Reverse Shoulder Arthroplasty and Latissimus Dorsi Tendon Transfer.

In a systematic review, we critically examined and synthesized the results of individual studies on reverse shoulder arthroplasty (RSA) with latissimus dorsi tendon transfer. Two electronic databases were searched. For each included study, 2 reviewers evaluated the quality of its methods and retrieved data. In cases in which outcomes data were similar between studies, data were pooled using frequency-weighted (FW) mean values to generate summary outcomes. Seven studies met the inclusion and exclusion criteria, and 133 patient cases were reviewed. FW mean age was 69.5 years. Patients were followed up an FW mean of 39.9 months. FW mean Constant score improved from 28.7 before surgery to 64.4 afterward (P = .0001). External rotation improved from an FW mean of -4° to 25° (P < .0001). The overall complication rate was 22.8%. RSA combined with latissimus dorsi tendon transfer can improve function and external rotation in patients with cuff tear arthropathy and teres minor dysfunction. Its overall complication rate appears to be similar to that of RSA alone, though the rate of neuropraxia may be increased.

Metal Allergy as a Cause of Implant Failure in Shoulder Arthroplasty.

Metal allergy is an uncommon and poorly understood cause of failure of orthopedic implants. To the authors' knowledge, there have been no reports of the management of shoulder arthroplasty patients with metal allergy. The authors present their experience with the diagnosis and management of patients with metal allergy. Patients with metal allergy undergoing shoulder arthroplasty were identified through retrospective chart review from January 1, 2012, to January 31, 2015. Case characteristics collected included patient risk factors (age, sex, prior cutaneous reactions to metal), metal allergy factors (type of metal allergy, method of diagnosis), and surgery factors (implant type, primary/revision, type of shoulder arthroplasty). Outcomes measured included American Shoulder and Elbow Surgeons score, Penn Shoulder Score, and Single Assessment Numeric Evaluation score. Eleven patients were identified with metal allergy. Five were diagnosed prior to the index arthroplasty, and 6 were diagnosed after shoulder replacement. The diagnosis was made through skin patch testing, memory lymphocyte immunostimulation assay, or clinical history. Patients identified after implantation presented with progressive pain and stiffness, but none had cutaneous manifestations. Patients with metal allergy had better results undergoing primary shoulder arthroplasty than undergoing revision. Metal allergy is rare but may be a clinically significant cause of unsatisfactory shoulder arthroplasty. Given the superior results of primary shoulder arthroplasty compared with revision, screening for metal allergy by clinical history is recommended. [Orthopedics. 2017; 40(5):e844-e848.].

Heterotopic ossification of the long head of the triceps after reverse total shoulder arthroplasty.

BACKGROUND: Heterotopic ossification (HO) around shoulder arthroplasty is a frequent finding with unclear clinical relevance. This study evaluated the incidence, relevance, and predisposing factors of HO in the long head of the triceps tendon after reverse shoulder arthroplasty. METHODS: Retrospective chart review was conducted to identify patients who had a reverse shoulder arthroplasty performed between 2008 and 2012. Patient demographics, implant types, and diagnoses were noted. Three fellowship-trained shoulder/elbow surgeons independently evaluated postoperative Grashey radiographs using a novel classification system. RESULTS: Within a 164-patient cohort, the overall HO rate in the long head of the triceps tendon was 61.6%; 23.2% of osteophytes were considered impinging, 14.6% had notching, 14.0% were free-floating, and 3.0% appeared ankylosed. Although not statistically significant, revision surgery had a higher rate of HO (68.3%) compared with primary surgery (59.4%). There was no difference in HO rates between diagnoses or implant types. Male and female HO rates were 74.0% and 56.1%, respectively (P = .0304). Between patients with and without HO, forward elevation was 121° compared with 133° (P = .0087) and external rotation was 19° compared with 25° (P = .0266); however, HO size did not significantly affect motion. CONCLUSIONS: Using our novel classification scheme, HO was a common finding in this series. Men had a higher rate of HO formation, and HO formation was associated with worse postoperative motion. Further study is needed to fully characterize the clinical implications of HO involving the long head of the triceps tendon and to explore potential preventive measures.

Effectiveness of a microvascular surgery training curriculum for orthopaedic surgery residents.

