Comparison Of Early And Late Aseptic Baseplate Failure In Primary Reverse Shoulder Arthroplasty With And Without Structural Glenoid Autograft.

INTRODUCTION: Early reverse total shoulder arthroplasty (RTSA) designs demonstrated high glenoid baseplate complication and revision rates. While contemporary designs have reduced the incidence of glenoid baseplate failures, there are reports of elevated failure risks in RTSA with glenoid bone grafting within the first 2 years. This study aims to evaluate the incidence and etiology of aseptic glenoid baseplate failure with a contemporary central screw baseplate. The null hypothesis is that majority of the baseplate failure occurs within the first 2 years and use of glenoid bone grafting does not lead to higher risk of baseplate failure. METHODS: In 2014 - 2019, 753 consecutive patients who underwent primary RSA using the same inlay press-fit humeral stem and monoblock central screw baseplate were retrospectively reviewed. Fracture and septic arthropathy cases were excluded. All patients underwent preoperative radiographic and computed tomography evaluation. If there was significant glenoid erosion (Walch A2, B2, B3, C1, C2, E2, E3, and/or E4 variants), patient-specific structural glenoid bone grafting was performed. All patients underwent standardized radiographic follow-up and failure was strictly defined as any hardware breakage and/or shift in glenoid baseplate position. Failures were defined as "early" if occurring within 2 years and "late" if occurring greater than 2 years after surgery. Comparative analysis was performed to evaluate demographics, glenoid graft use, and graft union rates between the cohorts. RESULTS: There were 23 patients with baseplate failures (23/753, 3.0%) at mean of 23 months. Twenty-two failures (96%) occurred in patients who received structural glenoid bone grafting. Only 1 failure (0.2%) occurred when bone grafting was not indicated (p<0.001). The most common failure pattern was associated with B2 glenoid (16/23, 70%). There were 5 (22%) early failures and 18 (78%) late failures. There were no differences in any patient demographic characteristics between cohorts. All 5 early failures had graft nonunion and 4/5 occurred without trauma. In the 18 late failures , 9/18 (50%) occurred without trauma (p=0.135). Seventeen of these patients had glenoid grafting, of which 9/17 (53%) had graft nonunion. CONCLUSIONS: Contemporary RTSA glenoid baseplate designs have an acceptably low incidence of failure. However, the addition of structural bone graft to correct glenoid wear leads to higher aseptic baseplate failure rate. The majority of these patients suffer failure after the 2-year postoperative mark, highlighting the necessity of longer follow-up. Further analysis is necessary to quantify glenoid characteristics (severity of glenoid erosion, critical size of graft) associated with failure.

Cystocerebral Syndrome in a Patient with Altered Mental Status.

BACKGROUND Cystocerebral syndrome is delirium occurring in the elderly that results from urinary retention and acute bladder distension. Urinary retention can cause cerebral issues, such as altered mental status, without having an infection present. The pathophysiology is possibly due to increased catecholamine secretion while attempting to micturate. Due to its presenting symptoms, most physicians begin cerebrovascular workup, performing unnecessary and, often, invasive imaging studies. Although easily overlooked as a differential diagnosis, cystocerebral syndrome is an easily treatable cause of delirium and should be considered during treatment of elderly patients with delirium. CASE REPORT The patient was an 89-year-old man with a medical history of chronic obstructive airway disease, dementia, hypertensive disorder, and gastroesophageal reflux disease who presented with altered mental status secondary to urinary incontinence. The computed tomography scan without contrast showed a large volume of impacted stool in the cecum, with a distended urinary bladder. This case report describes his presentation, medical treatment, and outcome and discusses areas of gap improvement. CONCLUSIONS To date, there are only a handful of published articles on cystocerebral syndrome. This case report aims to add the awareness of bladder distention as an etiology of cystocerebral syndrome to the body of knowledge in the scientific community in the hope that patients will be identified and treated earlier, more safely, and at a reduced cost. Cystocerebral syndrome needs to be extensively addressed in research, and physicians should consider it one of the important differential diagnoses of delirium among elderly men.

A Rare Case of Myxedema Coma Precipitated by a Single Dose of Haloperidol in a Patient With Paranoid Schizophrenia.

Myxedema coma is a rare and potentially life-threatening condition that occurs when severe hypothyroidism is untreated or inadequately managed. It is characterized by a rapid drop in mental status, hypothermia, respiratory failure, hypotension, and other symptoms of severe metabolic dysfunction. The condition primarily affects older women with a history of thyroid dysfunction but can occur in any age or gender group. A common trigger for this condition is seen with a drop in atmospheric temperatures or during the cold winter months. However, a rare, poorly documented trigger is recent antipsychotic use in severe hypothyroid states. The diagnosis of myxedema coma requires prompt recognition and treatment, as delays can result in significant morbidity and mortality which is the objective of this case report.

