Ronald A. Navarro

The results of conservative management of juvenile osteochondritis dissecans using joint scintigraphy A prospective study

A prospective clinical study used joint scintigraphy to investigate conservative treatment of juvenile osteo chondritis dissecans (JOCD) of the femoral condyle. The predictive value of scintigraphic evaluation and various parameters (age at onset, sex, location and size of lesion) were analyzed. Over a 10 year period, the senior author followed 92 knees in 76 patients, 60 of whom were male and 16 female (11 and 5 bilaterals, respectively). All patients were participants in athletics or exercise programs. All patients had orthopaedic assessment, roentgen ographic studies (AP, lateral, and tunnel views), 99m- Technetium phosphate compound joint scintigraphy, and instruction in a symptom-free existence (with all athletic activity proscribed). Patients were reevaluated and scanned every 8 weeks. No casts or braces were used, although crutches were sometimes necessary to maintain symptom-free levels. Based on specific indications for failure of conserva tive treatment, 50% of these patients failed and under went surgery. Of the 92 knees, 52 were successfully treated conservatively, while 40 failed. Average fol lowup was 4.2 years. Average age at onset was 12.5 years; the success group averaged 12.1 years and the failure group 13.0 years. The average lesion size was 363.2 mm2, with 309.5 mm2 in the success group and 436.0 mm2 in the failure group. Parameters of location, sex, and scan classification were not statistically signif icant as predictive factors.

Serratus anterior dysfunction : Recognition and treatment

Recognition of scapular winging may be difficult, and potential errors in treatment can result. Such treatment errors may cause morbidity for the patient. In addition, electrical evidence of long thoracic nerve injury usually is required to confirm the etiology of scapular winging as being caused by serratus anterior dysfunction. Although various conditions may result in scapular winging, primary serratus anterior dysfunction can be treated effectively by transfer of the pectoralis major tendon; however, this surgical approach sometimes may give an unacceptable cosmesis, and there may be local morbidity to the donor site of the iliotibial band graft that is used to augment the tendon transfer. The authors report eight patients with primary chronic scapulothoracic winging refractory to conservative treatment. Five of these patients had an incorrect diagnosis, and this resulted in 17 surgical procedures without resolution of their pain or improvement of function. Of the eight patients who required additional surgery to stabilize the scapula, only five patients had an electromyographic study that showed long thoracic nerve palsy, although all patients had profound scapulothoracic winging. All patients underwent a modified pectoralis major transfer with autogenous semitendinosus and gracilis tendon augmentation using two small incisions. Although one patient had a postoperative infection develop, the remaining seven patients had resolution of their winging, improved function, and satisfactory cosmesis.

Patient and Procedure-specific Risk Factors for Deep Infection After Primary Shoulder Arthroplasty

BackgroundDeep infection after shoulder arthroplasty is a diagnostic and therapeutic challenge. The current literature on this topic is from single institutions or Medicare samples, lacking generalizability to the larger shoulder arthroplasty population.Questions/purposesWe sought to identify (1) patient-specific risk factors for deep infection, and (2) the pathogen profile after primary shoulder arthroplasty in a large integrated healthcare system.MethodsA retrospective cohort study was conducted. Of 4528 patients identified, 320 had died and 302 were lost to followup. The remaining 3906 patients had a mean followup of 2.7 years (1 day-7 years). The study endpoint was the diagnosis of deep infection, which was defined as revision surgery for infection supported clinically by more than one of the following criteria: purulent drainage from the deep incision, fever, localized pain or tenderness, a positive deep culture, and/or a diagnosis of deep infection made by the operating surgeon based on intraoperative findings. Risk factors evaluated included age, sex, race, BMI, diabetes status, American Society for Anesthesiologists (ASA) score, traumatic versus elective procedure, and type of surgical implant. For patients with deep infections, we reviewed the surgical notes and microbiology records for the pathogen profile. Multivariable Cox regression models were used to evaluate the association of risk factors and deep infection. Adjusted hazard ratios and 95% CI are presented.ResultsWith every 1-year increase in age, a 5% (95% CI, 2%–8%) lower risk of infection was observed. Male patients had a risk of infection of 2.59 times (95% CI, 1.27–5.31) greater than female patients. Patients undergoing primary reverse total shoulder arthroplasty had a 6.11 times (95% CI, 2.65–14.07) greater risk of infection compared with patients having primary unconstrained total shoulder arthroplasty. Patients having traumatic arthroplasties were 2.98 times (95% CI, 1.15–7.74) more likely to have an infection develop than patients having elective arthroplasties. BMI, race, ASA score, and diabetes status were not associated with infection risk (all p > 0.05). Propionibacterium acnes was the most commonly cultured organism, accounting for 31% of isolates.ConclusionsYounger, male patients are at greater risk for deep infection after primary shoulder arthroplasty. Reverse total shoulder arthroplasty and traumatic shoulder arthroplasties also carry a greater risk for infection. Propionibacterium acnes was the most prevalent pathogen causing infection in our primary shoulder arthroplasty population.Level of Evidence Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Shoulder arthroplasty in patients 59 years of age and younger

