Radiographic and clinical comparison of pegged and keeled glenoid components using modern cementing techniques: midterm results of a prospective randomized study.

BACKGROUND: Glenoid component loosening remains a significant issue after anatomic shoulder arthroplasty. Pegged glenoid components have shown better lucency rates than keeled components in the short term; however, midterm to long-term results have not fully been determined. We previously reported early outcomes of the current randomized controlled group of patients, with higher glenoid lucency rates in those with a keeled glenoid. The purpose of this study was to evaluate the radiographic and clinical outcomes of these components at minimum 5-year follow-up. METHODS: Fifty-nine total shoulder arthroplasties were performed in patients with primary glenohumeral osteoarthritis. Patients were randomized to receive either a pegged or keeled glenoid component. Three raters graded radiographic glenoid lucencies. Clinical outcome scores and active mobility outcomes were collected preoperatively and at yearly postoperative appointments. RESULTS: Of the 46 shoulders meeting the inclusion criteria, 38 (82.6%) were available for minimum 5-year radiographic follow-up. After an average of 7.9 years, radiographic lucency was present in 100% of pegged and 91% of keeled components (P = .617). Grade 4 or 5 lucency was present in 44% of pegged and 36% of keeled components (P = .743). There were no differences in clinical outcome scores or active mobility outcomes between shoulders with pegged and keeled components at last follow-up. Within the initial cohort, 20% of the keeled shoulders (6 of 30) and 7% of the pegged shoulders (2 of 29) underwent revision surgery (P = .263). Kaplan-Meier analysis showed no significant difference in survival rates between groups (P = .560). CONCLUSION: At an average 7.9-year follow-up, non-ingrowth, all-polyethylene pegged glenoid implants are equivalent to keeled implants with respect to radiolucency, clinical outcomes, and need for revision surgery.

Financial impact of third-party reimbursement changes for CPT Code 29826: experience of a large group practice.

BACKGROUND: On January 1, 2012, the Centers for Medicare & Medicaid Services converted Current Procedural Terminology (CPT) code 29826 (arthroscopic acromioplasty) from a stand-alone code to an add-on code and reduced the relative value units from 19.58 to 5.24. The goal of this study was to quantify the financial impact of this change on a large single-specialty orthopaedic surgery practice. METHODS: Custom software was used to query the database that harbors billing data for a large single-specialty orthopaedic group. Data were independently generated based on patient identification data and insurance class, and compared between 2011 and 2012. Codes 29826, 29827 (shoulder arthroscopy, rotator cuff repair), 29822 (shoulder arthroscopy, debridement, limited), 29823 (shoulder arthroscopy, debridement, extensive), and 29824 (shoulder arthroscopy, distal claviculectomy) were all searched independently for each year and cross-referenced with each other and all other shoulder codes. Modifier codes for surgical assistants were analyzed separately and subsequently combined with primary surgeon data for financial analysis. This included assessment of surgeon reimbursement per occurrence of code 29826 and surgeon reimbursement by Medicare compared with non-Medicare payers. RESULTS: Code 29826 was used 1536 times in 2011 and 1410 times in 2012 (-2.59% after correcting for all shoulder arthroscopy cases per year). Code 29822 was used significantly more in 2012 both alone (1.45%, p = 0.001) and in total (2.45%), but the use of 29823 did not change (p = 0.17). A combination of three of the five selected codes was used significantly less in 2012 (p < 0.001), while the use of any combination of four codes was used significantly more in 2012 (p < 0.001). Assistant use did not appreciably change between years. Average reimbursement for code 29826 by all payers in 2011 was $456.84 and $441.64 in 2012. Average payment by Medicare was $268.58 in 2011 and $171.02 in 2012 (-36.3%). Medicare paid 54.3% of other payers per case in 2011 and 33.1% of other payers in 2012. CONCLUSIONS: Reimbursement for code 29826 by non-Medicare payers did not decrease dramatically between 2011 and 2012. However, Medicare reimbursement fell substantially.

What went wrong and what was done about it: pitfalls in the treatment of common shoulder surgery.

When performing revision shoulder surgery, it is important that the surgeon understands why the index procedure failed and has a clear plan to address problems in the revision procedure. The most common cause of failure after anterior instability shoulder surgery is a failure to treat the underlying glenoid bone loss. For most defects, a Latarjet transfer can effectively restore anterior glenoid bone stock and restore shoulder stability. Persistent anterior shoulder pain after rotator cuff surgery may be the result of missed biceps pathology. This can be effectively treated via a biceps tenodesis. The most difficult failures to treat after acromioclavicular joint reconstruction surgery are those involving fractures of either the coracoid or the clavicle. Clavicle hook plates can be used as supplemental fixation during the treatment of these fractures to help offload the fracture site and allow healing while restoring stability to the acromioclavicular articulation. A failed hemiarthroplasty for a proximal humeral fracture frequently results when the tuberosities fail to heal correctly. This complication can be avoided by paying close attention to the implant position and the tuberosity fixation. If hemiarthroplasty is unsuccessful, the patient is best treated with conversion to a reverse shoulder arthroplasty.

Glenoid perforation does not affect the short-term outcomes of pegged all-polyethylene implants in total shoulder arthroplasty.

