Interdisciplinary consensus statements on imaging of DRUJ instability and TFCC injuries.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of distal radioulnar joint (DRUJ) instability and triangular fibrocartilage complex (TFCC) injuries by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on DRUJ instability and TFCC injuries. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panelists consisted of twenty-seven musculoskeletal radiologists. The panelists scored their degree of agreement to each statement on an 11-item numeric scale. Scores of "0," "5," and "10" reflected complete disagreement, indeterminate agreement, and complete agreement, respectively. Group consensus was defined as a score of "8" or higher for 80% or more of the panelists. RESULTS: Three of fourteen statements achieved group consensus in the first Delphi round and ten statements achieved group consensus in the second Delphi round. The third and final Delphi round was limited to the one question that did not achieve group consensus in the previous rounds. CONCLUSIONS: Delphi-based agreements suggest that CT with static axial slices in neutral rotation, pronation, and supination is the most useful and accurate imaging technique for the work-up of DRUJ instability. MRI is the most valuable technique in the diagnosis of TFCC lesions. The main indication for MR arthrography and CT arthrography are Palmer 1B foveal lesions of the TFCC. CLINICAL RELEVANCE STATEMENT: MRI is the method of choice for assessing TFCC lesions, with higher accuracy for central than peripheral abnormalities. The main indication for MR arthrography is the evaluation of TFCC foveal insertion lesions and peripheral non-Palmer injuries. KEY POINTS: • Conventional radiography should be the initial imaging technique in the assessment of DRUJ instability. CT with static axial slices in neutral rotation, pronation, and supination is the most accurate method for evaluating DRUJ instability. • MRI is the most useful technique in diagnosing soft-tissue injuries causing DRUJ instability, especially TFCC lesions. • The main indications for MR arthrography and CT arthrography are foveal lesions of the TFCC.

Scaphoid kinematics in scapholunate instability: a dynamic CT study.

OBJECTIVE: The scaphoid is proposed to be driven by the distal carpal row in scapholunate instability (SLI) as it is dissociated from the proximal row. The aim of this study was to describe the 6 degrees of freedom kinematics of the scaphoid using dynamic CT in the normal and SLI wrists. We hypothesised that the SLI scaphoid would demonstrate kinematic evidence conforming to distal row motion. MATERIALS AND METHODS: We studied dynamic CT scans of 17 SLI and 17 normal wrists during ulnar to radial deviation and extension to flexion. The radio-scaphoid angles in three anatomic planes were calculated in the wrist neutral position and during wrist motion. The centroid position was also calculated in the wrist neutral position and during wrist motion. The scapho-capitate motion index (SCI) was calculated as a ratio between the scaphoid and the capitate motion. RESULTS: In the neutral position of the wrist, the SLI scaphoid was flexed, internally rotated, and radially translated compared to the normal scaphoid. During wrist motion, the SLI scaphoid had more 'in-plane' motion and less 'out-of-plane' motion with a higher SCI during wrist neutral to radial deviation and extension to neutral. CONCLUSION: We have described the malalignment of the SLI scaphoid in the neutral position of the wrist and 6 degrees of freedom kinematics during wrist motion of the SLI scaphoid compared to the normal. The SLI scaphoid conformed more to the distal row motion than the normal scaphoid. This information may help define the surgical reconstruction techniques for SLI.

Risk factors for intra-articular involvement in proximal humeral fractures.

INTRODUCTION: Identification of intra-articular involvement in proximal humeral fractures is important for operative decision making. The aim of this study was to identify the risk factors associated with intra-articular involvement in proximal humeral fractures. MATERIALS AND METHODS: One hundred consecutive three-dimensional computed tomography reconstructions of proximal humeral fractures were identified. The fracture lines were then accurately transcribed onto a two-dimensional superior view of the humeral head and each fracture was assessed for intra-articular involvement. Statistical analyses were undertaken to identify risk factors for intra-articular involvement and extent of involvement. Furthermore, for each risk factor, common fracture patterns were identified and compared to anatomical landmarks. RESULTS: Overall, 58% of the fractures involved the articular surface. High-energy mechanism, female gender, age ≥ 65, and posterior dislocation were risk factors for intra-articular involvement. Low-energy mechanism, female gender, age ≥ 65, varus angulation, and posterior dislocation were risk factors for increased extension of the fracture onto the articular surface. CONCLUSION: Intra-articular involvement in proximal humeral fractures is influenced by demographics and fracture characteristics (mechanism of injury, angulation, and dislocation). Patients with identified risk factors should be appropriately evaluated for intra-articular fractures during preoperative planning to assist in operative decision making. LEVEL OF EVIDENCE: Basic science; anatomy study.