BACKGROUND While shoulder arthroplasty is a well established treatment for a variety of conditions about the shoulder, the results of shoulder replacement in younger patients are not as predictable. The purpose of this study is to examine the indications for shoulder arthroplasty in patients 59 years old and younger, and to analyze revision rates between younger and older patients. METHODS This is a retrospective cohort study of shoulder arthroplasties performed within a statewide integrated healthcare system between 2005 and 2010. Patients were stratified into 2 groups based on age at time of index replacement procedure: younger patients (≤59 years) and older patients (>59 years). RESULTS There were 2981 primary arthroplasties followed for a median time of 2.2 years (interquartile range, 1.0-3.8), 90 (3.0%) of which required revisions. After adjusting for procedure type and diagnosis, younger patients had a two times higher risk (95% CI 1.2-3.5, P = .007) of revision than older patients. When looking at the risk of revision in younger and older patients separately, the risk of revision in hemiarthroplasty (RR = 4.5 vs RR = 1.7) and reverse total shoulder arthroplasty (RR = 33.6 vs RR = 3.0) compared to total shoulder arthroplasty were higher in younger patients compared to older patients. CONCLUSION This study suggests patients 59 years and younger have an increased risk of revision at early follow-up. The higher risk of revision in younger patients receiving hemiarthroplasty may support the use of total shoulder arthroplasty in patients 59 years of age and younger.

Complications following tension-band fixation of patellar fractures with cannulated screws compared with Kirschner wires.

BACKGROUND Displaced patellar fractures are commonly stabilized with a modified anterior tension-band construct. The goal of the current study was to compare the incidence of complications after tension-band fixation of the patella with Kirschner wires as compared with cannulated screws. METHODS We performed a retrospective cohort study of consecutive, surgically treated patellar fractures. Patients were divided into two cohorts: fractures fixed with use of Kirschner wires and fractures fixed with use of cannulated screws. The primary outcome measure was early loss of fixation that necessitated revision surgery. Secondary outcomes included early postoperative infection and the need for implant removal. RESULTS Four hundred and forty-eight patellar fractures were studied. Kirschner wires were used for fixation in 315 (70%), and cannulated screws were used for fixation in 133 (30%). The incidence of fixation failure was 3.5% in the Kirschner-wire group and 7.5% in the screw group (p = 0.065). A postoperative infection occurred in 4.4% of patients in the Kirschner-wire group and 1.5% of patients in the screw group (p = 0.17). One hundred sixteen (37%) patients in the Kirschner-wire group and 30 (23%) in the screw group underwent elective implant removal (p = 0.003). After adjusting for confounding variables, a trend toward increased incidence of fixation failure with screws as compared with Kirschner wires was present (p = 0.083). Patients treated with Kirschner wires were twice as likely to undergo implant removal compared with those treated with screws (p = 0.002). CONCLUSIONS Serious complications are uncommon following treatment of patellar fractures with a modified tension-band technique, with use of either Kirschner wires or cannulated screws. In both groups the rate of fixation failure was low, as was the rate of postoperative infection. Symptomatic implants, the most common complication observed, were twice as frequent in patients treated with Kirschner wires.

