Superior migration of the humeral head does not significantly affect outcomes at an average of 11 years after total shoulder arthroplasty.

BACKGROUND: Superior migration of the humeral head has been linked with rotator cuff dysfunction and glenoid loosening after total shoulder arthroplasty (TSA). We aimed to determine if superior migration was associated with poor shoulder function following anatomic TSA at long-term follow-up. METHODS: In this retrospective cohort study, we reviewed patients undergoing TSA by a single surgeon at an urban, academic institution. To study the effect of superior migration on TSA outcomes, we stratified the cohort by ≥ and <7 mm of acromiohumeral interval (AHI) and compared range of motion and patient reported outcomes (PROs). Clinical variables included preoperative and postoperative forward elevation (FE), internal rotation, external rotation, visual analog scale, American Shoulder and Elbow Surgeons shoulder score, and Simple Shoulder Text score. Radiographic variables included immediate postoperative and long-term follow-up AHI, lateral humeral offset, and glenoid loosening scores. RESULTS: After applying exclusion criteria, 121 TSAs were included. The mean age was 63.9 ± 9.5 years, and 66 surgeries (55%) were in male patients. The mean follow-up for our cohort was 11.2 years (range, 5-26 years). Nine shoulders underwent revision surgery. All range of motion and PROs improved significantly from preoperative to the most recent postoperative follow-up. The mean AHI immediately following surgery was 10.9 ± 4.1 mm, while the mean AHI at most recent follow-up was 8.4 ± 3.5 mm. Glenoid loosening was observed in 29 (23.8%) shoulders at the most recent follow-up appointment. Although AHI correlated weakly with FE (r = 0.252; P = .006), we did not observe a clear threshold of migration which led to degraded function. Importantly, glenoid loosening was not related to AHI at long-term follow-up (P = .631). None of FE, internal rotation, external rotation, visual analog scale, American Shoulder and Elbow Surgeons shoulder score, Simple Shoulder Text, or revisions were significantly different between patients with ≥ and <7 mm of AHI. CONCLUSION: Our results suggest that anatomic TSA provides durable improvements to pain, function, and PROs despite changes to the AHI.

Two Parallel Headless Compression Screws for Scaphoid Fractures: Radiographic Analysis and Preliminary Outcome.

BACKGROUND: Despite surgical fixation, the scaphoid nonunion rate remains at 3% to 5%. Recent biomechanical studies have demonstrated increased stability with 2-screw constructs. The objective of our study is to determine the preliminary union rate and anatomic feasibility of 2-screw surgical fixation for scaphoid fractures. METHODS: This study is a retrospective case series of 25 patients (average age 32 years) with scaphoid fractures treated with 2 parallel headless compression screws (HCS). Postoperative evaluation included Mayo Wrist Score (MWS), range of motion, time to union, and return to activity. Bivariate analysis for gender and Pearson correlation coefficient for body size (height, weight, and body mass index) was conducted against radiographically measured scaphoid width, screw lengths, and the distance between the 2 screws. RESULTS: All fractures healed with an average time to union of 9.9 weeks (median 7.6 weeks; range: 4.1-28.3). The mean MWS was 93.3 (range: 55-100), with 3 complications (12%), one of which affected the outcome of the surgery. The bivariate analysis demonstrated that the female gender was associated with significantly smaller scaphoid width (P = .004) but a similar distance between the 2 screws (P = .281). The distance between the 2 screws and the body size demonstrated a weak-to-no correlation. CONCLUSIONS: The 2-screw construct for scaphoid fracture achieved a favorable union rate and clinical outcome. Gender was the only variable significantly associated with scaphoid width and screw length. The distance between the screws was constant regardless of gender and body size, indicating that the technique for parallel screw placement can remain consistent. TYPE OF STUDY: Therapeutic. LEVEL OF EVIDENCE: Level IV.

Two Cases of Delayed Flexor Tendon Rupture Decades After Reconstruction.

Two patients are presented with late-term ruptures of their flexor tendon grafts 10 and 40 years, respectively, after reconstruction. Both occurred from low-energy mechanisms. Their ruptures were intratendinous and not at the proximal or distal insertions. Electron microscopy demonstrated degeneration and increased matrix deposition. Immunohistology showed viable tenocytes, but no clear vascular organization to the disrupted grafts. Even after clinically successful flexor tendon autograft, tendons may still be at risk of degeneration and rupture a decade or more after reconstruction.

