Satisfying Outcomes Scores and Survivorship Achieved With Impaction Grafting for Revision THA in Young Patients

Background

The increasing number of total hip arthroplasties (THAs) performed in younger patients will inevitably generate larger numbers of revision procedures for this specific group of patients. Unfortunately, no satisfying revision method with acceptable survivorship 10 years after revision has been described for these patients so far.

Questions/purposes

The purposes of this study were to (1) analyze the clinical outcome; (2) complication rate; (3) survivorship; and (4) radiographic outcome of cemented revision THA performed with impaction bone grafting (IBG) on both the acetabular and femoral sides in one surgery in patients younger than 55 years old.

Methods

During the period 1991 to 2007, 86 complete THA revisions were performed at our institution in patients younger than 55 years. In 34 of these 86 revisions (40%), IBG was used on both the acetabular and femoral sides in 33 patients. Mean patient age at revision surgery was 46.4 years (SD 7.6). No patient was lost to followup, but three patients died during followup. None of the deaths were related to the revision surgery. The mean followup for the surviving hips was 11.7 years (SD 4.6). We also analyzed complication rate.

Results

The mean Harris hip score improved from 55 (SD 18) preoperatively to 80 points (SD 16) at latest followup (p = 0.009). Six hips underwent a rerevision (18%): in four patients, both components were rerevised; and in two hips, only the cup was revised. Patient 10-year survival rate with the endpoint of rerevision for any component for any reason was 87% (95% confidence interval [CI], 67%–95%) and with the endpoint of rerevision for aseptic loosening, the survival rate was 97% (95% CI, 80%–100%). In total six cups were considered radiographically loose, of which four were rerevised. Three stems were radiographically loose, of which none was rerevised.

Conclusions

IBG is a valuable biological revision technique that may restore bone stock in younger patients. Bone stock reconstruction is important, because these patients likely will outlive their revision implants. Bone reconstruction with impaction grafting may facilitate future revisions.

Level of Evidence

Level IV, therapeutic study.     

Conversion of Stemmed Hemi- or Total to Reverse Total Shoulder Arthroplasty: Advantages of a Modular Stem Design

Background

If revision of a failed anatomic hemiarthroplasty or total shoulder arthroplasty is uncertain to preserve or restore satisfactory rotator cuff function, conversion to a reverse total shoulder arthroplasty has become the preferred treatment, at least for elderly patients. However, revision of a well-fixed humeral stem has the potential risk of loss of humeral bone stock, nerve injury, periprosthetic fracture, and malunion or nonunion of a humeral osteotomy with later humeral component loosening.

Questions/purposes

The purposes of this study were to determine whether preservation of a modular stem is associated with (1) less blood loss and operative time; (2) fewer perioperative and postoperative complications, including reoperations and revisions; and/or (3) improved Constant and Murley scores and subjective shoulder values for conversion to a reverse total shoulder arthroplasty compared with stem revision.

Methods

Between 2005 and 2011, 48 hemiarthroplasties and eight total shoulder arthroplasties (total = 56 shoulders; 54 patients) were converted to an Anatomical™ reverse total shoulder arthroplasty system without (n = 13) or with (n = 43) stem exchange. Complications and revisions for all patients were tallied through review of medical and surgical records. The outcomes scores included the Constant and Murley score and the subjective shoulder value. Complete clinical followup was available on 80% of shoulders (43 patients; 45 of 56 procedures, 32 with and 13 without stem exchange) at a minimum of 12 months (mean, 37 months; range, 12–83 months).

Results

Blood loss averaged 485 mL (range, 300–700 mL; SD, 151 mL) and surgical time averaged 118 minutes (range, 90–160 minutes; SD, 21 minutes) without stem exchange and 831 mL (range, 350–2000 mL; SD, 400 mL) and 176 minutes (range, 120–300 minutes; SD, 42 minutes) with stem exchange (p = 0.001). Intraoperative complications (8% versus 30%; odds ratio [OR], 5.2) and reinterventions (8% versus 14%; OR, 1.9) were substantially fewer in patients without stem exchange. The complication rate leading to dropout from the study was substantial in the stem revision group (six patients; 43 shoulders [14%]), but there were no complication-related dropouts in the stem-retaining group. If, however, such complications could be avoided, with the numbers available we detected no difference in the functional outcome between the two groups.

Conclusions

Patients undergoing revision of stemmed hemiarthroplasty or total to reverse total shoulder arthroplasty without stem exchange had less intraoperative blood loss and operative time, fewer intraoperative complications, and fewer revisions than did patients whose index revision procedures included a full stem exchange. Therefore modularity of a shoulder arthroplasty system has substantial advantages if conversion to reverse total shoulder arthroplasty becomes necessary and should be considered as prerequisite for stemmed shoulder arthroplasty systems.

Level of Evidence

Level III, therapeutic study.     

Can the Ream and Run Procedure Improve Glenohumeral Relationships and Function for Shoulders With the Arthritic Triad?

Background

The arthritic triad of glenoid biconcavity, glenoid retroversion, and posterior displacement of the humeral head on the glenoid is associated with an increased risk of failure of total shoulder joint replacement. Although a number of glenohumeral arthroplasty techniques are being used to manage this complex pathology, problems with glenoid component failure remain. In that the ream and run procedure manages arthritic pathoanatomy without a glenoid component, we sought evidence that this procedure can be effective in improving the centering of the humeral head contact on the glenoid and in improving the comfort and function of shoulders with the arthritic triad without the risk of glenoid component failure.

Questions/purposes

We asked, for shoulders with the arthritic triad, whether the ream and run procedure could improve glenohumeral relationships as measured on standardized axillary radiographs and patient-reported shoulder comfort and function as recorded by the Simple Shoulder Test.

