Foot and Ankle Bone Marrow Edema Assessment in Long Distance Runners.

BACKGROUND: The clinical significance of foot and ankle bone marrow edema (BME) is poorly understood. METHODS: Magnetic resonance imaging (MRI) and the visual analog scale (VAS) pain scores were collected for 17 runners who participated in the Twin Cities Marathon, immediately postmarathon and at a 6-week follow-up. Bone marrow edema lesions were classified using lesion frequency, anatomical location, and grading scale change to calculate a BME score for each affected bone. Spearman rank correlation coefficient test was used to identify a possible correlation between VAS and postmarathon BME. A paired Student t test was used to detect differences between total mileage ran 6 weeks postmarathon in participants with or without BME. RESULTS: After completing the marathon, 8 BME lesions were identified in 5 participants (29.4%; 5/17), 3 were men, and 2 were women, with a mean age of 33.8 years (range: 24-52), and BMI of 22.9 ± 4. All lesions were resolved on 6-week follow-up imaging. VAS pain scores did not correlate with postmarathon BME. A significant difference in total miles logged over 6 weeks postmarathon could not be found among participants with and without BME. CONCLUSION: Foot and ankle BME changes identified by MRI were not correlated to clinical symptoms and may resolve with self-directed activity in less time than other areas of the lower extremity. LEVEL OF EVIDENCE: Level II, Prospective Cohort Study.

Resident Impact on Primary Total Knee Arthroplasty: A Consecutive Series Under a Single Surgeon.

Background: The literature has displayed conflicting evidence on resident involvement in surgical procedures. The goal of this study was to assess the impact of resident involvement on primary total knee arthroplasty (TKA) under a single fellowship-trained adult reconstruction surgeon. Methods: Two hundred sequential patients were retrospectively reviewed by a single surgeon: the first cohort represented the final 100 TKAs performed by the surgeon without resident involvement (NRI), serving as the control group, and the second cohort represented the initial 100 TKAs performed by the same surgeon with resident involvement (RI), serving as the experimental group. Perioperative variables such as number of people in operating room (OR), surgical time, and tourniquet time, and postoperative variables such as infection, minor complications, medial distal femoral angle, medial proximal tibia angle, and total angulation were assessed. Results: The rate of infection was significantly lower in the RI group (0%) compared to the NRI group (1%) (P = .043). The number of staff in the OR (P < .001), the tourniquet time (P < .001), and OR time (P < .001) were significantly higher in the RI group compared to the NRI group. There was no difference in coronal plane radiographic measurements: medial distal femoral angle (P = .10), medial proximal tibia angle (P = .19), or total angulation (P = .27). Conclusions: Resident involvement in primary TKA neither demonstrated any significant difference in coronal plane radiographic alignment of the prosthesis nor an increased risk of infection despite increased operative time, tourniquet time, and number of people in OR. Level of evidence: Level 3 - Therapeutic retrospective cohort study.

Comparing the Use of Axillary Radiographs and Axial Computed Tomography Scans to Predict Concentric Glenoid Wear.

BACKGROUND: Axillary radiographs traditionally have been considered sufficient to identify concentric glenoid wear in osteoarthritic shoulders; however, with variable glenoid wear patterns, assessment with use of computed tomography (CT) has been recommended. The purpose of the present study was to compare the use of axillary radiographs and mid-glenoid axial CT scans to identify glenoid wear. METHODS: Preoperative axillary radiographs and mid-glenoid axial CT scans for 330 patients who underwent anatomic total shoulder arthroplasty were reviewed. Five independent examiners with differing levels of experience characterized the glenoid morphology as either concentric or eccentric. The morphologies determined with use of axillary radiographs and CT scans were assessed for correlation, and both intraobserver and interobserver consistency were calculated. RESULTS: Concentric wear identified with use of radiographs was confirmed with use of CT scans in an average of 61% of cases (range, 53% to 76%). Intraobserver consistency averaged 75% for radiographs and 73% for CT scans. There was significant interobserver consistency, as higher levels of training corresponded with greater consistency between imaging analyses (p < 0.001). The most senior observer identified the highest proportion of concentric wear on radiographs (p < 0.001), showed the greatest consistency between attempts when using CT (p < 0.001), and had the greatest agreement of radiographs and CT evaluating glenoid morphology (p < 0.001). CONCLUSIONS: For the experienced shoulder surgeon, concentric glenoid wear identified on axillary radiographs will appear concentric on 2-dimensional CT in approximately 75% of cases. Obtaining a CT scan to confirm glenoid wear patterns most greatly benefits less-experienced surgeons. Across all levels of experience, axillary radiographs and single-slice, mid-glenoid CT scans appear insufficient for consistently predicting wear patterns. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Medial calcar bone resorption after anatomic total shoulder arthroplasty: does it affect outcomes?

