Outcomes of Total Shoulder Arthroplasty With Posterior Capsular Plication.

BACKGROUND: Glenoid loosening and instability are among the most common complications after anatomic total shoulder arthroplasty (TSA), resulting in poor function. Posterior instability is one contributing factor. The purpose of this study is to report the clinical and radiographic outcomes of a series of patients treated with posterior capsule plication for intraoperative posterior instability during TSA. It is hypothesized that patients undergoing this procedure will have improvement in posterior stability intraoperatively while not limiting their ROM postoperatively. METHODS: Patients of the senior author were identified who had undergone TSA with posterior capsule plication from 2014 to 2015 based on Current Procedural Terminology (CPT) codes. Their records and preoperative radiographs were retrospectively reviewed for demographic data and preoperative range of motion (ROM) which was documented in the clinic notes. Patients were then evaluated postoperatively to determine the outcomes after TSA with posterior capsule plication. Final follow-up was conducted via telephone survey. RESULTS: Nineteen patients were identified for review; however, only 14 had all imaging available. The mean age at the time of surgery was 63 years. There were 2 A1, 6 B1, and 6 B2 Walch-type glenoids based on preoperative imaging. All but one had equivalent or better ROM for active forward elevation and external rotation postoperatively. One patient required return to operating room at 5 months after developing adhesive capsulitis. CONCLUSION: This study indicates that the use of posterior capsule plication during TSA is a safe method to address posterior subluxation, while still allowing for improved ROM postoperatively.

Native join Propionibacterium septic arthritis.

Propionibacterium species are associated with normal skin flora and cultures may be dismissed as contaminants. They are increasingly recognized as a cause of septic arthritis following shoulder arthroplasty and arthrotomy. We identified three cases of Propionibacterium septic arthritis in native joints mimicking atypical osteoarthritis and review the literature, clinical course, and treatment of 18 cases. Two cases of Propionibacterium acne in native knee joints and one in a sternoclavicular joint are described. A literature search for Propionibacterium septic arthritis was performed. Clinical course, treatment, and outcome are reviewed for all cases. Our three cases were combined with 15 cases from the literature. Fourteen cases showed few signs of acute infection, slow culture growth, and delayed diagnosis. In 3 cases an early culture was dismissed as a contaminant. Six cases were reported as caused by recent arthrocentesis. Fifteen cases were cured with antibiotics, although 5 of these 15 also required surgical intervention. Two patients were diagnosed while undergoing surgery for osteoarthritis. Four patients required arthroplasty and two of our patients will require arthroplasty for good functional results. Propionibacterium as a cause of septic arthritis in native joints demonstrates few signs of acute infection, presents with prolonged course, and is often misdiagnosed or unsuspected. Anaerobic growth may be delayed or missed altogether, and outcomes are consequently poor. Consider Propionibacterium septic arthritis in atypical osteoarthritis prior to arthroplasty.

Patient-Reported Outcomes After Revision of Metal-on-Metal Total Bearings in Total Hip Arthroplasty.

BACKGROUND: Failure of metal-on-metal (MOM) total hip arthroplasty (THA) bearings is often accompanied by an aggressive local reaction associated with destruction of bone, muscle, and other soft tissues around the hip. Little is known about whether patient-reported physical and mental function following revision THA in MOM patients is compromised by this soft tissue damage, and whether revision of MOM THA is comparable with revision of hard-on-soft bearings such as metal-on-polyethylene (MOP). METHODS: We identified 75 first-time MOM THA revisions and compared them with 104 first-time MOP revisions. Using prospective patient-reported measures via the Veterans RAND-12, we compared Physical Component Score and Mental Component Score function at preoperative baseline and postoperative follow-up between revision MOM THA and revision MOP THA. RESULTS: Physical Component Score did not vary between the groups preoperatively and at 1 month, 3 months, and 1 year postoperatively. Mental Component Score preoperatively and 1 and 3 months postoperatively were lower in patients in the MOM cohort compared with patients with MOP revisions (baseline: 43.7 vs 51.3, P < .001; 1 month: 44.9 vs 53.3, P < .001; 3 months: 46.0 vs 52.3, P = .016). However, by 1 year, MCS scores were not significantly different between the revision cohorts. CONCLUSION: Postrevision physical function in revised MOM THA patients does not differ significantly from the outcomes of revised MOP THA. Mental function is markedly lower in MOM patients at baseline and early in the postoperative period, but does not differ from MOP patients at 1 year after revision. This information should be useful to surgeons and physicians facing MOM THA revision.

Use of the spider limb positioner in oncologic lower extremity surgery.