Methods

Between January 1, 2006 and December 14, 2011, we performed 531 primary anatomic glenohumeral arthroplasties for arthritis, of which 221 (42%) were ream and run procedures. Of these, 30 shoulders in 30 patients had the ream and run procedure for the arthritic triad and had two years of clinical and radiographic follow-up. These 30 shoulders formed the basis for this case series. The average age of the patients was 56 ± 8 years; all but one were male. Two of the 30 patients requested revision to total shoulder arthroplasty within the first year after their ream and run procedure because of their dissatisfaction with their rehabilitation progress. For the 28 shoulders not having had a revision, we determined on the standardized axillary views before and after surgery the glenoid type, glenoid version (90° minus the angle between the plane of the glenoid face and the plane of the body of the scapula), and location of the humeral contact point with respect to the anteroposterio dimension of the glenoid (the ratio of the distance from the anterior glenoid lip to the contact point divided by the distance between the anterior and posterior glenoid lips). We also recorded the patient’s self-assessed shoulder comfort and function before and after surgery using the 12 questions of the Simple Shoulder Test.

Results

For the 28 unrevised shoulders the mean followup was 3.0 years (range, 2–9.2 years). In these patients, the ream and run procedure resulted in improved centering of the humeral head on the face of the glenoid (preoperative: 75% ± 7% posterior; postoperative: 59% ± 10% posterior; mean difference 16% [95% CI, 13%–19%]; p < 0.001), notably this improved centering was achieved without a significant change in the glenoid version. Patient-reported function was improved (preoperative Simple Shoulder Test: 5 ± 3, postoperative Simple Shoulder Test: 10 ± 4, mean difference 5 [95% CI, 4–6], p < 0.001).

Conclusions

For shoulders with the arthritic triad, the ream and run procedure can provide improvement in humeral centering on the glenoid and in patient-reported shoulder comfort and function without the risk of glenoid component failure. In that ream and run is a new procedure, substantial additional clinical research with long-term follow-up is needed to define specifically the shoulder characteristics, the patient characteristics and the technical details that are most likely to lead to durable improvements in the comfort and function of shoulders with the challenging pathology known as the arthritic triad.

Level of Evidence

Level IV, therapeutic study.     

What is the Best Clinical Test for Assessment of the Teres Minor in Massive Rotator Cuff Tears?

Background

Few studies define the clinical signs to evaluate the integrity of teres minor in patients with massive rotator cuff tears. CT and MRI, with or without an arthrogram, can be limited by image quality, soft tissue density, motion artifact, and interobserver reliability. Additionally, the ill-defined junction between the infraspinatus and teres minor and the larger muscle-to-tendon ratio of the teres minor can contribute to error. Therefore, we wished to determine the validity of clinical testing for teres minor tears.

Question/Purposes

The aim of this study was to determine the accuracy of commonly used clinical signs (external rotation lag sign, drop sign, and the Patte test) for diagnosing the teres minor’s integrity.

Methods

We performed a prospective evaluation of patients referred to our shoulder clinic for massive rotator cuff tears determined by CT arthrograms. The posterosuperior rotator cuff was examined clinically and correlated with CT arthrograms. We assessed interobserver reliability for CT assessment and used three different clinical tests of teres minor function (the external rotation lag sign, drop sign, and the Patte test). One hundred patients with a mean age of 68 years were available for the analysis.

Results

The most accurate test for teres minor dysfunction was an external rotation lag sign greater than 40°, which had a sensitivity of 100% (95% CI, 80%–100%) and a specificity of 92% (95% CI, 84%–96%). External rotation lag signs greater than 10° had a sensitivity of 100% (95% CI, 80%–100%) and a specificity of 51% (95% CI, 40%–61%). The Patte sign had a sensitivity of 93% (95% CI, 70%–99%) and a specificity of 72% (95% CI, 61%–80%). The drop sign had a sensitivity of 87% (95% CI, 62%–96%) and a specificity of 88% (95% CI, 80%–93%). An external rotation lag sign greater than 40° was more specific than an external rotation lag sign greater than 10° (p < 0.001), and a Patte sign (p < 0.001), but was not more specific than the drop sign (p < 0.47). There was poor correlation between involvement of the teres minor and loss of active external rotation.

Conclusions

Clinical signs can predict anatomic patterns of teres minor dysfunction with good accuracy in patients with massive rotator cuff tears. This study showed that the most accurate test for teres minor dysfunction is an external rotation lag sign and that most patients’ posterior rotator cuff tears do not lose active external rotation. Because imaging is not always accurate, examination for integrity of the teres minor is important because it may be one of the most important variables affecting the outcome of reverse shoulder arthroplasty for massive rotator cuff tears, and the functional effects of tears in this muscle on day to day activities can be significant. Additionally, teres minor integrity affects the outcomes of tendon transfers, therefore knowledge of its condition is important in planning repairs.

Level of Evidence

Level III, diagnostic study.     

Implant Design Variations in Reverse Total Shoulder Arthroplasty Influence the Required Deltoid Force and Resultant Joint Load

Background

Reverse total shoulder arthroplasty (RTSA) is widely used; however, the effects of RTSA geometric parameters on joint and muscle loading, which strongly influence implant survivorship and long-term function, are not well understood. By investigating these parameters, it should be possible to objectively optimize RTSA design and implantation technique.

Questions/purposes

The purposes of this study were to evaluate the effect of RTSA implant design parameters on (1) the deltoid muscle forces required to produce abduction, and (2) the magnitude of joint load and (3) the loading angle throughout this motion. We also sought to determine how these parameters interacted.

Methods

Seven cadaveric shoulders were tested using a muscle load-driven in vitro simulator to achieve repeatable motions. The effects of three implant parameters—humeral lateralization (0, 5, 10 mm), polyethylene thickness (3, 6, 9 mm), and glenosphere lateralization (0, 5, 10 mm)—were assessed for the three outcomes: deltoid muscle force required to produce abduction, magnitude of joint load, and joint loading angle throughout abduction.

