Peter C. Poon

Early Motion for Achilles Tendon Ruptures: Is Surgery Important? A Randomized, Prospective Study

Background Comparisons of surgically and nonsurgically treated Achilles tendon ruptures have demonstrated that those treated with surgery allow earlier motion and tend to show superior results. However, early motion enhances tendon healing with or without surgery and may be the important factor in optimizing outcomes in patients with Achilles tendon rupture. Hypothesis There is no difference in the outcome of acute Achilles tendon rupture treated nonoperatively or operatively if controlled early motion is allowed as part of the rehabilitation program. Study Design Randomized, controlled clinical trial; Level of evidence, 1. Methods Patients with acute rupture of the Achilles tendon were randomized to surgery or no surgery, with both groups receiving early motion controlled in a removable orthosis, progressing to full weightbearing at 8 weeks from treatment. Both groups were followed prospectively for 12 months with measurements of range of motion, calf circumference, and the Musculoskeletal Functional Assessment Instrument (MFAI) outcome score; any reruptures and any complications were noted. Results Both groups were comparable for age and sex. There were no significant differences between the 2 groups in plantar flexion, dorsiflexion, calf circumference, or the MFAI scores measured at 2, 8, 12, 26, or 52 weeks. One patient in each group was noncompliant and required surgical rerepair of the tendon. There were no differences in complications and a similar low number of reruptures in both groups. Conclusion This study supports early motion as an acceptable form of rehabilitation in both surgically and nonsurgically treated patients with comparable functional results and a low rerupture rate. There appears to be no difference between the 2 groups, suggesting that controlled early motion is the important part of treatment of ruptured Achilles tendon.

Comparison of functional outcomes of reverse shoulder arthroplasty versus hemiarthroplasty in the primary treatment of acute proximal humerus fracture.

Background:  Treatment of complex proximal humeral fractures remains controversial. In cases where adequate open reduction and internal fixation cannot be achieved, hemiarthroplasty has been the traditional treatment; however, clinical results have been mixed. Reverse shoulder arthroplasty (RSA) has been suggested as an alternative, and this study aimed to compare the functional results of RSA versus hemiarthroplasty in patients with acute proximal humeral fracture.

The SMR reverse shoulder prosthesis in the treatment of cuff-deficient shoulder conditions

BACKGROUND Reverse total shoulder arthroplasty (RSA) is a relatively recent concept that provides further options in the management of cuff-deficient shoulder disorders. While early results utilizing the Delta III prosthesis (DePuy, Warsaw, IN) have been promising, there is limited data in the literature on outcomes utilizing differing prosthetic designs. We report on the outcomes of Reverse total shoulder arthroplasty (RSA) utilizing a previously unreported prosthesis, the SMR Modular Shoulder System (Systema Multiplana Randelli, Lima-LTO, Italy). MATERIAL AND METHODS 49 arthroplasties in 48 patients who underwent Reverse Shoulder Arthroplasty with the SMR prosthesis were available for follow up. There were 10 males and 38 females with a mean age of 78.9 years (55-94) at time of operation. The most common indications were cuff tear arthropathy and osteoarthritis with cuff deficiency (66%), followed by fracture and fracture sequelae (16%). RESULTS At a mean 38 months follow up, 89% of patients rated their outcome as good or excellent. The mean American Shoulder and Elbow Surgeon Score was 70.1 (range 3-100), and the mean Oxford Shoulder Score 22.0 (12-47). The mean active anterior elevation was 122 degrees (range 45-180) and the mean external rotation 14.7 degrees (25-75). Inferior glenoid notching was seen in 24% of patients. There was no radiological evidence of component loosening and no reoperations. CONCLUSION Modern RSA designs give encouraging results in the treatment of cuff deficient shoulder conditions. Our early experience with the SMR RSA shows favourable outcomes and a low rate of complications. LEVEL OF EVIDENCE Level 4 Retrospective case series, no control group.

