Preventing infection in shoulder surgery.

Although rare, infection after shoulder surgery can represent a devastating complication. Infection can negatively affect clinical outcomes, and eradication often requires a protracted treatment course. Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes are among the most frequently isolated pathogens. Perioperative measures can be implemented to reduce infection risk. Here we review various perioperative practices and their efficacy at reducing infection after shoulder surgery.

Preoperative Ultrasonography Is Unreliable in Predicting Hamstring Tendon Graft Diameter for ACL Reconstruction.

BACKGROUND: Hamstring autograft size <8 mm has been shown to be a predictor for failure after anterior cruciate ligament (ACL) reconstruction. The ability to predict graft size preoperatively is helpful in counseling patients about the possible need for graft augmentation. PURPOSE: To determine whether preoperative ultrasound (US) measurements of hamstring tendons can predict intraoperative graft diameter during ACL reconstruction. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Twenty patients undergoing unilateral isolated ACL reconstruction were prospectively enrolled in the study (10 males, 10 females; mean ± SD age, 22.8 ± 6.6 years; height, 175.1 ± 7.1 cm; weight, 81.4 ± 14.2 kg; body mass index, 26.5 ± 4.1 kg/m2). Hamstrings were assessed by US, and double-looped semitendinosus-gracilis hamstring size was independently calculated with a freehand selection method on a nonmagnified US image by 2 orthopaedic surgeons. Intraoperative autograft size was determined with a standard graft-sizing tool. Intra- and interrater reliability was measured with intraclass correlation coefficients (ICCs) and standard error of the measure (SEM). A receiver operating characteristic curve was calculated to assess the ability of the US measurement to predict intraoperative measurements. RESULTS: The mean autograft diameter by US was 8.9 ± 0.98 mm, while the mean intraoperative hamstring graft size was 8.1 ± 0.89 mm. There was excellent intrarater (ICC2,1 = 0.95, SEM = 0.32 mm) and interrater (ICC2,1 = 0.88, SEM = 0.55 mm) reliability for US measurements. Receiver operating characteristic analysis showed that US did not consistently quantify graft size. Graft size did not significantly correlate with height, weight, or body mass index in our sample (P > .05). CONCLUSION: These results suggest that preoperative US imaging of the hamstring tendons is unreliable in predicting intraoperative graft diameter.

Proximal Humerus Fracture-Dislocation with Laceration of the Axillary Artery: A Case Report.

BACKGROUND: Proximal humerus fractures account for approximately 4-6% of all fractures. While the majority of these fractures are treated non-operatively, the amount of fracture displacement, concomitant injuries, and patient factors often result in the need for surgical stabilization. Although concomitant neurovascular injury in the setting of low-energy trauma is rare, injury to the surrounding neurovascular structures have previously been reported. METHODS: We report a case of a 79-year-old male who sustained a low energy fall resulting in a two-part fracture dislocation of the proximal humerus with an associated brachial plexopathy and axillary artery laceration. The patient underwent emergent open reduction internal fixation of his fracture in addition to an axillary-brachial artery bypass using a reverse-saphenous vein graft. The current article reports the presentation, management and prognosis of this rare injury. RESULTS: At 6 months, the patient demonstrated limited active shoulder abduction with no observed motor function at this elbow, wrist or hand. Radiographic follow up demonstrated a reduced glenohumeral joint with evidence avascular necrosis of the humeral head. CONCLUSION: Fracture-dislocations of the proximal humerus may be associated with significant neurovascular injury in the setting of low energy trauma. Despite early treatment, the prognosis of patients with this constellation of injuries is guarded.

Arthroscopic Reduction and Balloon Humeroplasty in the Treatment of Acute Hill-Sachs Lesions.

Shoulder instability is often associated with an impaction fracture of the humeral head, commonly referred to as a "Hill-Sachs lesion." This lesion is present in both anterior and posterior instability. Forty percent to 90% of anterior shoulder dislocations have associated Hill-Sachs lesions, whereas 29% to 86% of posterior shoulder dislocations have reverse Hill-Sachs lesions. Both of these lesions can contribute to recurrent instability of the shoulder and require surgery to be treated. Currently, the most common procedures to address Hill-Sachs lesions are the remplissage procedure (transfer of the infraspinatus into the posterior humeral head defect), capsular shift, disimpaction technique, humeral head resurfacing, bone block transfer, or shoulder arthroplasty. Reverse Hill-Sachs lesions are managed with similar procedures, such as the remplissage-equivalent technique described by McLaughlin, which involves transfer of the subscapularis tendon to fill the humeral head defect. The procedure has the advantage of "exteriorizing" the humeral head defect, but in the case of large lesions, it can result in significant loss of the articulating articular surface. The purpose of this article is to describe an arthroscopically assisted disimpaction technique with supplemental grafting using a balloon osteoplasty technique for a reverse Hill-Sachs lesion with bone cement to support and maintain the reduction.

The prevalence and combined prevalences of anatomic factors associated with recurrent patellar dislocation: a magnetic resonance imaging study.

