Robert J. Nowinski

Outcome of nonoperative management of full-thickness rotator cuff tears.

The study documented the functional outcome in a consecutive series of 46 patients from an individual practice meeting the inclusion criteria of (1) a full-thickness rotator cuff tear seen by ultrasonography, arthrogram, or magnetic resonance imaging, (2) absence of a Workers’ Compensation claim or previous surgery, (3) followup of at least 1 year, and (4) election of nonoperative management by the patient. Twenty-six of the tears involved only the supraspinatus, two involved the supraspinatus and infraspinatus, and two involved the supraspinatus, infraspinatus, and subscapularis (16 reports did not specify the size of the tear). Treatment consisted only of patient education and a home program of gentle stretching and strengthening. Patients completed the Simple Shoulder Test at the initial visit and sequentially at 6-month intervals thereafter. At an average followup of 2.5 ± 1.6 years, 27 (59%) patients experienced improvement with nonoperative treatment, 14 (30%) patients experienced worsening, and five (11%) patients remained unchanged. The average number of Simple Shoulder Test functions the patients could perform initially was 5.6 ± 3.2. At the latest followup, the average number of Simple Shoulder Test functions the patients could perform improved to 7.0 ± 3.8. The ability to sleep on the affected side and the ability to place the hand behind the head were significantly improved.

Early Follow-up of Reverse Total Shoulder Arthroplasty in Patients Sixty Years of Age or Younger

BACKGROUND Reverse shoulder arthroplasty (RSA) is an accepted treatment that provides reproducible results in the treatment of shoulder arthritis and rotator cuff deficiency. Concerns over the longevity of the prosthesis have resulted in this procedure being reserved for the elderly. There are limited data in the literature with regard to outcomes in younger patients. We report on the early outcomes of RSA in a group of patients who were sixty years or younger and who were followed for a minimum of two years. METHODS A retrospective multicenter review of sixty-six patients (sixty-seven RSAs) with a mean age of 52.2 years was performed. The indications included rotator cuff insufficiency (twenty-nine), massive rotator cuff disorder with osteoarthritis (eleven), failed primary shoulder arthroplasty (nine), rheumatoid arthritis (six), posttraumatic arthritis (four), and other diagnoses (eight). Forty-five shoulders (67%) had at least one prior surgical intervention, and thirty-one shoulders (46%) had multiple prior surgical procedures. RESULTS At a mean follow-up time of 36.5 months, mean active forward elevation of the arm as measured at the shoulder improved from 54.6° to 134.0° and average active external rotation improved from 10.0° to 19.6°. A total of 81% of patients were either very satisfied or satisfied. The mean American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) score for pain improved from 40.0 to 72.4 and 7.5 to 3.0, respectively. The ability to achieve postoperative forward arm elevation of at least 100° was the only significant predictor of overall patient satisfaction (p < 0.05) that was identified in this group. There was a 15% complication rate postoperatively, and twenty-nine shoulders (43%) had evidence of scapular notching at the time of the latest follow-up. CONCLUSIONS RSA as a reconstructive procedure improved function at the time of short-term follow-up in our young patients with glenohumeral arthritis and rotator cuff deficiency. Objective outcomes in our patient cohort were similar to those in previously reported studies. However, overall satisfaction was much lower in this patient population (81%) compared with that in the older patient population as reported in the literature (90% to 96%).

Antibiotic-loaded bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a retrospective, cohort study of 501 shoulders

BACKGROUND Deep infection after primary reverse total shoulder arthroplasty is a devastating event and has an increased incidence compared with anatomic total shoulder arthroplasty. Recent reports in the hip and knee arthroplasty literature suggest that antibiotic-loaded bone cement may lower infection rates for primary arthroplasties. We conducted a retrospective cohort study to evaluate the effect of antibiotic-loaded bone cement vs plain bone cement on the prevention of deep infection after primary reverse total shoulder arthroplasty. MATERIALS AND METHODS Four surgeons from their respective facilities participated in the retrospective cohort data collection. From 1999 to 2008, 501 consecutive primary reverse total shoulder arthroplasties were performed. Patients with revision of failed previous arthroplasties were excluded, and patients with any other previous shoulder procedure were included. Two groups were examined in this retrospective cohort: In group 1 (265 shoulders), the cement used for humeral fixation did not have antibiotics; in group 2 (236 shoulders), antibiotic-impregnated bone cement containing tobramycin, gentamycin, or vancomycin/tobramycin was used for fixation. RESULTS At an average postoperative follow-up of 37 months, no deep infection had developed in the 236 shoulders in group 2, whereas a deep infection had developed in 8 of the 265 shoulders (3.0%) in group 1. This difference between the groups was significant (P < .001). CONCLUSIONS Antibiotic-impregnated bone cement was effective in the prevention of postoperative deep infection after primary reverse total shoulder arthroplasty during short-term follow-up.

