The effect of tranexamic acid for visualization on pump pressure and visualization during arthroscopic rotator cuff repair: an anonymized, randomized controlled trial.

BACKGROUND: Tranexamic acid (TXA) has been used surgically to decrease blood loss. The ability of TXA to improve arthroscopic visualization and allow for reduction in pump pressure is unknown. The purpose of this study was to determine the effect of intravenous (IV) TXA on change in pump pressure and visualization during arthroscopic rotator cuff repair. METHODS: This was a single-center, prospective, randomized, double-anonymized controlled trial. Patients with full-thickness rotator cuff tears undergoing operative repair were enrolled. Patients were randomized to receive 1 g of IV TXA preoperatively or no TXA (control group). All patients underwent arthroscopy using saline irrigation fluid with 3 mL epinephrine injected into the first 1000-mL saline bag. Total operative time, final pump pressure, number of increases in pump pressure, total amount of irrigation fluid used, blood pressure and anesthesia medical interventions for blood pressure were recorded. Visualization was measured by a visual analog scale (VAS) completed by the surgeon at the end of the case. Postoperative VAS pain scores were obtained 24 hours after surgery. The primary aim of this study was to investigate the effect that IV TXA has on change in pump pressure (ΔP) during shoulder arthroscopy, with a ΔP of 15 mm Hg set as a threshold for clinical significance. RESULTS: There were 50 patients randomized to the TXA group and 50 patients in the no TXA group. No significant differences were found between the TXA group and the control group regarding any measure of pump pressure, including the final arthroscopic fluid pump pressure (44.5 ± 8.1 mm Hg vs. 42.0 ± 8.08 mm Hg, P = .127), the mean ΔP (20.9 ± 10.5 mm Hg vs. 21.8 ± 8.5 mm Hg, P = .845), or the number of times a change in pump pressure was required (1.7 ± 0.9 vs. 1.7 ± 0.8, P = .915). Overall arthroscopic visualization was not significantly different between the TXA group and the control group (7.2 ± 1.8 vs. 7.4 ± 1.6, P = .464). No significant difference existed between the TXA and control groups regarding postoperative pain scores assessed by VAS pain scale (4.1 ± 2.0 vs. 4.3 ± 1.9, P = .519) at 24 hours after surgery. CONCLUSION: The use of IV TXA demonstrated no measurable improvement in surgeon ability to maintain a lower pump pressure during arthroscopic rotator cuff repair. Additionally, there was no measurable improvement in arthroscopic visualization or early pain scores.

What do positive and negative Cutibacterium culture results in periprosthetic shoulder infection mean? A multi-institutional control study.

BACKGROUND: Deep tissue culture specimens obtained at the time of revision shoulder arthroplasty are commonly positive for Cutibacterium. Clinical interpretation of positive cultures can be difficult. This was a multi-institutional study evaluating the accuracy of cultures for Cutibacterium using positive control (PC) and negative control (NC) samples. The relationship between time to culture positivity and strength of culture positivity was also studied. METHODS: Eleven different institutions were each sent 12 blinded samples (10 PC and 2 NC samples). The 10 PC samples included 2 sets of 5 different dilutions of a Cutibacterium isolate from a failed total shoulder arthroplasty with a probable periprosthetic infection. At each institution, the samples were handled as if they were received from the operating room. Specimen growth, time to culture positivity, and strength of culture positivity (based on semiquantitative assessment) were reported. RESULTS: A total of 110 PC samples and 22 NC samples were tested. One hundred percent of specimens at the 4 highest dilutions were positive for Cutibacterium. At the lowest dilution, 91% of samples showed positive findings. Cutibacterium grew in 14% of NC samples. Cutibacterium grew in PC samples at an average of 4.0 ± 1.3 days, and all of these samples showed growth within 7 days. The time to positivity was significantly shorter (P < .001) and the strength of positivity was significantly higher (P < .001) in true-positive cultures compared with false-positive cultures. CONCLUSIONS: This multi-institutional study suggests that different institutions may report highly consistent rates of culture positivity for revision shoulder arthroplasty samples with higher bacterial loads. In contrast, with lower bacterial loads, the results are somewhat less consistent. Clinicians should consider using a shorter time to positivity and a higher strength of positivity as adjuncts in determining whether a tissue culture sample is a true positive.

What is the clinical impact of positive cultures at the time of primary total shoulder arthroplasty?

