Utility of Recovery Room vs Post-Operative Day 1 Radiographs Following Shoulder Arthroplasty.

Background: Postoperative radiographs may be performed on different timelines after shoulder arthroplasty. Radiographs obtained in the post-operative recovery unit (PACU) are often of poorer quality. The purpose of the current study was to explore and compare the quality of PACU radiographs and radiographs performed in the radiology suite on post-operative Day 1 (POD1), as well as determine their impact on changes in post-operative management. Methods: Our series included 50 consecutive anatomic total shoulder arthroplasties (TSA) for which post-operative radiographs were obtained in the PACU and 50 consecutive TSA for which post-operative radiographs were obtained in the radiology suite on POD 1. TSA radiographs were blinded and reviewed by 3 authors and graded on their quality using criteria described using previously published methods. The weighted kappa was used to describe the intra-rater agreement and inter-rater agreement between two raters. Results: There was no difference in age, sex, BMI, and comorbidities between cohorts. Intra-observer reliability was moderate to substantial with weighted kappa values of 0.65±0.07 (p<0.001), 0.58±0.09 (p<0.001), and 0.67±0.07 (p<0.001). Inter-observer reliability was moderate to substantial with weighted kappa values of 0.605±0.07 (p<0.001), 0.66±0.07 (p<0.001), and 0.65±0.08 (p<0.001). When assessing quality of radiographs, 30% of radiographs obtained in PACU were deemed quality while 57% of radiographs obtained in the radiology suite were deemed quality (p<0.001). Conclusion: Post-operative radiographs in the PACU do not alter patient management and are often inadequate to serve as baseline radiographs. Conversely, radiographs obtained in the radiology suite are of higher quality and can serve as a superior baseline radiograph. Level of Evidence: IV.

Periostin Is a Biomarker for Anterior Shoulder Instability: Proteomic Analysis of Synovial Fluid.

BACKGROUND: The incremental biological changes in the synovial microenvironment of the shoulder in acute and chronic instability that may contribute to joint degeneration are poorly understood. Proteomic analysis of synovial fluid in patients with shoulder instability may improve our understanding of proteins that are shed into shoulder synovial fluid after an injury. HYPOTHESIS: Injury-specific factors such as the direction of instability and the severity of glenoid and humeral bone loss are associated with the proteome of synovial fluid in patients with shoulder instability. STUDY DESIGN: Descriptive laboratory study. METHODS: Synovial fluid lavage samples were compared between patients with anterior (n = 12) and posterior (n = 8) instability and those without instability (n = 5). Synovial proteins were identified with liquid chromatography-tandem mass spectrometry. Orthogonal validation of protein targets found to be significant on tandem mass spectrometry was performed in a separate set of prospective patients with Western blotting. Data were processed and analyzed, and P values were adjusted with the Benjamini-Hochberg method for multiple comparisons. RESULTS: A total of 25 patients were included. Tandem mass spectrometry identified 720 protein groups in synovial fluid of patients with shoulder instability. There were 4 synovial proteins that were significantly expressed in patients with anterior instability relative to posterior instability: periostin (POSTN) (adjusted P value = .03; log fold change [logFc] = 4.7), transforming growth factor beta-induced protein ig-h3 (adjusted P value = .05; logFc = 1.7), collagen type VI alpha-3 chain (adjusted P value = .04; logFc = 2.6), and coagulation factor V (adjusted P value = .04; logFc = -3.3). Among these targets, POSTN showed a moderate correlation with the Hill-Sachs lesion size (r = 0.7). Prospective validation with Western blotting confirmed a significantly higher level of POSTN in synovial fluid of patients with anterior instability (P = .00025; logFc = 5.1). CONCLUSION: Proteomic analysis enriched our understanding of proteins that were secreted into shoulder synovial fluid of patients with shoulder instability. The identification of POSTN, a proinflammatory catabolic protein involved with tissue remodeling and repair, as a significant target in anterior shoulder instability is a novel finding. Therefore, further study is warranted to determine the role that POSTN may play in the progression of bone loss and posttraumatic osteoarthritis. CLINICAL RELEVANCE: Proteomic analysis of synovial fluid in patients with shoulder instability improved our understanding of this abnormality after an injury.

