Balancing clinician and patient priorities for total shoulder replacement preoperative education programs

OBJECTIVE

To investigate patient and clinician preferences regarding a preoperative educational program for patients undergoing shoulder replacement surgery.

METHODS

This study used a cross-sectional survey of patients awaiting shoulder replacement surgery and clinicians. The survey was comprised of 41 questions for patients and clinicians, regarding preferences for receiving information, content preferences and device preferences. Descriptive statistics were reported for survey questions.

RESULTS

180 patients and 175 clinicians completed the survey. Patients and clinicians' top choices for ways to receive information were: in-person, website and booklets, with use of CD/DVD being extremely unlikely. Patients and clinicians had different preferences regarding content choices. Patients rated the following content topics as important to include in a program: including other patient's previous experiences with this surgery (83 % patients; 40 % clinicians), information for caregivers (84 % patients; 65 % clinicians), expectations for hospital stay (89 % patients; 57 % clinicians), process of anesthesia (87 % patients; 51 % clinicians), and how the surgery is performed (94 % patients; 60 % clinicians).

CONCLUSIONS

Clinicians and patients have differing priorities and perspectives on the content and delivery of preoperative education programs, however, therapeutic goals and accessibility should be considered when designing programs.

PRACTICE IMPLICATIONS

Creating education programs should include the lens of both clinicians and patients.

Radial Head Fractures Treated with Modular Metallic Radial Head Replacement: Outcomes at a Mean Follow-up of Eight Years

BACKGROUND

Radial head arthroplasty is commonly used to treat acute unreconstructible radial head fractures. The purpose of this study was to report on the clinical and radiographic outcomes at a minimum follow-up of five years after radial head arthroplasty with a modular metallic implant for the treatment of acute radial head fractures.

METHODS

The cases of fifty-five patients with unreconstructible radial head fractures treated acutely with a smooth-stemmed modular metallic radial head implant were retrospectively reviewed. A wide variety of injuries, which ranged from isolated radial head fractures to so-called terrible triad injuries, were included. All patients returned for an interview, physical examination, and radiographic evaluation at a mean of eight years (range, five to fourteen years) postoperatively. Elbow and forearm motion, elbow strength, and grip strength were measured. Radiographs were evaluated, and validated patient-rated outcome questionnaires were completed. A longitudinal subgroup analysis was performed for thirty-three patients who were previously evaluated at two years postoperatively.

RESULTS

At a mean of 8.2 ± 2.9 years, the mean arc of flexion (and standard deviation) of the affected elbow was 11° ± 14° to 137° ± 15°. Elbow strength and motion were significantly diminished compared with the unaffected elbow (p < 0.05). The mean Mayo Elbow Performance Index (MEPI) was 91 ± 13 points. Twenty-five patients (45%) had stem lucencies; twenty-one (38%), ulnohumeral arthritis; and twenty (36%), heterotopic ossification, including one with radioulnar synostosis. Two patients underwent secondary elbow surgery, but no patient required implant removal or revision. In the subgroup evaluated longitudinally, there was a significant improvement in MEPI scores from the two-year to the eight-year follow-up (p = 0.012), with no loss of motion or strength (p > 0.05).

CONCLUSIONS

The mid-term outcomes of radial head arthroplasty with a smooth-stemmed modular metallic prosthesis are comparable with previously reported short-term outcomes, with no evidence of functional deterioration. Radial head arthroplasty with a smooth-stemmed metallic modular implant is a good treatment option for patients with acute unreconstructible radial head fractures, and sustained clinical outcomes may be expected beyond five years of follow-up.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

IGF2 expression and β-catenin levels are increased in Frozen Shoulder Syndrome

PURPOSE

Frozen Shoulder Syndrome is a fibrosis of the shoulder joint capsule that is clinically associated with Dupuytren's disease, a fibrosis of the palmar fascia. Little is known about any commonalities in the pathophysiology of these connective tissue fibroses. β-catenin, a protein that transactivates gene expression, and levels of IGF2 mRNA, encoding insulin-like growth factor-II, are elevated in Dupuytren's disease. The aim of this study was to determine if correlating changes in β-catenin levels and IGF2 expression are evident in Frozen Shoulder Syndrome.

