software to generate ROM at the operative level, and at each cranial and caudal adjacent level. Results. There were 200 total patients included (155 ProDisc-L, average age 39 years; 45 arthrodesis, average age 40 years). At 24 months, the L4/5 TDR group experienced a significant improvement in total lumbar ROM from baseline (+6.3°), whereas there was no change seen with L5/S1 TDR or any fusion group. Between-group comparisons from baseline to 24 months postoperatively revealed: (1) significantly more contribution from the operative level towards total lumbar range in TDR at operative level L4/5 (TDR: −2.5%, fusion: −16.8%, P = 0.006), and operative level L5/S1 (TDR: −5.1%, fusion: −15.9%, P < 0.001), and (2) the relative contribution towards total lumbar range of motion from the first cranial adjacent segment to fusion at L5/S1 increased by 12.1%, compared with −1.2% seen in TDR (P = 0.03). There were elevated contributions from the more cranial adjacent levels to a fusion when compared with TDR, however, these differences were not statistically significant. At operative level L4/5, there was significantly increased ROM from the first caudal segment below TDR (6%, P = 0.03), but not below fusion (3.1%, P = 0.59). Conclusion. In conclusion, patients with TDR lost slight relative contribution to total lumbar motion from the operative level which was mostly compensated for by the caudal adjacent level (if operated at L4/5). In contrast, the significant loss of relative range of motion contribution from the operative level in fusions was redistributed among multiple cranial adjacent levels, most notably at the first cranial adjacent level.

Athletic performance outcomes following lumbar discectomy in professional basketball players.

Study Design. Retrospective case-control study. Objective. To quantify the athletic performance profiles after lumbar discectomy (LD) in a cohort of National Basketball Association (NBA) players in comparison with a control group of matched NBA players who did not undergo LD during the same study period. Summary of Background Data. LD provides symptomatic relief and improved functional outcomes in the majority of patients as assessed by validated measures such as Oswestry Disability Index, Visual Analog Scale, and Short Form-36 (SF-36). Among professional athletes, however, the goal of lumbar HNP treated by discectomy is not only to improve functional status but also, ultimately, to return the player to preinjury athletic performance levels. No study to date has compared the athletic performance profiles before and after discectomy in professional athletes. Methods. An analysis of NBA games summaries, weekly injury reports, player profiles, and press releases was performed to identify 24 NBA players who underwent LD for symptomatic lumbar HNP between 1991 and 2007. A 1:2 case: control study was performed using players without history of lumbar HNP who were matched for age, position, experience, and body mass index as control subjects (n = 48). Paired t tests were conducted on the following parameters: games played, minutes per game, points per 40 minutes, rebounds per 40 minutes, assists per 40 minutes, steals per 40 minutes, blocks per 40 minutes, and shooting percentage. For each athletic performance outcome, between-group comparisons evaluating preindex to postindex season performance were done (index season = season of surgery). Results. In the LD group, 18 of 24 players (75%) returned to play again in the NBA, compared with 42 of 48 players (88%, P = 0.31) in the control group. One year after surgery, between-group comparisons revealed statistically significant increase in blocked shots per 40 minutes in the LD (0.18) versus control group (−0.33; P = 0.008) and a smaller decrease in rebounds per 40 minutes in the LD (−0.25) versus control group (−1.42; P = 0.049). No other performance variable was found to be significantly different between the study and control group. Conclusion. Compared with a closely matched control cohort, we found that 75% of surgical patients returned to play again in the NBA, compared with 88% in control subjects who did not undergo surgery. For those players who returned, overall athletic performance was slightly improved or no worse than control subjects.

Case Reports: Two Cases of Glenohumeral Chondrolysis after Intraarticular Pain Pumps

BackgroundAcute idiopathic chondrolysis in young adults is rare. The etiology often is unknown and outcomes can be devastating owing to rapid development of painful secondary osteoarthritis. There have been some recent reports of chondrolysis after arthroscopic shoulder procedures. Animal and laboratory data suggest chondrolysis is related to the use of intraarticular pain pumps, although there is no conclusive evidence that this is causative in patients.Case descriptionWe present two cases of young adults with chondrolysis of the humeral head after intraarticular pain pump use with humeral head resurfacing and biologic glenoid resurfacing.Literature reviewSeveral authors report glenohumeral chondrolysis after shoulder arthroscopy involving the use of bupivacaine pain pumps. In addition, experimental animal studies have confirmed the presence of chondrolysis after bupivacaine infusion.Purposes and clinical relevanceThese cases provide additional evidence of an important association between postarthroscopic chondrolysis of the glenohumeral joint and the use of bupivacaine pain pumps.

Soft-tissue management in revision total shoulder arthroplasty.

&NA; Revision total shoulder arthroplasty can be technically challenging. Results are inferior to those of primary arthroplasty, particularly when the indications for revision are related to soft‐tissue problems. Patient selection is important. In the stiff arthroplasty, the surgeon must address rotator cuff and capsular contractures as well as exuberant soft‐tissue adhesions. Unstable arthroplasty can be the result of asymmetric soft‐tissue balancing or deficiencies (eg, subscapularis deficiency) that can lead to loss of the rotator cuff force couples and, subsequently, to instability on attempted glenohumeral motion. Infection must be considered in the workup of the failed total shoulder. In this era of ever‐increasing use of shoulder arthroplasty, surgeons will be presented with growing numbers of patients who require revision surgery. An organized approach is needed to diagnose and manage the stiff or unstable total shoulder arthroplasty.

Primary musculoskeletal sarcoidosis.

Sarcoidosis is a well-described clinical entity with several types of presentation among different organ systems. However, primary musculoskeletal manifestation is a rare and seldom-described manifestation. A retrospective review of patients seen at our institution from 1999 to 2009 was performed to identify patients with such presentation. Eleven patients with musculoskeletal sarcoidosis were identified. Seven patients presented with solitary lesions, while 4 presented with multiple foci of disease. Histologically, all lesions revealed granulomatous inflammation consistent with sarcoidosis. Cultures and gram stain were negative in all patients. One patient was found to have evidence of pulmonary sarcoidosis after diagnosis of musculoskeletal sarcoidosis. Eight patients had primarily soft tissue involvement with visible masses, while 3 patients had primarily osseous involvement with no mass. Pain was reported by 9 of 11 patients. On magnetic resonance imaging, all lesions were dark on T1, bright on T2, and poorly marginated. Magnetic resonance imaging was noted to be more accurate in revealing the pathology than radiographic imaging. Four patients underwent complete excision and 1 received a steroid injection. The remaining patients required no further treatment after diagnosis. Musculoskeletal sarcoidosis is rare and can present as single or multiple lesions. Definitive diagnosis is made by biopsy. The decision to operate should be based on symptoms, issues with cosmesis, impending fractures, growth, and/or involvement of neuro-vascular structures. Patients should be evaluated for pulmonary involvement.

Adolescent disc dysplasia and back pain

PurposeAdolescent disc dysplasia can be a cause of significant back pain and functional impairment in patients. We present a case series of patients inflicted with adolescent disc dysplasia (ADD).MethodsA retrospective search was performed identifying patients presenting with ADD. Radiographic studies and advanced imaging were described. We documented presenting symptoms and clinical course.ResultsSix patients were identified. All patients presented with mechanical back pain, which worsened with flexion and extension. Magnetic resonance imaging was most accurate imaging modality.ConclusionAmong our patient cohort, treatment for adolescent disc dysplasia consisted of a combination of physical therapy and bracing. Neither approach proved to be very effective, with only one patient asymptomatic at follow-up.