Unconstrained shoulder arthroplasty

Ｓｈｏｕｌｄｅｒａｒｔｈｒｏｐｌａｓｔｙｈａｓｂｅｅｎｓｕｃｃｅｓｓｆｕｌｉｎｔｒｅａｔｍｅｎｔｆｏｒｍａｎｙｄｉｓｏｒｄｅｒｓｏｆｓｈｏｕｌｄｅｒｗｈｉｃｈｒｅｓｕｌｔｉｎｍｏｄｅｒａｔｅｏｒｓｅｖｅｒｅｐａｉｎ ,ｉｎｃｌｕｄｉｎｇｅｎｄ ｓｔａｇｅｇｌｅｎｏｈｕｍｅｒａｌｄｅｇｅｎｅｒａｔｉｖｅａｒｔｈｒｉｔｉｓ ,ｒｈｅｕｍａｔｏｉｄａｒｔｈｒｉｔｉｓ ,ｈｕｍｅｒａｌｈｅａｄｎｅｃｒｏｓｉｓａｎｄｐｒｏｘｉｍａｌｈｕｍｅｒａｌｆｒａｃｔｕｒｅｓｅｔｃ .Ｉｎｔｈｅｐａｓｔ 10ｙｅａｒｓ ,ｍｏｄｕ…     

Reverse shoulder arthroplasty in revision of failed shoulder arthroplasty—outcome and follow-up

Purpose

The number of shoulder arthroplasties has increased over the last decade, which can partly be explained by the increasing use of the reverse total shoulder arthroplasty technique. However, the options for revision surgery after primary arthroplasty are limited in cases of irreparable rotator cuff deficiency, and tuberosity malunion, nonunion, or resorption. Often, conversion to a reverse design is the only suitable solution. We analysed the functional outcome, complication rate and patient satisfaction after the revision of primary shoulder arthroplasty using an inverse design.

Methods

Over a ten-year period 57 patients underwent revision surgery for failed primary shoulder arthroplasty using a reverse design. Of the 57 patients, 50 (mean age, 64.2 years) were available after an average follow-up of 51 months. Clinical evaluation included the Constant Murley Score, the UCLA score, and the Simple Shoulder Test, whereas radiological evaluation included plain radiographs in standard projections. Patients were also requested to rate their subjective satisfaction of the final outcome as excellent, good, satisfied or dissatisfied.

Results

Compared to the preoperative status, the overall functional outcome measurements based on standardised outcome shoulder scores improved significantly at follow-up. The overall mean Constant Murley score improved from 18.5 to 49.3 points, the mean UCLA score improved from 7.1 to 21.6 points, and the mean simple shoulder test improved from 1.2 to 5.6 points. The average degree of abduction improved from 40 to 93° (p < 0.0001), and the average degree of anterior flexion improved from 47 to 98° (p < 0.0001). The median VAS pain score decreased from 7 to 1. Complications occurred in 12 cases (24 %).A total of 32 (64 %) patients rated their result as good or excellent, six (12 %) as satisfactory and 12 (24 %) as dissatisfied.

Conclusion

In revision shoulder arthroplasty after failed primary shoulder arthroplasty an inverse design can improve the functional outcome, and patient satisfaction is usually high. However, the complication rate of this procedure is also high, and patient selection and other treatment options should be carefully considered.     

How does gout impact outcomes following primary shoulder arthroplasty?: Gout and shoulder arthroplasty