Anterior hip dislocation complicated by thrombus in the common femoral vein: A case report.

CASE: A 90-year-old male sustained a low energy anterior hip dislocation without fracture after a ground-level fall. Magnetic resonance imaging (MRI) detected femoral vessel compression and thrombosis. The patient underwent placement of an inferior vena cava (IVC) filter prior to successful closed reduction in the operating room. CONCLUSION: Anterior hip dislocations are rare events that require urgent intervention to reduce the risk of complications. One underreported complication is femoral vessel thrombosis from direct compression against the femoral head. Dedicated imaging should be considered to rule out a thrombus. An IVC filter can be placed prior to reduction attempts to avoid potential thrombotic emboli.

Surgical Approach and Internal Fixation Techniques for Intra-Articular Distal Humerus Fracture With Coronal Shear Capitellar Fracture.

Intra-articular distal humerus fractures with an associated coronal shear capitellar fragment present a challenge for stable internal fixation. Adequate visualization and fixation of the capitellar shear fragment are difficult to achieve with conventional exposures, including the olecranon osteotomy. The capitellar fragment often translates anterior and proximally and is challenging to visualize with intact soft tissue attachments from a posterior approach. We describe a surgical exposure that releases the lateral ulnar collateral ligament in addition to an olecranon osteotomy to allow complete visualization of the entire articular surface. In contrast to an isolated capitellar fracture, the column stability and the posterior cortex are frequently disrupted with distal humerus fractures. Depending on the comminution of the posterior cortex, a supplemental posterolateral plate or headless compression screws can provide fixation to the coronal fracture plane. The lateral ulnar collateral ligament is repaired at the conclusion of fracture stabilization through a bone tunnel or to the plate to restore lateral stability. Despite the release of the ligament and additional soft tissue stripping, there were no cases of elbow instability or avascular necrosis in our case series of 9 patients.

Risk Factors for Staphylococcus aureus Nasal Colonization in Joint Arthroplasty Patients.

BACKGROUND: Several studies have shown that Staphylococcus aureus (S aureus) nasal colonization is associated with surgical site infection and that preoperative decolonization can reduce infection rates. Up to 30% of joint arthroplasty patients have positive S aureus nasal swabs. Patient risk factors for colonization remain largely unknown. The aim of this study was to determine whether there is a specific patient population at increased risk of S aureus nasal colonization. METHODS: This study is a retrospective review of 716 patients undergoing hip or knee arthroplasty beginning in 2011. All patients were screened preoperatively for nasal colonization. Univariate and multivariate analyses were used to assess risk factors for nasal colonization. RESULTS: A total of 716 patients undergoing joint arthroplasty had preoperative nasal screening. One hundred twenty-five (17.50%) nasal swabs were positive for methicillin-susceptible S aureus (MSSA), 13 (1.80%) were positive for methicillin-resistant S aureus (MRSA), and 84 (11.70%) were positive for other organisms. In bivariate analysis, diabetes (P = .04), renal insufficiency (P = .03), and immunosuppression (P = .02) were predictors of nasal colonization with MSSA/MRSA. In multivariate analysis, immunosuppression (P = .04; odds ratio, 2.0; 95% confidence interval, 1.03-3.71) and renal insufficiency (P = .04; odds ratio, 2.5; 95% confidence interval, 1.01-6.18) were independent predictors of nasal colonization with MSSA/MRSA. CONCLUSION: Overall, 17.5% of patients undergoing primary hip or knee arthroplasty screened positive for S aureus. Diabetes, renal insufficiency, and immunosuppression are risk factors for such colonization. Given that these comorbidities are already known independent risk factors for periprosthetic joint infection, these patients should be particularly screened and when necessary, decolonized.

Postoperative Complications Predict 30-Day Readmission in Geriatric General Surgery Patients.