BACKGROUND: The glenoid vault can be perforated during pegged glenoid preparation in total shoulder arthroplasty. The clinical implications of glenoid vault perforation, however, are unknown. The purpose of this study was to determine the effects of perforation of the glenoid during total shoulder arthroplasty on clinical and radiographic outcomes. MATERIALS AND METHODS: Eighteen patients with known intraoperative glenoid perforations were prospectively identified and compared with 34 patients matched by age, gender, diagnosis, and arm dominance during the same period. Patients were evaluated with multiple outcome scores. Radiographs were evaluated for glenoid lucency immediately postoperatively and at final follow-up. RESULTS: Average follow-up was 28.1 months for the perforated group and 31.2 months for the matched controls. Both groups had significant improvements in outcome scores postoperatively. American Shoulder and Elbow Surgeons scores increased from 39.8 to 91.0 (P < .001) in the perforated group and from 36.9 to 82.6 (P < .001) in the control group. Constant scores increased from 24.4 to 77.4 (P < .001) in the perforated group and from 36.9 to 75.6 (P < .001) in the control group. Ninety-four percent of the perforated group and 80% of the matched controls were satisfied or very satisfied with their result (P = .896). The presence and number of perforations were not related to the American Shoulder and Elbow Surgeons score (P = .549), Constant score (P = .154), or radiographic lucency grade (P = .584). CONCLUSIONS: Glenoid perforation during pegged glenoid preparation in total shoulder arthroplasty does not seem to have an adverse effect on clinical or radiographic outcomes at an average of 2 years of follow-up.

Ultrasound evaluation of arthroscopic full-thickness supraspinatus rotator cuff repair: single-row versus double-row suture bridge (transosseous equivalent) fixation. Results of a prospective, randomized study.

BACKGROUND: The purpose of this study was to compare the structural outcomes of a single-row rotator cuff repair and double-row suture bridge fixation after arthroscopic repair of a full-thickness supraspinatus rotator cuff tear. MATERIAL AND METHODS: We evaluated with diagnostic ultrasound a consecutive series of ninety shoulders in ninety patients with full-thickness supraspinatus tears at an average of 10 months (range, 6-12) after operation. A single surgeon at a single hospital performed the repairs. Inclusion criteria were full-thickness supraspinatus tears less than 25 mm in their anterior to posterior dimension. Exclusion criteria were prior operations on the shoulder, partial thickness tears, subscapularis tears, infraspinatus tears, combined supraspinatus and infraspinatus repairs and irreparable supraspinatus tears. Forty-three shoulders were repaired with single-row technique and 47 shoulders with double-row suture bridge technique. Postoperative rehabilitation was identical for both groups. Ultrasound criteria for healed repair included visualization of a tendon with normal thickness and length, and a negative compression test. RESULTS: Eighty-three patients were available for ultrasound examination (40 single-row and 43 suture-bridge). Thirty of 40 patients (75%) with single-row repair demonstrated a healed rotator cuff repair compared to 40/43 (93%) patients with suture-bridge repair (P = .024). CONCLUSION: Arthroscopic double-row suture bridge repair (transosseous equivalent) of an isolated supraspinatus rotator cuff tear resulted in a significantly higher tendon healing rate (as determined by ultrasound examination) when compared to arthroscopic single-row repair.

Femoral neck fracture as the sentinel sign of child abuse in an infant: a case report.

UNLABELLED: Child abuse is a significant problem encountered by orthopedic surgeons in the USA. Fractures are the second most common presentation of physical abuse. In this case report, we present a 5-month-old male infant who initially presented with acute hip pain secondary to a femoral neck fracture as a result of abuse. The patient was taken to the operating room for open reduction and pinning of the femoral neck fracture. Further investigation found evidence of fractures of the bilateral femur and fibula at various stages of healing. To our knowledge, a femoral neck fracture in a nonambulatory infant resulting from abuse has not been reported previously. Physicians treating these injuries should consider child abuse in their differential diagnosis when presented with this clinical scenario. LEVEL OF EVIDENCE: Level IV.

Management of ankle syndesmosis injuries in the athlete.

Syndesmotic injuries or high ankle sprains in athletes can occur in elite and recreational athletes. They typically require a longer recovery and a significant delay in return to play compared with routine ankle sprains. Avoiding a misdiagnosis is important and is dependent on being aware of the mechanism of injury, a thorough physical examination, and careful interpretation of imaging studies. Management is guided by the severity of injury and the demands of the athlete. Many mild or stable injuries can be treated nonoperatively; however, acute surgical repair or stabilization in high-grade injuries can provide excellent results and an earlier return to play in selected cases.

Rupture of the flexor pollicis longus tendon after volar fixed-angle plating of a distal radius fracture: a case report.

We report a case of complete rupture of the flexor pollicis longus tendon 13 months after volar fixed-angle plating of a distal radius fracture. Tendon disruption was associated with a prominent distal volar lip of the plate. The plate was placed at the volar distal lip of the radius, at the location recommended by the manufacturer. Most previous reports of flexor tendon ruptures after volar plating of distal radius fractures have been in improperly placed plates, custom-made plates that were later taken off the market, or in physiologically abnormal tendons. This may be a unique case of flexor pollicis longus rupture with a currently commercially available volar fixed-angle plate, placed at the site recommended by the manufacturer, in a patient without other predisposition to tendon rupture.