IntroductionStudies have shown that the overall prevalence of gout has increased. Data shows that patients with gout have worse outcomes following total joint arthroplasty, however studies investigating the effects of gout following primary total shoulder (TSA) and reverse shoulder arthroplasty (RSA) are limited. The purpose of this study was to compare outcomes of patients with and without gout undergoing primary shoulder arthroplasty, evaluating (1) in-hospital length of stay (LOS); (2) medical complications; (3) cost of care.MethodsA retrospective query using a nationwide administrative claims database was performed from January 2005 to March 2014 for all patients who underwent primary TSA and RSA for the treatment of glenohumeral osteoarthritis, yielding a total of 11,414 patients to be included. For the TSA cohort, 7702 patients were identified within the study (n = 1,185) and control (n = 6417) cohorts. Similarly, 3712 patients were identified within the RSA cohorts (gout n = 621 and control n = 3,091). Primary endpoints were in-hospital LOS, 90-day medical complications, and total global 90-day episode of care (EOC) costs. Multivariate logistic regression analyses were used to calculate the odds (OR) of medical complications, whereas Welch's t-tests were used to compare LOS and costs of care. A P value less than .05 was considered statistically significant.ResultsPatients with gout undergoing primary TSA (3- vs. 2-days, P < .0001) and RSA (3- vs. 2-days, P < .0001) had significantly longer in-hospital LOS. Gout patients undergoing either TSA (41.2 vs. 11.3%; OR: 3.30, P < .0001) or RSA had significantly higher incidence and odds (50.6 vs. 17.9%; OR: 2.10, P < .0001) of developing 90-day medical complications compared to their counterparts. Study group patients incurred significantly higher total global 90-day episode of care costs following both TSA ($15,007.84 vs. $13,447.06, P < .0001) and RSA ($19,659.27 vs. $16,783.70, P< .0001).ConclusionThis study demonstrates that patients with gout undergoing primary shoulder arthroplasty have longer in-hospital LOS, in addition to higher rates of complications, and increased costs of care. The study can be used by orthopedic surgeons to educate patients who have gout on complications which may occur following their surgical procedure.Level of EvidenceLevel III, retrospective comparative study.     

Proximal humeral fractures treated with arthroplasty

P74ro50x%iyme aaolrfs h houulmdm.eer raAalfl t effrrraa cactgtuuerr ee5ss0,ainc wc oopumanteiten nf othsra vomeldo reaer m tthhucaanhnhigher incidence of proximal humeral fractures thanmen.In patients younger than50years old,high-energy trauma is the most common cause of proximalhumeral fractures,and after age50,minimal-to-moderate trauma is the most common cause.1Neer s classification,the most popularclassification system for proximal humeral fractures,isbased on the anatomical relationship o…     

No clinical difference between large metal-on-metal total hip arthroplasty and 28-mm-head total hip arthroplasty?

Purpose  

We aimed to test the claim of greater range of motion (ROM) with large femoral head metal-on-metal total hip arthroplasty.     

Primary total hip arthroplasty for acetabular fracture

Objective:To explore the operative indications and operative methods of primary total hip arthroplasty for acetabular fracture and to observe the clinical curative effect. Methods:We retrospectively summarized and analyzed the traumatic conditions, fracture types, complications, operative time, operative techniques, and short-term curative effect of 11 patients(10 males and 1 female, with a mean age of 42. 4 years) with acetabular fracture who underwent primary total hip arthroplasty. Results: The patients were followed up for 6-45 months (mean = 28 months). Their average Harris score of postoperative hip joint was 78. Conclusion:Under strict mastery of indications, patients with acetabular fracture may undergo primary total hip arthroplasty, but stable acetabular components should be made.     

Does the sequence and timing of total shoulder arthroplasty relative to lower extremity arthroplasty influence postoperative complications?

BackgroundAs the number of total knee, hip, and shoulder arthroplasties increases, so do the number of patients requiring multiple arthroplasties in different joints. Evidence-based guidance on the sequence and timing of hip and knee arthroplasty (TJA) in total shoulder arthroplasty (TSA) patients is lacking. The objectives of the present study were to examine the relationship between the sequence and timing of these lower extremity arthroplasties on surgical and medical complications following TSA.MethodsPatients from the 100% Medicare dataset who underwent lower extremity Total Joint Arthroplasty (TJA) and TSA between 2005 and 2014 were identified. Patients were stratified into 6 groups: (1) patients who underwent TSA less than 3 months after TJA, (2) patients who underwent TSA between 3 months and 1 year after TJA, (3) patients who underwent TSA greater than 1 year after TJA, (4) patients who underwent TSA less than 3 months prior to TJA, (5) patients who underwent TSA between 3 months and 1 year prior to TJA, and (6) patients who underwent TSA greater than 1 year prior to TJA. Revision rate, indication for revision surgery, and medical complications of all groups were compared using a regression analysis.ResultsPatients who underwent TSA within 3 months prior to lower extremity TJA had a significantly higher incidence of revision shoulder surgery and unplanned emergency department visits within 90 days compared to all other groups (P < .05). These patients had higher rates of implant wear, periprosthetic lysis, and mechanical complications as the indication for revision compared to all other patients who also underwent revision surgery (P < .05).ConclusionTSA should be performed greater than 3 months before lower extremity TJA or at any point following lower extremity TJA to avoid the increased risk of revision surgery due to implant wear or lysis and increased rates of emergency room presentation.Level of evidenceLevel III     

Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies?

