High comorbidity burden and low incidence of adverse events in primary shoulder arthroplasty in tertiary care at a university hospital.

Background: Reducing perioperative risk is in the focus of primary arthroplasty caregivers. Primary shoulder arthroplasty patients are considered among those with the lowest perioperative risk. Nonetheless, in tertiary care centres and university settings patients with significant comorbidities are being treated. It remains unclear whether the overall comorbidity burden is truly higher and if this results in an increased frequency of adverse events (AE). As a result, we conducted a study to assess the comorbidity burden and the frequency of major perioperative adverse events and predictive factors following primary shoulder arthroplasty in the university setting. Methods: A retrospective cohort analysis was conducted on patients undergoing primary shoulder arthroplasty for a non-trauma, non-tumour indication from January 1st, 2014 through December 31st, 2018. Administrative data were recorded to assess comorbidity burden and revision surgery within the first postoperative year. Major adverse events were routinely recorded on a weekly basis by the treating physicians. Descriptive and comparative statistical analyses were performed. The cohort was compared against a large North American sample. Results: Of 386 patients who underwent 400 primary shoulder arthroplasties 14 (3.5 %) experienced adverse events. While AE were distributed equally among anatomical and reverse shoulder arthroplasties, no adverse event was recorded in the 34 hemiarthroplasty patients. The cohort showed an increased comorbidity burden in international comparison. Peptic ulcer disease was significantly associated with AE, while mild liver disease experienced a trend towards AE. Conclusion: We found an increased comorbidity burden and a low rate of AE for primary shoulder arthroplasty in a tertiary care and university setting. The distinct role of peptic ulcer disease in this cohort and the trend in mild liver disease merit further investigation in larger samples. The findings underscore the importance of perioperative risk assessment and management. Level of evidence: III, retrospective cohort study.

Undersizing of the tibial component in Oxford unicompartmental knee arthroplasty (UKA) increases the risk of periprosthetic fractures.

INTRODUCTION: Tibial periprosthetic fractures (TPF) after unicompartmental knee arthroplasty (UKA) are a rare condition that affects about 1% of cases. Known risk factors include age, sex, body mass index (BMI), and bone density, as well as surgical technique and prosthesis design. The purpose of the study was to determine if undersizing of the tibial component in relation to the femoral component increases the risk of tibial periprosthetic fractures. MATERIAL AND METHODS: Over a 6-year-period 1542 patients with cemented (n = 363) and uncemented (n = 1179) medial UKA were retrospectively evaluated. Tibial periprosthetic fractures were identified and classified, and epidemiologic data were documented at follow-up. Undersizing was defined as a smaller tibial component compared to the femoral implant. The association of potential risk factors for TPF with the incidence of TPF was investigated with binominal logistic regression. RESULTS: Fourteen patients (0.9%) suffered from TPF at a median of 1 month after surgery. The mean follow-up period was 5.9 ± 1.7 years. Fractures were more common in cases with undersized tibial components [odds ratio (OR) 3.2, p < 0.05]. Furthermore, older age (OR 1.1, p < 0.05) and female sex (OR 6.5, p < 0.05) were identified as significant risk factors, while BMI (p = 0.8) and cemented implantation (p = 0.2) had no effect on fracture rate. Revision surgery included open reduction and internal fixation or conversion to total knee arthroplasty. CONCLUSIONS: Undersizing of implant sizes in UKA increases the risk for TPF especially in patients with small tibial implants. Therefore, mismatched implants should be avoided for UKA particularly when risk factors like obesity, older age, or female gender are present. Tibial periprosthetic fractures were successfully treated by open reduction and internal fixation or conversion to total knee arthroplasty.

Isolated medial patellofemoral reconstruction outcomes: A systematic review and meta-analysis.

