Tunnel-free acromioclavicular joint reconstruction is associated with improved initial reduction and higher patient satisfaction.

Background: Many surgical techniques have been described for acromioclavicular (AC) joint reconstruction. Creation of bone tunnels through the clavicle or coracoid has been shown to be a risk factor for fracture. Use of an AC reconstruction technique that does not create bone tunnels may obviate this risk. This study aims to evaluate clinical outcomes of AC joint reconstruction using a tunnel-free technique compared to reconstruction using a cortical button and clavicular drill holes. Methods: Consecutive patients who underwent AC joint reconstruction by a single surgeon in a subspecialty referral practice were included. One group of patients received cortical button fixation (button group), in which sutures were passed around the coracoid, brought up through a drill hole in the clavicle, and tied over a cortical button. The other group of patients received tunnel-free fixation, in which a self-locking tape suture was passed in a cerclage fashion around the base of the coracoid and the clavicle and tensioned with a tensioning device (cerclage group). Both groups underwent reconstruction of the coracoclavicular (CC) ligament and AC joint capsule using tibialis anterior allograft. Patient-reported outcome scores and satisfaction were collected and compared between groups. Radiographs were reviewed to evaluate CC ligament distance and loss of reduction. Results: Twenty-two patients were included in the study (button n = 10, cerclage n = 12). Preoperative demographics and injury characteristics were not different between groups. Average radiographic follow-up was not different between groups (button: 231 days, cerclage: 105 days). Postoperative American Shoulder and Elbow Surgeons, visual analog scale, and Single Assessment Numeric Evaluation scores were similar between groups. Two postoperative clavicle fractures were sustained in the button group. These occurred through clavicular drill holes and were preceded by tunnel widening. No fractures occurred in the cerclage group. CC distance at initial follow-up was significantly less in the cerclage group (button: 11.2 ± 4.5 mm, cerclage: 7.0 ± 2.9 mm, P =.023). Loss of reduction was similar throughout the postoperative period (button: 4.3 ± 2.6 mm, cerclage: 4.8 ± 4.1 mm, P >.05. Forty percent of patients were unsatisfied with their clavicle after button fixation (n = 4/10), compared with zero after cerclage fixation (n = 0/12, P =.03). Reasons for dissatisfaction were fracture (n = 2) and persistent cosmetic deformity (n = 2). Conclusion: Tunnel-free AC joint reconstruction is associated with improved initial radiographic appearance and patient satisfaction compared to single cortical button fixation. Postoperative clavicle fracture and persistent cosmetic deformity drive patient dissatisfaction, which may be minimized by avoiding clavicular drill holes and using a tensioned self-locking cerclage suture to improve initial reduction.

Clinical outcomes of rotator cuff repair with subacromial bursa reimplantation: a retrospective cohort study.

Background: The subacromial bursa has been found to be a rich, local, source of mesenchymal stem cells but is removed for visualization during rotator cuff repair. Reimplantation of this tissue may improve rotator cuff healing. The purpose of this study is to evaluate clinical outcomes of rotator cuff repair with and without subacromial bursa reimplantation. Methods: Patients aged 37-77 with a full-thickness or near full-thickness supraspinatus tears underwent arthroscopic transosseous-equivalent double row rotator cuff repair. In patients prior to July 2019, the subacromial bursa was resected for visualization, and discarded. In patients after July 2019, the subacromial bursa was collected using a filtration device connected to an arthroscopic shaver and reapplied to the bursal surface of the tendon at the completion of the rotator cuff repair. Rotator cuff integrity was evaluated via magnetic resonance imaging on bursa patients at 6 months postoperatively. Minimum 18-month clinical outcomes (Single Assessment Numeric Evaluation, American Shoulder and Elbow Surgeons, patient satisfaction) were compared between bursa and nonbursa cohorts. Results: A total of 136 patients were included in the study (control n = 110, bursa n = 26). Preoperative demographics and tear characteristics were not different between groups. Average follow-up was significantly longer in the control group (control: 3.2 ± 0.7 years; bursa: 1.8 ± 0.3 years; P < .001). The control group showed a significantly higher Single Assessment Numeric Evaluation score (control: 87.9 ± 15.8, bursa: 83.6 ± 15.1, P = .037) that did not meet minimum clinically important difference. The American Shoulder and Elbow Surgeons and patient satisfaction scores were similar between the groups. Symptomatic retears were not significantly different between groups (control: 9.1%, bursa 7.7%, P = .86). Seven patients in the control group underwent reoperation (6.4%), compared to 0 patients in the bursa group (0%, P = .2). Six-month postoperative magnetic resonance images obtained on bursa patients demonstrated 85% rotator cuff continuity (n = 17/20) as defined via Sugaya classification. Conclusion: Augmentation of rotator cuff repair with bursal tissue does not appear to have negative effects, and given the accessibility and ease of harvest of this tissue, further research should be performed to evaluate its potential for improved tendon healing or clinical outcomes.

