Difficulty in decision making in the treatment of displaced proximal humerus fractures: the effect of uncertainty on surgical outcomes.

BACKGROUND: Decision making in the management of proximal humerus fractures can be difficult in situations in which the surgeon is uncertain of the ideal treatment. METHODS: Two shoulder surgeons operatively treated 476 proximal humerus fractures from 1998-2014 with open reduction-internal fixation (ORIF), hemiarthroplasty, or reverse shoulder arthroplasty. Operative treatment was stratified by year to determine the evolution of technological influences on treatment over time. To evaluate the effect of uncertainty, 274 clinical vignettes were created for all patients with 1 year of follow-up or more and reviewed by 3 fellowship-trained shoulder surgeons to determine the type of treatment for each case. To evaluate the effect of certainty, range of motion for each patient with unanimous agreement on treatment was analyzed. RESULTS: ORIF treatment increased from 40% to 62% after release of the proximal humerus locking plate. Introduction of the fracture stem in 2011 increased reverse shoulder arthroplasty for fractures from 8.8% to 44.3%. Unanimous agreement on either operative or nonoperative treatment occurred 70.5% of the time. Only 63.5% of patients received the actual treatment selected (P = .001). Patients for whom unanimous agreement matched actual treatment in the ORIF treatment group showed improvement of forward elevation (144° vs 123°, P = .005) and abduction (129° vs 103°, P = .002). CONCLUSION: Successful management of displaced proximal humerus fractures requires both technical and decision-making abilities. The difficulty in making these decisions is reflected by the agreement of experienced shoulder surgeons only 63.5% of the time regarding the treatment performed. When uncertainty occurs, patients may have reduced outcomes as seen in the ORIF treatment group.

The influence of patient- and surgeon-specific factors on operative duration and early postoperative outcomes in shoulder arthroplasty.

BACKGROUND: Increased operative duration has been shown to have demonstrable effects on the outcomes and complications in multiple areas of orthopedic surgery. We sought to determine if patient- and surgeon-specific factors correlated to operative duration in shoulder arthroplasty. Our hypothesis was that increased surgeon and trainee volume would decrease operative times and that more complex pathology would increase operative duration. METHODS: A retrospective review of primary and revision total and reverse shoulder arthroplasties performed at a single institution from 2012 through 2015 was performed evaluating the correlation between specific patient and surgeon factors and operative duration. The influence of operative duration on postoperative length of stay and risk of readmission within 30 days was also analyzed. RESULTS: For surgeon-specific factors, high surgeon volume (>30 shoulder arthroplasties/year) was associated with shorter operative duration (105.9 vs. 128.3 minutes; P < .001). Progression through the fellowship academic year was found to be associated with decreased surgical times (100.7 vs. 116.5 minutes; P < .0001). Certain complex pathologic processes (reverse shoulder arthroplasty for sequelae of prior fracture, total shoulder arthroplasty for dysplastic glenoid morphology, revision surgery) showed increased operative times. Patients with postoperative readmission had a longer mean operative time (163 vs. 107.1 minutes). CONCLUSIONS: Increased surgeon and trainee volumes were associated with decreased operative duration in shoulder arthroplasty. Patients with more complex pathology were more likely to have increased surgical times. Postoperative readmission within 30 days was associated with increased operative duration. Consideration of patient selection by surgeons to minimize operative times may reduce readmissions.

Patients Undergoing Total Shoulder Arthroplasty on the Dominant Extremity Attain Greater Postoperative ROM.

