Determination of rotator cuff tear reparability: an ultrasound-based investigation.

Background: The use of ultrasound as a viable diagnostic tool for routine office visit evaluation of rotator cuff integrity is slowly gaining acceptance in orthopedic practice. However, the reliability of accurately assessing rotator cuff tear reparability by ultrasound has limited evidence in the literature. The purpose of this study was to compare preoperative assessment of cuff tear reparability via ultrasound with the arthroscopic determination of reparability at the time of surgery. Methods: We prospectively collected preoperative ultrasound and arthroscopic imaging data on 145 patients (80 or 55% men and average age of 60.7 years) who underwent arthroscopic posterior superior rotator cuff repair. Three independent experienced orthopedic surgeons retrospectively reviewed all ultrasound studies and arthroscopic imaging and determined if the posterior superior rotator cuff tendon edge was able to be viewed via ultrasound and determined with the arthroscopic images if the tear was reparable. Results: On review of the ultrasound and arthroscopic data, if the edge of the rotator cuff tendon was able to be viewed on the coronal ultrasound image, it was most likely reparable with a positive predictive value of 97.6% and a positive likelihood ratio of 5.8. Sensitivity was 84.4%, and specificity was 76.9%. The negative predictive value was 37.5%, and the negative likelihood ratio was 0.17. The interobserver reliability was 0.63, and the observers were unanimous in determining the tendon edge was able to be visualized in 99 of 145 cases (68%). Conclusion: Preoperative ultrasound evaluation of the shoulder for posterior superior rotator cuff tears is a useful tool for assessing rotator cuff integrity and may help predict intraoperative reparability of the tendon. This study demonstrates that if the cuff tear edge is able to be visualized, there is a high probability of successful arthroscopic restoration of the tendon to its native attachment. Conversely, if the tear edge is unable to be visualized, there is a moderate chance of the tear being irreparable. These results help expand the knowledge base of the usefulness of in-office ultrasound performed by the surgeon in predicting the results of surgical intervention for rotator cuff tears.

Early to midterm outcomes of anatomic shoulder arthroplasty performed on dysplastic glenoids.

BACKGROUND: Treatment of primary osteoarthritis with glenoid dysplasia or Walch type C glenoids remains controversial. There is scant literature available on patient outcomes after anatomic shoulder arthroplasty in patients with Walch type C glenoids. The purpose of this study was to evaluate the outcomes of total shoulder arthroplasty (TSA) for Walch type C dysplastic glenoids with standard (nonaugmented) glenoid components compared with TSA for glenoids with concentric wear and minimal erosion (Walch type A1). We hypothesized that TSA performed for Walch type C dysplastic glenoids with standard glenoid components can reliably produce successful results at short- to midterm follow-up. METHODS: We identified all patients who had primary anatomic TSA performed for osteoarthritis in a prospective shoulder arthroplasty registry collected from 2004 to the present time. Twenty-nine patients met inclusion criteria of a preoperative Walch type C dysplastic glenoid, treatment with TSA using standard (nonaugmented) glenoid components, and a minimum of 2-year clinical follow-up. A matched cohort of 58 patients with a type A1 glenoid and minimum of 2-year clinical follow-up for anatomic shoulder arthroplasty served as the control group. The American Shoulder and Elbow Surgeons (ASES) score, the Single Assessment Numeric Evaluation (SANE), patient satisfaction, complications, and revisions were evaluated in both cohorts. RESULTS: The mean follow-up for this study was 4.5 years (standard deviation, 2.6 years; range, 2-10 years). Baseline measures were not significantly different between the Walch type C dysplastic group and the matched type A1 cohort (all P > .05). Both groups showed significant improvements in ASES, ASES pain, and SANE scores from baseline to the final follow-up (all P < .001). The Walch type C group had no significant differences in ASES score (P = .118), ASES pain (P = .730), or SANE score (P = .168) compared with the matched type A1 cohort. The complication rate of patients with a type C glenoid was 14% (4 of 29) with a 7% (2 of 29) revision rate. Similarly, the complication rate for the A1 matched cohort was 17% (10 of 58) with a 12% (7 of 58) revision rate. Both groups had high patient satisfaction without statistical differences (P = .549). In addition, there were no differences in the rate of radiographic lucencies or Lazarus scores (P = .222). CONCLUSIONS: Anatomic TSA reliably produced clinically significant improvements in pain and function and similar short- to midterm outcomes in patients with Walch type C dysplastic glenoids compared with patients with type A1 glenoids. Anatomic TSA with standard (nonaugmented) glenoid components should remain an option in patients with Walch type C dysplastic glenoids despite emerging treatment options including augmented glenoid components and reverse TSA.