Results

Increasing humeral lateralization decreased deltoid forces required for active abduction (0 mm: 68% ± 8% [95% CI, 60%–76% body weight (BW)]; 10 mm: 65% ± 8% [95% CI, 58%–72 % BW]; p = 0.022). Increasing glenosphere lateralization increased deltoid force (0 mm: 61% ± 8% [95% CI, 55%–68% BW]; 10 mm: 70% ± 11% [95% CI, 60%–81% BW]; p = 0.007) and joint loads (0 mm: 53% ± 8% [95% CI, 46%–61% BW]; 10 mm: 70% ± 10% [95% CI, 61%–79% BW]; p < 0.001). Increasing polyethylene cup thickness increased deltoid force (3 mm: 65% ± 8% [95% CI, 56%–73% BW]; 9 mm: 68% ± 8% [95% CI, 61%–75% BW]; p = 0.03) and joint load (3 mm: 60% ± 8% [95% CI, 53%–67% BW]; 9 mm: 64% ± 10% [95% CI, 56%–72% BW]; p = 0.034).

Conclusions

Humeral lateralization was the only parameter that improved joint and muscle loading, whereas glenosphere lateralization resulted in increased loads. Humeral lateralization may be a useful implant parameter in countering some of the negative effects of glenosphere lateralization, but this should not be considered the sole solution for the negative effects of glenosphere lateralization. Overstuffing the articulation with progressively thicker humeral polyethylene inserts produced some adverse effects on deltoid muscle and joint loading.

Clinical Relevance

This systematic evaluation has determined that glenosphere lateralization produces marked negative effects on loading outcomes; however, the importance of avoiding scapular notching may outweigh these effects. Humeral lateralization’s ability to decrease the effects of glenosphere lateralization was promising but further investigations are required to determine the effects of combined lateralization on functional outcomes including range of motion.     

Presentation of frozen shoulder among diabetic and non-diabetic patients

Objective

The literature is inconsistent regarding the level of pain and disability in frozen shoulder patients with or without diabetes mellitus. The aim of this study is to evaluate some demographic features of frozen shoulder patients and to look into the disparity of information by comparing the level of pain and disability due to frozen shoulder between diabetic and non-diabetic people.

Design

This is a prospective comparative study. People with frozen shoulder attending an outpatient department were selected by consecutive sampling. Disability levels were assessed by the Shoulder Pain & Disability Index (SPADI). Means of pain and disability scores were compared using unpaired t-test.

Results

Among 140 persons with shoulder pain 99 (71.4%) had frozen shoulder. From the participating 40 frozen shoulder patients, 26 (65%) were males and 14 (35%) were females. Seventeen participants (42.5%) were diabetic, two (5%) had impaired glucose tolerance and 21 (52.5%) patients were non-diabetic. Mean disability scores (SPADI) were 51 ± 15.5 in diabetic and 57 ± 16 in non-diabetic persons. The differences in pain and disability level were not statistically significance (respectively, p = 0.24 and p = 0.13 at 95% confidence interval).

Conclusions

No difference was found in level of pain and disability level between frozen shoulder patients with and without diabetes.     

Differential Cytotoxicity of Corticosteroids on Human Mesenchymal Stem Cells

Background

Corticosteroids are a common, short-term, local antiinflammatory and analgesic for treating patients with musculoskeletal disorders. Studies have shown the deleterious effects of corticosteroids on chondrocytes, suggesting a potentiation of degenerative joint disease. Mesenchymal stem cells (MSCs) are the direct progenitors of chondrocytes and other musculoskeletal tissue. Additionally, they serve an important antiinflammatory role, which can combat the chronic inflammatory state that mediates degenerative joint disease. Little is known about how corticosteroids interact with this regenerative and reparative cell population.

Questions/purposes

We asked: (1) Are corticosteroids cytotoxic to MSCs in a dose–response fashion? (2) Is there a differential effect in the level of cytotoxicity to MSCs between commercially available corticosteroid preparations?

Methods

Human MSCs were isolated and cultured from periarticular adipose tissue obtained from 20 patients undergoing primary THA. MSCs were exposed for 60 minutes to one of four commonly used corticosteroid preparations: betamethasone sodium phosphate-betamethasone acetate (6 mg/mL), dexamethasone sodium phosphate (4 mg/mL), methylprednisolone (40 mg/mL), or triamcinolone acetonide (40 mg/mL). Among the four preparations (treatment groups), cells were exposed to increasing concentrations of drugs according to the following titrations of the commercially available preparation: 0.0 (control solution of 1X phosphate buffered saline), 3.125, 6.25, 12.5, 25, 50, 75, and 100 % (undiluted commercial product). Cells were allowed to recover in standard culture media for 24 hours. After the recovery period, cell viability was measured using -(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium (MTS) tetrazolium dye-based cellular viability assay and live-dead cell fluorescent staining. For the MTS assay, measurements were quantified in units of optical density (OD). ANOVA was performed at every experimental steroid concentration. When this global test was statistically significant, all pairwise comparisons were performed at that concentration with p values adjusted by the Tukey method to guard against Type I error.

Results

Exposure to corticosteroids decreased MSC viability in a curvilinear dose–response pattern. For betamethasone, the mean MTS OD at 0% steroid concentration was 1.03 (SD, 0.12) and decreased to 0.00 (SD, 0.00) at 25% steroid concentration. For dexamethasone, the mean MTS OD at 0% steroid concentration was 1.00 (SD, 0.07) and decreased to 0.00 (SD, 0.01) at 100% steroid concentration. For methylprednisolone, the mean MTS OD at 0% steroid concentration was 1.03 (SD, 0.09) and decreased to 0.00 (SD, 0.00) at 100% steroid concentration. For triamcinolone, the mean MTS OD at 0% steroid concentration was 1.02 (SD, 0.09) and decreased to 0.00 (SD, 0.00) at 75% steroid concentration. There were large differences among commercially available preparations, and these differences were present at every concentration. In general, dexamethasone was most gentle on MSCs (average OD by steroid concentration: 0% = 1.00; 3.125% = 0.86; 6.25% = 0.74; 12.5% = 0.53; 25% = 0.30; 50% = 0.20; 75% = 0.09; 100% = 0.00, triamcinolone and methylprednisolone were intermediate (triamcinolone average OD by steroid concentration: 0% = 1.02; 3.125% = 0.82; 6.25% = 0.64; 12.5% = 0.45; 25% = 0.18; 50% = 0.03; 75% = 0.00; 100% = 0.00; methylprednisolone average OD by steroid concentration: 0% = 1.03; 3.125% = 0.74; 6.25% = 0.54; 12.5% = 0.31; 25% = 0.12; 50% = 0.01; 75% = 0.00; 100% = 0.00), and betamethasone was most toxic (average OD by steroid concentration: 0% = 1.03; 3.125% = 0.74; 6.25% = 0.27; 12.5% = 0.02; 25% = 0.00; 50% = 0.00; 75% = 0.00; 100% = 0.00). ANOVA testing showed p values less than 0.0001 at every tested concentration (with the exception of the 0% control solution; p = 0.204) with subsequent pairwise comparisons supporting the relationships described above. The outcomes were maintained after stratifying by age, sex, or indication for THA (osteoarthritis versus avascular necrosis).

