Indications and outcomes of glenoid osteotomy for posterior shoulder instability: a systematic review.

Background: There is limited evidence examining glenoid osteotomy as a treatment for posterior shoulder instability. Methods: A search of Medline, Embase, PubMed and Cochrane Central Register of Controlled Trials was conducted from the date of origin to 28th November 2019. Nine out of 3,408 retrieved studies met the inclusion criteria and quality was assessed using the Methodological Index for Non-randomized Studies tool. Results: In 356 shoulders, the main indication for osteotomy was excessive glenoid retroversion (greater than or equal to approximately -10°). The mean preoperative glenoid version was -15° (range, -35° to -5°). Post-operatively, the mean glenoid version was -6° (range, -28° to 13°) and an average correction of 10° (range, -1° to 30°) was observed. Range of motion increased significantly in most studies and all standardized outcome scores (Rowe, Constant-Murley, Oxford instability, Japan Shoulder Society Shoulder Instability Scoring and mean shoulder value) improved significantly with high rates of patient satisfaction (85%). A high complication rate (34%, n = 120) was reported post-surgery, with frequent cases of persistent instability (20%, n = 68) and fractures (e.g., glenoid neck and acromion) (4%, n = 12). However, the revision rate was low (0.6%, n = 2). Conclusion: Glenoid osteotomy is an appropriate treatment for posterior shoulder instability secondary to excessive glenoid retroversion. However, the high rate of persistent instability should be considered when making treatment decisions.Level of Evidence: Systematic review; Level 4.

Hybrid Glenoid Designs in Anatomic Total Shoulder Arthroplasty: A Systematic Review.

Background: Hybrid glenoid components in total shoulder arthroplasty (TSA) utilize both polyethylene and metal components to provide short-term stability and long-term biologic fixation through bone ingrowth. Questions/Purpose: We sought to systematically review the literature for studies that assessed outcomes of TSA performed using hybrid glenoid components. Methods: PubMed, Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Embase were searched systematically for articles measuring clinical and patient-reported outcomes and rates of complication and revision following TSA using a hybrid glenoid component. Results: Seven studies with 593 shoulders were included in this review. The mean age of patients was 65 ± 1 years, and 46% of the population was male. Mean follow-up was 50 months (4.2 years). The overall complication rate was 7% and rate of revision was 2.5%; glenoid radiolucency was present in 33% of shoulders at mean follow-up of 50 months. Mean improvements in forward elevation, external rotation, internal rotation score, and abduction were 49°, 28°, 2 points, and 42°, respectively. Mean improvements in Constant, American Shoulder and Elbow Surgeons (ASES), and University of California, Los Angeles (UCLA) scores were 36 points, 52 points, and 17 points, respectively. Conclusion: Our review found that TSA using hybrid glenoid components results in low rates of complication and revision at early follow-up. Long-term studies are warranted to understand more fully the role of hybrid glenoid components in TSA.

Anatomic total shoulder arthroplasty in rheumatoid arthritis: A systematic review.

Purpose: Given the poor soft-tissue quality in rheumatoid arthritis patients, many believe that rheumatoid arthritis should be treated with reverse total shoulder arthroplasty (rTSA). The purpose of this paper is to systematically assess outcomes of anatomic total shoulder arthroplasty (aTSA) in rheumatoid arthritis to determine if aTSA remains a viable option. Methods: A comprehensive literature search was conducted identifying articles relevant to aTSA in the setting of rheumatoid arthritis with intact rotator cuff. Outcomes include clinical outcomes and rates of complication and revision. Results: Ten studies were included with a total of 279 shoulders with mean follow-up of 116 ± 69 months. The mean age was 68 ± 10 years. Survivorship was 97%, 97% and 89% at 5, 10 and 20 years, respectively. The overall complication rate was 9%. Radiolucency was present in 69% of patients, of which 34% were at risk of loosening at 79 months. The overall rate of revision was 8.4%. Studies generally reported clinically significant improvements in range of motion, Constant score and ASES score. Conclusion: aTSA in the rheumatoid patient results in improvements in range of motion and patient-reported outcomes. Rates of complications and survivorship are generally good in this population. However, it should be noted that there is significant heterogeneity in outcome reporting amongst the literature on this topic and that many studies fail to adequately report complication and revision rates. When compared to rTSA in patients with rheumatoid arthritis, evidence suggests that aTSA is still a viable treatment option despite the shift in utilization to rTSA.