METHODS

Tissue from patients with Frozen Shoulder Syndrome and rotator cuff tear were obtained during shoulder arthroscopies. Total protein extracts were prepared from tissue aliquots and β-catenin immunoreactivity was assessed by Western immunoblotting. In parallel, primary fibroblasts were derived from these tissues and assessed for IGF2 expression by quantitative PCR.

RESULTS

β-catenin levels were significantly increased in Frozen Shoulder Syndrome relative to rotator cuff tear when assessed by Western immunoblotting analyses. IGF2 mRNA levels were significantly increased in primary fibroblasts derived from frozen shoulder syndrome tissues relative to fibroblasts derived from rotator cuff tissues.

CONCLUSIONS

As in Dupuytren's disease, β-catenin levels and IGF2 expression are elevated in Frozen Shoulder Syndrome. These findings support the hypothesis that these connective tissue fibroses share a common pathophysiology.

Surgical Technique for Single and Double-Incision Method of Acute Distal Biceps Tendon Repair

Introduction

Distal biceps tendon ruptures can be repaired with either a single or a double-incision technique.

Step 1 Single-Incision Technique Surgical Exposure and Preparation of the Tendon

Through a single anterior incision, identify the tendon and debride the distal degenerated portion.

Step 2 Single-Incision Technique Preparation of the Radius

Expose the bicipital tuberosity and prepare the bone for insertion of suture anchors.

Step 3 Single-Incision Technique Tendon Reattachment

Suture the tendon with a reduction knot technique that allows for anatomic tendon apposition to bone.

Step 1 Double-Incision Technique Surgical Exposure and Preparation of the Tendon

Through a small anterior incision retrieve the tendon, debride the distal degenerated portion of the tendon, and place your sutures.

Step 2 Double-Incision Technique Preparation of the Radius

Through a second posterolateral incision, expose the biceps tuberosity and, using a burr, create a trough for the tendon.

Step 3 Double-Incision Technique Tendon Reattachment

Pass the sutures through the transosseous tunnels and tension the sutures, allowing the biceps tendon to be pulled into the trough created in the bicipital tuberosity, and then tie the sutures.

Step 4 Postoperative Care

Assess tension across the repaired tendon, initiate prophylaxis against heterotopic ossification, and begin rehabilitation.

Results

We recently conducted a prospective randomized controlled trial at our center comparing the single and double-incision techniques for the repair of acute distal biceps tendon ruptures¹¹.

What to Watch For

IndicationsContraindicationsPitfalls & Challenges.

Single versus double-incision technique for the repair of acute distal biceps tendon ruptures: a randomized clinical trial

BACKGROUND

This clinical trial was done to evaluate outcomes of the single and double-incision techniques for acute distal biceps tendon repair. We hypothesized that there would be fewer complications and less short-term pain and disability in the two-incision group, with no measureable differences in outcome at a minimum of one year postoperatively.

METHODS

Patients with an acute distal biceps rupture were randomized to either a single-incision repair with use of two suture anchors (n = 47) or a double-incision repair with use of transosseous drill holes (n = 44). Patients were followed at three, six, twelve, and twenty-four months postoperatively. The primary outcome was the American Shoulder and Elbow Surgeons (ASES) elbow score. Secondary outcomes included muscle strength, complication rates, and Disabilities of the Arm, Shoulder and Hand (DASH) and Patient-Rated Elbow Evaluation (PREE) scores.

RESULTS

All patients were male, with no significant differences in the mean age, percentages of dominant hands affected, or Workers' Compensation cases between groups. There were also no differences in the final outcomes (at two years) between the two groups (p = 0.4 for ASES pain score, p = 0.10 for ASES function score, p = 0.3 for DASH score, and p = 0.4 for PREE score). In addition, there were no differences in isometric extension, pronation, or supination strength at more than one year. A 10% advantage in final isometric flexion strength was seen in the patients treated with the double-incision technique (104% versus 94% in the single-incision group; p = 0.01). There were no differences in the rate of strength recovery. The single-incision technique was associated with more early transient neurapraxias of the lateral antebrachial cutaneous nerve (nineteen of forty-seven versus three of forty-three in the double-incision group, p < 0.001). There were four reruptures, all of which were related to patient noncompliance or reinjury during the early postoperative period and appeared to be unrelated to the fixation technique (p = 0.3).

