Uncemented Reverse Total Shoulder Arthroplasty as Initial Treatment for Comminuted Proximal Humerus Fractures.

OBJECTIVES: To determine whether uncemented implants would provide similar outcomes while avoiding the complications associated with cement in the treatment of elderly patients with proximal humerus fractures (PHFs) with primary reverse total shoulder arthroplasty (RTSA). DESIGN: Case series. SETTING: A single Level I trauma center. PATIENTS/PARTICIPANTS: A prospectively obtained cohort of 30 patients who underwent uncemented RTSA as initial treatment for a comminuted PHF: 4 male, 26 female; average age 71 ± 11 years. INTERVENTION: Uncemented RTSA. MAIN OUTCOME MEASURES: (1) Radiographic analysis, (2) postoperative clinical range of motion, and (3) functional outcome scores: the American Shoulder and Elbow Surgeons Shoulder score and the Simple Shoulder Test score. RESULTS: Radiographic analysis showed 97% achieved stable humeral stem fixation and 70% had healing of the tuberosities in anatomical position. Average range of motion was 130 ± 31 degrees of forward flexion, 32 ± 18 degrees of external rotation, and internal rotation to the midlumbar spine. Average American Shoulder and Elbow Surgeons Shoulder score was 82.0 ± 13.5 (with an average pain rating of 0.8 ± 1.3), and average Simple Shoulder Test score was 69.4% ± 19.1%. CONCLUSIONS: Our data show that treatment of comminuted PHFs in elderly patients with uncemented RTSA can consistently produce good clinical outcomes with a low rate of complications and suggest that cement may not be necessary for RTSA in the trauma setting. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Influence of Body Mass Index on Clinical Outcomes in Reverse Total Shoulder Arthroplasty.

The purpose of this study was to compare reverse total shoulder arthroplasty (RTSA) outcomes in normal weight, overweight, and obese patients. A RTSA outcomes registry was reviewed for rotator cuff-deficient patients with a minimum 2-year follow-up. Fractures, rheumatoid arthritis, and revisions were excluded. Based on World Health Organization body mass index (BMI) classification, there were 29 normal weight, 50 overweight, and 51 obese patients. All groups demonstrated significant improvements from preoperative to most recent follow-up in function scores, pain, and forward elevation. Obese and overweight groups had significantly worse preoperative rotation than the normal weight group. Postoperatively, there was no significant difference in absolute values or degree of improvement of rotation between groups. There was no significant difference in the incidence of radiographic or clinical complications between groups. Results of this study suggest that BMI has little influence on outcomes or risk of complication following RTSA. Longer-term studies are needed to determine if these results are maintained. (Journal of Surgical Orthopaedic Advances.

Preoperative deltoid size and fatty infiltration of the deltoid and rotator cuff correlate to outcomes after reverse total shoulder arthroplasty.

