Reverse shoulder arthroplasty for patients with cuff tear arthropathy: do clinical outcomes differ by inlay vs. onlay design?

BACKGROUND: The influence of position of the humeral tray (inlay or onlay) on clinical outcomes in reverse shoulder arthroplasty (RSA) is a topic of debate. The purpose of this study was to compare clinical and radiographic outcomes of patients with cuff tear arthropathy treated with RSA systems with inlay or onlay humeral tray design, similar neck-shaft angles, and lateralized glenospheres. METHODS: This was a retrospective study of prospectively obtained data from 1 tertiary care center. We identified all patients who underwent primary RSA between 2009 and 2017 (N = 511). We included 102 patients with diagnosed cuff tear arthropathy treated with RSA prostheses with a lateralized glenosphere and 135° neck-shaft angle (with either an inlay or onlay humeral tray design) who had a minimum of 2 years of follow-up (mean, 44 months; range, 24-125 months). Sixty-three patients (62%) had an inlay humeral tray (inlay group) and 39 (38%) had an onlay tray (onlay group). All patients underwent preoperative and postoperative evaluations, including measures of patient-reported outcomes (PROs), shoulder range of motion (ROM) testing, and radiographic imaging. Clinical relevance of changes in PROs and ROM was evaluated using published values for minimal clinically important differences. RESULTS: The 2 groups did not differ by demographic characteristics except for a higher proportion of women in the inlay group (75%) than in the onlay group (56%) (P = .04). Preoperative PROs and ROM were not significantly different between groups. At final follow-up, PROs and ROM were not different between groups in terms of statistical significance or clinical relevance. We found no significant differences in the rate of baseplate loosening (inlay, 3.2% vs. onlay, 5.1%, P = .63), revision surgery (inlay, 0% vs. onlay 5.1%, P = .07), acromial stress fracture (inlay, 3.2% vs. onlay, 5.1%, P = .63), prosthesis dislocation (inlay, 0% vs. onlay, 2.6%, P = .20), or scapular notching (inlay, 21% vs. onlay, 7.7%, P = .08). CONCLUSION: At 2-year minimum follow-up, the position of the humeral tray in RSA prostheses (either inlay or onlay) for cuff tear arthropathy was not associated with PROs, shoulder ROM, or rates of complications, including baseplate loosening, acromial stress fracture, and scapular notching.

Epidemiology of Pediatric Dog Walking-Related Injuries Among Children Presenting to US Emergency Departments, 2001 to 2020.

BACKGROUND: Dog walking is associated with a significant injury burden among adults, but the risk of injury associated with dog walking among children is poorly understood. This study describes the epidemiology of children treated at US emergency departments for injuries related to leash-dependent dog walking. METHODS: The National Electronic Injury Surveillance System (NEISS) database was retrospectively analyzed to identify children (5 to 18 years of age) presenting to US emergency departments between 2001 and 2020 with dog walking-related injuries. Primary outcomes included annual estimates of injury incidence, injury characteristics, and risk factors for fracture or traumatic brain injury (TBI). Weighted estimates, odds ratios (ORs), and 95% confidence intervals (CIs) were generated using NEISS sample weights. RESULTS: An estimated 35,611 children presented to US emergency departments with injuries related to dog walking. The mean age of patients was 11 years, and most patients were girls (63%). Over half (55%) of injuries were orthopaedic, and patients commonly injured their upper extremity (57%) and were hurt while falling when pulled or tripped by the leash (55%). The most frequent injuries were wrist strain/sprain (5.6%), finger strain/sprain (5.4%), and ankle strain/sprain (5.3%). On multivariable analysis, injured children aged 5 to 11 years were more likely to have sustained a TBI (OR: 3.2, 95% CI: 1.1-9.7) or fracture (OR: 1.6; 95% CI: 1.1-2.3). Boys were more likely than girls to have experienced a fracture (OR: 2.0, 95% CI: 1.3-2.5). CONCLUSIONS: Dog walking-related injuries in children are primarily orthopaedic and involve the upper extremity. Younger children and boys are at greater risk for serious dog walking-related injuries. LEVEL OF EVIDENCE: Level III.

