Reverse Total Shoulder Arthroplasty Within 6 Weeks of Proximal Humerus Fracture is Associated with the Lowest Risk of Revision.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) has become an increasingly popular treatment strategy in the management of complex proximal humeral fractures (PHF). However, no definitive consensus has been reached regarding the optimal surgical timing of RTSA following PHF, particularly considering nonoperative management is often a viable option. Therefore, the aim of this study was (1) to identify optimal timing intervals that maximize the likelihood of revision following RTSA and (2) to determine differences in revision etiologies using the identified timing intervals. METHODS: A retrospective cohort analysis of patients undergoing PHF-indicated RTSA from 2010 to 2021 was conducted using a national administrative claims database. Stratum specific likelihood ratio (SSLR) analysis was conducted to determine data-driven timing strata between PHF and RTSA that maximized the likelihood of revision surgery within 2-years of RTSA. To control for confounders, multivariable regression analysis was conducted to confirm the identified data-driven strata's association with 2-year revision rates as well as compare the likelihood of various indications for revision including mechanical loosening, dislocation, periprosthetic joint infection (PJI), and periprosthetic fracture (PPF). RESULTS: In total, 11,707 patients undergoing TSA following PHF were included in this study. SSLR analysis identified two timing categories: 0-6 weeks and 7-52 weeks from the time of PHF to TSA surgery. Relative to the 0-6 week cohort, the 7-52 week cohort was more likely to undergo revision surgery within 2-years (OR: 1.93, P < 0.001). Moreover, the 7-52 week cohort had significantly higher odds of revision indicated for dislocation (OR: 2.24, P < 0.001), mechanical loosening (OR: 1.71, P < 0.001), PJI (OR: 1.74, P < 0.001), and PPF (OR: 1.96, P < 0.001). CONCLUSIONS: Using SSLR, we were successful in identifying two data-driven timing strata between PHF and RTSA that maximized the likelihood of 2-year revision surgery. As it can be difficult to determine whether RTSA or nonoperative management is initially more appropriate, considering the results of this study, an early trial of 4 to 6 weeks of nonoperative management may be appropriate without altering the risks associated with RTSA.

Rotator cuff in asymptomatic volunteers: contrast-enhanced US depiction of intratendinous and peritendinous vascularity.

PURPOSE: To test the hypothesis that regional variations in supraspinatus tendon vascularity exist and can be imaged and quantified in asymptomatic individuals by using contrast material-enhanced ultrasonography (US). MATERIALS AND METHODS: After institutional review board approval and informed consent were obtained, 31 volunteers aged 22-65 years (mean age, 41.5 years) underwent lipid microsphere contrast-enhanced shoulder US performed with an L8-4 transducer operating in contrast harmonic mode and a mechanical index of 0.07 in a HIPAA-compliant protocol. Images were obtained in the volunteers at rest and after exercise. Quantitative analysis was performed by using the time-enhancement postcontrast data derived from four regions of interest (ROIs): bursal medial, articular medial, bursal lateral, and articular lateral. Two 2-minute acquisitions were performed after each contrast material bolus. Baseline enhancement and peak enhancement for each ROI were estimated from these acquisitions. Baseline gray-scale and power Doppler US images of the supraspinatus tendon were obtained by using an L12-5 transducer. The Mann-Whitney nonparametric test was used to test for significant differences between ROIs in all volunteers. RESULTS: In the volunteers at rest before exercise, significant variations in regional enhancement between the articular medial zone and both the bursal medial zone (P = .002) and the bursal lateral zone (P = .003) were observed. Differences in enhancement between the articular medial and articular lateral zones approached significance. Greater differentiation (P < .001) was observed after exercise, with a significant increase in apparent enhancement in each ROI in all volunteers. CONCLUSION: This study revealed the spatial distribution of the blood supply to the supraspinatus tendon in asymptomatic individuals. The addition of exercise to the protocol resulted in a significantly increased level of enhancement compared with that at rest and enabled more sensitive assessment of intratendinous and peritendinous vascularity. SUPPLEMENTAL MATERIAL: http://radiology.rsnajnls.org/cgi/content/full/2483071400/DC1.

Contrast-enhanced ultrasound characterization of the vascularity of the rotator cuff tendon: age- and activity-related changes in the intact asymptomatic rotator cuff.