Three-dimensional cortical and trabecular bone microstructure of the proximal ulna.

INTRODUCTION: The three-dimensional (3D) microstructure of the cortical and trabecular bone of the proximal ulna has not yet been described by means of high-resolution 3D imaging. An improved characterization can provide a better understanding of their relative contribution to resist impact load. The aim of this study is to describe the proximal ulna bone microstructure using micro-computed tomography (micro-CT) and relate it to gross morphology and function. MATERIALS AND METHODS: Five dry cadaveric human ulnae were scanned by micro-CT (17 µm/voxel, isotropic). Both qualitative and quantitative assessments were performed on sagittal image stacks. The cortical thickness of the trochlear notch and the trabecular bone microstructure were measured in the olecranon, bare area and coronoid. RESULTS: Groups of trabecular struts starting in the bare area, spanning towards the anterior and posterior side of the proximal ulna, were observed; within the coronoid, the trabeculae were orthogonal to the joint surface. Consistently among the ulnae, the coronoid showed the highest cortical thickness (1.66 ± 0.59 mm, p = 0.04) and the olecranon the lowest (0.33 ± 0.06 mm, p = 0.04). The bare area exhibited the highest bone volume fraction (BV/TV = 43.7 ± 22.4%), trabecular thickness (Tb.Th = 0.40 ± 0.09 mm) and lowest structure model index (SMI = - 0.28 ± 2.20, indicating plate-like structure), compared to the other regions (p = 0.04). CONCLUSIONS: Our microstructural results suggest that the bare area is the region where most of the loading of the proximal ulna is concentrated, whereas the coronoid, together with its anteromedial facet, is the most important bony stabilizer of the elbow joint. Studying the proximal ulna bone microstructure helps understanding its possible everyday mechanical loading conditions and potential fractures. LEVEL OF EVIDENCE: N.A.

Precision Medicine for Kienböck Disease in the 21st Century.

One of the most popular treatment algorithms for Kienböck disease is based on a progression of successive radiographic changes that was developed in the 1970s. Since then, 2 other important classifications systems have been introduced. One is centered on contrasted magnetic resonance imaging findings and the other, articular cartilage degeneration. All 3 systems have been used, in isolation, to recommend specific treatment modalities. To coordinate all available clinical data and to simplify the treatment selection process, we combined the 3 classification systems into 1 unified classification and treatment algorithm. With the added consideration of some recently introduced surgical options and further knowledge of how Kienböck disease affects children and the elderly, we anticipate that this unified classification system will allow for a more precise and individualized treatment plan.

Regional differences in the three-dimensional bone microstructure of the radial head: implications for observed fracture patterns.

INTRODUCTION: A characterization of the internal bone microstructure of the radial head could provide a better understanding of commonly occurring fracture patterns frequently involving the (antero)lateral quadrant, for which a clear explanation is still lacking. The aim of this study is to describe the radial head bone microstructure using micro-computed tomography (micro-CT) and to relate it to gross morphology, function and possible fracture patterns. MATERIALS AND METHODS: Dry cadaveric human radii were scanned by micro-CT (17 µm/pixel, isotropic). The trabecular bone microstructure was quantified on axial image stacks in four quadrants: the anterolateral (AL), posterolateral (PL), posteromedial (PM) and anteromedial (AM) quadrant. RESULTS: The AL and PL quadrants displayed the significantly lowest bone volume fraction and trabecular number (BV/TV range 12.3-25.1%, Tb.N range 0.73-1.16 mm-1) and highest trabecular separation (Tb.Sp range 0.59-0.82 mm), compared to the PM and AM quadrants (BV/TV range 19.9-36.9%, Tb.N range 0.96-1.61 mm-1, Tb.Sp range 0.45-0.74 mm) (p = 0.03). CONCLUSIONS: Our microstructural results suggest that the lateral side is the "weaker side", exhibiting lower bone volume faction, less trabeculae and higher trabecular separation, compared to the medial side. As the forearm is pronated during most falls, the underlying bone microstructure could explain commonly observed fracture patterns of the radial head, particularly more often involving the AL quadrant. If screw fixation in radial head fractures is considered, surgeons should take advantage of the "stronger" bone microstructure of the medial side of the radial head, should the fracture line allow this.

