Outcomes of femoral head allograft for the management of glenoid bone defects in revision reverse shoulder arthroplasty: a case-controlled study.

BACKGROUND: Revision shoulder arthroplasty often requires management of glenoid bone defects. Options include using allograft, harvesting iliac crest autograft, or using augmented metal components. The purpose of this study is to report outcomes of revision shoulder arthroplasty requiring management of glenoid bone defects with femoral head allograft in a large cohort of patients using a single reverse shoulder implant system and compare them to a matched cohort based on the indication for surgery. Outcomes of patients who had successful glenoid reconstruction were compared to those that required a re-revision, and to a control group that was revised without the need for bone graft. METHODS: This was a retrospective review of data collected from 2009 to 2018. There were 36 patients in the bone graft group and 52 in the control group. All patients underwent revision to a reverse shoulder arthroplasty to manage a failed total shoulder arthroplasty (n = 29 and 11), hemiarthroplasty (n = 1 and 24), or reverse shoulder arthroplasty (n = 6 and 17). All patients had a minimum of 2 yr of clinical follow-up. The primary endpoint was survival of baseplate fixation. Secondary outcomes included range of motion and functional outcome scores. Patients that had recurrent baseplate failure and were re-revised were compared to patients with bone graft that did not require additional surgery, and to patients who were revised without the need for bone graft. Patients who required revisions for reasons other than recurrent baseplate failure were also recorded. RESULTS: Five of 36 (14%) patients had recurrent baseplate failure. Mean time to failure was 12 mo. Three of 5 had successful re-implantation of another baseplate. Two of 5 were revised to a hemi arthroplasty after failure of their revisions. Preoperative American Shoulder and Elbow Surgeons scores were 31 in the grafted patients that did not require re-revision, 39 in the grafted patients that required re-revision, and 33 in the control group. Final American Shoulder and Elbow Surgeons scores were 64, 36, and 56, respectively. One patient required revision surgery not related to baseplate failure. There were no baseplate failures in the control group. CONCLUSION: The use of femoral head allograft to manage glenoid bone defects in the revision setting produces predictable improvement in functional outcomes that is not inferior to those in patients revised without bone graft. However, there is a 14% rate of baseplate failure.

The Relationship Between Cigarette Smoking and the Prevalence, Frequency and Severity of Back Pain.

The purpose of this study was to examine the relationship between smoking and back pain in a cross-sectional analysis. Using the Osteoarthritis Initiative database, a multi-center, longitudinal, observational cohort study with 4796 participants, we examined the prevalence of back pain and of limitations in activity due to back pain, as well as the frequency and severity of back pain in participants who were current smokers compared to those who had never smoked. Data was evaluated using binary and ordinal logistic regression analyses. An increase in prevalence, frequency and severity of back pain was strongly associated with smoking. This demonstrates a relationship between smoking and back pain; however, further studies are needed to evaluate causation. (Journal of Surgical Orthopaedic Advances 29(3):165-168, 2020).

Body mass index as a risk factor for dislocation of total shoulder arthroplasty in the first 30 days.

BACKGROUND: Dislocation of total shoulder arthroplasty has an incidence as high as 31%. Obesity is one of many proposed risk factors, but no consensus exists on this relationship. The purpose of this study was to determine whether there is a relationship between body mass index (BMI) and dislocation of total shoulder arthroplasty. METHODS: The National Surgical Quality Improvement Program database was used to identify patients older than 50 years who underwent anatomic or reverse total shoulder arthroplasty between the years 2012 and 2016 for primary or secondary osteoarthritis, post-traumatic arthritis, or cuff tear arthropathy. Patients requiring reoperation or readmission for dislocation were identified by Current Procedural Terminology code. The relationship between World Health Organization BMI classification and dislocation was assessed. RESULTS: A total of 9382 patients were identified; 46% were male and 54% female, with an average age of 68.7 years (range 50-90) and average BMI of 31.2 (range 15.1-79.3). There were only 24 dislocation events within the first 30 days after the procedure (0.26%). Ten of 24 (42%) occurred after discharge. Seventy percent of cases (17 of 24) required an open procedure. Underweight patients (BMI < 18.5) experienced the highest dislocation rate (1/50, 2.00%), whereas overweight patients (BMI 25-29.9) experienced the lowest dislocation rate (3/3069, 0.1%). CONCLUSION: The rate of dislocation of total shoulder arthroplasty in the acute postoperative period differs across categories of BMI. However, there does not appear to be a linear association between BMI and risk of dislocation of total shoulder arthroplasty. Further studies are required to elucidate the risk factors for total shoulder dislocation.

