Comparing the Use of Axillary Radiographs and Axial Computed Tomography Scans to Predict Concentric Glenoid Wear.

BACKGROUND: Axillary radiographs traditionally have been considered sufficient to identify concentric glenoid wear in osteoarthritic shoulders; however, with variable glenoid wear patterns, assessment with use of computed tomography (CT) has been recommended. The purpose of the present study was to compare the use of axillary radiographs and mid-glenoid axial CT scans to identify glenoid wear. METHODS: Preoperative axillary radiographs and mid-glenoid axial CT scans for 330 patients who underwent anatomic total shoulder arthroplasty were reviewed. Five independent examiners with differing levels of experience characterized the glenoid morphology as either concentric or eccentric. The morphologies determined with use of axillary radiographs and CT scans were assessed for correlation, and both intraobserver and interobserver consistency were calculated. RESULTS: Concentric wear identified with use of radiographs was confirmed with use of CT scans in an average of 61% of cases (range, 53% to 76%). Intraobserver consistency averaged 75% for radiographs and 73% for CT scans. There was significant interobserver consistency, as higher levels of training corresponded with greater consistency between imaging analyses (p < 0.001). The most senior observer identified the highest proportion of concentric wear on radiographs (p < 0.001), showed the greatest consistency between attempts when using CT (p < 0.001), and had the greatest agreement of radiographs and CT evaluating glenoid morphology (p < 0.001). CONCLUSIONS: For the experienced shoulder surgeon, concentric glenoid wear identified on axillary radiographs will appear concentric on 2-dimensional CT in approximately 75% of cases. Obtaining a CT scan to confirm glenoid wear patterns most greatly benefits less-experienced surgeons. Across all levels of experience, axillary radiographs and single-slice, mid-glenoid CT scans appear insufficient for consistently predicting wear patterns. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Medial calcar bone resorption after anatomic total shoulder arthroplasty: does it affect outcomes?

BACKGROUND: The incidence of medial calcar resorption has been shown to be common after uncemented total shoulder arthroplasty (TSA). With etiologies including stress shielding, debris-induced osteolysis, and infection, the clinical impact of medial calcar resorption has not been specifically examined. The purpose of this study was to determine whether resorption is associated with inferior outcomes or higher rates of radiographic loosening in TSA patients. METHODS: We conducted a retrospective review of TSA patients with minimum 2-year clinical follow-up. Patient-reported and functional outcome measures were recorded preoperatively and postoperatively. Postoperative radiographs were evaluated for glenoid and humeral component loosening. A new calcar resorption grading system was introduced to quantify the degree of resorption and assess the progression. RESULTS: A total of 171 patients met the inclusion criteria, with average clinical and radiographic follow-up periods of 50 and 46 months, respectively. Calcar resorption was identified in 110 patients (64.3%). No significant overall differences were observed between the patients with and without calcar resorption. Subgroup analysis showed that patients with grade 3 resorption had a higher incidence of glenoid radiolucencies (50%, P = .001) and patients with a progression from grade 1 to grade 3 had higher incidences of glenoid (50%, P = .003) and humeral (9%, P = .039) radiolucencies. CONCLUSION: Medial calcar resorption following TSA with a standard-length press-fit humeral component is common. Overall, no differences in patient-reported outcome measures or radiographic loosening were found compared with patients without calcar resorption. However, grade 3 calcar resorption and more dramatic progression of resorption should raise the suspicion of prosthetic loosening.

Outcomes of anatomic total shoulder arthroplasty in patients with excessive glenoid retroversion: a case-control study.