Interdisciplinary consensus statements on imaging of scapholunate joint instability.

OBJECTIVES: The purpose of this agreement was to establish evidence-based consensus statements on imaging of scapholunate joint (SLJ) instability by an expert group using the Delphi technique. METHODS: Nineteen hand surgeons developed a preliminary list of questions on SLJ instability. Radiologists created statements based on the literature and the authors' clinical experience. Questions and statements were revised during three iterative Delphi rounds. Delphi panellists consisted of twenty-seven musculoskeletal radiologists. The panellists scored their degree of agreement to each statement on an eleven-item numeric scale. Scores of '0', '5' and '10' reflected complete disagreement, indeterminate agreement and complete agreement, respectively. Group consensus was defined as a score of '8' or higher for 80% or more of the panellists. RESULTS: Ten of fifteen statements achieved group consensus in the second Delphi round. The remaining five statements achieved group consensus in the third Delphi round. It was agreed that dorsopalmar and lateral radiographs should be acquired as routine imaging work-up in patients with suspected SLJ instability. Radiographic stress views and dynamic fluoroscopy allow accurate diagnosis of dynamic SLJ instability. MR arthrography and CT arthrography are accurate for detecting scapholunate interosseous ligament tears and articular cartilage defects. Ultrasonography and MRI can delineate most extrinsic carpal ligaments, although validated scientific evidence on accurate differentiation between partially or completely torn or incompetent ligaments is not available. CONCLUSIONS: Delphi-based agreements suggest that standardized radiographs, radiographic stress views, dynamic fluoroscopy, MR arthrography and CT arthrography are the most useful and accurate imaging techniques for the work-up of SLJ instability. KEY POINTS: • Dorsopalmar and lateral wrist radiographs remain the basic imaging modality for routine imaging work-up in patients with suspected scapholunate joint instability. • Radiographic stress views and dynamic fluoroscopy of the wrist allow accurate diagnosis of dynamic scapholunate joint instability. • Wrist MR arthrography and CT arthrography are accurate for determination of scapholunate interosseous ligament tears and cartilage defects.

Long-Term Outcome of Surgical Treatment for Kienböck Disease Using an Articular-Based Classification.

PURPOSE: The aim of this study was to report the outcomes of surgery using the Bain and Begg articular-based classification for the treatment of Kienböck disease. METHODS: We identified and followed patients who had surgery for Kienböck disease between 1995 and 2014. Assessment included functional scoring using a modification of the Gartland and Werley score, pain levels, and grip strength. RESULTS: Thirty-one patients were operated on for Kienböck disease between 1995 and 2014. Twenty-seven patients were assessed (12 men and 15 women). Mean age at the index procedure was 45.1 years (range, 20-82 years). Median follow-up after the index procedure was 10 years (range, 2-18 years). On the Bain and Begg classification, 5 patients had grade 0, 4 had grade 1, 5 had grade 2a, 10 had grade 2b, 1 had grade 3, and 1 had grade 4. The median pain visual analog scale improved from a preoperative score of 5 (interquartile range [IQR], 5-6) to a postoperative score of 2 (IQR, 0-3). The median functional scores from the modified Gartland and Werley score improved from 67 (IQR, 57.0-78.5) to 97 (IQR, 90.0-97.0). Eighteen out of 20 working patients returned to the same level of work. There was a significant improvement in power grip and tip pinch following surgery. One patient required a secondary salvage procedure. No patient required a full wrist fusion or arthroplasty. CONCLUSIONS: This study confirms that the Bain and Begg arthroscopic classification and an articular-based approach to Kienböck disease provide a high probability of good long-term relief of pain and a minimal chance of requiring a salvage procedure. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Defining the proximity of the axillary nerve from defined anatomic landmarks: an in vivo magnetic resonance imaging study.