The Effect of Age on the Benefits of Early Decompression for Cervical Spondylotic Myelopathy.

Cervical myelopathy is the most common cause of acquired spinal cord dysfunction in people aged >55 years. Advanced age and duration of symptoms have been implicated in the literature as negative prognostic indicators for postoperative functional improvement, but very few studies have evaluated the interaction of these factors. We retrospectively reviewed 125 patients who underwent surgery for cervical myelopathy. Patients were stratified according to age greater or less than 65 years and duration of symptoms of greater or less than 12 and 24 months. Functional outcomes were assessed using the Nurick score. Simple regression and multiple regression analyses were done, controlling for sex, preoperative Nurick score, surgical approach, smoking status, diabetes status, prior surgery, number of levels fused, ethanol use, and signal change on preoperative magnetic resonance imaging. The average change in Nurick score in all patients was 1.36, with a significant difference between patients with symptoms for <24 months and those with symptoms for >24 months (1.54 vs 0.98, P = .03). Multiple regression analysis revealed that older patients had a significant difference at 24 months (1.69 vs 1.25, P = .01), whereas younger patients showed slightly lower improvement overall and a change in Nurick score at both thresholds that was statistically nonsignificant.

The Association Between Body Mass Index and the Prevalence, Severity, and Frequency of Low Back Pain: Data From the Osteoarthritis Initiative.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To determine whether there is an association between body mass index (BMI) and the prevalence, severity, and frequency of low back pain and identify other potential patient risk factors for the development of low back pain. SUMMARY OF BACKGROUND DATA: Many studies have implicated that a high BMI is a risk factor for low back pain. However, few studies have examined the association between increased BMI and the prevalence, severity, and frequency of low back pain. METHODS: Data from the Osteoarthritis Initiative, a multicenter, prospective study of knee osteoarthritis, were used to conduct this study, which included 4796 patients. BMI was categorized according to the World Health Organization classification and the prevalence, severity, and frequency of low back pain were assessed. Logistic regression was performed to identify additional patient risk factors associated with low back pain. RESULTS: The prevalence of low back pain was found to be significantly higher in patients with an elevated BMI compared to those with normal or underweight BMI and demonstrated a stepwise increase with each BMI category. Approximately 47.4% of patients with normal or underweight BMI complained of low back pain compared with 72.8% of morbidly obese patients (P < 0.0001). No association was seen between BMI and the frequency or severity of low back pain episodes. Osteoarthritis of the back and depression were patient variables found to be associated with all three measures (prevalence, severity, and frequency) of low back pain. CONCLUSION: Elevated BMI is strongly associated with an increased prevalence of low back pain. Depression and osteoarthritis of the back are associated with the prevalence, severity, and frequency of low back pain. LEVEL OF EVIDENCE: 3.

Does Tobacco Use Attenuate Benefits of Early Decompression in Patients With Cervical Myelopathy?

STUDY DESIGN: A retrospective cohort. OBJECTIVE: This study investigates the interplay between duration of preoperative symptoms and smoking status with respect to postoperative outcomes in patients with cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Many studies have established the harms of smoking and several have identified the benefits of early decompression in patients with cervical myelopathy, but to our knowledge, none have assessed the relationship between these two variables. METHODS: The medical records of all 212 patients operated on by the senior author between March 2005 and July 2012 were reviewed. Inclusion criteria were the diagnosis of CSM with a Nurick score, surgical intervention, and at least 2 years of follow-up. Patients were categorized according to smoking status and quantification of tobacco use by packs per day and pack-years, and duration of symptoms according to thresholds of 6, 12, or 24 months. Age, sex, preoperative Nurick score, duration of preoperative symptoms, duration of follow-up, procedure performed, prior surgery, number of levels operated on, diabetes status, ethanol use, and signal change on preoperative magnetic resonance imaging were also recorded for ordered logistical regression analysis. RESULTS: One hundred twenty-five patients met all criteria. Eighty patients were smokers and 45 were nonsmokers. The median change in Nurick score for nonsmokers was 2 compared with 1 in smokers. Nonsmokers had a statistically significant likelihood of decreased change in Nurick score for symptom duration of greater than 24 months (odds ratio = 0.06, P = 0.0025). Smokers did not show a significant difference in the change in Nurick score for any threshold of symptom duration. CONCLUSION: Increased duration of symptoms significantly affects outcomes in surgical decompression of CSM. A history of cigarette use may attenuate the benefit of early decompression and results in lower improvement in Nurick score regardless of symptom duration. LEVEL OF EVIDENCE: 3.

Chronic Antiplatelet Use Associated With Increased Blood Loss in Lumbar Spinal Surgery Despite Adherence to Protocols.

