Pre-shaped Allograft for Glenoid Reconstruction in Anterior Shoulder Instability.

Anteroinferior glenoid bone loss plays a significant role in recurrent glenohumeral instability. Current surgical strategies to reconstruct the glenoid include coracoid transfer (Bristow-Latarjet procedure), iliac crest autograft, and allograft (osteochondral and iliac crest). These may carry drawbacks of technical difficulty, increased surgical time, neurovascular injury, and nonanatomic reconstruction. We report a technique to manage glenoid bone loss using a pre-shaped, predrilled allograft (Glenojet; Arthrosurface) that matches the native contour of the glenoid. The surgical technique and outcomes are described with an accompanying video and figures.

A New Option for Glenoid Reconstruction in Recurrent Anterior Shoulder Instability.

Anteroinferior glenoid bone loss plays a significant role in recurrent glenohumeral instability. Surgical strategies for reconstructing the glenoid in these cases include coracoid transfer, iliac crest autograft, and allograft (osteochondral and iliac crest). In this article, we report on a new technique for managing glenoid bone loss, preshaped allograft, and describe surgical technique and outcomes. So far we have implanted this allograft in 15 patients, and at short-term follow-up there are no known cases of recurrent instability or graft resorption.

Non-operative management of ulnar collateral ligament injuries in the throwing athlete.

Medial ulnar collateral ligament (UCL) injuries have become increasingly prevalent in overhead athletes. The orthopaedic literature contains a wealth of information on operative management of these injuries. However, there are few high-quality longitudinal studies on non-operative care of UCL injuries. The purpose of this review is to describe the non-operative approach to managing UCL injuries, including recommended rehabilitation strategies and predictors of successful non-operative treatment.

Shoulder and Elbow Injuries in the Adolescent Athlete.

With the recent increase in youth sports participation and single-sport youth athletes over the past 30 years, there has been an increase in the number of acute and overuse sports injuries in this population. This review focuses on overuse and traumatic injuries of the shoulder and elbow in young athletes. In particular we discuss little league shoulder, glenohumeral internal rotation deficit, glenohumeral instability, superior labrum anterior posterior lesions, Little League elbow, Panner disease, osteochondritis dissecans of the capitellum, posteromedial elbow impingement, and posterolateral rotatory instability of the elbow. There is a significant emphasis on the evaluation and management of upper extremity injury in the overhead thrower.

Poor Agreement on Classification and Treatment of Subscapularis Tendon Tears.

PURPOSE: To assess the inter- and intraobserver agreement for classification and management of subscapularis tendon pathology based on arthroscopy and magnetic resonance imaging (MRI). METHODS: Twenty-two orthopaedic surgeons from the Multicenter Orthopaedic Outcomes Network (MOON) shoulder group reviewed still arthroscopic and MRI images of the subscapularis tendon from patients with a random assortment of subscapularis morphology. The surgeons were asked to classify the pathology based on 2 systems (Lafosse and Lyons) and choose whether they would repair the tendon and, if so, the method of repair (open or arthroscopic). The survey was administered 3 times to each surgeon. Inter- and intraobserver reliability between testing rounds was determined by kappa analysis. RESULTS: Interobserver reliability on classification of tears was poor based on MRI (k = 0.18 to 0.19) and fair based on arthroscopy (k = 0.26 to 0.29). Interobserver agreement on whether surgical treatment was indicated was fair for both MRI (k = 0.28) and arthroscopy (k = 0.38), while the agreement for type of surgery was poor based on MRI (k = 0.18) and fair based on arthroscopy (k = 0.28). Interobserver agreement did not improve when both MRI and arthroscopy were provided simultaneously (k = 0.24 to 0.30). Intraobserver reliability for classification and treatment was fair to moderate for both MRI (k = 0.32 to 0.50) and arthroscopic imaging (k = 0.39 to 0.56). When considering just those patients with normal tendons, surgeon agreement improved. For all questions, the arthroscopic images had a higher level of agreement among surgeons than the MRI (P < .001). CONCLUSIONS: Although surgeons tended to have higher reliability when presented with arthroscopic images compared with MRI, there was very little agreement on the classification and management of subscapularis tendon tears.

Consequences of single sport specialization in the pediatric and adolescent athlete.

Pediatric and adolescent sports participation has increased with a concomitant increase in injuries. Sports have transitioned from recreational to deliberate, structured activities wherein success is determined by achievement of 'elite' status. This has led to specialization in a single sport with intensive, repetitive activity at younger ages causing physical and emotional consequences, particularly true for the growing athlete who is particularly susceptible to injury. Clinicians caring for this population must understand the epidemiology of youth sports specialization, the unique physiology/structure of this age group, and the potential physical and emotional consequences.

