Managing rotator cuff tear arthropathy: a role for cuff tear arthropathy hemiarthroplasty as well as reverse total shoulder arthroplasty.

BACKGROUND: Disabling cuff tear arthropathy (CTA) is commonly managed with reverse shoulder arthroplasty (RSA). However, for patients with CTA having preserved active elevation, cuff tear arthropathy hemiarthroplasty (CTAH) may offer a cost-effective alternative that avoids the complications unique to RSA. We sought to determine the characteristics and outcomes of a series of patients with CTA managed with these procedures. MATERIALS AND METHODS: We retrospectively reviewed 103 patients with CTA treated with shoulder arthroplasty, the type of which was determined by the patient's ability to actively elevate the arm. Outcome measures included the change in the Simple Shoulder Test (SST), the percent maximum improvement in SST (%MPI), and the percentage of patients exceeding the minimal clinically important difference for the change in SST and %MPI. Postoperative x-rays were evaluated to assess the positions of the center of rotation and the greater tuberosity for each implant. RESULTS: Forty-four percent of the 103 patients were managed with CTAH while 56% were managed with RSA. Both arthroplasties resulted in clinically significant improvement. Patients having RSA improved from a mean preoperative SST score of 1.7 (interquartile range [IQR], 0.0-3.0) to a postoperative score of 6.3 (IQR, 2.3-10.0) (P < .01). Patients having CTAH improved from a preoperative SST score of 3.1 (IQR, 1.0-4.0) to a postoperative score of 7.6 (IQR, 5.0-10.) (P < .001). These improvements exceeded the minimal clinically important difference. Instability accounted for most of the RSA complications; however, it did not account for any CTAH complications. The postoperative position of the center of rotation and greater tuberosity on anteroposterior radiographs did not correlate with the clinical outcomes for either procedure. CONCLUSION: For 103 patients with CTA, clinically significant improvement was achieved with appropriately indicated CTAH and RSA. In view of the lower cost of the CTAH implant, it may provide a cost-effective alternative to RSA for patients with retained active elevation.

Anatomic total shoulder arthroplasty for posteriorly eccentric and concentric osteoarthritis: a comparison at minimum 5-year follow-up.

BACKGROUND: In patients with glenohumeral osteoarthritis and posteriorly eccentric wear patterns, the early to mid-term results of TSA using conservative glenoid reaming with no attempt at version correction have been favorable at early follow-up. The purpose of this study is to compare the clinical and radiographic outcomes of TSA using this technique for patients with and without eccentric wear patterns at a minimum 5-year follow-up. METHODS: Patients who underwent TSA with minimum 5-year follow-up were identified from an institutional registry. Preoperative and postoperative radiographs were used to determine humeroglenoid alignment (HGA-AP), humeroscapular alignment (HSA-AP), version, Walch classification and glenoid component seating. The outcome measures were the Simple Shoulder Test, glenoid component radiolucencies, and the occurrence of complications or revisions. RESULTS: Two hundred and ten patients were included in the study, of which 98 (47%) had posteriorly decentered humeral heads and 108 (51%) had centered humeral heads. There were 77 shoulders with Walch type A glenoids and 122 with Walch type B glenoids. At a mean 8-year follow-up, the final SST, change in SST and percentage of maximal improvement was not correlated with pre- and postoperative humeral head centering, Walch classification or glenoid version. There were no preoperative predictors of a low final SST. Two patients (1%) underwent open re-operations during the study period. In patients with Walch B1 and B2 glenoids (n=110), there were no differences in outcome measures between patients with postoperative retroversion of more and less than 15o. While 15 of 51 patients (29%) with minimum 5-year radiographs had glenoid radioluciences, these radiographic findings were not associated with inferior clinical outcomes. On multivariable analysis glenoid component radiolucencies were most strongly associated with incomplete component seating (OR 3.3, p = 0.082). CONCLUSION: The results of TSA with conservative glenoid reaming without attempt at version correction are favorable at minimum 5 year, mean 8-year follow-up. There were no differences in clinical and radiographic outcomes between patients with eccentric and concentric wear patterns. Incomplete glenoid component seating was the greatest predictor of glenoid component radiolucency, but these radiolucencies were not associated with inferior clinical outcomes.

Anatomic Total Shoulder: Predictors of Excellent Outcomes at Five Years after Arthroplasty.

PURPOSE: The objectives of this study were to: report minimum 5-year outcomes in patients undergoing TSA and determine characteristics predictive of patients achieving an excellent functional outcome. METHODS: Pre-operative demographic variables and Simple Shoulder Test (SST) scores were obtained pre-operatively and at a minimum of five years after surgery. A final SST ≥ 10 and percentage of maximal possible improvement (% MPI) of ≥ 66.7% were determined to be the thresholds for excellent outcomes. Univariate and multivariate analysis were performed to identify factors associated with excellent five year clinical outcomes. RESULTS: Of 233 eligible patients, 188 (81%) had adequate follow-up for inclusion in this study. Mean SST scores improved from 3.4 ± 2.4 to 9.7 ± 2.2 (p < 0.001). Male sex was an independent predictor of both SST ≥ 10 (OR 3.46, 95% CI 1.70-7.31; p < 0.001) and %MPI ≥ 66.7 (OR 2.27, 95% CI 1.11-4.81, p = 0.027). Workers' Compensation insurance was predictive of not obtaining SST ≥ 10 (OR 0.12, 95% 0.02-0.60; p = 0.016) or %MPI ≥ 66.7 (OR 0.16, 95% CI 0.03-0.77, p = 0.025). MCID was passed by the vast majority (95%) of patients undergoing TSA and did not necessarily indicate an excellent, satisfactory outcome. CONCLUSION: Male sex and commercial insurance coverage were significantly associated with these excellent outcomes, while Workers' Compensation insurance was associated with failure to achieve this result. Thresholds for excellent outcomes, such as final SST ≥ 10 and %MPI ≥ 66.7, may be useful in identifying the characteristics of patients who benefit most from TSA.