CONCLUSIONS

There were no significant differences in outcomes between the single and double-incision distal biceps repair techniques other than a 10% advantage in final flexion strength with the latter. Most complications were minor, with a significantly greater prevalence in the single-incision group.

Humeral head bone defects: remplissage, allograft, and arthroplasty

The Hill-Sachs lesion is a well-known entity that threatens recurrent instability, but the treatment options are multiple and the surgical indications remain undefined. The evidence for each operative technique is limited to retrospective reviews and small case series without controls. The decision of which technique to use resides with the surgeon. Older, osteopenic patients, especially those with underlying arthritis and large defects, should be managed with complete humeral resurfacing. Humeralplasty is best used in younger patients with good quality bone in an acute setting with small- to moderate-sized bone defects. Partial resurfacing and remplissage are best used with small to moderate lesions, and both require further study. Allograft humeral reconstruction is an established technique for patients with moderate to large defects, and is best applied to nonosteopenic bone. Surgeons must be able to recognize the presence of humeral bone loss via specialized radiographs or cross-sectional imaging and understand its implications. The techniques to manage humeral bone loss are evolving and further biomechanical and clinical studies are required to define the indications and treatment algorithms.

What is a Successful Outcome Following Reverse Total Shoulder Arthroplasty?

Background:

With variations in joint destruction, patient expectations and health status, it can be difficult to interpret outcomes following arthroplasty. The purpose of this study was to determine the relationships between different outcome indicators in 44 patients followed for two years after a reverse shoulder arthroplasty.

Methods:

Prospectively collected outcomes included the Constant-Murley score, Simple Shoulder Test (SST), range of motion (ROM), strength, patient satisfaction with their care and independent clinician case-review to determine global clinical outcome. Continuous outcomes were divided in two subgroups according to definitions of functional outcomes. Cohen’s kappa was used to evaluate agreement between outcomes. Pearson correlations were used to quantify interrelationships.

Results:

Although 93% of patients were substantially satisfied, fewer had good results on the other outcomes: 68% on global clinical outcome, 46% on SST and 73% on Constant-Murley score. The SST demonstrated better than chance agreement with Constant-Murley score, ROM in flexion, abduction and external rotation, and strength in external rotation. No agreement between satisfaction and other outcomes were observed. Significant correlations were observed between Constant-Murley score and SST (r = 0.78). The Constant-Murley score and SST demonstrated variable correlation with ROM and strength in flexion, abduction, internal and external rotation (0.38 < r < 0.73); the highest correlations being observed with shoulder elevation ROM (r > 0.50).

Conclusions:

Results show that outcome varies according to patient perspective and assessment methods. Patient satisfaction with their care was related to neither self-reported nor physical impairment outcomes. Positive patient ratings of satisfaction may not necessarily be evidence of positive outcomes.

Metastatic breast carcinoma of the coracoid process: two case reports

BACKGROUND

The coracoid process of the scapula is a rare site of involvement for metastatic disease or for primary tumors. We are unaware of any reports in the literature of pathologic coracoid process fractures and only one report of metastatic disease to the coracoid.

METHODS AND RESULTS

In this case report, we present two cases with metastatic breast carcinoma of the coracoid process, one of which presented with a pathologic fracture of the coracoid.

CONCLUSIONS

An orthopaedic surgeon must be aware of the potential for metastatic disease to the coracoid as they may be the first medical provider to encounter evidence of malignant disease.

Improved accuracy of computer assisted glenoid implantation in total shoulder arthroplasty: an in-vitro randomized controlled trial

BACKGROUND

Glenoid replacement is challenging due to the difficult joint exposure and visualization of anatomical reference landmarks. Improper positioning of the glenoid component or inadequate correction of the retroversion using currently available instrumentation may lead to early failure. The objective of this study was to evaluate a computer-assisted technique to achieve a more accurate placement of the glenoid component compared to traditional techniques.