Preoperative metaphyseal cancellous bone density is associated with intraoperative conversion to stemmed total shoulder arthroplasty.

Background: Methods to determine whether a stemless humeral component is appropriate for anatomic total shoulder arthroplasty are varied and often subjective. Objective preoperative data regarding metaphyseal bone quality may help guide surgical decision-making. This study sought to evaluate preoperative proximal humeral bone quality and determine whether it is predictive of intraoperative conversion to a stemmed humeral component. Methods: Consecutive patients who underwent primary anatomic total shoulder arthroplasty from a single-surgeon practice were enrolled. All patients received a preoperative computed tomography (CT) scan for surgical templating purposes. The exclusion criteria were lack of a preoperative CT scan, preoperative plan for a stemmed component, and intraoperative conversion to a stem for a reason other than bone quality (ie, fracture). Preoperative CT scans were analyzed with an automated templating software. Cortical index and thickness were calculated, and bone density of the proximal diaphysis, cancellous metaphysis, and cortical metaphysis was obtained by averaging Hounsfield units (HU) across anatomically defined regions using a previously validated technique. The decision to convert to a stemmed humeral component was made intraoperatively based on a lack of stability of the trial stemless component. Bone quality measurements were compared between stemless and stemmed groups. An exact logistic regression was used incorporating gender and age. Results: A total of 79 patients who underwent primary anatomic total shoulder arthroplasty were included in this study. Of these patients, 6 underwent intraoperative conversion to a stemmed humeral component (7.6%). There was no significant difference between cohorts in terms of cortical index and bone density within the proximal diaphysis and cortical metaphysis. On univariate analysis, cortical thickness, metaphyseal cancellous bone density, and gender were significantly different between groups. Patients receiving a stem had significantly lower metaphyseal cancellous bone density than those receiving stemless components (5.5 ± 11.2 HU vs. 47.6 ± 29.4 HU, P<.001). All patients converted to stems were female individuals (P = .01) and had metaphyseal cancellous bone density less than 20 HU (P<.001). Conclusions: Metaphyseal cancellous bone density can be calculated on preoperative CT scans and is associated with intraoperative conversion to a stemmed humeral component in anatomic shoulder arthroplasty. A threshold of 20 HU can be used to predict which patients are more likely to require stemmed components.

Use of intraoperative platelet-rich plasma during rotator cuff repair is correlated with increased patient-level charges across multiple categories.

BACKGROUND: As the efficacy of platelet-rich plasma (PRP) as an adjunct in rotator cuff repair (RCR) is debated, the decision to use PRP may be more heavily affected by its cost. We sought to quantify whether augmenting arthroscopic RCR with PRP injections at the time of surgery is correlated with increased patient-level charges. METHODS: All outpatient records reported in Texas from 2010 to 2018 were obtained from the publicly available Texas Healthcare Information Collection database through the Texas Department of State Health Services. All records including a Current Procedural Terminology code for arthroscopic RCR were included. Of the 139,587 records identified within this group, 1662 also contained a Current Procedural Terminology code for intraoperative PRP injection. Patient-level charge data were compared between those who received and those who did not receive concomitant PRP injection during the same outpatient surgical encounter. Subgroup analyses were performed across surgical facilities and insurance types. Mann-Whitney U tests were used to compare charges between PRP and non-PRP cases. Linear regression was used to predict the change in billed charges according to standard charge categories. P values less than .05 were considered statistically significant. RESULTS: The total charges for arthroscopic RCR over the 8-year period were $4.66 billion, coming to $33,371 ± $22,118 per case. Cases that included PRP injection were found to have significantly greater overall charges than cases that did not ($54,452 ± $33,637 vs. $33,117 ± $21,818; P < .001). Linear regression indicated that concomitant PRP injections predicted an increase in combined total charges by $22,027 (95% confidence interval, $20,425-$23,628; P < .001). CONCLUSIONS: PRP utilization at the time of rotator cuff surgery is correlated with increased patient-level charges overall, which occur across all charge subcategories and persist across surgical facility, surgeon volume, and insurance type. Detailed cost analysis is recommended to explore this charge correlation, and future cost-benefit analyses of PRP use in RCR should explore costs beyond that solely associated with PRP preparation, as these may have previously been overlooked.

