Effect of Posterior Tibial Slope on Outcomes After Posterior Cruciate Ligament Reconstruction.

Background: Increased posterior tibial slope (PTS) leads to a relative anterior translation of the tibia on the femur. This is thought to decrease the stress on posterior cruciate ligament (PCL) reconstruction (PCLR) grafts. Purpose/Hypothesis: The purpose of this study was to analyze the effect of PTS on knee laxity, graft failure, and patient-reported outcome (PRO) scores after PCLR without concomitant anterior cruciate ligament reconstruction (ACLR). It was hypothesized that patients with higher PTS would have less knee laxity, fewer graft failures, and better PROs compared with patients with lower PTS. Study Design: Case-control study; Level of evidence, 3. Methods: All patients who underwent PCLR between 2001 and 2020 at a single institution were identified. Patients were excluded if they underwent concomitant or prior ACLR or proximal tibial osteotomy, were younger than 18 years, had <2 years of in-person clinical follow-up, and did not have documented PRO scores (Lysholm score and International Knee Documentation Committee [IKDC] score). Data were collected retrospectively from a prospectively gathered database. PTS measurements were recorded from perioperative lateral knee radiographs. A linear regression model was created to analyze PTS in relation to PRO scores. Patients with a grade 1 (1-5 mm) or higher posterior drawer were compared with those who had a negative posterior drawer. Results: A total of 37 knees met inclusion criterion; the mean age was 30.7 years at the time of surgery. The mean clinical follow-up was 5.8 years. No significant correlation was found between either the Lysholm score or the IKDC score and the PTS. Twelve knees (32.4%) had a positive posterior drawer at final follow-up. The mean PTS in knees with a positive posterior drawer was 6.2°, whereas that for knees with a negative posterior drawer was 8.3° (P = .08). No significant differences in PRO scores were identified for knees with versus knees without a positive posterior drawer. No documented graft failures or revisions were found. Conclusion: No significant differences were found in PROs or graft failure rates based on PTS at a mean of 5.8 years after PCLR. Increased tibial slope trended toward being protective against a positive posterior drawer, although this did not reach statistical significance.

Outcomes of Humeral Allograft-Prosthetic Composites with Plate Fixation in Revision Total Elbow Arthroplasty.

Background: Traditionally, the reconstruction of severe distal humeral bone loss at the time of revision total elbow arthroplasty (TEA) has used allograft-prosthetic composites (APCs) stabilized with cerclage wires or cables. We have migrated to plate fixation when revision TEA using a humeral APC is performed. This study shows the outcomes of patients treated with a humeral APC with plate fixation during revision TEA. Methods: Between 2009 and 2019, 41 humeral APCs with plate fixation of distal humeral allograft to the native humerus were performed in the setting of revision TEA. There were 12 male patients (29%) and 29 female patients (71%), with a mean age of 63 years (range, 41 to 87 years). The mean allograft length was 12 cm. All elbows had a minimum follow-up of 2 years (mean follow-up, 3.3 years). Patients were evaluated for visual analog scale pain scores, range of motion, the ability to perform select activities of daily living, and the Mayo Elbow Performance Score (MEPS). Outcomes including reoperations, complications, and revisions were noted. The most recent radiographs were evaluated for union at the allograft-host interface, failure of the plate-and-screw construct, or component loosening. Results: The mean postoperative flexion was 124° (range, 60° to 150°) and the mean postoperative extension was 26° (range, 0° to 90°); the mean arc of motion was 99° (range, 30° to 150°). The mean MEPS was 58 points (range, 10 to 100 points). Two surgical procedures were complicated by neurologic deficits. The overall reoperation rate was 14 (34%) of 41. Of the 33 patients with complete radiographic follow-up, 12 (36%) had evidence of nonunion at the allograft-host interface with humeral component loosening, 1 (3%) had evidence of partial union, and 1 (3%) had ulnar stem loosening. Conclusions: Revision TEA with a humeral APC using compression plating was successful in approximately two-thirds of the elbows. Further refinement of surgical techniques is needed to improve union rates in these complex cases. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hemiarthroplasty versus total shoulder arthroplasty in B2 glenoids with an intact rotator cuff: a long-term matched cohort analysis.

