Yousef Shishani

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.

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.

Neer Award 2015: A randomized, prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty

BACKGROUND Tranexamic acid (TXA) is an antifibrinolytic agent that has been shown to significantly reduce blood loss and transfusion requirements after total knee and hip arthroplasty. The purpose of this study was to evaluate the effect of TXA on postoperative blood loss after shoulder arthroplasty. METHODS A total of 111 patients (62 women; average age, 67 years) who underwent shoulder arthroplasty were prospectively randomized in double-blinded fashion to receive either 100 mL of normal saline or 100 mL of normal saline with 2 g TXA by topical application into the wound at the completion of the case. All patients received a postoperative drain. Drain output representing postoperative blood loss, transfusion requirements, and change in hemoglobin level were recorded. All postoperative complications were noted. RESULTS The average blood loss recorded after surgery was 170 mL in the placebo group and 108 mL in the TXA group (P = .017). The average change in hemoglobin level was 2.6 g/dL in the placebo group and 1.7 g/dL in the TXA group (P < .001). There were no transfusion requirements or postoperative complications noted in either group. DISCUSSION In this cohort of patients, those treated with TXA experienced a significantly lower amount of postoperative blood loss and a significantly smaller change in hemoglobin level compared with those treated with placebo. Further work is required to determine the effectiveness and clinical significance of TXA in reducing transfusion requirements in shoulder arthroplasty and, more specifically, shoulder arthroplasty performed for complicated patients or for trauma and fracture patients.

Diagnostic accuracy in detecting tears in the proximal biceps tendon using standard nonenhancing shoulder MRI.

Background There is a paucity of data in the literature evaluating the performance of noncontrast MRI in the diagnosis of partial and complete tears of the proximal portion of the long head of the biceps (LHB) tendon. The objective of this study was to evaluate the accuracy of noncontrast magnetic resonance imaging (MRI) compared to arthroscopy for the diagnosis of pathology involving the intra-articular portion of the LHB tendon. Methods We conducted a retrospective review of 66 patients (mean age 57.8 years, range 43–70 years) who underwent shoulder arthroscopy and evaluation of the LHB tendon after having had a noncontrast MRI of the shoulder. Biceps pathology was classified by both MRI and direct arthroscopic visualization as either normal, partial tearing, or complete rupture, and arthroscopy was considered to be the gold standard. We then determined the sensitivity, specificity, and positive- and negative-predictive values of MRI for the detection of partial and complete LHB tears. Results MRI identified 29/66 (43.9%) of patients as having a pathologic lesion of the LHB tendon (19 partial and ten complete tears) while diagnostic arthroscopy identified tears in 59/66 patients (89.4%; 50 partial and 16 complete). The sensitivity and specificity of MRI for detecting partial tearing of the LHB were 27.7% and 84.2%, respectively (positive predictive value =81.2%, negative predictive value =32.0%). The sensitivity and specificity of MRI for complete tears of the LHB were 56.3% and 98.0%, respectively (positive predictive value =90.0%, negative predictive value =87.5%). Conclusion Standard noncontrast MRI of the shoulder is limited in detecting partial tears and complete ruptures of the intra-articular LHB tendon. Surgeons may encounter pathologic lesions of the LHB tendon during arthroscopy that are not visualized on preoperative MRI.

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.

The Safety of Controlled Hypotension for Shoulder Arthroscopy in the Beach-Chair Position

BACKGROUND The safety of controlled hypotension during arthroscopic shoulder procedures with the patient in the beach-chair position is controversial. Current practice for the management of intraoperative blood pressure is derived from expert opinion among anesthesiologists, but there is a paucity of clinical data validating their practice. The purpose of this study was to evaluate the effect of controlled hypotension on cerebral perfusion with use of continuous electroencephalographic monitoring in patients undergoing shoulder arthroscopy in the beach-chair position. METHODS Fifty-two consecutive patients who had undergone shoulder arthroscopy in the beach-chair position were enrolled prospectively in this study. All patients underwent preoperative blood pressure measurements, assignment of an American Society of Anesthesiologists (ASA) grade, and a preoperative and postoperative neurological and Mini-Mental State Examination (MMSE). The target systolic blood pressure for all patients was 90 to 100 mm Hg during surgery. Continuous intraoperative monitoring was performed with standard ASA monitors and a ten-lead portable electroencephalography monitor. Real-time electroencephalographic monitoring was performed by an attending-level neurophysiologist. RESULTS All patients violated at least one recommended limit for blood pressure reduction. The average decrease in systolic blood pressure and mean arterial pressure from baseline was 36% and 42%, respectively. Three patients demonstrated ischemic changes on electroencephalography that resolved with an increase in blood pressure. No adverse neurological sequelae were observed in any patient on the basis of the MMSE. CONCLUSIONS This study provides the first prospective data on global cerebral perfusion during shoulder arthroscopy in the beach-chair position with use of controlled hypotension. Our study suggests that patients may be able to safely tolerate a reduction in blood pressure greater than current recommendations. In the future, intraoperative cerebral monitoring may play a role in preventing neurological injury in patients undergoing shoulder arthroscopy in the beach-chair position.

