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.

Which Components of the Simple Shoulder Test Show Improvement After Scapulothoracic Fusion for Recalcitrant Scapular Winging? Clinical Results at a Minimum of 5 Years of Follow-up.

BACKGROUND: Scapular winging is an uncommon but important cause of shoulder pain and disability. Surgical management can include soft tissue procedures such as split pectoralis major transfer, the Eden-Lange procedure, or a triple tendon transfer. When these procedures do not alleviate symptomatic winging or are inappropriate, scapulothoracic fusion is an alternative, but data on its longer-term effectiveness are sparse. QUESTIONS/PURPOSES: (1) What changes in outcome scores were observed (VAS, Single Assessment Numeric Evaluation [SANE], and Simple Shoulder Test [SST] scores), and what proportion of the patients improved by an amount larger than the minimum clinically important difference (MCID) for the outcome tool in question? (2) Which components of the SST are patients able to perform at a minimum of 5 years? (3) What complications occurred after surgery? METHODS: We performed a retrospective study in a single, large, urban referral medical center of patients who underwent scapulothoracic fusion. Between January 2011 and November 2016, 15 patients underwent scapulothoracic fusion to treat symptomatic scapular winging. Only patients with nondystrophic etiology were included in the analysis (n = 13). Of the 13 remaining patients, one patient was lost to follow-up and another patient died during data collection, leaving 11 patients for the final analysis. Six patients had brachial plexus injuries affecting multiple nerve roots and periscapular muscles, and five had persistent symptoms despite prior tendon transfer. The median age of the patients was 43 years (range 20 to 67 years), and there were six male and five female patients. All patients had a minimum of 5 years of follow-up. There was a median follow-up of 79 months (range 61 to 128 months). The VAS pain score (range 0 to 10, higher scores represent more pain; MCID = 2), SST score (range 0 to 12, higher scores represent less pain and better shoulder function; MCID = 2.3), and SANE score (range 0 to 100, higher scores represent better shoulder function; MCID = 28) were recorded before surgery and at the most recent follow-up. We compared scores from before surgery with those taken at the most recent follow-up and ascertained the proportion of patients whose improvement exceeded the MCID. The number of patients achieving fusion (as confirmed by a CT image), complications, and reoperations was recorded via a record review as well as direct patient query by telephone. RESULTS: The median VAS pain score improved from 7 (range 3 to 10) preoperatively to 3 (range 2 to 5) at the latest follow-up (p < 0.001). The median SANE score improved from 30 (range 0 to 60) preoperatively to 65 (range 40 to 85) at the latest follow-up (p < 0.001). The median SST score improved from 0 (range 0 to 9) to 8 (range 5 to 10) at the latest follow-up (p < 0.001). Ten of 11 patients had improvements exceeding the MCID for VAS, six of 11 had improvements for SANE scores, and nine of 11 had improvements for SST. Preoperative to postoperative improvements in these components of the SST were seen (responses of "yes"): comfort at rest (three of 11 improved to 11 of 11; p < 0.001), sleep comfortably (three of 11 improved to 11 of 11; p < 0.001), place coin on shelf (two of 11 improved to 10 of 11; p < 0.001), lift 1 pound above shoulder (two of 11 improved to eight of 11; p = 0.03), and carry 20 pounds with the arm at side (one of 11 improved to nine of 11; p < 0.001). All 11 patients had successful fusion noted on CT images. There were three complications (progression of glenohumeral arthritis, broken wires, and perioperative chest tube placement) and one reoperation for progression of glenohumeral arthritis with subsequent total shoulder arthroplasty. CONCLUSION: Patients with recalcitrant symptomatic scapular winging often undergo an exhaustive course of clinical examinations, diagnostic tests, physical therapy, and multiple surgical procedures. Those with brachial plexus palsy with involvement of multiple nerves may continue to have symptoms despite nonoperative management and subsequent soft tissue tendon transfers. Scapulothoracic fusion could be considered for patients with persistent pain and decreased function because of recalcitrant scapular winging who are either not candidates for the procedure or have persistent symptoms despite prior soft tissue procedures. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Metacarpal Fractures in the National Football League: Injury Characteristics, Management, and Return to Play.