BACKGROUND: Treatment of patellar instability remains up for debate, and a combination of tibial tubercle osteotomy and medial patellofemoral ligament reconstruction (MPFLr) of the medial patellofemoral ligament (MPFL) has become the mainstay treatment for recurrent lateral patellar dislocation. Due to limited small studies, there remains a variety of surgical techniques still being practiced. The use of MPFL reconstruction, in isolation, has demonstrated promise. PURPOSE: The purpose of this systematic review and meta-analysis is to investigate if isolated medial patellofemoral ligament reconstruction (iMPFLr) can safely and efficaciously restore knee stability and to present the patient demographics, surgical techniques, graft choices, clinical outcomes, and complications after iMPFLr for recurrent patellar dislocation (RPD). METHODS: A review of the current literature according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, yielded 299 abstracts. Twenty-seven articles met the inclusion/exclusion criteria accounting for 1200 patients. Data was pooled and analyzed focusing on patient demographics, graft type used, Kujala, International Knee Documentation Committee (IKDC), Lysholm, Tegner, and complications. RESULTS: Across all studies the weighted mean age was found to be an average of 24.5 years, BMI was 24.9 kg/m2, follow-up was 47.3 months, as 67% were female, TT-TG distance was 15.3 mm, and Caton Deschamps index 1.11. The pooled effect size difference of pre versus post assessment of Kujala was -2.8, IKDC was -4.5, Lysholm was -6.4, and Tegner was -0.74. The pooled complication rate was found to be 8% across all included studies. A subgroup analysis was also performed, specifically looking at how single bundle, double bundle, gracilis, semitendinosus and knee angle during fixation effect outcome data. CONCLUSION: This systematic review and meta-analysis demonstrates that isolated MPFL reconstruction is a safe and effective treatment for recurrent patellar dislocations. Given the efficacy of isolated MPFL reconstruction, future investigations should aim to uncover the exact TT-TG distance, trochlear dysplasia, and patella alta grade for selecting patients to undergo this procedure. Furthermore, more primary research needs to be conducted on this topic due to the overall lack of published data from randomized controlled studies and no broad standardization of outcome measurements. LEVEL OF EVIDENCE: (4) Systematic Review and Meta-Analysis.

Loss of FOCAD, operating via the SKI messenger RNA surveillance pathway, causes a pediatric syndrome with liver cirrhosis.

Cirrhosis is usually a late-onset and life-threatening disease characterized by fibrotic scarring and inflammation that disrupts liver architecture and function. While it is typically the result of alcoholism or hepatitis viral infection in adults, its etiology in infants is much less understood. In this study, we report 14 children from ten unrelated families presenting with a syndromic form of pediatric liver cirrhosis. By genome/exome sequencing, we found recessive variants in FOCAD segregating with the disease. Zebrafish lacking focad phenocopied the human disease, revealing a signature of altered messenger RNA (mRNA) degradation processes in the liver. Using patient's primary cells and CRISPR-Cas9-mediated inactivation in human hepatic cell lines, we found that FOCAD deficiency compromises the SKI mRNA surveillance pathway by reducing the levels of the RNA helicase SKIC2 and its cofactor SKIC3. FOCAD knockout hepatocytes exhibited lowered albumin expression and signs of persistent injury accompanied by CCL2 overproduction. Our results reveal the importance of FOCAD in maintaining liver homeostasis and disclose a possible therapeutic intervention point via inhibition of the CCL2/CCR2 signaling axis.

Leg length measures appear inaccurate in the early phase following total hip arthroplasty.

The aims of this study were to (1) assess reliability of leg length discrepancy (LLD) measurements at different anatomical landmarks, (2) longitudinally investigate LLD in patients within the first year following total hip arthroplasty (THA) and to (3) correlate changes in LLD with functional outcome. Ninety-nine patients with short stem THA (53.3% males, mean age: 61.0 ± 8.1 years) were prospectively included. Upright pelvic anteroposterior (a.p.) radiographs taken at 6 timepoints (preoperatively, discharge, 6, 12, 24, 52 weeks postoperatively) were used to assess LLD at 5 anatomical landmarks (iliac crest, upper sacroiliac joint, lower sacroiliac joint, tear drop figure, greater trochanter). WOMAC and Harris Hip Score (HHS) were obtained preoperatively and at 6 and 52 weeks. LLD measures significantly increased in the initial phase following THA, from discharge to 6 weeks postoperatively and remained constant thereafter. Documentation of LLDs is dependent on measurement site: LLDs varied significantly between trochanter and iliac crest to tear drop figure (p < 0.001). Functional assessments did not correlate with the occurrence of LLDs [WOMAC (p = 0.252); HHS (p = 0.798)]. Radiographic assessment of LLD following THA may not be performed early postoperatively, as measurements appear to inaccurately reflect actual LLDs at this time, potentially due incomplete leg extension and/or inhibited weight-bearing.

Femoral Head and Liner Exchange in Patients with Atraumatic Dislocation. Results of a Retrospective Study with 6 Years Follow-Up.