BACKGROUND: Total shoulder arthroplasty (TSA) provides excellent functional outcomes and pain relief in appropriately selected patients. Although it is known to affect other shoulder conditions, the role of hand dominance after TSA has not been reported, to our knowledge. QUESTIONS/PURPOSES: We asked: (1) Does TSA of the dominant arm result in greater postoperative ROM compared with TSA of the nondominant arm? (2) Does hand dominance affect validated outcome scores after TSA? METHODS: We performed a review of all patients who underwent primary TSAs between 2008 and 2011 with a minimum of 12 months followup. During that time, one surgeon performed 156 primary TSAs. One hundred twenty-seven patients met the minimum followup requirement for this analysis (81%), whereas 29 (19%) were lost to followup. Seven patients were excluded for surgical indications other than glenohumeral osteoarthritis. A total of 58 patients underwent TSA of the dominant upper extremity and 62 underwent TSA of the nondominant upper extremity. Patient demographics, preoperative and postoperative ROM, and preoperative and postoperative outcome scores, were collected from the medical records. Student's t-tests and chi-square tests were used for analysis. Demographics and preoperative ROM did not differ between patients undergoing TSA on the dominant or the nondominant upper extremity. RESULTS: Dominant-arm TSAs showed greater postoperative forward elevation and external rotation. Postoperative active forward elevation in the dominant group was 151° versus 141° in the nondominant group (mean difference, 10°; 95% CI, 1°-18°; p = 0.033). Postoperative active external rotation was 61° in the dominant group, versus 51° in the nondominant group (mean difference, 10°; 95% CI, 5°-15°; p < 0.001). Active internal rotation did not differ (dominant, 52°, nondominant, 50°; mean difference, 2°; 95% CI, -3° to 7°; p = 0.419). There were no differences in postoperative VAS (dominant, 0.9, nondominant, 1.4; mean difference, 0.5; 95% CI, -0.1 to 1.1; p = 0.129), simple shoulder test (dominant, 9.8, nondominant, 9.2; mean difference, 0.5; 95% CI, -0.5 to 1.5; p = 0.278), and American Shoulder and Elbow Surgeons scores (dominant, 84, nondominant, 80; mean difference, 4; 95% CI, -2 to 10; p = 0.211). CONCLUSIONS: Patients who underwent TSA of their dominant upper extremity had greater postoperative active forward elevation and active external rotation compared with patients who had TSA of their nondominant upper extremity. This average difference of 10° active forward elevation and active external rotation could be useful for preoperative and postoperative counseling of patients. Regardless of hand dominance, similar functional outcomes were achieved. LEVEL OF EVIDENCE: Level III, therapeutic study.

Neer Award 2015: A randomized, prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty.

BACKGROUND: Tranexamic acid (TXA) is an antifibrinolytic agent that has been shown to significantly reduce blood loss and transfusion requirements after total knee and hip arthroplasty. The purpose of this study was to evaluate the effect of TXA on postoperative blood loss after shoulder arthroplasty. METHODS: A total of 111 patients (62 women; average age, 67 years) who underwent shoulder arthroplasty were prospectively randomized in double-blinded fashion to receive either 100 mL of normal saline or 100 mL of normal saline with 2 g TXA by topical application into the wound at the completion of the case. All patients received a postoperative drain. Drain output representing postoperative blood loss, transfusion requirements, and change in hemoglobin level were recorded. All postoperative complications were noted. RESULTS: The average blood loss recorded after surgery was 170 mL in the placebo group and 108 mL in the TXA group (P = .017). The average change in hemoglobin level was 2.6 g/dL in the placebo group and 1.7 g/dL in the TXA group (P < .001). There were no transfusion requirements or postoperative complications noted in either group. DISCUSSION: In this cohort of patients, those treated with TXA experienced a significantly lower amount of postoperative blood loss and a significantly smaller change in hemoglobin level compared with those treated with placebo. Further work is required to determine the effectiveness and clinical significance of TXA in reducing transfusion requirements in shoulder arthroplasty and, more specifically, shoulder arthroplasty performed for complicated patients or for trauma and fracture patients.

A Modified Ogata-Goldsand Technique for Simplified Intraoperative Measurement of Femoral Version.