Outcomes and complications of distal humeral hemiarthroplasty for distal humeral fractures - A systematic review.

BACKGROUND: Distal humeral hemiarthroplasty has been performed for a variety of indications with the most common being management of distal humeral fractures. This systematic review evaluates the outcomes and complications of distal humeral hemiarthroplasty for this pathology. METHODS: We searched PubMed, EMBASE, and MEDLINE for studies reporting indications and outcomes of patients undergoing distal humeral hemiarthroplasty. Study screening, risk of bias assessment, and data extraction were performed. Summery statistics were provided. RESULTS: We included 11 studies (N = 163) in this review. In all studies, the indication for distal humeral hemiarthroplasty was the presence of an intraarticular, comminuted, unreconstructable fracture. The mean post-operative MEPS, FullDASH, and QuickDASH (SD) scores were 83.6 (6.1) points, 25.4 (10.3), and 15.7 (7.4) points, respectively. The mean post-operative range of motion (SD) was 106° (11°) in the flexion and extension arc and 153° (19°) in the protonation and supination arc. The overall rate of adverse events and complication was 63%. The rate for major complications was 11%. The mean total revision rate was 4% (0% to 15) and total re-operation rate was 29% (0% to 88%). CONCLUSION: Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates.

Diagnosis and Treatment of Snapping Scapula Syndrome: A Scoping Review.

CONTEXT: Snapping scapula syndrome (SSS) is commonly misdiagnosed and underreported due to lack of awareness. OBJECTIVE: This scoping review aims to summarize the current evidence related to SSS diagnosis and treatment to aid clinicians in managing the condition more effectively. DATA SOURCES: PubMed, Medline, and Embase databases were searched for studies related to the etiology, diagnosis, or treatment of SSS (database inception to March 2020). STUDY SELECTION: Databases were searched for available studies related to the etiology, diagnosis, or treatment of SSS. STUDY DESIGN: A scoping review study design was selected to explore the breadth of knowledge in the literature regarding SSS diagnosis and treatment. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Primary outcomes abstraction included accuracy of diagnostic tests, functional outcomes, and pain relief associated with various nonoperative and operative treatment options for SSS. RESULTS: A total of 1442 references were screened and 40 met the inclusion criteria. Studies commonly reported SSS as a clinical diagnosis and relied heavily on a focused history and physical examination. The most common signs reported were medial scapular border tenderness, crepitus, and audible snapping. Three-dimensional computed tomography had high interrater reliability of 0.972, with a 100% success rate in identifying symptomatic incongruity of the scapular articular surface. Initial nonoperative treatment was reported as successful in most symptomatic patients, with improved visual analogue scale (VAS) scores (7.7 ± 0.5 pretreatment, to 2.4 ± 0.6). Persistently symptomatic patients underwent surgical intervention most commonly involving bursectomy, superomedial angle resection, or partial scapulectomy. High satisfaction rates of surgery were reported in VAS (6.9 ± 0.7 to 1.9 ± 0.9), American Shoulder and Elbow Surgeons scores (50.3 ± 12.2 to 80.6 ± 14.9), and mean simple shoulder test scores (5.6 ± 1.0 to 10.2 ± 1.1). CONCLUSION: Focused history and physical examination is the most crucial initial step in the diagnostic process, with supplemental imaging used to assess for structural etiologies when nonoperative management fails. Nonoperative management is as effective as surgical management in pain relief and is advised for 3 to 6 months before operative treatment.

Stemless reverse total shoulder arthroplasty: a systematic review of short- and mid-term results.

