Anatomic vs. reverse shoulder arthroplasty for glenohumeral osteoarthritis with intact rotator cuff: a retrospective comparison of patient-reported outcomes using the systems outcomes database with up to 5-year follow-up

BackgroundThe growing enthusiasm for the use of reverse shoulder arthroplasty (RSA) in the treatment of primary glenohumeral osteoarthritis (GHOA) with an intact rotator cuff is based on data derived from single-center studies with limited generalizability and follow-up. This study compared patient-reported outcomes (PROs) between RSA and total shoulder arthroplasty (TSA) for the treatment of primary GHOA with up to 5-year follow-up and examined temporal trends in the treatment of GHOA between 2012 and 2021.MethodsA retrospective review was performed on patients with primary GHOA undergoing primary arthroplasty surgery from the Surgical Outcomes System global registry between 2012 and 2021. PROs including the American Shoulder and Elbow Surgeons (ASES) score, Single Assessment Numeric Evaluation (SANE) score, and visual analog scale (VAS) for pain were compared between RSA and TSA at 1, 2, and 5 years postoperatively.ResultsA total of 4451 patients were included, with 2693 (60.5%) undergoing TSA and 1758 (39.5%) undergoing RSA. Both RSA and TSA provided clinically excellent outcomes at 1 year postoperatively (ASES: 80.8 ± 17.9 vs. 85.9 ± 15.2, respectively; SANE: 74.8 ± 24.7 vs. 79.5 ± 22.9; VAS pain: 1.3 ± 2.0 vs. 1.1 ± 1.7; all P < .05) that were maintained at 2 years (ASES: 81.3 ± 19.3 vs. 87.3 ± 14.9; SANE: 74.8 ± 26.2 vs. 79.7 ± 24.7; VAS pain: 1.3 ± 2.1 vs. 1.0 ± 1.6; all P < .05) and 5 years (ASES: 81.7 ± 16.5 vs. 86.9 ± 15.3; SANE: 71.6 ± 28.5 vs. 78.2 ± 25.9; VAS pain: 1.0 ± 1.7 vs. 1.0 ± 1.7; all P < .05), with statistical significance favoring TSA. After controlling for age and sex, there was an adjusted difference of 4.5 units in the ASES score favoring TSA (P = .005) at 5 years postoperatively but no differences in adjusted SANE (P = .745) and VAS pain (P = .332) scores. The use of RSA for GHOA grew considerably over time, from representing only 17% of all replacements performed for GHOA in 2012 to nearly half (47%) in 2021 (P < .001).ConclusionRSA as a treatment for GHOA with an intact rotator cuff seems to yield PROs that are largely clinically equivalent to TSA extending to 5 years postoperatively. The observed statistical significance favoring TSA appears to be of marginal clinical benefit based on established minimal clinically important differences and may be a result of the large sample size. Further research using more granular clinical data and examining differences in range of motion and complications is warranted as it may change the value analysis.     

Limited posterolateral surgical approach to the knee for excision of osteoid osteoma

An 18-year-old man suffered four years of undiagnosed knee pain until a CAT scan revealed an epiphyseal osteoid osteoma of the tibia located subchondrally, just medial to the proximal tibiofibular joint. A nidus in this location is not easily accessible, and its proximity to the joint surface raised concerns about damage to the tibial plateau. To facilitate excision of the tumor, cadaveric dissections were performed to develop a limited posterior approach to the proximal, lateral portion of the tibia. The CAT scan was used to calculate the precise dimensions of the tumor and its relation to the posterior tibial cortex and the proximal tibiofibular joint. With the use of the exposure developed in the laboratory and the calculations derived from the CAT scan, the tumor could be excised by removing a single block of bone 15 mm3. Intraoperative radiographs confirmed the presence of the nidus within the excised block of bone. This case report reaffirms the frequent difficulties and tardiness in diagnosing osteoid osteomas and the need to include these tumors in the differential diagnosis of knee pain and epiphyseal lesions. Before CAT scans were used, the working diagnoses were torn meniscus, juvenile rheumatoid arthritis, and bone hemangiomatosis.     

Experience with hemoperfusion for organophosphate poisoning.

