Use of a Low Profile Ultra-High Molecular Weight Polyethylene Diaphyseal Humeral Cement Restrictor in Shoulder Arthroplasty.

Background: When implanting a cemented humeral stem, a reliable method to prevent inappropriate extension and enable pressurization of cement in the intramedullary canal is required. The aim was to assess the outcomes of a dedicated humeral diaphyseal cement restrictor. Methods: In total 218 shoulders (207 patients) were included in the study, all of whom underwent a cemented total shoulder arthroplasty and a retrospective review was performed. The primary outcomes of interest were device stability in the medullary canal, successful occlusion of the canal, cement extrusion and quality of cement mantle. Results: The majority of the cohort was female (63.3%) males and the average patient age was 71.7 years (SD 8.45). In 81.7% the device was deemed to be stable in the medullary canal. The device was significantly more stable in primary (84.2%) compared to revision cases (64.3%, p = 0.02). In 69.7% Barrack grade A mantle quality was achieved, this was higher in primary cases (74.2%) compared to revision cases (39.3%) (p = 0.00006). Discussion: We noted excellent cementation outcomes using a cement restrictor specifically designed for the diaphyseal humerus anatomy. However, this humeral specific restrictor was noted to be more stable in primary as compared to revision cases.

Comparing Access to Engaging Hill-Sachs Lesions Between the Modified Posterior Deltoid Split Approach and Standard Deltopectoral Approach for Bone Grafting.

Background: Hill-Sachs lesions are common after shoulder instability, and treatment options vary but include remplissage or implantation of structural bone graft. Large Hill-Sachs lesions not addressed by remplissage are challenging to manage and may frequently require an open surgical approach for bone filling treatment options. The optimal approach to maximize visualization of the humeral head during these procedures remains unclear. Purpose/Hypothesis: The purpose of this study was to compare the area of the humeral head accessed using a modified posterior deltoid split approach versus a standard deltopectoral approach without surgical dislocation, with particular attention to access of engaging Hill-Sachs lesions for the purpose of bone grafting in the setting of anterior shoulder instability. It was hypothesized that both approaches would provide equal access to a simulated Hill-Sachs lesion. Study Design: Controlled laboratory study. Methods: Four human cadaveric shoulders were mounted in the beach-chair position. The modified posterior deltoid split approach and nonextensile deltopectoral approaches were performed. A typical Hill-Sachs lesion was simulated on the humeri. The percentage of the total surface area of the humeral head that was accessed, including access to the simulated Hill-Sachs lesion, was mapped using 3-dimensional digitizing software. Results: The deltopectoral approach provided 45% ± 15.2% access (range, 24% to 58%) to the humeral head versus 22.2% ± 6.1% (range, 17% to 30%) for the modified posterior deltoid split approach (P = .057). The modified posterior deltoid split approach enabled 100% access of the simulated Hill-Sachs lesion compared with 0% for the nonextensile deltopectoral approach. The angle of access to the articular surface was direct and perpendicular with the modified posterior deltoid split approach. Conclusion: The overall surface area of the humeral head accessed via the modified posterior deltoid split approach was less compared with the deltopectoral approach; however, the entire area of a typical Hill-Sachs lesion was able to be accessed from the modified posterior deltoid split approach, whereas this area was not well visualized from the standard deltopectoral approach. Clinical Relevance: The modified posterior deltoid split approach provided sufficient access to the humeral head for the purposes of grafting an engaging Hill-Sachs lesion in the setting of anterior shoulder instability.

The Air-Lift Technique for Improving Ease and Safety When Establishing the Modified Midanterior Portal in Hip Arthroscopy.

Hip arthroscopy continues to increase in popularity and has an ever-expanding range of indications; however, the steep learning curve introduces significant risk of iatrogenic chondrolabral injury when accessing the joint and establishing arthroscopic portals. This article presents a technique for establishing the modified midanterior portal and is particularly useful when the available space is tight. We present "the air-lift" as a safe and simple adjunct to standard portal creation when performing hip arthroscopy in the supine position.

Modern Patellofemoral Arthroplasty.