The natural history of the blood supply to the rotator cuff and its role in the etiology of rotator cuff disease has not been definitively established. To date, there has not been an in-vivo dynamic assessment of the baseline vascularity of the asymptomatic rotator cuff. This study was designed to test the hypothesis that regional variations in supraspinatus tendon vascularity exist with an age-dependent decrease in asymptomatic individuals with intact rotator cuffs. Lipid microsphere, contrast-enhanced ultrasound shoulder examinations were done in 31 patients with a mean age of 41.5 years (range, 22-65 years). Images were obtained at baseline, after contrast administration at rest, and after contrast administration following exercise to visualize the intratendinous blood flow to the supraspinatus tendon. Qualitative and quantitative analysis was performed by determining 4 regions of interest (bursal medial, articular medial, bursal lateral, and articular lateral) with quantification and analysis software (QLAB Philips, Andover, MA) to examine each region of interest and normalize data for interpretation of the mean intensity per pixel. A statistically significant decrease in blood flow to the supraspinatus tendon with age was observed in a comparative analysis of patients aged younger than 40 and older than 40, (P < .05 for all 4 zones after exercise and for the bursal medial, articular medial, and bursal lateral zones after exercise; P = .07 for the articular lateral zone after exercise). A statistically significant increase in blood flow with exercise was observed in an analysis of all patients (P < .001). The age-related decrease in the vascular supply of the tendon observed in this study is consistent with published reports demonstrating an increasing prevalence of rotator cuff pathology with age and may predispose to the development of rotator cuff tendinopathy and, ultimately, attritional tears.

Radiologic and intraoperative findings in revision hip arthroscopy.

PURPOSE: The purpose of this study was to identify possible causes of failure of hip arthroscopy by reviewing the intraoperative and radiologic findings in a series of patients requiring revision hip arthroscopy. METHODS: We retrospectively reviewed 24 revision hip arthroscopy cases performed in 23 patients (14 female and 9 male; mean age, 33.6 years; 1 bilateral). The review included indications for surgery, intraoperative findings, and arthroscopic interventions for both the primary and revision surgeries. Imaging studies, including radiography, magnetic resonance imaging, and 3-dimensionally reconstructed computed tomography scans, were analyzed for the presence of preoperative bony impingement lesions (e.g., femoral head-neck junction "cam" lesions or anterosuperior acetabular "pincer" lesions). RESULTS: The mean interval between previous hip arthroscopy and recurrence of symptoms was 6.1 months. In 13 of 24 cases (54%), patients had no significant improvement at any point after the primary hip arthroscopy. The mean interval between the previous hip arthroscopy and revision surgery was 25.6 months. Unaddressed or undertreated bony impingement lesions were found in 19 of 24 cases (79%) and were identified on imaging studies before revision hip arthroscopy. A tight psoas tendon and corresponding labral impingement lesion were identified by arthroscopic visualization in 7 of 24 cases, for which partial psoas tendon release was performed. Eight cases of failed labral repair were addressed with labral debridement and removal of suture material. Of these 8 cases, 6 also had bony impingement, which was also addressed at the time of the revision surgery. CONCLUSIONS: Failure to address bony impingement lesions of the hip and a tight psoas tendon are key factors in unsuccessful hip arthroscopy and may require revision surgery. Furthermore, failure of labral repairs may be the result of unrecognized bony impingement at the time of initial surgery. LEVEL OF EVIDENCE: Level IV, prognostic case series.

Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip.

Disorders of the lateral or peritrochanteric space (often grouped into the greater trochanteric pain syndrome), such as recalcitrant trochanteric bursitis, external snapping iliotibial band, and gluteus medius and minimus tears, are now being treated endoscopically. We outline the endoscopic anatomy of the peritrochanteric space of the hip and describe surgical techniques for the treatment of these entities. Proper portal placement is key in understanding the peritrochanteric space and should be first oriented at the gluteus maximus insertion into the linea aspera, as well as the vastus lateralis. When tears of the gluteus medius and minimus are encountered, suture anchors can be placed into the footprint of the abductor tendons in a standard arthroscopic fashion. Our initial experience indicates that recalcitrant trochanteric bursitis, external coxa saltans, and focal, isolated tears of the gluteus medius and minimus tendon may be successfully treated with arthroscopic bursectomy, iliotibial band release, and decompression of the peritrochanteric space and suture anchor tendon repair to the greater trochanter, respectively.

Partial-thickness rotator cuff tears.

Partial-thickness tears of the rotator cuff have been diagnosed with increased frequency because of a heightened awareness of the condition by clinicians and improved diagnostic methods. Research into the causes, natural history, and optimal treatment of this condition lags behind that of full-thickness tears. However, despite the limitations in the existing literature, there has emerged a consensus among shoulder experts that partial-thickness rotator cuff tears should be aggressively treated in the active athlete because of the unfavorable natural history of these lesions and success of accepted surgical algorithms. This review will provide an overview of the theories regarding the origins of partial-thickness rotator cuff tears, discuss the relative accuracy of accepted diagnostic techniques, and summarize the indications and methods of operative repair with an emphasis on the results of various treatment approaches.