Outcomes of anatomic shoulder arthroplasty performed on B2 vs. A1 type glenoids.

BACKGROUND: Glenoid component malpositioning and glenoid component retroversion have been associated with higher rates of radiolucencies, raising concerns about its implications on glenoid loosening and ultimate failure of anatomic total shoulder arthroplasty (TSA). Although there is literature regarding the relative advantages of techniques to address posterior glenoid bone loss, we are not aware of studies comparing outcomes of TSA on these challenging Walch type B2 glenoids vs. more common A1 glenoids. The purpose of this study is to compare outcomes of TSA performed on A1 glenoids and B2 glenoids treated with asymmetric glenoid reaming. METHODS: We identified 1045 shoulders that had primary TSAs performed for osteoarthritis in a prospective shoulder arthroplasty registry. Two hundred eighty-nine shoulders met inclusion criteria of a preoperative Walch type A1 (178) or B2 (111) glenoid morphology, treatment with TSA, asymmetric reaming in the B2 group, and a minimum of 2-year clinical and radiographic follow-up. Postoperative radiographs were assessed for lucencies, and patient-reported outcome measures were collected at all follow-up visits. RESULTS: Follow-up averaged 40 ± 15 months for all patients, and more men presented with a B2 glenoid (80 of 111; 72%) compared with A1 (101 of 178; 57%) (P = .009). Age at surgery (P = .166), dominant-sided surgery (P = .281), body mass index (P = .501), smoking (P = .155), preoperative opioid use (P = .154), and diabetes (P = .331) were not significantly different between groups. Both groups had similar Constant Strength scores preoperatively (A1: 4.7 ± 7.1, and B2: 4.3 ± 7.3) but the B2 group improved significantly more at final follow-up (A1: 10.3 ± 6.2 vs. B2: 12.7 ± 6.7, P = .005). The Total Constant score was also significantly better at follow-up in the B2 glenoid group (P = .039). All other Constant subscales, American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), and Single Assessment Numerical Evaluation (SANE) measures showed significant improvement preoperatively to final follow-up (all P <.001) but there were no significant differences between the A1 and B2 glenoid groups (all P > .05). A similar proportion of patients rated their satisfaction as either very satisfied or satisfied between the A1 (160; 90%) and B2 (100; 90%) (P = .613). Lazarus scores were also similar between the A1 and B2 groups (P = .952) as were the rates of humeral radiolucent lines (P = .749) and humeral osteolysis (P = .507). CONCLUSIONS: Although patients with B2 glenoids may present a more technically challenging anatomic total shoulder arthroplasty, treatment with concurrent asymmetric glenoid reaming produced similar, successful clinical and radiographic early to midterm outcomes for patients undergoing TSA compared with A1 glenoids. Additional follow-up on this cohort will be important to confirm the durability of these early results.

Clinical outcomes following reverse shoulder arthroplasty-allograft composite for revision of failed arthroplasty associated with proximal humeral bone deficiency: 2- to 15-year follow-up.

