Glenohumeral osteoarthritis: frequency of underlying diagnoses and the role of arm dominance-a retrospective analysis in a community-based musculoskeletal practice.

Patients with shoulder pain are commonly seen in adult primary care, and are typically referred to musculoskeletal specialists when their symptoms are persistent. Rotator cuff disorders (RCD) most commonly underlie non-traumatic shoulder pain in adults, and glenohumeral osteoarthritis (GHOA) has been considered to be relatively uncommon (Nakagawa et al., J Shoulder Elb Surg 8:580-584, 1999). Our impression has been that GHOA affects significant numbers of patients, is less well studied, and may be under recognized. Among adults referred to a musculoskeletal practice for shoulder pain evaluation, we determined the relative numbers of patients with a clinical diagnosis of RCD and GHOA by age and by gender, assessed the role of handedness in GHOA, and the proportion of patients with underlying conditions (versus primary or idiopathic GHOA). We also assessed the frequency of progression to operative management over a defined time interval. This is a retrospective case series of patients presenting to a musculoskeletal referral practice for shoulder pain. Patients with a clinical diagnosis of GHOA were identified with electronic medical records, and then assessed for demographic data, physical measures, comorbidities, and progression to surgical intervention within 2 years. Among non-traumatic shoulder pain patients presenting to our practice during a 9-month period in 2013, RCD was diagnosed in 984 patients, and GHOA was diagnosed in 209 patients. 152 of the GHOA patients (73%) had primary (idiopathic) GHOA, without associated inflammatory conditions or cuff arthropathy. Primary GHOA affected the dominant arm in 38.7%, the non-dominant arm in 33.8%, and was bilateral in 27.5%. Patients diagnosed with primary GHOA were older than those with RCD (69.8 ± 12.2 vs 57.1 ± 15.1; p = 0.0001). Women represented 54% of cases of primary GHOA, and their presentation age was older than men (72.9 ± 11.2 vs 66.1 ± 12.4; p = 0.0005). Primary GHOA patients had a mean BMI of 31.0 ± 6.3, 48.7% had hyperlipidemia and 57.2% had hypertension. 24.3% were treated surgically within 2 years of follow-up. GHOA is a significant cause of shoulder pain in older age groups, and the majority of these patients have primary (idiopathic) GHOA. Primary GHOA affects dominant and non-dominant arms at similar rates, suggesting that anatomical and/or systemic factors are more important than overuse in GHOA pathogenesis. Given the prominence of GHOA in older age groups, changes in population demographics, and limitations of non-operative treatment, continued increases in shoulder replacement surgery are likely. Efforts to further understand GHOA pathogenesis and develop new, more effective therapies are advocated.

Arthroscopic Partial Trapeziectomy With Soft Tissue Interposition for Symptomatic Trapeziometacarpal Arthritis: 6-Month and 5-Year Minimum Follow-Up.

PURPOSE: To determine if arthroscopic partial trapeziectomy (APT) and soft tissue interposition arthroplasty is an effective treatment for symptomatic trapeziometacarpal arthritis. METHODS: We retrospectively evaluated 30 consecutive patients with symptomatic isolated trapeziometacarpal arthritis, Eaton-Littler stages II and III. Treatment consisted of an APT with soft tissue interposition utilizing an acellular dermal matrix as the interposition material. At a minimum of 6 months and 5 years after surgery, Numeric Pain Rating Scale (NPRS), Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH), grip strength, oppositional and appositional pinch strengths, arthroplasty space, and thumb range of motion (ROM) were evaluated. RESULTS: At 6-month minimum follow-up, 30 of 30 patients reported a significant reduction in pain; preoperative NPRS averaged 8.2 and decreased to 1.3. Average QuickDASH score was 17.5. Twenty-nine of 30 thumbs could adduct fully in the plane of the palm. Twenty-four patients were available for 5-year minimum follow-up. Average QuickDASH score measured 8.9, whereas pain (mean NPRS, 0.8), grip, and pinch strengths were not significantly different from the 6-month assessment. There was a small reduction in arthroplasty space at 5-year follow-up that did not affect clinical outcome measures. Thumb ROM did not change between the 6-month and the 5-year follow-up. Complications were rare. CONCLUSIONS: An APT with interposition arthroplasty utilizing an acellular dermal matrix as the interposition material is a safe and reliable procedure with satisfactory outcomes at short- and long-term follow-up. Pain, strength, QuickDASH, and ROM do not significantly change between the 6-month and the 5-year follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arthroscopic versus open irrigation and debridement in native knee septic arthritis: A retrospective review.

