Mixed-reality improves execution of templated glenoid component positioning in shoulder arthroplasty: a CT imaging analysis.

INTRODUCTION: Glenoid placement is critical for successful outcomes in total shoulder arthroplasty (TSA). Preoperative templating with three-dimensional imaging has improved implant positioning, but deviations from the planned inclination and version still occur. Mixed-Reality (MR) is a novel technology that allows surgeons intra-operative access to three-dimensional imaging and templates, capable of overlaying the surgical field to help guide component positioning. The purpose of this study was to compare the execution of preoperative templates using MR vs.standard instruments (SIs). METHODS: Retrospective review of 97 total shoulder arthroplasties (18 anatomic, 79 reverse) from a single high-volume shoulder surgeon between January 2021 and February 2023, including only primary diagnoses of osteoarthritis, rotator cuff arthropathy, or a massive irreparable rotator cuff tear. To be included, patients needed a templated preoperative plan and then a postoperative computed tomography scan. Allocation to MR vs. SI was based on availability of the MR headset, industry technical personnel, and the templated preoperative plan loaded into the software, but preoperative or intraoperative patient factors did not contribute to the allocation decision. Postoperative inclination and version were measured by two independent, blinded physicians and compared to the preoperative template. From these measurements, we calculated the mean difference, standard deviation (SD), and variance to compare MR and SI. RESULTS: Comparing 25 MR to 72 SI cases, MR significantly improved both inclination (P < .001) and version (P < .001). Specifically, MR improved the mean difference from preoperative templates (by 1.9° inclination, 2.4° version), narrowed the SD (by 1.7° inclination, 1.8° version), and decreased the variance (11.7-3.0 inclination, 14.9-4.3 version). A scatterplot of the data demonstrates a concentration of MR cases within 5° of plan relative to SI cases typically within 10° of plan. There was no difference in operative time. CONCLUSION: MR improved the accuracy and precision of glenoid positioning. Although it is unlikely that 2° makes a detectable clinical difference, our results demonstrate the potential ability for technology like MR to narrow the bell curve and decrease the outliers in glenoid placement. This will be particularly relevant as MR and other similar technologies continue to evolve into more effective methods in guiding surgical execution.

Short-term outcomes after primary reverse total shoulder arthroplasty in patients with cervical spine pathology or previous cervical spine surgery compared to those without.

BACKGROUND: Cervical spine (c-spine) and shoulder pathology have been known to cause similar symptoms and often co-exist, making an accurate diagnosis difficult, especially in an elderly population. Reverse total shoulder arthroplasty (rTSA) has been shown to decrease pain and improve quality of life when shoulder pathology is the source of pain and disability. The purpose of this study was to identify the prevalence of c-spine pathology in a cohort of patients who underwent rTSA and to compare postoperative outcome scores to a cohort without c-spine pathology. METHODS: A retrospective review was performed utilizing a single institution's operative records of primary rTSAs. Radiology reports, imaging, and operative reports were reviewed, and presence of any c-spine pathology or previous surgery were recorded. Additionally, postoperative outcome scores (American Shoulder and Elbow Surgeons [ASES], Constant Score, University of California, Los Angeles [UCLA], and Simple Shoulder Test [SST]) were evaluated at >2 years post-rTSA. RESULTS: A total of 438 primary rTSA cases were evaluated. Of these, 143 (32.6%) had documentation of prior c-spine pathology and/or history of previous c-spine surgery. After applying further exclusion criteria, a total of 50 patients with c-spine pathology and 108 patients without c-spine pathology were found to have complete medical records and postoperative outcome scores to allow comparison between groups. Patients without c-spine pathology were found to have statistically higher postoperative UCLA, ASES, and SST scores when compared to patients with c-spine pathology. Patients without c-spine pathology also demonstrated a significant improvement in the difference between their postoperative and preoperative UCLA and ASES scores. CONCLUSION: This study demonstrated a high prevalence of c-spine pathology (32.6%) in a cohort of patients who underwent primary rTSA. Additionally, short-term outcome scores of patients undergoing rTSA with concomitant c-spine pathology are significantly lower than those of patients without a history of c-spine pathology.

Utility of Allograft Talus as a Source for Grafting of Concurrent Humeral and Glenoid Defects Associated With Anterior Glenohumeral Instability: An Anthropometric Analysis.