BACKGROUND: The location of the axillary nerve in the shoulder makes it vulnerable to traumatic or iatrogenic injury. Cadaveric studies have reported the location of the axillary nerve but are limited because of tissue compression, dehydration, and decay. Three-Tesla (T) magnetic resonance imaging (MRI) allows high anatomic resolution of neural structures. The aim of our study was to better define the location of the axillary nerve from defined bony surgical landmarks in vivo, using MRI scan. METHODS: Using MRI, we defined a number of anatomic points and measured the distance from these to the perineural fat surrounding the axillary nerve using simultaneous tracker lines on both images. Two observers were used. RESULTS: A total of 187 consecutive 3-T MRI shoulder scans were included. Mean age was 57.9 years (range 18-86). The axillary nerve was located at a mean of 14.1 mm inferior from the bony glenoid at the anterior border, 11.9 mm from the midpoint, and 12.0 mm from the posterior border. There was a significant difference between distance at the anterior border and midpoint (P < .001), and between the anterior and posterior borders (P < .001). The axillary nerve was located at a mean of 12.6 mm medial to the humeral shaft at the anterior border, 9.9 mm at the midpoint, and 8.6 mm from the posterior border. There was a significant difference between distance at the anterior border and midpoint (P = .008) and between the anterior and posterior borders (P = .002). The mean distance of the axillary nerve from the anterolateral edge of the acromion was 53.3 mm (95% confidence interval [CI] 52.3, 54.2; range 33.9-76.3). The mean distance of the axillary nerve from the inferior edge of the capsule was 2.7 mm (95% CI 2.9, 3.1; range 0.3-9.9). There was a positive correlation between humeral head diameter and axillary nerve distance from the inferior glenoid (R2 = 0.061, P < .001). There was a positive correlation between humeral head diameter and distance from the anterolateral edge of the acromion (R2 = 0.140, P < .001). CONCLUSION: Our study has defined the proximity of the axillary nerve from defined anatomic landmarks. The proximity of the axillary nerve to the inferior glenoid and medial humeral shaft changes as the axillary nerve passes from anterior to posterior. The distance of the axillary nerve from the anterolateral edge of the acromion remains relatively constant. Both sets of distances may be affected by humeral head size. The study has relevance to the shoulder surgeon when considering "safe zones" during arthroscopic or open surgery.

3D mapping of scaphoid fractures and comminution.

OBJECTIVE: Acute and subacute scaphoid fractures were assessed using 3D computer tomography (CT). The aims were to describe fracture morphology, to map fractures onto a 3D scaphoid model and to correlate this to scaphoid anatomy. MATERIALS AND METHODS: A retrospective, multicentre database search was performed to identify CT studies of acute and subacute scaphoid fractures. CT scans of scaphoid fractures less than 6 weeks from time of injury were included in this retrospective, multicentre study. CTs were segmented and converted into three-dimensional models. Following virtual fracture reduction, fractures were mapped onto a three-dimensional scaphoid model. RESULTS: Seventy-five CT scans were included. The median delay from injury to CT was 29 days. Most studies were in male patients (89%). Most fractures were comminuted (52%) or displaced (64%). A total of 73% of displaced fractures had concomitant comminution. Waist fractures had higher rates of comminution and displacement when compared with all other fractures. Comminution was located along the dorsal ridge and the volar scaphoid waist. CONCLUSION: Our study is the first to describe acute fracture morphology using 3D CT and to correlate comminution and displacement to fracture types. The dorsal ridge and volar waist need prudent assessment, especially in waist fractures.

Reverse total shoulder arthroplasty compared to stemmed hemiarthroplasty for proximal humeral fractures: a registry analysis of 5946 patients.