BACKGROUND: Cultures taken at the time of primary shoulder arthroplasty are commonly positive for Cutibacterium acnes. Despite our limited understanding of the clinical implication of deep tissue inoculation from dermal colonization, significant efforts have been made to decolonize the shoulder prior to surgery. The purpose of this study is to determine differences in clinical outcomes based on culture positivity at the time of primary shoulder arthroplasty. METHODS: A series of 134 patients who underwent primary anatomic or reverse total shoulder arthroplasty and had intraoperative cultures obtained via a standard protocol were included. In each case, 5 tissue samples were collected and processed in a single laboratory for culture on aerobic and anaerobic media for 13 days. Minimum 2-year functional outcomes scores (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Single Assessment Numeric Evaluation [SANE]) and reoperation data were analyzed. RESULTS: Forty-two (31.3%) patients had positive cultures (30 C acnes and 21 with at least 2 positive cultures) at the time of surgery. There was no statistically significant difference in postoperative functional outcome scores (ASES: 82.5 vs. 81.9; P = .89, SANE: 79.5 vs. 82.1; P = .54) between culture-positive and culture-negative cohorts. There were no cases of infection. Two patients (4.8%; 2/42) with positive cultures required reoperation compared with 4 patients (5.6%; 4/71) without positive cultures. CONCLUSION: The apparent colonization by nonvirulent organisms in patients undergoing primary shoulder arthroplasty does not appear to have a clinically significant effect on functional outcomes or need for repeat surgery in the short term.

Outcomes of open reduction and internal fixation of proximal humerus fracture dislocations.

INTRODUCTION: Proximal humeral fracture with associated glenohumeral dislocation (PHFD) is a challenging clinical problem. Outcomes of open reduction and internal fixation (ORIF) of these injuries have not been widely reported. The purpose of this analysis is to report our experience with ORIF of PHFD. METHODS: A retrospective review of our 2 institutions' shoulder surgery databases was conducted to identify all PHFDs that were treated with ORIF from 2008 through 2017. Radiographs were reviewed for fracture healing by 12 weeks postoperatively. All reoperations were recorded. Patient-reported outcomes using Simple Shoulder Test (SST) and American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) scores at a minimum 2-year follow-up were recorded. RESULTS: There were 20 PHFDs identified: they were 50% male, 55.8 ± 10.3 years old (range 31.3-66.3), and had a body mass index of 29.3 ± 8.2 (15.2-47.8). Seven (35%) patients experienced varus collapse, nonunion, or avascular necrosis and 6 (30%) patients underwent reoperation. Of the 17 patients who did not go on to revision or arthroplasty, 14 (82.3%) had patient-reported outcomes at a mean follow-up of 4.9 ± 2.2 years (2.3-8.8). These patients had an average SST 8.0±4.0 yes responses (0-12) and ASES scores of 71.6 ± 20.4 (20.2-94.9). CONCLUSION: ORIF of PHFD carries a high rate of reoperation. In patients who achieve healing, functional scores are satisfactory. This information is important for proper patient counseling prior to surgery.

Addition of 3% hydrogen peroxide to standard skin preparation reduces Cutibacterium acnes-positive culture rate in shoulder surgery: a prospective randomized controlled trial.

BACKGROUND: Hydrogen peroxide is an inexpensive and effective antimicrobial agent that can be implemented in surgical skin preparations. The purpose of this study was to evaluate the decolonization effect of Cutibacterium acnes when adding hydrogen peroxide to a standard sterile preparation for shoulder surgery. METHODS: This was a single-institution, prospective, randomized controlled trial of male patients undergoing shoulder arthroscopy (April 2018 and May 2019). Patients were randomized to a standard skin preparation vs. an additional sterile preparation with 3% hydrogen peroxide. After draping, a 3-mm punch biopsy was obtained from the posterior arthroscopic portal site of all patients. Anaerobic and aerobic culture substrates were used and held for 13 days. RESULTS: Seventy male patients were randomized into the hydrogen peroxide group and 70 male patients were in the traditional group. Twelve (17.1%) patients in the hydrogen peroxide group and 24 (34.2%) patients in the traditional group had positive cultures for C acnes (P = .033). Cultures were positive at a mean of 4.5 days (range 3-7) in the hydrogen peroxide group and 4.1 days (range 3-8) in the traditional group (P = .48). There were no cases of skin reaction to the surgical preparation in either group. DISCUSSION: The results of this study suggest that the addition of hydrogen peroxide to preoperative surgical site preparation can reduce the C acnes culture rate. Hydrogen peroxide is inexpensive and can be added to the typical skin preparation used prior to shoulder surgery without substantial risk of skin reactions.

Defining optimal calcar screw positioning in proximal humerus fracture fixation.