Increasing rates of ulnar collateral ligament repair outpace reconstruction in isolated injuries: review of a Texas surgical database.

Background: The gold standard of treatment for ulnar collateral ligament (UCL) injuries has been reconstruction. Despite early repair studies yielding less than satisfactory results, there has been recent renewed interest in UCL repair due to improved outcomes and new technologies. Data regarding clinical use of these procedures are lacking. The purpose of this study was to define the epidemiological trends of UCL repair and reconstruction surgery from 2010 to 2019, compare demographic characteristics of patients undergoing either procedure, and determine incidence of concomitant procedures in each surgical group as well as comparing respective patient-level charges. Methods: A retrospective database analysis of UCL surgeries was performed through the Texas Healthcare Information Collection database, a comprehensive and publicly available statewide billing dataset. Inclusion criteria were defined using Current Procedural Terminology billing codes for elbow UCL repair and reconstruction between 2010 through 2019, excluding patients who had concomitant elbow fractures or lateral collateral ligament tears indicative of high-energy trauma. Procedural volume changes, patient demographics, and commonly performed concomitant procedures including elbow arthroscopy, ulnar nerve surgery, and platelet-rich plasma injection were compared. Total patient-level charges were compared across groups. Results: A total of 1664 patients were included, consisting of 484 UCL repairs and 1180 reconstructions. Total UCL surgeries increased eleven-fold when corrected for population growth from 2010 (N = 25) to 2019 (N = 315). In 2010, repair constituted 23% of all UCL tear surgeries and increased to 40% by the end of 2019. The annual frequency of UCL repair increased at a 5.4% faster rate than UCL reconstruction from 2010 to 2019 (P < .001). There were no significant differences between any demographic data between UCL repair and reconstruction except for rural surgical settings which demonstrated 1.8 times greater odds of undergoing reconstruction (P = .05). There were no differences among commonly associated procedures including ulnar nerve surgery (P = .217), elbow arthroscopy (P = .092), and platelet-rich plasma injection (P = .837) with no differences in patient-level charges at any time point (P = .47). Conclusion: While reconstruction remains more common, the annual frequency of UCL repair is increasing at a faster rate. Since were no demographic differences aside from surgical setting, it can be inferred that patients who were previously receiving reconstruction are instead undergoing repair. This highlights the need for future studies to further identify surgical indications for the two interventions.

Treatment of Acromioclavicular Joint Instability With a Tunnel-Free Reconstruction Technique.

Acromioclavicular joint injuries are a common shoulder injury encountered by orthopaedic surgeons. Many different surgical techniques have been described for the operative treatment of these injuries with no single, clear gold standard technique on which surgeons agree. Among the most common complications after surgical management of acromioclavicular injuries are loss of reduction, infection, fracture of clavicle or coracoid, and need for reoperation. We propose an arthroscopic-assisted, tunnel-free surgical technique using a tibialis anterior allograft combined with a FiberTape Cerclage (Arthrex, Naples, FL) to manage both acute and chronic acromioclavicular joint injuries. No bony tunnels are drilled and no hardware is implanted, which should obviate the risk for subsequent bony failure through a fracture, nor require subsequent hardware removal. In addition, the combination of suspensory and allograft fixation should impart sufficient stability to maintain an adequate reduction even in the face of failure of one of the fixation methods.

Reliability and accuracy of telemedicine-based shoulder examinations.