BACKGROUND: There is an increasing trend toward the use of reverse total shoulder arthroplasty (RTSA) over stemmed hemiarthroplasty (HA) for the management of proximal humeral fractures. There are limited data available comparing the revision rates for RTSA and HA in the setting of a fracture. The aim of this study was to compare the revision rates for RTSA and HA when used for the treatment of a fracture and to analyze the effect of demographics and prosthesis fixation on these revision rates. METHODS: Data obtained from the Australian Orthopaedic Association National Joint Replacement Registry from April 16, 2004, to December 31, 2017, included all procedures for primary diagnosis proximal humeral fracture. The analyses were performed using Kaplan-Meier estimates of survivorship and hazard ratios from Cox proportional hazards models. RESULTS: Over the study period, there were 3049 (51%) RTSA and 2897 (49%) HA procedures. The cumulative percent revision rate at 9 years was lower for the RTSA than for the HA: 7.0% (95% confidence interval [CI], 4.8-10.1) compared with 11.7% (95% CI, 10.3-13.2). Between 0 and 6 months, the HA had a significantly lower revision rate than the RTSA (hazard ratio, 0.50; 95% CI, 0.34-0.72; P < .001). Between 6 month and 3 years, the HA had a significantly higher revision rate. For the RTSA, males have a significantly higher rate of revision compared with females. There is a higher rate of early revision due to instability in younger persons (55-64) and males. For both RTSA and HA, cemented prostheses have lower revision rates compared with cementless prostheses. CONCLUSIONS: RTSA has a significantly lower revision rate compared with HA for the treatment of proximal humeral fractures in females. Younger patients (<65) and males are at risk of early revision secondary to instability. In these patient groups, either alternatives to RTSA or further attention to fixation of tuberosities and shoulder rehabilitation may be indicated.

Intrathoracic shoulder dislocation causing rupture of the right main bronchus.

An intrathoracic shoulder dislocation is a rare injury, usually the result of high-energy trauma [Hawkes et al. in Am J Orthop 43(4):E74-E78, 2014; Tsai et al. in Ann Thorac Cardiovasc Surg 20:592-594, 2014, in Rupprecht et al. Bull Emerg Trauma 5(3):212-214, 2017; Abellan et al. J Orthop Surg (Hong Kong)18(2):254-257, 2010]. It often occurs in conjunction with thoracic, pelvic, and long bone injuries. In addition, there is often significant injuries to the shoulder girdle and chest wall associated with neurovascular compromise [Abellan et al. J Orthop Surg (Hong Kong)18(2):254-257, 2010; Lin et al. JBJS Case Connect 6(1):e61, 2016]. Following a literature review, it appears that no cases have been reported of an intrathoracic shoulder dislocation associated with a rupture of the ipsilateral main bronchus. We present a case of a rupture of the right main bronchus that occurred due to high-energy impact and an associated intrathoracic right-shoulder fracture dislocation. Computed tomography identified diastasis of the ipsilateral first intercostal space, humeral head indentation in the hilum of the lung, and a pneumoarthrogram of the right glenohumeral joint.

A new radiographic view of the scaphotrapeziotrapezoid joint-a cadaveric study.

BACKGROUND: The scaphotrapeziotrapezoid joint (STTJ) has a complex osseous and ligamentous anatomy. Precise radiographic assessment is paramount when assessing osteoarthritic, post-traumatic, or post-operative patients. There has been no described technique to image the STTJ without any wrist movement, unobscured by the rest of the carpus. The aim of this study was to define an optimal radiographic method to assess the STTJ while maintaining the wrist in neutral position. METHODS: Computer tomography 3-D reconstructions of three uninjured wrists were initially used to determine an approximate beam angle. Serial radiographs of 12 cadaveric wrists were taken. The forearms were positioned in varying degrees of pronation and supination. The beam angle was concurrently adjusted to varying degrees of caudal tilt. From the images obtained, we assessed if the adjacent carpus obscured the view of the STTJ. RESULTS: Optimal STTJ imaging was in the semi-pronated wrist position with the X-ray beam tilted caudal. We found that the STTJ was best visualized at 48° supination from a fully pronated wrist and a caudal beam angle of 22°. CONCLUSIONS: The described wrist and beam orientation can aid in achieving an unobstructed view of the STTJ with little technical effort. This can aid in imaging ambulatory patients where symptoms prevent using other imaging techniques as well as patients in the operating room where imaging timing can be critical.