BACKGROUND: The incidence of medial calcar resorption has been shown to be common after uncemented total shoulder arthroplasty (TSA). With etiologies including stress shielding, debris-induced osteolysis, and infection, the clinical impact of medial calcar resorption has not been specifically examined. The purpose of this study was to determine whether resorption is associated with inferior outcomes or higher rates of radiographic loosening in TSA patients. METHODS: We conducted a retrospective review of TSA patients with minimum 2-year clinical follow-up. Patient-reported and functional outcome measures were recorded preoperatively and postoperatively. Postoperative radiographs were evaluated for glenoid and humeral component loosening. A new calcar resorption grading system was introduced to quantify the degree of resorption and assess the progression. RESULTS: A total of 171 patients met the inclusion criteria, with average clinical and radiographic follow-up periods of 50 and 46 months, respectively. Calcar resorption was identified in 110 patients (64.3%). No significant overall differences were observed between the patients with and without calcar resorption. Subgroup analysis showed that patients with grade 3 resorption had a higher incidence of glenoid radiolucencies (50%, P = .001) and patients with a progression from grade 1 to grade 3 had higher incidences of glenoid (50%, P = .003) and humeral (9%, P = .039) radiolucencies. CONCLUSION: Medial calcar resorption following TSA with a standard-length press-fit humeral component is common. Overall, no differences in patient-reported outcome measures or radiographic loosening were found compared with patients without calcar resorption. However, grade 3 calcar resorption and more dramatic progression of resorption should raise the suspicion of prosthetic loosening.

Outcomes of anatomic total shoulder arthroplasty in patients with excessive glenoid retroversion: a case-control study.

BACKGROUND: Ideal management of severe glenoid retroversion during anatomic total shoulder arthroplasty (TSA) remains controversial, as previous reports have suggested that severe retroversion may negatively impact clinical outcomes. The purpose of this study was to evaluate the impact of severe glenoid retroversion on clinical and radiographic TSA outcomes using a standard glenoid component, as well as to compare outcomes among patients with less severe retroversion. METHODS: A case-control study was performed comparing 40 patients treated with TSA with more than 20° of glenoid retroversion preoperatively (average follow-up, 53 months) vs. a matched cohort of 80 patients with less than 20° of retroversion (average follow-up, 49 months). In all patients, the surgical technique, implant design, and postoperative rehabilitation protocol were identical. Patients were matched based on sex, age, indication, and prosthetic size. Comparisons were made regarding patient-reported outcome measures (PROMs), motion, postoperative radiographic loosening, and the presence of medial calcar resorption. RESULTS: Preoperatively, both groups demonstrated similar PROMs and measured motion, except for preoperative Single Assessment Numeric Evaluation scores and American Shoulder and Elbow Surgeons total scores, which were higher for the severe retroversion group (44.4 vs. 31.3 [P = .012] and 34.9 vs. 29.4 [P = .048], respectively). Postoperative PROMs and motion were also similar between the 2 cohorts. No significant differences were observed for postoperative radiographic findings. Medial calcar resorption was identified in 74 patients (61.7%). Calcar resorption and individual resorption grades were not found to differ significantly. CONCLUSION: At midterm follow-up, preoperative severe glenoid retroversion does not appear to influence clinical or radiographic outcomes of TSA using a standard glenoid component.

Primary Monoblock Inset Reverse Shoulder Arthroplasty Resulted in Decreased Pain and Improved Function.