BACKGROUND: Reverse total shoulder arthroplasty (RTSA) allows the deltoid to substitute for the nonfunctioning rotator cuff. To date, it is unknown whether preoperative deltoid and rotator cuff parameters correlate with clinical outcomes. QUESTIONS/PURPOSES: We asked whether associations exist between 2-year postoperative results (ROM, strength, and outcomes scores) and preoperative (1) deltoid size; (2) fatty infiltration of the deltoid; and/or (3) fatty infiltration of the rotator cuff. METHODS: A prospective RTSA registry was reviewed for patients with cuff tear arthropathy or massive rotator cuff tears, minimum 2-year followup, and preoperative shoulder MRI. Final analysis included 30 patients (average age, 71±10 years; eight males, 22 females). Only a small proportion of patients who received an RTSA at our center met inclusion and minimum followup requirements (30 of 222; 14%); however, these patients were found to be similar at baseline to the overall group of patients who underwent surgery in terms of age, gender, and preoperative outcomes scores. The cross-sectional area of the anterior, middle, and posterior deltoid was measured on axial proton density-weighted MRI. Fatty infiltration of the deltoid, supraspinatus, infraspinatus, teres minor, and subscapularis were quantitatively assessed on sagittal T1-weighted MR images. Patients were followed for Constant-Murley score, American Shoulder and Elbow Surgeons (ASES) scores, subjective shoulder value, pain, ROM, and strength. Correlations of muscle parameters with all outcomes measures were calculated. RESULTS: Preoperative deltoid size correlated positively with postoperative Constant-Murley score (67.27±13.07) (ρ=0.432, p=0.017), ASES (82.64±14.25) (ρ=0.377; p=0.40), subjective shoulder value (82.67±17.89) (ρ=0.427; p=0.019), and strength (3.72 pounds±2.99 pounds) (ρ=0.454; p=0.015). Quantitative deltoid fatty infiltration (7.91%±4.32%) correlated with decreased postoperative ASES scores (ρ=-0.401; p=0.047). Quantitative fatty infiltration of the infraspinatus (30.47%±15.01%) correlated with decreased postoperative external rotation (34.13°±16.80°) (ρ=-0.494; p=0.037). CONCLUSIONS: Larger preoperative deltoid size correlates with improved validated outcomes scores, whereas fatty infiltration of the deltoid and infraspinatus may have deleterious effects on validated outcomes scores and ROM after RTSA. The current study is a preliminary exploration of this topic; future studies should include prospective enrollment and standardized MRI with a multivariate statistical approach. Quantitative information attained from preoperative imaging not only holds diagnostic value, but, should future studies confirm our findings, also might provide prognostic value. This information may prove beneficial in preoperative patient counseling and might aid preoperative and postoperative decision-making by identifying subpopulations of patients who may benefit by therapy aimed at improving muscle properties. LEVEL OF EVIDENCE: Level III, prognostic study.

Clinical and radiographic results of cementless reverse total shoulder arthroplasty: a comparative study with 2 to 5 years of follow-up.

BACKGROUND: Most studies of reverse total shoulder arthroplasty (RTSA) involve cemented humeral stems. To our knowledge, this is the first study to compare the results of cementless RTSA, using a porous-coated stem designed for uncemented fixation, with cemented RTSA. METHODS: A prospective database of patients undergoing RTSA was retrospectively reviewed for patients with a diagnosis of cuff tear arthropathy or severe rotator cuff deficiency with minimum 2-year follow-up. Of these, 37 patients had cemented RTSA and 64 patients had cementless RTSA. Outcome measures included Constant-Murley scores, American Shoulder and Elbow Surgeons scores, visual analog pain scale scores, range of motion, patient satisfaction, and radiographic evidence of complication. RESULTS: Compared with preoperative values, both cohorts demonstrated significant improvements (P < .01) in all functional scores, active forward elevation, and active internal rotation. There was no significant difference (P > .05) in comparing the changes in these values after surgery between the cemented and cementless cohorts. On radiographic evaluation, there was no evidence of loosening or humeral components "at risk" of loosening in either group. There was no significant difference (P = 1.0) in the incidence of humeral component radiolucent lines between the cemented and uncemented cohorts. There was no significant difference (P = .30) in the incidence of scapular notching between the cemented (n = 8) and uncemented (n = 10) cohorts. CONCLUSION: Cementless fixation of a porous-coated RTSA humeral stem provides clinical and radiographic outcomes equivalent to those of cemented stems at minimum 2-year follow-up. With advantages such as simplified operative technique, no cement-related complications, greater ease of revision, and long-lasting biologic fixation, uncemented fixation may provide several benefits over cemented fixation.

T1ρ magnetic resonance imaging for detection of early cartilage changes in knees of asymptomatic collegiate female impact and nonimpact athletes.