BACKGROUND: Anatomic reduction and placement of an inferior calcar screw are strategies to prevent fixation failure in proximal humerus factures. Optimal position of the calcar screw remains unknown. METHODS: There were 168 shoulders (68.5% female; average age, 63.6 ± 11.5 years) that underwent open reduction and internal fixation of a displaced proximal humerus fracture involving the surgical or anatomic neck. Univariate and multivariate analyses were performed on preoperative clinical, preoperative radiographic, and postoperative radiographic variables to determine association with fixation failure. A receiver operating characteristic curve was performed to determine a maximum distance from the inferior screw to the calcar ("calcar distance") as well as a maximum ratio of this distance and the head diameter ("calcar ratio"). RESULTS: There were 26 of 168 (15.5%) patients with radiographic failures (19 related to fixation failure). Univariate analysis and multivariate analyses found quality of reduction (P < .001), calcar distance (P < .001), and calcar ratio (P < .001) to be significantly associated with radiographic success. In all patients, receiver operating characteristic analysis found quantifiable thresholds of 12 mm or within the bottom 25% of the humeral head as measures to prevent fixation failure. CONCLUSIONS: Quality of reduction, calcar distance, and calcar ratio independently correlated with fixation failure. This study provides optimal distances and ratios for calcar screw placement that can be used clinically.

Short-Term Results of a Convertible Diaphyseal-fit Anatomic Shoulder Arthroplasty System.

Objectives: The purpose of this analysis is to present a two-year follow-up of patient-reported outcomes, revision rate, and notable radiographic features of a convertible, diaphyseal-fit anatomic total shoulder arthroplasty system (ATSA). Methods: From June 2012 to June 2015, 100 shoulders were treated with ATSA using a convertible, diaphyseal-fit stem. Functional outcomes and radiographic findings were assessed preoperatively and at 6 months, 1 year, and 2 years postoperatively. Complications and reoperations were also determined. Results: Ninety-three shoulders were analyzed in this study. Patients were 47.3% male and had an average age of 67.3±8.1-years-old (range 44.7-89.1). Two-year clinical outcomes show a revision rate of 4.3%. Average pre-operative ASES was 37.1±18.9 (6.7-86.7), SST (77.4%) was 3.1±2.4 yes responses (0-9), and SANE (88.2) was 25.4±21.5% (0-85.0%). At two years post-operative average (75% follow-up) ASES was 89.3±15.1 (37.0-100), SST was 10.0±2.5 yes responses (0-12), and SANE was 85.6%±17.0% (33.0-100%). Radiographic analysis at two years identified 2 shoulders (4%) with glenoid radiolucency (both Lazarus grade 1), 5 shoulders with at least one humeral radiolucent line (10%), and 9 shoulders (18%) with stress-shielding. There were 12 shoulders (24%) with distal pedestal formation. This finding was associated with the presence of radiolucent lines (P=0.002). Conclusion: This two-year analysis identified improvement in ASES, SST, and SANE scores and a low revision rate. resence of a distal pedestal was associated with increased rates of radiolucent lines. Further analysis with longer-term and more robust follow-up will improve our understanding of the risks and benefits of this shoulder system.

Rotational Osteotomy of the Humeral Shaft for Malunion in Osteogenesis Imperfecta: A Case Report.

CASE: We report a case of an adult with osteogenesis imperfecta, who underwent humeral shaft osteotomy to correct an internal rotation deformity results from a humeral shaft malunion. The patient incurred a temporary radial nerve palsy. CONCLUSIONS: Humeral shaft malunion can be successfully treated with rotational osteotomy of the humerus through an anterior approach; however, the risk of radial nerve palsy exists and may be minimized by a posterior approach.

Outcomes of shoulder arthroplasty following axillary lymph node dissection.

INTRODUCTION: Shoulder arthroplasty with previous axillary lymph node dissection historically has unsatisfactory outcomes. We analyzed outcomes of primary shoulder arthroplasty in patients with previous axillary lymph node dissection. METHODS: Thirty-two primary shoulder arthroplasties after prior axillary lymph node dissection were performed. These patients were analyzed for patient-reported outcomes, range of motion, complications, and reoperations. RESULTS: Average age was 70.8 ± 7.5 years old. There were 19 anatomic total shoulder arthroplasties, four hemiarthroplasties, and nine reverse total shoulder arthroplasties. Eight were performed by a superior approach while 24 were performed by a deltopectoral approach with cephalic vein preservation. There were three complications (one deltoid dehiscence, one axillary nerve palsy, and one postoperative pneumonia). There was one revision (hemiarthroplasty to reverse total shoulder arthroplasty for cuff failure at 91 weeks), two reoperations, and no infections. Patient-reported outcomes were available for 21/26 (80.1%) of the surviving shoulders at 4.8 ± 2.0 years. Average visual analog scale pain score was 7.1 ± 14.5, Simple Shoulder Test score 8.3 ± 2.6 "yes" responses, Single Assessment Numeric Evaluation score 80.2 ± 17.4, and American Shoulder and Elbow Surgeons score 83.6 ± 14.1. CONCLUSION: Axillary lymph node dissection is not a contraindication to shoulder arthroplasty. A deltopectoral exposure can be utilized without substantial risk of worsening lymphedema or wound complications. While a superior approach avoids cephalic vein injury, important approach-related complications (deltoid dehiscence and axillary nerve palsy) were observed.Level of evidence: Level IV-case series.

