Early follow-up of reverse total shoulder arthroplasty in patients sixty years of age or younger.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is an accepted treatment that provides reproducible results in the treatment of shoulder arthritis and rotator cuff deficiency. Concerns over the longevity of the prosthesis have resulted in this procedure being reserved for the elderly. There are limited data in the literature with regard to outcomes in younger patients. We report on the early outcomes of RSA in a group of patients who were sixty years or younger and who were followed for a minimum of two years. METHODS: A retrospective multicenter review of sixty-six patients (sixty-seven RSAs) with a mean age of 52.2 years was performed. The indications included rotator cuff insufficiency (twenty-nine), massive rotator cuff disorder with osteoarthritis (eleven), failed primary shoulder arthroplasty (nine), rheumatoid arthritis (six), posttraumatic arthritis (four), and other diagnoses (eight). Forty-five shoulders (67%) had at least one prior surgical intervention, and thirty-one shoulders (46%) had multiple prior surgical procedures. RESULTS: At a mean follow-up time of 36.5 months, mean active forward elevation of the arm as measured at the shoulder improved from 54.6° to 134.0° and average active external rotation improved from 10.0° to 19.6°. A total of 81% of patients were either very satisfied or satisfied. The mean American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) score for pain improved from 40.0 to 72.4 and 7.5 to 3.0, respectively. The ability to achieve postoperative forward arm elevation of at least 100° was the only significant predictor of overall patient satisfaction (p < 0.05) that was identified in this group. There was a 15% complication rate postoperatively, and twenty-nine shoulders (43%) had evidence of scapular notching at the time of the latest follow-up. CONCLUSIONS: RSA as a reconstructive procedure improved function at the time of short-term follow-up in our young patients with glenohumeral arthritis and rotator cuff deficiency. Objective outcomes in our patient cohort were similar to those in previously reported studies. However, overall satisfaction was much lower in this patient population (81%) compared with that in the older patient population as reported in the literature (90% to 96%).

Resection arthroplasty for failed shoulder arthroplasty.

BACKGROUND: As shoulder arthroplasty becomes more common, the number of failed arthroplasties requiring revision is expected to increase. When revision arthroplasty is not feasible, resection arthroplasty has been used in an attempt to restore function and relieve pain. Although outcomes data for resection arthroplasty exist, studies comparing the outcomes after the removal of different primary shoulder arthroplasties have been limited. MATERIALS AND METHODS: This was a retrospective multicenter review of 26 patients who underwent resection arthroplasty for failure of a primary arthroplasty at a mean follow-up of 41.8 months (range, 12-130 months). Resection arthroplasty was performed for 6 failed total shoulder arthroplasties (TSAs), 7 failed hemiarthroplasties, and 13 failed reverse TSAs. RESULTS: Patients who underwent resection arthroplasty demonstrated significant improvement in visual analog scale pain score (6 ± 4 preoperatively to 3 ± 2 postoperatively). Mean active forward flexion and mean active external rotation decreased, but this difference was not significant. Subgroup analysis revealed that postoperative mean active forward flexion was significantly greater in patients undergoing resection arthroplasty after failed TSA than after reverse TSA (P = .01). CONCLUSIONS: Resection arthroplasty is effective in relieving pain, but patients have poor postoperative function. Patients with resection arthroplasty for failed reverse shoulder arthroplasty have worse function than those with failed hemiarthroplasty or TSA. Surgeons should be aware of this when assessing postoperative function. There is no difference in functional outcome between hemiarthroplasty and TSA.

Pectoralis major tendon transfer for the treatment of scapular winging due to long thoracic nerve palsy.

