Primary and revision reverse total shoulder arthroplasty using a patient-matched glenoid implant for severe glenoid bone deficiency.

BACKGROUND: Severe glenoid bone loss in the setting of both primary and revision reverse total shoulder arthroplasty (rTSA) continues to remain a significant challenge. The purpose of this study was to report on radiographic and clinical outcomes of primary and revision rTSA using a patient-matched, 3-dimensionally printed metal glenoid implant to address severe glenoid bone deficiency. This is a follow-up study to previously reported preliminary results. METHODS: A retrospective review was performed on 62 patients with severe glenoid bone deficiency who underwent either primary or revision rTSA using the Comprehensive Vault Reconstruction System (VRS) (Zimmer Biomet) at a single institution. Preoperative and postoperative values for the Disabilities of the Arm, Shoulder and Hand (DASH), Constant, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Simple Shoulder Test (SST), Single Assessment Numeric Evaluation (SANE), and visual analog scale (VAS) pain scores as well as active range of motion (ROM) were collected and compared using the Wilcoxon signed rank test with the level of statistical significance set at P < .05. The percentage of patients achieving minimal clinically important difference (MCID) and substantial clinical benefit (SCB) was also calculated. RESULTS: Fifty-five of 62 shoulders (88.7%) were able to be contacted at a minimum of 2 years postoperatively, with 47 of 62 (75.8%) having complete clinical and radiographic follow-up with a mean age of 67.5 years (range, 48-85 years) and follow-up of 39.2 months (range, 25-56 months). There were 19 primary and 28 revision rTSAs. Significant improvements were seen in mean active forward flexion (63.1° ± 30.3° to 116.8° ± 35°), abduction (48.1° ± 16.1 to 76.2° ± 13.4°) (P < .001), external rotation (16° ± 23.7° to 32.1° ± 24.5°) (P < .005), DASH (59.9 ± 17.7 to 35.7 ± 24.3), Constant (23.4 ± 13.1 to 53.1 ± 17.4), ASES (27.8 ± 16.2 to 69.1 ± 25.2), SST (3.3 ± 2.5 to 7.6 ± 3.5), SANE (28.9 ± 18.3 to 66.7 ± 21.2), and VAS pain (7.1 ± 2.4 to 1.8 ± 2.6) scores (P < .001). MCID and SCB was achieved in a majority of patients postoperatively. The overall complication rate was 29.1%, with only 1 baseplate failure. CONCLUSION: This study demonstrates promising evidence that the VRS implant can be used as a viable option to achieve clinically important improvement in a majority of patients treated for severe glenoid bone deficiency with rTSA in both the primary and revision setting.

Hemiarthroplasty for the treatment of distal humerus fractures: long-term clinical results.

BACKGROUND: Total elbow arthroplasty is a treatment for unreconstructable distal humerus fractures; implant longevity remains a concern, especially in younger patients. However, distal humeral hemiarthroplasty (DHH) offers an alternative with potential long-term advantages. METHODS: This is a retrospective study of 10 patients who underwent DHH for distal humerus fractures over a 4-year period (2008-2012) by a single surgeon. Patients underwent testing of range of motion, Mayo Elbow Performance Scores (MEPS), Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), visual analog scale (VAS), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test, Charlson Comorbidity Index (CCI), and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores. Average patient age at surgery was 71.9 years (range 56-81 years); average follow-up was 115.2 months (range 96-144 months). RESULTS: Patients maintained improvements in MEPS (mean 88, range 75-100) and DASH scores (mean 37.1, range 11.21-55.09), along with no statistically significant decrease in range of motion or scores in comparison to either short- or midterm results. Mean VAS score was 2.2 (range 0-7), SANE 69 (range 55-85), ASES 76.66 (range 51.67-100), and CCI 4.3 (range 1-7). Participants had an average flexion of 126° (range: 90°-140°), extension of 36° (range: 30°-45°), supination of 66° (range: 60°-70°), and pronation of 64° (range: 45°-80°). No elbow dislocations, subluxations, or heterotopic ossification were observed. Complications included 1 fracture and 1 complaint of prominent hardware. Four patients were deceased, and 1 patient was lost to follow-up. CONCLUSION: This long-term review suggests that DHH may be an effective treatment for certain distal humerus fractures. The data suggest that elbow range of motion and functional use are maintained from comparison with short- and midterm studies, with no appreciable change in radiographic cartilage wear along the radius or ulna.