Conclusions

Commonly used intraarticular corticosteroids had a dose-dependent, profound, and differential effect on MSCs in this in vitro model, with betamethasone being the most toxic. Further studies are needed to assess if the in vitro effects of these agents translate into similar in vivo outcomes.

Clinical Relevance

Corticosteroids frequently are used by physicians to reduce inflammation in patients with musculoskeletal disorders, but these agents may hinder MSCs’ innate regenerative capacity in exchange for temporary analgesia. Our study suggests that choosing dexamethasone may result in less harmful effects when compared with other injectable steroids.

Electronic supplementary material

The online version of this article (doi:10.1007/s11999-014-3925-y) contains supplementary material, which is available to authorized users.     

The influence of shoulder pain on functional limitation,perceived health,and depressive mood in patients with traumatic paraplegia

Objective

To assess whether functional activity, perceived health, and depressive symptoms differ between individuals with traumatic paraplegia with and without shoulder pain.

Design

Cross sectional and comparative investigation using the unified questionnaire.

Setting

Neural Regeneration and Repair Division unit of Taipei Veterans General Hospital in Taiwan.

Participants

Seventy-six patients with paraplegia (23 with and 53 without shoulder pain) who had experienced spinal cord injury at American Spinal Injury Association Impairment Scale T2 to T12 neurologic level (at least 6 months previously).

Outcome measures

Spinal Cord Independence Measure (SCIM), a single item from the Medical Outcomes Study 36-Item Short-Form Health Survey, and Patient Health Questionnaire-9 (PHQ-9) depression scale.

Results

Shoulder pain was prevalent in 30% patients. Patients with shoulder pain had significantly worse perceived health and greater depressive symptoms than those without. No significant difference was found in functional ability between groups. Greater shoulder pain intensity was related to higher depressive scores (r = 0.278, P = 0.017) and lower self-perceived health scores (r = −0.433, P < 0.001) but not SCIM scores (P = 0.342).

Conclusion

Although shoulder pain was unrelated to functional limitation, it was associated with lower perceived health and higher depressive mood levels.     

Latissimus Dorsi and Teres Major Transfer With Reverse Shoulder Arthroplasty Restores Active Motion and Reduces Pain for Posterosuperior Cuff Dysfunction

Background

In patients with rotator cuff dysfunction, reverse shoulder arthroplasty can restore active forward flexion, but it does not provide a solution for the lack of active external rotation because of infraspinatus and the teres minor dysfunction. A modified L’Episcopo procedure can be performed in the same setting wherein the latissimus dorsi and teres major tendons are transferred to the lateral aspect of proximal humerus in an attempt to restore active external rotation.

Questions/purposes

(1) Do latissimus dorsi and teres major tendon transfers with reverse shoulder arthroplasty improve external rotation function in patients with posterosuperior rotator cuff dysfunction? (2) Do patients experience less pain and have improved outcome scores after surgery? (3) What are the complications associated with reverse shoulder arthroplasty with latissimus dorsi and teres major transfer?

Methods

Between 2007 and 2010, we treated all patients undergoing shoulder arthroplasty who had a profound external rotation lag sign and advanced fatty degeneration of the posterosuperior rotator cuff (infraspinatus plus teres minor) with this approach. A total of 21 patients (mean age 66 years; range, 58–82 years) were treated this way and followed for a minimum of 2 years (range, 26–81 months); none was lost to followup, and all have been seen in the last 5 years. We compared pre- and postoperative ranges of motion, pain, and functional status; scores were drawn from chart review. We also categorized major and minor complications.

Results

Active forward flexion improved from 56° ± 36° to 120° ± 38° (mean difference: 64° [95% confidence interval {CI}, 45°–83°], p < 0.001). Active external rotation with the arm adducted improved from 6° ± 16° to 38° ± 14° (mean difference: 30° [95% CI, 21°–39°], p < 0.001); active external rotation with the arm abducted improved from 19° ± 25° to 74° ± 22° (mean difference: 44° [95% CI, 22°–65°], p < 0.001). Pain visual analog score improved from 8.4 ± 2.3 to 1.7 ± 2.1 (mean difference: −6.9 [95% CI, −8.7 to −5.2], p < 0.001), and Single Assessment Numeric Evaluation score improved from 28% ± 21% to 80% ± 24% (mean difference: 46% [95% CI, 28%–64%], p < 0.001). There were six major complications, five of which were treated operatively. Overall, three patients’ latissimus and teres major transfer failed based on persistent lack of external rotation.

Conclusions

In patients with posterior and superior cuff deficiency, reverse shoulder arthroplasty combined with latissimus dorsi and teres major transfer through a single deltopectoral incision can reliably increase active forward flexion and external rotation. Patients experience pain relief and functional improvement but have a high rate of complications; therefore, we recommend the procedure be limited to patients indicated for reverse who have profound external rotation loss and a high grade of infraspinatus/teres minor fatty atrophy.

Level of Evidence

Level IV, therapeutic study.     

Increased Risk of Periprosthetic Femur Fractures Associated With a Unique Cementless Stem Design

Background

Postoperative periprosthetic femur fractures are an increasing concern after primary total hip arthroplasty (THA). Identifying and understanding predisposing factors are important to mitigating future risk. Femoral stem design may be one such factor.