BACKGROUND: Painful scapular winging due to chronic long thoracic nerve (LTN) palsy is a relatively rare disorder that can be difficult to treat. Pectoralis major tendon (PMT) transfer has been shown to be effective in relieving pain, improving cosmesis, and restoring function. However, the available body of literature consists of few, small-cohort studies, and more outcomes data are needed. MATERIALS AND METHODS: Outcomes of 26 consecutive patients with electromyelogram-confirmed LTN palsy who underwent direct (n = 4) or indirect transfer (n = 22) of the PMT for dynamic stabilization of the scapula were reviewed. All patients were followed up clinically for an average of 21.8 months (range, 3-62 months) with evaluations of active forward flexion, active external rotation, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and observation of scapular winging. RESULTS: Preoperative to postoperative results included increases in the mean active forward flexion from 112° to 149° (P < .001) an in mean active external rotation from 53.8° to 62.8° (P = .045), an improvement in the mean ASES score from 28 to 67.0 (P < .001), and an improvement in the mean VAS pain score from 7.7 to 3.0 (P < .001). Recurrent scapular winging occurred in 5 patients. There was no difference in outcome by length of follow-up. CONCLUSIONS: PMT transfer is an effective treatment for painful scapular winging resulting from LTN palsy. This is the largest reported series of consecutive patients treated with PMT transfer for the correction of scapular winging.

All-arthroscopic biologic total shoulder resurfacing.

The treatment of advanced, bipolar glenohumeral osteoarthritis in the young patient is particularly challenging because of the expected failure of a traditional shoulder arthroplasty within the patient's lifetime. We have had early success performing osteochondral allograft resurfacing of the humeral head articular surface and glenoid articular surface, and we describe a new all-arthroscopic technique for performing this procedure. In the context of our new procedure, we have reviewed the available literature on the topic of biologic resurfacing with osteochondral allograft and have provided an overview of the relevant findings. Although only short-term follow-up data are available, our results in young patients have been promising in terms of regained motion, minimal pain, and accelerated rehabilitation. We believe that this new arthroscopic biologic shoulder resurfacing technique has the potential to be superior to other available treatments for this patient population because it preserves bone stock, limits damage to surrounding structures, and allows for early rehabilitation. Although longer-term follow-up is needed, early results have been greatly encouraging.

Reverse total shoulder arthroplasty.

Reverse total shoulder arthroplasty was initially approved for use in rotator cuff arthropathy and well as chronic pseudoparalysis without arthritis in patients who were not appropriate for tendon transfer reconstructions. Traditional surgical options for these patients were limited and functional results were sub-optimal and at times catastrophic. The use of reverse shoulder arthroplasty has been found to effectively restore these patients function and relieve symptoms associated with their disease. The procedure can be done through two approaches, the deltopectoral or the superolateral. Complication rates associated with the use of the prosthesis have ranged from 8-60% with more recent reports trending lower as experienced is gained. Salvage options for a failed reverse shoulder prosthesis are limited and often have significant associated disability. Indications for the use of this prosthesis continue to be evaluated including its use for revision arthroplasty, proximal humeral fracture and tumor. Careful patient selection is essential because of the significant risks associated with the procedure.

Inter- and intraobserver reliability of the clock face representation as used to describe the femoral intercondylar notch.

PURPOSE: To validate the use of the clock face reference as a reliable means of communicating femoral intercondylar notch position. METHODS: A single red mark was made on ten identical left Sawbones femurs in the intercondylar notch at variable locations. Ten surgeons, who routinely perform ACL reconstructions, were presented the femurs in random order and asked to state the position of the mark to the nearest 30-min interval. Responses were recorded and then repeated 3 weeks later. The same 10 surgeons were presented with 30 actual arthroscopic photographs of the intercondylar notch, performed at 90° of knee flexion, with a probe pointing at various locations (10 knees; 3 photographs/knee) along the lateral aspect of the notch. The results were then analyzed with an ICC, Cronbach's alpha test, and descriptive statistics. RESULTS: For the Sawbones, the ICC was 0.996 while individual physician's Cronbach's alpha test ranged from 0.954 to 0.999, indicating a very high interobserver and intraobserver reliability. The mean range of responses among the 10 surgeons was 1.6 h, SD 0.6. For the photographs, the ICC was also high at 0.997. There was a mean range of 1.1 h, SD 0.4, among surgeons. CONCLUSIONS: The clock face method is commonly utilized for both placement of the femoral tunnel during ACL reconstruction as well as describing the location of the ACL femoral tunnel between communicating surgeons. Despite a high statistical interobserver correlation, there is significant range among different surgeons' responses. The present study questions the reliability of the clock face method for use between surgeons as a stand alone tool. Other methods also utilizing anatomic landmarks may be more accurate for describing intercondylar notch anatomy. LEVEL OF EVIDENCE: III.