Hindfoot containment orthosis for management of bone and soft-tissue defects of the heel.

BACKGROUND: Bone, soft-tissue, and nerve deficits of the weightbearing surface of the foot are frequent sequelae from foot trauma or diabetes mellitus and present challenging treatment issues. Injury to the specialized, shock-absorbing, heel-pad tissue containing spirally arranged fat chambers is particularly difficult to manage. Appropriate footwear modifications and shoe inserts for protection of this skin are essential to the long-term management of bone and soft-tissue defects of the heel. This study evaluated the performance of a new custom total contact foot orthosis (Hindfoot Containment Orthosis, HCO) which was designed to contain the soft tissues of the heel, reduce shear forces, redistribute weightbearing load, and accommodate bone or soft-tissue deformity of the heel. METHODS: Twenty-two patients treated with HCO were retrospectively reviewed. Followup averaged 26 months. The effectiveness of the orthosis was assessed by how well the integrity of the soft tissue was maintained (e.g. the number of ulcerations since dispensing the orthosis), the number of refabrications of the orthosis that were required, and whether or not revision surgery was required. RESULTS: Ten patients had superficial ulcerations. No patient required revision surgery. A total of 62 refabrications of the orthoses in 22 patients were required over a 2-year period. Overall results were good in 17 (77%) patients, fair in four (18%), and poor in one. CONCLUSIONS: The HCO is effective for preservation of soft-tissue integrity of the heel pad after bony or soft-tissue injury. Important factors in achieving success with the HCO are patient compliance and periodic monitoring for refabrication of the orthosis to accommodate skeletal growth, change in foot size or shape, and compression or wear of insert materials.

Treatment of complex proximal tibia fractures with the less invasive skeletal stabilization system.

OBJECTIVE: Proximal tibia fractures with metaphyseal comminution present a difficult treatment challenge. The Less Invasive Skeletal Stabilization (LISS) internal fixator system has theoretical advantages (minimally invasive fixed angle construct) for the treatment of these injuries. This report presents clinical results of the LISS system for treatment of complex proximal tibia fractures and illustrates the unique properties of the system. DESIGN: Prospective clinical trial. SETTING: Level I trauma center. PATIENTS: Twenty-eight consecutive patients with comminuted proximal tibia metaphyseal fractures (41A3, 41C2, or 41C3) treated with LISS plates. OUTCOME MEASUREMENTS: Healing, fracture alignment, infectious and implant-related complications, and functional outcome based on the Lower Extremity Measure (LEM). RESULTS: Average follow-up was 23 months (range 12-48). Thirty-seven of 38 patients healed their fracture after the index procedure. The other healed after implant removal without the need for further fracture repair. Postoperative fracture alignment was satisfactory in 37 of the 38 cases and was maintained in all patients at union. There were no infectious complications. The average LEM score was 88. CONCLUSIONS: The LISS internal fixator system can be used successfully to treat complex proximal tibia fractures without the need for additional medial stabilization. Surgeons attempting to use fixed angle internal fixation plating systems should familiarize themselves with the significant technical differences between these and traditional plating systems to assure satisfactory results.

Juvenile and adolescent elbow injuries in sports.

Elbow injuries in skeletally immature athletes continue to increase as juvenile and adolescent athletes participate in organized athletics at earlier ages and with greater intensity. Specialization in specific sports at younger ages has led to an increase in injuries related to repetitive microtrauma. As a result, the spectrum of injuries commonly seen in skeletally immature athletes has increased at a time when long-term outcomes and less invasive interventions with biologic principles are gaining greater attention. Optimal treatment of these injuries requires a knowledge of the complex developmental and radiographic anatomy, the pathophysiology and natural history, and the indications and expected outcomes for conservative and operative management.

Effective glenoid version in professional baseball players.

The pathomechanics of the throwing shoulder have yet to be fully elucidated. The focus of this study reported here was to further characterize the morphology of the glenoid in a population of elite throwing athletes. We obtained magnetic resonance imaging scans of 38 professional baseball players (dominant shoulders) and of 35 age matched nonthrowing control patients (17 dominant and 18 nondominant shoulders). Seven measurements were made by 3 blinded reviewers on 3 axial images per patient: version of superior glenoid, middle glenoid, inferior glenoid, superior capsulolabral junction, middle capsulolabral junction, inferior capsulolabral junction, and depth of concavity of glenoid in a middle slice. Mean age of the 38 players (24 pitchers, 14 fielders) was 26.8 years, and mean age of the 35 control patients was 27.6 years. Intraclass correlation coefficients ranged from .55 to .84 for the version measurements. There were no statistically significant differences between the pitchers and the fielders on any of the 7 measurements, but such differences were found between the throwers and the dominant-shoulder control patients on all 7 measurements. There were only 2 differences (version of superior glenoid, depth of concavity of glenoid in a middle slice) between dominant- and nondominant- shoulder control patients. There was significantly more retroversion in the osseous and soft tissues of the elite throwing athletes than in the nonthrowing control patients. This increased retroversion may play a role in development of internal impingement in the overhead athlete.