Rate of incidental findings on routine preoperative computed tomography for shoulder arthroplasty.

BACKGROUND: Incidental findings are commonly noted in advanced imaging studies. Few data exist regarding the rate of incidental findings on computed tomography (CT) for preoperative shoulder arthroplasty planning. This study aims to identify the incidence of these findings and the rate at which they warrant further work-up to help guide orthopedic surgeons in counseling patients. METHODS: A retrospective review was performed to identify patients with available preoperative shoulder CT who subsequently underwent shoulder arthroplasty procedures at a single institution between 2015 and 2021. Data including age, sex, and smoking status were obtained. Radiology reports for CTs were reviewed for incidental findings and categorized based on location, tissue type, and/or body system. The rate of incidental findings and the rate at which further follow-up was recommended by the radiologist were determined. RESULTS: A total of 617 patients was identified. There were 173 incidental findings noted in 146 of these patients (23.7%). Findings ranged from pulmonary (59%), skin/soft tissue (16%), thyroid (13%), vascular (9%), spinal (2%), and abdominal (1%) areas. Of the pulmonary findings, 50% were pulmonary nodules and 47% were granulomatous disease. Overall, the final radiology report recommended further follow-up for 50% of the patients with incidental findings. CONCLUSIONS: Incidental findings are relatively common in preoperative CTs obtained for shoulder arthroplasty, occurring in nearly one-quarter of patients. Most of these findings are pulmonary in nature. Overall, half of the patients with incidental findings were recommended for further follow-up. These results establish population data to guide orthopedic surgeons in patient counseling. Level of evidence: III.

Musculoskeletal Biorepository: Establishment, Sustainment, and Tips for Success.

A biorepository, also referred to as a "biobank," is a collection of biologic samples that are stored for laboratory research. With the emergence of precision medicine, the importance of leveraging individual patient biomolecular signatures to improve diagnosis, prognosis, and treatment is becoming increasingly recognized. Successful development and sustainment of a biorepository provides the potential for transformative preclinical research. Establishing a biobank requires a team approach with involvement of the institutions' research laboratory team and regulatory body. Execution of research activities requires a coordinated team approach for case identification, consent process, data and specimen collection, specimen processing, and storage and archiving. The advancing fields of precision medicine and orthobiologics provide incredible opportunities for institutions to generate novel lines of inquiry in musculoskeletal diseases through a multiomics approach (genomic, transcriptomic, proteomic, microbiomic). In addition, a biobank is an important component of post-market surveillance for the rapidly emerging field of orthobiologics.

The Effect of Pulsed Electromagnetic Field and Combined Magnetic Field Exposure Time on Healing of a Rabbit Tibial Osteotomy.

Background: This study compares effectiveness of two commercially available signals, Pulsed Electromagnetic Field (PEMF) and Combined Magnetic Field (CMF) clinical signals, to stimulate bone healing in rabbit tibial osteotomies. Methods: One millimeter osteotomies in New Zealand White rabbits, stabilized with external fixators, were exposed daily to either signal for 30 minutes, three or six hours. Osteotomized sham controls received no signal exposure. Analyses of torsional strength, periosteal callus area and fracture healing stage demonstrated dose responses to increasing daily exposures to both signals. Results: By 14 days torsional strength increased over shams in the three and six hour-treated groups, significant only for the six hour groups (p<0.05). By 21 days both three and six hour-treated groups were significantly stronger than shams (p<0.05, p<0.005) and the PEMF 30 minute treated group also showed significance (p<0.05). PEMF versus CMF-treated groups were not different at any exposure time. Conclusions: Both CMF and PEMF signals were most effective in this model when used for six hours per day. Clinical Relevance: In this model we demonstrate that though both PEMF and CMF are "bioactive" and promote healing at shorter and longer exposure dosages, there exists an "optimal" threshold effect of 6 hours/day electromagnetic wave stimulation for bone healing.

The Telescoping Hip Plate for Treatment of Femoral Neck Fracture: Design Rationale, Surgical Technique and Early Results.