BACKGROUND: Anatomic factors, including patella alta, increased tibial tubercle-trochlear groove (TT-TG) distance, rotational deformities, and trochlear dysplasia, are associated with dislocation of the patella. Identifying the presence of these anatomic factors both in isolation and in combination may influence treatment in patients with patellar dislocation. PURPOSE: The aim of this study was to compare the prevalence and combined prevalences of these anatomic factors using magnetic resonance imaging in a group of patients with and without histories of recurrent dislocation of the patella. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: The prevalence and combined prevalences of patella alta, increased TT-TG distance, rotational deformity, and trochlear dysplasia on magnetic resonance imaging were reported and compared in 60 patients (60 knees) with and 120 patients (120 knees) without histories of recurrent patellar dislocation. RESULTS: Patients with recurrent patellar dislocation possessed higher rates of patella alta (60.0% vs. 20.8%), increased TT-TG distance (42.0% vs. 3.2%), rotational deformity (26.7% vs. 2.5%), and trochlear dysplasia (68.3% vs. 5.8%) compared with patients without histories of patellar dislocation. Multiple anatomic factors were identified in 58.3% of patients (35/60) with recurrent dislocation compared with only 1.7% of controls (2/120). CONCLUSION: Recurrent patellar dislocation is associated with an increased prevalence of patella alta, increased TT-TG distance, rotational deformity, and trochlear dysplasia compared with patients with no histories of patellar dislocation. Multiple anatomic factors were identified in the majority of patients with recurrent dislocation. Further research may identify which factors play a greater role in patellar stability and may allow physicians to predict which first-time dislocation patients are more likely to sustain recurrence.

Multifocal juvenile osteochondritis dissecans of the knee: a case series.

BACKGROUND: This retrospective case series reports on a group of patients with multifocal juvenile osteochondritis dissecans (MJOCD) of the knee and discusses demographic data, lesion location, stage, and treatment results. METHODS: Records of patients identified with MJOCD of the knee at a single institution were retrospectively reviewed. Demographic, radiographic, and surgical results were recorded. Lesions were descriptively classified and lesions undergoing surgical treatment were staged. Results of operative and nonoperative treatment were recorded. RESULTS: Fifty-nine lesions were identified in 28 patients who met the inclusion criteria. There were 22 males (78%) and 6 females (21%). Average age was 11.8 years (males, 6 to 17; females, 10 to 14). Thirty-six (61%) lesions were on the medial femoral condyle (MFC), 19 (32%) on the lateral femoral condyle, 2 (3%) on the trochlea, 1 (2%) on the patella, and 1 (2%) on the anteromedial tibial plateau. Forty-four (74%) lesions required operative treatment. Of the 32 stable lesions managed surgically, 25 (78%) achieved healing with operative treatment. All 12 unstable lesions identified were managed surgically with 5 (41%) healed after the initial operation. Lesions located on the MFC had a significantly higher rate of healing (89%) compared with lateral femoral condyle lesions (37%) (P<0.0001). CONCLUSIONS: MJOCD of the knee defines a subset of patients with >1 identified lesion occurring in the same or the contralateral knee. Prevalence of MJOCD of the knee is unknown. A high percentage of these patients require surgical intervention with only one quarter of stable lesions healing with conservative treatment. Healing rates of stable lesions after surgery was nearly twice that of unstable lesions undergoing surgical intervention. Lesions located on the MFC healed at a statistically significant greater rate than other locations within the knee. Sex, age, and associated discoid menisci had no effect on healing prognosis. LEVEL OF EVIDENCE: Level IV-case series.

Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial.

Controlling postoperative pain and nausea after total joint arthroplasty remains an important challenge. We conducted a prospective, randomized controlled trial with 120 patients to determine if the addition of perioperative dexamethasone to a multimodal regimen improves antiemetic and analgesic control, enhances mobility, and shortens hospital length of stay after total hip and knee arthroplasty. Patients administered 10mg of intravenous dexamethasone intraoperatively consumed less daily rescue anti-emetic and analgesic medication, reported superior VAS nausea and pain scores, ambulated further distances, and had a significantly shorter length of stay compared to the control group (P<0.05). A second, 24-hour postoperative dose of 10mg intravenous dexamethasone provided significant additional pain and nausea control and further reduced length of stay (P<0.05). No adverse events were detected with the administration of the intraoperative and/or postoperative dexamethasone.

Superior versus anteroinferior plating of clavicle fractures.

Plate fixation of displaced clavicle fractures has proven to be reliable and reproducible, leading to high union rates and a low rate of associated complications. However, the decision of whether to place the plate superiorly or anteroinferiorly on the clavicle has remained controversial. The authors performed a retrospective review on a consecutive series of patients who underwent plate fixation for a displaced midshaft clavicle fracture at a Level I urban trauma center. A review of surgical records identified 138 patients with a displaced midshaft clavicle fracture requiring operative stabilization. A total of 105 patients who met the inclusion criteria were included in the analysis. Both superior and anteroinferior techniques resulted in a similar time to radiographic union (12.6±4.8 vs 11.3±5.2 weeks, respectively) and identical union rates (95%). At final follow-up, patient-reported implant prominence was nearly double in patients with a retained superior plate (54% vs 29%, respectively; P=.04). No significant difference existed in mean visual analog scale score at a mean of 2.77 years postoperatively, although a significant difference existed in the Oxford Shoulder Score questionnaire, with a mean score of 41.4 in the superior group and 44.4 in the anteroinferior group (P=.008). Implant removal occurred more frequently after superior plating but was not significant. Both superior and anteroinferior clavicle plating are safe treatment methods for displaced clavicle fractures. Superior plating leads to an increased rate of patient-reported implant prominence and may prompt more requests for implant removal.