Hemiarthroplasty for the treatment of distal humeral fractures: midterm clinical results.

BACKGROUND: Total elbow arthroplasty is a treatment for unreconstructable distal humeral fractures; however, longevity of the implant remains a concern in younger, more active patients. Distal humeral hemiarthroplasty (DHH) offers an alternative with multiple advantages. METHODS: This is a retrospective study of 10 patients who underwent DHH for distal humeral fractures during a 4-year period (2008-2012) by a single surgeon. Patients underwent testing of range of motion, Mayo Elbow Performance Score, Disabilities of Arm, Shoulder and Hand, visual analog scale, Single Assessment Numeric Evaluation, and American Shoulder and Elbow Surgeons scores. Average patent age at surgery was 71.9 years (range, 56-81 years); average follow-up was 73.2 months (range, 36-96 months). RESULTS: Patients maintained improvements in Mayo Elbow Performance Scores (mean, 89.23; range, 75-100) and Disabilities of Arm, Shoulder and Hand scores (mean, 33.71; range 11.2-55.1), along with no significant decrease in range of motion compared with 1 year after surgery. Mean visual analog scale was 2.43 (range, 0-5), Single Assessment Numeric Evaluation was 74.14 (range, 50-100), and American Shoulder and Elbow Surgeons score was 72.14 (range, 48.33-100). Participants had an average flexion of 128.7° (range, 95°-142°), extension deficit of 27.1° (range, 0°-45°), supination of 79.1° (range, 45°-90°), and pronation of 73.3° (range, 50°-90°). No heterotopic ossification, elbow dislocations, or subluxations were observed. Complications included 1 fracture and 1 complaint of prominent hardware. Two patients died, and 1 patient was lost to follow-up. CONCLUSION: This midterm review suggests that DHH may be an effective treatment for certain distal humeral fractures. The data suggest that elbow range of motion and functional use are maintained from comparison with short-term studies. Additional studies must be conducted to further define the role of DHH for complex fractures of the distal humerus.

Retrograde headless compression screw fixation of olecranon stress fractures in throwing athletes: a novel technique.

Background: An olecranon stress fracture (OSF) is a rare injury most commonly seen in high-level overhead throwing athletes with no clear consensus on surgical treatment. The most common surgical treatment described in the literature is cannulated screw fixation but there have been high rates of reported hardware irritation and need for subsequent hardware removal. Hypothesis/Purpose: This study describes a novel surgical technique in the treatment of OSFs in high-level throwing athletes using retrograde headless compression screws. We hypothesized that patients would have excellent outcomes and decreased rates of hardware irritation postoperatively. Methods: A retrospective review of competitive-level throwing athletes who sustained OSFs that were treated operatively using a novel technique using retrograde cannulated headless compression screws to avoid disruption of the triceps tendon. Postoperative outcome measures obtained included the Disabilities of the Arm, Shoulder and Hand score, Mayo Elbow Performance Score, Simple Elbow Test score, Single Assessment Numerical Evaluation score, Visual Analog Scale, arch of motion, and time to return to sport as well as level returned to. Radiographs were obtained routinely at 2-week, 6-week, 12-week, 6-month, 1-year, and 2-year follow-up. Results: Five of 5 patients who met inclusion criteria were available for final follow-up. Mean age at time of surgery was 20 years (range 17-24). Mean follow-up was 17 months (range 4-33). All patients were baseball players, 4 of which were pitchers and 1 position player. All patients were able to return to sport at the same level or higher at a mean of 5.8 months (range 3-8). Postoperatively, mean arch of motion was 138°, Visual Analog Scale score was 0, Single Assessment Numerical Evaluation score was 90, Disabilities of the Arm, Shoulder and Hand score was 2.0, Mayo Elbow Performance Score was 100, and Simple Elbow Test score was 12. There was no incidence of hardware removal. Conclusion: This study presents a novel surgical technique in the treatment of OSFs in high-level throwing athletes. The results presented demonstrate that this technique is safe and effective for getting athletes back to play quickly without any complications of hardware irritation which has previously shown to be a significant problem in prior literature.