BACKGROUND: Patients with pain and disability due to a prior failed shoulder arthroplasty with associated proximal humeral bone loss have limited reconstruction options. Our purpose was to report the results of a large cohort of patients treated with a reverse shoulder allograft-prosthetic composite (APC). METHODS: Between 2002 and 2012, a total of 73 patients were treated with a reverse shoulder APC and had adequate follow-up. Clinical outcome scores, range of motion, and radiographic evidence of failure were assessed. The minimum follow-up period was 2 years, with an average of 67.9 months (range, 21-157 months). Of the patients, 43 had more than 5 years' follow-up and 12 had more than 10 years' follow-up. RESULTS: The total American Shoulder and Elbow Surgeons score improved from 33.8 to 51.4 (P < .0001), and the Simple Shoulder Test score improved from 1.3 to 3.5 (P < .0001). Good to excellent results were reported in 42 of 60 patients (70%), 10 patients (17%) reported satisfactory results, and 8 patients (13%) were unsatisfied. Range of motion improved in forward flexion (49° to 75°, P < .001) and abduction (45° to 72°, P < .001). Revision was required in 14 patients (19%) for periprosthetic fracture (n = 6), instability (n = 2), glenosphere dissociation (n = 2), humeral loosening (n = 2), and infection (n = 2) at a mean of 38 months postoperatively. The reoperation-free survival rate of all reconstructions was 88% (30 of 34) at 5 years, 78% (21 of 27) at 10 years, and 67% (8 of 12) beyond 10 years. Ten patients had radiographic evidence of humeral loosening at final follow-up, and 2 required revision. CONCLUSIONS: The use of a reverse total shoulder APC provides reliable pain relief and improved range of motion, with an acceptable rate of complications. Although ultimate function achieved is limited, patient satisfaction remains high.

The effect of residency training on arthroscopic knot tying and knot stability: which knot is best tied by Orthopaedic surgery residents?

BACKGROUND: The aim of this study is to evaluate which of three arthroscopic knots are most reliably taught to and executed by residents at varying levels of training. METHODS: Three arthroscopic knots, the Samsung Medical Center (SMC), the Weston, and the surgeon's knot, were taught to 16 orthopaedic surgery residents. Each knot was tied in triplicate at two sessions 1 week apart. The knots were then biomechanically tested for strength. Corresponding knots tied by a sports medicine fellow served as the respective controls. RESULTS: Comparing all knots regardless of year of training, the SMC knot failed at significantly higher loads (237.2 ± 66.6 N) than the surgeon's knot (203.7 ± 45.3 N, p = 0.049) and the Weston knot (193.5 ± 56.1 N, p = 0.013). No significant differences in knot strength were found when comparing knots tied by residents at different levels of training and when comparing residents to the sports medicine fellow. There was no difference in conditioning elongation between surgeon's (p = 0.343), Weston (p = 0.486), or SMC knots (p = 0.200) tied by post-graduate year one and five residents. CONCLUSIONS: We report the first study that evaluates the loop strength of an arthroscopically tied knot performed by orthopaedic surgery residents in various levels of training. In our cohort, the SMC knot required a higher load to failure, when compared to the Surgeon's and Weston knot, after a simple arthroscopic knot tying curriculum. Based on these findings, he SMC knot should be considered as a part of future orthopaedic surgery resident arthroscopic training programs.

Humeral Bone Loss in Revision Shoulder Arthroplasty.

Revision shoulder arthroplasty is becoming more prevalent as the rate of primary shoulder arthroplasty in the US continues to increase. The management of proximal humeral bone loss in the revision setting presents a difficult problem without a clear solution. Different preoperative diagnoses often lead to distinctly different patterns of bone loss. Successful management of these cases requires a clear understanding of the normal anatomy of the proximal humerus, as well as structural limitations imposed by significant bone loss and the effect this loss has on component fixation. Our preferred technique differs depending on the pattern of bone loss encountered. The use of allograft-prosthetic composites, the cement-within-cement technique, and combinations of these strategies comprise the mainstay of our treatment algorithm. This article focuses on indications, surgical techniques, and some of the published outcomes using these strategies in the management of proximal humeral bone loss.

Comparison of Femoral Head Rotation and Varus Collapse Between a Single Lag Screw and Integrated Dual Screw Intertrochanteric Hip Fracture Fixation Device Using a Cadaveric Hemi-Pelvis Biomechanical Model.