BACKGROUND: Ideal management of severe glenoid retroversion during anatomic total shoulder arthroplasty (TSA) remains controversial, as previous reports have suggested that severe retroversion may negatively impact clinical outcomes. The purpose of this study was to evaluate the impact of severe glenoid retroversion on clinical and radiographic TSA outcomes using a standard glenoid component, as well as to compare outcomes among patients with less severe retroversion. METHODS: A case-control study was performed comparing 40 patients treated with TSA with more than 20° of glenoid retroversion preoperatively (average follow-up, 53 months) vs. a matched cohort of 80 patients with less than 20° of retroversion (average follow-up, 49 months). In all patients, the surgical technique, implant design, and postoperative rehabilitation protocol were identical. Patients were matched based on sex, age, indication, and prosthetic size. Comparisons were made regarding patient-reported outcome measures (PROMs), motion, postoperative radiographic loosening, and the presence of medial calcar resorption. RESULTS: Preoperatively, both groups demonstrated similar PROMs and measured motion, except for preoperative Single Assessment Numeric Evaluation scores and American Shoulder and Elbow Surgeons total scores, which were higher for the severe retroversion group (44.4 vs. 31.3 [P = .012] and 34.9 vs. 29.4 [P = .048], respectively). Postoperative PROMs and motion were also similar between the 2 cohorts. No significant differences were observed for postoperative radiographic findings. Medial calcar resorption was identified in 74 patients (61.7%). Calcar resorption and individual resorption grades were not found to differ significantly. CONCLUSION: At midterm follow-up, preoperative severe glenoid retroversion does not appear to influence clinical or radiographic outcomes of TSA using a standard glenoid component.

Predicting outstanding results after reverse shoulder arthroplasty using percentage of maximal outcome improvement.

BACKGROUND: The purpose of this study was to determine whether thresholds regarding the percentage of maximal improvement in the Simple Shoulder Test (SST) score and American Shoulder and Elbow Surgeons (ASES) score exist that predict excellent patient satisfaction after reverse shoulder arthroplasty (RSA). METHODS: Patients undergoing RSA with a single implant system were evaluated preoperatively and at a minimum 2-year follow-up. Receiver operating characteristic curve analysis determined thresholds to predict excellent patient satisfaction by evaluating the percentage of maximal improvement for SST and ASES scores. Preoperative factors were analyzed as independent predictors for achieving SST and ASES score thresholds. RESULTS: There were 198 (SST score) and 196 (ASES score) patients who met inclusion criteria. For SST and ASES scores, receiver operating characteristic curve analysis identified 61.3% (P < .001) and 68.2% (P < .001) maximal improvement as the threshold for maximal predictability of excellent satisfaction, respectively. Significant positive correlation between the percentage of maximum score achieved and excellent patient satisfaction for both groups was found (r = 0.440 [P < .001] for SST score; r = 0.417 [P < .001] for ASES score). Surgery on the dominant hand, greater baseline visual analog scale pain score, and cuff arthropathy were independent predictors for achieving the SST and ASES score threshold. CONCLUSION: Thresholds for the achievement of excellent satisfaction after RSA were 61.3% of maximal SST score improvement and 68.3% of maximal ASES score improvement. Independent predictors of achieving these thresholds were dominant-sided surgery and higher baseline visual analog scale pain scores for the SST score and rotator cuff arthropathy for the ASES score.

Lesser tuberosity osteotomy in total shoulder arthroplasty: impact of radiographic healing on outcomes.