Invasive Pyoderma Gangrenosum and Concomitant Methicillin-Sensitive Staphylococcus aureus Septic Arthritis of the Glenohumeral Joint.

A 78-year-old man with a history of multiple cancers presented with severe shoulder pain, elevated inflammatory markers, an ulcerating skin lesion along the anterior shoulder, symptoms concerning for septic arthritis, and a lytic lesion of the humeral head. A negative work-up for malignancy prompted infectious work-up and biopsies, revealing positive methicillin-sensitive Staphylococcus aureus cultures, yet a curious finding of perivascular lymphocytic infiltrates and fibrinoid necrosis from both the dermal vessel wall from a skin biopsy and humeral head bone biopsy, suggestive of pyoderma gangrenosum. This was a previously undocumented presentation of pyoderma gangrenosum invasion into a large joint with concomitant bacterial septic arthritis. [Orthopedics. 2023;46(5):e321-e325.].

Surgeon-Therapist Communication Must Be Improved in Rotator Cuff Repair Rehabilitation: An Electronic Survey of Physical Therapists on Postoperative Rehabilitation Protocols and Communication with Treating Surgeons.

BACKGROUND: There is no consensus on postoperative rotator cuff repair protocols in orthopedic or physical therapy literature. Despite surgical management, the frequency of rotator cuff retears continues to be high. OBJECTIVES: This study is designed to investigate the current concepts of postoperative rehabilitation and to evaluate the state of communication between referring surgeons and treating physical therapists. METHODS: A survey was conducted over a 2-year period, performed by an online survey company. RESULTS: Six hundred responses were obtained from physical therapists. Most rehab protocols were based on size of tear, tissue quality, and open versus arthroscopic repair. Current intervention concepts and professional experience guided protocol development. Thirty-three percent of therapists receive operative notes ≤ 25% of the time. Sixteen percent reported not receiving operative notes and not having access to the physician >50% of the time. Most patients were seen within 2 weeks, with passive range of motion started in 83% of cases. Sixty percent started active-assist range of motion at ≤ 4 weeks. Sixty-four percent of therapy was continued for 12 to 16 weeks. Patient compliance, poor tissue quality, and rapid rehab progression were reported as common causes of failure. CONCLUSION: Most rehabilitation programs follow protocols developed by surgeons and physical therapists. Tissue quality, size of tear, and repair type are usually documented in the operative report, and are rarely conveyed to the therapist. This study highlights the lack of communication between the physician and the therapist. Improving communication regarding the findings at surgery, opening lines of communication, and making alterations to the protocol may improve patient outcomes.

Incidence of Metal Hypersensitivity in Orthopedic Surgical Patients Who Self-Report Hypersensitivity History.

INTRODUCTION: Metallic implants are integral to the practice of orthopedic surgery. Delayed-onset T-cell-mediated metal hypersensitivity (diagnosed by patch testing) is reported in 10% to 17% of the general population. Inconclusive evidence exists about the role of metal hypersensitivity in persistently painful or aseptic loosening of arthroplasties. Literature suggests that preoperative patch testing may influence surgical practice. OBJECTIVE: To determine the incidence of metal hypersensitivity in orthopedic surgical patients who self-report hypersensitivity and to characterize which metals are most commonly implicated. METHODS: A retrospective chart review of patients from a single surgeon's practice was conducted during a 1-year period. All patients were questioned about metal hypersensitivity history; all patients who responded affirmatively were sent for patch testing for specific metals. RESULTS: Only 41 (4.9%) of 840 patients self-reported any metal hypersensitivity. Of these, 34 (83%) were patch-test positive to 1 or more metals. There were 27 whose test results were positive for nickel, 4 each to cobalt or gold thiosulfate, and 1 each to tin or titanium. Seven patients had positive results to multiple metals, all of whom were also nickel hypersensitive. Six patients had metal orthopedic implants before patch testing, and 4 (67%) tested positively to a metal in their implant. CONCLUSION: Metal hypersensitivity can be concerning for treating surgeons and patients. Greater awareness of a history to hypersensitivity may prevent patient exposure to implants containing metals that may cause hypersensitivity. Non-metal-containing or nonreactive metal implants are an option for patients in whom metal hypersensitivity is suspected or confirmed.