BACKGROUND: The first-generation, lateral-center-of-rotation reverse shoulder arthroplasty (RSA) modular design has demonstrated durable early-, mid-, and long-term outcomes. The second-generation monoblock implant shares a similar design but eliminates the modular junction and facilitates inset placement within the metaphysis to avoid humeral-sided junctional failures and facilitate metaphyseal press-fit. However, no paper has specifically examined the radiographic findings and improvements in pain and function after the use of this next generation design. QUESTIONS/PURPOSES: (1) After second-generation, lateral-center-of-rotation monoblock RSA, what are the improvements in shoulder scores, general health scores, and ROM at a minimum of 2 years of followup? (2) Are the differences in shoulder scores, health scores, and ROM associated with fixation (cemented versus cementless components)? (3) How frequently do complications occur (defined as humeral loosening, dislocation, baseplate failure, scapular notching, acromial fractures, and revision surgery) after inset monoblock RSA? METHODS: We retrospectively studied patients undergoing primary RSA between 2010 and 2015 with preoperative data and a minimum of 2 years of clinical followup. Of the 329 primary RSA performed during this period, 125 were excluded based on the use of a different generation humeral stem of the same design, three based on need for a nickel-free implant, and 39 due to a lack of preoperative shoulder scores. Of the remaining 162 patients, 137 patients (85%) met the inclusion criteria with a mean age of 74 years (range, 46-90 years). The predominant indications were osteoarthritis with a massive rotator cuff tear (74%) and fracture sequelae (16%). During the study, humeral implants were typically inserted using an uncemented press-fit technique (85%), with only 21 patients requiring a cemented humeral stem. The mean clinical and radiographic followup period was 37 months (range, 24-82 months). Patient-reported outcome measures (PROMs) including the Simple Shoulder Test, American Shoulder and Elbow Surgeons Total, VAS for pain, SF-12, Single Assessment Numeric Evaluation, and measured active motion (forward elevation and external and internal rotation) were recorded at pre- and postoperative intervals. Postoperative radiographs were evaluated for baseplate failure, glenoid and humeral loosening, scapular notching, and acromion fractures. Complications were recorded in the longitudinally maintained institutional repository. RESULTS: At the most recent followup examination, there were improvements in measured motion, general health outcomes, and all PROMs. There were no differences between the cemented and press-fit techniques. Complications observed included 17 of 137 patients (12%) with scapular notching, six postoperative acromion fractures (4%), and two revision procedures (1%). No patients experienced gross humeral loosening or baseplate failure. CONCLUSIONS: Primary RSA using a second-generation monoblock inset humeral component resulted in improvements in pain and functional outcomes as well as low rates of acromion fractures, humeral radiolucency, and complications. Future studies are needed to provide a more definitive analysis on the use of an uncemented technique for humeral stem fixation and the effect of an inset stem on postoperative acromion fractures. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Predicting outstanding results after reverse shoulder arthroplasty using percentage of maximal outcome improvement.

BACKGROUND: The purpose of this study was to determine whether thresholds regarding the percentage of maximal improvement in the Simple Shoulder Test (SST) score and American Shoulder and Elbow Surgeons (ASES) score exist that predict excellent patient satisfaction after reverse shoulder arthroplasty (RSA). METHODS: Patients undergoing RSA with a single implant system were evaluated preoperatively and at a minimum 2-year follow-up. Receiver operating characteristic curve analysis determined thresholds to predict excellent patient satisfaction by evaluating the percentage of maximal improvement for SST and ASES scores. Preoperative factors were analyzed as independent predictors for achieving SST and ASES score thresholds. RESULTS: There were 198 (SST score) and 196 (ASES score) patients who met inclusion criteria. For SST and ASES scores, receiver operating characteristic curve analysis identified 61.3% (P < .001) and 68.2% (P < .001) maximal improvement as the threshold for maximal predictability of excellent satisfaction, respectively. Significant positive correlation between the percentage of maximum score achieved and excellent patient satisfaction for both groups was found (r = 0.440 [P < .001] for SST score; r = 0.417 [P < .001] for ASES score). Surgery on the dominant hand, greater baseline visual analog scale pain score, and cuff arthropathy were independent predictors for achieving the SST and ASES score threshold. CONCLUSION: Thresholds for the achievement of excellent satisfaction after RSA were 61.3% of maximal SST score improvement and 68.3% of maximal ASES score improvement. Independent predictors of achieving these thresholds were dominant-sided surgery and higher baseline visual analog scale pain scores for the SST score and rotator cuff arthropathy for the ASES score.

Lesser tuberosity osteotomy in total shoulder arthroplasty: impact of radiographic healing on outcomes.

BACKGROUND: Lesser tuberosity osteotomy (LTO) has gained popularity in anatomic total shoulder arthroplasty (TSA); however, healing rates have not been universally high. This study examined differences in outcomes based on variations in LTO healing. METHODS: A retrospective review identified primary TSA patients with 2-year minimum follow-up treated with a LTO. Postoperative radiographs classified LTO healing as "bony union," "nondisplaced nonunion," "displaced nonunion," and "not seen," creating 4 cohorts. Comparisons were made among patient-reported outcome measures (PROMs), motion, and radiographic evidence of component loosening. RESULTS: The study cohort consisted of 189 patients who met inclusion criteria, with an average age of 69.5 years (range, 32-89 years) and follow-up of 50 months (range, 24-95 months). There were 143 patients with union, 16 with nondisplaced nonunion, 14 with displaced nonunion, and 16 not seen. There were no differences in preoperative comparisons. All cohorts demonstrated significant improvements in PROMs and ranges of motion; however, the displaced nonunion cohort had no improvement in Single Assessment Numeric Evaluation (0.114) or internal rotation (P = .279). Patients with displaced nonunion had lower postoperative functional scores (Simple Shoulder Test and American Shoulder and Elbow Surgeons scores; P < .01), and higher pain scores (visual analog scale for pain; P < .01). However, 85.7% of patients reported they would have the same procedure again. Simple Shoulder Test (2.5) and American Shoulder and Elbow Surgeons score (37.5) improvements exceeded minimal clinically important difference thresholds for TSA. A higher rate of glenoid gross loosening was present in the displaced nonunion cohort (3 patients [21.4%]; P < .01). There were no cases of loose humeral stems. CONCLUSION: Patients with a displaced nonunion LTO site have lower functional scores and higher pain scores but still achieve substantial clinical improvement and high satisfaction rates.