The Kaiser Permanente Shoulder Arthroplasty Registry: Results from 6,336 primary shoulder arthroplasties

Background and purpose — Shoulder arthroplasty is being performed in the United States with increasing frequency. We describe the medium-term findings from a large integrated healthcare system shoulder arthroplasty registry. Patients and methods — Shoulder arthroplasty cases registered between January 2005 and June 2013 were included for analysis. The registry included patient characteristics, surgical information, implant data, attrition, and patient outcomes such as surgical site infections, venous thromboembolism, and revision procedures. Results — During the study period, 6,336 primary cases were registered. Median follow-up time for all primaries was 3.3 years; 461 cases were lost to follow-up by ending of health plan membership. Primary cases were predominantly female (56%) and white (81%), with an average age of 70 years. The most common reason for surgery was osteoarthritis in 60% of cases, followed by acute fracture (17%) and rotator cuff tear arthropathy (15%). In elective shoulder arthroplasty procedures, 200 all-cause revisions (4%) were reported, with glenoid wear being the most common reason. Interpretation — Most arthroplasties were elective procedures: over half performed for osteoarthritis. Glenoid wear was the most common reason for revision of primary shoulder arthroplasty in elective cases.

Minimizing Disparities in Osteoporosis Care of Minorities With an Electronic Medical Record Care Plan

BackgroundEthnic disparities in care have been documented with a number of musculoskeletal disorders including osteoporosis. We suggest a systems approach for ensuring osteoporosis care can minimize potential ethnic disparities in care.Questions/purposesWe evaluated variations in osteoporosis treatment by age, sex, and race/ethnicity by (1) measuring the rates of patients after a fragility fracture who had been evaluated by dual-energy xray absorptiometry and/or in whom antiosteoporosis treatment had been initiated and (2) determining the rates of osteoporosis treatment in patients who subsequently had a hip fracture.Patients and MethodsWe implemented an integrated osteoporosis prevention program in a large health plan. Continuous screening of electronic medical records identified patients who met the criteria for screening for osteoporosis, were diagnosed with osteoporosis, or sustained a fragility fracture. At-risk patients were referred to care managers and providers to complete practice guidelines to close care gaps. Race/ethnicity was self-reported. Treatment rates after fragility fracture or osteoporosis treatment failures with later hip fracture were calculated. Data for the years 2008 to 2009 were stratified by age, sex, and race/ethnicity.ResultsWomen (92.1%) were treated more often than men (75.2%) after index fragility fracture. The treatment rate after fragility fracture was similar among race/ethnic groups in either sex (women 87.4%–93.4% and men 69.3%–76.7%). Osteoporotic treatment before hip fracture was more likely in white men and women and Hispanic men than other race/ethnic and gender groups.ConclusionsRacial variation in osteoporosis care after fragility fracture in race/ethnic groups in this healthcare system was low when using the electronic medical record identifying care gaps, with continued reminders to osteoporosis disease management care managers and providers until those care gaps were closed.