PURPOSE: This study investigated metacarpal fracture occurrences, characteristics, treatments, and return-to-play times for National Football League (NFL) athletes. METHODS: NFL players who sustained metacarpal fractures during the 2012 to 2018 seasons were reviewed. All players on the 32 NFL team active rosters with metacarpal fractures recorded through the NFL Injury Database were included. Player age, time in the league, player position, injury setting, injury mechanism, fractured ray, management, and return-to-play were recorded. RESULTS: There were 208 injury occurrences resulting in 1 or more metacarpal fractures, identified in 205 players. Of these, 81 (39%) injuries were operated. Return-to-play data were available for 173 (83%) injured players. The median return-to-play time for all athletes was 15 days (interquartile range, 1-55 days). Of the injured players, 130 (71%) missed time but returned the same season. Within this 130-player subset, 69 (53%) were treated nonsurgically and 61 (47%) operatively with median return-to-play times of 16 days (interquartile range, 6-30 days) and 20 days (interquartile range, 16-42 days) respectively. Eighteen individuals in this 130-player subgroup sustained a thumb metacarpal fracture. The return-to-play time was slower for patients sustaining thumb metacarpal fractures compared to other metacarpal fractures, and was significantly longer (median, 55 days) following nonsurgical treatment of thumb fractures compared with operative intervention (median, 24 days). A regression analysis revealed no trend or difference in return to football with respect to player age, time in the league, injury setting (practice vs game), injury mechanism, articular involvement, multiple concomitant injuries, or player position. CONCLUSIONS: Most NFL players who sustain metacarpal fractures miss less than 3 weeks and return to play the same season. The only variables that lessen the return-to-play time are involvement of lesser digit metacarpals and operative intervention for treatment of thumb metacarpal fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

What is the optimal management of a loose glenoid component after anatomic total shoulder arthroplasty: a systematic review.

BACKGROUND: Total shoulder arthroplasty (TSA) provides excellent long-term clinical outcomes in the treatment of glenohumeral arthritis. However, symptomatic glenoid polyethylene loosening can be seen at intermediate follow-up and can lead to shoulder pain and dysfunction. The purpose of this study was to perform a systematic review of the available literature to determine the optimal management of symptomatic glenoid loosening with regard to reoperation and patient satisfaction following various approaches to symptomatic glenoid loosening. METHODS: This study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies investigating revision arthroplasty for the treatment of glenoid loosening with clinical outcomes were identified. Clinical failure was defined as a repeat procedure after revision arthroplasty. RESULTS: Overall, 14 studies met inclusion criteria that included 483 patients with a mean age of 66.5 ± 3.0 years who underwent revision arthroplasty for symptomatic glenoid loosening. There were 8 studies that discussed conversion to a hemiarthroplasty (HA, 148 patients), 7 studies that discussed glenoid reimplantation in a single setting (1-stage TSA, 157 patients), 2 studies that discussed glenoid reimplantation in a staged setting (2-stage TSA, 18 patients), and 2 studies that discussed conversion to a reverse shoulder arthroplasty (RSA, 164 patients). All patients underwent glenoid component removal. The length of follow-up was significantly shorter in the RSA group (41 months for RSA vs. 56 months for HA vs. 55 months for 1-stage TSA vs. 62 months for 2-stage TSA, P < .001). The reoperation rate at the final follow-up was 19% for the HA cohort, 20% for the 1-stage TSA cohort, 22% for the 2-stage TSA cohort, and 21% for the RSA cohort (P = .971). Patient satisfaction rate at the final follow-up was 62% for the HA cohort, 66% for the 1-stage TSA cohort, 71% for the 2-stage TSA cohort, and 86% for the RSA cohort (P = .045). Positive cultures were noted in 15% of patients with Cutibacterium acnes comprising 72% of positive cultures. CONCLUSIONS: Overall, the optimal management of symptomatic glenoid loosening remains unclear. All 4 types of revision arthroplasty (HA, 1-stage TSA, 2-stage TSA, and RSA) had a similar reoperation rate (20%) at the latest follow-up. Conversion to RSA provided a higher proportion of patients satisfied with the procedure. However, the length of follow-up was significantly shorter than other groups, and therefore longer-term follow-up of this group is needed to determine if results are durable.

Minimum 10-year follow-up of anatomic total shoulder arthroplasty and ream-and-run arthroplasty for primary glenohumeral osteoarthritis.