INTRODUCTION: Stemless reverse total shoulder arthroplasty is used to treat rotator cuff deficient arthropathies, rheumatoid arthritis, and osteoarthritis. It has several advantages over the stemmed implant including preservation of bone stock, reduced surgical time, and easier revision. METHODS: A systematic search was conducted in MEDLINE, EMBASE, PubMed, and CENTRAL to retrieve all relevant studies evaluating stemless reverse total shoulder arthroplasty. RESULTS: The literature search identified 1993 studies out of which 7 studies were included in this review; 324 patients underwent stemless reverse total shoulder arthroplasty with a weighted mean age of 74.1 (SD = 8.6, range = 38 to 93) years and a weighted mean follow-up time of 44 (SD = 6.6, range = 3 to 95) months. The included studies reported significant improvements in range of motion and functional scores comparable to stemmed reverse total shoulder arthroplasty. The weight mean flexion and abduction was (135 ± 12)° and (131 ± 12)° post-operatively, respectively. The weighted mean constant score increased from (26.7 ± 5.2) Patients (pts) to (63.0 ± 8.0) pts post-operatively. Overall complication and revision rate were 12.3% and 5.2%. CONCLUSION: Early and mid-term results indicate stemless reverse total shoulder arthroplasty has similar clinical outcomes to stemmed reverse total shoulder arthroplasty. There was no radiological evidence of humeral loosening at the latest follow-up.

Glenoid bone grafting in primary anatomic total shoulder arthroplasty: a systematic review.

BACKGROUND: Primary anatomic total shoulder arthroplasty can be challenging in patients with complex glenoid wear patterns and bone loss. Severe retroversion (>15°) or significant bone loss may require bone grafting. This review summarizes the rate of revision and long-term outcomes of anatomic total shoulder arthroplasty with bone graft. METHODS: A systematic search of MEDLINE, Embase, PubMed, and CENTRAL databases was conducted from the date of inception to 23 October 2018. Two reviewers independently screened articles for eligibility and extracted data for analysis. The primary outcome was rate of revision. The secondary outcomes were rate of component loosening, functional outcome, and range of motion. RESULTS: Of the 1056 articles identified in the search, 26 underwent full-text screening and 7 articles were included in the analysis. All procedures were one-stage anatomic total shoulder arthroplasties. The rate of revision was 5.4% with component loosening and infection listed as indications over a weighted mean follow-up period of 6.3 years. Complications occurred in 12.6% of patients. CONCLUSION: Glenoid bone grafting in anatomic total shoulder arthroplasty results in comparable revision rates and improvement in pain compared to augmented glenoid components and reverse shoulder arthroplasty. Due to the low quality of evidence, further prospective studies should be conducted. LEVEL OF EVIDENCE: IV.

Subscapularis-sparing approaches in shoulder arthroplasty: A systematic review.

BACKGROUND: Novel approaches for anatomic and reverse total shoulder arthroplasty (aTSA and rTSA) that spare the subscapularis (SSC) have recently been described. Outcomes for the SSC-sparing approach were evaluated through this systematic review. METHODS: Medline, Embase, PubMed, and CENTRAL were searched. RESULTS: From 2051 citations, 8 studies were included (aTSA group, n = 241; rTSA group, n = 68). SSC-sparing aTSA and rTSA were associated with significant postoperative improvements in shoulder function and range of motion at 12- to 24-month follow-up. CONCLUSION: The SSC-sparing approach may provide a safe alternative for up to two years post-surgery. Evidence for long-term use remains inconclusive.

The Role of Deltoid Ligament Repair in Ankle Fractures With Syndesmotic Instability: A Systematic Review.

Ankle fractures are the fourth most common fracture requiring surgical management. The deltoid ligament is a primary ankle stabilizer against valgus forces. It is frequently ruptured in ankle fractures; however, there is currently no consensus regarding repair. A systematic database search was conducted with Medline, PubMed, and Embase for relevant studies discussing patients with ankle fractures involving deltoid ligament rupture and repair. Screening, quality assessment, and data extraction were performed independently and in duplicate. Data extracted included pain, range of motion (ROM), function, medial clear space (MCS), syndesmotic malreduction, and complications. After screening, 9 eligible studies from 1990 to 2018 were included (N = 508). Compared to nonrepair groups, deltoid ligament repair patients had lower syndesmotic malreduction rates (0%-9% vs 20%-35%, p ≤ .05), fewer implant removals (5.8% vs 41% p ≤ .05), and longer operating time by 16-20 minutes (p ≤ .05). There was no significant difference for pain, function, ROM, MCS, and complication rate (p ≤ .05). In conclusion, deltoid ligament repair offers lower syndesmotic malreduction rates and reduced re-operation rates for hardware removal in comparison to trans-syndesmotic screws. Repair groups demonstrated equivalent or better outcomes for pain, function, ROM, MCS, and complication rates. Other newer syndesmotic fixation methods such as suture-button fixation require further evaluation when compared to the outcomes of deltoid ligament repair. A randomized control trial is required to further examine the outcomes of ankle fracture patients who undergo deltoid ligament repair versus trans-syndesmotic screw fixation.