BACKGROUND: Femoral anteversion can be difficult to determine intraoperatively, particularly in cases with complicated deformity. Although biplanar methodology exists for measuring femoral anteversion, the measurements are generally based on the proximal femur, without consideration for the femoral bow. METHODS: We directly measured femoral version in 70 mature cadaveric femora. Using the standard Ogata-Goldsand approach, femoral version was geometrically calculated after measuring apparent neck-shaft angle and the ß-angle, which is the angle between the femoral neck and proximal femoral shaft on a direct lateral view. We then used a modified ß-angle, measured between the femoral neck and a line representing the entire femur. RESULTS: Mean anatomic femoral anteversion was 20±11 degrees. Mean calculated femoral version using the standard Ogata-Goldsand technique was 32±13 degrees, whereas mean calculated femoral version using the modified Ogata-Goldsand technique was 22±12 degrees. Repeated measures ANOVA analysis found an overall statistically significant difference between the 3 groups (P<0.0001). Pairwise comparisons revealed a significant difference between directly measured version and the standard Ogata-Goldsand technique (P<0.0001) but not between directly measured version and the modified Ogata-Goldsand technique (P=0.76). CONCLUSIONS: Standard biplanar imaging techniques do not account for the femoral bow and can significantly overestimate femoral anteversion. If a line is drawn from the posterior femoral condyles to the posterior aspect of the greater trochanter, femoral anteversion is better approximated. Intraoperatively, we obtain this line by positioning a marker over the skin under fluoroscopy. Clinically, if one aims for a modified ß-angle of 5 degrees, a postosteotomy anteroposterior radiograph is no longer necessary, given the knowledge that with apparent neck-shaft angles ranging from 115 to 155 degrees, version will lie within a generally accepted range between 2 and 11 degrees. CLINICAL RELEVANCE: In complex operative cases where imaging is desired to measure intraoperative femoral version, we recommend a modified and simplified lateral view measurement technique, which improves accuracy by accounting for the femoral bow.

Important Differences Exist in Posterior Condylar Offsets in an Osteological Collection of 1,058 Femurs.

Posterior condylar offset (PCO) has important implications in total knee arthroplasty (TKA) function and design. In an osteological study of 1,058 femurs, we measured PCO using two separate techniques with a 3D digitizer. Measurements were standardized for the size of the femur. The medial PCO was greater than lateral PCO (32.6mm vs. 31.2mm, P<0.0001). In 53% of individuals, the medial PCO differed between sides by more than 2mm. Age did not affect standardized medial or lateral PCO. Compared with African-Americans, Caucasians had a larger standardized medial (1.3mm vs. 1.2mm, P=0.006) and lateral (1.1mm vs. 1.0mm, P=0.004) PCOs. The standardized medial (1.2mm vs. 1.3mm, P=0.073), and lateral (1.1mm vs. 1.1mm, P=0.098), PCO did not differ between men and women, respectively.

Biologic resurfacing of the glenoid with humeral head resurfacing for glenohumeral arthritis in the young patient.

BACKGROUND: Resurfacing of the glenoid with an interposition soft tissue graft in conjunction with humeral head arthroplasty has been proposed as an option to improve glenohumeral arthritis in young patients while avoiding the potential complications associated with total shoulder arthroplasty. There currently exist minimal outcomes data for this procedure, and the results have not been consistent. The purpose of this study was to report on the outcomes in our cohort of patients aged younger than 55 years. METHODS: A multicenter review of 16 patients who had undergone humeral head arthroplasty with soft tissue interposition grafting of the glenoid was performed. All patients had a minimum follow-up time of 24 months, unless revision surgery was required because of failure of the procedure. RESULTS: At a mean follow-up of 60 months, the patients showed improvement in the visual analog scale score for pain from 8.1 to 5.8 (P < .05), and the American Shoulder and Elbow Surgeons score improved from 23.2 to 57.7 (P < .05). Forward elevation improved from 128° to 134° (P = .33), and external rotation improved from 28° to 32° (P = .5). Internal rotation showed no improvement. Conversion to a total shoulder arthroplasty was performed in 7 patients (44%) at a mean of 36 months. CONCLUSIONS: The optimal management for the young patient with arthritis has not yet been established. Because of the limited improvement in patient outcomes and the relatively high revision rate, biologic resurfacing of the glenoid with humeral head resurfacing is no longer our primary treatment option for young patients and should be used with caution.