BACKGROUND: Reports on long term outcomes and failures of shoulder arthroplasty are uncommon. The purpose of this study is to present minimum 10-year outcomes in consecutive patients undergoing ream-and-run and anatomic total shoulder arthroplasty (TSA) for primary glenohumeral arthritis. METHODS: This study analyzed consecutive patients who had undergone a ream-and-run or TSA with minimum 10-year follow-up. Pain scores and Simple Shoulder Test (SST) values were obtained preoperatively and at a minimum of 10 years postoperatively via e-mail or mail-in response. Percentage of maximum possible improvement (%MPI) was also calculated. RESULTS: Of 127 eligible patients, 63 (50%) responded to a 10-year survey. This included 34 patients undergoing ream-and-run arthroplasty and 29 patients undergoing TSA. The ream-and-run patients were significantly younger than the TSA patients (60 ± 7 vs. 68 ± 8, P < .001), predominantly male (97% vs. 41%, P < .001), and had a lower American Society of Anesthesiologists classification (P = .018). In the ream-and-run group, the mean pain score improved from a preoperative value of 6.5 ± 1.9 to 0.9 ± 1.3 (P < .001), and the mean SST score improved from 5.4 ± 2.4 to 10.3 ± 2.1 at 10-year follow-up (P < .001). Twenty-eight (82%) achieved an SST improvement above the minimally clinically important difference (MCID) of 2.6. Four patients (12%) underwent single-stage exchange to another hemiarthroplasty, whereas 1 (3%) required manipulation under anesthesia. In the TSA group, the pain score improved from a preoperative value of 6.6 ± 2.2 to 1.2 ± 2.3 (P < .001), and the SST score improved from 3.8 ± 2.6 to 8.9 ± 2.6 at 10-year follow-up (P < .001). Of the 29 patients who underwent a TSA, 27 (93%) achieved an SST improvement above the MCID of 1.6. No patient in the TSA group required reoperation. CONCLUSION: Although the characteristics of the patients differ between the 2 groups, excellent functional results can be obtained with the ream-and-run arthroplasty and TSA for glenohumeral osteoarthritis.

Factors associated with success of ream-and-run arthroplasty at a minimum of 5 years.

BACKGROUND: Ream-and-run arthroplasty offers improvements in shoulder pain and function for patients with primary glenohumeral arthritis who wish to avoid limitations associated with a polyethylene glenoid component. Longer-term clinical outcome assessments of the ream-and-run procedure are sparse in the literature. This study aimed to present minimum 5-year functional outcomes in a large cohort following ream-and-run arthroplasty to determine factors associated with clinical success and reoperation. METHODS: Patients who underwent ream-and-run surgery with a minimum of 5 years of follow-up were identified through a retrospective review of a prospectively maintained database from a single academic institution. To assess clinical outcomes, the Simple Shoulder Test (SST) was administered and assessed to determine achievement of the minimal clinically important difference, as well as the necessity for open revision surgery. Factors associated with P < .1 on univariate analysis were included in multivariate analysis. RESULTS: Of 228 patients who consented to undergo long-term follow-up, 201 (88%) were included in our analysis (mean follow-up period, 7.6 ± 2.1 years). The average age was 59.4 ± 8.8 years, and 93% of patients were men. The majority of patients had a diagnosis of osteoarthritis (79%) or capsulorrhaphy arthropathy (10%). SST scores improved from a mean of 4.9 ± 2.5 preoperatively to a mean of 10.2 ± 2.6 at latest follow-up. The minimal clinically important difference in the SST score of 2.6 was reached by 165 patients (82%). Male sex (P = .020), nondiabetic status (P = .080), and lower preoperative SST score (P < .001) were included in a multivariate analysis. Male sex (P = .010) and lower preoperative SST score (P < .001) were associated with clinically important improvements in SST scores on multivariate analysis. Open revision surgery was required in 22 patients (11%). Younger age (P < .001), female sex (P = .055), and higher preoperative pain score (P = .023) were included in a multivariate analysis. Only younger age was predictive of open revision surgery (P = .003). CONCLUSIONS: Ream-and-run arthroplasty can provide significant and clinically important improvements in clinical outcomes at minimum 5-year follow-up. Successful clinical outcomes were significantly associated with male sex and lower preoperative SST scores. Reoperation was more common in younger patients.