Background: Walch B2 glenoids present unique challenges to the shoulder arthroplasty surgeon, particularly in young, active patients who may wish to avoid the restrictions typically associated with an anatomic total shoulder arthroplasty (TSA). Long-term data are limited when comparing hemiarthroplasty (HA) and TSA for patients with an intact rotator cuff. The purpose of our study was to compare the long-term outcomes of HA vs. TSA in a matched analysis of patients with B2 glenoids, primary osteoarthritis (OA), and an intact rotator cuff. Methods: A retrospective review was performed of all patients who underwent HA or TSA between January 2000 and December 2011 at a single institution. Inclusion criteria were primary OA, Walch B2 glenoid morphology, an intact rotator cuff intraoperatively, at least 2 years of clinical follow-up, or revision within 2 years of surgery. Fifteen HAs met inclusion criteria and were matched 1:2 with 30 TSAs using age, sex, body mass index, and implant selection. Clinical outcomes including range of motion (ROM), visual analog scale (VAS) for pain, subjective shoulder value score, American Shoulder and Elbow Surgeons (ASES) score, complications, and revisions were recorded. Postoperative radiographs were reviewed to assess for stem loosening, humeral head subluxation, glenoid loosening, and glenoid erosion. Results: A total of 15 HAs and 30 TSAs met inclusion criteria at a mean follow-up of 9.3 years. The mean age at the time of surgery was 60.2 years for HA and 65.4 years for TSA (P = .08). Both cohorts had significant improvements in ROM, subjective shoulder value, and VAS pain scores (P < .001). TSA had higher postoperative ASES scores compared to HA (P = .03) and lower postoperative VAS pain scores (P = .03), although the decrease in pain from preoperatively to final follow-up was not significantly different between HA and TSA (P = .11). HAs were more likely to have posterior humeral subluxation (P < .001) and stem lucencies (P = .02). Revisions occurred in 11.1% of the cohort with no difference for HA and TSA (P = .73). Conclusions: At nearly 10 years of follow-up, HA and TSA both showed significant improvements in ROM and pain when performed for primary glenohumeral OA in B2 glenoids with intact rotator cuffs. Compared to HA, TSAs had less posterior humeral subluxation, less stem lucencies, higher ASES scores, and lower postoperative VAS pain scores. However, our study failed to demonstrate a difference in ROM, complication, or revision rates between HA and TSA.

Osteochondral Autograft Transfer for Capitellar Chondral and Osteochondral Defects.

Chondral and osteochondral lesions of the humeral capitellum, most notably osteochondritis dissecans, most commonly present in adolescent baseball players and gymnasts. A variety of surgical techniques can be used to address these lesions. Osteochondral autograft transfer has recently shown superior rates of return to sport. We describe osteochondral autograft transfer from the contralateral knee to treat a large full-thickness chondral lesion of the humeral capitellum. Osteochondral allograft backfill of the donor site is shown as well. This surgical procedure is technically demanding but very reproducible and maximizes return to play in patients while minimizing donor-site morbidity.

Fatal Neurologic Dysfunction During Continuous-Flow Left Ventricular Assist Device Support.

BACKGROUND: During continuous-flow left ventricular assist device (CF-LVAD) support, neurologic dysfunction (ND) is a common complication and can be fatal. Few reports provide detailed data on neurologic mortality in such patients. Therefore, we examined ND-related mortality during CF-LVAD support. METHODS: Between November 2003 and March 2016, 526 patients underwent implantation of a CF-LVAD (403 HeartMate II [Thoratec, Pleasanton, CA] and 123 HVAD [HeartWare International, Framingham, MA]) at our center. We categorized ND as hemorrhagic or ischemic and recorded resulting deaths. Records were reviewed to determine preoperative demographics, perioperative variables, prevalence and causes of postimplantation ND, duration of support until ND, time from ND to death, laboratory data and medications at the time of ND, post-ND treatment procedures, and causes of hemorrhagic ND. We also performed Cox multivariable logistic regression analysis to identify predictors of ND-related mortality by calculating odds ratios and confidence intervals. RESULTS: Neurologic dysfunction occurred in 141 patients (26.8%), 48 (9.1%) of whom subsequently died. Median duration of left ventricular assist device support before ND was 230 days (range, 3 to 2,422), and median time from ND to death was 3.5 days (range, 0 to 55). Parenchymal hemorrhage was the most frequent cause of early conversion (76.7%). In the Cox multivariable regression analysis, predictors of fatal ND were age, ischemic cause of heart failure, history of stroke, and longer intraoperative aortic cross-clamp time. CONCLUSIONS: Our study elucidates the characteristics and risk factors of patients who died of ND during CF-LVAD support. Further studies are required to find ways to decrease the incidence of fatal ND during CF-LVAD support.

Effect of concomitant mitral valve procedures for severe mitral regurgitation during left ventricular assist device implantation.

The effect of performing a concomitant mitral valve procedure (MVP) during continuous-flow left ventricular assist device (CF-LVAD) implantation has been reported for patients with moderate-to-severe mitral regurgitation (MR), but moderate MR is less of a clinical concern for CF-LVAD patients. There is a paucity of reports focusing on patients with severe MR. Thus, the purpose of this study was to analyze the effect of performing a concomitant MVP during CF-LVAD implantation in patients with severe preoperative MR. Between November 2003 and March 2016, 526 patients underwent primary implantation of a CF-LVAD at our center. Patients with severe MR who underwent a concomitant MVP were compared to those who did not in regard to overall survival, perioperative complications, postoperative echocardiography data, bridge-to-transplantation success, and CF-LVAD explantation. Of the 108 patients with severe MR, 26 underwent a concomitant MVP and 82 did not. These groups showed no difference in survival (p = 0.61). Additionally, the two groups had similar rates of postoperative right heart failure (p = 0.69) and readmissions (p = 0.42). The 24-month follow-up echocardiography results were also similar. Furthermore, the groups showed no difference in bridge-to-cardiac transplantation success (30.0% vs 25.0%, p = 0.80) or CF-LVAD explantation rates (0.0% vs 0.0%. p = 1.0). Our findings suggest that patients with severe MR who undergo a MVP during CF-LVAD implantation do not have superior outcomes to those who do not. However, assessments of other outcomes may show some benefits to performing concomitant MVPs.