Complications after surgical treatment of distal clavicle fractures.

INTRODUCTION: Distal clavicle fractures have low rates of union when treated with conservative measures. Operative treatment is generally recommended for Neer type II and V. Multiple fixation methods exist with no clear gold standard. The goal of the current study is to assess the outcomes and complications of distal clavicle fractures treated with one of three fixation methods: standard clavicular plate, hook plate or suture fixation about the coracoid. METHODS: This is a retrospective cohort study of surgically-treated unstable Neer type II and V distal clavicle fractures in adults. These operations were performed by multiple surgeons within a single healthcare system between January 2010 and September 2012. Patients were divided into three cohorts: pre-contoured clavicular locking plates, hook plates, and suture-only fixation methods. Univariate and mulivariate modeling analyses were performed. RESULTS: A total of 74 distal clavicle fractures comprised the final cohort. Fifty-eight (77%) of these fractures were Neer type II; the remaining 16 (21.6%) were Neer type V. Median follow-up time was 12 months (range 10-28). BMI, smoking status, diabetes, and ASA class were similar among all cohorts. Twenty-one patients were treated with suture fixation alone (28.3%), 37 with a contoured clavicular plate (50%) and 16 with hook plate fixation (21.6%). Twenty-one patients (28.4%) experienced complications, including two hardware failures requiring revision surgery. A total of 10/16 (62.5%) patients with hook plates required hardware removal for irritation, compared to 6/37 (16.2%) with a contoured clavicular plate (OR=8.61, p value=0.001), and none with sutures alone. A total of 3/21 patients (14.2%) treated with suture fixation methods were diagnosed with adhesive capsulitis post-operatively; no patients in the plate fixation groups received this diagnosis. The Neer V group had a higher proportion of any complications (37.5%) compared to Neer II (25.9%), and a higher rate of stiffness (12.5% v. 1.7% in Neer II). CONCLUSION: This study compared the outcomes of three different fixation methods for unstable distal clavicle fractures. The overall union rate with any method of operative intervention was very high (98.6%), consistent with previous studies. Hook plates had a much higher re-operation rate, mostly owing to a higher incidence of hardware removal, an expected outcome owing to the prominence of these plates in the subacromial space. Contoured clavicular plates were associated with a lower incidence of irritation and hardware removal than hook plates, although one patient in this group experienced loss of fracture fixation and went on to asymptomatic radiographic non-union. Suture-only fixation methods had the lowest rate of re-operation, with only one of 21 procedures resulting in failure and requiring revision. However, there was a significantly higher rate of adhesive capsulitis in the suture fixation cohort, perhaps due to the tethering effect of the clavicle to the coracoid or violation of the rotator interval. While this study supports that most distal clavicle fracture fixation methods can achieve stable union, there is a highly variable complication profile associated with each fixation method. The routine use of hook plate fixation cannot be recommended.

Risk Factors for Mortality and Readmission After Shoulder Hemiarthroplasty for Fracture.

BACKGROUND: Limited information exists regarding mortality and readmission following proximal humerus fracture. This study examines risk factors following hemiarthroplasty for these fractures. METHODS: A retrospective analysis of prospectively collected data on 788 patients treated with hemiarthroplasty for acute proximal humerus fracture from January 2005 to December 2011 was conducted. One-year mortality and 30- and 90-day hospital readmission were evaluated. Patient risk factors included age, race, gender, diabetes, American Society of Anesthesiologists (ASA) score, and body mass index. RESULTS: One-year mortality rate was 5.2%. Patients with ASA ≥3 had 2.37 times (95% confidence interval [CI]: 1.05-5.32) greater mortality risk versus patients with ASA1/2. The 30-day readmission rate was 8.4% and at 90 days was 12.6%. Females had 0.53 risk of readmission versus males (95% CI: 0.29-0.96). Patients with ASA ≥3 had 1.79 (95% CI: 1.04-3.09) risk of 90-day readmission versus patients with ASA1/2; females had 0.52 (95% CI: 0.31-0.85) risk of readmission versus males. Increased age increased all odds ratios. CONCLUSIONS: Readmission rate after hemiarthroplasty for proximal humerus fracture is significant both at 30 and 90 days and is higher in males. Age and ASA ≥3 correlate with this. Diabetes and obesity were not significant risk factors for readmission or mortality.