Revision of total shoulder arthroplasty to hemiarthroplasty: results at mean 5-year follow-up.

BACKGROUND: Although there is a trend to manage failed anatomic total shoulder arthroplasties (aTSA) with revision to a reverse total shoulder arthroplasty, such revisions can be complicated by difficulties in baseplate fixation, instability, and acromial stress fractures. Some cases of failed aTSA may be safely revised to a hemiarthroplasty (HA). The objectives of this study were to report patient-reported outcomes after conversion from aTSA to HA and assess patient and shoulder characteristics associated with a successful outcome. METHODS: Patients who underwent revision from aTSA to HA between 2009 and 2018 were contacted. Patient demographics, surgical history, intraoperative findings, and microbiology results were collected. Patient-reported outcomes were collected with minimum 2-year follow-up. Preoperative radiographic characteristics were reviewed for component positioning and component loosening. Patients with a clinically significant improvement exceeding the minimal clinically important difference (MCID) of the Simple Shoulder Test (SST) were compared with those patients who did not improve past the MCID. RESULTS: Twenty-nine patients underwent conversion from aTSA to HA with a mean follow-up of 4.5 ± 1.8 years. Intraoperative glenoid or humeral component loosening was found in all 29 patients. Pain improved in 25 of 30 patients (87%), and mean pain scores improved from 6.2 ± 2.3 to 3.1 ± 2.4 (P < .001). SST scores improved from 4.1 ± 3.1 to 7.3 ± 3.2 (P < .001), and 18 of 29 patients (62%) had improvement above the SST MCID threshold of 2.4. The mean American Shoulder and Elbow Surgeons score at the latest follow-up was 64 ± 19, and the Single Assessment Numeric Evaluation score was 65 ± 23. Twenty-two of 29 (76%) patients were satisfied with the procedure. Four patients (14%) required conversion to total shoulder arthroplasty-2 to anatomic and 2 to reverse. An additional 3 patients (10%) had a revision HA performed. No significant differences in patient or shoulder characteristics were found in those patients who improved greater than the MCID of the SST compared patients who improved less than the MCID of the SST. Fifty-nine percent of patients had ≥2 positive cultures with the same bacteria, and 82% of these were with Cutibacterium. Seven of 8 patients (88%) with a loose humeral component had ≥2 positive cultures with the same bacteria. DISCUSSION: Component loosening is a common failure mode after aTSA. Revision to HA can improve pain and patient-reported outcomes in most patients.

Predictors of success following single-stage revision shoulder arthroplasty: results at a mean of five year follow-up in one hundred and twelve patients.

PURPOSE: The objective was to determine factors associated with a successful outcome at a minimum of two years after revision of a failed shoulder arthroplasty. METHODS: We conducted a retrospective study of revision shoulder arthroplasties performed over a ten year period and collected patient-reported outcome data and re-revision data. A successful outcome was defined by improvement greater than the minimal clinically important difference (MCID) for the Simple Shoulder Test (SST). RESULTS: One hundred twelve patients with average follow-up of five years were included. Improvement of VAS pain scores (6.6 ± 2.3 to 2.9 ± 2.6) and SST scores (2.7 ± 2.6 to 6.6 ± 3.3) were significant (p < 0.001). Males were more likely to have a successful outcome than females (p = 0.01). CONCLUSION: Two-thirds of patients experienced clinically significant improvement at a minimum of two years after revision shoulder arthroplasty. Male sex was the strongest independent predictor of a successful outcome.

Variation in technique and postoperative management of the Latarjet procedure among orthopedic surgeons.