Primary arthroscopic repair of massive rotator cuff tears results in significant improvements with low rate of re-tear.

PURPOSE: To conduct a systematic review of outcomes following primary arthroscopic repair of chronic massive rotator cuff tears (RCTs) and to assess clinical outcomes and rates of repair failure. The authors' preferred treatment algorithm is also provided. METHODS: Medline, Embase and PubMed were searched identifying articles pertaining to primary arthroscopic repair of chronic massive RCTs without the use of augmentation. Primary outcomes were patient-reported outcomes and the secondary outcome was the rate of repair failure. Outcome data were pooled and presented as well as assessment of study methodological quality. Data from studies reporting similar outcome measures were pooled when possible, and mean differences alongside confidence intervals and p values were reported, where appropriate. RESULTS: Twenty-six studies (1405 participants) were included, with mean age of 62 years (range 52-69). The mean duration of symptoms pre-operatively was 31 months (range 6-40), and the mean follow-up time was 39 months (range 12-111). Complete repair was performed in 78% of patients and partial repair was performed in 22%. Both complete and partial repairs resulted in significant improvements with respect to pain, range of motion and functional outcome scores. The rate of repair failure for the total cohort was 36% at a mean follow-up of 31 months, and for the complete and partial repair subgroups the failure rate was 35% and 40%, respectively. CONCLUSIONS: Arthroscopic repairs of chronic, massive RCTs, whether complete or partial, are associated with significant improvements in pain, function and objective outcome scores. The rate of repair failure is lower than previously reported, however, still high at 36%. The present paper finds that arthroscopic repair is still a viable treatment option for massive RCTs. LEVEL OF EVIDENCE: IV.

A systematic review of outcomes of wrist arthrodesis and wrist arthroplasty in patients with rheumatoid arthritis.

Surgical management of end-stage rheumatoid wrists is a contentious topic. The standard surgical treatment has traditionally been wrist arthrodesis. Wrist arthroplasty, however, offers an alternative that preserves some wrist motion. A systematic review of MEDLINE, EMBASE and CENTRAL databases was conducted. Data from 23 studies representing 343 cases of wrist arthrodesis and 618 cases of wrist arthroplasty were included. Complication rates were 17% for arthrodesis and 19% for arthroplasty, and both procedures were effective at alleviating pain and improving grip strength. Functional assessment by Disabilities of the Arm, Shoulder, and Hand and Patient-Related Wrist Evaluation of arthroplasty patients revealed clinically meaningful functional improvement compared with preoperative measurements. In contrast to previously published findings both procedures demonstrated comparable complication rates. While this can be speculated to be from advancements in prosthetics, robust long-term follow-up data on wrist arthroplasty are not available yet.

Arthroscopic Bankart Repair With Remplissage in Comparison to Bone Block Augmentation for Anterior Shoulder Instability With Bipolar Bone Loss: A Systematic Review.