Improved accuracy of implant placement with an imageless handheld robotic system compared to conventional instrumentation in patients undergoing total knee arthroplasty: a prospective randomized controlled trial using CT-based assessment of radiological outcomes.

PURPOSE: Image-free handheld robotic-assisted total knee arthroplasty (RATKA) has shown to achieve desired limb alignment compared to conventional jig-based instrumented total knee arthroplasty (CTKA). The aim of this prospective randomized controlled trial (RCT) was to evaluate the accuracy of a semi-autonomous imageless handheld RATKA compared to CTKA in order to achieve the perioperative planned target alignment of the knee postoperatively. METHODS: Fifty-two patients with knee osteoarthritis were randomized in 1:1 ratio to undergo unilateral CTKA or an imageless handheld RATKA. A full-length lower limb CT-scan was obtained pre- and 6-week postoperative. The primary outcomes were radiologic measurements of achieved target hip-knee-ankle axis (HKA-axis) and implant component position including varus and external rotation and flexion of the femur component, and posterior tibial slope. The proportion of outliers in above radiographic outcomes, defined as > 3° deviation in postoperative CT measurements as compared to perioperative planned target, were also noted. Knee phenotypes were compared with use of the Coronal Plane Alignment of the Knee (CPAK) classification. RESULTS: Baseline conditions were comparable between both groups. The overall proportion and percentage of outliers (n = 38, 24.4% vs n = 9, 5.8%) was statistically significant (p < 0.001) in favor of RATKA. The achieved varus-valgus of the femoral component (varus 1.3° ± 1.7° vs valgus - 0.1° ± 1.9°, p < 0.05) with statistically significant less outliers (0% vs 88.5%, p < 0.01), the achieved HKA-axis (varus 0.4° ± 2.1° vs valgus - 1.2° ± 2.1°, p < 0.05) and the posterior tibial slope (1.4° ± 1.1° vs 3.2° ± 1.8°, p < 0.05) were more accurate with RATKA. The most common postoperative CPAK categories were type II (50% CTKA vs 61.5% RATKA), type I (3.8% CTKA vs 23.1% RATKA) and type V (26.9% CTKA vs 15.4% RATKA). CPAK classification III was only found in CTKA (19.2%). Type VI, VII, VIII, and IX were rare in both populations. CONCLUSIONS: The present trial demonstrates that an imageless handheld RATKA system can be used to accurately perioperatively plan the desired individual component implant positions with less alignment outliers whilst aiming for a constitutional alignment. LEVEL OF EVIDENCE: I.

Image-free handheld robotic-assisted technology improved the accuracy of implant positioning compared to conventional instrumentation in patients undergoing simultaneous bilateral total knee arthroplasty, without additional benefits in improvement of clinical outcomes.