Background and Objectives: Femoral head and liner exchange is an established treatment for polyethylene wear but has had a more limited role in the treatment of other conditions including dislocation, because of concerns about an increased postoperative dislocation rate. Some authors have considered dislocation associated with polyethylene wear to be a contraindication for this procedure. Materials and Methods: Our retrospective review evaluated the outcome of head and liner exchange in a small consecutively operated heterogeneous cohort of 20 patients who presented with dislocation unrelated to trauma, component malposition or component loosening. Of this group, 12 had prior primary total hip arthroplasty, and 8 had prior revision total hip arthroplasty, and included 4 patients with prior revision for dislocation. Mean follow-up was 6 ± 3.5 years (range 1-145 months). Results: Kaplan-Meier analysis revealed a revision-free implant survival from any cause of 80% (confidence interval 95%:64.3-99.6%) at 5 years after head and liner exchange (index surgery). At final follow-up, 83.3% of patients (n = 10) with prior primary total hip arthroplasty and 62.5% of patients (n = 5) with prior revision total hip arthroplasty, had not required subsequent revision for any cause. None (0%) of the primary total hip arthroplasty group and 3 (38%) of the revision arthroplasty group had required revision for further dislocation. Of the eight revision arthroplasty patients, four had a prior revision for dislocation and three of these four patients required further revision for dislocation after index surgery. The fourth patient had no dislocation after index surgery. One additional patient who had prior revision surgery for femoral component fracture suffered dislocation after index surgery, but was successfully treated with closed reduction. Conclusions: In our study population, femoral head and liner exchange was an effective treatment option for patients with prior primary total hip arthroplasty and also for a highly select group of revision total arthroplasty patients with no prior history of dislocation. Femoral head and liner exchange does not appear to be a viable treatment option for patients who have had revision total arthroplasty after prior dislocations.

Is Negative Pressure Wound Therapy with Instillation Suitable for the Treatment of Acute Periprosthetic Hip Joint Infection?

BACKGROUND: Periprosthetic joint infection (PJI) can be devastating for the patient and demanding for the surgeon. In acute PJI, attempts are made to retain the prosthesis by debridement of the infected tissue, targeted antibiotic therapy and an exchange of modular components with implant retention (DAIR). There has been sparse research with adjunctive negative pressure wound treatment with wound irrigation (NPWTI) on the treatment outcome. QUESTIONS/PURPOSES: The goal was to assess the efficacy of our protocol of DAIR with adjunctive NPWTI in acute PJI and to reduce the need for later additional DAIR and Irrigation and Debridement (I and D). PATIENTS AND METHODS: Our cohort of 30 patients (31 hips) with acute PJI was divided into two groups based on symptom presentation up to 6 weeks or >6 weeks from prior (index) surgery (acute early or acute late groups, respectively). All received DAIR with an exchange of modular components and NPWTI with polyhexanide instillation, with the goal of bacterial elimination and biofilm elimination. Postoperatively, the patients were followed up clinically and radiographically for a mean of 4.3 years. RESULTS: Of the 31 PJI hips, 19 were early acute and 12 were late acute. In total, 21 hips had no evidence of residual infection, 10 required further surgical revision: 1 due to dislocation and 9 due to infection. Of these nine, seven had a removal of all the components and two were treated with irrigation and debridement (I and D), with the demise of one patient from pneumonia shortly after the procedure. The Kaplan-Meier 60-month revision free implant survival from infection was 73.2% (CI: 58.9-91.0%) and at the final follow up, the mean Harris Hip Score (HHS) was 81.1 ± 11.8 and the mean WOMAC score was 33.3 ± 20.1. CONCLUSIONS: Our results are in line with those reported in prior studies. However, the utility of our protocol is inconclusive and needs further evaluation based on our small cohort and the lack of a control group. LEVEL OF EVIDENCE: IV.

Promising results after hemi-shoulder arthroplasty using pyrolytic carbon heads in young and middle-aged patients.