PURPOSE: To compare morphologic data of the talus using magnetic resonance images with previously reported values of the humeral head and the glenoid as a potential graft source for both the humeral head as well as glenoid reconstruction in the setting of concomitant glenoid and humeral head defects. METHODS: All magnetic resonance images of the ankle were reviewed for assessment of the morphology and variation of the talus among individuals. Patients with post-traumatic, osteoarthritic, or surgical changes to the distal tibia about the mid- or hind- foot, or patients with incomplete medical records were excluded. Radiographic parameters that were measured included the maximum vertical height (MVH), the height to the talar neck, the radius of curvature (ROC) of the talar dome, ROC of the subtalar joint, and the maximum medial-to-lateral width of the talar dome. Demographic data also were collected on each individual. Statistical analysis was performed via a linear regression model with backwards elimination to determine which demographic data correlated most strongly with talar anthropometric values. RESULTS: A total of 82 study patients met inclusion criteria (59 male, 23 female; mean age 40.91 ± 14.69 years). Sex was found have a positive correlation of the following talar dimensions: MVH (P = .039), talar dome ROC (P < .001), and subtalar joint ROC (p = 0.001). Height was the most positive correlation for medial-to-lateral width (P < .001), height to the talar neck (P = .004), and also correlate for MVH (P = .004). Body mass index was found to have multicollinearity and was therefore not used as a variable. CONCLUSIONS: Allograft talus appears to be a viable graft, as demonstrated in this anthropometric study for both reconstruction of the glenoid and humeral head when cases of bipolar glenohumeral bone loss are present. CLINICAL RELEVANCE: This study aims to further evaluate potential allograft donor sites for bipolar lesions.

Reverse Total Shoulder Arthroplasty in the Setting of an Intramuscular Lipoma With Extension Into the Glenoid: A Case Report.

Glenoid bone loss from an infiltrating intramuscular lipoma causing erosive changes is a rare occurrence. A 71-year-old woman with symptomatic rotator cuff arthropathy in the setting of an intramuscular infiltrating lipoma and secondary glenoid bone loss was treated with single-stage tumor excision and reverse total shoulder arthroplasty (rTSA) using an injectable, hard self-setting calcium phosphate as structural bone graft substitute. The patient demonstrated excellent clinical and radiographic outcomes at 2-year follow-up. Infiltrating lipomas resulting in functional rotator cuff arthropathy and erosive osseous glenoid changes are exceedingly rare, yet significant glenoid bony defects present a challenge in the setting of shoulder arthroplasty. This report describes the use of structural bone graft substitute for the management of a glenoid bone defect from a rare case of an intramuscular infiltrating lipoma, while maintaining excellent improvement in functional outcomes and pain after rTSA.

Pelvic Ring Fracture Management and Subsequent Pregnancy: A Summary of Current Literature.

INTRODUCTION: The incidence of pelvic ring injuries is 34.3% per 100,000 capita. No studies have determined the ability of a female patient to have a vaginal delivery after undergoing pelvic fracture fixation. However, many obstetricians are generally unwilling to have their patients attempt a vaginal delivery in the setting of symphyseal or sacroiliac fixation. METHODS: An exhaustive search of the National Library of Medicine database was performed, and it is hypothesized that cesarean section rates would be higher for women who have a child after one of these pelvic ring injuries. RESULTS: There is a 15% increase in cesarean rates using data from the National Center for Health Statistics. In addition, there is an observable increase in new cesarean rates. DISCUSSION: Currently, there is no clear evidence to support an elective cesarean section as the sole indication after a prior pelvic fracture. To date, no studies have determined the ability of a female patient to have a vaginal delivery after undergoing pelvic fracture fixation. CONCLUSION: Thus, until the increased cesarean section rate has been explained, it could be problematic to counsel the patient to avoid a vaginal delivery after sustaining a pelvic ring fracture. Hence, conducting additional studies on this topic would deem to be necessary.

Comparison of clinical outcomes and complications in 2-part vs. 3- or 4-part proximal humerus fractures treated using an intramedullary nail designed to capture the tuberosities.