PURPOSE: The purpose of this study was to compare the clinical and radiological outcomes in patients who underwent simultaneous bilateral total knee arthroplasty (SB-TKA) using either robotic-assisted TKA (RA-TKA) or conventional TKA (C-TKA). METHODS: Included were the patients who underwent SB-TKA between January 2018 and January 2020 and had a minimum follow-up of 2 years. Of 151 patients included, 117 patients were operated using an image-free handheld robotic sculpting system (RA-TKA group) and 34 patients operated using conventional instrumentation (C-TKA group). The key outcomes noted were multiple patient-reported outcomes (PROs), adverse events, and radiological outcomes. Two investigators independently measured the radiological outcomes on pre- and post-operative radiographs in coronal plane (medial proximal tibial angle [MPTA] and anatomic lateral distal femoral angle [aLDFA]) and sagittal plane (posterior tibial slope [PTS] and posterior condylar offset [PCO]). The chi-square test was used to examine categorical variables. Student's t test was used to analyze the continuous variables. RESULTS: Patients in both groups were similar in baseline characteristics (gender, body mass index, incidence of comorbidities, and length of hospital stay) except that RA-TKA group patients younger (66.7 ± 8.9 vs 70.4 ± 10.5, P = 0.037) than C-TKA group. The operative time was longer in RA-TKA group as compared to C-TKA (189.3 ± 37.1 vs 175.0 ± 28.2, P = 0.040). The final PROs at each were similar between the two groups (P > 0.05). The values of PROs at final follow-up in RA-TKA compared to C-TKA were VAS pain (0.4 ± 0.9 vs 0.4 ± 0.5), KOOS-JR (89.3 ± 5.8 vs 87.1 ± 5.3), and physical (55.9 ± 2.8 vs 55.4 ± 3.2), mental (61.1 ± 4.4 vs 60.2 ± 4.7) component of VR-12 scores, and KSS satisfaction (37.5 ± 1.1 vs 37.1 ± 2.2) (all P > 0.50 or non-significant [n.s.]). While one patient in RA-TKA required revision of femoral component for peri-prosthetic fracture, none of the patient in conventional group were revised (0.85% vs 0%, P = n.s.). The proportion of patients with outliers in RA-TKA group was lower for aLDFA (2.6% vs 22.1%, P < 0.01) and PTS (0% vs 35%, P < 0.01). CONCLUSION: This comparative study in patients undergoing SB-TKA found reduction of outliers in femoral and tibial implant positioning with RA-TKA as compared to C-TKA. There were no differences in both groups for pain, function, and satisfaction at a minimum of 2 years of follow-up. LEVEL OF EVIDENCE: III Therapeutic Study.

Achieving functional alignment in total knee arthroplasty: early experience using a second-generation imageless semi-autonomous handheld robotic sculpting system.

PURPOSE: In order to minimize errors during achieving the targeted alignment of the total knee arthroplasty (TKA) components, robotic-assisted surgery has been introduced with the aim to help surgeons to improve implant survival, clinical outcomes, and patient satisfaction. The primary goal of this paper is to highlight surgical tips and tricks on how to achieve functional alignment (FA) through intra-operative boney mapping, numeric gap, and alignment data, using the next generation of imageless robotic surgical systems. METHOD: This retrospective case-series contains planned and achieved data on the FA and joint gap data obtained from 526 patients captured and assessed with use of a semi-autonomous imageless handheld robotic sculpting systems. All patients were operated upon by two experienced TKA surgeons. RESULTS: The mean difference between planned and achieved alignment was 1.46° (≥ 7° varus group), 1.02° (< 7° varus group), 1.16° (< 7° valgus group), and 1.43° (≥ 7° valgus group). The mean observed planned and achieved extension and flexion gaps were below 1.47 mm for medial extension gaps, 1.12 mm for the lateral extension gaps, 1.4 mm for the medial flexion gaps, and 1.16 mm for the lateral flexion gaps. CONCLUSION: Analysis of these first cases highlights the capability of the next generation of imageless robotic-assisted total knee replacement using a semi-autonomous handheld robotic sculpting to maintain accuracy of the desired alignment. The system allows the surgeon to choose freely their own alignment philosophy while maintaining efficiency.

Lateralized glenosphere reverse shoulder arthroplasty: inlay and onlay designs have similar clinical outcomes in patients with glenohumeral osteoarthritis.