Questions/purposes

The goals of our study were to compare the (1) frequency of periprosthetic femur fracture and implant survivorship; (2) time to fracture in those patients who experienced periprosthetic femur fracture; and (3) predictive risk factors for periprosthetic femur fracture between a unique stem design with an exaggerated proximal taper angle and other contemporary cementless, proximally fixed, tapered stems.

Methods

We reviewed all hips in which a femoral hip component with a uniquely exaggerated proximal taper angle (ProxiLock) was implanted during primary THA at a single academic institution. That group of patients was compared with a cohort of patients who underwent primary THA during the same time interval (1995–2008) in which any other cementless, proximally fixed, tapered stem design was used. The two groups differed somewhat in terms of sex, age, and body mass index, although these differences were of unclear clinical significance. During the study, 3964 primary THAs were performed using six different designs of cementless, proximally fixed, tapered femoral hip prostheses. There were 736 stems in the ProxiLock (PL) patient group and 3228 stems in the non-ProxiLock (non-PL) group. In general, the stem highlighted in this study became the routine cementless stem used for primary THA for three arthroplasty surgeons without specific patient or radiographic indications. Periprosthetic fractures were identified within each group. The incidence, timing, type, and treatment required for each fracture were analyzed. The Kaplan-Meier method was used to determine study patient survival free of any postoperative fracture. Radiographs and the electronic medical record of each patient who sustained a fracture were reviewed. Followup was comparable between groups at all time points.

Results

The Kaplan-Meier estimate for fracture-free patient survival was worse in the PL group at all time points with survival of 98.4% (range, 97.4%–99.3%), 97.1% (range, 95.9%–98.3%), 95.4% (range, 93.8%–97.0%), and 92.6% (range, 89.6%–95.3%) at 30 days, 1 year, 5 years, and 10 years, respectively, for the PL patient group compared with 99.8% (range, 99.7%–99.9%), 99.6% (range, 99.3%–99.8%), 99.3% (range, 99.0%–99.6%), and 98.4% (range, 97.5%–99.1%) in the non-PL patient group (p < 0.001). Patients in the PL group had increased cumulative probability of both early and late fractures with cumulative probabilities of fracture of 2.5% (range, 1.3%–3.6%) at 90 days and 7.4% (range, 4.7%–10.4%) at 10 years compared with probabilities of 0.3% (range, 0.1%–0.5%) at 90 days and 1.6% (range, 0.8%–2.5%) at 10 years in the non-PL group (p < 0.001). Patients in the PL group had an increased risk of postoperative periprosthetic femur fracture (hazard ratio [HR], 5.6; 95% confidence interval [CI], 3.4–9.1; p < 0.001); fracture requiring reoperation (HR, 8.4; 95% CI, 4.4–15.9); p < 0.001); and fracture requiring stem revision (HR, 9.1; 95% CI, 4.5–18.5; p < 0.001). Age older than 60 years was also a risk factor for fracture (HR, 3.7; 95% CI, 2.1–6.4), but sex, body mass index, and preoperative diagnosis were not predictive.

Conclusions

Hips implanted with an uncemented femoral stem, which has a uniquely exaggerated proximal taper angle, had an increased risk of both early and late postoperative periprosthetic femur fracture. The majority of patients with a fracture underwent reoperation or stem revision. The unique proximal geometry, lack of axial support from the smooth cylindrical distal stem as well as resorption of the hydroxyapatite coating and poor ongrowth with subsequent subsidence may contribute to increased risk of fracture. Although this particular stem has recently been discontinued by the manufacturer, these findings are important in regard to followup care for patients with this stem implanted as well as for future cementless stem design in general.

Level of Evidence

Level III, therapeutic study.     

Cemented Bipolar Hemiarthroplasty Provides Definitive Treatment for Femoral Neck Fractures at 20 Years and Beyond

Background

Displaced femoral neck fractures frequently are treated with bipolar hemiarthroplasties. Despite the frequency with which bipolar hemiarthroplasty is used to treat these fractures, there are few long-term data.

Questions/purposes

We sought to evaluate (1) the cumulative incidence of revision for any reason of bipolar hemiarthroplasties at 20 years, and the proportion of patients who lived more than 20 years who still have the prosthesis in situ from the index arthroplasty, (2) the cumulative incidence of aseptic loosening at 20 years, and (3) the Harris hip score of the surviving patients at long term.

Methods

We performed 376 cemented bipolar hemiarthroplasties for displaced femoral neck fractures in 359 patients between 1976 and 1985. At a minimum of followup of 20 years (mean, 24 years; range, 20–31 years), 339 of 359 patients (94%) were deceased, leaving 20 patients in the study group. Of those, one patient was confirmed to be lost to followup and two others had radiographic followup only. Three hundred fifty-nine patients (99.2%) (376 of the original 379 hips) were followed until death, revision of the hemiarthroplasty, or for at least 20 years (of clinical followup). Bipolar hemiarthroplasty was performed for displaced femoral neck fractures. Cemented fixation was the standard of care between 1976 and 1985 at our institution. The mean age of the patients at the time of surgery was 79 years (range, 60–99 years). The cumulative incidence of revision, estimated with death as a competing risk, and radiographs were evaluated for signs of aseptic loosening by a surgeon not involved in the clinical care of the patients. Clinical function was evaluated with the Harris hip score. The mean age of the patients at the time of surgery was 79 years.

Results

The 20-year cumulative incidence of revision for any reason was 3.5% (95% CI, 1.6%–5.3%). Of the 20 patients who survived more than 20 years, seven had the implant intact. The 20-year cumulative incidence of revision for aseptic loosening was 1.4% (95% CI, 0.2%–2.6%). The mean Harris hip score in patients who were still living and patient who did not have revision surgery was 63 ± 22, however 13 of the 20 patients had undergone revision surgery.

