Comparison of clinical outcomes of revision reverse total shoulder arthroplasty for failed primary anatomic vs. reverse shoulder arthroplasty.

Background: Both anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (RTSA) are being increasingly performed. In the event of a complication necessitating revision, RTSA is more commonly performed in both scenarios. The purpose of this study was to compare clinical outcomes between patients undergoing revision RTSA for failed primary anatomic versus reverse total shoulder arthroplasty. Methods: We performed a retrospective review of a prospective single-institution shoulder arthroplasty database. All revision RTSAs performed between 2007 and 2019 with a minimum 2-year clinical follow-up were initially included. After excluding patients with a preoperative diagnosis of infection, an oncologic indication, or incomplete outcomes assessment, we included 45 revision RTSAs performed for failed primary aTSA and 15 for failed primary RTSA. Demographics, surgical characteristics, active range of motion (external rotation [ER], internal rotation, forward elevation [FE], abduction), outcome scores (American Shoulder and Elbow Surgeons score, Constant Score, Shoulder Pain and Disability Index, Simple Shoulder Test, and University of California, Los Angeles score), and the incidence of postoperative complications was compared between groups. Results: Primary aTSA was most often indicated for degenerative joint disease (82%), whereas primary RTSA was more often indicated for rotator cuff arthropathy (60%). On bivariate analysis, no statistically significant differences in any range of motion or clinical outcome measure were found between revision RTSA performed for failed aTSA vs. RTSA. On multivariate linear regression analysis, revision RTSA performed for failed aTSA vs. RTSA was not found to significantly influence any outcome measure. Humeral loosening as an indication for revision surgery was associated with more favorable outcomes for all four range of motion measures and all five outcome scores assessed. In contrast, an indication for revision of peri-prosthetic fracture was associated with poorer outcomes for three of four range of motion measures (ER, FE, abduction) and four of five outcome scores (Constant, Shoulder Pain and Disability Index, Simple Shoulder Test, University of California, Los Angeles). A preoperative diagnosis of fracture was associated with a poorer postoperative range of motion in ER, FE, and abduction, but was not found to significantly influence any outcome score. However, only two patients in our cohort had this indication. Complication and re-revision rates after revision RTSA for failed primary aTSA and RTSA were 27% and 9% vs. 20% and 14% (P = .487 and P = .515), respectively. Conclusion: Clinical outcomes of patients undergoing revision RTSA for failed primary shoulder arthroplasty did not significantly differ based on whether aTSA or RTSA was initially performed. However, larger studies are needed to definitively ascertain the influence of the primary construct on the outcomes of revision RTSA.

Twenty-two Years of Pediatric Musculoskeletal Firearm Injuries: Adverse Outcomes for the Very Young.

BACKGROUND: Firearm injuries are a significant cause of morbidity and mortality for children in the United States. The purpose of this study is to investigate the 22-year experience of pediatric firearm-related musculoskeletal injuries at a major pediatric level 1 hospital and to analyze the risk of adverse outcomes in children under 10 years of age. METHODS: An institutional review board-approved, retrospective cohort analysis was conducted on pediatric firearm-related musculoskeletal injuries at our institution from 1995 to 2017. A total of 189 children aged 0 to 18 years were identified using International Classification of Diseases, 9th Revision/10th Revision codes, focusing on musculoskeletal injuries by firearms. Exclusion criteria were primary treatment at an outside hospital, isolated nonmusculoskeletal injuries (eg, traumatic brain injury), and death before orthopaedic intervention. Two cohorts were included: age below 10 years and age 10 years and above. Primary outcome measure was a serious adverse outcome (death, growth disturbance, amputation, or impairment). Standard statistical analysis was used for demographic data, along with linear mixed models and multivariable logistic regression for adverse outcome. RESULTS: Of the 189 children, 46 (24.3%) were below 10 years of age and 143 (75.7%) were 10 years and above. Fifty-two (27.5%) of the total group had an adverse outcome, with 19 (41.3%) aged below 10 years and 33 (23.1%) aged 10 years and above (P=0.016). Adverse outcomes were 3 deaths, 17 growth disturbances, 7 amputations, and 44 impairments. For those below 10 years of age, rural location (P=0.024), need for surgical treatment (P=0.041), femur injury (P=0.032), peripheral nerve injury (P=0.006), and number of surgeries (P=0.022) were associated with an adverse outcome. CONCLUSIONS: Over one fourth of survivors of musculoskeletal firearm injuries had an adverse outcome. Children 10 years and above represent the majority of firearm injuries in our population; however, when injured, those below 10 years are more likely to have an adverse outcome. LEVEL OF EVIDENCE: Level III.

Intramedullary Antibiotic Delivery for Emphysematous Osteomyelitis of the Femur.

The authors present a case of bilateral femoral emphysematous osteomyelitis caused by Escherichia coli in a 60-year-old woman with rheumatoid arthritis who was receiving long-term prednisone therapy. The infection in both femoral shafts was eradicated with surgical debridement, followed by insertion of intramedullary rods composed of culture-specific antibiotic cement into the femoral canals in conjunction with 6 weeks of intravenous antibiotics. The rods were subsequently removed, and no signs of further osteomyelitis were recognized at follow-up. To the authors' knowledge, this is the first case of its kind reported in the orthopedic literature. Emphysematous osteomyelitis, a rare and dangerous entity, can be successfully managed by intramedullary antibiotic delivery in the subacute setting. [Orthopedics. 2019; 42(1):e128-e130.].