BACKGROUND: The Latarjet procedure has become a treatment of choice for glenohumeral instability in the setting of large glenoid osseous defects (>20%) and for prior failed soft tissue repairs. However, surgical techniques and postoperative rehabilitation protocols vary among expert shoulder surgeons. The purpose of this survey study was to characterize the variation in current practice patterns among fellowship-trained orthopedic shoulder surgeons and identify factors related to variation. METHODS: A 9-question survey was created (SurveyMonkey, San Mateo, CA, USA) and distributed to orthopedic surgeons who are active members of the American Shoulder and Elbow Surgeons or American Orthopaedic Society for Sports Medicine. The survey asked questions regarding surgeon experience with the Latarjet procedure, fellowship training, open vs. arthroscopic approach, method of coracoid-to-glenoid fixation, period of sling use postoperatively, and time before clearance to return to sport. Subgroup analysis was performed to determine whether further variation was evident between surgeons who completed sports medicine vs. shoulder and elbow fellowship training. RESULTS: In total, 242 surgeons completed the survey. Of these, 55% indicated performing a sports medicine fellowship and 39% indicated completing a shoulder and elbow fellowship. Among all surgeons, the classic open Latarjet procedure was the strongly preferred technique (79%), followed by the open congruent-arc (17%) and all-arthroscopic (3%) techniques. With respect to fixation, 98% used screw fixation and only 1% indicated cortical button use. With respect to the postoperative course, >85% of surgeons preferred immobilization for 3-6 weeks after the procedure and 42% of respondents stated they waited ≥6 months prior to clearing their patients to return to sport. Subgroup analysis revealed that surgeons who completed a shoulder and elbow fellowship performed the classic open technique 89% of the time compared with 63% of those who completed a sports medicine fellowship (P < .001). CONCLUSION: The results of our survey study indicate an overall strong preference for the open classic Latarjet technique as well as an overall strong preference for screw fixation of the coracoid graft to the glenoid among all surgeons. Shoulder and elbow fellowship-trained surgeons are significantly more likely to perform open surgery with a classic technique compared with sports medicine fellowship-trained surgeons. Furthermore, the significant variation in postoperative sling use and return to sport suggests that further research is needed to develop an evidence-based postoperative Latarjet rehabilitation protocol.

Variation in management of humeral and clavicular shaft fractures amongst fellowship trained orthopedic traumatologists.

BACKGROUND: There exists a wide variety of opinions on the appropriate management of diaphyseal humeral and clavicular fractures amongst orthopedic surgeons. The purpose of this study is to determine if there is a preference amongst orthopedic traumatologists on treatment of diaphyseal humerus and clavicle fractures with respect to various patient populations. METHODS: A 6-question survey was created using Surveymonkey.com and distributed via the Orthopedic Trauma Association (OTA) website to fellowship trained orthopedic surgery traumatologists to survey the preferred management of a simple oblique middle 1/3rd diaphyseal humerus fracture and a middle 1/3rd displaced diaphyseal clavicle fracture in the following 3 clinical settings: a healthy laborer, an older patient with co-morbidities, and if the surgeon themselves sustained the injury. The ratio of operative to non-operative management was calculated for all 6 questions. A chi-square value was performed to determine if the results are clinically significant based on the clinical scenario. RESULTS: There was 56 responses to the survey that were included in the analysis. Overall, there was a statistically significant trend towards surgical management of the surgeon's own diaphyseal humerus fractures (55%) compared to that of healthy patients (41%) and those with medical comorbidities (21%) (p = 0.02) A similar trend was noted for operative management for diaphyseal clavicle fractures by the surgeon on their own fractures (43%) compared to that of healthy patients (38%) and those with medical comorbidities (18%) (p = 0.02). CONCLUSION: While there are an increasing number of relative indications for treatment of diaphyseal humerus shaft and clavicle fractures, the results of this survey indicate that fellow-ship-trained orthopedic trauma surgeons prefer surgical management of simple humerus and clavicular fractures in young, healthy patients as well as in themselves.

Masquelet Reconstruction for Posttraumatic Segmental Bone Defects in the Forearm.

PURPOSE: The Masquelet technique is a procedure increasingly utilized for addressing segmental bone defects. The technique involves staged procedures consisting of bone debridement and temporary spacer placement to induce membrane formation, followed by delayed bone grafting. This report summarizes our center's experience with the Masquelet technique to reconstruct bone loss exclusively in the forearm. METHODS: We reviewed all cases in which the Masquelet technique was used to reconstruct segmental bone defects in the forearm resulting from acute trauma or nonunion, with or without infection, between 2014 and 2017 at a level-1 trauma center. Injury mechanism, prior surgeries, extent of bone defect, and demographic data were collected. Union was assessed along with treatment-related complications or reoperations. RESULTS: We identified 9 patients with segmental bony defects in the forearm treated with the Masquelet technique. Among this cohort, 5 patients had bone defects associated with acute open fractures and 4 patients presented with nonunion (1 atrophic and 3 infected nonunions). The median bony defect was 4.7 cm (range, 1.7-5.4 cm) at the time of grafting. Second stage grafting was performed with Reamer Irrigator Aspirator autograft from the femur in 8 patients and iliac crest bone cancellous graft in 1 patient. Union was achieved in all 9 patients. Six patients achieved union by 3-month follow-up, 2 patients by 6 months, and 1 patient by 12 months. One patient required a reoperation for plate fracture prior to union treated with revision internal fixation and grafting. CONCLUSIONS: The Masquelet technique effectively reconstructed traumatic and posttraumatic segmental defects in the forearm with a low incidence of complication. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Dysbaric osteonecrosis: a literature review of pathophysiology, clinical presentation, and management.