Early Motion for Achilles Tendon Ruptures: Is Surgery Important?

Background Comparisons of surgically and nonsurgically treated Achilles tendon ruptures have demonstrated that those treated with surgery allow earlier motion and tend to show superior results. However, early motion enhances tendon healing with or without surgery and may be the important factor in optimizing outcomes in patients with Achilles tendon rupture. Hypothesis There is no difference in the outcome of acute Achilles tendon rupture treated nonoperatively or operatively if controlled early motion is allowed as part of the rehabilitation program. Study Design Randomized, controlled clinical trial; Level of evidence, 1. Methods Patients with acute rupture of the Achilles tendon were randomized to surgery or no surgery, with both groups receiving early motion controlled in a removable orthosis, progressing to full weightbearing at 8 weeks from treatment. Both groups were followed prospectively for 12 months with measurements of range of motion, calf circumference, and the Musculoskeletal Functional Assessment Instrument (MFAI) outcome score; any reruptures and any complications were noted. Results Both groups were comparable for age and sex. There were no significant differences between the 2 groups in plantar flexion, dorsiflexion, calf circumference, or the MFAI scores measured at 2, 8, 12, 26, or 52 weeks. One patient in each group was noncompliant and required surgical rerepair of the tendon. There were no differences in complications and a similar low number of reruptures in both groups. Conclusion This study supports early motion as an acceptable form of rehabilitation in both surgically and nonsurgically treated patients with comparable functional results and a low rerupture rate. There appears to be no difference between the 2 groups, suggesting that controlled early motion is the important part of treatment of ruptured Achilles tendon.

Comparison of functional outcomes of reverse shoulder arthroplasty with those of hemiarthroplasty in the treatment of cuff-tear arthropathy: a matched-pair analysis.

BACKGROUND Rotator cuff-tear arthropathy has traditionally represented a challenge to the shoulder arthroplasty surgeon. The poor results of conventional total shoulder arthroplasty in rotator-cuff-deficient shoulders due to glenoid component loosening have led to hemiarthroplasty being the traditional preferred surgical option. Recently, reverse total shoulder arthroplasty has gained increasing popularity because of a clinical perception of an improved functional outcome, despite the lack of comparative data. The aim of this study was to compare the early functional results of hemiarthroplasty with those of reverse shoulder arthroplasty in the management of cuff-tear arthropathy. METHODS The results of 102 primary hemiarthroplasties for rotator cuff-tear arthropathy were compared with those of 102 reverse shoulder arthroplasties performed for the same diagnosis. Patients were identified from the New Zealand Joint Registry and matched for age, sex, and American Society of Anesthesiologists (ASA) scores. Oxford Shoulder Scores (OSS) collected at six months postoperatively as well as mortality and revision rates were compared between the two groups. RESULTS There were fifty-one men and fifty-one women in each group, with a mean age of 71.6 years in the hemiarthroplasty group and 72.6 years in the reverse shoulder arthroplasty group. The mean OSS at six months was 31.1 in the hemiarthroplasty group and 37.5 in the reverse shoulder arthroplasty group. At the time of follow-up, there were nine revisions in the hemiarthroplasty group and five in the reverse shoulder arthroplasty group. No difference in mortality rate was seen between the two groups. CONCLUSIONS In this unselected population with rotator cuff-tear arthropathy, controlled for age, sex, and ASA score, reverse shoulder arthroplasty resulted in a functional outcome that was superior to that of hemiarthroplasty. Longer-term follow-up is needed to confirm these findings.