Recent estimates suggest an annual incidence of greater than 125,000 femoral neck fractures. Surgical treatment is indicated for the majority of these fractures, which are estimated to double by the year 2050. Most displaced femoral neck fractures in elderly patients are treated with arthroplasty secondary to high complication rates associated with internal fixation. Traditional implants used for internal fixation, typically in elderly patients with stable fracture morphology and younger patients regardless of morphology, include the sliding hip screw (SHS), with or without a supplemental anti-rotation screw, and multiple cancellous lag screws. Complications have been reported with both of these fixation techniques, especially as they apply to treating displaced femoral neck fractures in the elderly. Yet, complications of nonunion, loss of fixation and osteonecrosis, among others, still frequently occur in stable patterns of femoral neck fracture treated with internal fixation. Accordingly, additional implants have been designed recently to improve outcomes and avoid such complications in this population. The Targon Femoral Neck Plate (Aesculap, Tuttlinger, Germany) has been used in Europe for the treatment of both displaced and nondisplaced femoral neck fractures by combining a side plate and multiple cancellous lag screws. Multiple studies have shown superior rates of both nonunion and osteonecrosis when compared to the SHS and multiple cancellous screws in both displaced and nondisplaced femoral neck fractures. This article details the design rationale, surgical technique and early postoperative results of a new hybrid implant used for the treatment of both displaced and nondisplaced femoral neck fractures.

Assessment of SiCaP-30 in a Rabbit Posterolateral Fusion Model with Concurrent Chemotherapy.

Chemotherapy derivatives of the rabbit posterolateral fusion model are considered a challenging environment in which to test bone graft materials. The purpose of this study was to determine the performance characteristics of SiCaP-30 as a bone graft substitute relative to autograft (iliac crest bone graft [ICBG]), Actifuse ABX and ß-Tricalcium Phosphate-Bioactive Glass-Type I Collagen (ßTCP-BG) in a rabbit posterolateral spine fusion model with concurrent chemotherapy treatment This was a randomized, controlled study in a laboratory setting with blinded assessment of fusion by manual palpation and flexibility testing. Sixty rabbits were entered into the study with 45 used for analysis. Chemotherapeutic agents, doxorubicin and cis-platin (2.5 mg/kg), were administered one week prior to surgery, and one, two and three weeks post surgery. Bilateral posterolateral lumbar intertransverse process fusions were performed at L5-L6. The lateral two thirds of the transverse processes were decorticated and covered with 3cc/side of one of the following graft materials: autologous ICBG, Actifuse ABX (ApaTech Ltd, UK), Vitoss BA (Orthovita, USA) or SiCaP-30 (ApaTech Ltd., UK). Animals were euthanized 12 weeks post surgery. The ICBG group had a 45% (5/11) manual palpation fusion rate and correlated with motion analysis fusion results of 36% (4/11). The Actifuse ABX group had a 33% (4/12) manual palpation fusion rate and a motion analysis fusion rate of 25% (3/12). No motion segments in the Vitoss BA group (0/11) showed any signs of fusion. The SiCaP-30 group demonstrated a statistically higher manual palpation and motion analysis fusion rate of 82% (9/11; p<0.05) and produced superior bone formation compared with Actifuse ABX and ßTCP-BG.

The effect of transdermal nicotine on fracture healing in a rabbit model.

OBJECTIVE: Cigarette smoking inhibits fracture healing and places the patient at a higher risk of delayed union and nonunion. Nicotine has been implicated as the primary ingredient responsible for these effects. However, an analysis of current published investigations reveals conflicting data, with some evidence that nicotine alone does not significantly affect healing. We undertook an animal study of the effects of transdermal nicotine on fracture healing. METHODS: Twenty-two adult male New Zealand white rabbits were randomly assigned to the nicotine group or the control group. A midshaft tibial osteotomy was performed on the left tibiae of all 22 rabbits. The nicotine rabbits were exposed using a 10.5-mg transdermal patch applied daily to the ear. Radiographs were obtained, and the area of fracture callus was assessed. Rabbits were euthanized at 21 days. Fractures were stressed to failure, and load/deformation curves were recorded. RESULTS: The average area of callus formation was greater in the control group ( CONTROL: 0.158 cm, Nicotine: 0.124 cm), but the difference was not statistically significant (P = 0.30). There was a significant difference between the 2 groups for mean normalized torque to failure (Nicotine: 36% of nonfractured side, CONTROL: 69% of nonfractured side, P = 0.028). The control group mean normalized stiffness was significantly greater than that for the nicotine rabbits ( CONTROL: 87%, Nicotine: 43%, P = 0.036). There were 3 nonunions in the nicotine group (27%) compared with none in the control group (P = 0.062). CONCLUSIONS: In a rabbit model of fracture healing, transdermal nicotine exposure resulted in decreased mechanical strength of healing fractures at 21 days and a higher rate of nonunion at 21 days compared with that of controls.