The shape of the proximal femur influences acetabular wear patterns over time.

BACKGROUND: Femoroacetabular impingement has been proposed as a cause of early osteoarthritis, but it is not known how this develops over time or whether the shape of the proximal femur influences this risk. QUESTIONS/PURPOSES: (1) Which areas of the acetabulum are worn more frequently by individuals with a cam deformity of the proximal femur? (2) Do observed acetabular wear patterns differ based on the etiology of the cam deformity? (3) Do wear patterns of individuals with a cam deformity differ based on an individual's age? METHODS: We examined 645 corresponding femora and acetabuli from the Hamann-Todd Osteological Collection and determined the offset and alpha angle using photographs; 370 specimens met inclusion criteria and were examined for signs of wear and the locations of wear were recorded. Specimens were separated into eight subgroups based on age either younger than 40 years or older than 60 years, alpha angle greater or less than 55°, and degree of anterior head-neck offset. We compared the prevalence of wear between groups in each location. RESULTS: Individuals with abnormal geometry of the proximal femur demonstrated different wear patterns from individuals with normal geometry. There were few differences in wear patterns identified based on the etiology of the femoral deformity. Abnormal femoral geometry was associated with more frequent wear primarily at the anterosuperior acetabulum for individuals younger than 40 years of age and globally for individuals older than 60 years of age. CONCLUSION: Femoral geometry appears to influence the pattern of acetabular wear occurring over time.

Orthopaedic surgeons frequently underestimate the cost of orthopaedic implants.

BACKGROUND: A poor understanding of cost among healthcare providers may contribute to high healthcare expenditures. Currently, it is unclear whether and how much surgeons know about the costs of implantable medical devices (IMDs). QUESTIONS/PURPOSES: We (1) determined the level of comfort with orthopaedic IMD costs among orthopaedic residents and attending surgeons, (2) quantified how accurately surgeons understand the costs of orthopaedic IMDs, and (3) identified which constructs yield the most accurate cost estimations among residents and attending surgeons. METHODS: A questionnaire was presented to 60 residents and 37 attending orthopaedic surgeons from two large academic medical centers. Respondents estimated the cost of 13 commonly used orthopaedic devices. Fifty-one surgeons participated (36 residents, 15 attending surgeons), for an overall response rate of 53%. Cost estimates were compared against the actual material costs, and we recorded the percentage error for each estimate. RESULTS: More than ½ of the respondents rated their knowledge of IMD cost as poor. The mean percentage error in estimation for all respondents was 69% (range, 29%-289%). Overall, 67% of responses were underestimations and 33% were overestimations. Residents demonstrated a mean percentage error of 73% (range, 29%-289%) while attending surgeons had a mean percentage error of 59% (range, 49%-79%). Residents and attending surgeons demonstrated differences in accuracy within groups and between groups based on the IMD being estimated. CONCLUSIONS: We found the knowledge of orthopaedic IMD costs among the orthopaedic residents and attending surgeons surveyed was poor. Further investigation of how physicians conceptualize material costs will be important to healthcare cost control.

Resection arthroplasty for failed shoulder arthroplasty.

BACKGROUND: As shoulder arthroplasty becomes more common, the number of failed arthroplasties requiring revision is expected to increase. When revision arthroplasty is not feasible, resection arthroplasty has been used in an attempt to restore function and relieve pain. Although outcomes data for resection arthroplasty exist, studies comparing the outcomes after the removal of different primary shoulder arthroplasties have been limited. MATERIALS AND METHODS: This was a retrospective multicenter review of 26 patients who underwent resection arthroplasty for failure of a primary arthroplasty at a mean follow-up of 41.8 months (range, 12-130 months). Resection arthroplasty was performed for 6 failed total shoulder arthroplasties (TSAs), 7 failed hemiarthroplasties, and 13 failed reverse TSAs. RESULTS: Patients who underwent resection arthroplasty demonstrated significant improvement in visual analog scale pain score (6 ± 4 preoperatively to 3 ± 2 postoperatively). Mean active forward flexion and mean active external rotation decreased, but this difference was not significant. Subgroup analysis revealed that postoperative mean active forward flexion was significantly greater in patients undergoing resection arthroplasty after failed TSA than after reverse TSA (P = .01). CONCLUSIONS: Resection arthroplasty is effective in relieving pain, but patients have poor postoperative function. Patients with resection arthroplasty for failed reverse shoulder arthroplasty have worse function than those with failed hemiarthroplasty or TSA. Surgeons should be aware of this when assessing postoperative function. There is no difference in functional outcome between hemiarthroplasty and TSA.