BACKGROUND: Telemedicine has become a critical component in the evaluation and management of patients with shoulder pathology. However, the interobserver reliability of findings on virtual physical examination relative to in-person evaluation is unclear. The purpose of this study was to determine the reliability of prerecorded video telemedicine for the evaluation of shoulder pathology compared with traditional in-person physical examination. METHODS: New patients with unilateral shoulder pain presenting to a single-surgeon shoulder clinic were recruited between July and November 2020. In 1 visit, patients were evaluated with standardized in-person and video-guided telemedicine physical examinations in randomized order. Patients were evaluated for range of motion (ROM) and symptoms including pain, weakness, and apprehension. The telemedicine examination was recorded and consisted of a video guide displaying self-directed shoulder examination maneuvers that patients performed during remote coaching by an independent non-physician observer. The in-person physical examination was performed by the treating physician. The telemedicine videos were evaluated by two independent observers for interobserver reliability. The treating physician subsequently evaluated the telemedicine videos after a minimum two-month washout period for intraobserver reliability and intra-platform reliability. Interobserver and intraobserver reliability analyses were conducted using Kuder-Richardson formula 20 (KR-20). Specificity and likelihood ratios were calculated with P < .05 representing statistical significance. RESULTS: A total of 32 patients (17 male and 15 female patients; average age, 50.2 ± 16.2 years) were included in the analysis. Overall Kuder-Richardson formula 20 (KR-20) reliability across 40 physical examination maneuvers was 0.391 ± 0.332 (76.4% ± 15.4% agreement) between the in-person and telemedicine examinations. Telemedicine maneuvers examining ROM limitations had the highest degree of reliability, sensitivity, specificity, and likelihood of also producing a positive finding on the in-person examination (0.700 ± 0.114, 66.5%, 81.0%, and 6.06, respectively). Telemedicine maneuvers identifying apprehension associated with glenohumeral instability were found to have the lowest reliability, sensitivity, and likelihood of producing a positive finding on the in-person examination (0.170 ± 0.440, 23.5%, and 0.518, respectively). All patients were satisfied with their telemedicine experience. CONCLUSION: The overall reliability of a non-physician-directed video-guided telemedicine examination ranged from unacceptable to good. Shoulder ROM limitations identified during the telemedicine examinations were found to be the most reliable, whereas evaluations of instability were found to be the least reliable. Although initial telemedicine evaluation by a non-physician may be appropriate for ROM evaluation, in-person physician evaluation is recommended to confirm suspected diagnoses, especially if clinical concern for shoulder instability exists. Alternative methods of telemedicine delivery should be explored to improve the reliability of self-directed physical examination maneuvers.

Trends in Acromioplasty Utilization During Arthroscopic Rotator Cuff Repair: An Epidemiological Study of 139,586 Patients.

INTRODUCTION: Acromioplasty remains very common during rotator cuff repair (RCR) despite limited evidence of clinical efficacy. This study observed the incidence of acromioplasty from 2010 to 2018 in Texas using a publicly available database. METHODS: A total of 139,586 records were analyzed from the Texas Healthcare Information Collection database ranging from 2010 to 2018. These cases were divided into those with and without acromioplasty (N = 107,427 and N = 32,159, respectively). Acromioplasty use was standardized as the number of acromioplasties per RCR (acromioplasty rate). Two subgroup analyses were conducted: surgical institution type and payor status. RESULTS: In 2010, acromioplasty occurred in 84% of all RCR cases with nearly continuous decline to 74% by 2018 (P < 0.001). All subgroups followed this pattern except teaching hospitals which displayed insignificant change from 2010 to 2018 (P = 0.99). The odds of receiving acromioplasty in patients with neither Medicare nor Medicaid was higher than those with Medicare or Medicaid coverage (odds ratio = 1.36, P < 0.001). DISCUSSION: Overall acromioplasty rates decreased modestly, but markedly, beginning in 2012. Despite this small decrease in acromioplasty rate, it remains a commonly performed procedure in conjunction with RCR. Both the academic status of the surgical facility and the payor status of the patient affect the acromioplasty rate.

Is outpatient shoulder arthroplasty safe in patients aged ≥65 years? A comparison of readmissions and complications in inpatient and outpatient settings.