Background: Intramedullary nail fixation for proximal humerus fractures has been shown to provide satisfactory results. The quality of reduction correlates with clinical outcomes, the rate of complications, avascular necrosis, and postoperative loss of fixation. The purpose of this study was to evaluate the clinical outcomes and complications of 2-part proximal humerus fractures compared to 3- or 4-part proximal humerus fractures. Methods: A single-center retrospective review was carried out of patients who underwent an intramedullary nail for a proximal humerus fracture by one of three surgeons between the years of 2009 and 2022, and who had a minimum of 12-months follow-up. Fracture pattern, American Shoulder and Elbow Surgeons score, Single Assessment Numeric Evaluation score, satisfaction, pain score, range of motion, and complications were recorded. The mechanism of injury (high energy vs. low energy), method of reduction (open vs. percutaneous), and evidence of radiographic healing were assessed. A P value of <.05 was considered to be statistically significant. Results: The study included 78 patients (62 female, 16 male). The number of patients in each group (2-part, N = 32 vs. 3- or 4-part, N = 46), mean age (2-part, 64 vs. 3- or 4-part,61), follow-up (2-part, 42.5 months vs. 3- or 4-part, 34.5 months), injury type (2-part, 88% low energy vs. 3- or 4-part, 78% low energy), and method of reduction (2-part, 81% percutaneous vs. 3- or 4-part 72% percutaneous) were similar among the two groups. There was fracture union in all patients. All patients demonstrated satisfactory patient-reported outcome measures. However, 2-part fractures did have a significantly lower pain score, higher Single Assessment Numeric Evaluation score, and higher percentage of patients being satisfied or very satisfied when compared to 3- or 4-part fractures. The rate of subsequent procedures was 13% (n = 4) in 2-part fractures compared to 19% (n = 9) in 3- or 4-part fractures but was not statistically significant (P = .414). The overall rate of conversion to arthroplasty was 3.2% in 2-part fractures and 10.4% in 3- or 4-part fractures. Conclusion: Multipart proximal humerus fractures remain difficult to treat. However, this study demonstrates an overall acceptable outcome with improvement in range of motion, patient-reported outcomes, and similar complication rates between 2-part and 3- or 4-part proximal humerus fractures treated with an intramedullary nail. However, the improvement in certain parameters is not as marked in 3- or 4-part fractures as 2-part fractures.

The Radius of Curvature of the Inferior Distal Clavicle Is Similar to That of the Glenoid in Both the Axial and Coronal Planes and Similar to the Inferior Coracoid.

Purpose: The purposes of this study were to use computed tomography (CT) scans to compare the radius of curvature (ROC) of the inferior concave surface of the distal clavicle to the glenoid, determine graft dimensions, and compare the ROC of the congruent-arc distal clavicle autograft (DCA) to the congruent-arc Latarjet graft. Methods: Patients who underwent bony glenoid reconstruction via a Laterjet procedure between January 2018 and January 2023 at a single institution were retrospectively identified. CT scans were used to measure the ROC of the glenoid on the axial and coronal sequences, measure the ROC of the distal clavicle on the sagittal oblique sequences, and determine the dimensions of the distal clavicle and coracoid graft. Results: A total of 42 patients were included (Latarjet, n = 22; control, n = 20). The mean ROC of the inferior surface of the distal clavicle was not significantly different from the ROC of the glenoid in the coronal (P = .15) or axial planes (P = .65). The ROC of the coracoid when measured in the sagittal plane was not significantly different from the ROC of the distal clavicle (P = .25). The length, depth, and surface area of the coracoid in the congruent arc orientation were significantly larger than the distal clavicle (P < .005). Patients in the control group tended to have both a larger inferior clavicle ROC and a larger coracoid ROC compared to the Latarjet group (32.8 mm vs 29.6 mm, P < .0001; 31.8 mm vs 30.9 mm, P = .02). Conclusions: The ROC of the inferior distal clavicle is similar to that of the glenoid in both the axial and coronal planes and similar to the inferior coracoid. Clinical Relevance: CT analysis reveals that the congruent-arc DCA technique provides a robust graft with dimensions that are suitable for reconstruction of the anterior glenoid.

Radius of curvature of the radial head matches the capitellum: a magnetic resonance imaging analysis.