INTRODUCTION: The objective of this prospective cohort study was the assessment of short-term outcome results of shoulder hemiarthroplasty (HA) using pyrolytic carbon (PC) heads. PC has been introduced as a new material to avoid surgical revision due to glenoid erosion after HA. Glenoid erosion due to the use of metallic heads is known to reduce durability. HYPOTHESIS: HA using PC heads shows comparable or better radiographic and clinical outcome compared to the conventional HA using metallic heads in the short-term. PATIENTS AND METHODS: This study was conducted as a single center prospective cohort follow-up study including a total number of 16 consecutive HA with PC heads. Inclusion criteria were indication for HA, an intact rotator cuff, no proximal humeral fractures in patient's history and age>18years. Mean age at the time of arthroplasty was 52.8±10.8years. The mean follow-up was 24.3±8.1months. Baseline and follow-up Numeric Rating Scale (NRS), Constant Scores (CS), Range of Motion (ROM) and radiographs were assessed. RESULTS: At a mean follow-up of 24.3months the mean CS (p<0.001), mean NRS (p<0.001) and mean ROM (p<0.05) improved statistically significant. Subgroup analysis revealed no differences between subgroups (sex, age, diagnosis, and handedness). Survival rate was high (94.1%). One periprosthetic fracture occurred as the only complication during follow-up. Radiographs showed glenoid erosion in one case and subacromial space reduction in two cases. DISCUSSION: PC heads in HA show satisfying short-term results at a mean follow-up of two years, which are comparable to those of conventional HA. The clinical improvements were highly significant with good implant survival. However, long-term follow-up results are necessary, especially compared to conventional HA. LEVEL OF EVIDENCE: IV; observational therapeutic cohort study.

3-T T2 mapping magnetic resonance imaging for biochemical assessment of normal and damaged glenoid cartilage: a prospective arthroscopy-controlled study.

This study evaluated the ability of T2 mapping to assess the glenoid cartilage using arthroscopy as the gold standard. Eighteen consecutive patients (mean age: 52.4 ± 14.72 years, including 12 men) with shoulder pain underwent T2 mapping at 3-T with subsequent shoulder arthroscopy. With correlation to cartilage-sensitive morphologic sequences regions-of-interest were placed in the corresponding T2 maps both in normal-appearing cartilage and focal cartilage lesions using a quadrant-wise approach. Inter-reader and intra-reader correlation coefficients (ICCs) between two independent radiologists as well as cut-off values with their sensitivities/specificities for the detection of cartilage damage were calculated. The mean T2 value for healthy cartilage was 23.0 ± 3 ms with significantly higher values in the superior quadrants compared to the inferior quadrants (p < 0.0001). In 5 patients with focal cartilage damage significantly higher T2 values of 44.7 ± 3.7 ms (P < 0.01) were observed. The maximum T2 value in normal cartilage (27.3 ms) was lower than the minimum value in damaged cartilage (40.8 ms) resulting in perfect sensitivities/specificities of 100% (95% confidence-interval 47.8-100.0) for all cut-off values between 27.3-40.8 ms. ICCs ranged between 0.63 and 0.99. In conclusion, T2 mapping can evaluate biochemical cartilage integrity and discriminates arthroscopy-proven healthy and damaged glenoid cartilage with high diagnostic performance.

Scapulohumeral rhythm in patients after total shoulder arthroplasty compared to age-matched healthy individuals.

PURPOSE: The coordination of the glenohumeral joint and the shoulder girdle has been known as scapulohumeral rhythm. The effects of anatomical total shoulder arthroplasty (aTSA) are still subject to research. Former studies showed a higher amount of scapula lateral rotation to compensate for reduced glenohumeral elevation. The purpose of the present study was to confirm this mechanism and examine additional effects on the sternoclavicular and acromioclavicular joints' kinematics. METHODS: 3D motion analysis was used to examine 23 shoulders of 16 patients with a mean age of 71.2 (SD: 5.2) years with a mean follow up of 5.4 (SD: 2.1) years after aTSA and to compare kinematics and coordination to 22 shoulders of 11 healthy age-matched individuals with a mean age of 69.6 (SD: 5.3) years while performing elevation movement in frontal and sagittal plane. RESULTS: The ratio of glenohumeral to shoulder girdle contribution was reduced compared to healthy individuals: Shoulder girdle contribution to elevation was 36.5% (SD: 8.1) in the aTSA group vs. 28.5% (SD: 8.2) in the control group in the sagittal plane and 38.1% (SD: 9.1) vs. 30.2% (SD: 7.1) in the frontal plane. Kinematics of the sternoclavicular and acromioclavicular joints showed significantly different patterns. CONCLUSION: Patients after aTSA showed altered shoulder girdle kinematics and higher contribution of the shoulder girdle towards elevation. Whether this is a result of the surgery, of limited glenohumeral range of motion or due to the preoperative status remains unclear. Further investigation with a prospective study design is necessary.

Blood Management in Revision Total Hip Arthroplasty for Metal-on-Metal Devices: The Efficiency of an Intraoperative Cell Salvage System.