BACKGROUND: Whether or how the position of the humeral tray (inlay or onlay) in reverse shoulder arthroplasty (RSA) affects outcomes is unclear. Our goal was to compare the clinical and radiographic results of RSA systems with inlay vs. onlay designs but with similar neck shaft angles (NSAs) and lateralized glenospheres. METHODS: We screened the institutional database at our tertiary academic center for patients who underwent primary RSA (with a lateralized glenosphere and a 135° NSA) from 2009 through 2017. The indication for surgery was glenohumeral osteoarthritis with glenoid bone loss (Walch classification A2, B2, B3, or C) and an intact rotator cuff. All patients were followed for a minimum of 2 years (mean, 47 months; range, 24-123 months). The humeral tray design was inlay for 79 patients and onlay for 71. All patients underwent preoperative and postoperative evaluations, including physical examination, radiography, and patient-reported outcome measures (visual analog scale for pain, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and Western Ontario Osteoarthritis of the Shoulder index). RESULTS: Compared with preoperative values, both groups achieved minimal clinically important differences in range of motion and patient-reported outcomes at the final follow-up. We found no significant differences between groups in any of these measures at the final follow-up. Rates of revision (inlay, 3.8% vs. onlay, 1.4%), scapular notching (inlay, 5.1% vs. onlay, 7.0%), acromial stress fracture (inlay, 0% vs. onlay, 2.8%), and tuberosity resorption (inlay, 25% vs. onlay, 27%) were not significantly different between groups (all, P > .05). CONCLUSION: For patients with glenohumeral osteoarthritis with glenoid bone loss and an intact rotator cuff who underwent RSA using a lateralized glenosphere prosthesis with a 135° NSA, there were no significant differences between the inlay and onlay groups for range of motion, patient-reported outcomes, or complication rates. These findings are limited to this off-label indication for RSA.

Age and Racial Disparities in Telemedicine Utilization in an Academic Orthopedic Surgery Department.

Introduction: The COVID-19 pandemic has highlighted significant racial and age-related health disparities. In response to pandemic-related restrictions, orthopedic surgery departments have expanded telemedicine use. We analyzed data from a tertiary care institute during the pandemic to understand potential racial and age-based disparities in access to care and telemedicine utilization. Materials and Methods: Data on patient race and age, and numbers of telemedicine visits, in-person office visits, and types of telemedicine were extracted for time periods during and preceding the pandemic. We calculated odds ratios for visit occurrence and type across race and age groups. Results: Patients ages 27-54 were 1.3 (95% confidence interval [CI] 1.1-1.4, p < 0.01) and 1.2 (95% CI 1.0-1.3, p < 0.05) times more likely to be seen than patients <27 during the pandemic, versus the 2019 and 2020 controls. Patients 54-82 were 1.3 (95% CI 1.1-1.5, p < 0.001) times more likely to be seen than patients <27 during the pandemic versus the 2019 control. Patients 27-54, 54-82, and 82+, respectively, were 3.3 (95% CI 2.6-4.2, p < 1e-20), 3.5 (95% CI 2.8-4.4, p < 1e-24), and 1.9 (95% CI 1.1-3.4, p < 0.05) times more likely to be seen by telemedicine than patients <27. Among pandemic telemedicine appointments, Black patients were 1.5 (95% CI 1.2-1.9, p < 1e-3) times more likely to be seen by audio-only telemedicine than White patients, as compared with video telemedicine. Conclusions: Telemedicine access barriers must be reduced to ensure that disparities during the pandemic do not persist.

Descriptive Epidemiology of Injuries in Professional Speedball Athletes.

CONTEXT: Speedball is an increasingly popular racquet sport played in more than 25 countries. Our objective was to describe injury incidence and patterns among Egyptian national-level speedball athletes. DESIGN: Descriptive epidemiological. METHODS: We conducted a survey of athletes who were registered with the Egyptian Speedball Federation during the 2018-2019 professional season. The survey inquired about injury types and athlete exposures (AEs). The response rate was 63% (100/160 athletes). Respondent ages ranged from 18 to 41 years. We analyzed demographic characteristics; number, location, and mechanism of injuries; treatment; and speedball participation time lost because of injury. RESULTS: Of 100 respondents, 65 reported having sustained at least one injury during the season for a total of 90 injuries and a rate of 4.7 injuries per 1000 AEs (95% confidence interval, 3.7 to 5.7). More injuries occurred during practice (77%) than during competition (23%). Thirty percent of respondents reported having missed a competition because of injury. The most frequent anatomic locations of injury were the shoulder (50%; 2.4/1000 AEs), elbow (14%; 0.68/1000 AEs), and low back (9%; 0.4/1000 AEs). The most frequently cited causes of injury were increased intensity of training (40%) and lack of warming up (18%). Seventy-seven percent of injured respondents underwent treatment by a health care professional, and 9% of these respondents underwent surgery. CONCLUSION: The shoulder was the most common anatomic location for injuries in speedball athletes. Our results suggest that attention should be directed toward sport-specific injury prevention and intervention strategies because speedball is a fast-growing sport in several countries.