OBJECTIVE: This study compared the stabilizing effect of 2 intertrochanteric (IT) fracture fixation devices in a cadaveric hemi-pelvis biomechanical model. METHODS: Eleven pairs of cadaveric osteopenic female hemi-pelves with intact hip joint and capsular ligaments were used. An unstable IT fracture (OTA 31-A2) was created in each specimen and stabilized with a single lag screw device (Gamma 3) or an integrated dual screw (IDS) device (InterTAN). The hemi-pelves were inverted, coupled to a biaxial apparatus and subjected to 13.5 k cycles of loading (3 months) using controlled, oscillating pelvic rotation (0-90 degrees) plus cyclic axial femoral loading at a 2:1 body weight (BW) ratio. Femoral head rotation and varus collapse were monitored optoelectonically. For specimens surviving 3 months of loading, additional loading was performed in 0.25 × BW/250 cycle increments to a maximum of 4 × BW or failure. RESULTS: Femoral head rotation with IDS fixation was significantly less than the single lag screw construct after 3 months of simulated loading (P = 0.016). Maximum femoral head rotation at the end of 4 × BW loading was 7× less for the IDS construct (P = 0.006). Varus collapse was significantly less with the IDS construct over the entire loading cycle (P = 0.021). CONCLUSIONS: In this worst-case model of an osteopenic, unstable, IT fracture, the IDS construct, likely owing to its larger surface area, noncylindrical profile, and fracture compression, provided significantly greater stability and resistance to femoral head rotation and varus collapse.

Early Radiographic and Clinical Outcomes Study Evaluating an Integrated Screw and Interbody Spacer for One- and Two-Level ACDF.

BACKGROUND: Multiple techniques and implants can be used in ACDF, the newest of which are integrated cage and screw constructs. These devices may be beneficial over anterior plate constructs due to a negligible anterior profile that may reduce dysphagia. The goal of this study is to review the early radiographical and clinical results associated with a low profile integrated intervertebral cage in one- and two-level anterior column fusions. METHODS: Fusion rates, incidence of hardware failure and deformity correction were assessed through 1 year. Patientreported scores, including VAS for neck pain, and improvements in axial neck pain and neurologic deficit from the preoperative baseline were quantified at 3, 6 and 12 months post-operatively. The incidence of dysphagia was recorded. RESULTS: Lordosis and disc space height at the operated levels increased an average of 4.5° and 3.3mm after device placement (p<0.001). Sagittal plane correction was maintained at 1 year. VAS improved from an average of 5.1 preoperatively to 3.1 immediately postoperatively and was maintained at 12 months. At 3 months, patient-reported improvements in axial neck pain and neurologic deficit were 85% and 93%, respectively. Reported improvements were sustained for both parameters at 12 months (77% and 86%, respectively). Fusion was noted in 93% of the operated levels. There were two documented cases of dysphagia that lasted more than 5 weeks, both following two level ACDFs with the test device (3.5% rate of chronic dysphagia). CONCLUSIONS: The low profile integrated device improved lordosis at the operated level that was maintained at 1 year. Fusion rates with the new device are consistent with ACDF using anterior plating. In combination with improvements in pain and a minimal rate of dysphagia, study findings support the use of integrated interbody spacers for use in one- and two-level ACDF procedures. LEVEL OF EVIDENCE: Level IV, Case Series.

The effects of glenoid wear patterns on patients with osteoarthritis in total shoulder arthroplasty: an assessment of outcomes and value.

BACKGROUND: Despite the success of total shoulder arthroplasty (TSA), concerns remain about the longevity of the implant, in particular, glenoid component survivorship. The purpose of this study was to determine whether preoperative glenoid wear patterns affect clinical outcomes and value in patients undergoing TSA. METHODS: A comparative cohort study was conducted of 309 patients with a total of 344 TSA procedures, performed for primary glenohumeral osteoarthritis. Computed tomography scans were obtained in all patients, with preoperative glenoid wear pattern characterized as either concentric (n = 196; follow-up time, 49.2 months) or eccentric (n = 148; follow-up time, 52.3 months) according to a modified Levine classification. A clinical, radiographic, and economic assessment was performed between the 2 wear patterns. RESULTS: There was no significant difference in American Shoulder and Elbow Surgeons (ASES) score in the concentric group (80.8 ± 20.8) compared with the eccentric group (77.6 ± 21.2) at final follow-up (P = .159). Range of motion and final visual analog scale for pain score were similar between the 2 groups. Radiographic evidence of gross glenoid loosening was significantly lower in the concentric group [11 of 195 (5.6%)] compared with the eccentric group [18 of 147 (12.2%)] (P = .030). Revision rates were similar between the concentric group [4 of 195 (2.0%)] and the eccentric group [3 of 147 (2.0%)]. A value assessment also showed no significant difference between the concentric and eccentric groups [concentric 26.1 vs. eccentric 25.5 (ΔASES score/$10,000 hospital cost) (P = .479)]. CONCLUSIONS: Similar clinical results and value can be expected with both concentric and eccentric glenoid wear patterns in TSA. Concerns arise, however, as the eccentric group demonstrated a more than 2-fold increased rate of glenoid component loosening compared with the concentric group.