Failure of Anatomic Total Shoulder Arthroplasty with Revision to another Anatomic Total Shoulder Arthroplasty.

BACKGROUND: While outcomes of primary anatomic total shoulder arthroplasty (aTSA) are generally favorable, results after revision procedures are less reliable. This study examines the functional outcomes, complications, and implant survival in patients who underwent revision of aTSA to aTSA. METHODS: Patients who underwent revision aTSA were identified from 2008-2015. Demographic, clinical, surgical, and outcomes data were analyzed. Patient-reported outcomes including the American Shoulder and Elbow Surgeons Score (ASES), Single Assessment Numerical Evaluation (SANE), Visual Analog Scale for pain (VAS), the Short Form-12 Health Survey (SF-12), and patient satisfaction were recorded. RESULTS: Twenty patients underwent revision from a primary aTSA to aTSA (55% male, 62.0±6.8 years-old). Revision aTSA occurred at 2.5±3.4 years after index surgery. Seven (35%) required future revision at 1.8±1.9 years after revision aTSA. Among the 13 patients who did not undergo revision, twelve (92.3%) had over two-year follow-up (4.0±2.4 years). Average ASES score was 70.1±23.5, SANE 66.0±29.4, VAS 2.7±3.0, SF-12 Mental 52.4±10.5, SF-12 Physical 36.8±8.9, and satisfaction of 3.6±1.2. CONCLUSION: Results of revision aTSA to aTSA were unpredictable and the revision rate was high. The cases that do not undergo revision had satisfactory, but inconsistent functional results. Reverse arthroplasty may be more reliable in this patient population.

Outcomes of Shoulder Arthroplasty Performed for Postinfectious Arthritis.

BACKGROUND: The purpose of this study was to evaluate the functional outcomes, infection rate, and complications associated with shoulder arthroplasty for sequelae of prior septic arthritis. METHODS: This is a retrospective cohort study of 17 patients who underwent shoulder arthroplasty for sequelae of septic arthritis. Patients were analyzed for patient-reported outcomes, complications, and reoperations. RESULTS: The 17 patients in this cohort were an average age of 65.4 ± 12.2 years old, were 58.8% male, and had an average body mass index of 27.9 ± 4.1 kg/m2. These patients underwent 14 reverse shoulder arthroplasties (RSAs; 11 after antibiotic spacer placement), one anatomic total shoulder arthroplasty after antibiotic spacer placement, and two hemiarthroplasties (both after antibiotic spacer placement). Two patients underwent reoperation (dislocated RSAs). There were four complications (23.5%): two RSA dislocations, one acromial stress fracture, and one atraumatic rotator cuff tear after hemiarthroplasty. There were no cases of postoperative wound complications or infection. At an average of 4.1 ± 1.8 years of follow-up for all 17 of 17 cases, the average visual analogue scale pain score was 4.6 ± 2.3, average Single Assessment Numeric Evaluation Score was 59.3 ± 23.7, average American Shoulder and Elbow Surgeons Score was 57.6 ± 15.5, and average Simple Shoulder Test was 6.9 ± 2.6 based on "yes" responses. CONCLUSIONS: Shoulder arthroplasty after septic arthritis had inconsistent functional outcomes and high complication rates but no reinfection.

Short-Term Results of the DePuy Global Unite Platform Shoulder System: A Two-Year Outcome Study.

