Total shoulder arthroplasty for osteoarthritis in patients with Parkinson's disease: a matched comparison of 90-day adverse events and 5-year implant survival.

BACKGROUND: Patients with Parkinson's disease and shoulder osteoarthritis may be indicated for total shoulder arthroplasty. However, short- and long-term outcomes after total shoulder arthroplasty in this population remain poorly characterized. METHODS: A retrospective matched case-control study was performed using data abstracted from the 2010-2018 PearlDiver Mariner administrative database. Patients undergoing total shoulder arthroplasty were identified, and those with and without the diagnosis of Parkinson's disease were matched (1:10) based on age, gender, Elixhauser comorbidity index, diabetes, chronic kidney disease, obesity, coronary artery disease, and congestive heart failure. Ninety-day incidence of adverse events were compared with multivariate regressions. Implant survival was also assessed for up to 5 years, based on the occurrence of revision surgery. Kaplan-Meier implant survival curves were compared using a log-rank test. RESULTS: In total, 478 patients with Parkinson's disease were matched to 4715 patients without Parkinson's disease. After adjusting for demographic and comorbid factors, patients with Parkinson's disease had significantly higher odds of prosthetic dislocation (odds ratio = 3.07, P = .001), but did not experience increased odds of other 90-day adverse events. Five-year follow-up was available for 428 (89.5%) of those with Parkinson's disease and 3794 (80.5%) of those without Parkinson's disease. There was 97.2% implant survival in the Parkinson's disease cohort and 97.7% implant survival in the matched control cohort (not significantly different, P = .463). CONCLUSIONS: Patients with Parkinson's disease undergoing total shoulder arthroplasty, compared with patients without Parkinson's disease, have 3-fold higher odds of periprosthetic dislocation in the 90-day postoperative period, but equivalent rates of other short-term adverse events as well as implant survival at 5 years. Accordingly, surgeons should be mindful of the short-term risk of implant instability but should have confidence in long-term total shoulder implant success in the Parkinson's disease population.

The Van Gorder approach for total elbow arthroplasty.

BACKGROUND: Surgical management of the triceps during exposure for total elbow arthroplasty (TEA) is critical to a successful outcome. Previously described techniques include elevating the triceps insertion from one side or leaving the triceps insertion attached and dislocating the joint. Another approach to the elbow, first described in 1933 by Willis Campbell, MD, and subsequently modified by George Van Gorder, MD, involves turning down the triceps tendon without disrupting the triceps insertion. This approach offers complete visualization of the joint and provides excellent exposure for TEA. Only the original report of the technique and a small series of patients using this technique for TEA exist in the literature. The goal of this study was to evaluate outcomes of the Van Gorder approach in a large series of patients undergoing TEA. METHODS: All patients who underwent TEA from 2008 to 2016 were retrospectively reviewed. Only patients who underwent primary TEA performed through the Van Gorder approach with at least 6 months' follow-up were included for analysis. Patients with prior elbow surgery were excluded. Demographic data, indication for surgery, postoperative range of motion, triceps function, and need for additional surgery were recorded. Prospectively collected visual analog scale (VAS) and Global Health Quality of Life scores were also analyzed. RESULTS: A total of 53 patients met inclusion criteria. The mean age was 62 years, 81% were female, and the average follow-up was 30.2 months. The most common surgical indications included inflammatory arthritis (47%), osteoarthritis (24%), and fracture (19%). Postoperatively, average elbow arc of motion was an 8°-137°. There was 1 patient (1.89%) who developed failure of their triceps extension mechanism. A total of 10 patients (19%) underwent additional elbow surgery most commonly for superficial wound complications. Preoperative VAS scores decreased significantly, starting at 3 months postoperatively (6.76 to 3.37, P < .001), and remained constant at the 12- and 24-month postoperative visits. CONCLUSIONS: This is the largest study evaluating the Van Gorder surgical approach to the elbow for primary TEA with an average follow-up of 32 months. Overall rates of triceps failure and reoperation are consistent with other approaches for TEA.

The Association Between Rotator Cuff Muscle Fatty Infiltration and Glenoid Morphology in Glenohumeral Osteoarthritis.