Peripheral Quantitative Computed Tomography Predicts Humeral Diaphysis Torsional Mechanical Properties With Good Short-Term Precision.

Peripheral quantitative computed tomography (pQCT) is a popular tool for noninvasively estimating bone mechanical properties. Previous studies have demonstrated that pQCT provides precise estimates that are good predictors of actual bone mechanical properties at popular distal imaging sites (tibia and radius). The predictive ability and precision of pQCT at more proximal sites remain unknown. The aim of the present study was to explore the predictive ability and short-term precision of pQCT estimates of mechanical properties of the midshaft humerus, a site gaining popularity for exploring the skeletal benefits of exercise. Predictive ability was determined ex vivo by assessing the ability of pQCT-derived estimates of torsional mechanical properties in cadaver humeri (density-weighted polar moment of inertia [I(P)] and polar strength-strain index [SSI(P)]) to predict actual torsional properties. Short-term precision was assessed in vivo by performing 6 repeat pQCT scans at the level of the midshaft humerus in 30 young, healthy individuals (degrees of freedom = 150), with repeat scans performed by the same and different testers and on the same and different days to explore the influences of different testers and time between repeat scans on precision errors. IP and SSI(P) both independently predicted at least 90% of the variance in ex vivo midshaft humerus mechanical properties in cadaveric bones. Overall values for relative precision error (root mean squared coefficients of variation) for in vivo measures of IP and SSI(P) at the midshaft humerus were <1.5% and were not influenced by pQCT assessments being performed by different testers or on different days. These data indicate that pQCT provides very good prediction of midshaft humerus mechanical properties with good short-term precision, with measures being robust against the influences of different testers and time between repeat scans.

Are quadrilateral surface buttress plates comparable to traditional forms of transverse acetabular fracture fixation?

BACKGROUND: Several construct options exist for transverse acetabular fracture fixation. Accepted techniques use a combination of column plates and lag screws. Quadrilateral surface buttress plates have been introduced as potential fixation options, but as a result of their novelty, biomechanical data regarding their stabilizing effects are nonexistent. Therefore, we aimed to determine if this fixation method confers similar stability to traditional forms of fixation. QUESTIONS/PURPOSES: We biomechanically compared two acetabular fixation plates with quadrilateral surface buttressing with traditional forms of fixation using lag screws and column plates. METHODS: Thirty-five synthetic hemipelves with a transverse transtectal acetabular fracture were allocated to one of five groups: anterior column plate+posterior column lag screw, posterior column plate+anterior column lag screw, anterior and posterior column lag screws only, infrapectineal plate+anterior column plate, and suprapectineal plate alone. Specimens were loaded for 1500 cycles up to 2.5x body weight and stiffness was calculated. Thereafter, constructs were destructively loaded and failure loads were recorded. RESULTS: After 1500 cycles, final stiffness was not different with the numbers available between the infrapectineal (568±43 N/mm) and suprapectineal groups (602±87 N/mm, p=0.988). Both quadrilateral plates were significantly stiffer than the posterior column buttress plate with supplemental lag screw fixation group (311±99 N/mm, p<0.006). No difference in stiffness was identified with the numbers available between the quadrilateral surface plating groups and the lag screw group (423±219 N/mm, p>0.223). The infrapectineal group failed at the highest loads (5.4±0.6 kN) and this was significant relative to the suprapectineal (4.4±0.3 kN; p=0.023), lag screw (2.9±0.8 kN; p<0.001), and anterior buttress plate with posterior column lag screw (4.0±0.6 kN; p=0.001) groups. CONCLUSIONS: Quadrilateral surface buttress plates spanning the posterior and anterior columns are biomechanically comparable and, in some cases, superior to traditional forms of fixation in this synthetic hemipelvis model. CLINICAL RELEVANCE: Quadrilateral surface buttress plates may present a viable alternative for the treatment of transtectal transverse acetabular fractures. Clinical studies are required to fully define the use of this new form of fixation for such fractures when accessed through the anterior intrapelvic approach.