Medial collateral ligament recession for chronic medial knee laxity.

The medial collateral ligament (MCL) is the primary restraint to valgus stress of the knee. Although the MCL has demonstrated an ability to reliably heal with conservative management, chronic medial instability has been well described following an isolated MCL injury or in combination with an anterior cruciate ligament (ACL) tear. When the MCL heals with persistent medial laxity surgical treatment may be necessary to prevent chronic medial instability and valgus overload of a reconstructed cruciate ligament. We present a simple technique for MCL recession that can be used for isolated MCL laxity as well as in chronic ACL/MCL knee injuries. This technique allows for secure fixation with bone-to-bone healing, avoids donor-site morbidity, maintains relative MCL isometry, and can be performed through a modest incision.

Repair of medial collateral ligament injury during total knee arthoplasty.

Intraoperative midsubstance lacerations of the medial collateral ligament (MCL) must be addressed during surgery, and failure to obtain coronal plane stability could affect patient outcomes and satisfaction. This article reports our results of a series of patients who sustained an intraoperative MCL injury during a primary total knee arthroplasty and were treated by direct primary repair and no change in implant constraint or postoperative protocol. Over a 5-year period, 9 patients sustained this complication. We reviewed their subjective satisfaction and stability, as well as objective measures such as functional scores, physical examinations, and radiographs. Average patient age was 58 years, and mean patient body mass index was 43.3. All patients were satisfied with the procedure and demonstrated no instability on physical examination. Average Knee Society pain score was 91.5 and functional score was 73.3. No radiographic changes or signs of loosening were noted. This novel approach for intraoperative midsubstance lacerations of the MCL does not involve altering implants or postoperative protocols and has encouraging results.

Septic knee-induced deep venous thrombosis in a young adult.

This article describes a case of a 26-year-old man presenting with left knee pain of 1 week's duration, fever, and acute onset of shortness of breath the day of admission. An arthrocentesis of the knee joint was grossly positive for methicillin-resistant Staphylococcus aureus. A left lower extremity venous duplex showed thrombosis of the superficial femoral, popliteal, posterior tibial, peroneal, and gastrocnemius veins. Pulmonary computed tomography-angiography was positive for acute pulmonary emboli. Initial management consisted of anticoagulation, intravenous antibiotics, and 2 arthroscopic irrigation and debridement procedures. After a normal transesophageal echocardiogram, a diagnosis of septic knee-induced deep venous thrombosis (DVT) of the left lower leg with subsequent septic pulmonary emboli was established. The patient was discharged to a long-term care facility for a 6-week monitored course of intravenous antibiotics. His DVT and pulmonary emboli were managed successfully with oral warfarin. Two months after his initial presentation, the patient returned with acute worsening knee pain. A knee arthrocentesis was unremarkable; however, radiographic imaging revealed fulminant osteomyelitis of the distal femur. He has since undergone open arthrotomy with excisional irrigation and debridement and is on a chronic oral antibiotic regimen. Sparse pediatric literature has shown an association between musculoskeletal sepsis and thrombosis. Only 1 case of septic knee-induced DVT exists in the adult literature, and it was not associated with pulmonary emboli. Our case provides evidence that DVT must be considered by the treating physician as a possible and devastating complication of septic arthritis.

Diabetic neuroarthropathy of the shoulder.

Neuroarthropathy of the foot and ankle is a relatively common complication of diabetes mellitus. Likewise, neuroarthropathy of the shoulder has been well reported in relation to syringomyelia. Diabetes mellitus, however, has rarely been reported to cause neuroarthropathy of any joint in the upper extremity and has never previously been reported in the shoulder. This article presents a case of a 77-year-old woman who presented with a secondary complaint of mild right shoulder pain, which had been present since she sustained a proximal humerus fracture four months earlier. The patient's past medical history was notably positive for diabetes mellitus with substantial peripheral neuropathy in the upper and lower extremities. Radiographic examination revealed significant degeneration of the humeral head, consistent with neuroarthropathy of the shoulder. Computed tomography and magnetic resonance imaging demonstrated no syrinx within the spinal cord. The patient's medical history included no etiologies of neuroarthropathy of the shoulder that had been previously reported in the literature. After a thorough literature review, we believe this to be the first case of diabetic shoulder neuroarthropathy to be documented. No significant differences in clinical or radiographic presentations appear to be present between reported etiologies of this pathology, including diabetes mellitus. Consequently, we recommend that diabetes mellitus always be considered as an etiology in the differential diagnosis of neuroarthropathy of the shoulder.