Impact of prosthetic design on clinical and radiologic outcomes of total shoulder arthroplasty: a prospective study.

BACKGROUND: This prospective longitudinal study compared clinical and radiologic outcomes of total shoulder arthroplasty (TSA) using 3 different prosthetic designs, the Neer II system, the Bigliani-Flatow (BF), and a stemless prosthesis, the Total Evolutive Shoulder System (TESS). MATERIALS AND METHODS: Patients with advanced osteoarthritis of the glenohumeral joint who underwent TSA were followed up for 2 years. Four patient-oriented disability outcomes were used. The clinical data collected before surgery and at follow-up assessments during a 2-year period included active range of motion (ROM) in 6 directions and strength. Radiographic signs of glenoid and humeral component loosening were recorded. The incidence of humeral head subluxation was documented. RESULTS: Seventy-four patients completed the study. There was a significant improvement in the 4 disability measures, ROM, and strength at 2 years in all 3 groups (P < .0001). Active external rotation at 90° abduction was statistically significantly lower in the Neer II group (P = .001). The incidence of lucent lines around the glenoid component was higher in the Neer II group (P = .0002). No statistically significant relationship was seen between type of prosthesis and patient satisfaction (P > 0.05). CONCLUSIONS: The 3 types of TSA prostheses used in this study all provided significant improvement in pain and function and were associated with high patient satisfaction. The Neer II was associated with less active external rotation and more lucent lines.

The fulcrum axis: an accurate measure of glenoid version on radiographs and computed tomography.

BACKGROUND: Proper glenoid position in total shoulder arthroplasty (TSA) is important. However, traditional glenoid version (GV) measurements overestimate retroversion on radiographs (XR) and computed tomography (CT).The fulcrum axis (FA) uses palpable surface landmarks and may be useful as an intra-operative guide. Also, the FA has not yet been validated on XR or CT in an arthritic population. METHODS: Four observers measured FA and GV on the XR, CT and three-dimensional CT (3DCT) of 40 patients who underwent TSA at a single institution from 2009 to 2015. Reliability and accuracy of FA and GV were calculated for XR and CT, using 3DCT as the gold standard. RESULTS: The mean FA and GV were 7.768° and 18.910° on XR; 6.23° and 12.920° on CT; and 8.100° and 7.740° on 3DCT, respectively. FA and GV were significantly different for XR and CT (p < 0.001) but not for 3DCT (p = 0.725). The inter-rater reliability, intra-rater reliability and accuracy of FA were not significantly different from GV and were 0.929 to 0.948, 0.779 to 0.974 and 0.674 to 0.705, respectively. However, the absolute difference of FA was closer to the gold standard (3DCT) than GV for XR (0.330° versus 11.172°) and CT (1.871° versus 5.178°) (p < 0.001). CONCLUSIONS: FA showed comparable reliability and accuracy to GV. However, FA more accurately reflected the gold standard.

Traumatic injuries of the distal radioulnar joint.

Traumatic injuries of the distal radioulnar joint (DRUJ) may give rise to complex wrist pathologies. Substantial ongoing disability can arise should these injuries go unrecognized resulting in sub-optimal treatment and lack of appropriate rehabilitation. Injuries of the DRUJ may occur in isolation but more commonly are found with a fracture of the radius. These challenging DRUJ injuries may be simple or complex (irreducible or severe instability), acute or chronic. An adequate knowledge of the stabilizers of the DRUJ is essential in understanding treatment options. Traumatic instability of the DRUJ is reviewed and the anatomy and stabilizing factors are discussed. An algorithm to guide selection of treatment options in complex cases is presented.

Intrathoracic Glenohumeral Dislocation without Fracture of the Humerus: A Case Report and Review of the Literature.

CASE: A fifty-three-year-old man presented with an intrathoracic glenohumeral dislocation (ITGHD) and associated hemothorax, rib fracture, massive rotator cuff tear, and axillary nerve palsy following an ice hockey injury. Treatment consisted of closed reduction and staged open rotator cuff repair. Despite a substantial injury, the patient recovered nearly normal use of the arm two years postoperatively. CONCLUSION: ITGHD is an extremely rare entity. This injury should be managed by a multidisciplinary team with anticipation of associated thoracic and vascular injuries. In cases with repairable pathology (e.g., an acute rotator cuff tear), good functional outcomes can be obtained.

Combined Volar Hamate Dislocation and Scapholunate Ligament Rupture: A Case Report.