BACKGROUND: The aim of this series was to investigate the efficiency of an intraoperative cell salvage system (ICS) removing metal ions during revision of metal-on-metal (MoM) devices to proof the possibility of re-transfusion of the collected blood. MATERIALS AND METHODS: Between 2014 and 2018, five consecutive patients underwent revision surgery of their MoM total hip arthroplasty due to wear of the polyethylene-metal sandwich inlay or local massive metallosis with aseptic loosing of the cup. Aspiration of joint fluid of all hip prostheses was done and blood was taken to measure the metal ion concentrations, preoperatively. Perioperatively, blood was collected using an ICS before and after filtration and analyzed for Co and Cr concentrations. At that time, there was no re-transfusion of the collected and filtrated blood due to unknown metal ion concentrations. RESULTS: The mean preoperative serum Co and Cr concentrations in the blood were 31.28 µg/L (range 0.22-77.47) and 17.33 µg/L (range 0.59-51.31), whereas the mean local concentrations in the aspiration fluid were 728-fold and 822-fold higher. The Co and Cr concentrations measured in the collected blood before filtration were 70.61 µg/L (range 9.40-173.00) and 337.21 µg/L (range 8.76-1383.0) and decreased markedly to average concentrations of 15.49 µg/L and 41.88 µg/L, respectively. These differences were statistically not significant (Co: p = 0.117, Cr: p = 0.175), although the mean reduction rates were 78% and 88% for Co and Cr, respectively. CONCLUSION: The current series showed that in case of revision of MoM hip devices, metal ions are still contained in the collected blood following filtration using a modern high-level ICS. Therefore, we would only recommend blood re-transfusion in case of low preoperative Co and Cr concentrations and sufficient renal function to warrant patients' safety.

Mid-term to long-term results of primary arthroscopic Bankart repair for traumatic anterior shoulder instability: a retrospective study.

BACKGROUND: The arthroscopic method offers a less invasive technique of Bankart repair for traumatic anterior shoulder instability. The aim of the study is to determine the mid-/long-term functional outcome, failure rates and predictors of failure after primary arthroscopic Bankart repair for traumatic anterior shoulder instability. METHODS: A total of 100 patients were primarily operated using arthroscopic Bankart repair after traumatic anterior shoulder instability. Medical records were retrospectively reviewed, and patients were assessed using postal questionnaire after a mean follow-up of 8.3 years [3-14]. Clinical assessment was performed using Constant score, Rowe score, and American Shoulder and Elbow Surgeons score. RESULTS: The overall recurrence rate was 22%. The Kaplan-Meier failure-free survival estimates. were 80% at 5 years and 70% at 10 years. Nearly half (54.5%) of recurrences occurred at 2 years postoperative. Compared with normal shoulder, there were statistical differences in all 3 scores. Failure rate was significantly affected by age at the time of surgery with 86% of recurrence cases observed in patients aged 30 years or younger. Nevertheless, Younger age at the time of surgery (P = 0.007) as well age at the time of initial instability (P = 0.03) was found to correlate negatively with early recurrence within 2 years of surgery. Among those with recurrent instability, recurrence rate was found to be higher if there had been more than 5 instability episodes preoperatively (P = 0.01). Return to the preinjury sport and occupational level was possible in 41 and 78%, respectively. CONCLUSION: Failure-free survival rates dropped dramatically over time. Alternative reconstruction techniques should be considered in those aged ≤30 years due to the high recurrence rate.

Does the degree of osteoarthritis influence the clinical outcome after anatomic total shoulder arthroplasty?

BACKGROUND: The degree of preoperative osteoarthritis has been shown to influence the postoperative outcome and the patients' satisfaction rate in hip and knee joint replacement surgery. However, no corresponding information is available for total shoulder arthroplasty (TSA). We therefore set out to evaluate the influence of preoperatively measured end-stage osteoarthritis on the postoperative clinical outcome of TSA. METHODS: A retrospective analysis of 103 anatomic total shoulder replacements (96 patients) was performed. Patients were evaluated radiologically with X-rays in two planes and clinically using the Constant and Murley score (CS) and the self-reported satisfaction with the result. The degree of osteoarthritis was radiographically analyzed with the aid of the classifications according to Kellgren/Lawrence, Gerber, Guyette, and Allain and according to whether complete narrowing of the glenohumeral joint was present or not [bone-on-bone contact (BOB) or no bone-on-bone contact (No BOB)]. RESULTS: The clinical results of TSA did not differ significantly among the various stages of osteoarthritis in any of the classifications (p > 0.05). The CS was significantly higher postoperatively for both the BOB and the No BOB group (p < 0.0001). Patients with BOB had a significantly lower CS preoperatively than patients with No BOB (p = 0.0172). In addition, the preoperative pain level was significantly higher in patients with BOB (p = 0.014). Postoperatively, no significant difference in CS (p = 0.6738) was found between the BOB group and the No BOB group. The mean improvement in CS was not statistically significant (p = 0.2218). CONCLUSION: In contrast to hip and knee joint replacement procedures, a milder grade of osteoarthritis does not adversely influence the functional result or subjective satisfaction rate after TSA. The degree of osteoarthritis on conventional X-rays has no bearing on the postoperative clinical outcome. Therefore, the decision on when to carry out anatomic total shoulder arthroplasty should depend on the patient's pain level and loss of quality of life.