Conclusions

The long-term survivorship of bipolar hemiarthroplasty prostheses used to treat displaced femoral neck fractures in the elderly was high, and the procedure can be considered definitive for the majority of elderly patients with a femoral neck fracture. In this series, 6% (20 patients, 339 of 359) of the patients survived more than 20 years after treatment of a femoral neck fracture with a bipolar hemiarthroplasty. Of those, 35% (seven of 20) survived with their index prosthesis in situ.

Level of Evidence

Level IV, therapeutic study.     

Do Patients With a Failed Metal-on-metal Hip Implant With a Pseudotumor Present Differences in Their Peripheral Blood Lymphocyte Subpopulations?

Background

Early adverse tissue reactions around metal-on-metal (MoM) hip replacements, especially pseudotumors, are a major concern. Because the causes and pathomechanisms of these pseudotumors remain largely unknown, clinical monitoring of patients with MoM bearings is challenging.

Questions/purposes

The purpose of this study was to compare the lymphocyte subpopulations in peripheral blood from patients with a failed MoM hip implant with and without a pseudotumor and patients with a well-functioning MoM hip implant without a pseudotumor. Potential differences in the systemic immune response are expected to reflect local differences in the periprosthetic tissues.

Methods

Consenting patients who underwent a revision of a failed MoM hip implant at The Ottawa Hospital (TOH) from 2011 to 2014, or presented with a well-functioning MoM hip implant for a postoperative clinical followup at TOH from 2012 to 2013, were recruited for this study, unless they met any of the exclusion criteria (including diagnosed conditions that can affect peripheral blood lymphocyte subpopulations). Patients with a failed implant were divided into two groups: those with a pseudotumor (two hip resurfacings and five total hip arthroplasties [THAs]) and those without a pseudotumor (10 hip resurfacings and two THAs). Patients with a well-functioning MoM hip implant (nine resurfacings and three THAs) at 5 or more years postimplantation and who did not have a pseudotumor as demonstrated sonographically served as the control group. Peripheral blood subpopulations of T cells (specifically T helper [Th] and cytotoxic T [Tc]), B cells, natural killer (NK) cells, memory T and B cells as well as type 1 (expressing interferon-γ) and type 2 (expressing interleukin-4) Th and Tc cells were analyzed by flow cytometry after immunostaining. Serum concentrations of cobalt and chromium were measured by inductively coupled plasma-mass spectrometry.

Results

The mean percentages of total memory T cells and, specifically, memory Th and memory Tc cells were lower in patients with a failed MoM hip implant with a pseudotumor than in both patients with a failed implant without a pseudotumor and patients with a well-functioning implant without a pseudotumor (memory Th cells: 29% ± 5% [means ± SD] versus 55% ± 17%, d = 1.8, 95% confidence interval [CI] [1.2, 2.5] and versus 48% ± 14%, d = 1.6, 95% CI [1.0, 2.2], respectively; memory Tc cells: 18% ± 5% versus 45% ± 14%, d = 2.3, 95% CI [1.5, 3.1] and versus 41% ± 12%, d = 2.3, 95% CI [1.5, 3.1], respectively; p < 0.001 in all cases). The mean percentage of memory B cells was also lower in patients with a failed MoM hip implant with a pseudotumor than in patients with a well-functioning implant without a pseudotumor (12% ± 8% versus 29% ± 16%, d = 1.3, 95% CI [0.7, 1.8], p = 0.025). In addition, patients with a failed MoM hip implant with a pseudotumor had overall lower percentages of type 1 Th cells than both patients with a failed implant without a pseudotumor and patients with a well-functioning implant without a pseudotumor (5.5% [4.9%–5.8%] [median with interquartile range] versus 8.7% [6.5%–10.2%], d = 1.4, 95% CI [0.8, 2.0] and versus 9.6% [6.4%–11.1%], d = 1.6, 95% CI [1.0, 2.2], respectively; p ≤ 0.010 in both cases). Finally, serum cobalt concentrations in patients with a failed MoM hip implant with a pseudotumor were overall higher than those in patients with a well-functioning implant without a pseudotumor (5.8 µg/L [2.9–17.0 µg/L] versus 0.9 µg/L [0.6–1.3 µg/L], d = 2.2, 95% CI [1.4, 2.9], p < 0.001).

Conclusions

Overall, results suggest the presence of a type IV hypersensitivity reaction, with a predominance of type 1 Th cells, in patients with a failed MoM hip implant with a pseudotumor.

Clinical Relevance

The lower percentages of memory T cells (specifically Th and Tc) as well as type 1 Th cells in peripheral blood of patients with a failed MoM hip implant with a pseudotumor could potentially become diagnostic biomarkers for the detection of pseudotumors. Although implant design (hip resurfacing or THA) did not seem to affect the results, as suggested by the scatter of the data with respect to this parameter, future studies with additional patients could include the analysis of implant design in addition to correlations with histological analyses of specific Th subsets in periprosthetic tissues.     

Evaluation of content and accessibility of hand fellowship websites

Background

Graduates of general, orthopedic, and plastic surgery residencies utilize web-based resources when applying for hand fellowship training. The purpose of this study was to evaluate the accessibility and content of hand fellowship websites (HFWs).

Methods

Websites of accredited hand surgery fellowships were eligible for study inclusion. HFWs were evaluated for comprehensiveness in the domains of education and recruitment. Website content was correlated with program characteristics via Fisher exact tests.

Results

Fifteen plastic, 65 orthopedic, and 1 general surgery hand fellowships were analyzed. Seventy-four hand fellowships maintained an HFW (91 %). HFWs were not found for 3 plastic and 4 orthopedic hand programs (20 versus 6 %, p = 0.118). HFWs provided only half of all analyzed content (54 %—education and 49 %—recruitment). Orthopedic programs had more education content than plastic surgery programs (55 versus 44 %, p = 0.030). Programs in the South had more education content than programs in the Northeast (63 versus 47 %, p = 0.001), but not more than programs in the West (54 %) or Midwest (55 %). Larger programs with more fellows had greater education content than those with only one fellow (57 versus 49 %, p = 0.042). Programs affiliated with top-ranked medical schools had less education content than lower-ranked schools (48 versus 56 %, p = 0.045). No differences existed in recruitment content between programs.