CASE: A twenty-two-year-old male patient presented to our trauma center after a motor-vehicle accident in which he sustained multiple injuries, including a volar dislocation of the hamate and ipsilateral scapholunate dissociation. Following closed reduction of the hamate dislocation, open reduction and stabilization of these carpal injuries was undertaken two days post-injury via a dorsal approach. Percutaneous Kirschner wires were used as well as two mini suture anchors to repair the scapholunate ligament. The patient was immobilized for six weeks and Kirschner wires were removed at twelve weeks postoperatively. CONCLUSION: To our knowledge, hamate dislocation with scapholunate dissociation and its surgical treatment have not previously been described. Successful surgical treatment for this injury pattern may be performed dorsally via direct reduction and repair of the scapholunate ligament with percutaneous pinning of the affected carpal bones.

Intra-articular fractures of the upper extremity: new concepts in surgical treatment.

New techniques of internal fixation, postoperative rehabilitation, and emphasis on functional as well as radiographic outcome have refined the surgical treatment of complex fractures of the glenoid, humeral head, supracondylar and intracondylar humerus, olecranon, radial head, distal radius, and distal radioulnar joint over the past decade. Early stabilization and rehabilitation of these injuries leads to soft-tissue stabilization and facilitates the patient's ability to place the hand in three-dimensional space.

Exposures of the elbow.

This article describes the basic bony, ligamentous, and neurologic anatomy of the structures about the elbow. The surgical exposures of the elbow joint are described, providing details of the various posterior, lateral, and medial approaches to the articular segments. Clinical applications describing the potential benefits of each surgical exposure are provided as examples.

Compartment Syndrome following Open Femoral Fracture with an Isolated Femoral Vein Injury Treated with Acute Repair.

Acute compartment syndrome is a surgical emergency and its diagnosis is more difficult in obtunded or insensate patients. We present the case of a 34-year-old woman who sustained a Gustilo-Anderson grade III open midshaft femur fracture with an isolated femoral vein injury treated with direct repair. She developed lower leg compartment syndrome at 48 hours postoperatively, necessitating fasciotomies. She was subsequently found to have a DVT in her femoral vein at the level of the repair and was started on therapeutic anticoagulation. This case highlights the importance of recognition of isolated venous injuries in a trauma setting as a risk factor for developing compartment syndrome.

Traumatic injuries of the distal radioulnar joint.

Traumatic injuries of the distal radioulnar joint (DRUJ) may give rise to complex wrist pathologies. Substantial ongoing disability can arise should these injuries go unrecognized resulting in sub-optimal treatment and lack of appropriate rehabilitation. Injuries of the DRUJ may occur in isolation but more commonly are found with a fracture of the radius. These challenging DRUJ injuries may be simple or complex (irreducible or severe instability), acute or chronic. An adequate knowledge of the stabilizers of the DRUJ is essential in understanding treatment options. Traumatic instability of the DRUJ is reviewed and the anatomy and stabilizing factors are discussed. An algorithm to guide selection of treatment options in complex cases is presented.

Mycobacterium chelonae infection following silicone arthroplasty of the metacarpophalangeal joints: a case report.

We present a case of infection caused by an uncommon pathogen, Mycobacterium chelonae, in a patient that underwent Swanson silicone arthroplasty of the metacarpophalangeal joints for rheumatoid arthritis. This is the first report of an infection caused by nontuberculous Mycobacteria in flexible silicone implants in the hand. The patient was successfully treated with implant removal, debridement, and antimicrobials tailored to the results of in vitro susceptibility testing.

Factors contributing to failure of rotator cuff surgery in persons with work-related injuries.

PURPOSE: Shoulder pain is a major musculoskeletal and economic concern in industrialized countries, with the rate of surgical failure reportedly higher in patients injured at work. The purposes of this study were (1) to examine the prevalence of identifiable causes of rotator cuff surgery failure and (2) to examine the relationship among the existence of these causes and outcome scores, patient expectations, and overall satisfaction. METHODS: This was a cross-sectional study of patients who experienced continued impairments following surgical treatment for work-related injuries. The primary outcome was a disease-specific measure, the Western Ontario Rotator Cuff (WORC) index. Patients were categorized into two groups based on the existence of an identifiable reason for surgical failure vs. no reason for failure, as demonstrated by clinical and radiologic investigations and decided upon by a shoulder surgeon and a physical therapist. Analyses included a t-test for independent sample means, linear regression, non-parametric Wilcoxon test, and Fisher's exact test. RESULTS: Thirty-eight consecutive patients were included in the study, and 24 causes of surgical failure were identified in 19 patients (50%). Overall, patients with findings of failure were more disabled according to the total WORC index and had higher levels of symptoms, emotional difficulties, and limitations in sports and recreational activities. Expectations and satisfaction levels were not significantly different between groups. CONCLUSION: Our results indicate that 50% of patients who reported failed surgery had at least one reason to explain their ongoing symptoms, emotional difficulties, and functional limitations.