The prevalence of injury in Kendo.

OBJECTIVE: Kendo is a Japanese martial art analogous to fencing, which is becoming increasingly popular worldwide. The large number of participants creates a need to assess injury patterns to better train them. The purpose of this study is to describe current injury rates in kendo and compare these rates to other martial arts. METHODS: This retrospective study used an online questionnaire sent to 500 active members of the All United States Kendo Federation and World Kendo Federation. The questionnaire, based on the NCAA Injury Surveillance System, contains questions regarding location and type of injuries sustained during competition and practice, time lost to training, and competitor demographics. Statistical analyses between competitor demographics and injury rates are provided. Injury rates are expressed as injury rates/minute of competition or practice and by athlete exposures. 95% CIs were calculated. RESULTS: Responses from 307 of 500 kendo players were received (response rate = 61.4%). 41 (18%) male and 13 (16%) female participants reported injury to only one body region, while 16 (7%) men and one (1%) woman reported no injuries. 166 (74%) males and 70 (83%) females reported injuries to two or more body regions. The most common sites of injury involved the foot/ankle (65.1%), wrist/hand (53.5%) and elbow/forearm (48.8%). Most injuries occurred during practice (87.9% foot/ankle, 89.9% wrist/hand, elbow/forearm 92.2%). The most common injuries were contusions, abrasions, and sprains/strains. Injury rates were 121/1000 A-E (0.025 injuries/min) in tournaments versus 20.5/1000 A-E (0.011 injuries/min) in training. 26% of injuries resulted in time off of participation, with an average recovery time of 15 days (range = 1 day-1 year). CONCLUSIONS: Although more total injuries occurred in practice than in competition, there was a lower injury rate in kendo than in taekwondo and western-style fencing. This study demonstrates that kendo is a relatively safe sport compared to other martial arts sports.

Bilateral deltoid myositis ossificans in a weightlifter using anabolic steroids.

A 40-year-old male weightlifter presented with a 6-month history of a painless mass in the right deltoid. He had no history of trauma to the shoulder other than an arthroscopic rotator cuff repair a few weeks earlier. Physical examination showed a firm, nontender mass located longitudinally and coinciding with the deltoid, measuring 12×14×4 cm. There was no limitation in range of motion or functioning. Magnetic resonance imaging (MRI) and computed tomography (CT) scans suggested a lobulated, heterogeneous mass with multiple areas of calcification that raised suspicion for soft tissue sarcoma vs myositis ossificans. Marginal resection of the soft tissue mass was performed, and pathologic studies confirmed the diagnosis of xanthogranulomatous myositis ossificans with dystrophic calcifications and central cystic degeneration. At 2-week follow-up, the patient had improved range of motion and pain, but he noted a second soft tissue mass in the left deltoid. The MRI and CT scans showed a 10.5×16×3.4-cm linear, lobulated lesion with multiple calcifications, similar in appearance to the contralateral deltoid. The patient admitted to frequently injecting anabolic steroids into his deltoids. Because the patient was asymptomatic on the left side and the MRI appearance of the left deltoid mass was similar to that of the myositis ossificans seen on the right side, the patient opted for nonsurgical treatment. This is a rare case of myositis ossificans occurring bilaterally in the deltoids after repeated injections of anabolic steroids. There is currently no known association between anabolic steroids and myositis ossificans. This condition often mimics malignant neoplasms, illustrating the necessity of resection for diagnostic confirmation.

Sequence analyses of cyanobacterial bicarbonate transporters and their homologues.

The primary HCO3- uptake system in the cyanobacterium Synecocystis is the Na+-dependent transporter SbtA. SbtA and its homologues were identified and shown to display a common topology of ten transmembrane segments (TMSs). These proved to have arisen by an intragenic duplication event from an ancestral gene encoding a five TMS protein product. A region of SbtA shows sufficient similarity to 10 TMS ABC-type integral membrane transport proteins to suggest a common origin. Phylogenetic analyses of the SbtA family revealed two clusters of cyanobacterial homologues with all non-cyanobacterial family members outside of these two clusters. The tree topology suggests that SbtA family members display multiple transport functions.