Conclusions

Most hand surgery fellowships lack readily accessible and comprehensive websites. The paucity of online content suggests HFWs are underutilized as educational resources and future opportunity may exist to optimize these tools.     

Closed retrograde multiple intramedullary Kirschner wires fixation for humeral shaft fractures with the limb flexed over an articulated support

Objective

To evaluate the results of multiple closed intramedullary Kirschner wiring via a supracondylar entry point for humeral shaft fractures.

Patients and methods

The charts of 37 patients with humeral shaft fractures treated with the Hackethal''s technique between January 2007 and December 2011 were reviewed retrospectively. The operation was performed with the patient lying in supine (n = 22) or lateral (n = 15) position. The elbow was flexed over an articulated support with the arm kept in a vertical position. Thirty-three patients were available for final evaluation with a mean follow-up delay of 14 (range, 6–24) months. We were concerned about fracture union, range of motion of the shoulder and the elbow, and complications. Final evaluation used the criteria by Qidwai.

Results

Bone union rate was 94%. Restriction of ranges of motion of the shoulder more than 20° was noticed in two patients due to protruding wires. Three patients developed limitation of elbow extension owing to backing out of the wires. The overall results were excellent (n = 26; 79%), good (n = 4; 12%), and poor (n = 3; 9%).

Conclusion

Closed Hackethal''s technique using K-wires gives satisfactory results in terms of bone union and elbow and shoulder function in selected humeral shaft fractures. The articulated support precludes the transolecranon traction.     

What Is the Rerevision Rate After Revising a Hip Resurfacing Arthroplasty? Analysis From the AOANJRR

Background

More than 15,000 primary hip resurfacing arthroplasties have been recorded by the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) with 884 primary procedures requiring revision for reasons other than infection, a cumulative percent revision rate at 12 years of 11%. However, few studies have reported the survivorship of these revision procedures.

Questions/purposes

(1) What is the cumulative percent rerevision rate for revision procedures for failed hip resurfacings? (2) Is there a difference in rerevision rate among different types of revision or bearing surfaces?

Methods

The AOANJRR collects data on all primary and revision hip joint arthroplasties performed in Australia and after verification against health department data, checking of unmatched procedures, and subsequent retrieval of unreported procedures is able to obtain an almost complete data set relating to hip arthroplasty in Australia. Revision procedures are linked to the known primary hip arthroplasty. There were 15,360 primary resurfacing hip arthroplasties recorded of which 884 had undergone revision and this was the cohort available to study. The types of revisions were acetabular only, femoral only, or revision of both acetabular and femoral components. With the exception of the acetabular-only revisions, all revisions converted hip resurfacing arthroplasties to conventional (stemmed) total hip arthroplasties (THAs). All initial revisions for infection were excluded. The survivorship of the different types of revisions and that of the different bearing surfaces used were estimated using the Kaplan-Meier method and compared using Cox proportional hazard models. Cumulative percent revision was calculated by determining the complement of the Kaplan-Meier survivorship function at that time multiplied by 100.

Results

Of the 884 revisions recorded, 102 underwent further revision, a cumulative percent rerevision at 10 years of 26% (95% confidence interval, 19.6–33.5). There was no difference in the rate of rerevision between acetabular revision and combined femoral and acetabular revision (hazard ratio [HR], 1.06 [0.47–2], p = 0.888), femoral revision and combined femoral and acetabular revision (HR, 1.00 [0.65–2], p = 0.987), and acetabular revision and femoral revision (HR, 1.06 [0.47–2], p = 0.893). There was no difference in the rate of rerevision when comparing different bearing surfaces (metal-on-metal versus ceramic-on-ceramic HR, 0.46 [0.16–1.29], p = 0.141; metal-on-metal versus ceramic-on-crosslinked polyethylene HR, 0.51 [0.15–1.76], p = 0.285; metal-on-metal versus metal-on-crosslinked polyethylene HR, 0.62 [0.20–1.89], p = 0.399; and metal-on-metal versus oxinium-on-crosslinked polyethylene HR, 0.53 [0.14–2.05], p = 0.356).

Conclusions

Revision of a primary hip resurfacing arthroplasty is associated with a high risk of rerevision. This study may help surgeons guide their patients about the outcomes in the longer term after the first revision of hip resurfacing arthroplasty.

Level of Evidence

Level III, therapeutic study.     

Do Current Recommendations for Upper Instrumented Vertebra Predict Shoulder Imbalance? An Attempted Validation of Level Selection for Adolescent Idiopathic Scoliosis

Background

Shoulder balance for adolescent idiopathic scoliosis (AIS) patients is associated with patient satisfaction and self-image. However, few validated systems exist for selecting the upper instrumented vertebra (UIV) post-surgical shoulder balance.

Questions/Purposes

The purpose is to examine the existing UIV selection criteria and correlate with post-surgical shoulder balance in AIS patients.

Methods

Patients who underwent spinal fusion at age 10–18 years for AIS over a 6-year period were reviewed. All patients with a minimum of 1-year radiographic follow-up were included. Imbalance was determined to be radiographic shoulder height |RSH| ≥ 15 mm at latest follow-up. Three UIV selection methods were considered: Lenke, Ilharreborde, and Trobisch. A recommended UIV was determined using each method from pre-surgical radiographs. The recommended UIV for each method was compared to the actual UIV instrumented for all three methods; concordance between these levels was defined as “Correct” UIV selection, and discordance was defined as “Incorrect” selection.

Results

One hundred seventy-one patients were included with 2.3 ± 1.1 year follow-up. For all methods, “Correct” UIV selection resulted in more shoulder imbalance than “Incorrect” UIV selection. Overall shoulder imbalance incidence was improved from 31.0% (53/171) to 15.2% (26/171). New shoulder imbalance incidence for patients with previously level shoulders was 8.8%.