OBJECTIVE: To perform a general literature review of dysbaric osteonecrosis (DON) to describe its pathophysiology, prevalence in scuba divers, prognosis, and treatment options. DATA SOURCES: A literature search on PubMed was performed using the term "dysbaric osteonecrosis" yielding 67 results. There was no exclusion based on dates. Articles that mainly dealt with decompression sickness secondary to tunnel work, mining, or airplane travel were not selected. An additional search on PubMed using the terms "(osteonecrosis diving) NOT dysbaric" was performed to identify other publications not picked up in the initial search. MAIN RESULTS: Dysbaric osteonecrosis is associated with prolonged hyperbaric exposure and rapid decompression that cause nitrogen bubbles to enter the fatty marrow-containing shafts of long bones leading to reduction in blood flow and subsequent osteonecrosis. Patients may present asymptomatically, and typical radiographic findings of DON include: decalcification of bone, cystic lesions, osteosclerotic patterns, nontraumatic fractures, bone islands, and a subchondral crescent sign. Surgical treatment options are comprised of core decompression and free vascularized fibular graft, whereas nonsurgical treatment options consist of monitoring, physical therapy, and bisphosphonate therapy. CONCLUSIONS: Although the incidence of DON has decreased significantly over the past 2 decades, the lack of timely diagnosis and optimal management keeps DON relevant in the orthopedic and sport medicine community.

Effectiveness of telemedical applications in postoperative follow-up after total joint arthroplasty.

We hypothesized that a postoperative clinical telemedicine tool will be effective in reducing the total number of unscheduled postoperative clinic visits and calls while increasing patient satisfaction. The medical charts of 34 patients who underwent telemedicine follow-up during their postoperative care were compared to that of 44 patients who did undergo telemedicine follow-up. There were 14 unscheduled clinic visits in the non-telemedicine follow-up group compared to only 3 in the telemedicine follow-up group (P = 0.01). There were 40 in-clinic calls made by patients in the non-telemedicine follow-up group compared to only 6 made by patients in the telemedicine group (P < 0.01). In addition, patients who underwent telemedicine follow-up rated their postoperative satisfaction higher than those who did not undergo telemedicine follow-up.

Factors determining discharge destination for patients undergoing total joint arthroplasty.

Discharge destination to skilled nursing facilities (SNF) following total joint arthroplasty (TJA) plays an important role in healthcare costs. The pre-operative, intra-operative, and post-operative factors of 50 consecutive patients discharged to an SNF following TJA were compared to that of 50 consecutive patients discharged to home. Patients discharged to SNFs had slower pre-operative Get Up and Go scores (TGUG), lower pre-operative EQ-5D scores, higher ASA scores, increased hospital length of stay, increased self-reported post-operative pain, and decreased physical therapy achievements. We believe that the results of this study indicate that patients who get discharged to SNFs fit a certain criteria and this may be used to guide post-operative discharge destination during pre-operative planning, which can help lower costs while helping decrease the length of inpatient stay.

Recalcitrant macular edema after intravitreal bevacizumab is responsive to an intravitreal dexamethasone implant in retinal vein occlusion.

PURPOSE: To test the efficacy of an intravitreal dexamethasone implant in patients with recalcitrant macular edema secondary to retinal vein occlusion. METHODS: A retrospective chart review was performed for 18 patients with retinal vein occlusion who received multiple bevacizumab intravitreal injections before treatment with an intravitreal dexamethasone implant. RESULTS: Two subgroups of bevacizumab-resistant patients were identified. Both subgroups responded to subsequent treatment with an intravitreal dexamethasone implant with an average reduction in central foveal thickness of 146.8 ± 33.65 µm. A visual acuity improvement of 0.26 ± 0.07 (logarithm of minimal angle of resolution) was also noted. Intraocular pressure increased by an average of 3.33 ± 0.66 mmHg and was managed by 1.0 ± 0.5 topical drops. CONCLUSION: A subset of patients do not have resolution of macular edema after treatment with intravitreal bevacizumab. Such patients may respond to treatment with an intravitreal dexamethasone implant.