Angular-Stable Locked Intramedullary Nailing of Two-Part Surgical Neck Fractures of the Proximal Part of the Humerus A Multicenter Retrospective Observational Study

BACKGROUND The ideal fixation technique for the treatment of proximal humeral fractures remains unclear. In the present study, we evaluated the experience of three surgeons with the treatment of two-part surgical neck fractures with angular-stable intramedullary fixation. METHODS Forty-eight patients with forty-eight Neer two-part surgical neck proximal humeral fractures were managed with locked angular-stable intramedullary nail fixation by three surgeons. Shoulder pain and outcomes were quantified with Constant scores and standard radiographs. RESULTS Thirty-eight patients (including twenty-eight female patients and ten male patients) with a mean age of sixty-five years were followed for at least twelve months (mean, twenty months; range, twelve to thirty-six months). All fractures healed primarily. The mean follow-up Constant score (and standard deviation) was 71 ± 12 points (range, 37 to 88 points), with a mean age-adjusted Constant score of 97% (range, 58% to 119%). The mean Constant pain score was 13 ± 2.2 (possible range, 0 to 15 points, with 15 points representing no pain). The mean forward flexion was 132° ± 22°. All fractures but one healed with a neck-shaft angle of ≥125°. CONCLUSIONS Patients who were managed with locked angular-stable intramedullary nailing of two-part surgical neck proximal humeral fractures via an articular entry point had reliable fracture-healing, favorable clinical outcomes, and little residual shoulder pain.

Pectoralis major tendon transfer for the treatment of scapular winging due to long thoracic nerve palsy

BACKGROUND Painful scapular winging due to chronic long thoracic nerve (LTN) palsy is a relatively rare disorder that can be difficult to treat. Pectoralis major tendon (PMT) transfer has been shown to be effective in relieving pain, improving cosmesis, and restoring function. However, the available body of literature consists of few, small-cohort studies, and more outcomes data are needed. MATERIALS AND METHODS Outcomes of 26 consecutive patients with electromyelogram-confirmed LTN palsy who underwent direct (n = 4) or indirect transfer (n = 22) of the PMT for dynamic stabilization of the scapula were reviewed. All patients were followed up clinically for an average of 21.8 months (range, 3-62 months) with evaluations of active forward flexion, active external rotation, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and observation of scapular winging. RESULTS Preoperative to postoperative results included increases in the mean active forward flexion from 112° to 149° (P < .001) an in mean active external rotation from 53.8° to 62.8° (P = .045), an improvement in the mean ASES score from 28 to 67.0 (P < .001), and an improvement in the mean VAS pain score from 7.7 to 3.0 (P < .001). Recurrent scapular winging occurred in 5 patients. There was no difference in outcome by length of follow-up. CONCLUSIONS PMT transfer is an effective treatment for painful scapular winging resulting from LTN palsy. This is the largest reported series of consecutive patients treated with PMT transfer for the correction of scapular winging.

Resection arthroplasty for failed shoulder arthroplasty

BACKGROUND As shoulder arthroplasty becomes more common, the number of failed arthroplasties requiring revision is expected to increase. When revision arthroplasty is not feasible, resection arthroplasty has been used in an attempt to restore function and relieve pain. Although outcomes data for resection arthroplasty exist, studies comparing the outcomes after the removal of different primary shoulder arthroplasties have been limited. MATERIALS AND METHODS This was a retrospective multicenter review of 26 patients who underwent resection arthroplasty for failure of a primary arthroplasty at a mean follow-up of 41.8 months (range, 12-130 months). Resection arthroplasty was performed for 6 failed total shoulder arthroplasties (TSAs), 7 failed hemiarthroplasties, and 13 failed reverse TSAs. RESULTS Patients who underwent resection arthroplasty demonstrated significant improvement in visual analog scale pain score (6 ± 4 preoperatively to 3 ± 2 postoperatively). Mean active forward flexion and mean active external rotation decreased, but this difference was not significant. Subgroup analysis revealed that postoperative mean active forward flexion was significantly greater in patients undergoing resection arthroplasty after failed TSA than after reverse TSA (P = .01). CONCLUSIONS Resection arthroplasty is effective in relieving pain, but patients have poor postoperative function. Patients with resection arthroplasty for failed reverse shoulder arthroplasty have worse function than those with failed hemiarthroplasty or TSA. Surgeons should be aware of this when assessing postoperative function. There is no difference in functional outcome between hemiarthroplasty and TSA.