3D motion analysis of latissimus dorsi tendon transfer in patients with posterosuperior rotator cuff tears: Analysis of proprioception and the ability to perform ADLS.

BACKGROUND: Massive irreparable posterosuperior rotator cuff tears may result in a loss of external rotation. Most of these patients lose their ability to perform activities of daily living (ADLs), especially where external rotation and abduction are needed. Latissimus dorsi tendon transfer (LDTT) is a method to restore abduction and external rotation in patients with posterosuperior rotator cuff tears. There are no objective data concerning whether LDTT can restore range of motion (ROM), especially in performing ADLs and if proprioception changes after LDTT. METHODS: We examined 12 patients 4.2 years (1-9 years) after LDTT with simultaneous 3D motion analysis; the opposite, nonaffected side was assessed as control. The measurement protocol included maximum values in flexion/extension, abduction/adduction, internal/external rotation in 0° and in 90° flexion and in 90° abduction. To evaluate competences, we measured seven activities of daily life and examined the proprioceptive ability using an active angle reproduction test. RESULTS: In total, 4.2 years (1-9 years) after LDTT there was no significant difference in flexion/extension and abduction/adduction compared to the healthy side. Maximum external rotation was significantly reduced compared to the opposite side. Eleven patients (85%) were able to perform all ADL. Proprioceptive ability did not differ from the healthy side. CONCLUSION: LDTT cannot fully restore a patient's ability for external rotation after a posterosuperior rotator cuff tear. However, 4.2 years after surgery, 85% of the patients are able to perform all ADLs. Proprioceptive ability is not affected by the transfer.

Variation of the glenohumeral and scapulothoracic motion in progressive severity of glenohumeral osteoarthritis.

INTRODUCTION: The aim of this study is to investigate the variation of the glenohumeral and scapulothoracic motion in progressive severity of glenohumeral osteoarthritis using a 3-D-motion analysis. Moreover, the variation of the Constant Score is evaluated. HYPOTHESIS: The hypothesis is that the motion of the scapulothoracic joint may partly compensate for the loss of the glenohumeral joint movement in patients with increasing severity of glenohumeral osteoarthritis. MATERIAL AND METHODS: A total of 21 patients with primary osteoarthritis of the glenohumeral joint were clinically examined, divided in three groups (SP1-SP3) according to size of their caudal osteophyte. The contribution of the scapulothoracic (acromioclavicular and sternoclavicular) joint to the total arm (humerothoracical) elevation in sagittal and frontal plane was measured with 3D motion analysis and the Constant Score was evaluated. DISCUSSION: In sagittal plane elevation (anteversion) the contribution of the scapulothoracic joint to the total elevation was while arm raising 32.7% (SD 8.0%) in Group SP1, 36.6% (SD 11.0%) in Group SP2 and 49.6% (SD 9.0%) in Group SP3 (p=0.002). The contribution of the scapulothoracic joint to the total elevation while arm lowering was 31.4% (SD 9.0%) in Group SP1, 39.0% (SD 13.0%) in Group SP2 and 49.7% (SD 12.0%) in Group SP3 (p=0.043). In frontal plane elevation (abduction) the contribution of the scapulothoracic joint was while arm raising 33.7% (SD 8.0%) in Group SP1, 34.0% (SD 10.0%) in Group SP2 and 42.3% (SD 9.0%) in Group SP3 (p=0.071). While arm lowering the contribution of the scapulothoracic joint was 30.8% (SD 10.0%) in Group SP1, 36.3% (SD 12.0%) in Group SP2 and 44.8% (SD 8.0%) in Group SP3 (p=0.022). The group SP1 achieved a Constant Score of 78.00 (SD 9.823) points. The group SP2 achieved a Constant Score of 53.57 (SD 13.92) and the group SP3 38.64 (SD 10.40). There is a significant difference between the three groups (p<0.001). Increasing severity of glenohumeral osteoarthritis leads to a reduced motion of the glenohumeral joint. Instead the magnitude of the scapulothoracic motion increases. LEVEL OF PROOF: V, Case Series.