Acute compartment syndrome caused by hematoma after shoulder surgery: a case series.

BACKGROUND: The development of acute compartment syndrome (ACS) of the upper extremity after an elective surgical shoulder procedure is rare but can have devastating results. We describe a series of patients who developed ACS of the upper extremity caused by hematoma formation and subsequent upper extremity swelling after undergoing elective surgical shoulder procedures. METHODS: We retrospectively reviewed the database of our tertiary care institution between 2004 and 2019 to find patients who developed ACS after elective shoulder surgery. We found 4 such patients and reviewed their medical records and extracted data on their history, clinical examination, predisposing factors, treatment, and clinical and radiographic outcomes. RESULTS: Of the 4 patients treated, 2 had undergone reverse total shoulder arthroplasty, 1 had undergone open biceps tenodesis, and 1 had undergone closed manipulation for adhesive capsulitis. Two patients developed symptoms of ACS within 24 hours of the index procedure. Both were treated with immediate decompression of the hematoma, and both experienced complete pain relief and full recovery of function at 1-year follow-up. Two patients were on anticoagulation therapy. Of these, 1 patient developed ACS symptoms 14 days after a revision reverse total shoulder arthroplasty and was treated successfully with compartment release. Despite treatment, the other patient developed extensive necrosis of muscles and nerves in the upper extremity and severe neurologic deficits in hand and forearm function. CONCLUSION: ACS of the upper extremity caused by hematoma formation can lead to catastrophic outcomes if diagnosis and treatment are not immediate. Providers should be aware of ACS and the need for prompt diagnosis and treatment.

Combined Intravenous and Intraarticular Tranexamic Acid Does Not Offer Additional Benefit Compared with Intraarticular Use Alone in Bilateral TKA: A Randomized Controlled Trial.