Purpose

Whilst patients undergoing total knee replacements generally have good relief of their symptoms, up to 20% complain of persisting pain. Revision rates have therefore been rising, particularly so for unexplained pain. We reviewed the causes of painful total knee replacements including extrinsic causes.

Methods

Forty-five consecutive patients referred to our department with painful total knee replacement were reviewed with our standard protocol, including history and examination, inflammatory markers and radiological studies including radiographs of the hip and knee and computed tomography scan of the knee joint.

Results

Of the 45 patients, 15 patients had degenerative hip and lumbar spine disease which resolved after injections of the relevant joints. Nine patients had unexplained pain.

Conclusions

Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis. We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.     

Effectiveness of the Cobb–Stainsby excision arthroplasty

Background

Dislocated metatarsophalangeal joints from clawed or hammer toes can be a disabling consequence of several conditions. The Cobb–Stainsby forefoot arthroplasty combines partial phalangectomy (Stainsby) with extensor tendon transfer to the metatarsal head (Cobb). We present a retrospective, three surgeon case series of 215 toes in 126 patients.

Wear in total knee arthroplasty—just a question of polyethylene?: Metal ion release in total knee arthroplasty

Purpose

Biological reactions against wear particles are a common cause for revision in total knee arthroplasty. To date, wear has mainly been attributed to polyethylene. However, the implants have large metallic surfaces that also could potentially lead to metal wear products (metal ions and debris). The aim of this study was to determine the local release of cobalt, chromium, molybdenum and titanium in total knee arthroplasty during a standard knee wear test.

Methods

Four moderately conforming fixed-bearing implants were subjected to physiological loadings and motions for 5×10⁶ walking cycles in a knee wear simulator. Polyethylene wear was determined gravimetrically and the release of metallic wear products was measured using high resolution-inductively coupled plasma-mass spectrometry.

Results

A polyethylene wear rate of 7.28 ± 0.27 mg/10⁶ cycles was determined and the cumulative mass of released metals measured 1.63 ± 0.28 mg for cobalt, 0.47 ± 0.06 mg for chromium, 0.42 ± 0.06 mg for molybdenum and 1.28 ± 0.14 mg for titanium.

Conclusion

For other metallic implants such as metal-on-metal total hip arthroplasty, the metal wear products can interact with the immune system, potentially leading to immunotoxic effects. In this study about 12 % by weight of the wear products were metallic, and these particles and ions may become clinically relevant for patients sensitive to these materials in particular. Non-metallic materials (e.g. ceramics or suitable coatings) may be considered for an alternative treatment for those patients.     

Patella in total knee arthroplasty: to resurface or not to��a cohort study of staged bilateral total knee arthroplasty

The aim of this study was to assess medium term results of patellar resurfacing in total knee arthroplasty, specifically looking at anterior knee pain, patellofemoral function and need for reoperation. A prospective cohort study was conducted with patients undergoing staged bilateral knee arthroplasty with the patella being resurfaced only on one side. This was due to change in the clinical practice of the senior author. Sixty patients were reviewed clinically and radiologically on a regular basis. The surgery was either performed or supervised by the senior author in all cases. All patients received the cemented press-fit condylar© prosthesis. The Knee Society clinical rating system was used. Scores were recorded pre-operatively and post-operatively at three months, one year, two years and three yearly thereafter. The mean age of patients in the study group was 75 years (range: 62–89 years). There were 42 women and 18 men in the study. The mean duration of follow-up was 4.5 years (range: 2–12 years). There was no significant difference in the pre-operative scores in both groups. There were significantly better scores (p < 0.05) on the resurfaced side as compared to the non-resurfaced side at final follow-up. No revision was carried out for patellofemoral complications on the resurfaced side. Four patients required revision in the form of patellar resurfacing on the non-resurfaced side for persistent anterior knee pain. Patellar resurfacing is recommended in total knee arthroplasty for better functional outcome with regards to anterior knee pain and patellofemoral function.     

The “learning curve” of total hip arthroplasty

Total hip arthroplasty (THA) is one of the major breakthroughs in modern orthopedics this century. Since its introduction in the early 1960s by Sir J. Charnley, it has become the most common form of arthroplasty. The art of performing THA has developed to a large extent, yet with the inevitable price of a learning curve. The rates of early and late complications reported in the orthopedic literature have been decreasing gradually, along with improved short- and long-term results. We report the results of two similar series of THA performed with an interval of 15 to 20 years, which show that the improvement of the results that form the learning curve of THA at our institution is statistically significant.