BACKGROUND: Recent studies indicate that outpatient total shoulder arthroplasty (TSA) is cost-effective and may have a low complication rate similar to inpatient TSA. However, existing studies have included younger patient cohorts who typically possess fewer medical comorbidities. Patients aged ≥65 years are commonly enrolled in Medicare, which has traditionally designated TSA as an inpatient-only procedure. The purpose of this study was to compare surgical complication rates and 90-day readmission rates between inpatient and outpatient TSA performed in adults aged ≥65 years. METHODS: Medical records for all patients aged ≥65 years who underwent primary anatomic or reverse TSA by a single surgeon from July 2015 to May 2020 were reviewed. Patients were preselected for outpatient or inpatient surgery based on lack of significant cardiopulmonary comorbidities and patient preference. Demographics, body mass index (BMI), and American Society of Anesthesiologists (ASA) scores were collected in addition to emergency department (ED) visits and readmissions within 90 days of the index surgery. Relationships among frequency and types of complications and surgical setting (inpatients vs. outpatient) were assessed. Complication rates and demographic variables between inpatient and outpatient procedures were compared. Logistic regressions were performed to account for interacting predictor variables on the odds of having complications. RESULTS: A total of 145 shoulders (138 patients; 95 male, 43 female) were included in the analysis, of which 98 received inpatient TSA and 47 received outpatient TSA. Average age was 75.5 ± 7.2 for inpatient TSA and 70.5 ± 4.5 for outpatient TSA (P < .001). Patient age (P < .001), ASA score ≥3 (P < .001), and reverse TSA (P = .002) were significantly positively correlated with receiving inpatient surgery. There were 16 complications (16.3%) in the inpatient group and 9 complications (19.1%) in the outpatient group (P = .648). There were no significant differences in the frequency of postoperative complications, return to the ED, or reoperations between inpatient and outpatient procedures (P > .05). Each 1-year increase in age increased the predicted odds of having a surgical complication by 14% (odds ratio = 1.14; P = .021), irrespective of surgical setting. Those who underwent inpatient TSA had a significantly higher frequency of 90-day readmission (inpatient=16, outpatient=1; P = .034). CONCLUSIONS: Postoperative complications and ED returns were not significantly different between inpatient and outpatient TSA. Each 1-year increase in age increased the odds of postoperative surgical complications by 14%, regardless of surgical setting. Outpatient TSA was found to be safe for appropriately selected patients aged ≥65 years, and re-evaluation of TSA as an inpatient-only procedure should be considered.

Current Controversies in the Treatment of Geriatric Proximal Humeral Fractures.

➤: Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. Factors such as surgeon experience as well as the quality and maintenance of the reduction may influence operative outcomes, and their impact on these findings merits further investigation. ➤: In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation (ORIF). ➤: In the geriatric population, reverse total shoulder arthroplasty has demonstrated improved functional outcomes, with a decreased rate of reoperation, compared with hemiarthroplasty. Tuberosity repair has been shown to improve functional outcomes and range of motion after both procedures and should be performed at the time of arthroplasty. ➤: Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humeral fractures. Augmentative procedures, including cortical strut augmentation, are being investigated to address this issue; their role in the treatment of these fractures is unclear at this time.

A Geographic Population-level Analysis of Access to Total Shoulder Arthroplasty in the State of Texas.

INTRODUCTION: Managing costs and improving access to care are two important goals of healthcare policy. The purposes of this study were to (1) evaluate the changes in distribution of total shoulder arthroplasty (TSA) cases in the state of Texas from 2010 to 2015 and (2) to evaluate patient access to TSA surgery centers as measured by driving miles. METHODS: Inpatient (IP) and outpatient (OP) records were obtained from 2010 to 2015 from the Texas Department of State Health Services. All primary elective anatomic or reverse TSAs for patients with Texas-based home residence zip codes were included. Driving miles between patient zip codes and their chosen TSA surgery centers were estimated, and the results were compared between IP (high-volume [HV-IP] or low-volume [LV-IP]) and OP centers. Paired student t-tests, multivariate regressions, and mixed-model analysis of variance (ANOVA) were performed for volume comparisons, interactions between TSA centers types, and yearly trend data, respectively. RESULTS: Between 2010 and 2015, a total of 21,092 TSA procedures were performed across 321 surgery centers in the state of Texas (19,629 IP [93.1%] and 1,463 OP [6.9%]). During this time, the cumulative volume of IP TSA per 100,000 Texas residents increased by 109.1%, whereas the cumulative volume of OP TSA increased by 143.7%. Approximately 85.5% of included patients resided within 50 miles of any TSA surgery center; however, only 47.0% of the total Texas population resided within 50 miles of any TSA surgery center. This relationship remained true at every time point irrespective of their volume designations (OP, IP, HV-IP, and LV-IP). CONCLUSION: Despite the overall increase in TSA volume over time, the majority all TSA utilization in the state of Texas occurred in patients who resided within 50 miles of a TSA center. Increasing volume seems to reflect concentration of care into HV-IP and OP centers. Strategies to improve access to TSA care for underserved areas should be considered. LEVEL OF EVIDENCE: Level II.