Use and outcome of 1,220 primary total elbow arthroplasties from the Australian Orthopaedic Association National Joint Arthroplasty Replacement Registry 2008-2018.

Background and purpose - The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) was analyzed to determine trends in use of primary total elbow arthroplasty (TEA), the types of prostheses used, primary diagnoses, reasons for and types of revision, and whether the primary diagnosis or prosthesis design influenced the revision rate.Patients and methods - During 2008-2018, 1,220 primary TEA procedures were reported of which 140 TEAs were revised. Kaplan-Meier estimates of survivorship were used to describe the time to first revision and hazard ratios (HR) from Cox proportional hazard models, adjusted for age and sex, were used to compare revision rates.Results - The annual number of TEAs performed remained constant. The 3 most common diagnoses for primary TEA were fracture/dislocation (trauma) (36%), osteoarthritis (OA) (34%), and rheumatoid arthritis (RA) (26%). The cumulative percentage revision for all TEAs undertaken for any reason was 10%, 15%, and 19% at 3, 6, and 9 years. TEAs undertaken for OA had a higher revision rate compared with TEAs for trauma (HR = 1.8, 95% CI 1.1-3.0) and RA (HR = 2.0, CI 1.3-3.1). The Coonrad-Morrey (50%), Latitude (30%), Nexel (10%), and Discovery (9%) were the most used prosthesis designs. There was no difference in revision rates when these 4 designs were compared. The most common reasons for revision were infection (35%) and aseptic loosening (34%).Interpretation - The indications for primary and revision TEA in Australia are similar to those reported for other registries. Revision for trauma is lower than previously reported.

Is external fixation a better way than plaster to supplement K-wires in non-comminuted distal radius fractures?

BACKGROUND: Distal radius fractures represent about one-sixth of all fractures. There is still no consensus on the treatment of this fracture. We have several issues to assess and address; one of them is the fixation method. We tried to compare the effectiveness of two methods of stabilisation of distal radial fracture. Comparison between the techniques of Kirschner wire (K-wire) fixation with plaster and K-wire fixation with external fixation (Ex-Fix) was undertaken to assess which treatment modality gives better results in patients with distal radius fracture Frykman VII and VIII with no metaphyseal comminution. METHOD: Fifty-six patients were chosen randomly and then allocated to two different modalities of stabilisation randomly as well, they were followed up; three of them were lost to follow-up because of death and two moved away from the area. Fifty-one patients were randomised in two groups: 24 were treated with K-wire and spanning Ex-Fix supplementation and 27 were treated with K-wires and plaster. Patients were prospectively monitored following the operation with a minimum follow-up of 1 year. Measurement of range of motion was obtained after surgery. Visual Analogue Scale (VAS) scores for pain and satisfaction levels were also recorded. RESULTS: There was statistically significant difference in favour of the Ex-Fix patient group for pain (VAS, Ex-Fix group: mean 14.9; plaster group: mean 28.1) and satisfaction (Ex-Fix group: mean 89.7;plaster group: mean 76.3). Although one would expect that range of motion would be reduced in the Ex-Fix group, there were no statistically significant differences found, with the exception of supination where results were in favour of the Ex-Fix group (mean 54.4; plaster group: mean 45.2). CONCLUSION: In our study, xternal fixator (Ex-Fix) supplementation of K-wiring favoured patients with distal radius fracture, even though there was no metaphyseal comminution, and therefore is suggested in contrast to plaster supplementation.

Cementless versus cemented glenoid components in conventional total shoulder joint arthroplasty: analysis from the Australian Orthopaedic Association National Joint Replacement Registry.