Fifty-six percent of proximal femoral cortical hypertrophies 6 to 10 years after Total hip arthroplasty with a short Cementless curved hip stem - a cause for concern?

BACKGROUND: Thigh pain and cortical hypertrophies (CH) have been reported in the short term for specific short hip stem designs. The purpose of the study was to investigate 1) the differences in clinical outcome, thigh pain and stem survival for patients with and without CHs and 2) to identify patient and surgery-related factors being associated with the development of CHs. METHODS: A consecutive series of 233 patients with 246 hips was included in the present retrospective diagnostic cohort study, who had received a total hip arthroplasty (THA) between December 2007 and 2009 with a cementless, curved, short hip stem (Fitmore, Zimmer, Warsaw, IN, USA). Clinical and radiographic follow-up, including the radiographic parameters for hip geometry reconstruction, were prospectively assessed 1, 3, and 6 to 10 years after surgery. RESULTS: Cortical hypertrophies were observed in 56% of the hips after a mean of 7.7 years, compared to 53% after 3.3 years being mostly located in Gruen zone 3 and 5. There was no significant difference for the Harris Hip Score and UCLA score for patients with and without CHs. Only one patient with a mild CH in Gruen zone 5 and extensive heterotopic ossifications around the neck of the stem reported thigh pain. The Kaplan Meier survival rate after 8.6 years was 99.6% (95%-CI; 97.1-99.9%) for stem revision due to aseptic loosening and no association with CHs could be detected. Postoperative increase in hip offset was the only risk factor being associated with the development of CHs in the regression model (ΔHO; OR 1.1 (1.0-1.2); p = 0.001). CONCLUSIONS: The percentage of cortical hypertrophies remained almost constant in the mid-term compared to the short-term with the present cementless short hip stem design. The high percentage of cortical hypertrophies seems not be a cause for concern with this specific implant in the mid-term. LEVEL OF EVIDENCE: Diagnostic Level IV.

Mid-term results with an anatomic stemless shoulder prosthesis in patients with primary osteoarthritis.

OBJECTIVE: The introduction of a stemless prosthesis in shoulder arthroplasty represents a novel design whereby the proximal humerus is restored anatomically, while leaving the diaphysis of the humerus untouched. The aim of this study was to present the mid-term results of total evolutive shoulder system (TESS; Biomet®), a stemless shoulder prosthesis. METHODS: The study included 38 consecutive patients (18 men and 20 women; mean age: 66 years; range: 55-81 years) treated with shoulder arthroplasty between 2009 and 2011 with TESS for primary glenohumeral arthritis. Total shoulder arthroplasty (TSA) was performed in 28 cases (74%), hemi-shoulder arthroplasty (HSA) in 10 (26%). Constant score, active range of motion, patient satisfaction rate, and radiological assessment were analyzed. Mean time of follow-up was 37 months. RESULTS: Constant score improved from 21.8 points (28.6 adjusted for age) preoperatively to 74.1 points (86.6 adjusted for age) postoperatively. Active range of motion increased significantly from the pre- to postoperative status. Eighty-nine percent were very satisfied or satisfied with shoulder replacement surgery. One cemented glenoid was revised due to aseptic loosening. None of the components were found to be loose at the final follow-up. No signs of stress shielding were seen. CONCLUSIONS: This study shows promising results of this implant concept in the short- to mid-term. These results are comparable with the results achieved with long-established arthroplasty designs. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Size of ischial fibro-ostosis is associated with heterotopic ossification after total hip arthroplasty.