BACKGROUND: Glenoid morphology and rotator cuff muscle quality are important anatomic factors that can impact longevity of the glenoid component following total shoulder arthroplasty (TSA). We hypothesized that rotator cuff muscle fatty infiltration is associated with increased pathologic glenoid bone loss in glenohumeral osteoarthritis (OA). METHODS: We retrospectively reviewed 190 preoperative computed tomography (CT) scans of 175 patients (mean age, 66 years; range, 44 to 90 years) who underwent TSA for the treatment of primary glenohumeral OA. Two-dimensional orthogonal CT images were reformatted in the plane of the scapula from 3-dimensional images. Pathologic joint-line medialization was defined with use of the glenoid vault model. Pathologic glenoid version was measured directly. Glenoid morphology was graded according to a modified Walch classification (subtypes A1, A2, B1, B2, B3, C1, and C2). Rotator cuff muscle fatty infiltration was assessed and assigned a Goutallier score on the sagittal CT slice just medial to the spinoglenoid notch for each muscle. RESULTS: There was a significant difference in the Goutallier score for the supraspinatus, infraspinatus, and teres minor muscles between Walch subtypes (p ≤ 0.05). High-grade posterior rotator cuff muscle fatty infiltration was present in 55% (21) of 38 B3 glenoids compared with 8% (3) of 39 A1 glenoids. Increasing joint-line medialization was associated with increasing fatty infiltration of all rotator cuff muscles (p ≤ 0.05). Higher fatty infiltration of the infraspinatus, teres minor, and combined posterior rotator cuff muscles was associated with increasing glenoid retroversion (p ≤ 0.05). After controlling for joint-line medialization and retroversion, B3 glenoids were more likely to have fatty infiltration of the supraspinatus and infraspinatus muscles than B2 glenoids were. CONCLUSIONS: High-grade rotator cuff muscle fatty infiltration is associated with B3 glenoids, increased pathologic glenoid retroversion, and increased joint-line medialization. Additional studies are needed to determine the causal relationship between these muscle changes and glenoid wear, whether these muscle changes independently affect clinical and radiographic outcomes in anatomic TSA, and whether fatty infiltration can improve postoperatively with correction of pathologic version and/or joint-line restoration. CLINICAL RELEVANCE: This study investigates the association between different patterns of glenoid bone loss and rotator cuff muscle fatty infiltration. Both factors have been shown to affect clinical outcome following TSA.

Comparison of Ultrasound and MRI for the Diagnosis of Glenohumeral Dysplasia in Brachial Plexus Birth Palsy.

BACKGROUND: In this study, we investigated the agreement between measurements made on ultrasound and those made on magnetic resonance imaging (MRI) in the assessment of glenohumeral dysplasia resulting from brachial plexus birth palsy. METHODS: Thirty-nine patients (14 male and 25 female) with brachial plexus birth palsy were evaluated at 2 tertiary care centers. All patients underwent ultrasonography and MRI for suspected glenohumeral dysplasia. Studies were obtained at an average of 2 months apart (range, 0 to 6 months). The average patient age at the time of the initial imaging study was 20 months (range, 4 to 54 months). Four blinded independent evaluators measured the alpha angle, the posterior humeral head displacement (PHHD), and glenoid version on both the ultrasound and MRI study for each patient. The percentage of the humeral head anterior to the scapular axis (PHHA) was determined on MRI only. Measurements were obtained on OsiriX software (Pixmeo). Intraclass correlation coefficients (ICCs) were used to assess the intrarater and interrater reliability, and Bland-Altman plots were used to compare MRI and ultrasound measurement agreement. RESULTS: We found excellent interrater reliability for measurements of the alpha angle on MRI, glenoid version on MRI, and the alpha angle on ultrasound (ICC: 0.83, 0.75, and 0.78, respectively). The interrater reliability for the PHHD on both MRI and ultrasound was good (ICC: 0.70 and 0.68, respectively), and the interrater reliability for the PHHA on MRI was fair (ICC: 0.57). However, the interrater reliability for glenoid version on ultrasound was poor (ICC: 0.30). Relative to MRI measurements, ultrasound measurements were found to underestimate the alpha angle and glenoid version by an average of 13° ± 23° and 6° ± 17°, respectively, and overestimate the PHHD by an average of 4% ± 20%. Increasing patient age corresponded with a significant increase in the MRI-ultrasound measurement difference for the alpha angle (p < 0.01) and a marginally significant increase in the difference for the PHHD (p < 0.06). CONCLUSIONS: Measurements on MRI and ultrasound were reliable, with measured bias. The poor agreement between measurements on MRI and ultrasound calls into question the validity of using ultrasonography as a stand-alone modality in the evaluation of glenohumeral dysplasia. MRI remains the gold standard for fully evaluating the glenohumeral joint. The clinical role of ultrasonography may be that of a screening tool or a way of evaluating joint reduction in real time. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Chronic Elbow Dislocation: Evaluation and Management.