Background: The purpose of this study is to utilize elbow magnetic resonance imaging (MRI) to compare the radius of curvature (ROC) of the radial head peripheral cartilaginous rim and the cartilage contour of the capitellum to evaluate if the radial head could be a suitable osteochondral autograft for capitellar pathology. Methods: All patients who underwent an MRI of the elbow over a three-year period were reviewed. Patients with the following diagnoses were excluded: osteochondritis dissecans, osteomyelitis, tumor, and osteoarthritis. The radius of curvature of the radial head (RhROC) was measured on the axial oblique MRI sequence. The radius of curvature of the capitellum (CapROC) was measured on sagittal oblique MRI sequences, the width of the articular surface of the capitellum on coronal MRI sequences and the radial head height (RhH) and capitellar vertical height on sagittal oblique sequences. All measurements were obtained at the midpoint of the radiocapitellar joint. Spearman's coefficient was used to assess the correlation between ROC measurements. Results: Eighty-three patients were included with a mean age of 43 +/- 17 years (57 males and 26 females, 51 right and 32 left elbows). The median RhROC and CapROC measurements were 12.3 mm (interquartile range [IQR] 1.6) and 11.9 mm (IQR 1.7), respectively. The median difference was 0.3 mm (IQR = 0.6; CI 95% = [0.24, 0.46]; P < .001). A strong positive correlation was found between RhROC and CapROC (ρ = 0.89; r2 = 0.819; P < .001). Ninety-four percent (78/83) of patients had a median difference between the RhROC and CapROC of less than or equal to 1 mm, and 63% (52/83) were within 0.5 mm. The inter-rater and intra-rater reliability for RhROC and CapROC was good, intraclass correlation coefficient (ICC) = 0.89, ICC = 0.87, and ICC = 0.96, ICC = 0.97, respectively. RhH was 10.6 ± 1.3 mm, and the width of the articular surface of the capitellum was found to be 13.8 ± 1.6 mm. Conclusion: The ROC of the convex peripheral cartilaginous rim of the radial head is similar to the ROC of the capitellum. In addition, the RhH was approximately 78% of the capitellar articular width. Based on this imaging analysis, the radial head could prove to be a robust local osteochondral autograft with a similar cartilage contour in the reconstruction of the capitellum in complex intra-articular distal humerus fractures with associated radial head fractures and in the setting of "kissing lesions" of the radiocapitellar joint. Furthermore, an osteochondral plug harvested from the "safe zone" of the peripheral cartilaginous rim of the radial head could be utilized to treat isolated osteochondral lesions of the capitellum.

Antibiotic cement-coated intramedullary nail is cost-effective for the initial treatment of GAâ ¢ open tibia fractures.

OBJECTIVE: To evaluate the cost-effectiveness of antibiotic cement-coated intramedullary nails (IMN) in the initial management of Gustilo-Anderson type Ⅲ (GAIII) open tibia fractures. METHODS: A break-even equation was used to analyze the costs associated with antibiotic cement-coated IMN and postoperative infection following GAⅢ open tibia fractures. This equation produced a new infection rate, which defines what percentage the antibiotic coated IMN needs to decrease the initial infection rate for its prophylactic use to be cost-effective. The postoperative infection rate used for calculations was 30%, a value established in current literature for these fracture types (6-33%). The institutional costs associated with a single operative debridement and resultant inpatient stay and treatment were determined. A sensitivity analysis was conducted to demonstrate how various total costs of infection and different infection rates affected the break-even rate, the absolute risk reduction (ARR), and the number needed to treat (NNT). RESULTS: Financial review yielded an average institutional cost of treating a postoperative infection to be $13,282.85. This number was inclusive of all procedures during an inpatient stay. The added cost of the antibiotic coated implant to the hospital is $743.42. Utilizing the break-even formula with these costs and a 30% initial infection rate, antibiotic coated IMN was economically viable if it decreased infection rate by 0.056% (NNT = 1,785.714). CONCLUSION: This break-even analysis model suggests the initial use of an antibiotic coated IMN in the setting of GAⅢ open tibia fractures is cost-effective.

Revision Open Subpectoral Biceps Tenodesis With Allograft Tendon Reconstruction for Symptomatic Failed Biceps Tenodesis.