Pectoralis major tendon transfer for the treatment of scapular winging due to long thoracic nerve palsy.

BACKGROUND: Painful scapular winging due to chronic long thoracic nerve (LTN) palsy is a relatively rare disorder that can be difficult to treat. Pectoralis major tendon (PMT) transfer has been shown to be effective in relieving pain, improving cosmesis, and restoring function. However, the available body of literature consists of few, small-cohort studies, and more outcomes data are needed. MATERIALS AND METHODS: Outcomes of 26 consecutive patients with electromyelogram-confirmed LTN palsy who underwent direct (n = 4) or indirect transfer (n = 22) of the PMT for dynamic stabilization of the scapula were reviewed. All patients were followed up clinically for an average of 21.8 months (range, 3-62 months) with evaluations of active forward flexion, active external rotation, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and observation of scapular winging. RESULTS: Preoperative to postoperative results included increases in the mean active forward flexion from 112° to 149° (P < .001) an in mean active external rotation from 53.8° to 62.8° (P = .045), an improvement in the mean ASES score from 28 to 67.0 (P < .001), and an improvement in the mean VAS pain score from 7.7 to 3.0 (P < .001). Recurrent scapular winging occurred in 5 patients. There was no difference in outcome by length of follow-up. CONCLUSIONS: PMT transfer is an effective treatment for painful scapular winging resulting from LTN palsy. This is the largest reported series of consecutive patients treated with PMT transfer for the correction of scapular winging.

All-arthroscopic biologic total shoulder resurfacing.

The treatment of advanced, bipolar glenohumeral osteoarthritis in the young patient is particularly challenging because of the expected failure of a traditional shoulder arthroplasty within the patient's lifetime. We have had early success performing osteochondral allograft resurfacing of the humeral head articular surface and glenoid articular surface, and we describe a new all-arthroscopic technique for performing this procedure. In the context of our new procedure, we have reviewed the available literature on the topic of biologic resurfacing with osteochondral allograft and have provided an overview of the relevant findings. Although only short-term follow-up data are available, our results in young patients have been promising in terms of regained motion, minimal pain, and accelerated rehabilitation. We believe that this new arthroscopic biologic shoulder resurfacing technique has the potential to be superior to other available treatments for this patient population because it preserves bone stock, limits damage to surrounding structures, and allows for early rehabilitation. Although longer-term follow-up is needed, early results have been greatly encouraging.

No relationship between mild limb length discrepancy and spine, hip or knee degenerative disease in a large cadaveric collection.

BACKGROUND: Although asymptomatic mild limb length discrepancy (LLD) in children is generally treated non-operatively, there is limited high quality follow up data to support this recommendation. HYPOTHESIS: We hypothesized that there would be no association between LLD and arthritic changes with mild limb length discrepancy. MATERIALS AND METHODS: We studied 576 well-preserved cadaveric skeletons ranging from 40 to 79 years of age. Limb length discrepancy was based on combined femoral and tibial lengths measured using digital calipers. Degenerative disease was hand graded in the spine, hips and knees using a previously described classification system. Power was set at 90%. RESULTS: Average age was 56±10 years and average LLD was 4.8±4.0mm. Multiple regression analysis did not demonstrate any correlation between LLD and degenerative disease. After screening to find 26 additional specimens with LLD 10mm or greater, and assessing a potentially quadratic relationship, we still did not find any detrimental effects of LLD. DISCUSSION: Our data support the general clinical recommendation of observation for mild asymptomatic LLD. These results do not apply to larger LLD nor LLD associated with other deformities or clinical symptoms. LEVEL OF EVIDENCE: Not applicable, anatomic basic science study.