Inpatient surgical site infection after shoulder arthroplasty.

BACKGROUND: Surgical site infection (SSI) after joint arthroplasty is associated with prolonged hospitalization, reoperation, inferior outcomes, and substantial resource utilization. As the number of shoulder replacements performed in the United States continues to rise, measuring the incidence of inpatient SSI after hemiarthroplasty (HSA) and total shoulder arthroplasty (TSA), and associated risk factors for infection is worthwhile. METHODS: Using the Nationwide Inpatient Sample (NIS), we reviewed 241,193 patients undergoing TSA or reverse TSA and 159,795 undergoing HSA between 2002 and 2011 and identified patients with an associated diagnosis of SSI during the admission. Demographic characteristics, preoperative diagnoses, further surgical procedures, associated comorbidities, and in-hospital events associated with SSI were sought in multivariable logistic regression analysis. RESULTS: An in-hospital SSI developed in 0.08% of patients undergoing TSA or reverse TSA and in 0.11% of patients undergoing HSA. Independent risk factors for inpatient SSI included TSA vs HSA (odds ratio [OR], 1.83), Medicaid insurance vs private insurance (OR, 3.93), diagnosis of fracture nonunion (OR, 5.76), avascular necrosis (OR 2.71), or proximal humeral fracture (OR, 2.62) vs primary osteoarthritis, comorbidities, in-hospital events (blood transfusion, pneumonia, and acute renal failure), and increased duration of hospital stay. CONCLUSIONS: The small percentage of SSI that occurs during the initial inpatient stay after shoulder arthroplasty is related to diagnoses other than primary osteoarthritis in more infirm patients with low-income government insurance (Medicaid). Patients considering shoulder arthroplasty can use this information to help decide between the potential improvement in comfort and function of the shoulder and the potential for major adverse events such as infection.

Clinical presentation of posterolateral rotatory instability of the elbow in children.

BACKGROUND: Posterolateral rotatory instability is a type of ulnohumeral instability seen following elbow trauma. It is caused by a deficiency in the lateral collateral ligament complex that allows the radius and ulna to subluxate as a single unit with respect to the distal part of the humerus. There are few studies on this type of instability in children. Our purpose was to evaluate cases of posterolateral rotatory instability in children to better understand its presentation and manifestation as compared with those in adults. METHODS: This was a retrospective chart review of patients from three academic centers. Eligible for inclusion were patients with a diagnosis of posterolateral rotatory instability who were treated with lateral ulnar collateral ligament reconstruction when they were less than nineteen years of age. RESULTS: Nine patients met the inclusion criteria. The mean age at the initial injury was ten years, and the average time from the initial injury to the final operation was 3.7 years. Six patients had prior elbow dislocation, and three had an isolated elbow fracture. Six of the nine patients had a forearm or elbow contracture. Only one patient had a positive pivot-shift test during the preoperative office examination, but all had a positive pivot-shift test when examined under anesthesia. Six had radiographic evidence of posterolateral rotatory instability. All patients underwent lateral ulnar collateral ligament reconstruction. At the time of follow-up, at a minimum of one year after the ligament reconstruction, there was no evidence of deformity secondary to early physeal closure and all elbows remained stable. CONCLUSIONS: Although posterolateral rotatory instability of the elbow is rare, it does exist in children. The instability may not always be recognized because of masking by contracture but, as is the case with adult patients, radiographs may show evidence of the instability. In children with contracture, the clinician should consider the possibility of a masked posterolateral rotatory instability and plan accordingly at the time of contracture release. Surgical correction is technically difficult, and traditional ligament reconstruction in skeletally immature patients may pose a risk to the lateral humeral condylar and epicondylar physes. LEVEL OF EVIDENCE: Therapeutic level IV. See instructions for authors for a complete description of levels of evidence.

Surgeon perceptions and patient outcomes regarding proximal ulna fixation: a multicenter experience.