BACKGROUND: Glenoid loosening is a common mode of failure after total shoulder arthroplasty (TSA). Newer cementless glenoid components have been introduced to promote biological fixation with the aim to decrease glenoid loosening. Limited data are available comparing revision rates between cemented and cementless glenoid fixation in TSA. The study aim was to compare the revision rates of cemented and cementless design glenoid components used in conventional TSA performed for the diagnosis of osteoarthritis. The secondary aim was to compare various subclasses of glenoid components. METHODS: Data were obtained between April 16, 2004, and December 31, 2016, from the Australian Orthopaedic Association National Joint Replacement Registry. Within the study period, 10,805 primary conventional TSAs were identified. The analysis was undertaken for the diagnosis of osteoarthritis, which represented 95.8% of all conventional TSA procedures. RESULTS: At 5 years, in patients with primary TSA procedures, those with cemented glenoids had a lower revision rate than those with cementless glenoids: 3.7% versus 17.9% (hazard ratio for entire period, 4.77). The most common revision diagnosis for primary conventional TSA with cementless glenoid fixation was rotator cuff insufficiency (4.4% for cementless vs 0.4% for cemented), instability and/or dislocation (3.8% for cementless vs 0.8% for cemented), and loosening and/or lysis (1.1% for cementless vs 1.1% for cemented). CONCLUSIONS: Cementless glenoid components in conventional TSA had a significantly higher revision rate than cemented glenoid components. The loosening rates between cemented and cementless glenoid components were similar. Glenoid design and fixation are important considerations when selecting a prosthesis for TSA.

Fracture line morphology of complex proximal humeral fractures.

BACKGROUND: The aim of this study was to assess proximal humeral fracture patterns using 3-dimensional computed tomography images and relate them to the normal osseous landmarks and soft-tissue attachments. METHODS: Forty-eight 3-dimensional computed tomography scans of proximal humeral fractures were retrospectively collected, and the fractures were transcribed onto proximal humeral templates. We analyzed the common location and orientation of the fracture lines, with a focus on fractures of the articular surface, tuberosities, metaphysis, and proximal diaphysis. These fractures were compared with the attachments of the rotator cuff and glenohumeral capsule. RESULTS: Fifty-two percent of the fractures involved the articular surface. No fractures passed through the bicipital groove, and fractures were more commonly found on the posterior lesser tuberosity and on the anterior greater tuberosity, coinciding with the intervals between the rotator cuff tendon insertions. Intracapsular fractures of the calcar were more common (68%) than extracapsular fractures (32%). On the anterolateral aspect of the proximal humerus, fractures radiated from the articular margin, vertically down through the tuberosity zone between the rotator cuff footprints, meeting horizontally oriented fractures in the metaphyseal zone. On the posterior aspect, vertical fractures from the tuberosity zone continued downward to the metaphyseal zone adjacent to the infraspinatus and teres minor footprints. CONCLUSIONS: Fractures of the proximal humerus follow characteristic patterns. Fractures frequently split the greater tuberosity and are closely related to the intervals of the rotator cuff attachments.

Shoulder Stiffness: Current Concepts and Concerns.

UNLABELLED: Shoulder stiffness can be caused by various etiologies such as immobilization, trauma, or surgical interventions. The Upper Extremity Committee of ISAKOS defined the term "frozen shoulder" as idiopathic stiff shoulder, that is, without a known cause. Secondary stiff shoulder is a term that should be used to describe shoulder stiffness with a known cause. The pathophysiology of frozen shoulder is capsular fibrosis and inflammation with chondrogenesis, but the cause is still unknown. Conservative treatment is the primary choice. Pain control by oral medication, intra-articular injections with or without joint distension, and physical therapy are commonly used. In cases with refractory stiffness, manipulation under anesthesia or arthroscopic capsular release may be indicated. Because of various potential risks of complications with manipulations, arthroscopic capsular release is preferred. After the capsular release, stepwise rehabilitation is mandatory to achieve satisfactory outcome. LEVEL OF EVIDENCE: Level V, evidence-based review.

Kienböck Disease: Moving Forward.

Over the past decade, a plethora of new information has been reported regarding etiology, natural history, classification, and treatment options for lunate osteonecrosis. New disease classifications have been described based on advanced imaging determination of lunate viability as well as a cartilage-based arthroscopic classification. Here we review the newest literature regarding Kienböck disease and present a new treatment algorithm that incorporates the traditional osseous classification system with a perfusion/viability classification and an articular cartilage-based classification.