Timing of wound closure in open fractures based on cultures obtained after debridement.

BACKGROUND: The timing of wound closure in open fractures has remained an inexact science. Numerous recommendations have been made for the management of these injuries regarding the optimal time to perform competent wound closure, with all advice based on subjective parameters. The purpose of this study was to determine the utility of a prospective protocol with use of wound cultures obtained after irrigation and debridement as a guide to the timing of wound closure following an open fracture of an extremity. METHODS: Four hundred and twenty-two open fractures had emergency irrigation and debridement, fracture stabilization, and open wound management. Wound cultures were obtained for aerobic and anaerobic analysis following debridement. At forty-eight hours after debridement, patients were again returned to surgery. If the initial culture results were positive, a repeat irrigation and debridement was carried out, and additional cultures were obtained after debridement. This procedure was repeated, and the wound was not closed until negative culture results were achieved. RESULTS: Of the 422 open fractures, 346 were available for long-term follow-up. The overall deep infection rate was 4.3%. Gustilo Type-II fractures had a deep infection rate of 4%, and Type-III fractures had an infection rate of 5.7%. Type-III fractures demonstrated differences among the fracture patterns within this type, as infection developed in 1.8% of Type-IIIA injuries, 10.6% of Type-IIIB fractures, and 20% of Type-IIIC fractures. Fractures requiring multiple debridement procedures and those in patients with diabetes or an increased body mass index demonstrated higher rates of infection. With the numbers studied, fractures in which the wound was closed in the presence of positive cultures (a protocol breach) did not have a significantly increased risk of deep infection (p = 0.0501). CONCLUSIONS: The use of this standardized protocol was shown to achieve a very low rate of deep infection compared with historical controls. An increased number of irrigation and debridement procedures are required to achieve this improved outcome. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Evaluation of a new spine classification system, does it accurately predict treatment?

STUDY DESIGN: The Thoracolumbar Injury Severity Score (TLISS) was introduced as a novel classifications system. Its aim was to simplify classification of thoracolumbar fractures, grade their severity in an ordinal manner as a guide to management. This study attempted to validate the TLISS as a guide to management. OBJECTIVE: To evaluate the TLISS as a tool for guiding management of thoracolumbar fractures using the outcomes of 97 previously treated spinal fracture. SUMMARY OF BACKGROUND DATA: The TLISS was proposed as a tool for guidance of the management of thoracolumbar fractures to aid the surgeon in choosing management. METHOD: Ninety-seven sequential traumatic thoracolumbar fractures were retrospectively reviewed for their management and outcomes. The presenting clinical information had all personal identifiers removed and the fractures were reevaluated by the treating physician using the TLISS. Eighty-one patients had received management that agreed with the suggested management of the TLISS. Nine patients had a score of 4. Seven patients received management that disagreed with the TLISS. Variables affecting the management that differed from the management suggested by the TLISS were identified in each patient and assessed. RESULT: Of the 97 patients identified, 81 had received management that agreed with the suggested management of the TLISS. Of the 16 remaining patients, 3 patients scored a 3 or less and received an operation, 1 of which, failed conservative management. Four scored a 5 or more and were managed conservatively, none with known failure. Nine patients scored the ambiguous score of 4. Of these, 4 were managed operatively and 5 nonoperatively. CONCLUSIONS: As a management tool, the TLISS seems to consistently suggest treatment consistent with past treatment recommendations. Multilevel contiguous fractures and extension injuries in the ankylosed thoracic spine appear to be the most consistent exceptions to the TLISS guidelines.

Teachability and reliability of a new classification system for lower cervical spinal injuries.

