Mid-term outcomes after reverse total shoulder arthroplasty with latissimus dorsi transfer.

Background: Reverse total shoulder arthroplasty is a common treatment for patients with rotator cuff arthropathy who have failed a prior rotator cuff repair. Latissimus dorsi transfer can be performed simultaneously to reverse total shoulder arthroplasty for patients with preoperative external rotation deficiency. Current literature is limited with several studies providing functional and pain improvements at short-term follow-up; however, there is a deficit in data regarding mid-term outcomes. The purpose of this study was to evaluate the clinical and radiographic outcomes following reverse total shoulder arthroplasty with latissimus dorsi transfer with mid-term follow-up. We hypothesized significant improvement in external rotation and shoulder functionality for patients with preoperative external rotation lag. Methods: We retrospectively reviewed patients who underwent reverse total shoulder arthroplasty with latissimus dorsi transfer. Preoperative and postoperative changes in range of motion were assessed. American Shoulder and Elbow Surgeon Score and the Simple Shoulder Test were used to evaluate changes in shoulder function while pain scores were assessed using the Visual Analog Scale (VAS). Radiographs were reviewed for rotator cuff arthropathy, fatty infiltration, scapular notching, baseplate loosening, and osteolysis. We reported frequency and mean ± standard deviation for categorical and continuous variables, respectively. Means were compared using the paired Student's t-test and proportions using the Chi-square test. Results: Fifteen patients met the inclusion criteria. The mean age of the cohort was 71.7 ± 8.4 years (range 51.2-87.8 years) with a mean follow-up of 6.3 ± 4.1 years (range 1.0-14.5 years). Reverse total shoulder arthroplasty with latissimus dorsi transfer improved external rotation (-7 ± 21.3° to 38 ± 15.8°; p value = 0.001). There was no statistically significant difference regarding forward flexion (116.3 ± 45.4° to 133.7 ± 14.7°; p value = 0.17) and internal rotation (T12 to L2; p value = 0.57). The procedure led to an increase in American Shoulder and Elbow Surgeon Score scores (37 ± 19 to 62 ± 22; p = 0.005) and Simple Shoulder Test scores (2 ± 2 to 6 ± 3; p value = 0.001) with a significant reduction in Visual Analog Scale scores (5 ± 3 to 2 ± 3; p value = 0.022). The procedure corrected external rotation lag in 10 patients. Radiographically, rotator cuff arthropathy was found to be grade 3 in two patients, grade 4 A in four patients, grade 4B in eight patients, and grade 5 in one patient. On postoperative imaging, scapular notching was found in six patients (40%). Twelve patients had cortical humeral erosion at the site of the latissimus dorsi transfer. Only one patient experienced a shoulder-related complication which was aseptic baseplate loosening and required a revision reverse total shoulder arthroplasty with allograft. Conclusions: In this study, patients undergoing reverse total shoulder arthroplasty with latissimus dorsi transfer experienced improvements in range of motion, functional scores, and pain at mid-term follow-up. The shoulder-related complication rate was low.Level of evidence: IV; Case series.

Long-term follow-up of perianchor cyst formation after rotator cuff repair.

BACKGROUND: Perianchor cyst formation (PCF) can occur after arthroscopic rotator cuff repair with poly-L-lactic acid (PLLA) anchors; however, little is known about PCF after all-suture anchor (ASA) use. METHODS: We reviewed patients who underwent double-row arthroscopic rotator cuff repair from 2012 to 2017 with ASAs implanted in the medial row and PLLA anchors in the lateral row. We evaluated PCF (graded on magnetic resonance imaging) and compared physical examination and functional surveys between patients with PCF (WC) and without PCF (WoC) at long-term follow-up. RESULTS: Among twenty-two patients (23 shoulders), 93% of PLLA anchors (vs. 79% ASA) displayed a grade 0 PCF, P = .100. No PLLA anchors had a grade 3 or 4 PCF, compared to 11% of ASAs, P = .158. At a mean postoperative follow-up time of 113 weeks, there was no significant difference between WC and WoC cohorts with regard to range of motion, rotator cuff strength, American Shoulder and Elbow Surgeons survey scores, or retear rates. However, the WoC cohort had a significantly higher University of California at Los Angeles shoulder survey score at final follow-up (34.3 WoC vs. 30.9 WC, P = .024). CONCLUSION: No difference was found in PCF between ASAs and PLLA anchors. At long-term follow-up, WoC patients had significantly improved functional outcome scores, based on the University of California at Los Angeles survey, but equivalent range of motion and rotator cuff strength examinations compared with WC patients.