Assessment of Mastergraft(®) strip with bone marrow aspirate as a graft extender in a rabbit posterolateral fusion model.

STUDY DESIGN/SETTING: Randomized, controlled study in a laboratory setting. Blinded observations/assessment of study outcomes. OBJECTIVE: The Purpose of this study is to determine the performance characteristics of Mastergraft(®) Strip with bone marrow aspirate (BMA) as a bone graft extender in a rabbit posterolateral spine fusion model. SUMMARY OF BACKGROUND DATA: The rabbit posterolateral fusion model is an established environment for testing of fusion concepts. It offers the opportunity to obtain radiographic, histological, and biomechanical data on novel fusion materials. METHODS: Thirty six rabbits were entered into the study with 34 used for analysis. Bilateral posterolateral lumbar intertransverse fusions were performed at L5-L6. the lateral two thirds of the transverse processes were decorticated and covered with graft material: autograft only (2.5 - 3.0 cc/side), 75% Mastergraft(®) Strip + 5.0 cc BMA / 25% autograft (3.0 cc total per side), or 50% Mastergraft(®) Strip + 5.0cc BMA and 50% autograft (3.0 cc total per side). Animals were humanely euthanized at 8 weeks post surgery. RESULTS: The autograft group had a 60% radiographic fusion rate (6/10) and a manual palpation fusion rate of 50% (5/10). the 50% Mastergraft(®) Strip group had a 75% radiographic and manual palpation fusion rate (9/12). the 75% Mastergraft(®) Strip group demonstrated a 58% (7/12) radiographic and manual palpation fusion rate. Histologically, no adverse inflammatory reactions of significant size were present. The two Mastergraft(®) Strip groups demonstrated a tendency towards more bone development across the fusion bed. CONCLUSIONS: In this commonly used rabbit posterolateral fusion model, Mastergraft(®) Strip with BMA in an autograft extender mode produces biomechanical and radiographic results similar to autograft fusion alone.

Case report and literature review anterior shoulder dislocation with three-part proximal humerus fracture and humeral shaft fracture.

Dislocation of the shoulder and proximal humerus fracture with coexistent humeral shaft fracture is a rare injury reported in literature. There have been a total of 20 cases reported in the literature since 19401-13 (see Table 1). These injuries often occur as a result of high velocity trauma and most have been treated, at least partially, with invasive or operative management. We present the case of a woman with an anterior dislocation, three-part proximal humerus fracture and concomitant humerus shaft fracture and discuss her non-invasive treatment.

B2A peptide on ceramic granules enhance posterolateral spinal fusion in rabbits compared with autograft.

STUDY DESIGN: Six groups of 10 animals underwent single level, uninstrumented posterolateral lumbar fusions. Graft sites were implanted with autologous bone, autologous bone plus B2A coated granules with concentrations of 0-, 50-, 100-, or 300 microg/mL, or no graft material. Explanted motion segments were analyzed by Faxitron radiographs, computerized tomography (CT), manual palpation, and histology. OBJECTIVE: The synthetic peptide B2A2-K-NS (B2A) was evaluated as a novel agent for augmenting spinal fusion in a posterolateral, noninstrumented rabbit lumbar spine fusion model. SUMMARY OF BACKGROUND DATA: There have been many efforts to increase the rate of posterolateral spinal fusion while, at the same time minimizing, use of autologous bone with its inherent harvest morbidity. METHODS: B2A coated ceramic granules (0-, 50-, 100-, and 300 microg/mL) were mixed 1:1 with autogenous iliac crest bone and implanted. Autogenous bone alone was used as a positive control. Fusion was assessed at 6 weeks via radiographs and manual palpation. These results were confirmed with histology and CT. RESULTS: Fusion results from palpation and radiographic evaluations were similar. CT and histology confirmed bridging bone across the transverse processes for fused spines. The highest fusion rates were observed in the 100 mug B2A/mL group-89% in comparison to 33% for uncoated granules (0 microg B2A/mL) and 63% for autograft alone. These differences were statistically significant. CONCLUSION: All investigated B2A concentrations demonstrated increased fusion rates. Fusion masses resulting from the implantation of 100 mug B2A/mL granules demonstrated new woven bone: fused to the transverse processes, within granule pores, bridging bone across the transverse processes, and bridging residual bone graft and granules. It was concluded that each investigated concentration of B2A coated granules in a 1:1 mixture with autograft increased fusion rates in comparison to controls in this rabbit model.