There are conflicting reports regarding postoperative bleeding risks associated with discontinuation of antiplatelet therapy at least 7 days preoperatively. Most of the studies in the spine literature are based on surveys or anecdotal evidence. The majority of surgeons discontinue therapy 7 days preoperatively, but this varies widely from 5 to 21 days. The purpose of this retrospective study was to assess whether chronic antiplatelet use is associated with increased intraoperative blood loss, need for transfusion, and perioperative complications. Of 454 patients who underwent elective lumbar spinal surgery, 85 were on antiplatelet therapy and 369 were not. All patients stopped antiplatelet therapy at least 7 days preoperatively with approval from their cardiologist or primary care provider. Multiple regression analysis was performed and corrected for age, sex, antiplatelet therapy, number of levels decompressed/fused/instrumented, preoperative hematocrit, and postoperative hematocrit. Results showed that preoperative antiplatelet therapy, despite at least 7 days of discontinuation, is a statistically significant predictor (P=.04) of increased intraoperative blood loss. Blood transfusion was not associated with antiplatelet use but was associated with the number of levels fused, age, and low preoperative hematocrit (all P<.01). There were no recorded complications in either group. The authors conclude that antiplatelet therapy is associated with an increased risk of intraoperative blood loss in spine patients despite discontinuation at least 7 days preoperatively, but the clinical significance of this is unclear given the lack of association with blood transfusions and perioperative complications. [Orthopedics. 2016; 39(4):e695-e700.].

The Influence of Diabetes on Surgical Outcomes in Cervical Myelopathy.

STUDY DESIGN: A retrospective cohort. OBJECTIVE: The objective of the study was to determine what effect, if any, diabetes has on surgical outcomes in patients with cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Diabetes is known to impair healing and has been shown to affect outcomes in lumbar surgery, but few studies have assessed outcomes in cervical surgery, and cervical myelopathy in particular. METHODS: The records of 113 patients operated on by one surgeon were reviewed. Inclusion criteria were a diagnosis of CSM with a Nurick score, surgical interventions, and minimum 2 years follow-up. Patients were divided into two groups according to diabetes status (33 diabetic patients vs. 80 controls) and diabetic patients were further categorized by degree of perioperative glucose control. Simple and multiple regression analyses were done to compare outcomes as recorded by the Nurick score, controlling for age, gender, duration of symptoms, alcohol use, cocaine use, surgical approach, prior surgery, and signal change on preoperative magnetic resonance imaging. RESULTS: There was no relationship between diabetes status and preoperative Nurick score. However, diabetes status was associated with impaired improvement in Nurick score. Average perioperative glucose in diabetic individuals was linearly associated with impaired improvement in Nurick score. CONCLUSION: We conclude that hyperglycemia may impair postoperative healing of the spinal cord in patients with CSM. LEVEL OF EVIDENCE: 3.

The Effect of Smoking on Spinal Cord Healing Following Surgical Treatment of Cervical Myelopathy.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The purpose of this study was to compare outcomes of surgical treatment of cervical myelopathy between smokers and nonsmokers as assessed by the Nurick score. SUMMARY OF BACKGROUND DATA: The harmful effects of smoking on healing have been well established. However, the effect of smoking on postoperative outcomes for cervical myelopathy has not been specifically evaluated. METHODS: The medical records of 212 patients who underwent surgery for cervical spondylotic myelopathy were reviewed. Inclusion criteria were the diagnosis of cervical spondylotic myelopathy with a Nurick score, surgical intervention, and at least 2 years of follow-up. The patients were categorized into 2 groups according to smoking status and stratified according to pack years and packs per day. Age at presentation, sex, preoperative and postoperative Nurick score, duration of symptoms preoperatively, duration of follow-up, procedure performed, surgical approach, number of levels fused, diabetes status, cocaine use, ethanol use, preoperative magnetic resonance imaging signal change, and whether the patient belonged to the Veterans Administration (VA) were recorded. Analysis was done using simple linear regression and multiple regression. RESULTS: Univariate analysis demonstrated a postoperative improvement in nonsmokers of 1.53 points on the Nurick scale compared with 0.6 points in smokers (P < 0.001). There is a progressive decrease in improvement as the number of pack years and packs per day increase (P < 0.001). There is a greater improvement in Nurick score with greater (worse) preoperative score but only in patients with fewer than 25 pack years. Smoking status is not associated with preoperative Nurick score. CONCLUSION: Smoking status is associated with poor improvement in Nurick score after surgical treatment of cervical myelopathy. Smoking may have a directly toxic effect on the intrinsic healing capability of the spinal cord, particularly beyond 25 pack years. LEVEL OF EVIDENCE: 3.