Pars plana Ahmed valve and vitrectomy in patients with glaucoma associated with posterior segment disease.

PURPOSE: To assess the safety and efficacy of a modified technique for pars plana placement of the Ahmed valve in combination with pars plana vitrectomy in the treatment of glaucoma associated with posterior segment disease. METHODS: Thirty-nine eyes with glaucoma associated with posterior segment disease underwent pars plana vitrectomy combined with Ahmed valve placement. All valves were placed in the pars plana using a modified technique, without the pars plana clip, and using a scleral patch graft. RESULTS: The 24 eyes diagnosed with neovascular glaucoma had an improvement in intraocular pressure from 37.6 mmHg to 13.8 mmHg and best-corrected visual acuity from 2.13 logarithm of minimum angle of resolution to 1.40 logarithm of minimum angle of resolution. Fifteen eyes diagnosed with steroid-induced glaucoma had an improvement in intraocular pressure from 27.9 mmHg to 14.1 mmHg and best-corrected visual acuity from 1.38 logarithm of minimum angle of resolution to 1.13 logarithm of minimum angle of resolution. Complications included four cases of cystic bleb formation and one case of choroidal detachment and explantation for hypotony. CONCLUSION: Ahmed valve placement through the pars plana during vitrectomy is an effective option for managing complex cases of glaucoma without the use of the pars plana clip.

Total intravenous anesthesia compared to traditional general anesthesia in shoulder arthroscopy with interscalene block in the beach chair position.

Background: Shoulder arthroscopy is commonly performed in the beach chair position, which has been linked to cerebral oxygen desaturation. Previous studies comparing general anesthesia (GA) to total intravenous anesthesia (TIVA) using propofol indicate that TIVA can preserve cerebral perfusion and autoregulation, as well as shorten recovery time and reduce the incidence of postoperative nausea and vomiting. However, few studies have evaluated the use of TIVA in shoulder arthroscopy. Thus, this study seeks to determine if TIVA is superior to traditional GA methods in terms of improving operating room efficiency, shortening recovery time, and reducing adverse events while theoretically preserving cerebral autoregulation in patients undergoing shoulder arthroscopy in the beach chair position. Methods: This is a retrospective study of patients undergoing shoulder arthroscopy in the beach chair position, comparing 2 anesthetic techniques. One hundred fifty patients were included (75 TIVA and 75 GA). Unpaired t-tests were used to determine statistical significance. Outcome measures included operating room times, recovery times, and adverse events. Results: Compared to GA, TIVA significantly improved phase 1 recovery time (53.2 ± 32.9 min compared to 65.8 ± 41.3 min; P = .037) and total recovery time (120.3 ± 31.0 min compared to 131.5 ± 36.8 min; P = .048). TIVA also decreased time from case finish to out-of-room (6.5 ± 3.5 min compared to 8.4 ± 6.3 min; P = .021). However, the in-room to case start time was slightly longer for the TIVA group (31.8 ± 7.22 min compared to 29.2 ± 4.92 min; P = .012). Although not statistically significant, there were fewer readmissions in the TIVA group compared to the GA group (P = .08), and TIVA had lower rates of postoperative nausea and vomiting (P = .22) and higher intraoperative mean arterial pressures (87.1 ± 11.4 mmHg in the TIVA group compared to 85.0 ± 9.3 mmHg in the GA group; P = .22). Conclusion: TIVA may be a safe and efficient alternative to GA in shoulder arthroscopy in the beach chair position. Larger scale studies are needed to evaluate the risk of adverse events related to impaired cerebral autoregulation in the beach chair position.

Characterizing tourniquet induced hemodynamics during total knee arthroplasty using diffuse optical spectroscopy.