METHODS

Sixteen paired cadaveric shoulders were randomized to either traditional or computer-assisted glenoid implantation. Preoperative planning consisting of CT scanning with 3-dimensional image modeling of the shoulder specimens and intraoperative tracking with real-time feedback provided to the surgeon was employed in the computer-assisted group. A validated, previously published, standardized protocol for tracking the orientation of the glenoid in space using 3 glenoid surface landmarks was employed. All phases of glenoid implantation (initial guide pin insertion, reaming, drilling of the peg holes, and final component implantation) were tracked and recorded by the computer. A post-implantation CT scan was performed in both groups to compare how accurately the implants were placed.

RESULTS

The computer-assisted technique was more accurate in achieving the correct version during all phases of glenoid implantation and as measured on the post-implantation CT scan (P < .05). The largest errors with traditional glenoid implantation were observed during drilling and, more so, during reaming. The trend was to overly retrovert the glenoid.

CONCLUSIONS

Computer assisted navigation results in a more accurate glenoid component placement relative to traditional techniques.

LEVEL OF EVIDENCE

Basic Science Study.

Open reduction and internal fixation of proximal humerus fractures

Open reduction of proximal humeral fractures has the advantage of providing direct control over each fracture fragment and permitting anatomic reduction and fixation with advanced devices. Modern fixed-angle locking plates designed specifically for proximal humerus fractures have allowed the expansion of surgical indications permitting surgeons to address more complicated fractures. Advanced preoperative imaging and fluoroscopy allow a better understanding of fracture patterns and permit the surgeon to use this knowledge intraoperatively. Research is required to further validate fracture classification systems, to develop surgical guidelines for decision making, and to compare the outcomes of the various treatments options for proximal humerus fractures.

An anthropometric study of the bilateral anatomy of the humerus

The purpose of this study was to describe the extramedullary humeral morphology in paired humeri to determine whether geometric differences exist from side to side in the same individual. The anatomic characteristics of 28 paired, dry cadaveric humeri were measured by use of an electromagnetic tracking system. Of the characteristics examined, only the humeral head height was significantly different between right and left humeri in the same individual (P < .005). Most of the characteristics had excellent intra-specimen repeatability. In conclusion, there are few significant differences between contralateral humeral anatomic characteristics. Therefore, the uninjured contralateral humerus can provide a reasonable approximation to the native geometry of the fractured humerus and should be a reliable model for measuring parameters related to implant geometry and optimal positioning during hemiarthroplasty for the treatment of proximal humeral fractures.

Early experience with computer-assisted shoulder hemiarthroplasty for fractures of the proximal humerus: development of a novel technique and an in vitro comparison with traditional methods

A computer-assisted technique was developed for treatment of 4-part proximal humeral fractures via a hemiarthroplasty and tuberosity fixation. This was compared with a standard traditional method in 7 pairs of cadaveric shoulders. The computer-assisted technique used preoperative computed tomography data and computer simulations of anatomic characteristics of the contralateral humerus. This allowed accurate anatomic reconstruction by use of an electromagnetic tracking system and real-time intraoperative feedback. Various anatomic measurements were used to quantify the accuracy of the reconstruction. The differences between the intact and reconstructed values were improved with the computer-assisted technique for 5 of 7 characteristics. However, this was statistically significant only for humeral head offset (P < .05). With further investigation and refinement, this technique should allow for a more anatomic reconstruction of the proximal humerus, potentially resulting in improved patient outcomes. The technique may also prove to be a valuable resource for the laboratory training of inexperienced surgical trainees.