Propionibacterium acnes in primary shoulder arthroplasty: rates of colonization, patient risk factors, and efficacy of perioperative prophylaxis

BACKGROUND Recent literature has shown that Propionibacterium acnes can be cultured from superficial and deep layers of the shoulder. Our aims were to assess the rate of P. acnes colonization in patients undergoing primary shoulder arthroplasty, to identify patient-related risk factors, and to evaluate the efficacy of our perioperative antisepsis protocol. METHODS Thirty consecutive patients undergoing primary shoulder arthroplasty were included in our study. Swabs were taken perioperatively (4 superficial and 2 deep wound swabs) and analyzed quantitatively for P. acnes. Cefazolin minimum inhibitory concentration was determined for P. acnes isolates from positive deep cultures. RESULTS Twenty-two patients (73%) had positive cultures for P. acnes. Male gender (P = .024) and presence of hair (P = .005) had significantly higher rates of P. acnes superficial cultures. Subjects with positive superficial P. acnes cultures (P = .076) and presence of hair with a history of steroid injection (P = .092) were more likely to have deep P. acnes-positive cultures, but this was not statistically significant. Local topical antisepsis measures did not eradicate P. acnes (P = .12). Mean cefazolin minimum inhibitory concentration for P. acnes was 0.32 μg/mL. CONCLUSION P. acnes is commonly isolated from the skin and deep surgical wounds of patients undergoing primary total shoulder arthroplasty who have not had previous shoulder surgery. Male gender and presence of hair were significant risk factors for P. acnes colonization. Perioperative local topical antisepsis and cefazolin administration were not effective in eliminating P. acnes colonization.

A 2-dimensional glenoid vault method for measuring glenoid version on computed tomography.

BACKGROUND Accurate placement of the glenoid prosthesis in shoulder arthroplasty is critical; precise glenoid prosthesis alignment being a key element to avoid poor fixation and early loosening. The current recognized 2-dimensional (2-D) method for measuring glenoid version may be irrelevant to the above, as it does not take into account the complex and variable relationship of the scapular body in relation to the glenoid. On the contrary, a 3-dimensional (3-D) method, which focuses solely on the glenoid, is superior but not readily accessible. We have, therefore, developed a new 2-D method based solely on the glenoid vault which is readily accessible. MATERIALS AND METHODS To determine normal version using our method, computer tomography (CT) scans of 107 normal shoulders were assessed as the control group. We then assessed 63 arthritic shoulders to establish any significant difference. Inter- and intraobserver reliability were assessed using 4 observers who independently reviewed 50 blinded CT images 3 weeks apart. For comparison, the currently recognized method, as described by Friedman et al, was also utilized in this study. RESULTS Using our new method, the mean glenoid version in the control group was 19 ± 3° of retroversion; and in the arthritic group, 25 ± 6° of retroversion. Intra- and interobserver reliability were very high. CONCLUSION Our new 2-D glenoid vault method is relevant, as it focuses solely on the glenoid vault, is precise with a low standard deviation, and is reliably reproducible as shown by the intra- and interobserver reliability data, all while remaining readily accessible.

Endobutton versus transosseous suture repair of distal biceps rupture using the two-incision technique: a comparison series.

BACKGROUND The purpose of this study was to report the outcome of a large cohort of patients undergoing distal biceps tendon repair. We compared the endobutton and transosseous suture repair techniques, both performed through a 2-incision approach. METHOD At an average of 2.1 years after a distal biceps repair, 46 male patients (19 endobutton and 27 transosseous suture) were reviewed. The mean age of our patients was 50 years. RESULTS Forty-three patients (93%) were satisfied with the results of their distal biceps tendon repair. The average pain score was 1.3 of 10 at a mean 2.1 years after repair. More than 80% of patients had regained their premorbid function in both recreational and occupational activities. The mean Mayo Elbow Performance Score was 93 of 100. Biodex strength testing demonstrated restoration of 92% of low-velocity supination power, 102% of high-velocity supination power, and 104% endurance compared with the contralateral limb. There was no statistically significant difference in postoperative strength between the transosseous suture and endobutton groups. There were 3 complications in this series, 1 case of heterotopic ossification and 2 cases of injury to the lateral cutaneous nerve of the forearm. CONCLUSION In this large cohort of 2-incision distal biceps repairs, we found a high degree of patient satisfaction and a low complication rate. We did not find any difference in clinical outcome with regard to subjective patient rating, pain, range of motion, or supination strength when comparing the 2-incision endobutton and transosseous suture fixation techniques.