Tourniquet use creates a reduced blood surgical field during total knee arthroplasty (TKA), however, prolonged ischemia may cause postoperative tourniquet complications. To understand the effects of tourniquet-induced ischemia, we performed a prospective observational study using quantitative broadband diffuse optical spectroscopy (DOS) to measure tissue hemodynamics and water and lipid concentrations before, during, and after tourniquet placement in subjects undergoing TKA. Data was collected for 6 months and, of the total subjects analyzed (n = 24), 22 were primary TKAs and 2 were revision TKA cases. We specifically investigated tourniquet-induced hemodynamics based upon subject-specific tissue composition and observed a significant relationship between the linear rate of deoxygenation after tourniquet inflation and water/lipid ratio (W/L, p < 0.0001) and baseline somatic tissue oxygen saturation, StO2 (p = 0.05). Subjects with a low W/L ratio exhibited a lower tissue metabolic rate of oxygen consumption, (tMRO2 ) (p = 0.008). Changes in deoxyhemoglobin [HbR] (p = 0.009) and lipid fraction (p = 0.001) were significantly different between high and low W/L subject groups during deoxygenation. No significant differences were observed for hemodynamics during reperfusion and total tourniquet time was neither significantly related to the hemodynamic hyperemic response (p = 0.73) nor the time to max StO2 after tourniquet release (p = 0.57). In conclusion, we demonstrate that DOS is capable of real-time monitoring of tissue hemodynamics distal to the tourniquet during TKA, and that tissue composition should be considered. DOS may help surgeons stratify hemodynamics based upon tissue composition and eventually aid the preoperative risk assessment of vascular occlusions from tourniquet use during TKA.

Radiographic Outcomes of Dorsal Spanning Plate for Treatment of Comminuted Distal Radius Fractures in Non-Elderly Patients.

Purpose: Multifragmentary fractures of the distal radius with articular and metaphyseal comminution (AO 23-C3) represent challenging injuries to manage. Distal fracture lines, articular comminution, and limited distal bone stock may preclude stable fixation with a volar locking plate. The use of a dorsal spanning plate (DSP) offers an alternative treatment option in this setting. We examined the radiographic outcomes of a consecutive series of patients with comminuted intra-articular distal radius fractures not amenable to volar locked plating, who were treated with a DSP. Methods: We reviewed all distal radius fractures treated with a dorsal spanning plate at our institution between October, 2014 and March, 2018. Patients with AO 23-C3 fractures treated with dorsal spanning plate fixation were included in this study. Demographic data, time from plate placement to removal, and postoperative radiographic outcomes were examined. Results: We identified 24 patients, mean age 41 years (range, 19-62 years). Mean follow-up was 19.5 weeks (range, 12-35 weeks) from the time of plate placement. Plates were removed at a mean of 87 days (range, 40-215 days) after surgery. All patients achieved radiographic union. Mean radial height at the time of union was 11.1 mm (SD, ±3.7 mm; range, 6-18 mm), radial inclination was 19.7° (SD, ±5.4°; range, 9° to 30°), ulnar variance was 1.0 mm (SD, ±2.4 mm; range, -3 to 6 mm), and volar tilt was 1.4° (SD, ±5.2°; range, -10° to 14°). Mean articular displacement was 1.7 mm (SD, ±1.7 mm; range, 0-6 mm). Malalignment of at least one of these radiographic parameters was identified in 16 of 24 patients at the time of union. Conclusions: Dorsal spanning plate fixation offers an alternative treatment option for comminuted intra-articular distal radius fractures (AO 23-C3). Although this technique presents a straightforward means for fixation of complex distal radius fractures, radiographic outcomes may be inferior relative to less complex fractures treated with standard volar plating techniques. Type of study/level of evidence: Therapeutic IV.

Neuromuscular Choristoma Variant in the Forearm Presenting as a Posterior Interosseous Nerve Palsy: A Case Report.

CASE: A 14-year-old boy presented with an 18-month history of progressive left wrist drop. Magnetic resonance imaging studies were concerning for mass infiltration of the posterior interosseous nerve (PIN). Surgical resection and pathology confirmed a variant of neuromuscular choristoma (NMC), infiltrated with and surrounded by proliferation of smooth muscle, rather than skeletal muscle. Given the wide-spanning nerve involvement, the patient underwent tendon transfers at the time of surgical resection. CONCLUSION: We report here the first case report of a NMC in the PIN and the first pathologically confirmed case with exclusive smooth muscle involvement without a skeletal muscle component.