Third-Ray and Capitate Resection with Limited Midcarpal Fusion for Recurrent Giant Cell Tumor: A Case Report.

CASE: We describe a 23-year-old man who had multiple recurrences of a giant cell tumor (GCT) of the third metacarpal. Initial treatments consisted of curettage without the use of an adjuvant and bone-grafting. At the time of the latest recurrence, the lesion had extended into the capitate and the trapezoid. Treatment included third-ray resection and limited midcarpal fusion. No local recurrence was identified at more than 1 year after surgery. CONCLUSION: GCTs of the hand should be aggressively treated, but care should be taken to preserve function whenever possible.

Radiographic survival in total shoulder arthroplasty.

BACKGROUND: Glenoid component loosening is thought to be a major cause of failure. This study assesses radiographic and clinical failure in shoulder arthroplasty, identifying factors predictive of loosening. METHODS: Three-hundred two shoulder arthroplasties were implanted utilizing a cemented, keeled glenoid component, mean clinical follow-up 8.6 years. One-hundred fifty one shoulders had preoperative, early postoperative, and most recent radiographs, mean radiographic follow-up 8.0 years, minimum 4 years or less if revision was performed (2 cases). RESULTS: Fifty-two of 151 glenoid components (34%) showed a shift in position or a complete lucent line ≥1.5 mm. Four humeral components (3%) shifted or showed a 2-mm lucency in 3 zones. Component survival (Kaplan-Meier) free from radiographic failure at 5 and 10 years were 99% (95% CI) (98-100%) and 67% (95% CI) (58-78%). Glenoid components with lines at the keel on initial radiographs were at risk for radiographic failure, hazard ratio 4.6 95% CI 1.2-17.2, P = .02. No associations were found between radiographic survival and age, gender, diagnosis, glenoid erosion, and preoperative or early subluxation. Late subluxation superiorly was associated with the glenoid at risk for radiographic failure (P = .006). Glenoid component survivals free from revision at 5 and 10 years for the 302 shoulders were 99% (95% CI) (97-100%) and 93% (95% CI) (90-97%). CONCLUSION: Glenoid radiolucencies are seldom seen early, except beneath the faceplate. Glenoid radiolucencies develop, with notable changes 5 or more years following surgery. Humeral components seldom loosen. Revision rates remain low. The high frequency of late radiographic changes dictates the need for innovation.

Clinical meaning of unexpected positive cultures (UPC) in revision shoulder arthroplasty.

PURPOSE: This study analyzed the prevalence and clinical meaning of unexpected positive cultures (UPCs) in revision shoulder arthroplasty for causes different than infection. METHODS: Between 1976 and 2007, 107 consecutive patients with UPCs, no previous suspicion of infection, and fulfilling inclusion criteria were identified. Forty-five partial (PSA) and 62 total shoulder arthroplasties (TSA) with different preoperative diagnoses were reviewed. Cases were classified as true infections, possible infections, contaminants, and undetermined. Mean follow-up was 5.6 ± 5.3 years. RESULTS: The prevalence of UPC was 15%. Male sex was a risk factor for UPC. Results of preoperative blood tests and intraoperative pathology were negative in 94 and 97 cases, respectively. Most prevalent bacteria were Propionibacterium acnes (n = 68) and Staphylococcus epidermidis (n = 21). Fifty-three patients received treatment with antibiotics and 54 did not. In 11 patients, a postoperative arthroplasty infection during follow-up was diagnosed by culture and was produced by the same microorganism as the one isolated on the UPC (true infection). Risk factors for true infection vs contamination included revision of a TSA vs a PSA and the number of previous surgeries. Antibiotic use and number of positive cultures did not influence the rate of true infections. CONCLUSIONS: UPCs are a prevalent condition in revision shoulder arthroplasty for causes different than infection. In at least 25% of cases, UPC had no clinical relevance. In 10% of cases, a persistent infection was demonstrated.

Survival of the glenoid component in shoulder arthroplasty.

INTRODUCTION: This study was conducted to determine the survival of different glenoid component designs, assess the reasons for revision surgery, and identify patient and diagnostic factors that influence this need. METHODS: Between January 1, 1984, and December 31, 2004, 1337 patients underwent 1542 total shoulder arthroplasties with 6 types of glenoid components: Neer II all-polyethylene, Neer II metal-backed, Cofield 1 metal-backed bone-ingrowth, Cofield 1 all-poly keeled, Cofield 2 all-poly keeled, and Cofield 2 all-poly pegged. RESULTS: Revision was required in 125 shoulders for glenoid component failure. Survival rates free of revision by glenoid implant type at 5, 10, and 15 years were, respectively, 96%, 96%, and 95% for 99 Neer II all-poly; 96%, 94%, and 89% for 316 Neer II metal-backed; 86%, 79%, and 67% for 316 Cofield 1 metal-backed; 94%, 94%, and 87% for 18 Cofield 1 all-poly; 99%, 94%, and 89% for 497 Cofield 2 all-poly keeled; and 99% at 5 years for 358 Cofield 2 all-poly pegged. Glenoid component type was significantly associated with component revision (P < .001). Male gender was associated with a higher risk of revision (P < .001). Compared with degenerative arthritis, posttraumatic arthritis (P = .02) and avascular necrosis (P = .06) were associated with increased risk of revision. CONCLUSIONS: Survival is improved with cemented all-polyethylene glenoid components. Revision of cemented all-polyethylene components may be lessened with the use of pegged components in early follow-up. Male gender and the operative diagnoses of posttraumatic arthritis or avascular necrosis are associated with an increased risk of failure. LEVEL OF EVIDENCE: Level IV, Case Series, Treatment Study.