The effect of osteoporosis management on proximal humeral fracture

HYPOTHESIS AND BACKGROUND Proximal humeral fractures comprise 10% of fractures in the Medicare population. The effect, if any, of treating osteoporosis to prevent these fractures has not been determined. The primary objective is to determine the effectiveness of a systematic osteoporosis screening and treatment program on the hazard of developing a fracture over the treatment period. The secondary aim is to determine demographic risk factors. METHODS This is a retrospective cohort study in a health care organization serving 3.3 million members. Individuals selected for dual-energy x-ray absorptiometry screening were (1) women aged 65 years or older; (2) men aged 70 years or older; and (3) individuals aged 50 years or older who have a history of fragility fracture, use glucocorticoids, have a parental history of hip fracture, have rheumatoid arthritis, use alcohol at a high rate, or are cigarette smokers. Treatment consisted primarily of pharmacologic intervention with bisphosphonates. RESULTS Individuals diagnosed with osteoporosis had a hazard ratio of 7.43 for sustaining a fracture over the study period. Patients screened with dual-energy x-ray absorptiometry had a hazard ratio of 0.17 whereas those treated medically had a hazard ratio of 0.55 versus untreated controls. Risk factors that significantly increased the risk of a fracture developing included age, female gender, white race, diabetes mellitus, and history of a distal radius fracture. DISCUSSION AND CONCLUSION Over the study period, screening and treatment for osteoporosis significantly decreased the hazard ratio for proximal humeral fracture. This information broadens the impact of such programs because current best practices are primarily based on prevention of spine and hip fractures.

Complications in total shoulder and reverse total shoulder arthroplasty by body mass index

INTRODUCTION The purpose of this study was to identify the effects of body mass index (BMI) on long-term outcomes (revision rate, 1-year mortality rate, 3-year surgical site infection rate, and 90-day inpatient all-cause readmission rate) after total shoulder arthroplasty (TSA) and reverse TSA (RTSA). METHODS A large shoulder arthroplasty registry was used to review outcomes after TSA and RTSA. The registry monitors patients revision, mortality, infection, and readmission rates. The exposure of interest was the patients BMI at the time of the surgery, which was stratified by 5 kg/m2 increments. RESULTS Selected for this study were 4630 patients who underwent TSA and RTSA between 2007 and 2013, of which 3483 (75.2%) were TSA and 1147 (24.8%) were RTSA. The overall combined (TSA and RTSA) revision rate was 1.7%. After adjusting for confounders in the overall models (TSA and RTSA combined), higher BMI was not associated with higher risk of aseptic revision, 1-year mortality, or 3-year deep infection. In TSA-specific models, every 5 kg/m2 increase in BMI was marginally associated with a 16% increase in the likelihood of 90-day readmission. This association was not observed in the RTSA model. In RTSA-specific models, every 5 kg/m2 increase in BMI was marginally associated with higher risk of 3-year deep infection. This association was not observed in the TSA model. CONCLUSION Shoulder arthroplasty in obese patients is not associated with higher risk of aseptic revision. The BMI has different effects on TSA and RSA. The surgeon should anticipate increased risk of readmission after TSA and infection after RSA.

Establishing an international shoulder arthroplasty consortium

Shoulder replacement surgery has evolved dramatically since first attempted by P ean and Gluck and modernized by Neer. Interest in shoulder replacement surgery is growing globally and, in many countries, is the fastest growing market in joint arthroplasty surgery. In the coming year, over 57,000 replacements will be undertaken in the United States and over 4,000 in Australia. To a large extent, this growth is based on successful outcomes with patients benefiting from carefully executed surgery, using implants with established track records. However, with arthroplasty surgery of any joint, problems may be slow to become clinically apparent and long follow-up is required. Inevitably, with increases in shoulder replacement rates, the future revision burden will increase as well. In addition, often large patient volumes are needed to detect differences in outcomes, which may be beyond the scope of clinical trials. Internationally, joint arthroplasty registries are becoming increasingly recognized as important mechanisms for monitoring patient and prosthesis outcomes, providing large data sets that give an early indication when patient groups or implants are not functioning as expected. The ability to provide guidance and reduce revision burden in this current climate of increased scrutiny on health care expenditure has significant attraction. This level of monitoring requires informed clinician oversight to be relevant and interpreted appropriately. International interest in collaborative arrangements among joint registries already exists in the sphere of hip and knee arthroplasty with the formation of the International Society of Arthroplasty Registries (ISAR) and a collaborative data-sharing arrangement sponsored by the Food and Drug Administration with the International Consortium of Outcome Registries (ICOR). This environment of high-level data sharing greatly increases the potential insights and level of understanding into causes for revision. There are already a small number of national-level shoulder registries internationally, with the longest