A Diagnostic Dilemma: Is It Factitious Disorder With Nonepileptic Seizure or Malingering With Nonepileptic Seizure?

In reality, the lines between factitious disorder, functional disorder, and malingering are quite blurred. In factitious disorder and malingering, patients consciously and deliberately create false medical and/or psychiatric symptoms for self-gain, often approaching multiple healthcare facilities to evade detection. Although the factitious disorder is pervasive, and the literature lacks accurate and consistent information, comorbidity with nonepileptic seizure (NES, a component of functional disorder) is quite commonly documented. In our case, the patient feigned multiple symptoms including two seizures and a shoulder dislocation to gain access to opioids. The clinical picture was only significant for alcohol withdrawal, aspiration pneumonia (possibly intubation vs. NES-related), and self-induced shoulder dislocation. Generally, management of these disorders should involve multiple specialties, multiple approaches, and identifying the triggering and comorbid psychological disorders, such as abandonment issues, personality disorders, physical or emotional abuse, anxiety, depression, stress, and substance use. Blindly approaching patients with a factitious disorder or malingering will not lead to any productive outcomes. Perhaps, creating a patient database could help reduce futile efforts while providing patients with the required help. This case report describes the presentation, diagnosis, management, and outcomes related to a patient with NES, engaging the reader to decipher the most appropriate diagnosis.

Comprehensive Modified Latarjet Technique: What the Masters Taught Us.

The Latarjet surgical technique is one of the most effective and well-known techniques in the treatment of anterior shoulder instability1. The modified Latarjet technique is a history book of surgical details demonstrated by renowned masters of shoulder surgery. The procedure includes soft-tissue repair and osseous reconstruction to stabilize the glenohumeral joint in recurrent anterior instability. The procedure has been shown to have reliable success in reducing recurrent instability and minimizing risk of dislocation arthropathy2-4. DESCRIPTION: The Latarjet technique can be performed via a cosmetic axillary-based approach. The subscapularis is split horizontally without detachment as described by Neer5. The capsule is released like in a medially based T-plasty as described by Altchek et al.6. The coracoid osteotomy is performed with a 90° oscillating saw and prepared for en-face implantation as described by Edwards and Walch7. The inferior surface of the coracoid is decorticated and prepared per Molé8. Coracoid fixation is performed with two 3.5-mm cortical screws. The soft-tissue reconstruction is selectively tensioned per Warner et al.9. The capsular shift is augmented with a pants-over-vest repair per Kim et al.10. ALTERNATIVES: Nonoperative treatment in young patients with glenohumeral instability and bone loss can lead to recurrence rates as high as 87%11. Arthroscopic management with anterior capsulolabral repair and a remplissage procedure can be beneficial for patients with instability. In the setting of bone loss, arthroscopic repair is associated with failure rates as high as 75%12. RATIONALE: In the setting of glenoid and/or humeral bone loss, there is a loss of native osseous anatomy, leading to a higher risk of instability. Gerber and Nyffeler reported a >30% loss of compressive force when the vertical edge of the glenoid defect is greater than one-half of the glenoid diameter13. The Latarjet procedure is a reliable procedure that reconstructs the anterior osseous anatomy as well as the capsular laxity, restoring glenohumeral stability. When compared with arthroscopic labral repair, the Latarjet procedure is superior with more consistent improvements in functional outcomes with low risk of recurrence, even in high-risk populations of young, active athletes in contact sports2,3. EXPECTED OUTCOMES: At our institution, a total of 34 patients underwent Latarjet reconstruction as described in the present article and videos from 2013 to 2018, with a minimum follow-up of 1 year. Among these patients, the mean Single Assessment Numeric Evaluation score was 90.7 (range, 70 to 100). There were 4 cases of recurrent instability with graft fracture or resorption (11.8%). Zimmermann et al. presented a series of Latarjet reconstructions with similar functional outcomes and a recurrence rate of 11%4. Meta-analysis of long-term Latarjet studies show high rates of return to sports and successful outcomes in 86% of cases, with an 8.5% recurrence rate2. IMPORTANT TIPS: The Latarjet procedure can be consistently performed with a subscapularis-sparing approach, which minimizes adverse comorbidities.Splitting the subscapularis at the inferior one-third junction will position the surgical window directly over the bottom half of the glenoid, which optimizes coracoid implantation.A medially based T-plasty will maximize the glenoid exposure for direct coracoid implantation. Subsequently, the capsule may be shifted for capsular imbrication.Low-profile, non-bulky retractors will help to improve visualization.Adjusting the arm is a key technique in performing this surgical procedure. This adjustment will help to shift the surgical window, expose key anatomic structures, and allow a capsular shift without overtensioning. This cannot be overstated.

Complex Shoulder Girdle Stabilization Using Allograft Capsular Reconstruction and Pectoralis Major Transfer: A Case Report.