INTRODUCTION: The ideal procedure for isolated patellofemoral arthritis is a controversial topic. Patellofemoral arthroplasty (PFA) is an option that aims to restore normal kinematics to the knee while preserving bone. PFA has been shown to have benefits compared with total knee arthroplasty (TKA) in this patient population but has historically had a high failure rate. Revision rates are improving with modern implants and tight indications but still remain higher than TKA. This review summarizes current thinking around PFA using modern implants and techniques in 2023, provides an implant-specific analysis, and assesses how we can improve outcomes after PFA based on the current literature. The aim was to provide an outline of the evidence around PFA on which surgeons can make decisions to optimize patient outcome in this young and active population. METHODS: Four databases (MEDLINE, Embase, Scopus, and SPORTDiscus) were searched for concepts of patellofemoral joint arthroplasty. After abstract and text review, a screening software was used to assess articles based on inclusion criteria for studies describing indications, outcomes, and techniques for isolated PFA using modern implants, with or without concomitant procedures. RESULTS: A total of 191 articles were included for further examination, with 62 articles being instructional course lectures, systematic reviews, technique articles, narrative reviews, expert opinions, or meta-analyses. The remaining articles were case reports, trials, or cohort studies. Articles were used to create a thorough outline of multiple recurrent topics in the literature. CONCLUSIONS: PFA is an appealing option that has the potential to provide a more natural feeling and functioning knee for those with isolated PF arthritis. The high rate of revision is a cause for concern and there are several technical details that should be stressed to optimize results. The uncertain outcome after revision to TKA also requires more investigation. In addition, the importance of strict selection criteria and firm indications cannot be stressed enough to optimize longevity and attempt to predict those who are likely to have progression of tibiofemoral osteoarthritis. The development of new third-generation implants is promising with excellent functional outcomes and a much lower rate of maltracking and implant complications compared with earlier generations. The impact of these implants and improvement in surgical techniques on the revision rate of PFA will be determined from longer-term outcomes.

Review of Burkhart and DeBeer's (2000) article on traumatic glenohumeral bone defects and their relationship to failure of arthroscopic Bankart repair: Where have we taken the concept of glenoid bone loss in 2023?

This classic discusses the original publication by Burkhart and DeBeer "Traumatic Glenohumeral Bone Defects and Their Relationship to Failure of Arthroscopic Bankart Repair" published in 2000 in Arthroscopy. At that time, the authors sought to understand the reasons behind the failure of arthroscopic soft tissue repair. Based on their findings, the authors introduced the concept of the inverted pear glenoid and engaging Hill-Sachs lesion which is now part of the orthopedic lexicon. The importance of bony pathologic changes in anterior glenohumeral instability has become so apparent, that it now forms the basis of clinical understanding and underpins treatment algorithms. Since this publication over 20 years ago, the idea of glenohumeral bone loss has been extensively explored and refined. There is no doubt of the importance of structural bone loss yet there is still uncertainty as to the best management of those with subcritical bone loss. The purpose of revisiting this classic article is to look at where we are in understanding recurrent instability and bony deficiency while appreciating how far we have come. This review begins with a detailed summary of the classic article along with a historic perspective. Next, we look at the current evidence as it pertains to the classic article and how modern technology and innovation has advanced our ability to assess and quantify glenohumeral bone loss. We finish with expert commentary on the topic from two current surgeons with a research interest in shoulder instability to offer an insight into how modern surgeons view and address this issue. One of the original authors also reflects on the topic. The findings of this classic study changed the way we think about shoulder instability and opened the doors to an exciting body of research that is still growing today. Future research offers an opportunity for high quality evidence to guide management in the group of patients with subcritical bone loss and we eagerly await the results.

A comparison of operative autonomy between men and women in orthopaedic surgical training in Aotearoa New Zealand.

AIM: Recent studies have shown that women training in surgical and procedural specialties achieve less operative autonomy during training than men do. The aim of this study was to discern if there is a disparity in surgical autonomy for orthopaedic trainees by gender. METHODS: This was a retrospective study of operative procedures performed by 53 orthopaedic trainees (43 men, 10 women) in Aotearoa New Zealand over 10 years. The main outcome measure was the amount of surgical autonomy afforded to individual trainees as recorded in the training logbook, categorised as assisting a: primary surgeon with consultant scrubbed or present; or, primary surgeon unsupervised and teaching a colleague the procedure. RESULTS: Data was obtained for 41,622 procedures in total. Eighty point seven percent were performed by men and 19.3% by women. On average men performed 229 cases per year and women performed 251 cases per year. There was an overall significant difference in autonomy between men and women (p <0.001), with men performing more procedures unsupervised than women (45% of all cases versus 39% of all cases). This difference remained significant when trainee year group was accounted for. CONCLUSIONS: We conclude that women orthopaedic trainees in Aotearoa New Zealand perform fewer cases with meaningful autonomy than men. This disparity may have implications for the quality of training received by men versus women.

Hamate vs. capitate grafting for proximal interphalangeal joint fracture-dislocation: an MRI-based study of 35 hands.

We examined the MRI scans of 35 adult hands to assess the feasibility of the hamate and the capitate as potential donor grafts in the management of comminuted intra-articular fractures at the base of the middle phalanges. Essentially neither the hamate nor the capitate were perfect anatomic matches in most digits, but the capitate had the advantage of having more uniform facets, and the capitate facet shapes were similar to those of the little finger. The measurement of angles in the coronal and sagittal plane showed that in some respects the differences between the potential graft and the base of the middle phalanges were smaller for the capitate than for the hamate. Moreover, the sagittal morphology of the capitate made it less prone to joint overstuffing than the hamate. We conclude that the capitate may be considered as a graft donor in selected cases, especially for the little finger.

