Remplissage Versus Latarjet for Engaging Hill-Sachs Defects Without Substantial Glenoid Bone Loss: A Biomechanical Comparison

Background

Recurrent shoulder instability is commonly associated with Hill-Sachs defects. These defects may engage the glenoid rim, contributing to glenohumeral dislocation. Two treatment options to manage engaging Hill-Sachs defects are the remplissage procedure, which fills the defect with soft tissue, and the Latarjet procedure, which increases glenoid arc length. Little evidence exists to support one over the other.

Questions/purposes

We performed a biomechanical comparison of the remplissage procedure to the traditional Latarjet coracoid transfer for management of engaging Hill-Sachs defects in terms of joint stiffness (resistance to anterior translation), ROM, and frequency of dislocation.

Methods

Eight cadaveric specimens were tested on a shoulder instability simulator. Testing was performed with a 25% Hill-Sachs defect with an intact glenoid and after remplissage and Latarjet procedures. Joint stiffness, internal-external rotation ROM, and frequency of dislocation were assessed. Additionally, horizontal extension ROM was measured in composite glenohumeral abduction.

Results

After remplissage, stiffness increased in adduction with neutral rotation (12.7 ± 3.7 N/mm) relative to the Hill-Sachs defect state (8.7 ± 3.3 N/mm; p = 0.016). The Latarjet procedure did not affect joint stiffness (p = 1.0). Internal-external rotation ROM was reduced in abduction after the Latarjet procedure (49° ± 14°) compared with the Hill-Sachs defect state (69° ± 17°) (p = 0.009). Horizontal extension was reduced after remplissage (16° ± 12°) relative to the Hill-Sachs defect state (34° ± 8°) (p = 0.038). With the numbers available, there was no difference between the procedures in terms of the frequency of dislocation after reconstruction: 84% of specimens (27 of 32 testing scenarios) stabilized after remplissage, while 94% of specimens (30 of 32 testing scenarios) stabilized after the Latarjet procedure.

Conclusions

Both procedures proved effective in reducing the frequency of dislocation in a 25% Hill-Sachs defect model, while neither procedure consistently altered joint stiffness.

Clinical Relevance

In the treatment of shoulder instability with a humeral head bone defect and an intact glenoid rim, this study supports the use of both the remplissage and Latarjet procedures. Clinical studies and larger cadaveric studies powered to detect differences in instability rates are needed to evaluate these procedures in terms of their comparative efficacy at preventing dislocation, as any differences between them seem likely to be small.     

SSRIs for Hot Flashes: A Systematic Review and Meta-Analysis of Randomized Trials

Background

Hot flashes are the most commonly reported vasomotor symptom during the peri- and early post-menopausal period.

Objectives

To systematically review, appraise and summarize the evidence of the impact of different SSRIs on peri-menopausal hot flashes in healthy women in randomized, controlled trials.

Methods

A comprehensive literature search was conducted of MEDLINE?, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Scopus through March 2013. Two independent reviewers selected studies and extracted data. Random effects meta-analysis was used to pool outcomes across studies, and Bayesian mixed treatment methods were used to rank SSRIs in terms of effectiveness.

Results

We included a total of 11 randomized controlled trials with good methodological quality enrolling 2,069 menopausal and post-menopausal women (follow-up 1–9 months, mean age 36–76 years, mean time since menopause 2.3–6.6 years). Compared with placebo, SSRIs were associated with a statistically significant decrease in hot flash frequency (difference in means ?0.93; 95 % CI ?1.46 to ?0.37; I² = 21 %) and severity assessed by various scales (standardized difference in means ?0.34; 95 % CI ?0.59 to ?0.10; I² = 47 %). Adverse events did not differ from placebo. Mixed treatment comparison analysis demonstrated the superiority of escitalopram compared to other SSRIs in terms of efficacy.

Conclusion

SSRI use is associated with modest improvement in the severity and frequency of hot flashes but can also be associated with the typical profile of SSRI adverse effects.     

Predictors of Treatment with Mastectomy, Use of Sentinel Lymph Node Biopsy and Upstaging to Invasive Cancer in Patients Diagnosed with Breast Ductal Carcinoma In situ (DCIS) on Core Biopsy

Background

There are few established indications for sentinel lymph node biopsy (SLNB) in breast ductal carcinoma in situ (DCIS). This study examines factors contributing to the high rate of SLNB in DCIS in Alberta, Canada.

Methods

Patients who underwent definitive surgery from January 2009 to July 2011 for DCIS diagnosed on preoperative core-needle biopsy were identified using a provincial synoptic operative report database (WebSMR). The relationship between baseline patient and tumor characteristics and treatment with total mastectomy (TM), use of SLNB, and upstaging were examined.

Results

There were 394 patients identified in the study cohort. Mean age was 57 years, and average preoperative tumor size was 3 cm. Overall, 148 patients (37.6 %) underwent TM; predictors were preoperative tumor size [odds ratio (OR), 1.92 per 1-cm increase in size; 95 % CI 1.65–2.24] and surgeon. Upstaging to invasive cancer at surgery occurred in 23 %, predicted only by preoperative tumor size (OR 1.14 per 1 cm; 95 % CI 1.03–1.27). SLNB was performed in 306 patients overall (77 %) and 140 of those treated with BCS (61 %). Predictors of SLNB were larger preoperative tumor size (OR 1.55 per 1 cm; 95 % CI 1.18–2.04) and the surgeon. In patients treated with BCS, 3 patients who were upstaged had positive SLNs (>0.2 mm), and no patients with DCIS had a positive SLN.

Conclusions

SLNB use is high in patients undergoing BCS for DCIS. Tumor size and the operating surgeon predicted SLNB use. Despite a 23 % upstaging rate, the rate of clinically significant positive SLNs in patients treated with BCS is low, supporting omission of upfront SLNB.     

Treatment of Failed Allograft Prosthesis Composites Used for Hip Arthroplasty in the Setting of Severe Proximal Femoral Bone Defects

This study assessed failures of allograft prosthesis composites (APC) and revisions with a new APC. Twenty-one patients with failed APC’s after revision hip arthroplasty with severe proximal femoral bone loss underwent revision with a new APC. Causes of failure were aseptic loosening (18 patients), infection (3 patients). Of these 21 APC revisions, two patients failed (after 60, 156 months). The 5 and 10 year survival rates were 83.5% (95% CI, 79–100%, number at risk 12 and 6 accordingly). In addition, two patients had non-union at the host-allograft bone junction and were augmented with bone autograft and plate. These results suggest that failed APCs may be revised to a new APC with a predictable outcome.