Radiographic assessment of prosthetic humeral head size after anatomic shoulder arthroplasty

BACKGROUND Restoring the premorbid proximal humeral anatomy during shoulder arthroplasty is critical yet can be difficult because of the deformity of the arthritic head. The purpose of this study was to measure the variation between surgeons and between types of prosthetics in reproducing the anatomic center of rotation (COR) of the humeral head after anatomic shoulder arthroplasty. METHODS The anteroposterior radiographs of 125 stemmed and 43 resurfacing shoulder arthroplasties, performed by 5 experienced surgeons, were analyzed. All patients had primary replacement for treatment of end-stage glenohumeral arthritis. A best-fit circle to preserved nonarticular humeral landmarks was used to define the difference between the anatomic COR and the prosthetic COR. A difference in COR of >3.0 mm was considered clinically significant and analyzed for the cause of this deviation. RESULTS The average deviation of the postoperative COR from the anatomic COR was 2.5 ± 1.6 mm for stemmed cases and 3.8 ± 2.1 mm for resurfacings. Thirty-nine stemmed cases (31.2%) and 28 resurfacings (65.1%) were beyond 3.0 mm of deviation and regarded as outliers. The majority of the stemmed outliers and all resurfacing outliers were overstuffed. An improper humeral head size selection and inadequate reaming were the main reasons for the deviation in stemmed and resurfacing outliers, respectively. CONCLUSION A large percentage of shoulder replacements demonstrated significant deviations from an anatomic reconstruction. Resurfacing arthroplasty exhibited significantly greater deviations compared with stemmed arthroplasty (P < .001), indicating that surgeons have more difficulty in restoring the anatomy with resurfacings. Further studies are needed to assess the clinical impact of these deviations.

Salmonella Osteomyelitis Secondary to Iguana Exposure: A Case Report

Salmonella osteomyelitis is a rare condition that has been associated with patients having hemoglobinopathies or immunosuppression. Healthy patients with no underlying medical history have been known to have Salmonella osteomyelitis develop. Salmonella infection secondary to reptile exposure is an increasing condition in the United States. Several manifestations of salmonellosis have been described in the literature, but no cases of reptile associated bone or joint infections have been reported. The authors present a case of a 7-month-old girl who contracted Salmonella osteomyelitis of her proximal humerus with septic arthritis of the glenohumeral joint secondary to iguana exposure.

Intramedullary nailing of the proximal humerus: evolution, technique, and results

Proximal humerus fractures are the third most common fracture in the elderly. Although most fractures can be treated conservatively with acceptable outcomes, certain fracture patterns are at high risk for progression to humeral malunions, nonunions, stiffness, and post-traumatic arthrosis. The goal of antegrade humeral nailing of proximal humerus fractures is to provide stability to a reduced fracture that allows early motion to optimize patient outcomes. Certain technical pearls are pivotal in managing these difficult fractures with nails; these include rotator cuff management, respect of the soft tissues, anatomic tuberosity position, blood supply maintenance, knowledge of the deforming forces on the proximal humerus, fracture reduction, and rehabilitation strategies. Modern proximal humeral nail designs and techniques assist the surgeon in adhering to these principles and have demonstrated promising outcomes. Humeral nail designs have undergone significant innovation during the past 40 years and now can provide stable fixation in the humeral shaft distally as well as improved stability in the head and tuberosity fragments, which were the common site of fixation failure with earlier generation implants. Compared with other fixation strategies, such as locking plate fixation, no compelling evidence exists to suggest one technique over another. The purpose of this review is to describe the history, results, new designs, and techniques that make modern intramedullary nailing of proximal humerus fractures a viable treatment option.

A prospective, multicenter study to evaluate clinical and radiographic outcomes in primary rotator cuff repair reinforced with a xenograft dermal matrix

BACKGROUND Minimal information is currently available on the outcome of rotator cuff repair reinforced with an extracellular matrix (ECM) graft. Therefore, the purpose of this study was to determine the clinical and radiographic outcome of repair of large rotator cuff tears with ECM graft reinforcement. METHODS This was a prospective study of 61 shoulders with large repairable rotator cuff tears (3 to 5 cm). The rotator cuff tears were surgically repaired and reinforced with a xenograft ECM graft. The average patient age was 56 years (range, 40-69 years). The average tear size was 3.8 cm. RESULTS Follow-up was obtained at 6, 12, and 24 months in 58, 54, and 50 of the 61 patients, respectively. Functional outcome scores, isometric muscle strength, and active range of motion were significantly improved compared with baseline. Magnetic resonance imaging at 12 months showed retorn rotator cuff repairs in 33.9% of shoulders, using the criteria of a tear of at least 1 cm, and tears in 14.5% of the shoulders using the criteria of retear >80% of the original tear size. Three patients underwent surgical revision. Complications included 1 deep infection. CONCLUSIONS Repair of large rotator cuff tears structurally reinforced with xenograft ECM resulted in improved functional outcomes scores and strength. Adverse events were uncommon, and the rate of revision surgery was low.