CASE: A 21-year-old woman with a history of multiple failed surgical and conservative management for recurrent involuntary shoulder instability presented with 1-year history of shoulder pain. Physical examination demonstrated intractable static anterior glenohumeral instability, deficient capsular tissue, with reducible scapular winging secondary to long thoracic nerve palsy. Allograft capsular reconstruction and open split pectoralis major tendon transfer were performed to salvage shoulder motion and stabilize her shoulder girdle. CONCLUSION: This report presents a novel repair option for intractable shoulder instability and scapular winging. Surgeons should recognize potential causes of shoulder instability and familiarize themselves with multiple stabilization techniques as potential salvage options before glenohumeral fusion.

Custom Prosthetic Reconstruction for Severe Proximal Humeral Bone Loss Status Post Infected Arthroplasty: A Case Report.

CASE: A 68-year-old male, status post revision right reverse total shoulder arthroplasty (RTSA) for periprosthetic fracture, suffered a periprosthetic joint infection necessitating 2-stage revision. Imaging revealed 8.6 cm of ipsilateral proximal humeral bone loss (PHBL) including loss of the greater and lesser tuberosities. A 2-stage revision was performed using an antibiotic spacer, followed by a custom long-stem RTSA for definitive reconstruction. Two years postoperatively, the patient had significantly improved pain and functional range of motion. CONCLUSION: Custom long-stem RTSA could serve as a potentially viable reconstructive option in patients with severe PHBL.

Clinical and radiographic outcomes of cementless reverse total shoulder arthroplasty for proximal humeral fractures.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has demonstrated successful outcomes in the treatment of both acute and chronic proximal humeral fractures (PHFs). The traditional RTSA surgical technique uses a methyl methacrylate cemented humeral component to restore and maintain both humeral height and retroversion. However, use of humeral bone cement has been associated intraoperatively with cardiopulmonary risk, increased operative cost, and postoperatively with difficulty if revision arthroplasty is required. We report the clinical and radiographic outcomes of a completely cementless RTSA technique for PHF surgery. METHODS: Between 2013 and 2018, 60 consecutive patients underwent surgical management of a PHF with cementless RTSA. All surgical procedures were performed by a single senior shoulder surgeon using a modified deltopectoral approach and a completely uncemented RTSA technique. Fractures were defined as either acute or chronic based on a 4-week injury-to-surgery benchmark. The mean age was 67 years (range, 47-85 years). There were 18 acute and 42 chronic fractures. The mean time from injury to surgery was 2 weeks (range, 0.4-4 weeks) for acute fractures and 60 months (range, 1-482 months) for chronic fractures. We excluded 17 cases from postoperative evaluation because of revision and/or loss to follow-up. The remaining 43 cases underwent clinical and radiographic evaluation by 2 independent fellowship-trained shoulder surgeons at a mean of 21 months (range, 10-46 months) postoperatively. Independent statistical analysis was performed using the paired t test and Wilcoxon signed rank test. RESULTS: At final review, mean active anterior elevation was 157° (range, 100°-170°); active external rotation, 52° (range, 6°-80°); and active internal rotation, 66° (range, 0°-80°). Improvements were seen in the visual analog scale pain score (from 6 to 0.2, P < .001), Simple Shoulder Test score (from 9 to 93, P < .001), American Shoulder and Elbow Surgeons score (from 19 to 91, P < .001), and Single Assessment Numeric Evaluation score (from 21% to 89%, P < .001). Overall, 39 of 43 greater tuberosities (91%) demonstrated osseous healing to the humeral shaft. No significant differences in clinical and radiographic outcomes were found in acute vs. chronic cases, as well as cases with minimum follow-up of 1 year vs. 2 years. Overall, there were 4 major complications necessitating surgical revision (6.7%) and no cases of aseptic humeral stem loosening. CONCLUSION: Cementless RTSA for acute and chronic PHFs demonstrates clinical and radiographic outcomes similar to those after traditional cemented RTSA. The successful greater tuberosity healing and absence of humeral stem loosening in this short-term cohort are encouraging for the continued long-term success of this technique. By avoiding cemented humeral implants, surgeons may minimize intraoperative complications, operative cost, and postoperative revision difficulty.

Latissimus Dorsi Myotendinous Repair with Allograft Hamstring Tendon Graft Augmentation: A Case Report.

CASE: A 30-year-old male weightlifter presented after suffering a myotendinous rupture of his latissimus dorsi from heavy weightlifting. Latissimus dorsi injuries are rare, with little to no documented technique in the literature on management, particularly of ruptures through the myotendinous junction of the anatomical muscle. This case report describes the surgical technique, approach, and postoperative management of an acutely avulsed latissimus dorsi using an allograft hamstring tendon to repair the myotendinous junction. CONCLUSION: Allograft hamstring tendon graft augmentation is a viable repair option for patients with latissimus dorsi myotendinous rupture.