Biceps tenodesis and tenotomy are both effective surgical procedures for management of shoulder pain and dysfunction secondary to SLAP tears, biceps tendinitis, rotator interval pulley lesions, and failed SLAP repairs. These procedures are generally safe with low complication rates. However, failure of a proximal biceps tenodesis or tenotomy can rarely lead to symptomatic Popeye deformity with pain and cramping with repetitive forearm supination and elbow flexion. Surgical revision is indicated in young active patients to restore the length tension relationship of the biceps brachii to improve supination and flexion strength, as well as to provide symptomatic relief and improved endurance. Failed biceps tenodesis can be a challenging surgical scenario, as oftentimes there is limited available proximal biceps tendon tissue, especially in the setting of prior subpectoral biceps tenodesis. We report a technique of revision open subpectoral biceps tenodesis with allograft tendon augmentation for the management of symptomatic Popeye deformity in young active patients with little to no remaining proximal biceps tendon.

Benzoyl Peroxide is Cost-Effective for Preventing Infection by Cutibacterium Acnes in Arthroscopic Rotator Cuff Repair.

PURPOSE: To evaluate the cost-effectiveness of benzoyl peroxide (BPO) in decreasing postoperative infections through a mathematical model in the setting of arthroscopic rotator cuff repair (RCR). METHODS: A break-even equation compared the costs associated with perioperative BPO use and postoperative infection following an arthroscopic RCR. The postoperative infection rate used for calculations was 0.28%, a value established in current literature. The break-even analysis produced a new infection rate, which defined how much BPO is needed to reduce the known infection rate in order for its prophylactic use to be cost-effective. The institution's business office assessed the minimum itemized costs associated with the standard-of-care treatment of postoperative RCR infection. Sensitivity analysis was conducted to demonstrate how variability in the costs of BPO, in infection rates and in the cost of infection treatment affected the absolute risk reduction (ARR) and number needed to treat (NNT). RESULTS: Financial review yielded a minimum institutional cost of treating a postoperative infection following arthroscopic RCR of $24,991.31. Using the break-even formula to calculate the ARR at which the overhead costs of BPO and the treatment of infection were equal, BPO was economically viable if it decreased infection rate by 0.000734% (NNT = 1,361.92). This value was low because of the order of magnitude of difference between the costs of infection prevention when compared to the costs of treating postoperative infections. CONCLUSIONS: This break-even analysis model suggests that the use of preoperative BPO in the setting of arthroscopic RCR is cost-effective for prevention of infection with Cutibacterium acnes, given the high cost of treating the infection versus the low cost of the solution. CLINICAL RELEVANCE: The economic feasibility of preoperative use of BPO in the setting of arthroscopic RCR could alter the standard of care.

Predicting adjacent infections in pediatric septic arthritis: Do predictive criteria extrapolate across geographic regions?: Predicting Periarticular Infection in the Southeast.

PURPOSE: This study aims to assess previously determined predictive criteria for presence of adjacent infection in septic arthritis within a Southeastern United States (US) pediatric population. RESULTS: The sensitivity, specificity, positive predictive value, and negative predictive value of the Rosenfeld criteria were: 91.7%, 22.7%, 39.3%, and 83.3%, respectively. The patients with periarticular infection were more likely to have positive blood cultures than those with isolated septic arthritis. There was no difference in likelihood of secondary surgical intervention. CONCLUSIONS: Previously defined criteria to predict adjacent infection in pediatric septic arthritis did not demonstrate external validity in a Southeastern US pediatric population.

Guided growth for the Treatment of Infantile Blount's disease: Is it a viable option?

INTRODUCTION: Guided growth with temporary hemiepiphysiodesis has gained interest as a less invasive means for the treatment of coronal plane lower extremity deformities as well as leg length discrepancies. Its application to infantile Blount's disease has been less reported. The object of this study was to identify predictive factors of guided growth for treatment of infantile Blount's. METHODS: A retrospective review was performed of children undergoing guided growth for the treatment of infantile Blount's disease over an eight-year period. Inclusion criteria included treatment with THE for infantile Blount's disease. Clinical information, preoperative Langenskiold classification, and intra-operative and post-operative data. Preoperative variables were used to identify risk factors for speed of correction and the need for subsequent surgery. RESULTS: A total of 11 patients, 17 extremities, meeting inclusionary criteria. Preoperatively, 7 extremities were classified as Langenskiold stage ≥3, with 12 being classified as stage ≤2. Overall, the Drennan's angle improved from 18.3° to 0.3° by final follow-up at an average of 4.31 years. Eight extremities demonstrated deformity recurrence/persistence (stage ≤2:33% vs stage ≥3: 100%), requiring 24 reoperations. Children with Langenskiold stage ≥3 demonstrated a significantly higher rate of reoperation. CONCLUSION: Guided growth is a viable treatment option for Infantile Blount's disease presenting with Langenskiold stage ≤2 disease at treatment initiation. The treatment course can expect a 33% rate of recurrent deformity, treated successfully with repeat THE. No child stage ≤2 required corrective osteotomy. Caution should be used when considering guided growth for children presenting with Langenskiold stage ≥3.