Chronic elbow dislocation is defined as a dislocation that has remained unreduced for >2 weeks. The soft-tissue and skeletal changes that develop during this time usually prevent successful closed reduction. These changes include the development of extensive intra-articular fibrotic tissue, as well as contracture of the triceps, collateral ligaments, and elbow capsule. Ulnar nerve involvement and associated fractures may also be present. Because treatment of chronic elbow dislocation is challenging, a stepwise approach is used in the evaluation and management of this condition. No large series of data are available to guide treatment. Most patients are treated on the basis of the surgeon's anecdotal experience. Treatment typically involves open reduction, often with the use of hinged external fixators. The role of triceps lengthening or primary collateral ligament reconstruction remains a topic of debate.

Surgical management of the biconcave (B2) glenoid.

Glenohumeral osteoarthritis produces a wide spectrum of glenoid pathology. The B2 glenoid is defined by asymmetric posterior bone loss with the development of a biconcavity and posterior translation of the humeral head. Progressive bone loss results in increasing glenoid retroversion, which must be corrected during anatomic shoulder arthroplasty. The goals of arthroplasty should also include centering the humeral head and restoring the normal glenoid joint line. When there is minimal bone loss, this may be accomplished with a standard glenoid component and asymmetric reaming. More significant bone loss requires bone grafting or the use of an augmented glenoid component. Reverse shoulder arthroplasty is also an option for older patients or patients with severe bone loss.

Long-finger pollicization for macrodactyly of the thumb and index finger.

Pollicization of the long finger is rarely performed, and previously described for treating traumatic thumb and index finger loss. Because the long finger lacks the independence of motion and muscular attachments of the index finger, pollicization of the long finger requires modifications of the technique. We present the case of a 3-year-old girl with progressive macrodactyly of the thumb and index finger associated with a lipofibromatous hamartoma of the median nerve. The involved digits were severely enlarged, stiff, and nonfunctional. The child was treated with first and second ray resection followed by long-finger pollicization. Surgical pearls and pitfalls are discussed.

Distal tibia fractures: locked or non-locked plating? A systematic review of outcomes.

BACKGROUND AND PURPOSE: Although plating is considered to be the treatment of choice in distal tibia fractures, controversies abound regarding the type of plating for optimal fixation. We conducted a systematic review to evaluate and compare the outcomes of locked plating and non-locked plating in treatment of distal tibia fractures. PATIENTS AND METHODS: A systematic review was conducted using PubMed to identify articles on the outcomes of plating in distal tibia fractures that were published up to June 2012. We included English language articles involving a minimum of 10 adult cases with acute fractures treated using single-plate, minimally invasive techniques. Study-level binomial regression on the pooled data was conducted to determine the effect of locking status on different outcomes, adjusted for age, sex, and other independent variables. RESULTS: 27 studies met the inclusion criteria and were included in the final analysis of 764 cases (499 locking, 265 non-locking). Based on descriptive analysis only, delayed union was reported in 6% of cases with locked plating and in 4% of cases with non-locked plating. Non-union was reported in 2% of cases with locked plating and 3% of cases with non-locked plating. Comparing locked and non-locked plating, the odds ratio (OR) for reoperation was 0.13 (95% CI: 0.03-0.57) and for malalignment it was 0.10 (95% CI: 0.02-0.42). Both values were statistically significant. INTERPRETATION: This study showed that locked plating reduces the odds of reoperation and malalignment after treatment for acute distal tibia fracture. Future studies should accurately assess causality and the clinical and economic impact of these findings.

Radial nerve motor palsy following seasonal influenza vaccination: a case report.

This case report describes the course of a 26-year-old male who developed a dense motor palsy of the radial nerve after receiving a seasonal influenza vaccination. The palsy developed within 12 to 16 hours of inoculation and demonstrated no clinical recovery until 5 months postinjury. Electromyographic and nerve conduction studies obtained at six weeks postinjury were consistent with complete motor denervation. Sensory function was preserved. The injury was successfully treated nonoperatively with physical therapy and wrist splinting, and the palsy gradually resolved over the next several months.