Factors associated with failure of surgical revision and IV antibiotics to resolve Cutibacterium periprosthetic infection of the shoulder.

PURPOSE: Cutibacterium is the most common organism causing shoulder periprosthetic infection (PJI). While most shoulder PJIs are well treated by prosthesis exchange and antibiotics, in some cases this treatment fails to resolve the infection. The factors associated with these failures have not been previously identified. The aim of this study was to identify the characteristics of patients with failure of treatment for PJI. METHODS: Thirty-five patients suspected of having Cutibacterium PJI had revision arthroplasty with single-stage implant exchange followed by intravenous antibiotics. The characteristics of those with ≥ two positive cultures at revision surgery were compared to those who did not. The characteristics of those patients having a re-revision with ≥ two positive deep cultures (documented treatment failures) were compared to those who did not. RESULTS: The 17 patients that had ≥ two positive cultures at their index revision were more likely to be male, to have had ream and run procedures, and to have higher loads of Cutibacterium on pre-operative cultures of their unprepared skin. The five patients that had documented treatment failure had higher loads of Cutibacterium on their skin and in deep cultures obtained at their index revision. CONCLUSION: Patients harboring high loads of Cutibacterium on their unprepared skin prior to revision and high loads of Cutibacterium on deep cultures at the time of their index revision are at increased risk for failure of implant exchange and antibiotics to resolve a Cutibacterium PJI.

Routine Indwelling Urinary Catheterization Is Not Necessary During Total Hip Arthroplasty Performed Under Spinal Anesthesia.

Background: Perioperative indwelling urinary catheterization remains common in patients undergoing total hip arthroplasty. This study sought to examine the effect of routine catheterization following total hip arthroplasty performed under spinal anesthesia on urinary complications. Methods: A total of 991 consecutive patients who underwent primary total hip arthroplasty under spinal anesthesia over a 4-year period were retrospectively reviewed. Major postoperative urinary retention (POUR) was defined as persistent retention following 2 straight catheterizations, which required postoperative indwelling catheter placement. Minor POUR was defined as retention that resolved following 1 or 2 straight catheterizations. Statistical analyses were used to compare outcomes between those who received a routine indwelling catheter and those who did not. Results: Of the 991 patients included, 498 (50.3%) underwent routine indwelling urinary catheter placement preoperatively. Routine indwelling catheterization was associated with a higher rate of urinary tract infection (1.4% vs 0.0%, P = .015), but a lower rate of minor POUR (5.0% vs 10.3%, P = .001). There was no difference with respect to the rate of major POUR or discharge with an indwelling catheter. Multivariate analyses demonstrated indwelling catheterization to be independently associated with a lower rate of minor POUR (P = .021), but there was no association with overall POUR, major POUR, or discharge with a urinary catheter. Conclusion: These data suggest that routine indwelling urinary catheterization is likely unnecessary for patients undergoing total hip arthroplasty in the setting of spinal anesthetic and may even lead to increased risk of complications such as urinary tract infection.

Enhancing Vascularization through the Controlled Release of Platelet-Derived Growth Factor-BB.

Using delivery systems to control the in vivo release of growth factors (GFs) for tissue engineering applications is extremely desirable as the clinical use of GFs is limited by their fast in vivo turnover. Hence, the development of effective platforms that are able to finely control the release of GFs in vivo remains a challenge. Herein, we investigated the ability of multiscale microspheres, composed by a nanostructured silicon multistage vector (MSV) core and a poly(dl-lactide-co-glycolide) acid (PLGA) forming outer shell (PLGA-MSV), to release functional platelet-derived growth factor-BB (PDGF-BB) to induce in vivo localized neovascularization. The in vitro release of PDGF-BB was assessed by enzyme-linked immunosorbent assay (ELISA) over 2 weeks and showed a sustained, zero-order release kinetics. The ability to promote in vivo localized neovascularization was investigated in a subcutaneous injection model in BALB/c mice and followed by intravital microscopy up to 2 weeks. Fully functional newly formed vessels were found within the area where PLGA-MSVs were localized and covered 3.0 ± 0.9 and 19 ± 5.1% at 7 and 14 days, respectively, showing a 6-fold increase in 1 week. The distribution of CD31+ and α-SMA+ cells was detected by immunofluorescence on harvested tissues. CD31 was significantly more expressed (4-fold increase) compared to the untreated control. Finally, the level of up-regulation of angiogenesis-associated genes (Vegfa, Vwf, and Col3a1) was assessed by q-PCR, resulting in a significantly higher expression where PLGA-MSVs were localized (Vegfa: 2.32 ± 0.50 at 7 days and 4.37 ± 0.75 at 14 days; Vwf: 4.13 ± 0.82 and 7.74 ± 0.91; Col3a1: 5.43 ± 0.37 and 6.66 ± 0.89). Altogether, our data supported the conclusion that the localized delivery of PDGF-BB from PLGA-MSVs induced the localized de novo formation of fully functional vessels in vivo. With this study, we demonstrated that PLGA-MSV holds promise for accomplishing the controlled localized in vivo release of GFs for the design of innovative tissue engineering strategies.