Biologic Augmentation of Arthroscopic Rotator Cuff Repair Using Minced Autologous Subacromial Bursa.

Failure of rotator cuff repair surgery can be attributed to a variety of factors, including insufficient biologic environment to support healing. The subacromial bursal tissue has been shown to have a reservoir of mesenchymal stem cells and is a potential source for biologic augmentation during rotator cuff repair. We have developed a technique to capture the subacromial bursal tissue during subacromial bursectomy and then reimplant the tissue on the bursal surface of the rotator cuff tendon after rotator cuff repair. Our goal is to describe our technique of subacromial tissue collection and reimplantation that obviates the need of suturing a whole sleeve of bursal tissue while improving cell yield for rotator cuff healing.

Arthroscopic-assisted Fixation of a Nonunited Coronoid Stress Fracture in a Competitive Gymnast: A Case Report.

CASE: Gymnasts may suffer elbow injuries due to repetitive loading. However, coronoid stress fractures remain uncommon. We report a case of a high-level female competitive gymnast with a nondisplaced coronoid stress fracture that failed to heal with conservative management. Arthroscopic-assisted in situ fixation of the coronoid nonunion was performed, and the gymnast returned to competition after the fracture healed. CONCLUSION: Coronoid stress fractures should be considered in gymnasts presenting with chronic elbow pain. If nonoperative treatment is unsuccessful, arthroscopic fixation can be successful in stimulating healing of the nonunion without the morbidity of an open approach or bone grafting.

Quantification of patient-level costs in outpatient total shoulder arthroplasty.

BACKGROUND: Patient-level costs of inpatient and outpatient total shoulder arthroplasty (TSA) irrespective of payer status are seldom reported. The purpose of this study was to compare patient-level costs of primary elective TSA between inpatient and outpatient surgery centers. METHODS: By use of the Texas Health Care Information Collection database, inpatient and outpatient TSAs performed between 2010 and 2015 were identified according to billing codes. Patient-level costs (total charges and itemized charges) were analyzed according to type of surgery center (inpatient vs outpatient) and inpatient volume (high volume vs low volume). Statistical comparisons were performed using 1-way analysis of variance and 2-sample independent t tests. Mixed-model analysis of variance was used to compare the rate of cost change between inpatient and outpatient TSAs from 2010-2015. P < .05 represented statistical significance. RESULTS: A total of 21,331 inpatient TSAs and 1542 outpatient TSAs were performed from 2010-2015 in the state of Texas. Inpatient TSA costs were significantly higher than outpatient TSA costs ($76,109 [standard deviation (SD), $48,981] vs $22,907 [SD, $13,599]; P < .001). After exclusion of inpatient-specific charges, inpatient TSA remained 41.1% more expensive than outpatient TSA ($32,330 [SD, $24,221] vs $22,907 [SD, $13,599]; P < .0001). High-volume inpatient TSA was less expensive than low-volume inpatient TSA; however, high-volume inpatient TSA remained 33.4% more costly than outpatient TSA even after exclusion of inpatient-specific charges ($30,579 [SD, $23,233] vs $22,907 [SD, $13,599]; P < .0001). CONCLUSIONS: In the state of Texas, the patient-level costs of primary elective inpatient TSA were significantly higher than those of the equivalent outpatient procedure. This difference persisted after exclusion of low-volume inpatient TSA centers and inpatient-specific ancillary charges.

Humeral Bone Loss in Revision Total Shoulder Arthroplasty: the Proximal Humeral Arthroplasty Revision Osseous inSufficiency (PHAROS) Classification System.