Polyethylene Liner Dissociation after Reverse Shoulder Arthroplasty Dislocation: a Case Series.

Reverse shoulder arthroplasty is a common procedure. While dislocation is a common complication, there are few reports documenting dislocation with associated polyethylene liner dissociation from the humeral tray. There have been 4 instances of this occurrence over 9 years at our institution, and there are specific radiographic clues for diagnosis. Recognizing polyethylene liner dissociation on imaging is important prior to treatment. In a "routine" dislocation, closed reduction may be attempted but when the polyethylene is dissociated, open reduction is the only treatment option, as closed reduction can damage the components. Dislocations with polyethylene dissociation may not be initially recognized, prompting a non-operative period leading to wear and metallosis. These 4 cases demonstrate key findings present on imaging to recognize the difference between a dislocation with and without polyethylene liner dissociation, namely the subluxation appearance rather than dislocation.

Mathematical modeling of glenoid bone loss demonstrate differences in calculations that May affect surgical decision making.

OBJECTIVE: Two glenoid bone loss calculations are compared across a range of anatomic glenoid sizes. METHODS: 20 cadaveric paired glenoid diameters were measured to create glenoid models with bone loss calculated in 1 mm linear increments up to 50% bone loss comparing the linear measurement percentage (LMP) to the circle line method (CLM) gold standard. RESULTS: The LMP overestimates glenoid bone loss at every potential 1 mm increment across each glenoid model until bone loss reaches 50%. CONCLUSION: The widely-used LMP method overestimates bone loss compared to a gold standard potentially misguiding surgeons towards bony reconstruction in shoulder instability during preoperative planning.

From Lateral Ankle Sprain to Above-Knee Amputation: A Unique Case Report of Group A Streptococcus Necrotizing Soft-tissue Infection.

INTRODUCTION: Necrotizing fasciitis, also referred to necrotizing soft-tissue infection (NSTI), is an infrequent entity that results in orthopedic consultation. It is a rapidly spreading typically associated with a contaminated wound that spreads rapidly along fascial planes resulting in significant morbidity and mortality. However, it is a rare occurrence that such pathology occurs in an atraumatic fashion, which is without a wound through the skin. CASE REPORT: A 33-year-old female with no significant medical history presented to a walk-in orthopedic clinic with increasing ankle pain after a lateral ankle sprain 2 days prior. Patient denies any fevers, chills, shortness of breath, numbness, tingling, paresthesia, or any additional trauma since the initial ankle sprain. The patient was afebrile, maintaining oxygenation, normotensive, but tachycardic to just over 100. Physical examination was only significant for moderate swelling and ecchymosis about the lateral malleolus. X-rays and venous ultrasound were negative for any associated pathology. After a period of observation, the patient acutely decompensated with a significant increase in pain in the lower leg on passive stretch, an increase in compartment firmness and a worsening tachycardia up to the 120's. The patient was taken emergently for fasciotomies for presumed compartment syndrome. The patient was hemodynamically unstable during the case and transferred to the intensive care unit where she continued to decompensate, requiring multiple vasopressors. The affected extremity became necrotic at the level of the foot and her hemodynamic instability continued, causing a return to the operating room for an emergent guillotine above-knee amputation. The patient progressively stabilized and underwent a formal above-knee amputation 2 days later. Cultures obtained during the second case were positive for Group A Streptococcus. CONCLUSION: This case highlights the variable presentation of NSTIs as well as has having a high index of suspicion to ensure this highly morbid and fatal disease process is diagnosed expeditiously. This case is also unique in that it developed without any obvious wounds and that monomicrobial Group A Streptococcus was the culprit, while most NSTIs are polymicrobial.