The Affordable Care Act has placed unplanned patient readmissions under more scrutiny than ever. Geriatric patients, in particular, suffer a disproportionate amount of complications from any kind of hospitalization, including readmissions. This study seeks to identify risk factors in this population that predispose them to an unplanned readmission within 30 days after index surgery. The National Surgical Quality Improvement Program database was used to select patients 65 years and older, who underwent general surgery procedures in 2012. Patient demographics, comorbidities, complications, and readmissions were analyzed. A Cox regression survivorship model was used for multivariate analysis. A total of 7712 patients were reviewed; 617 patients (8.0%) had an unplanned readmission within 30 days of their operation. Cox regression revealed five different independent predictors of unplanned readmission within 30 days. They are age [P = 0.009, hazard ratio (HR) = 1.016, 95% confidence interval (CI) = 1.01-1.03], American Society of Anesthesiologists Class >2 (P = 0.037, HR = 1.22, CI = 1.024-1.475), operation time (minutes) (P = 0.001, HR = 1.001, CI = 1.00-1.002), any complication (P = 0.03, HR = 1.449, CI = 1.33-1.852), and deep vein thrombosis (P = 0.03, HR = 1.87, CI = 1.31-3.85). Using Cox regression to adjust for patient length of stay, age, American Society of Anesthesiologists class, any complication, operation time, and venous thromboembolism all independently increased the rate of unplanned readmissions. Patients who suffer any complication or a venous thromboembolism postoperatively are at a particularly high risk of readmission. These patients should be targeted for increased inpatient monitoring and included in preventable readmission programs after discharge.

Short-term complications in hip fracture surgery using spinal versus general anaesthesia.

BACKGROUND: Spinal anaesthesia when compared to general anaesthesia has been shown to decrease postoperative morbidity in orthopaedic surgery. The aim of the present study was to assess the differences in thirty-day morbidity and mortality for patients undergoing hip fracture surgery with spinal versus general anaesthesia. METHODS: The American College of Surgeons National Surgical Quality and Improvement Program (NSQIP) database was used to identify patients who underwent hip fracture surgery with general or spinal anaesthesia between 2010 and 2012 using CPT codes 27245 and 27244. Patient characteristics, complications, and mortality rates were compared. Univariate analysis and multivariate logistic regression were used to identify predictors of thirty-day complications. Stratified propensity scores were employed to adjust for potential selection bias between cohorts. RESULTS: 6133 patients underwent hip fracture surgery with spinal or general anaesthesia; 4318 (72.6%) patients underwent fracture repair with general anaesthesia and 1815 (27.4%) underwent fracture repair with spinal anaesthesia. The spinal anaesthesia group had a lower unadjusted frequency of blood transfusions (39.34% versus 45.49%; p<0.0001), deep vein thrombosis (0.72% versus 1.64%; p=0.004), urinary tract infection (8.87% versus 5.76%; p<0.0001), and overall complications (45.75% versus 48.97%; p=0.001). The length of surgery was shorter in the spinal anaesthesia group (55.81 versus 65.36 min; p<0.0001). After multivariate logistic regression was used to adjust for confounders, general anaesthesia (odds ratio, 1.29; 95% confidence interval, 1.14-1.47; p=0.0002) was significantly associated with increased risk for complication after hip fracture surgery. Age, female sex, body mass index, hypertension, transfusion, emergency procedure, operation time, and ASA score were risk factors for complications after hip fracture repair (all p<0.05). CONCLUSIONS: Patients who underwent hip fracture surgery with general anaesthesia had a higher risk of thirty-day complications as compared to patients who underwent hip fracture repair with spinal anaesthesia. Surgeons should consider using spinal anaesthesia for hip fracture surgery.

Short term outcomes of revision total knee arthroplasty.

Few studies have assessed postoperative complications in revision total knee arthroplasty (rTKA). The aim of this study was to assess which preoperative factors are associated with postoperative complications in rTKA. Using the National Surgical Quality Improvement (NSQIP) database, we identified patients undergoing rTKA from 2010 to 2012. Patient demographics, comorbidities, and complications within thirty days of surgery were analyzed. A total of 3421 patients underwent rTKA. After adjusted analysis, dialysis (P = 0.016) was associated with minor complications. Male gender (P = 0.03), older age (P = 0.029), ASA class >2 (P = 0.017), wound class >2 (P < 0.0001), emergency operation (P = 0.038), and pulmonary comorbidity (P = 0.047) were associated with major complications.