BACKGROUND: Our objective was to determine surgeon- and patient-based perceptions concerning proximal ulna fixation, including rates of implant removal and overall satisfaction. METHODS: Orthopedic surgeons were surveyed about surgical experience managing proximal ulna fractures and their perception regarding implant removal/revision. A retrospective chart review identified all patients who underwent fixation for proximal ulna fractures and osteotomies between January 2004 and December 2008. RESULTS: In total, 583 surgeons responded to the survey (80%). Of these, 67% believed that their implant removal rate was the same as other surgeons whereas 31% believed that their rate was lower. Seventy-one percent believed that patients required hardware removal less than 30% of the time. Ninety-eight percent believed that they were the same surgeons to remove the implant. In total, 138 consecutive patients were surveyed about their proximal ulna implant. Plating was performed in 80 (58%), and tension banding was performed in 55 (40%). The overall rate of implant removal was 64.5% (89 of 138) at 18.8 months. A second surgeon performed the removal in 68 patients (76%). Of the 49 patients without implant removal, 11 (22%) reported satisfaction with the implant and 19 (39%) reported a functional impairment because of the implant. If guaranteed a safe surgery, 36 (73%) would have the implant removed. CONCLUSION: Surgeons underestimate the rates of proximal ulna implant removal and patient dissatisfaction. Because 76% of the implant removals were performed by a second surgeon, in sharp contrast to the surgeon-perceived rate of 2%, we challenge surgeons to become more aware of this problem in their practices.

Use and outcomes of wound drain in spinal fusion for adolescent idiopathic scoliosis.

STUDY DESIGN: A multicenter retrospective analysis. OBJECTIVE: To evaluate outcomes of closed-suction wound drainage after posterior spinal fusion with instrumentation for adolescent idiopathic scoliosis and to identify surgeon patterns of drain use in this cohort. SUMMARY OF BACKGROUND DATA: There is little evidence on the use of drains in spinal surgery, particularly for repair of adolescent idiopathic scoliosis. Studies on hip and knee arthroplasty suggest no advantage to draining. There are few published reports on surgeon technique and rationale for drain use in spinal surgery. METHODS: Patients were divided into drain and no drain cohorts and followed for 2 years. Primary outcome was complication rate. A separate survey was conducted from surgeons in the Spinal Deformity Study Group to evaluate drain practice patterns. RESULTS: There were 324 drained and 176 undrained patients. Complication rate did not differ between the drain and no drain cohorts in any of the 4 categories (wound infection, neural injury, other infection, and other complication) at any time (all P > 0.1). More drained patients received postoperative transfusions compared with those without a drain (43% vs. 22%, P < 0.001). Of the 50 surgeons in the group, 36 used drains. Half of these did so out of habit. Surgeons tended to place deep drains with bulb suction, without drain manipulation. Half removed drains on the basis of output, whereas half removed them after 1 to 3 days. CONCLUSION: More patients tended to receive wound drains than not receive wound drains. Drains did not impact complication rate and drained patients received more blood product. There are no universal criteria for draining and practice patterns vary widely.

Patient self-assessment of appearance is improved more by all pedicle screw than by hybrid constructs in surgical treatment of adolescent idiopathic scoliosis.

STUDY DESIGN: A multicenter prospective cohort study. OBJECTIVE: To compare the effect of all pedicle screw versus hybrid constructs on patient self-assessment of appearance after posterior spinal fusion with instrumentation for adolescent idiopathic scoliosis (AIS). This will contribute to future cost-effective analyses on surgical management of AIS. SUMMARY OF BACKGROUND DATA: For surgical management of AIS, the Spinal Appearance Questionnaire (SAQ) and the Scoliosis Research Society outcomes instrument (SRS-30) are reliable surveys of patient satisfaction, but neither tool has been used to assess outcome by implant type. METHODS: Patients received either all pedicle screws or hybrid instrumentation. Self-assessment of appearance pre- and after surgery was measured by SAQ and SRS-30. Statistical significance was evaluated through P values (P < 0.01 in the SAQ, P < 0.05 in the SRS-30) and effect sizes. RESULTS: There were 93 patients in the all pedicle screw cohort and 61 in the hybrid cohort. There were no significant preoperative differences between the cohorts in the SAQ or SRS-30. All pedicle screw patients tended to see more improvement in shoulder level than hybrid patients in 2 separate SAQ questions (P = 0.025, Cohen's D = 0.20; P = 0.013, D = 0.24). The screw patients also tended to have better scores than hybrid patients in the category, "looking better in clothes" (P = 0.017, V = 0.24) at 2 years postoperative. All pedicle screw patients self-reported significant greater improvement than hybrid patients in the SRS-30 Appearance and Mental domains (P = 0.016, ES = 0.038; P = 0.005, ES = 0.051). There were no significant differences between cohorts in age, gender, baseline curve, or major curve magnitude. CONCLUSION: All pedicle screw constructs lead to better self-assessment of appearance in operative treatment of AIS, as determined by SAQ and SRS-30.

How to think about insurance: the economics of risk and how it may affect our practice.

Health insurance has evolved, over time, due to changing public needs, changing supplier offerings, and advances in technology. Understanding the motivations for change and the effects on radiology practice can help our leadership respond appropriately.