Greater tuberosity osteotomy and teres minor transfer for irreparable superior rotator cuff tears.

The purpose of this study was to evaluate the mid- to long- term objective, subjective and radiographic results of patients who underwent anterior-superior transfer of remaining infraspinatus tendon and teres minor tendon for irreparable superior rotator cuff tears. Thirteen patients were identified who underwent infraspinatus tendon transfer to a more superior position on the humeral head between January 1, 1990 and December 31, 2001. Nine shoulders in eight patients were available for clinical examination, radiographs and questionnaire follow-up at an average of 83.5 +/- 31.4 months. Radiographic examination revealed 1 fibrous union and 6 united tuberosity osteotomies. Samilson-Prieto grading of radiographs revealed 4 shoulders with mild, and 4 shoulders with moderate, OA. Seven of the patients were satisfied with their shoulder. There were two poor outcomes. Local antero-superior teres minor and residual infraspinatus transfer provides a viable option for irreparable rotator cuff defects. Mid- to long-term satisfactory outcome was achieved in 7 out of 9 shoulders.

Complications of locking plate fixation in complex proximal tibia injuries.

OBJECTIVES: To report the complications and pitfalls in the treatment of complex injuries of the proximal tibia when locking plates are used. DESIGN, SETTING, AND PATIENTS: This was a retrospective case series conducted at a university Level I trauma center. Thirty-seven patients with complex proximal tibia fractures (41C1, 41C2, 41C3, 41A2, 42A2) were treated with locking plates. INTERVENTION: All fractures were treated with locking plates (Less Invasive Stabilization System (LISS); Synthes, Paoli, PA). MAIN OUTCOME MEASUREMENTS: Healing, alignment, infection, and other complications. RESULTS: Twelve fractures (32%) healed without any complications. Eight patients (22%) developed deep infections that required operative debridements, and 5 of them had a hardware removal; 1 eventually required an above-knee amputation. Eight cases (22%) had postoperative malalignment, with hyperextension as the most common deformity. Three cases (8%) had loss of alignment into varus during healing. Other complications were 1 superficial wound dehiscence, 1 delayed soft-tissue breakdown, 4 hardware irritations, 1 peroneal nerve injury at the distal part of a 9-hole plate, 1 tibial tubercle nonunion, and 1 postoperative compartment syndrome. CONCLUSION: The complication rate, particularly infection, was higher than in previous reports. Other complications such as hardware prominence, malalignment, and loss of alignment were similar to those of historical controls. Some of the complications may reflect the techniques that were used and should decrease with more experience; however, some may be inherent in the treatment of high-energy fractures using locking plates.

The effects of silver coated external fixation pins.

We performed a randomized controlled trial in order to assess the effect silver coating of an external fixator pin has on pin infection. The experimental silver coated pins (SC) were compared to control stainless steel (SS) pins. A clamp design monolateral fixator was used, and pins were randomized to clamp position to allow side-by-side comparisons of pins in a similar environment. Nineteen patients and 33 clamps were entered and completed the study. There were no significant differences between the two types of pins in the rate of pin tract infection, clinical appearances of the pin sites, bacteriology of the pin tracts, torque to remove the pins, or radiographic lucency around the pin. We concluded that with the numbers available in this study, there were no detectable differences between the performance of SC and SS pins.

Excessive radiofrequency application: effects on capsular tissue in an animal model.