Orthopedic extremity surgery presents a unique set of restraints and difficulties relative to other surgical specialties. Among these is the positioning of heavy limbs in sometimes awkward positions for long periods of time. Ideal positioning of an extremity allows accurate and precise surgery to occur at otherwise difficult to access joints and proximal bones and soft tissues. Numerous solutions to this problem have been proposed, one such solution is the Smith and Nephew Spider Limb Positioning System. The table-mounted pneumatic arm features three fully articulating joints and a simple repositioning mechanism. Classic uses of the Spider Limb Positioner System include shoulder and elbow surgery, total knee replacement and ankle procedures. In our institution, the Spider Limb Positioner is used primarily for shoulder arthroscopy and total shoulder arthroplasty. In addition, we have had success using the system for orthopedic oncology cases. This manuscript addresses the conventional as well as unconventional uses implemented at our institution. Limb positioning in orthopedics provides a unique challenge for prepping, draping and surgery. The use of positioning aids can improve exposure, decrease contamination and reduce the risk of surgeon strain. Our institution has developed a solution to positioning of heavy lower limbs for hip disarticulation via the Smith and Nephew 'Spider'. This pneumatic, full articulating device used primarily for shoulder surgery can be modified to allow lower extremity use in the setting of hip disarticulation. This paper describes the standard and novel use of this device.

Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review.

BACKGROUND: Displaced proximal humeral fractures have traditionally been treated with hemiarthroplasty in older adults, but sometimes hemiarthroplasty results in poor functional outcomes due to rotator cuff deficiency. Reverse shoulder arthroplasty (RSA) can offer potentially improved outcomes in these situations. We assessed the functional outcomes of older adults treated with RSA for proximal humeral fractures compared with hemiarthroplasty. METHODS: We searched MEDLINE, the Cochrane Central Register of Controlled Trials, EMBASE, and 3 clinical trials registries. We included all studies treating proximal humeral fractures with RSA in adults with a mean age older than 60 years and 1 year of follow-up. We calculated weighted mean differences (WMD) for range of motion and standardized mean differences (SMD) for shoulder scores. Postoperative complications were evaluated qualitatively. RESULTS: Fifteen studies met inclusion criteria, including 377 patients treated with RSA and 504 patients treated with hemiarthroplasty. In controlled studies, the RSA group had improved forward flexion (WMD, 21°;, P = .02) and functional outcome scores (SMD, 0.44; P = .005) compared with the hemiarthroplasty group but decreased external rotation (WMD, -5°; P < .0001). Postoperative complications were similar between the 2 groups. CONCLUSION: RSA results in improved forward flexion and functional outcome scores compared with hemiarthroplasty for older adults with proximal humeral fractures. Complications do not appear to be appreciably higher in the RSA group in the existing follow-up. The results of this review suggest that RSA is a reasonable alternative for treating older adults with proximal humeral fractures, but more research and longer follow-up are needed. LEVEL OF EVIDENCE: Level IV, systematic review.

Demographic differences in adolescent-diagnosed and adult-diagnosed acetabular dysplasia compared with infantile developmental dysplasia of the hip.

BACKGROUND: Acetabular dysplasia is a common cause of hip pain that can lead to premature osteoarthritis. This study explores whether demographic characteristics of patients diagnosed with acetabular dysplasia in adolescence and adulthood [adult-diagnosed dysplasia (AD)] differ from those who are diagnosed with developmental dysplasia of the hip (DDH) in infancy. METHODS: Database review identified 633 patients undergoing periacetabular osteotomy for dysplasia from August 1991 to January 2008. Excluding patients with syndromal conditions and 80 lacking contact information, 421 patients received a questionnaire regarding birth and family history; 324 (70.3%) completed the survey. Thirteen were excluded because of unrelated hip conditions, leaving 311 patients for analysis. RESULTS: Respondents were divided into 2 groups according to whether they had a history of DDH in infancy (102 patients) or were diagnosed in adolescence/adulthood (209 patients). Statistically significant differences (P < 0.05) were found in sex distribution (female: DDH = 98.0%, AD = 88.0%), affected limb (left hip: DDH = 33.3%, AD = 19.1%), bilaterality (DDH = 45.1%, AD = 61.2%), and breech presentation (DDH = 25.3%, AD = 9.4%). Over 50% of all the respondents had a family history of hip disease; over 40% were first-order relatives. First-order family members of patients with AD had a higher incidence of hip replacement by the age of 65 (50.0% vs. 22.7%). Patients with DDH were more likely to have first-order family members with DDH (59.0% vs. 15.8%). CONCLUSIONS: This study confirms demographic differences between patients diagnosed with hip dysplasia in infancy versus adolescence/adulthood and supports the hypothesis that these represent distinct forms of dysplasia. In both, there is a familial tendency toward hip disease with a higher incidence of arthroplasty in the AD group's family members and higher frequency of infantile dysplasia in the DDH group's family members. CLINICAL RELEVANCE: Infantile DDH is diagnosed with neonatal examination and patients are routinely followed into adolescence. Adolescent/adult AD is not detected until symptoms develop. Further study is needed to determine whether younger family members of patients with hip osteoarthritis should be screened to detect potentially at-risk hips.