Conversion of Total Shoulder Arthroplasty to Reverse Total Shoulder Arthroplasty: Time to Conversion and Indications at a Tertiary Care Center.

Anatomic total shoulder arthroplasty (aTSA) and reverse shoulder arthroplasty (RSA) are increasingly common, with volume projected to increase over 90% by the year 2025. Therefore, it is critical to understand the expected longevity of aTSA using modern implants and techniques, rates of conversion to RSA, and most common indications for conversion if surgeons are to properly diagnose and treat patients. A retrospective review was conducted of 800 patients who had undergone aTSA, RSA, or hemiarthroplasty (HA) between 2015 and 2019 at a tertiary-care academic medical center. All patients who had undergone primary aTSA were included. Patients who had undergone primary HA, primary RSA, or had had primary surgery at an outside hospital were excluded. Primary outcomes were indications for and time to conversion from aTSA to RSA. Secondary outcomes were indications for primary aTSA and preliminary survivorship data of modern implants. Between 2015 and 2019, 235 patients underwent primary aTSA, with a mean time to follow-up of 3.43 years (0.07-5.24 years). Mean time to conversion from aTSA to RSA was 15.6 months, with a 2.13% conversion rate (5 patients). Eighty percent of the conversions (4 patients) were due to rotator cuff tear. We found that 2.13% of primary aTSA patients at our institution were converted to RSA at a mean of 15.6 months after the primary procedure. Rotator cuff tears were the indication for 80% of these. Since conversions occurred relatively soon after primary surgery, the authors recommend use of MRI without contrast prior to surgery to possibly reduce the risk of such failures. This study was a Level 3 retrospective database review.

A Multicenter Study of Early Anti-inflammatory Treatment in Patients With Acute Anterior Cruciate Ligament Tear.

BACKGROUND: It is increasingly recognized that biochemical abnormalities of the joint precede radiographic abnormalities of posttraumatic osteoarthritis (PTOA) by as much as decades. A growing body of evidence strongly suggests that the progression from anterior cruciate ligament (ACL) injury to PTOA is multifactorial, involving the interplay between biomechanical disturbances and biochemical homeostasis of articular cartilage. PURPOSE: The purposes of this randomized study using an acute ACL injury model were to (1) evaluate the natural progression of inflammatory and chondrodegenerative biomarkers, (2) evaluate the relationship between subjective reports of pain and inflammatory and chondrodegenerative biomarkers, and (3) determine if postinjury arthrocentesis and corticosteroid injection offer the ability to alter this biochemical cascade. STUDY DESIGN: Randomized controlled trial; Level of evidence, 2. METHODS: A total of 49 patients were randomized to 4 groups: group 1 (corticosteroid at 4 days after ACL injury, placebo injection of saline at 2 weeks), group 2 (placebo at 4 days after ACL injury, corticosteroid at 2 weeks), group 3 (corticosteroid at both time intervals), or a placebo group (saline injections at both time intervals). Patient-reported outcome measures and synovial biomarkers were collected at approximately 4 days, 11 days, and 5 weeks after injury. The change between the time points was assessed for all variables using Wilcoxon tests, and the relationship between changes in outcome scores and biomarkers were assessed by calculating Spearman ρ. Outcomes and biomarkers were also compared between the 4 groups using Kruskal-Wallis tests. RESULTS: No adverse events or infections were observed in any study patients. With the exception of matrix metalloproteinase 1 (MMP-1) and tumor necrosis factor-inducible gene 6 (TSG-6), chondrodegenerative markers worsened over the first 5 weeks while all patient-reported outcomes improved during this time, regardless of treatment group. Patient-reported outcomes did not differ between patients receiving corticosteroid injections and the placebo group. However, increases in C-telopeptide of type II collagen (CTX-II), associated with collagen type II breakdown, were significantly greater in the placebo group (1.32 ± 1.10 ng/mL) than in either of the groups that received the corticosteroid injection within the first several days after injury (group 1: 0.23 ± 0.27 ng/mL [ P = .01]; group 3: 0.19 ± 0.34 ng/mL [ P = .01]). CONCLUSION: PTOA begins at the time of injury and results early on in dramatic matrix changes in the knee. However, it is encouraging that early intervention with an anti-inflammatory agent was able to affect biomarkers of chondral degeneration. Should early intervention lead to meaningful changes in either the onset or severity of symptomatic PTOA, the current treatment paradigm for patients with ACL injury may have to be restructured to include early aspiration and intra-articular intervention. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01692756.

Logistical challenges and design considerations for studies using acute anterior cruciate ligament injury as a potential model for early posttraumatic osteoarthritis.

Anterior cruciate ligament (ACL) injuries are common and lead to posttraumatic osteoarthritis (PTOA) in a high percentage of patients. Research has been ineffective in identifying successful treatment options for people suffering from symptomatic PTOA resulting in a shift of focus toward the young, ACL injured patients at risk of developing PTOA. Randomized clinical trials examining the very early phase after ACL injury are ideal to study this population; however, these trials face significant challenges regarding recruitment as well as reproducibility of patient-reported outcomes (PROs) and inflammatory and/or chondrodegenerative biomarkers associated with early PTOA. The aim of this work was to develop an approach to allow for early recruitment into an RCT for early treatment following ACL injury and to analyze the variability of commonly used measures and biomarkers at various time points after injury. This paper reports the study design and data related to the first month of treatment for the placebo group of an ongoing 2-year clinical trial to evaluate the effect of an early intra-articular intervention after ACL injury. The results of this study suggest that acute ACL injury results in early changes of both inflammatory and chondrodegenerative biomarkers. These results also provide vital information for researchers to consider when developing future protocols, both related to the logistics of early patient enrollment as well as the appropriate timing of biomarker and patient-reported outcome collection. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:641-650, 2017.