Capsular attenuation has been seen after thermal capsulorrhaphy surgery. The purpose of this study was to evaluate the mechanical, histologic, and morphologic effects on capsular tissue after cumulative applications of radiofrequency energy. Ovine patellofemoral capsular tissue was treated with 1, 2, 4, or 8 applications of bipolar radiofrequency energy and then analyzed. No acute capsular ablation or destruction was seen grossly, even in the 8-application group. No definitive visual clues that excessive radiofrequency energy had been applied were seen. There was significant shrinkage and loss of tensile stiffness for all thermal application groups. Given the small sample sizes, post-application failure load, percent relaxation, and stiffness were not observed to be significantly different among the groups. Cumulative applications produced minimal further tissue shrinkage but were accompanied by larger, though not statistically significant, mechanical property losses and increased depth of tissue penetration. These findings suggest that there is no benefit to repeated applications of radiofrequency energy to capsular tissue.

Factors affecting outcome in tibial plafond fractures.

To determine what fracture- and patient-specific variables affect outcome, 29 patients with 32 tibial plafond fractures were evaluated at a minimum of 2 years from the time of injury (range, 24-129 months; average, 46.5 months). The rank order method was used to assess severity of injury and accuracy of articular reduction on radiographs and agreement among the five surgeons was excellent with intraclass correlation coefficients of 0.93 and 0.94. Outcome was assessed by four independent measures: a radiographic arthrosis score, a subjective ankle score, the Short Form-36 (SF-36), and the patient's ability to return to work. The four outcome measures did not correlate with each other. Radiographic arthrosis was predicted best by severity of injury and accuracy of reduction. However, these variables did not show any significant relationship to the clinical ankle score, the SF-36, or return to work. These outcome measures were more influenced by patient-specific socioeconomic factors. Higher ankle scores were seen in patients with college degrees and lower scores were seen in patients with a work-related injury. The ability to return to work was affected by the patient's level of education. This study highlights the difficulties of predicting patient outcome, after these severe articular fractures.

Cellular interactions and bone healing responses to a novel porous tricalcium phosphate bone graft material.

The use of a porous tricalcium phosphate bone void filler (Cellplex TCP, Wright Medical Technology, Inc, Arlington, Tenn) as an alternative to autograft in bone grafting was studied in benchtop, in vitro cell culture, and in vivo preclinical studies. The experimental design included material property quantification, scaffold seeding with mesenchymal stem cells, and implantation in a rabbit segmental defect model. Measured material properties denoted appropriate composition, porosity, and strengths as compared to the literature. Fluid uptake studies and mesenchymal stem cell affinity revealed the scaffold's capabilities as a suitable host for osteoprogenitor cells. In a 1-cm rabbit diaphyseal segmental defect stabilized with an external fixator, tricalcium phosphate was compared to intact autograft, crushed autograft, and open defects. Torsional strengths and stiffnesses of tricalcium phosphate-treated tibia were greater than or equivalent to both intact and crushed autograft controls. Tricalcium phosphate pores exhibited complete bony infiltration histologically. Collectively, the tricalcium phosphate material properties, cell seeding capabilities, and in vivo biological responses give evidence of this implant's functionality as a potential alternative for autograft.

Effects of pulsed electromagnetic field stimulation on distraction osteogenesis in the rabbit tibial leg lengthening model.

The purpose of this study was to determine whether exposure to pulsed electromagnetic field (PEMF) would shorten the healing time of regenerate bone in a rabbit tibial distraction model. Beginning 1 day after surgery, mid-shaft tibial osteotomies, stabilized with external fixators, were distracted 0.25 mm twice daily for 21 days and received either no exposure (sham control) or 1 hour per day exposure to low-amplitude, low-frequency PEMF. Tibiae were tested for torsional strength after 9, 16, and 23 days post-distraction. PEMF-treated tibiae were significantly stronger than shams at all three time points. By 16 days post-distraction, the PEMF group had achieved biomechanical strength essentially equivalent to intact bone. Shams did not achieve normal biomechanical strength even after 23 days post-distraction. In this tibial distraction model, short daily PEMF exposures accelerated consolidation of regenerate bone. Clinical usefulness awaits testing.