The effect of muscle loading on the kinematics of in vitro glenohumeral abduction

This in vitro study evaluated the effects of four different muscle-loading ratios on active glenohumeral joint abduction. Eight cadaveric shoulders were tested using a shoulder simulator designed to reproduce unconstrained abduction of the humerus via computer-controlled pneumatic actuation. Forces were applied to cables that were sutured to tendons or fixed to bone, to simulate loading of the supraspinatus, subscapularis, infraspinatus/teres minor, and anterior, middle, and posterior deltoid muscles. Four sets of muscle-loading ratios were employed, based on: (1) equal loads, (2) average physiological cross-sectional areas (pCSAs), (3) constant values of the product of electromyographic (EMG) data and pCSAs, and (4) variable ratios of the EMG and pCSA data which changed as a function of abduction angle. The investigator generated passive motions with no muscle loads simulated. Repeatability was quantified by five successive trials of the passive and simulated active motions. There was improved repeatability in the simulated active motions versus passive motions, significant for abduction angles less than 40 degrees (p=0.02). No difference was found in the repeatability of the four different muscle-loading ratios for simulated active motions (p0.067 for all angles). The improved repeatability of active over passive motion suggests simulated active motion should be employed for in vitro simulations of shoulder motion.

Fractional flexor tendon lengthening for advanced metacarpophalangeal flexion contracture in rheumatoid hands

This technical report discusses a subgroup of rheumatoid patients who have minimal ulnar drift but a severe fixed metacarpophalangeal joint flexion contracture for whom conventional metacarpophalangeal joint arthroplasty alone was insufficient to correct the deformity. We describe a surgical technique to deal with this clinical problem that uses fractional flexor tendon lengthening in the forearm to correct the severe flexion deformity at the metacarpophalangeal joint.

Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. Study of outcomes

BACKGROUND

Comminuted fractures of the radial head are challenging to treat with open reduction and internal fixation. Radial head arthroplasty is an alternative treatment with results that compare favorably with those reported after open reduction and internal fixation of similar fractures. The purpose of this study was to evaluate the two-year outcomes and the rate of recovery of a closely followed cohort of patients in whom an unreconstructible radial head fracture had been treated with a modular metallic prosthesis.

METHODS

Twenty-six patients (seventeen female and nine male; mean age, fifty-four years) with an unreconstructible comminuted radial head fracture and associated elbow injuries were treated with a modular metallic radial head arthroplasty. Patients who had presented more than four weeks following the injury or had had the radial head arthroplasty as a second-stage or salvage procedure were excluded. Of the twenty-six patients, twenty-two had an associated elbow dislocation, and thirteen of them also had an associated fracture of the coronoid process. Patients were prospectively followed at three, six, twelve, and twenty-four months. Self-reported limb function, general health, range of motion, and isometric strength were assessed by an independent observer.

RESULTS

Following treatment of the injury, significant decreases in self-reported and measured impairments were noted over time, with the majority of the recovery occurring by six months and little further recovery noted between six and twenty-four months. There were slight-to-moderate deficits in the range of motion and strength compared with the values on the contralateral, unaffected side. Patient satisfaction was high at three months and remained high at two years. All elbow joints remained stable, no implant required revision, and there was no evidence of overstuffing of the joint. Mild osteoarthritis was seen in five (19%) of the twenty-six patients.

CONCLUSIONS

An arthroplasty with a modular metallic radial head is a safe and effective option for the treatment of unreconstructible radial head fractures associated with other elbow injuries. Recovery primarily occurs by six months, with minimal additional improvements over the next eighteen months.

Reliability and comparison of acromion assessment techniques on X-ray and magnetic resonance imaging (reliability of acromion assessment techniques)

OBJECTIVE

To determine the reliability and correlation of plain radiography and magnetic resonance imaging (MRI) in the assessment of acromion morphology.

MATERIALS AND METHODS

Acromion morphology was assessed using the lateral acromion angle (LAA) and the acromion-humeral interval (AHI). Thirty patients who had X-rays and MRI for impingement syndrome were included. Six blinded observers assessed the acromion morphology subjectively and objectively.

RESULTS

Neither acromion assessment technique demonstrated a positive correlation (kappa and intraclass coefficient < 0.55) between X-ray and MRI. Both techniques were reliable (kappa and intraclass coefficient > 0.55) when measured objectively by experienced observers.

CONCLUSION

The LAA and the AHI are both reliable acromion assessment techniques on X-ray and MRI when measured objectively and by experienced observers.