STUDY DESIGN: Reliability and validation study. OBJECTIVE: The objective of this study is to evaluate a new lower cervical spine injury classification system and assess its reliability, teachability, and clinical applications. SUMMARY OF BACKGROUND DATA: The recently proposed Cervical Spine Injury Severity Score (CSISS) morphologically describes lower cervical spine injuries and grades them on a score of 1 to 20 depending on the integrity of the 4 columns that make up the cervical spine. Early data suggests that this classification system is both reliable and reproducible. Reliability data from additional institutions and data exploring teachability of this classification system is not available. METHODS: Fifteen subjects (12 residents and 3 attendings trained in the management of spinal trauma) reviewed radiographs and CT scans of 50 patients and scored them according to the CSISS. Six residents scored the patients 1 month before an instructional lecture given by the senior author and then again immediately following the lecture to assess teachability of the new classification system. All subjects then reviewed the films a final time 1 month later to assess both intraobserver and interobserver reliability. The patients' scores were also analyzed in conjunction with their clinical treatment. RESULTS: Interobserver reliability overall was excellent (0.975) with junior residents performing similarly to those with more extensive training. Intraobserver reliability was also excellent overall (0.983). Teachability scores improved in the ability to score all 4 columns. Furthermore, this classification system was a fair overall predictor of surgical candidates as a score of 7 predicted 19 out of 26 surgical patients (76% sensitivity, 100% specificity). CONCLUSION: The CSISS is a useful new adjunct in the treatment and classification of lower cervical spine injuries. The system is reliable, reproducible, and teachable. It is clinically useful for all levels of orthopedic training and experience.

Comparative reliability of 3 thoracolumbar fracture classification systems.

STUDY DESIGN: Prospective study of 3 spine surgeons, 3 spine fellows, 3 nonspine orthopedists, and 12 orthopedic residents classifying 97 thoracolumbar fractures using the Denis, Association for Osteosynthesis (AO), and Thoracolumbar Injury Severity Score (TLISS) systems and reclassifying them 3 months later. OBJECTIVE: To compare the reliability of the Denis, AO, and TLISS classification systems and evaluate the skills necessary for their use. SUMMARY OF BACKGROUND DATA: The Denis and AO systems are the traditional methods of classification of thoracolumbar fractures. The purpose of this study was to evaluate a novel classification system, the TLISS and compare its reliability among observers as compared with the Denis and AO classifications. METHOD: Ninety-seven sequential fractures from 1 surgeon's practice at a level 1 trauma center were collected. Twenty-one orthopedic physicians from two area level 1 trauma centers then completed the evaluation of the all fractures. Evaluator experience included staff, spine fellows, and residents. The interobserver and intraobserver reliability were determined. RESULT: In the TLISS, subgroups of evaluators, showed variation in reliability as expected with the highest reliability occurring in the senior resident group and attending spine surgeon group. The lowest reliabilities were in the nonspine attending orthopedists and junior residents. In each group, the neurologic status was consistently the category with the highest interobserver and intraobserver reliability. In the Denis and AO classifications, the highest reliabilities were again in the senior residents and spine attendings. The lowest were again in the nonspine attendings and junior residents. CONCLUSIONS: As a management tool, the TLISS seems to be an acceptably reliable system when compared with the Denis and AO systems. There is a base level of knowledge and familiarity necessary for the application of the system at reliable levels.

Atypical anterior wall fracture of the acetabulum: case series of anterior acetabular rim fracture without involvement of the pelvic brim.

OBJECTIVES: The purpose of this study was to describe a form of anterior wall acetabular fracture, which has been inadequately defined in the literature. DESIGN: Retrospective analysis of consecutive patients. SETTING: Level 1 trauma center. PATIENTS: A retrospective analysis of consecutive acetabulum patients treated by a single surgeon between 1999 and 2005 identified 6 patients with a form of anterior wall fracture without involvement of the pelvic brim. All fractures were treated operatively. INTERVENTION: Open reduction and internal fixation through an anterior surgical approach. MAIN OUTCOME MEASUREMENTS: Final radiographic appearance and modified Merle d'Aubigne score. RESULTS: All 6 cases demonstrated characteristics of an atypical fracture of the anterior wall, involving the anterior rim of the acetabulum similar in nature to those described for the posterior wall, rather than the standard anterior wall fracture type described by Letournel. Of the 6 cases that were identified, 5 had follow-up 1 year or greater with a mean modified Merle d'Aubigne Score of 17 (range: 17-18). CONCLUSION: A form of anterior wall acetabular fracture exists, which involves the anterior acetabular rim without involvement of the pelvic brim. It can occur in young patients with high-energy mechanisms of injury, as well as in the elderly with low-energy trauma. With appropriate surgical management, using a modified Smith-Peterson approach, good to excellent clinical outcomes should be expected.