Quantitative videographic analysis of intraoperative total shoulder arthroplasty is predictive of radiographic implant loosening.

BACKGROUND: It is believed that both patient and surgeon factors contribute to premature implant loosening. This video study was designed to answer the following questions: Can orthopedic surgeons reliably differentiate between procedures done well and those that will lead to early glenoid failure? Do the difficulty of the operation and the surgeon's performance predict a patient's outcome? Does the presence of a Walch B2 glenoid result in surgery that is evidently more difficult and performed in such a way to suggest early glenoid component failure? METHODS: Eleven upper extremity surgeons blindly graded a set of intraoperative videos of 15 total shoulder arthroplasty patients (grouped by outcome at 2 years). Evaluation questionnaires consisted of questions about the perceived difficulty and the surgeon's performance. Total and partial patient scores were calculated for each video. Higher calculated score would indicate worse postsurgical outcome. RESULTS: The loosening group had a significantly higher total score (P = .0057). Also, patients with B2 glenoids scored significantly higher than patients with other wear type. The analysis of overall procedure performance indicated difference between outcome groups (P = .0063). CONCLUSION: Our results indicate that surgeons could review surgical videos and differentiate the cases that were difficult or those that were more likely to lead to loosening of the glenoid component. The presence of a B2 glenoid was predictive of difficult surgery. The results of this study should serve as a starting point for surgeons interested in critically evaluating performance and also for those interested in finding ways to maximize patient outcomes after total shoulder arthroplasty.

Bone Graft Augmentation for Severe Glenoid Bone Loss in Primary Reverse Total Shoulder Arthroplasty: Outcomes and Evaluation of Host Bone Contact by 2D-3D Image Registration.

BACKGROUND: The treatment of patients with severe glenoid bone loss using reverse total shoulder arthroplasty (RSA) is challenging because of the difficulty in obtaining glenoid fixation. The outcomes following primary RSA with structural bone-grafting for severe glenoid bone loss and the amount of native bone support necessary to achieve clinical improvement are unclear. METHODS: We reviewed functional outcomes (American Shoulder and Elbow Surgeons [ASES] score, Simple Shoulder Test [SST], visual analog scale [VAS] for pain and function, patient satisfaction, and range of motion) for 57 patients who were treated with a primary RSA and glenoid bone-grafting for severe glenoid bone loss. Three glenoids were classified as type A2; 2, as type B2; and 2, as type C, according to the Walch classification; 16 glenoids, as grade E1; and 19, as grade E3, according to the Sirveaux classification; 9 glenoids, as grade 3, according to the Levigne classification; and 6 were unable to be classified. For the 44 patients with adequate preoperative computed tomographic (CT) data and postoperative radiographs, we evaluated native bone contact under the glenoid baseplate by matching the projected shape of the implant and scapula from the postoperative radiographs with a generated 3-dimensional (3D) model of the preoperative scapula. We then analyzed functional outcomes in relation to native bone support of the baseplate. RESULTS: At a mean of 46 months (minimum, 24 months), the patients demonstrated significant improvements in function, motion, and pain (change in the ASES total score = 38.6, change in SST = 5.4, change in forward elevation = 72.4°, change in abduction = 67.7°, change in external rotation = 24.3°, and change in VAS pain score = -4.6; p < 0.001 for all). On the basis of the generated 3D model, the baseplate contact to host bone was a mean (and standard deviation) of 17% ± 12% (range, 0% to 50%). There was no significant correlation between host bone coverage and change in the ASES score (p = 0.51) for the 44 patients included in this analysis. There were 4 major complications (7%) in the study group but no glenoid baseplate failures. CONCLUSIONS: Glenoid bone-grafting in a primary RSA in a shoulder with severe bone loss produces good functional outcomes that do not correlate with the degree of native bone contact under the baseplate. We had observed no glenoid component failures at the time of writing. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Rotational alignment of the knee is different in osteological specimens with and without a large cam deformity of the proximal femur.