PURPOSE: The purpose of this systematic review is to examine the rates of postoperative recurrence of instability, functional outcomes, and complications after treatment with bone augmentation procedures or arthroscopic Bankart repair with remplissage for recurrent anterior shoulder instability in the setting of subcritical glenoid bone loss. METHODS: EMBASE, PubMed, and MEDLINE were searched from database inception until June 2019 for articles examining either bone block augmentation to the glenoid or Bankart repair with remplissage (BRR) in the setting of subcritical glenoid bone loss. Search and data extraction were performed by 2 reviewers independently and in duplicate. A separate analysis was done for comparative studies. RESULTS: Overall, 145 studies were identified, including 4 comparative studies. Across all studies, postoperative recurrence rates ranged from 0% to 42.8% for bone block augmentation and 0% to 15% for Bankart repair with remplissage. In comparative studies reporting subcritical glenoid bone loss, rates were 5.7% to 11.6% in the Latarjet group and 0% to 13.3% in the Bankart repair with remplissage group. However, in all studies reporting 10% to 15% mean glenoid bone loss, there was an increased rate of recurrent instability with arthroscopic soft tissue repair (6.1% to 13.2%) in comparison with bony augmentation (0% to 8.2%). Lastly, complication rates ranged from 0% to 66.7% for the bone block group and 0% to 2.3% for arthroscopic Bankart repair with remplissage. CONCLUSION: Both bone block augmentation and Bankart repair with remplissage are effective treatment options for recurrent anterior shoulder instability in patients with bipolar bone loss but subcritical glenoid bone loss. Both have comparable functional outcomes, albeit bone block procedures carry an increased risk of complications. Arthroscopic BRR may be associated with a higher failure rate for preoperative glenoid bone loss >10%. Therefore, it may represent a stabilization procedure best suited for cases of recurrent anterior instability with glenoid bone loss <10% and the presence of a significant, off-track Hill-Sachs lesion. LEVEL OF EVIDENCE: Level IV, systematic review of Level II-IV studies.

Templating in shoulder arthroplasty - A comparison of 2D CT to 3D CT planning software: A systematic review.

BACKGROUND: Computed tomography (CT) utilizing computer software technology to generate three-dimensional (3D) rendering of the glenoid has become the preferred method for preoperative planning. It remains largely unknown what benefits this software may have to the intraoperative placement of the components and patient outcomes. PURPOSE: The purpose of this systematic review is to compare 2D CT to 3D CT planning in total shoulder arthroplasty. STUDY DESIGN: Systematic review. METHODS: A systematic database search was conducted for relevant studies evaluating the role of 3D CT planning in total shoulder arthroplasty. The primary outcome was component placement variability, and the secondary outcomes were intra- and inter-observer reliability in the context of preoperative planning. RESULTS: Following title-abstract and full-text screening, six eligible studies were included in the review (n = 237). The variability in glenoid measurements between 3D CT and 2D CT planning ranged from no significant difference to a 5° difference in version and 1.7° difference in inclination (p<0.05). Posterior bone loss was underestimated in 52% of the 2D measured patients relative to 3D CT groups. Irrespective of 2D and 3D planning (39% and 43% of cases respectively), surgeons elected to implant larger components than those templated. There was no literature identified comparing differences in time, cost, functional outcomes, complications, or patient satisfaction. CONCLUSION: The paucity of evidence exploring clinical parameters makes it difficult to comment on clinical outcomes using different methods of templating. More studies are required to identify how improved radiographic outcomes translate into improvements that are clinically meaningful to patients.

Management of Failed SLAP Repair: A Systematic Review.

BACKGROUND: Superior labrum anterior to posterior (SLAP) tears are a very common shoulder injury. The success rate of SLAP repair, particularly in the throwing athlete, has been variable in the literature. QUESTIONS/PURPOSES: The purpose of this systematic review was to evaluate the reported post-operative outcomes of management techniques for failed SLAP repair. METHODS: The electronic databases MEDLINE, Embase, and PubMed were searched for relevant studies, and pertinent data was abstracted. Only studies reporting outcomes of management techniques for failed SLAP repairs were included. RESULTS: A total of 10 studies (levels III to IV) evaluating 176 patients were included in this systematic review. Most subjects were male (86.6%), with a mean age at surgery of 36.3 years (range, 17 to 67 years). The most commonly reported reason for failed SLAP repair was persistent post-operative mechanical symptoms after index SLAP repair. Common techniques used in the management of failed SLAP repair include biceps tenodesis and revision SLAP repair. Return to activity was significantly higher after biceps tenodesis than after arthroscopic revision SLAP repair. However, compared to primary SLAP repair, biceps tenodesis demonstrated no statistically significant differences in return to work rates. Complications reported in one case were resolved post-operatively, and there was no reported revision failure or reoperation after revision surgery. CONCLUSION: The most common reason for failed SLAP repair is persistent post-operative mechanical symptoms. Revision surgery for failed SLAP repair has a high success rate. The rate of return to activity after biceps tenodesis was significantly higher than the rate after revision SLAP repair. Large high-quality randomized trials are required to provide definitive evidence to support the optimal treatment for failed SLAP repair.