BACKGROUND: The safe and effective acquisition of microvascular surgical skills is a challenge for any residency program. Variable clinical exposure to microsurgery, premiums on operating room efficiency, and a steep learning curve make these skills difficult to acquire through clinical experience alone. The purpose of this study was to determine the effectiveness of a training curriculum on the development of microvascular surgical skills in our orthopaedic residents. METHODS: A microvascular training curriculum was completed during each third-year resident's rotation on the hand and upper-extremity service. The training cycle began with learning the basics of microvascular surgery on nonliving models and progressed to performing end-to-end arterial anastomoses on a live rat femoral artery in the second session. Outcome evaluations consisted of the Global Rating Scale score, achievement of patency, and time to completion. T test analyses of Global Rating Scale scores, achievement of patency, and time to completion were conducted to determine significance (p < 0.05). RESULTS: All residents significantly improved (p < 0.005) on Global Rating Scale scores from a mean score (and standard deviation) of 15 ± 4 points for the initial score to 20 ± 3 points for the post-test score. Of the twelve residents, patency was achieved by eleven at the final evaluation, compared with six before training. Time to completion of the anastomosis also significantly improved (p < 0.005), from a mean of 37:17 ± 8:41 minutes for the initial time to 24:46 ± 5:32 minutes for the final time. CONCLUSIONS: In an effort to improve the microvascular surgical skills of orthopaedic residents at our institution, a microvascular training curriculum was developed and was implemented. This curriculum was effective at improving resident microvascular surgical skills at the completion of an eight-week course.

Late reconstruction of median nerve palsy.

The median nerve provides sensory innervation to the radial aspect of the hand, including the palm, thumb, index, long, and half of the ring fingers. It provides motor innervation to most of the volar forearm musculature and, importantly, to m ost of thenar musculature. The main goal of median nerve reconstructive procedures is to restore thumb opposition. There are a variety of transfers that can achieve this goal but tendon transfers must recreate thumb opposition, which involves 3 basics movements: thumb abduction, flexion, and pronation. Many tendon transfers exist and the choice of tendon transfer should be tailored to the patient's needs.

Sagittal plane knee joint moments following anterior cruciate ligament injury and reconstruction: a systematic review.

BACKGROUND: Gait adaptations in persons with anterior cruciate ligament (ACL) injuries have been debated. Many studies examine high speed, 3-dimensional video gait analysis to compare knee joint torques during simulated activities of daily living. METHODS: We performed a systematic review of the literature for published clinical papers that reported sagittal plane knee joint kinetics in ACL deficient or reconstructed individuals. We calculated weighted effect sizes (Cohen's d) to evaluate the magnitude of differences between the injured limb and the contralateral limb and healthy, uninjured limbs in control subjects. FINDINGS: Ten published papers reported kinetic data in ACL deficient subjects while walking for comparisons to the contralateral side (weighted average d=-0.83, range: -3.21, 1.07), and to healthy control knees (weighted average d=-1.0, range: -3.36, 0.17); four papers reported data during jogging compared to the contralateral side (weighted average d=-0.94, range: -4.15, 0.17), and to controls (weighted average d=-1.42, range: -3.83,-0.2). Four papers reported data for ACL-reconstructed patients compared to healthy controls during walking (weighted average d=-0.94, range: -0.4, -1.77) and jogging (weighted average d=-1.18). INTERPRETATION: Effect sizes comparing knee joint moments in injured vs. healthy control subjects appear to be slightly higher while jogging than walking, and higher in ACL-deficient patients compared to reconstructions. However, magnitudes are all large. Few studies report stair climbing. Consequently, it is difficult to make inferences with confidence during these tasks.

Development of injectable thermogelling chitosan-inorganic phosphate solutions for biomedical applications.

Thermosetting polymers are attractive candidates for biomedical applications as noninvasive therapeutic delivery vehicles. In the present study, the feasibility of developing a neutral physiological temperature setting injectable formulation based on chitosan and an inorganic phosphate salt have been demonstrated. The in situ gelling system was developed by adding different concentrations of ammonium hydrogen phosphate (AHP) to chitosan solution. The resulting solutions have pH in the range of approximately 7-7.2. The gelling time of the chitosan-AHP solution was determined by incubating the solutions at 37 degrees C. Depending on the concentrations of AHP added, the gelling time varied from 5 min to 30 h at 37 degrees C. Addition of various diluents to chitosan-AHP solution did not significantly change the gelling time of the solutions. The gels were found to be cytocompatible as evidenced from in vitro cytocompatibility evaluation using MC3T3-E1 mouse osteoblast like cells. The feasibility of using the gels as a stem cell carrier vehicle as well as a macromolecular delivery vehicle has been demonstrated.