OBJECTIVE: To evaluate the usefulness of extracorporeal clearance techniques in the treatment of organophosphate poisoning, particularly hemoperfusion. DESIGN: Retrospective study. SETTING: An ICU of a general hospital. PATIENTS: Ten patients with organophosphate poisoning initially received classic treatment with gastric lavage and washing of the whole skin surface, as well as the administration of cathartics, activated charcoal, atropine, and obidoxime or pralidoxime. All patients underwent one to three hemoperfusions. MEASUREMENTS AND MAIN RESULTS: Plasma insecticide concentrations and cholinesterase activity were determined daily. Two to three biopsies of fat tissue were carried out at 1- to 2-wk intervals. The amount of the insecticide removed during hemoperfusions was also determined. Five patients presented with a prolonged nicotinic syndrome. Two of these patients showed sequelae of delayed neurotoxicity. Another two of the five patients died and the remaining patient recovered without sequelae. In none of the patients could > 0.1% of the total absorbed poison be removed by hemoperfusion. No changes in symptoms were observed after these procedures. Fat tissue concentrations of the insecticide were 20 to 50 times higher than the concentrations in plasma. Atropine decreased the intestinal transit time, and 10 days after poisoning, a powerful cathartic treatment indicated the persistence of gut content, which probably caused prolonged absorption of the toxin. CONCLUSIONS: Extracorporeal cleansing mechanisms did not remove any clinically important amount of insecticide from our patients due to the high lipid solubility of these agents and no changes in symptoms were observed after these methods. The use of atropine decreases bowel peristalsis. Early use of powerful cathartics could avoid protracted absorption of the poison stored in the gut, although the potential benefits of this therapy require confirmation by the performance of prospective, controlled investigations.     

Neurofibroma in a patient with von Recklinghausen's disease seen as a malignant schwannoma. A case report

A rapidly growing, malignant schwannoma occurred in a 46-year-old woman with neurofibromatosis. Computed tomography, isotope bone scan, chest roentgenogram, and angiogram are helpful in determining the local extent and distant spread of such musculoskeletal tumors and are useful in planning appropriate surgical management. A well-planned biopsy, however, is essential to accurately determine the histologic diagnosis of the tumor. Clinical and roentgenographic presentation of some benign lesions may mimic malignant tumors. To confirm the diagnosis of a malignant or benign tumor, it is advisable to examine the musculoskeletal tumor histologically before proceeding with the definitive treatment, even if the clinical presentation strongly suggests malignancy.     

Sexuality in the climacteric years

Menopause is a time of anatomic, physiological and psychological changes that often influence in the sexuality of aging female. Being sexual functioning an important aspect of health and well-being, doctors should have an holistic approach reassuring about the possibility of treating the various symptoms. The central nervous system is an important target for sex steroid hormone; estrogen, progestagens and androgens are able to modulate several brain functions, and receptors for gonadal steroids have been identified in several brain areas. Because there is no test that physicians can make to assess sexual function, taking a sexual history is probably the most important aspect in the diagnostic and treatment of sexual problems. Hormonal transition with decreasing levels of estrogen and testosterone produces clinical effects, so women need to make adjustments for this period of life. Testosterone is an important component of female sexuality, and alterations in its circulating levels play an important role in psychological and sexual changes that occur after menopause. This is the reason why the research in identifying women who have a decrease androgen active should be aimed. Treatment may include education about sexuality and medical management of symptoms or problems interfering with sexual activity. Also treatment implications and the diverse aspects that may influence on sexuality in the climacteric years are discussed.     

Single dipole localization: Some numerical aspects and a practical rejection criterion for the fitted parameters

Summary There have been a number of attempts in the last years to localize the generators of brain electromagnetic activity, considering one current dipole as the source model. Single Dipole Localization (SDL) requires the selection of an optimization algorithm (OA). General aspects related with the selection, implementation and evaluation of some of the OA employed for SDL are discussed in this paper. Specifically the performance of two algorithms, those of Hooke-Jeeves and Levenberg-Marquardt, are tested by simulations. Suggestions for including restrictions to the dipole position and comments about some commonly used measures of the goodness of fit are given. Examples of erroneous implementations of these algorithms are also illustrated. A simple graphic rejection criterion, which can be easily used by inexperienced researchers, is introduced and tested in noisy and noise free simulations.The authors are grateful to Roberto D. Pascual Marqui for programming the Hooke-Jeeves algorithm.