The Top 50 Most-Cited Papers in the Diagnosis and Management of SLAP Tears.

PURPOSE: To identify and characterize the top 50 most-cited articles regarding SLAP tears. METHODS: Referencing the methodology of previous citation analyses, varying Boolean searches were performed using the Web of Science database and the search terms yielding the greatest number of results was used. The top 50 most-cited articles were identified and the following data points were gathered from each article: author, institution, country of origin, year of publication, publishing journal, level of evidence, and citation density. RESULTS: The total number of citations was 7834, with a median of 106 citations. The top 50 list was largely composed of diagnostic level I, II, and III studies (5, 7, and 8 total publications, respectively) and therapeutic level III (6 publications) or level IV (10 publications). Most articles originated from the United States (40). In total, 19 of the top 50 most-cited articles were published in the American Journal of Sports Medicine, followed by Arthroscopy (15) and the Journal of Bone and Joint Surgery (5). CONCLUSIONS: Our analysis demonstrated a correlation with earlier publications being cited more frequently than recent studies. Importantly, the current study found that therapeutic studies in the most cited list were largely level III or level IV evidence. This makes the management of SLAP tears seem anecdotal, with little in the way of high-impact level I or level II therapeutic studies. We must reconsider our current understanding of SLAP tears and their management with more studies that demonstrate a clearer treatment algorithm for these common injuries of the shoulder. CLINICAL RELEVANCE: Given the complexity of SLAP tears, this list of the most-cited articles can provide a reference point to better guide practice, resident education, and future areas of orthopaedic research.

Overview of Metatarsalgia.

Metatarsalgia can be viewed as more of a symptom rather than a distinct diagnosis. Timing of forefoot pain during the gait cycle and evaluation of whether the pain is from anatomic abnormalities, indirect overloading, or iatrogenic causes can suggest a specific metatarsalgia etiology. A thorough physical examination of the lower extremity, especially evaluation of the plantar foot, and weight-bearing radiographs are critical for diagnosis and treatment. Nonoperative treatment consists of physical therapy, orthotics, shoe wear modification, and injections. If conservative treatment fails, surgical options may be considered. [Orthopedics. 2019; 42(1):e138-e143.].

Perception Versus Reality in the Cost of Orthopedic Trauma Implants.

OBJECTIVE: Health care costs are increasing in medicine and in orthopedics. Device choice in orthopedic cases can impact the cost of the procedure and thus result in cost savings. This study aims to determine whether orthopedic attendings and residents accurately estimate device costs they are implanting in trauma cases and whether costs would influence their surgical device selection. DESIGN: Using nationally published average cost data for 13 implants, a survey was distributed at 6 US academic centers. Respondents were asked to select the correct cost from cost ranges. They also answered yes/no questions about their choices regarding published research outcomes for specific fractures. Residents' answers were compared with faculty answers using t tests for each cost estimate question, and chi-square tests for yes/no questions and frequencies. RESULTS: A total of 51 faculty members and 76 residents responded. Attending estimates were closer to the actual cost for most devices. The average total error in cost estimate for all 13 implants was $11,288.36 for residents (35.6% difference) and $10,208.33 for faculty members (32.2% difference). Significantly more faculty members estimated costs within 10% versus residents. When asked if the literature showed differences in outcome when using different implants to treat 4 common fractures, most answered these questions correctly. Further, 71.1% of residents said their choice of implant would change if costs affected physician reimbursements versus 58% for faculty members. CONCLUSIONS: Our data indicate orthopedic physicians are not aware of true implant costs and nearly half of attendings would not consider cost as a factor in deciding between equivalent implants, even if this affected their reimbursement. Most notably, participants showed a poor ability to closely estimate the cost of more expensive implants (actual device cost greater than $2000). Our results suggest that medical cost containment should be stressed to the next generation of surgeons.

Adolescent Shin Pain.

Shin pain is a common complaint in adolescent athletes. The term "shin splints" has historically been applied to these patients. Shin splints, more often than not, refers to a stress reaction of the tibia from overuse. Overuse injuries occur when repetitive microtrauma to the bone exceeds the biologic healing potential. Diagnosis is based on typical history and physical examination findings. Plain radiographs and advanced imaging are rarely necessary but can provide valuable prognostic information. Treatment consists of adequate rest and exercise modification. Time to return to sport depends on injury location and severity. Stress fractures have long-term implications on bone health, so modifiable risk factors should be addressed. It is important for primary care physicians to understand the significance of these injuries. [Pediatr Ann. 2017;46(1):e29-e32.].