Introduction: Native knee septic arthritis is a rare condition with a potential for high morbidity if not promptly treated. Treatment involves surgical decompression of the affected joint along with systemic antibiotic therapy. The purpose of this study is to compare arthroscopic versus open irrigation and debridement for treatment of native knee septic arthritis. Methods: A retrospective review was conducted at a single academic institution of all patients treated for native knee septic arthritis from January 2007 until August 2018 utilizing ICD and CPT codes. Patient demographics, type of surgical procedure, need for reoperation, laboratory values, length of stay, and comorbidities were compared. Results: A cohort of sixty-six patients who underwent 85 surgeries were included. Among these surgeries, 52 (61%) were arthroscopic while 33 (39%) were open arthrotomies, and 21% required more than one operation. While not statistically significant, the odds of reoperation was higher for those that underwent arthroscopic compared to open irrigation and debridement on univariable (OR = 4.05, p = .08) and multivariable analysis (OR = 4.39, p = .10). Additionally, patients were more likely to require a longer hospital stay if they initially underwent arthroscopic rather than open debridement (RR = 1.31, p = .02). Conclusion: Native knee septic arthritis can be treated with a single surgery in the majority of cases. In our sample, there was an increased odds of reoperation in those treated arthroscopically compared to open, though this finding was not statistically significant. We found longer length of stay for patients undergoing arthroscopic rather than open irrigation and debridement - even after controlling for multiple operations, culture status, sex, age, and comorbidities.

Treatment Trends in Pediatric Trigger Thumb Among Hand Surgeons, Pediatric Orthopedic Surgeons, and Pediatric Hand Surgeons.

BACKGROUND: The appropriate initial management of pediatric trigger thumb (PTT) remains controversial. Some providers advocate for prolonged nonoperative management, whereas others may offer surgical release to provide a reliable and expedient resolution. The goal of this study was to elucidate the practice patterns of surgeons with different fellowship training who treat patients with PTT. We hypothesized that an association between surgeon specialty training and treatment algorithm would be identified. METHODS: A cross-sectional survey was sent to mailing lists of 3 professional organizations whose members represent most providers caring for pediatric hand patients. Respondents were asked their training background and treatment recommendations for several clinical scenarios. Responses were compared across subspecialties. RESULTS: Of the respondents, 444 completed a fellowship in hand surgery, 167 completed a pediatric orthopedic fellowship, and 155 completed an additional congenital hand fellowship. Providers with hand fellowship training were more likely to offer surgical intervention as a first-line treatment for a 3-year-old patient with a flexible trigger thumb than those who completed a pediatric orthopedic fellowship (P = .001), and more likely to offer surgical intervention to a 3-year-old patient with an intermittent (P = .007), painful (P = .015), or locked (P = .012) trigger thumb than those providers who completed additional training in congenital hand surgery. No statistically significant differences in practice patterns were appreciated for children aged 6 and 18 months. CONCLUSION: Variability was appreciated in practice patterns for initial treatment recommendation for a patient presenting with PTT. Subspecialty training does appear to affect treatment recommendations for clinical scenarios involving a 3-year-old patient with PTT, although this trend is not observed when treating younger patients.