Perforation tolerance of glenoid implants to abnormal glenoid retroversion, anteversion, and medialization.

BACKGROUND Loosening of the glenoid implant is a common complication of total shoulder arthroplasty. To prevent this, we need to ensure the glenoid vault is not perforated during insertion of the glenoid implant to allow for cement containment and maximum pressurization. Factors affecting perforation potential include glenoid implant design and alignment. This study looks at the perforation tolerance of 15 commercially available glenoid implants to increased retroversion, increased anteversion, and medialization. MATERIALS AND METHODS Accurate 3-dimensional models of the 15 glenoid implants were created from exact dimensions obtained from the manufacturers and virtually implanted into 3-dimensional reconstructed models of 40 nonarthritic scapulae. Perforation tolerances of each implant to increased retroversion, increased anteversion, and medialization were determined through computer simulation to represent asymmetrical arthritic posterior wear, anterior wear, and eccentric corrective reaming, respectively. RESULTS In all 15 glenoid implants, the overall mean increased retroversion tolerated before perforation was 19°, increased anteversion was 16°, and abnormal version fully corrected by eccentric reaming was 17°. Each glenoid implant was evaluated individually to allow for direct comparison and, finally, size-matched and downsized glenoid implants in relation to the size of the humeral head. CONCLUSION The results from this study help surgeons, when faced with a severely arthritic glenoid, to choose the appropriate glenoid implant to minimize perforation potential, and provide guidance on how much abnormal version and how much corrective reaming can be tolerated before perforation occurs and fixation is compromised. These results can also help with future implant designs.

A comparison of concentric and eccentric glenospheres in reverse shoulder arthroplasty: a randomized controlled trial.

BACKGROUND Inferior scapular notching following reverse shoulder arthroplasty is due to mechanical impingement and, in some studies, has been associated with poorer functional scores, lower patient satisfaction, and more limited shoulder motion. We aimed to test the hypothesis that inferior positioning of the center of rotation with eccentric glenosphere designs decreases the adduction deficit before impingement occurs and improves clinical outcome. METHODS A randomized, controlled, double-blinded trial was performed. According to the results of a power analysis, fifty patients undergoing reverse shoulder arthroplasty for the diagnosis of cuff tear arthropathy were randomized intraoperatively to receive either a concentric or eccentric glenosphere. The glenoid baseplate was positioned flush to the inferior border of the glenoid before the glenosphere was then attached. Notching was assessed using an anteroposterior radiograph, and clinical outcome was assessed using the visual analog pain scale score, shoulder function rating, American Shoulder and Elbow Surgeons score, and Oxford shoulder score. Active forward elevation and external rotation were assessed. The outcome assessor was blinded to the treatment group. The mean follow-up period for the groups was forty-three and forty-seven months. RESULTS Patient demographics and preoperative scores were similar between the groups. At the time of the final follow-up, four patients (14.8%) in the concentric group had developed inferior scapular notching (two with Nerot grade I and two with Nerot grade II), ranging in size from 1.1 to 7.4 mm, compared with one patient (4.3%; Nerot grade I) in the eccentric group (p = 0.36). No notching occurred in any patient with glenoid overhang of >3.5 mm. No significant difference between the groups was seen with respect to functional outcome scores, patient satisfaction, or shoulder motion. CONCLUSIONS There were no differences in notching rates or clinical outcomes between concentric and eccentric glenospheres following reverse shoulder arthroplasty. Inferior glenosphere overhang of >3.5 mm, however, prevented notching. This may be achieved with a modified surgical technique, but eccentric glenospheres provide an additional option. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.