OBJECTIVE: To determine if T1ρ magnetic resonance imaging (T1ρ MRI) could assess early articular cartilage changes in knees of asymptomatic female collegiate athletes. It was hypothesized that impact cohort would demonstrate greater changes than nonimpact cohort. DESIGN: An institutional review board-approved prospective cohort study. Blinded MRI analyses. SETTING: Participants from collegiate athletic program. Imaging at university hospital, February 2008 to July 2009. PARTICIPANTS: Inclusion criteria were female collegiate athletes in athletic season and asymptomatic. Exclusion criteria were previous/current knee injuries/surgeries. Twenty-one female NCAA Division I athletes, 11 impact (basketball players) and 10 nonimpact (swimmers) participants were consented and imaged with 3.0-T MRI (Siemens) and T1ρ sequence (University of Pennsylvania). One patient was removed (injury diagnosis). Final roster was 10 impact and 10 nonimpact participants. No difference in cohort body mass index, height, or weight. MAIN OUTCOME MEASURES: Average T1ρ relaxation times (ART) for patellar and femoral cartilage to analyze defined regions and depth and modified International Cartilage Repair Society classification. RESULTS: Statistical analyses showed that ART of radial zone of central third weight-bearing region of cartilage in basketball players was significantly greater (P = 0.041) than swimmers and ART of the superficial zone in basketball players was significantly less (P = 0.003) than that of swimmers. For both groups, the ART of superficial zones were significantly greater than that of radial zones (P < 0.001). Four impact athletes showed macroscopic changes (none in nonimpact cohort). CONCLUSIONS: T1ρ MRI detected early changes in articular cartilage of asymptomatic collegiate female impact athletes, with significant differences between cohorts in radial zone of central third weight-bearing region and superficial zones ART. Both cohorts showed increased ART in superficial zone. Four impact athletes showed macroscopic changes. CLINICAL RELEVANCE: This study demonstrates a quantitative MRI sequence able to detect signal differences in articular cartilage in asymptomatic athletes.

Paralabral cysts of the hip: sonographic evaluation with magnetic resonance arthrographic correlation.

This retrospective study demonstrates the sonographic appearance paralabral cysts of the hip with magnetic resonance (MR) arthrography as the reference standard. Consensus review by 2 musculoskeletal radiologists was used to assess the paralabral cysts and determine their characteristics. The 3 paralabral cysts seen on sonography and confirmed with MR arthrography in this study were anechoic or hypoechoic, lobulated, and filled with contrast on MR imaging. A labral tear was also noted in all cases on both sonography and MR arthrography. Sonographic assessment for an anterior hip paralabral cyst and labral tear may be of diagnostic benefit.

Normal MR imaging anatomy of the thigh and leg.

Magnetic resonance (MR) imaging is the modality of choice for evaluating the soft tissues of the thigh and leg because of its superior soft tissue contrast resolution, multiplanar imaging capability, and lack of ionizing radiation. The superb image quality facilitates learning normal imaging anatomy, which ultimately forms the foundation of diagnostic interpretation. The purpose of this article is twofold: (1) depict normal MR anatomy throughout the thigh and leg using representative MR images, emphasizing a compartmental approach; and (2) describe and explain the rationale of standard imaging protocols.

Normal MR imaging anatomy of the knee.

Magnetic resonance (MR) imaging is the preferred imaging modality for evaluating internal derangement of the knee, due to its superior soft tissue contrast resolution, multiplanar imaging capability, and lack of ionizing radiation. The superb image quality facilitates learning of normal imaging anatomy and conceptualizing spatial relationships of anatomic structures, leading to improved understanding of pathologic processes, mechanisms of injury, and injury patterns, and ultimately increased diagnostic accuracy. This article depicts normal MR imaging anatomy and commonly encountered anatomic variants using representative MR images of the knee, and describes and explains the rationale of routine knee MR imaging protocol.

Normal magnetic resonance imaging anatomy of the ankle & foot.

This article discusses anatomic relationships, anatomic variants, and MRI protocols that pertain to the foot and ankle. MR images with detailed anatomic description form the cornerstone of this article. The superb image quality will facilitate learning normal imaging anatomy, as well as conceptualizing spatial relationships of anatomic structures.