Return to Sport After Coracoid Bone Block Transfer for Shoulder Instability: A Systematic Review.

BACKGROUND: Shoulder dislocations can be devastating for an athlete. Coracoid bone block transfer is often used for the treatment of recurrent shoulder instability. QUESTIONS/PURPOSES: The primary purpose of this study was to determine the rate and mean time of return to sport in athletes after a coracoid bone block transfer at the pre-operative level of competition, a lower level, or a different level. We also sought to determine how return to sport rates after a coracoid bone block procedure compared with rates after several comparator interventions. Finally, we looked to determine the post-operative clinical outcomes and complications reported after a coracoid bone block procedure. METHODS: We systematically searched three databases (PubMed, Embase, and MEDLINE) for studies reporting return to sport after a coracoid bone block procedure. RESULTS: A total of 52 studies (with levels of evidence ranging from II to IV) evaluating 2953 shoulders in 2888 patients were included in this systematic review. The mean rate of return to sport at any level was 88.4% (2291 of 2592 patients). However, the rate of return to the pre-operative level was 70.3% (1387 of 1974 patients). The mean time to return to sport was 5.38 months (range 21 days to 36 months). The rate of return to sport was higher after the Latarjet procedure, as compared with Bankart repair (87.0% and 75.8%, respectively). All studies showed improvements in clinical outcome measures after coracoid bone block intervention. The cumulative complication rate was found to be 6.46% (158 of 2446 patients). CONCLUSION: Coracoid bone block transfer allows for a high rate of return to sport, although the rate of return to sport at athletes' pre-operative level is lower. The rate of return to sport after Latarjet procedure is higher in comparison with Bankart repair. Additionally, coracoid bone block transfer is associated with improvements in a number of clinical outcome measures. Common post-operative complications include non-union between bone block and glenoid, hematoma, and infection.

Surgical treatment of trapezius palsy: A systematic review.

BACKGROUND: Trapezius palsy results from injury to the spinal accessory nerve. The condition presents with loss of shoulder abduction, pain, and winging of the scapula. Surgical treatment may improve functional outcomes and quality of life. PURPOSE: The purpose of this study was to report and evaluate the clinical outcomes following surgical management of trapezius palsy. STUDY DESIGN: Systematic review. METHODS: The electronic databases EMBASE, MEDLINE, and PubMed were searched for studies and relevant data were abstracted. Only studies reporting on outcomes after the surgical treatments of trapezius palsy were included. RESULTS: A total of 10 studies including 192 patients were included in this review. All surgical interventions resulted in improved function and pain reduction. Patients reported high satisfaction (90-92%) following nerve reconstruction or the Eden-Lange procedure, in comparison to neurolysis. The most common procedure reported was the Eden-Lange muscle transfer (32% reported cases) demonstrating the highest patient satisfaction rates with low complication rate of 7.7%. CONCLUSION: Patients failing conservative treatment report good outcomes following surgical treatment of trapezius palsy. All reported surgical procedures demonstrate reduction in pain the best results from the Eden-Lange muscle transfer. Further high-quality comparative studies are required to make definitive conclusions regarding the comparative efficacy of each surgical procedure.

Indications and outcomes of radial head excision: A systematic review.

BACKGROUND: Radial head excision has historically been a common surgical procedure for the operative management of radial head fractures and post-traumatic conditions. With recent advances in other surgical techniques, controversy exists regarding its indications. This review evaluates the indications and outcomes of radial head excision in traumatic and non-traumatic elbow pathology. METHODS: Multiple databases were searched for studies involving radial head excision. Screening and data abstraction were conducted in duplicate. Only studies reporting outcomes for radial head excision were included. RESULTS: Twenty-seven studies with 774 radial head excision patients were included. The most common indications involved acute excision of comminuted radial head fractures (n = 347) and rheumatoid arthritis (n = 201). Post-operative functional scores after acute excision were reported to be good to excellent. In the chronic setting of rheumatoid disease, radial head excision resulted in improved range of motion, although pain was not effectively relieved. DISCUSSION: Outcomes of radial head excision for acute fracture are good to excellent; however, it should not be performed when concurrent or ligamentous injuries are present. Although some studies compared excision to open reduction and internal fixation or replacement, more data are needed to make proper conclusions. The strength of these conclusions is limited by the quality of included literature.