BACKGROUND: Tranexamic acid (TXA) is efficacious for reducing blood loss and transfusion use in patients who undergo bilateral TKA, and it is administered intravenously alone, intraarticularly alone, or as a combination of these. However, it is unclear whether combined intravenous (IV) and intraarticular TXA offers any additional benefit over intraarticular use alone in patients undergoing bilateral TKA. QUESTIONS/PURPOSES: The purposes of our study was to determine (1) whether combined IV and intraarticular TXA reduces blood loss and blood transfusion use compared with intraarticular use alone and (2) whether the frequency of adverse events is different between these routes of administration in patients who undergo simultaneous or staged bilateral TKA. METHODS: Between April 2015 and May 2017, one surgeon performed 316 same-day bilateral TKAs and 314 staged bilateral TKAs. Of those, 98% of patients in each same-day TKA (310) and staged bilateral TKA (309) groups were eligible for this randomized trial and all of those patients agreed to participate and were randomized. The study included four groups: simultaneous TKA with intraarticular TXA only (n = 157), simultaneous TKA with IV and intraarticular TXA (n = 153), staged TKA with intraarticular TXA only (n = 156), and staged TKA with IV and intraarticular TXA (n = 155). There were no differences in demographic data among the intraarticular alone and IV plus intraarticular TXA groups of patients who underwent simultaneous or staged bilateral TKA in terms of age, proportion of female patients, BMI, or preoperative hematologic values. The primary outcome variables were total blood loss calculated based on patient blood volume and a drop in the hemoglobin level and administration of blood transfusion. The secondary outcomes of this study were a decrease in the postoperative hemoglobin level; the proportion of patients with a hemoglobin level lower than 7.0, 8.0, or 9.0 g/dL; and the frequencies of symptomatic deep vein thrombosis, symptomatic pulmonary embolism, wound complications, and periprosthetic joint infection. RESULTS: Total blood loss with intraarticular TXA alone in patients undergoing simultaneous bilateral TKA and those undergoing staged procedures was not different from the total blood loss with the combined IV plus intraarticular TXA regimen (1063 mL ± 303 mL versus 1004 mL ± 287 mL, mean difference 59 mL [95% CI -7 to 125]; p = 0.08 and 909 ml ± 283 ml versus 845 ml ± 278 ml; mean difference 64 mL [95% CI 1 to 127]; p = 0.046, respectively). The use of blood transfusions between intraarticular alone and combined IV and intraarticular TXA was also not different among patients undergoing simultaneous (0% [0 of 152] versus 1%; p = 0.149) and staged TKA (1% [1 of 155] versus 0% [0 of 153]; p = 0.98). Furthermore, the frequency of symptomatic thromboembolic events, wound complications, and periprosthetic joint infections was low, without any differences among the groups with the numbers available. CONCLUSION: Because there was no difference between intraarticular alone and combined intraarticular plus IV regimen of TXA administration, we recommend that IV and intraarticular TXA should not be used in combination. Moreover, other studies have found no differences between intraarticular and IV TXA used alone, and hence to avoid potential complications associated with systemic administration, we recommend that intraarticular alone is sufficient for routine TKA. LEVEL OF EVIDENCE: Level I, therapeutic study.

Unicompartmental knee arthroplasty, an enigma, and the ten enigmas of medial UKA.

Unicompartmental knee arthroplasty (UKA) is a bone- and ligament-sparing alternative to total knee arthroplasty in the patients with end-stage single-compartment degeneration of the knee. Despite being a successful procedure, the multiple advantages of UKA do not correlate with its usage, most likely due to the concerns regarding prosthesis survivability, patient selection, ideal bearing design, and judicious use of advanced technology among many others. Therefore, the purpose of this study is to review and summarize the debated literature and discuss the controversies as "Ten Enigmas of UKA."

New mobile-bearing TKA with unique ball and socket post-cam mechanism offers similar function and stability with better prosthesis fit and gap balancing compared to an established fixed-bearing prosthesis.

PURPOSE: A mobile-bearing (MB) posterior-stabilized total knee arthroplasty (TKA) system with ball and socket post-cam mechanism has been developed with the aims of better prosthesis fit and enhanced stability. However, the data are limited to compare its clinical outcomes with an already established fixed-bearing (FB) implant design. METHODS: This is a prospective randomized study comparing 260 patients in the MB group and 133 patients in FB group with a minimum 2 years of follow-up. Intraoperative variables, post-operative functional outcomes and incidence of adverse events were compared. RESULTS: MB group showed better prosthesis fit as the incidence of over-hang of femoral component at junction (medial: 1% vs. 5% and lateral: 2% vs 4%, p < 0.001) and trochlea (medial: 2% vs 30%, p = 0.042 and lateral: 13% vs 21%, p = 0.015) was less than FB group. MB group also showed better gap balancing as the incidence of medio-lateral gap difference more than 2 mm was less in flexion (2.3% vs. 16%, p < 0.001) and extension (3.1% vs. 9.8%, p = 0.005). Post-operative functional outcomes and incidence of adverse events showed no difference between the two groups at 2 years. CONCLUSIONS: New MB design offers similar functional outcomes and stability along with better intraoperative prosthesis fit and gap balancing compared to an established fixed-bearing design. Hence, this new MB design could be an alternative prosthesis of choice for posterior-stabilized TKA. LEVEL OF EVIDENCE: I.