BACKGROUND: The Global Unite Shoulder System is the next generation of implant from the Depuy Global Shoulder line. The primary feature of the Global Unite is adaptability through the interchangeable modular bodies, modular suture collars, and stems. Short-term functional and radiographic outcomes of the Global Unite Platform Shoulder System were assessed as well as complication and revision rates. METHODS: 95 subjects were enrolled prospectively between 2013 and 2015 that underwent anatomic or reverse shoulder arthroplasty utilizing the DePuy Global Unite Anatomic Platform Shoulder System. Functional outcome data (ASES and SANE) as well as radiographic data was collected on these patients pre-operatively, and at 6 months, 1 year and 2 years post-operatively. RESULTS: The cohort consisted of 97 shoulders in 95 patients of which 54 (56.8%) are males and 41 (43.2%) are female. There were 55/97 (56.7%) were primary anatomic total shoulder arthroplasties, 37/97 (38.1%) primary reverse shoulder arthroplasties, and 3/97 (3.1%) revision procedures to a reverse shoulder arthroplasty. Outcome scores demonstrated an increase in ASES score from a mean of 33.00 to 79.56 and SANE score of 21.30 to 84.08. CONCLUSION: The Depuy Global Unite shoulder system demonstrated very good short-term results in this two-year outcome study. Functional outcome scores are similar to current literature for anatomic and reverse primary cases. Radiographic measures at two years are promising with only 2 cases of grade 1 scapular notching and one case of grade 2 scapular notching. Overall the Depuy Global Unite is a versatile shoulder system with very good early outcomes.

The Midterm Results of the Delta Xtend Reverse Shoulder System: A Five-Year Outcome Study.

BACKGROUND: The purpose of this study was to examine the mid-term functional outcomes, radiographic results, and revision rates of patients treated with the Delta Xtend Reverse Shoulder System for both primary and revision arthroplasty indications. METHODS: A retrospective review was conducted of records for all individuals who underwent a reverse shoulder arthroplasty using the Delta Xtend Reverse Shoulder Prosthesis at a single institution. Radiographic analysis as well as pain and functional measures using the ASES, Quick DASH, SST, SF-12, Penn, SANE, EQ-5D and VAS, and VR-12 scores. Patients were evaluated for five-year outcomes. RESULTS: Fifty patients were available for 5-year outcomes. Thirty-three cases were primary arthroplasty cases and 17 were revision arthroplasty cases. Postoperative radiographs at five years out from surgery were available for 46 patients. The mean AGT overall was 32.6mm: 31.7mm the primary cases and 34.8mm for revision cases. Sirveaux scapular notching was: 65.2% (30/46) at Grade 0, 23.9% (11/46) at Grade 1, and 10.9% (5/46) at Grade 2. Overall, 32/46 of stems were in neutral position, 10/46 were in valgus position, and 4/46 were in varus position. There was no significant correlation between stem position and scapular notching. The mean outcome scores for all patients at five years were good to excellent. Two revision patients demonstrated loosening of the humeral stem on radiographs. Nine patients demonstrated calcification of the long head of the triceps tendon. CONCLUSION: In conclusion, the Delta Xtend Reverse Shoulder System has shown to be a reliable arthroplasty system for patients with CTA or failed prior arthroplasty. Patients are generally quite functional at five years out from their reverse shoulder arthroplasty using this implant. Radiographic measures used to interpret the status of the implant demonstrate that AGT is well maintained and scapular notching is minimal for the majority of cases. LEVEL OF EVIDENCE: IV.

Metal Allergy as a Cause of Implant Failure in Shoulder Arthroplasty.

Metal allergy is an uncommon and poorly understood cause of failure of orthopedic implants. To the authors' knowledge, there have been no reports of the management of shoulder arthroplasty patients with metal allergy. The authors present their experience with the diagnosis and management of patients with metal allergy. Patients with metal allergy undergoing shoulder arthroplasty were identified through retrospective chart review from January 1, 2012, to January 31, 2015. Case characteristics collected included patient risk factors (age, sex, prior cutaneous reactions to metal), metal allergy factors (type of metal allergy, method of diagnosis), and surgery factors (implant type, primary/revision, type of shoulder arthroplasty). Outcomes measured included American Shoulder and Elbow Surgeons score, Penn Shoulder Score, and Single Assessment Numeric Evaluation score. Eleven patients were identified with metal allergy. Five were diagnosed prior to the index arthroplasty, and 6 were diagnosed after shoulder replacement. The diagnosis was made through skin patch testing, memory lymphocyte immunostimulation assay, or clinical history. Patients identified after implantation presented with progressive pain and stiffness, but none had cutaneous manifestations. Patients with metal allergy had better results undergoing primary shoulder arthroplasty than undergoing revision. Metal allergy is rare but may be a clinically significant cause of unsatisfactory shoulder arthroplasty. Given the superior results of primary shoulder arthroplasty compared with revision, screening for metal allergy by clinical history is recommended. [Orthopedics. 2017; 40(5):e844-e848.].