BACKGROUND: Humeral bone loss is commonly encountered during revision shoulder arthroplasty and anticipating humeral bone defects can help the revision surgeon make appropriate plans to achieve adequate fixation and stability. No validated classification system exists to characterize humeral bone loss in the setting of revision shoulder arthroplasty. QUESTIONS/PURPOSES: The purposes of this study were (1) to create a classification system for humeral bone loss in revision shoulder arthroplasty; (2) to determine the classification system's reliability; and (3) to determine whether humeral bone loss type is associated with intraoperative humeral-related reconstruction characteristics. METHODS: This was a comparative retrospective radiographic study. First, six surgeons from five centers collaborated to create a classification by consensus. Second, two surgeons from two other centers who had fellowship training in shoulder and elbow surgery, who were blinded to each other's grades and all patient details other than plain radiographs, and who were not involved in creation of the system, classified true AP, AP, and lateral (axillary and/or scapular-Y) radiographs from 108 revision (413 radiographs) from one center that were performed between November 15, 2006, and January 4, 2018. Interobserver reliability was calculated by comparing those two reviews and determining Cohen's κ. In addition, one reviewer repeated his assessments twice, 4 months apart, to determine intraobserver reliability using Cohen's κ. Third, we performed a retrospective chart study of these same revisions to determine intraoperative humeral-related reconstruction characteristics such as the use of greater tuberosity fixation, stem length, humeral bone grafting, and the use of proximal humeral replacement or total humeral replacement; at the center where these revisions were performed during that timespan, no attempt to classify bone loss was made. During that period, the general indications for greater tuberosity fixation included the absence of a stable osseous connection between the greater tuberosity and the shaft of the humerus with a tuberosity amendable to repair; the general indications for use of longer stems were inability to obtain a minimum of two cortical widths of overlap between the implant and the humeral diaphysis and/or loss of the greater tuberosity; and the general indications for proximal and total humeral replacement were bone loss that was felt to be too severe to allow reconstruction with allograft. RESULTS: The classification system consists of three types of humeral bone loss: Type 1 is loss of the epiphysis with subtypes for loss of the calcar and loss of the greater tuberosity; Type 2 is loss of the metadiaphysis above the deltoid attachment with a subtype for cortical thinning; and Type 3 is bone loss extending below the deltoid attachment with a subtype for cortical thinning. We studied 108 revisions: 38 (35%) without bone loss, 34 (31%) Type 1, 27 (25%) Type 2, and nine (8%) Type 3. For reliability, interrater κ was 0.545 and in 71% (77 of 108) of revisions, the two raters agreed on a numeric type. Intrarater κ was 0.615 and in 77% (83 of 108) of revisions, the rater agreed with himself as to the numeric type. Stem length increased with class type (Type 1 median [range] 130 [70-210], Type 2 150 [70-210], Type 3 190 [70-240], p = 0.005). Most greater tuberosity fixation for intraoperative fracture was in Types 1 and 2 (13 of 18 compared with the five of 18 of greater tuberosity fixation that was within Types 0 and 3, p = 0.043). Most bone grafting was in Types 2 and 3 (eight of 13 compared with five of 13 of bone grafting was in Types 0 and 1, p = 0.044). Most proximal humeral and total humeral replacements were in Type 3 (three of four compared with one of four, p < 0.001). CONCLUSIONS: We developed the Proximal Humeral Arthroplasty Revision Osseous inSufficiency (PHAROS) system, which has adequate, if imperfect, reliability to classify humeral bone loss in the setting of revision shoulder arthroplasty. This classification system may be useful to anticipate the complexity of humeral reconstruction. Further validation incorporating advanced imaging and further evaluators will be necessary. LEVEL OF EVIDENCE: Level III, diagnostic study.

Suture Technique Influences the Biomechanical Integrity of Pectoralis Major Repairs.