BACKGROUND: Lesser tuberosity osteotomy (LTO) has gained popularity in anatomic total shoulder arthroplasty (TSA); however, healing rates have not been universally high. This study examined differences in outcomes based on variations in LTO healing. METHODS: A retrospective review identified primary TSA patients with 2-year minimum follow-up treated with a LTO. Postoperative radiographs classified LTO healing as "bony union," "nondisplaced nonunion," "displaced nonunion," and "not seen," creating 4 cohorts. Comparisons were made among patient-reported outcome measures (PROMs), motion, and radiographic evidence of component loosening. RESULTS: The study cohort consisted of 189 patients who met inclusion criteria, with an average age of 69.5 years (range, 32-89 years) and follow-up of 50 months (range, 24-95 months). There were 143 patients with union, 16 with nondisplaced nonunion, 14 with displaced nonunion, and 16 not seen. There were no differences in preoperative comparisons. All cohorts demonstrated significant improvements in PROMs and ranges of motion; however, the displaced nonunion cohort had no improvement in Single Assessment Numeric Evaluation (0.114) or internal rotation (P = .279). Patients with displaced nonunion had lower postoperative functional scores (Simple Shoulder Test and American Shoulder and Elbow Surgeons scores; P < .01), and higher pain scores (visual analog scale for pain; P < .01). However, 85.7% of patients reported they would have the same procedure again. Simple Shoulder Test (2.5) and American Shoulder and Elbow Surgeons score (37.5) improvements exceeded minimal clinically important difference thresholds for TSA. A higher rate of glenoid gross loosening was present in the displaced nonunion cohort (3 patients [21.4%]; P < .01). There were no cases of loose humeral stems. CONCLUSION: Patients with a displaced nonunion LTO site have lower functional scores and higher pain scores but still achieve substantial clinical improvement and high satisfaction rates.

Case-control comparison of "in-the-groove" and lateral-row arthroscopic biceps tenodesis with concomitant rotator cuff repair.

BACKGROUND: Lateral-row (LR) arthroscopic biceps tenodesis (BT) has been described as a technique using an LR rotator cuff repair (RCR) anchor for biceps fixation. This technique has not been compared with other BT techniques. The purpose of this study was to compare the clinical outcomes of patients undergoing a suprapectoral "in-the-groove" arthroscopic BT and patients treated with an LR tenodesis performed in conjunction with arthroscopic RCR. METHODS: Patients undergoing arthroscopic BT in the setting of an arthroscopic RCR were evaluated preoperatively and at a minimum of 12 months' follow-up. Patients who underwent an in-the-groove BT were matched 1:1 to patients who underwent an LR BT based on age at surgery and size of the rotator cuff tear using the Patte classification. Comparisons made included age, sex, body mass index, patient-reported outcome measures, range of motion, and patient satisfaction. RESULTS: There were 82 patients (41 in each group) who met the inclusion criteria, with an average follow-up period of 33 months and average age of 61 years. By use of the Patte classification, there were 20 matched pairs with stage 1 tears, 11 matched pairs with stage 2 tears, and 10 matched pairs with stage 3 tears. Comparisons of the 2 cohorts revealed no differences in preoperative or postoperative motion, patient-reported outcome measures, or patient satisfaction. Furthermore, no differences were found in overall improvements in motion or outcome measures, as well as overall satisfaction. CONCLUSIONS: Patients undergoing simultaneous RCR and BT demonstrate similar patient-reported and objective outcomes for both LR tenodesis and in-the-groove tenodesis techniques.

Distal Radius Skyline View: How to Prevent Dorsal Cortical Penetration.

Volar locked plating has become a standard treatment for operative stabilization of distal radius fractures. It is assumed that volar plating portends a low risk of extensor tendon irritation and rupture, especially when compared with dorsal plating constructs; however, extensor tendon tenosynovitis and rupture is a well-described complication after volar plating of the distal radius. Dorsal cortical penetration of screws may go unnoticed with traditional intraoperative fluoroscopic techniques and may contribute to extensor tendon irritation. This article presents the authors' experience with an additional fluoroscopic dorsal tangential radiograph helping the surgeon ascertain dorsal screw prominence following volar plate fixation. (Journal of Surgical Orthopaedic Advances.

Obtaining Volar Tilt in Distal Radius Fixation: Use of a Screw as a Proximal Post.

Volar plating of distal radius fractures was introduced as a means to circumvent some of the issues with dorsal-based plating but has been shown not to be a complete panacea, as other advantages and challenges have subsequently been discovered. Careful attention and proper technique must be utilized to restore and maintain volar tilt. This study reports a technique of using a locking screw as a proximal peg to reliably obtain the volar tilt in a simple fashion.