Tendinopathy of the long head of the biceps tendon: histopathologic analysis of the extra-articular biceps tendon and tenosynovium

Background Bicipital tendinitis is a common cause of anterior shoulder pain, but there is no evidence that acute inflammation of the extra-articular long head of the biceps (LHB) tendon is the root cause of this condition. We evaluated the histologic findings of the extra-articular portion of the LHB tendon and synovial sheath in order to compare those findings to known histologic changes seen in other tendinopathies. Methods Twenty-six consecutive patients (mean age 45.4±13.7 years) underwent an open subpectoral biceps tenodesis for anterior shoulder pain localized to the bicipital groove. Excised tendons were sent for histologic analysis. Specimens were graded using a semiquantitative scoring system to evaluate tenocyte morphology, the presence of ground substance, collagen bundle characteristics, and vascular changes. Results Chronic inflammation was noted in only two of 26 specimens, and no specimen demonstrated acute inflammation. Tenocyte enlargement and proliferation, characterized by increased roundness and size of the cell and nucleus with proteoglycan matrix expansion and myxoid degenerative changes, was found in all 26 specimens. Abundant ground substance, collagen bundle changes, and increased vascularization were visualized in all samples. Conclusion Anterior shoulder pain attributed to the biceps tendon does not appear to be due to an inflammatory process in most cases. The histologic findings of the extra-articular portion of the LHB tendon and synovial sheath are similar to the pathologic findings in de Quervain tenosynovitis at the wrist, and may be due to a chronic degenerative process similar to this and other tendinopathies of the body.

Acromial stress fractures: correlation with acromioclavicular osteoarthritis and acromiohumeral distance.

Fractures around the acromion are a known complication of reverse total shoulder arthroplasty. The literature provides limited data on the risk factors associated with this complication as well as the ultimate outcomes after nonoperative treatment. The goal of this study was to report clinical outcomes in patients with acromial fractures after nonoperatively treated reverse total shoulder arthroplasty. The authors performed a retrospective review of 125 patients undergoing reverse total shoulder arthroplasty that included several acromial stress fractures in the postoperative period. They prospectively compared radiographic data, including acromiohumeral distance, the presence of acromioclavicular joint arthritis, clinical measures of motion, visual analog scale (VAS) pain score, American Shoulder and Elbow Surgeons (ASES) score, and Single Assessment Numeric Evaluation (SANE) score, in 2 groups based on the presence or absence of fracture in the postoperative period. Fourteen patients (11.2%) had an acromial fracture after reverse total shoulder arthroplasty at an average of 5.1 months postoperatively. Patients who had fractures had worse postoperative forward elevation before fracture (116.6 vs 143.5; P=.02) and greater pain relief after reverse shoulder replacement, before fracture (P=.04). No significant difference was found between groups when the degree of arm lengthening was compared (27.6 vs 26.2 mm), and no difference was found in the prevalence of degenerative acromioclavicular joint changes identified preoperatively (66.4% vs 77.3%). After conservative management, most patients who had an acromial fracture returned to a functional level that was comparable to that achieved before fracture.

Cost Analysis of Hemiarthroplasty Versus Reverse Shoulder Arthroplasty for Fractures

Complex proximal humerus fractures in older patients can be treated with hemiarthroplasty (HA) or reverse shoulder arthroplasty (RSA), with both providing good pain relief and function. This study compared the costs, complications, and outcomes of HA vs RSA after proximal humerus fracture in older patients. Patients 65 years or older who were admitted between January 2007 and August 2011 with a 3- or 4-part proximal humerus fracture and treated with HA or RSA were identified. Surgeries were performed at the same institution by 1 of 3 surgeons trained in trauma or shoulder surgery. Operating room costs, implant costs, total costs to the patient and hospital, and range of motion were compared. In the study group, 8 patients (7 women and 1 man; mean age, 77 years) received HA and 16 patients (13 women and 3 men; mean age, 77 years) received RSA. Hemiarthroplasty implant cost and operating room cost were