PURPOSE: We studied a large osteological collection for differences in knee rotation based upon the presence or absence of a large cam deformity of the proximal femur. METHODS: We obtained 357 matched tibiae and femora from the Hamann-Todd Osteological Collection and measured: femoral head-neck alpha angle, anteroposterior axis (or Whiteside's line) at the distal femur relative to the posterior condylar axis, and position of the tibial tubercle with respect to the posterior condylar axis of the proximal tibia. We then divided these specimens into two groups based upon alpha angle <45° (Group 1, n = 73) or alpha angle >60° (Group 2, n = 122) and performed an independent samples t-test to evaluate for differences in measured parameters between groups using this subset of specimens. RESULTS: The mean alpha angles in Group 1 and 2 were 40.9° ± 3.3° and 67.0° ± 5.6°, respectively. Whiteside's line was externally rotated with respect to the posterior femoral condylar axis by a mean of 1.8° ± 6.8° in Group 1, vs. 3.0° ± 3.7° in Group 2 (p = 0.03). The tibial tubercle was externally rotated by a mean of 19.4° ± 6.8° in Group 1, versus 16.6° ± 5.1° in Group 2 (p = 0.003). CONCLUSIONS: Specimens with femoral head-neck alpha angle >60° demonstrated greater external rotation of the distal femur and a more internally-rotated tibial tubercle compared to specimens with an alpha angle <45°. Differences in anatomic characteristics of the knee may play a role in the development of patellofemoral pain in patients with a large cam deformity.

Medialized Versus Lateralized Center of Rotation in Reverse Shoulder Arthroplasty.

Reverse shoulder arthroplasty may be performed using components that medialize or lateralize the center of rotation. The purpose of this prospective study was to directly compare 2 reverse shoulder arthroplasty designs. Two treatment groups and 1 control group were identified. Group I comprised 9 patients using a medialized Grammont-style (GRM) prosthesis with a neck-shaft angle of 155°. Group II comprised 9 patients using a lateralized (LAT) prosthesis with a neck-shaft angle of 135°. Pre- and postoperative assessment of range of motion, American Shoulder and Elbow Surgeons score, and visual analog scale pain score were performed. Radiographic measurements of lateral humeral offset and acromiohumeral distance were compared. The GRM prosthesis achieved greater forward flexion (143.9° vs 115.6°; P=.05), whereas the LAT achieved greater external rotation (35.0° vs 28.3°; P=.07). The lateral humeral offset was greater for the LAT prosthesis compared with the GRM prosthesis, but this distance was not significantly different from that found in the control group. The acromiohumeral distance was significantly greater in the GRM prosthesis group compared with both the LAT and the control groups. The results of this study confirm that different reverse shoulder arthroplasty designs produce radiographically different anatomy. Whereas the GRM prosthesis significantly alters the anatomy of the shoulder, the LAT design can preserve some anatomic relationships found in the normal shoulder. The clinical outcomes indicate that this may have an effect on range of motion, with traditional designs achieving greater forward flexion and lateralized designs achieving greater external rotation.

Tendinopathy of the long head of the biceps tendon: histopathologic analysis of the extra-articular biceps tendon and tenosynovium.

BACKGROUND: Bicipital tendinitis is a common cause of anterior shoulder pain, but there is no evidence that acute inflammation of the extra-articular long head of the biceps (LHB) tendon is the root cause of this condition. We evaluated the histologic findings of the extra-articular portion of the LHB tendon and synovial sheath in order to compare those findings to known histologic changes seen in other tendinopathies. METHODS: Twenty-six consecutive patients (mean age 45.4±13.7 years) underwent an open subpectoral biceps tenodesis for anterior shoulder pain localized to the bicipital groove. Excised tendons were sent for histologic analysis. Specimens were graded using a semiquantitative scoring system to evaluate tenocyte morphology, the presence of ground substance, collagen bundle characteristics, and vascular changes. RESULTS: Chronic inflammation was noted in only two of 26 specimens, and no specimen demonstrated acute inflammation. Tenocyte enlargement and proliferation, characterized by increased roundness and size of the cell and nucleus with proteoglycan matrix expansion and myxoid degenerative changes, was found in all 26 specimens. Abundant ground substance, collagen bundle changes, and increased vascularization were visualized in all samples. CONCLUSION: Anterior shoulder pain attributed to the biceps tendon does not appear to be due to an inflammatory process in most cases. The histologic findings of the extra-articular portion of the LHB tendon and synovial sheath are similar to the pathologic findings in de Quervain tenosynovitis at the wrist, and may be due to a chronic degenerative process similar to this and other tendinopathies of the body.