Conclusions

We could not identify a set of UIV selection criteria that accurately predicted post-surgical shoulder balance. Further validated measures are needed in this area. The complexity of proximal thoracic curve correction is underscored in a case example, where shoulder imbalance occurred despite “Correct” UIV selection by all methods.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9451-y) contains supplementary material, which is available to authorized users.     

Revision knee arthroplasty with a rotating-hinge design in elderly patients with instability following total knee arthroplasty

Background

Revision knee arthroplasty with a rotating-hinge design could be an option for the treatment of instability following total knee arthroplasty (TKA) in elderly patients.

Purpose

To evaluate the clinical and radiographic results of revision arthroplasties in TKAs with instability using a rotating-hinge design in elderly patients.

Methods

We retrospectively reviewed 96 rotating-hinge arthroplasties. The average age of the patients was 79 years (range, 75–86 years); the minimum follow-up was 5 years (mean, 7.3 years; range, 5–10 years). Patients were evaluated clinically (Knee Society score) and radiographically (position of prosthetic components, signs of loosening, bone loss).

Results

At a minimum followup of 5 years (mean, 7.3 years; range, 5–10 years), Knee Society pain scores improved from 37 preoperatively to 79 postoperatively, and function scores improved from 34 to 53. ROM improved on average from −15° of extension and 80° of flexion before surgery to −5° of extension and 120° of flexion at the last followup (p = 0.03). No loosening of implants was observed. Nonprogressive radiolucent lines were identified around the femoral and tibial components in 2 knees. One patient required reoperation because of a periprosthetic infection.

Conclusions

Revision arthroplasty with a rotating-hinge design provided substantial improvement in function and a reduction in pain in elderly patients with instability following TKA.

Level of evidence

Level IV, therapeutic study.     

Trajectories of musculoskeletal shoulder pain after spinal cord injury: Identification and predictors

Objective/Background

Although shoulder pain is a problem in up to 86% of persons with a spinal cord injury (SCI), so far, no studies have empirically identified longitudinal patterns (trajectories) of musculoskeletal shoulder pain after SCI. The objective of this study was: (1) to identify distinct trajectories of musculoskeletal shoulder pain in persons with SCI, and (2) to determine possible predictors of these trajectories.

Design/Methods

Multicenter, prospective cohort study in 225 newly injured persons with SCI.

Outcome Measure

Shoulder pain was assessed on five occasions up to 5 years after discharge. Latent class growth mixture modeling was used to identify the distinct shoulder pain trajectories.

Results

Three distinct shoulder pain trajectories were identified: (1) a “No or Low pain” trajectory (64%), (2) a “High pain” (30%) trajectory, and (3) a trajectory with a “Decrease of pain” (6%). Compared with the “No or Low pain” pain trajectory, the “High pain” trajectory consisted of more persons with tetraplegia, shoulder pain before injury, limited shoulder range of motion (ROM), lower manual muscle test scores, or more spasticity at t₁. Multiple logistic regression analysis showed two significant predictors for the “High pain” trajectory (as compared with the “No or Low pain” trajectory): having a tetraplegia (odds ratio (OR) = 3.2; P = 0.002) and having limited shoulder ROM (OR = 2.8; P = 0.007).

Conclusion

Shoulder pain in people with SCI follows distinct trajectories. At risk for belonging to the “High pain” trajectory are persons with tetraplegia and those with a limited shoulder ROM at start of active rehabilitation.     

Rotator Cuff Fatty Infiltration and Atrophy Are Associated With Functional Outcomes in Anatomic Shoulder Arthroplasty

Background

Shoulder arthroplasty provides reliable pain relief and restoration of function. However, the effects of fatty infiltration and atrophy in the supraspinatus and infraspinatus muscles on functional outcomes are not well understood.

Questions/purposes

The purposes of this study were to (1) compare preoperative with postoperative fatty infiltration and atrophy of the supraspinatus and infraspinatus muscles after primary shoulder arthroplasty; and (2) identify any associations between these variables and outcome measures.

Methods

A retrospective analysis was undertaken of 62 patients with a mean age of 67 years (range, 34–90 years) who underwent shoulder arthroplasty. CT scans were conducted preoperatively and at 12 months postoperatively. Outcome variables included the degree of supraspinatus and infraspinatus fatty infiltration (percent fatty infiltration and Goutallier grade), muscle area (percent muscle area and Warner atrophy grade), shoulder strength, and the Western Ontario Osteoarthritis Score (WOOS), American Shoulder and Elbow Surgeons score, and Constant outcome score.

Results

Preoperatively, the mean percent fatty infiltration (FI) within the supraspinatus and infraspinatus was identical at 14%. One year after shoulder arthroplasty, both muscles had less fatty infiltration (6% and 7%, respectively; p < 0.001). Similarly, the Goutallier grade significantly improved postoperatively for the supraspinatus (p = 0.0037) and infraspinatus (p = 0.0007). Conversely, measures of muscle atrophy remained unchanged postoperatively (p > 0.251). Preoperatively, greater supraspinatus percent FI was negatively associated with preoperative shoulder strength (r = 0.37, p = 0.001) and Constant score (r = 0.38, p = 0.001). Postoperative infraspinatus percent FI was negatively associated with postoperative strength (r = 0.3, p = 0.021) and Constant score (r = 0.3, p = 0.04). Multivariable regression analysis of possible predictive factors demonstrated that preoperative supraspinatus percent muscle area (p = 0.016) and the diagnosis of osteoarthritis (p = 0.017) were associated with better followup WOOS scores, and preoperative supraspinatus strength was associated with postoperative strength (p = 0.0024). Higher degrees of preoperative percent FI were not associated with worse patient-reported outcomes postoperatively.

Conclusions

Supraspinatus and infraspinatus fatty infiltration improves after shoulder arthroplasty, whereas muscle area remains unchanged. Although further study of these variables is required, the negative associations identified between preoperative supraspinatus atrophy and the diagnosis of rheumatoid arthritis and postoperative quality-of-life outcome scores may aid the clinician in selecting the best treatment option for glenohumeral arthrosis and in the management of patient expectations.

Level of Evidence

Level III, prognostic study.