Jones Fracture: A Late Sequelae of Undercorrected or Recurrent Congenital Talipes Equinovarus: A Report of 2 Cases.

CASE: We present 2 cases in which patients previously treated for congenital talipes equinovarus (CTEV) presented with residual cavovarus deformity and lateral foot pain and were found to have Jones fractures. Both patients were indicated for surgical correction of their residual cavovarus deformity, although neither elected to proceed. These 2 patients were treated conservatively for their fractures with cast immobilization. At the final follow-up, both were clinically and radiographically healed. CONCLUSION: Residual cavovarus foot deformities after the treatment of CTEV are at risk for proximal fifth metatarsal or Jones fractures. Although conservative management may lead to healing of these fractures, the underlying stresses persist after conservative management increasing the risk for recurrent fracture. Correction of the residual deformity should be the main goal.

Extremity Pressure in Splints Wrapped With an Elastic Bandage Versus Bias Cut Stockinette: An Experimental Model.

BACKGROUND: Many variables affect the pressure caused by splinting or casting. The purpose of this study was to compare pressure underlying a splint wrapped with either an elastic bandage or a bias cut stockinette. METHODS: Thirty-two plaster volar resting splints were applied to a simulated extremity with a saline bag secured to it. A pressure transducer was connected to the saline bag to monitor changes in pressure once splints were applied, and 15 mL increments of saline were added to the bag to simulate swelling. Each dressing type was tested with normal application and tight application. RESULTS: Normal application splints wrapped with either bias cut stockinette or an elastic bandage demonstrated similar initial splint pressures (P = .81). With simulated swelling, splints wrapped with bias cut stockinette demonstrated a 15 mmHg (95% confidence interval [CI], 1.5-28.5) higher average pressure than those wrapped with an elastic bandage (P = .035). Tight application splints with an elastic bandage wrap demonstrated a 46 mmHg (95% CI, 16-77) higher initial splint pressure than those wrapped with bias cut stockinette (P = .009). CONCLUSIONS: Splints wrapped using either an elastic bandage or bias cut stockinette appear to have a similar safety profile, although in cases of excessive swelling, an elastic bandage may provide additional compliance. Tight splint application appears to be more hazardous with the use of an elastic bandage compared with a bias cut stockinette. Further study of the use of elastic bandages and bias cut stockinettes in the clinical setting may be warranted.

The Long Head of the Biceps Myotendinous Junction Is Located 1.14 Centimeters Distal to the Proximal Border of the Pectoralis Major Tendon: An Anatomic Study.

Purpose: To describe the proportional anatomic relationship of the long head of the biceps tendon (LHBT) myotendinous junction (MTJ) to pectoralis major tendon (PMT) and to provide an up-to-date review of the current literature. Methods: Ten fresh frozen cadaveric specimens were used. A deltopectoral approach was used for exposure and anatomical location of the MTJ as well as the proximal and distal borders of the PMT were identified by 2 fellowship-trained shoulder and elbow surgeons. The longitudinal length of the PMT, the distance from the long head of the biceps (LHB) MTJ to the proximal border of the PMT (pMTJ), and the distance from the LHB MTJ to the distal border of the PMT (dMTJ) were recorded. The relationship between the pMTJ and the PMT length was then reported as a ratio. Results: The PMT was found to have a length of 5.16 ± 0.64 cm (4.1-6.1 cm). The pMTJ was 1.14 ± 0.52 cm (0.5-1.9 cm), and the dMTJ was 4.02 ± 0.91 cm (2.5-5.3 cm). The pMTJ/PMT ratio was 0.23 ± 0.11 (0.10-0.39). Conclusions: We found the average length of the PMT footprint to be 5.16 cm with the LHB MTJ beginning 1.14 cm distal to its proximal border. Clinical Relevance: It is important to understand the LHBT and its relationship to surgically relevant surrounding anatomy to allow for appropriate tensioning and improved patient outcomes in the treatment of LHBT shoulder pathology.