Radiostereometric and Radiographic Analysis of Glenoid Component Motion After Total Shoulder Arthroplasty.

Aseptic glenoid component loosening is a common cause of total shoulder arthroplasty (TSA) failure, but early detection is difficult because pain often appears late and radiolucent lines are of uncertain significance. This study sought to answer the following questions: (1) What types of glenoid component motion may be observed during the first 3 years following implantation?; (2) Is the appearance of radiolucent lines around the glenoid component a reliable indicator of component motion?; and (3) Are clinical outcomes correlated with early glenoid component motion within the first 3 years after TSA? Eleven patients (mean age, 60.6 years) underwent TSA using a cemented, all-polyethylene glenoid component with tantalum bead implantation. Clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score, visual analog scale [VAS] pain score, and range of motion) were compared pre- and postoperatively, and radiolucencies were graded according to the criteria of Lazarus et al. Patients were evaluated using radiostereometric analysis at 6 months and 1, 2, and 3 years postoperatively to measure component micromotion in translation and rotation. At a mean follow-up of 50.2 months, mean ASES score had improved from 30.3 to 81.3 (P<.001), mean VAS pain score had improved from 8 to 1 (P<.001), active forward flexion had improved from 109° to 155° (P=.001), active external rotation had improved from 28° to 54° (P=.003), and internal rotation had improved from the level of the sacrum to L3 (P=.002). Radiolucencies were detected around none of the components at 1 year, 6 components at 2 years, and 5 components at 3 years, and these radiolucencies were mostly found around components that experienced high levels of rotational motion.

Scapular neck length and implications for reverse total shoulder arthroplasty: An anatomic study of 442 cadaveric specimens.

PURPOSE: Reverse total shoulder arthroplasty (RTSA) may be used to treat a variety of pathologic shoulder conditions, but complications such as scapular notching continue raise concerns. Variable anatomy surrounding the glenoid may have implications for future RTSA design, but at present the anatomy of the scapular neck in the human population has not been clearly defined. MATERIALS AND METHODS: 442 human scapulae from the Hamann-Todd Osteological Collection were measured for scapular neck length (SNL) and scapular neck angle (SNA). SNL was defined as the distance from the most lateral portion of the infraglenoid tubercle to the most inferolateral portion of the glenoid fossa. The SNA was measured according to Gerber et al. previously. The mean, standard deviation and ranges for SNL and SNA were calculated and compared based on sex and race, and interobserver variability was calculated. RESULTS: The mean SNL was 1.06 cm ± 0.33 cm (0.37-2.43 cm). Males demonstrated a larger SNL (1.08 cm ± 0.33 cm) than females (1.01 cm ± 0.32 cm) (P < 0.12), and Caucasians (1.09 cm ± 0.33 cm) demonstrated a significantly larger SNL than African-Americans (1.00 cm ± 0.32) (P < 0.01). The mean SNA was 106.7° ± 11.0° (76.9-139.4°). No significant correlation was found between SNL and SNA (Pearson Correlation Coefficient = 0.018) (P < 0.702). CONCLUSION: Scapular neck length and SNA vary widely within the population but there appears to be a tendency towards increased SNL in males and Caucasians. CLINICAL RELEVANCE: The anatomy of the scapular neck may have significant implications for RTSA design, surgical planning, and reduction of associated complications.