Chondrocyte death and cartilage degradation after autologous osteochondral transplantation surgery in a rabbit model.

BACKGROUND: Autologous osteochondral transplantation surgery requires an impact force on the graft that may cause chondrocyte death and matrix degradation. This study attempted to determine the degree to which this occurs in a rabbit model shortly after the procedure. HYPOTHESIS: Impaction of a press-fit autologous osteochondral graft in vivo results in chondrocyte necrosis, apoptosis, and matrix degradation at early time points. STUDY DESIGN: Controlled laboratory study. METHODS: Twenty New Zealand White rabbits underwent unilateral osteochondral transplantation (OT) surgeries, and 10, bilateral sham surgeries. Fifteen animals were sacrificed at time zero (10 sham-0 limbs, 10 OT-0 limbs), and 15, 4 days after surgery (10 sham-4 limbs, 10 OT-4 limbs). Chondrocyte viability/necrosis was determined with cell vital staining. Chondrocyte apoptosis was determined by TUNEL, Bcl-2, and M30 assays. Cartilage matrix degradation was determined by routine light and polarized light microscopy and COL2-3/4C(short) immunohistochemistry. Statistical analysis was performed with a 2-way analysis of variance (P < .05). RESULTS: There were significantly fewer viable cells in OT-4 than in sham-4. A similar difference in cell viability was found in OT-0 versus sham-0. There were more TUNEL-positive cells in OT-4 as compared with OT-0, sham-0, and sham-4; however, there was little or no staining of Bcl-2 and M30. Mankin scores were higher in both OT groups versus both sham groups at time zero and day 4. The OT-4 group had positive staining for COL2-3/4C(short) that corresponded with a loss of collagen birefringence at the superficial zone. CONCLUSION: Osteochondral transplantation procedures performed by tamping a press-fit graft induce chondrocyte necrosis and matrix metalloproteinase-mediated cartilage matrix degradation. However, apoptosis was not found to a major contributor to cell death in this model. CLINICAL RELEVANCE: Results of osteochondral transplantation procedures may be improved by atraumatic insertion and fixation techniques or by pharmacologic agents that can block these degradative processes.

Internal impingement of the shoulder in the overhead athlete.

Internal impingement of the shoulder refers to a constellation of pathologic conditions, including, but not limited to, articular-sided rotator cuff tears, labral tears, biceps tendinitis, anterior instability, internal rotation deficit, and scapular dysfunction. Physiologic adaptations to throwing include increased external rotation, increased humeral and glenoid retroversion, and anterior laxity, all of which may predispose an individual to internal impingement. Nonoperative treatment should always be attempted first, with a focus on increasing the range of motion and improving scapular function. When an operative intervention is chosen, it is important to address microinstability in order to have a good outcome and prevent failure.

Fifteen-year outcome of displaced intra-articular fractures of the distal radius.

PURPOSE: We previously reported the functional and radiographic outcomes of 21 young adults at an average of 7 years after open reduction and internal fixation of an intra-articular distal radius fracture (original study). The purpose of the current investigation was to evaluate the same cohort at an average of 15 years after surgery to evaluate the effect of additional time on both function and radiographic appearance. METHODS: We re-evaluated 16 of the original patients at an average of 15 years after surgery. Subjective assessment was performed with the Musculoskeletal Functional Assessment and the Hand Function Sort questionnaires. Objective assessment included a detailed physical examination and strength measurement. Standardized radiographs and computed tomography were used to assess wrist morphology, residual articular step and gap displacement, and the presence and degree of arthrosis. RESULTS: Subjectively patients continued to function at a high level at the last follow-up evaluation: the average Musculoskeletal Functional Assessment score was 10 and 14 of the 16 patients functioned at a high level according to the Hand Function Sort. Strength and range of motion remained essentially unchanged from the original report. Radiocarpal arthrosis was noted in 13 of the 16 wrists and joint space was reduced an additional 67% compared with the 7-year follow-up evaluation. Nonetheless there continued to be no correlation between the presence or degree of arthrosis and upper-extremity function. CONCLUSIONS: Radiocarpal arthrosis after intra-articular distal radius fractures can be expected to worsen over time. Despite joint space narrowing and evidence of advanced arthrosis, however, patients maintained a high level of function at the long-term follow-up evaluation. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic, Level II.