Long-term hip function in slipped capital femoral epiphysis treated with in situ pinning.

BACKGROUND: In recent years, there has been a trend toward more aggressive management of slipped capital femoral epiphysis (SCFE) with acute anatomical realignment; however, the literature is unclear with regard to the indications for this. QUESTIONS/PURPOSES: To collect long-term patient-reported outcome scores on a group of SCFE patients using modern hip scores. The second aim was to determine whether there is a threshold level of deformity beyond which patients have predictably poor outcomes following in situ pinning. PATIENTS AND METHODS: Patients presenting with SCFE between 2000 and 2009 completed a survey consisting of three modern hip scores and were classified into poor, intermediate, and good outcome groups. The posterior slope angle (PSA) was used to measure slip deformity. We examined the relationship between patient characteristics and functional outcomes. The relationship between PSA score and overall outcome was examined using receiver operator curve (ROC) analysis. RESULTS: The total study population was 63; 14% patients had poor, 29% had intermediate, and 57% had good functional outcomes. The mean Non-Arthritic Hip Scores (NAHSs) for those with poor outcomes was 51, 76 in the intermediate group, and 95 in the good group ( p <0.001). PSA was significantly lower in those with good functional outcomes. ROC analysis demonstrated that a higher PSA was moderately predictive of a poor clinical outcome (area under the curve of 0.668). In both the poor and intermediate outcome groups, 50% of patients had a PSA of 40° or greater, whereas only 31% of those with good clinical outcomes had PSA of 40° or greater. CONCLUSIONS: A significant proportion of post-SCFE patients have ongoing suboptimal hip function after pinning in situ. Those with a PSA more than 40° have a higher chance of a poor outcome.

Arthroscopic, open and mini-open approach for rotator cuff repair: no difference in pain or function at 24 months.

BACKGROUND: The New Zealand Rotator Cuff Registry was established in 2009 to collect prospective functional, pain and outcome data on patients undergoing rotator cuff repair (RCR). METHODS: Information collected included an operation day technical questionnaire completed by the surgeon and Flex Shoulder Function (SF) functional and pain scores preoperatively, immediately post-operatively and at 6, 12 and 24 months. A multivariate analysis was performed analysing the three surgical approaches to determine if there was a difference in pain or functional outcome scores. RESULTS: A total of 2418 RCRs were included in this paper. There were 418 (17.3%) arthroscopic, 956 (39.5%) mini-open and 1044 (43.2%) open procedures. Twenty-four-month follow-up data were obtained for pain and Flex SF in 71% of patients. At 24 months, there was no difference in the average Flex SF score for the arthroscopic, mini-open and open groups. There was no difference in improvement in Flex SF score at 24 months. At 24 months, there was no difference in mean pain scores. There was no difference in improvement in pain score from preoperation to 24 months. Most patients returned to work within 3 months of surgery, with no difference between the three surgical approaches. CONCLUSION: RCR has good to excellent outcomes in terms of improvement in pain and function at 2-year follow-up. We found no difference in pain or functional outcome at 24 months between arthroscopic, open and mini-open approaches for RCR.

The role of acromioplasty when repairing rotator cuff tears-no difference in pain or functional outcome at 24 months in a cohort of 2,441 patients.

AIM: The role of acromioplasty with rotator cuff repair remains unclear. This study aims to test the null hypothesis-that acromioplasty in conjunction with rotator cuff repair has no effect on improvement in pain or shoulder function at two years follow up. METHODS: Data was obtained from a collaborative nationwide project between March 2009 and December 2010, and consisted of a total of 2,441 patients undergoing primary repair of superior rotator cuff tears. Multivariate analysis was performed to assess the effect of the inclusion of acromioplasty at the time of rotator cuff repair on visual analogue scale (VAS) pain scores and Flex Shoulder Function (Flex SF) scores at 24-month follow up. RESULTS: On univariate analysis there was a significantly higher Flex SF score in the acromioplasty group (40.5) compared to the no acromioplasty group (38.7) and a lower mean pain score at 24 months in the acromioplasty group (1.44 vs 1.74). There was a significant difference in tear area and surgical repair technique between the two groups. On multivariate analysis there was no statistically significant difference in Flex SF or VAS pain scores between the two groups. CONCLUSION: There was no difference in pain or function scores at two years following rotator cuff repair regardless of whether or not acromioplasty was performed. This paper represents the largest study to date comparing acromioplasty to no acromioplasty in the setting of cuff repair. It supports previous literature in showing no significant difference in pain or shoulder function between the two groups.