Opioid requirements in primary versus revision reverse shoulder arthroplasty.

PURPOSE: The purpose of this study is to evaluate the inpatient pain medication use of patients who had a revision shoulder arthroplasty procedure performed and compare them to a cohort of patients who had a primary reverse total shoulder arthroplasty (rTSA) performed to determine whether revision shoulder arthroplasty requires more pain medication.. METHODS: A retrospective review was performed on patients undergoing revision arthroplasty (n = 75) and primary rTSA (n = 340). Inpatient medication records were reviewed to tabulate the visual analog pain (VAS) all narcotic medication use, and total morphine equivalent units (MEUs) were calculated for the duration of the inpatient stay. RESULTS: There was no significant difference between groups regarding age, sex, body mass index, Charlson Comorbidity Index, American Society of Anesthesiologists score, preoperative narcotic pain medication use, tobacco use, postoperative VAS scores or hospital length of stay. There were no predictors of total postoperative MEUs identified. Overall, patients in the revision arthroplasty group received significantly less total MEUs than those in the primary rTSA group, 134.96 MEUs vs. 69.79 MEUs, respectively (p < .0005). CONCLUSION: The perceived notion that revision shoulder arthroplasty is more painful may cause providers to be more inclined to increase narcotic use, or use more invasive pain control techniques. Based on these data, we found that revision shoulder arthroplasty did not require an increased opioid requirement, longer length of stay or increase VAS, suggesting that these patients can often be managed similarly to primary rTSA.

Utility of Allograft Talus as a Source for Grafting of Concurrent Humeral and Glenoid Defects Associated With Anterior Glenohumeral Instability: An Anthropometric Analysis.

PURPOSE: To compare morphologic data of the talus using magnetic resonance images with previously reported values of the humeral head and the glenoid as a potential graft source for both the humeral head as well as glenoid reconstruction in the setting of concomitant glenoid and humeral head defects. METHODS: All magnetic resonance images of the ankle were reviewed for assessment of the morphology and variation of the talus among individuals. Patients with post-traumatic, osteoarthritic, or surgical changes to the distal tibia about the mid- or hind- foot, or patients with incomplete medical records were excluded. Radiographic parameters that were measured included the maximum vertical height (MVH), the height to the talar neck, the radius of curvature (ROC) of the talar dome, ROC of the subtalar joint, and the maximum medial-to-lateral width of the talar dome. Demographic data also were collected on each individual. Statistical analysis was performed via a linear regression model with backwards elimination to determine which demographic data correlated most strongly with talar anthropometric values. RESULTS: A total of 82 study patients met inclusion criteria (59 male, 23 female; mean age 40.91 ± 14.69 years). Sex was found have a positive correlation of the following talar dimensions: MVH (P = .039), talar dome ROC (P < .001), and subtalar joint ROC (p = 0.001). Height was the most positive correlation for medial-to-lateral width (P < .001), height to the talar neck (P = .004), and also correlate for MVH (P = .004). Body mass index was found to have multicollinearity and was therefore not used as a variable. CONCLUSIONS: Allograft talus appears to be a viable graft, as demonstrated in this anthropometric study for both reconstruction of the glenoid and humeral head when cases of bipolar glenohumeral bone loss are present. CLINICAL RELEVANCE: This study aims to further evaluate potential allograft donor sites for bipolar lesions.

From Lateral Ankle Sprain to Above-Knee Amputation: A Unique Case Report of Group A Streptococcus Necrotizing Soft-tissue Infection.

INTRODUCTION: Necrotizing fasciitis, also referred to necrotizing soft-tissue infection (NSTI), is an infrequent entity that results in orthopedic consultation. It is a rapidly spreading typically associated with a contaminated wound that spreads rapidly along fascial planes resulting in significant morbidity and mortality. However, it is a rare occurrence that such pathology occurs in an atraumatic fashion, which is without a wound through the skin. CASE REPORT: A 33-year-old female with no significant medical history presented to a walk-in orthopedic clinic with increasing ankle pain after a lateral ankle sprain 2 days prior. Patient denies any fevers, chills, shortness of breath, numbness, tingling, paresthesia, or any additional trauma since the initial ankle sprain. The patient was afebrile, maintaining oxygenation, normotensive, but tachycardic to just over 100. Physical examination was only significant for moderate swelling and ecchymosis about the lateral malleolus. X-rays and venous ultrasound were negative for any associated pathology. After a period of observation, the patient acutely decompensated with a significant increase in pain in the lower leg on passive stretch, an increase in compartment firmness and a worsening tachycardia up to the 120's. The patient was taken emergently for fasciotomies for presumed compartment syndrome. The patient was hemodynamically unstable during the case and transferred to the intensive care unit where she continued to decompensate, requiring multiple vasopressors. The affected extremity became necrotic at the level of the foot and her hemodynamic instability continued, causing a return to the operating room for an emergent guillotine above-knee amputation. The patient progressively stabilized and underwent a formal above-knee amputation 2 days later. Cultures obtained during the second case were positive for Group A Streptococcus. CONCLUSION: This case highlights the variable presentation of NSTIs as well as has having a high index of suspicion to ensure this highly morbid and fatal disease process is diagnosed expeditiously. This case is also unique in that it developed without any obvious wounds and that monomicrobial Group A Streptococcus was the culprit, while most NSTIs are polymicrobial.