Pectoralis major ruptures occur in large, muscular individuals, and repair constructs may experience significant tension. Four different suture techniques were evaluated biomechanically to determine the effect of suture technique on optimizing fixation strength. Forty fresh-frozen cadaveric shoulders were repaired using endosteal buttons. The control group was repaired with #2 polyblend suture in a modified Mason-Allen stitch configuration. The triple group was repaired using the same suture and configuration, but with the addition of triple-loaded buttons. The configuration group was repaired using the same suture in a Krackow/Bunnell configuration. The tape group was repaired using 2-mm polyethylene tape and #5 polyblend suture in the Krackow/Bunnell configuration. Under cyclic loading, there was no significant difference between groups. Under load-to-failure testing, the tape group withstood a significantly greater maximum load (726.0±90.0 N) than the control and triple groups (330.2±20.2 and 400.2±35.2 N, respectively; P<.005), and similar load to the configuration group (509.9±68.6 N; P=.16). The configuration group failed via suture breakage (9/10); the other groups failed via suture pullout, in which suture pulled through tendon (26/30). Pectoralis major repair in a running, locked configuration appears to improve biomechanical performance by preventing suture pullout. Use of a polyethylene tape construct demonstrates the potential for improved failure loads, but its role remains undefined.

Biomechanical analysis of the pectoralis major tendon and comparison of techniques for tendo-osseous repair.

BACKGROUND: Various described surgical techniques exist for the repair of pectoralis major ruptures at the tendo-osseous junction. It is unclear how these techniques restore the native properties of the pectoralis major tendon because its biomechanical properties have not been described. HYPOTHESIS: All repairs will have lower initial biomechanical profiles than the native attachment, and transosseous sutures will demonstrate improved initial biomechanical performance compared with anchors or buttons. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty-four fresh-frozen cadaveric shoulders were randomized to 4 equal groups, including 3 experimental repair groups and 1 control group of intact pectoralis major tendons. The characteristics of the native anatomic footprint were recorded, and the experimental groups underwent pectoralis detachment, followed by subsequent repair. The restoration of the anatomic footprint was recorded. All specimens were tested with cyclic loading and load-to-failure protocols with load, displacement, and optical marker data simultaneously collected. RESULTS: Under cyclic loading, the intact specimens demonstrated a significantly higher secant stiffness (74.8 ± 1.6 N/mm) than the repair groups (endosteal Pec Button [PB], 46.2 ± 6.4 N/mm; suture anchor [SA], 45.9 ± 8.7 N/mm; transosseous [TO], 44.2 ± 5.5 N/mm). Measured as a percentage change, the PB and SA groups showed a significantly higher initial excursion than the intact group (PB, 24.0% ± 11.7%; SA, 17.5% ± 6.9%; intact, 2.2% ± 1.0%), and the PB group demonstrated a significantly higher cyclic elongation than the intact group (PB, 7.5% ± 2.9%; intact, 1.5% ± 1.5%). Under load-to-failure testing, the intact group showed a significantly greater maximum load (1454.8 ± 795.7 N) and linear stiffness (221.0 ± 111.7 N/mm) than the 3 repair groups (PB, 353.5 ± 88.3 N and 63.5 ± 6.9 N/mm; SA, 292.0 ± 73.3 N and 77.0 ± 7.8 N/mm; TO, 359.2 ± 110.4 N and 64.5 ± 14.1 N/mm, respectively). All repair constructs failed via suture pulling through the tendon. CONCLUSION: The biomechanical characteristics of the transosseous repair, suture anchors, or Pec Button repair were inferior to those of the native pectoralis tendon. There was no significant difference in any of the biomechanical outcomes among the repair groups. Further refinement and evaluation of suture technique and configuration in pectoralis major repair should be considered. CLINICAL RELEVANCE: Transosseous repair, suture anchors, and endosteal Pec Buttons appear to confer similar biomechanical integrity for pectoralis major repair. Restricting early activities to thresholds below the identified failure loads seems prudent until soft tissue healing to bone is reliably achieved.

Case report: unicameral bone cysts in a young patient with acquired generalized lipodystrophy.

We report the case of a 13-year-old boy with bilateral distal femoral unicameral bone cysts (UBCs) associated with acquired generalized lipodystrophy. As opposed to congenital generalized lipodystrophy, cystic bone lesions in acquired generalized lipodystrophy are rare. After radiographic and histologic confirmation of the UBCs, we performed percutaneous intramedullary decompression, curettage, and grafting. UBCs can be an important manifestation of acquired generalized lipodystrophy. Cystic bone lesions appear to be less common in acquired generalized lipodystrophy than in congenital generalized lipodystrophy, and intramedullary adipose tissue loss may be a predisposing factor for the development of bone lesions in patients with acquired generalized lipodystrophy. When evaluating a patient with lipodystrophy, doctors should recognize the clinical course may include the development of UBCs.