PURPOSE: The hypothesis of the present study was that degenerative fibro-ostosis (FO) of the ischial hamstring tendon insertion is a risk factor for heterotopic ossification (HO) following THA. METHODS: We followed 103 consecutive patients (43 males, 60 females, mean age 61 years) who underwent unilateral cementless THA for primary hip osteoarthritis and investigated the incidence of HO within the first 12 months after surgery. On pre-operative radiographs, a standardized evaluation for FO of the ischial hamstring tendon insertion concerning horizontal, vertical, and square dimensions was performed. HO was classified according to Brooker on radiographs at 12 months post-operatively. RESULTS: At follow-up, 56 patients (54%) had no radiographic evidence of HO, 23 (22%) were classified as Brooker I, 17 (17%) as II, 6 (6%) as III, and 1 (1%) as IV, respectively. Patients with post-operative HO had significantly greater vertical (3.0 mm vs. 2.3 mm, p = 0.001) and horizontal (47.9 mm vs. 39.1 mm, p = 0.025) dimensions of FO than patients without HO. Patients with FO and a vertical dimension of ≥ 2.5 mm were more likely to develop HO (55.6%) than patients with a vertical FO dimension of less than 2.5 mm (34.7%, OR = 2.35 p = 0.047). A weak correlation between the vertical and horizontal size of FO and the severity of HO was observed. CONCLUSION: Radiographic evidence of asymptomatic FO is a potential risk factor for the development of HO following THA and may be used as a simple diagnostic tool to pre-operatively identify patients at risk for post-operative HO. This association has not been previously described and further research to confirm the present findings and to justify additional prophylactic treatment in these patients is warranted.

Hemodynamic Assessment Before and After Endovascular Therapy for Critical Limb Ischemia and Association With Clinical Outcomes.

OBJECTIVES: This study sought to determine the relationship between change in ankle-brachial index (ABI) and toe-brachial index (TBI) and outcomes following revascularization of critical limb ischemia (CLI). BACKGROUND: An increase in ABI of 0.15 after revascularization for peripheral artery disease with claudication is considered significant. However, the utility of using change in ABI or TBI to predict outcomes in patients with CLI is unproven. METHODS: This was an observational study of 218 patients with Rutherford class V or VI CLI that underwent endovascular therapy. Receiver-operating characteristic curve analysis determined cutpoints in post-procedure ABI and TBI, as well as change in these values for endpoints of wound healing, major adverse limb events (MALE), and repeat revascularization. RESULTS: After multivariable Cox proportional hazards analysis adjusting for age, diabetes, glomerular filtration rate, smoking, Rutherford class, and baseline ABI or TBI, neither static post-procedure ABI nor post-procedure TBI were associated with wound healing (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 0.77 to 1.89; p = 0.40; HR: 1.49; 95% CI: 0.98 to 2.27; p = 0.065, respectively). However, change in ABI ≥0.23 was independently associated with wound healing (HR: 1.87; 95% CI: 1.12 to 3.15; p = 0.018) and less repeat revascularization (HR: 0.40; 95% CI: 0.19 to 0.84; p = 0.015), but not MALE. Increase in TBI ≥0.21 was independently associated with wound healing (HR: 1.63; 95% CI: 1.02 to 2.59; p = 0.039), and reduced MALE (HR: 0.27; 95% CI: 0.09 to 0.77; p = 0.014), but not repeat revascularization. CONCLUSIONS: A change in ABI and TBI from pre-procedural values provides prognostic value in determining which patients may have wound healing and reduced MALE.

Three-dimensional motion analysis for validation of shoulder internal rotation.

BACKGROUND: 10% of the points for the Constant-Murley score (CMS) are allocated for the capacity for internal rotation (IR), measured as unassisted active movement of the dorsum of the hand or the thumb to reach different anatomical landmarks. However, there is little information about the validity of this method and no three-dimensional measurement of the degree of IR that is necessary to reach these landmarks. METHODS: Sixteen volunteers with healthy shoulders were recruited. The degree of IR was defined using the following landmarks as described in the CMS: (1) lateral aspect of thigh, (2) buttock, (3) sacroiliac joint, (4) level of waist, (5) vertebra T12, (6) interscapular. The validity of IR measurement was assessed by simultaneous 3D motion analysis. RESULTS: Using the thumb as pointer, there were significant increases in IR from 39.3° at position 1 to 80.4° at position 2, followed by 105.1°, 108.6°, 110.1°, and 125.3° at position 3-6. Taking the dorsum of the hand as pointer, there were significant increases in IR between all positions, starting from 71.2° (position 1) and followed by 99.3°, 104.1°, 110.3°, 115.2°, and 119.7° at positions 2 to 6. Comparing the two measurement methods, a significant difference was found for the amount of IR between positions 1 and 2. CONCLUSION: Measurement of IR as described in the CMS is a suitable method. However, there was an increase of only 10° in IR between positions 3 and 5, which may be hard to measure with a standard goniometer in clinical practice.