Case-control comparison of "in-the-groove" and lateral-row arthroscopic biceps tenodesis with concomitant rotator cuff repair.

BACKGROUND: Lateral-row (LR) arthroscopic biceps tenodesis (BT) has been described as a technique using an LR rotator cuff repair (RCR) anchor for biceps fixation. This technique has not been compared with other BT techniques. The purpose of this study was to compare the clinical outcomes of patients undergoing a suprapectoral "in-the-groove" arthroscopic BT and patients treated with an LR tenodesis performed in conjunction with arthroscopic RCR. METHODS: Patients undergoing arthroscopic BT in the setting of an arthroscopic RCR were evaluated preoperatively and at a minimum of 12 months' follow-up. Patients who underwent an in-the-groove BT were matched 1:1 to patients who underwent an LR BT based on age at surgery and size of the rotator cuff tear using the Patte classification. Comparisons made included age, sex, body mass index, patient-reported outcome measures, range of motion, and patient satisfaction. RESULTS: There were 82 patients (41 in each group) who met the inclusion criteria, with an average follow-up period of 33 months and average age of 61 years. By use of the Patte classification, there were 20 matched pairs with stage 1 tears, 11 matched pairs with stage 2 tears, and 10 matched pairs with stage 3 tears. Comparisons of the 2 cohorts revealed no differences in preoperative or postoperative motion, patient-reported outcome measures, or patient satisfaction. Furthermore, no differences were found in overall improvements in motion or outcome measures, as well as overall satisfaction. CONCLUSIONS: Patients undergoing simultaneous RCR and BT demonstrate similar patient-reported and objective outcomes for both LR tenodesis and in-the-groove tenodesis techniques.

Midterm results of anatomic total shoulder arthroplasty with a third-generation implant.

BACKGROUND: Anatomic total shoulder arthroplasty (TSA) provides reliable, reproducible, and durable results; however, outcomes of many modern TSA systems are lacking. The present study reports early to midterm results of a third-generation TSA system using a traditional-length press-fit humeral stem and cemented glenoid. METHODS: A retrospective review was conducted of TSA patients with minimum 2-year clinical follow-up. Patient-reported outcome measures, including Simple Shoulder Test, American Shoulder and Elbow Surgeons Total, visual analog scale for pain, 12-Item Short Form Health Survey, and Single Assessment Numeric Evaluation, as well as measured active motion (forward elevation, external and internal rotation), were recorded at preoperative and postoperative intervals. Preoperative midglenoid axial computed tomography scans were used to evaluate eccentric glenoid wear, humeral head subluxation, and glenoid version. Most recent postoperative radiographs were used to evaluate glenoid loosening, humeral loosening, lesser tuberosity union, and medial calcar resorption. Patient satisfaction at final follow-up was reported as excellent, good, satisfied, or unsatisfied. RESULTS: There were 267 patients who met inclusion criteria, with a mean age of 70.9 years and mean clinical follow-up of 47 months. Average glenoid retroversion was 9.7°, and 27% had eccentric glenoid wear. At final follow-up, measured motion and nearly all patient-reported outcome measures showed significant improvements, with 75.6% of patients rating their satisfaction as excellent. No patient was considered "at risk" for humeral stem loosening. Glenoid radiolucencies were seen in 13.5% of shoulders (7 gross loosening). Five patients were revised to reverse TSA. CONCLUSION: TSA using a third-generation traditional-length press-fit stem and cemented glenoid provides excellent early to midterm outcomes with low rates of loosening and high rates of excellent satisfaction.

Arthroscopic Treatment of Popliteal Cysts.

Popliteal cysts, often referred to as Baker's cysts, are a common occurrence in the adult knee. Although controversy exists as to the exact indications for treatment, these structures can cause extreme discomfort and morbidity, including pain from rupture and symptoms from neurovascular compromise. Prior to the development of the arthroscope, open treatment of popliteal cysts was not uncommon. Complications such as poor wound healing, cyst recurrence, and knee flexion contractures were reported after such treatment. Owing to the presence of a valve-type structure, also called the posterior transverse synovial infold, there is 1-way flow of synovial fluid into the cyst. Although seldom described, there is a reproducible and relatively straightforward arthroscopic treatment for this pathology. This technical report will describe the arthroscopic treatment of popliteal cysts and clarify the posterior knee anatomy that gives the surgeon the landmarks to perform safe and effective arthroscopic treatment of popliteal cysts.