Stumbling upon the unexpected: A unique presentation of phosphaturic mesenchymal tumor in the hindfoot.

We describe an unexpected and unique case of phosphaturic mesenchymal tumor in a 38-year-old female presenting with a painful lump in the plantar hindfoot. Phosphaturic mesenchymal tumors are extremely rare, generally benign soft tissue or osseous tumors, which are associated with overexpression of fibroblast growth factor-23 and tumor-associated osteomalacia. Patients often present with progressive signs and symptoms including systemic bone pain, muscle weakness, and insufficiency fractures, and timely diagnosis is paramount to appropriate therapy. Tumor resection is almost always curative with normalization of laboratory markers and resolution of symptomatology.

Heterotopic Ossification following Total Elbow Arthroplasty in a Patient with Parkinson's Disease: Case Report and Literature Review.

Introduction. Heterotopic ossification (HO) usually develops following surgery or trauma. Risk factors for HO following elbow fractures include delay to surgery (>7 days), floating fractures, and elbow subluxation. Systemic risk factors for HO include male sex; concurrent cranial, neurological, or abdominal injury; high-energy trauma; previous development of HO; and contralateral fracture. To date, no studies have reported on Parkinson's disease (PD) as a risk factor for the development of HO. Case Presentation. A 68-year-old female with PD (treated with levodopa-carbidopa) sustained a right closed (OTA type A3) distal humerus fracture and was treated with a total elbow arthroplasty. Postoperatively, development of significant near-ankylosing HO was observed and contributed to significant restriction of elbow motion with activities of daily living. After HO maturation, the osseous growth was excised, and the area irradiated. The patient regained excellent elbow motion with no recurrence of HO. Discussion. A literature review revealed six cases of HO development in PD patients following arthroplasty. Patients with PD have higher serum concentrations of interleukins (IL) and tumor necrosis factor- (TNF-) α. These factors stimulate BMP-2 production which may promote osteogenesis. Levodopa-carbidopa may also influence HO through stimulation of growth hormone and IGF-1. Conclusion. Parkinsonism may promote heterotopic bone growth through the release of osteoinductive factors. HO development may also be mediated by levodopa-carbidopa therapy. Future research should highlight the link between HO and PD and identify if prophylaxis is warranted in PD patients undergoing arthroplasty.

Randomized control trial of ultrasound-guided erector spinae block versus shoulder periarticular anesthetic infiltration for pain control after arthroscopic shoulder surgery: Study protocol clinical trial (SPIRIT compliant).

INTRODUCTION: Moderate to severe postoperative pain and associated opioid use may interfere with patients' well-being and course of recovery. Regional anesthetic techniques provide an opportunity for opioid sparing and improved patient outcomes. A new regional technique called the erector spinae plane (ESP) block has the potential to provide effective analgesia after shoulder arthroscopy with minimal risks and decreased opioid consumption. Our primary objective is to determine whether, in patients who undergo arthroscopic shoulder surgery, a preoperative ESP block reduces pain scores as compared to periarticular infiltration at the end of surgery. Additionally, we will also examine other factors such as opioid consumption, sensory block, adverse events, patient satisfaction, and persistent pain. METHODS: This is a 2-arm, single-center, parallel-design, double-blind randomized controlled trial of 60 patients undergoing arthroscopic shoulder surgery. Eligible patients will be recruited in the preoperative clinic. Using a computer-generated randomization, with a 1:1 allocation ratio, patients will be randomized to either the ESP or periarticular infiltration group. Patients will be followed in hospital in the postanesthesia care unit, at 24 hours, and at 1 month. The study with be analyzed as intention-to-treat. DISCUSSION: This study will inform an evidence-based choice in recommending ESP block for shoulder arthroscopy, as well as providing safety data. The merits of the study include its double dummy blinding to minimize observer bias, and its assessment of patient important outcomes, including pain scores, opioid consumption, and patient satisfaction. This study will also help provide an estimate of the incidence of side effects and complications of the ESP block. TRIAL REGISTRATION NUMBER: NCT03691922; Recruited Date of registration: October 2, 2018.