Characterization of the dysplastic Walch type C glenoid

Aims

The Walch Type C dysplastic glenoid is characterized by excessive retroversion. This anatomical study describes its morphology.

Patients and Methods

A total of 29 shoulders with a dysplastic glenoid were analyzed. CT was used to measure retroversion, inclination, height, width, radius-of-curvature, surface area, depth, subluxation of the humeral head and the Goutallier classification of fatty infiltration. The severity of dysplasia and deficiency of the posterior rim of the glenoid were recorded.

Results

A type C glenoid occurred in 1.8% of shoulders referred to our tertiary centres. The mean retroversion, inclination, height, width, radius-of-curvature, surface area, and depth of the glenoid were 37°, 3°, 46 mm, 30 mm, 37°, 1284 mm3, and 16 mm, respectively. The mean posterior subluxation was 90%. The Goutallier class was < 2 in 25 shoulders (86%). Glenoid dysplasia was mild in four, moderate in 14, and severe in 11 shoulders. The typical appearance of the posterior glenoid rim had a rounded or ‘lazy J’ morphology. The glenoid neck was deficient in 18 shoulders (62%).

Conclusion

A dysplastic Type C glenoid characteristically has a uniconcave retroverted morphology, a deficient posteroinferior rim and scapular neck, and a reduced depth. These findings help to define the unique anatomical variations and may aid the planning of surgery and the development of components for these patients. Cite this article: Bone Joint J 2018;100-B:1074–9.

Five-year publication rate of clinical presentations at the open and closed American shoulder and elbow surgeons annual meeting from 2005-2010

BACKGROUND

The purpose of this study was to evaluate the five-year publication rate of papers presented at both the open and closed American Shoulder and Elbow Surgeons' (ASES) annual meetings from 2005 to 2010.

METHODS

Online abstracts of the presentations at the open and closed ASES annual meetings were independently screened for clinical studies and graded for quality using level of evidence. The databases PubMed (MEDLINE), Ovid (MEDLINE), and EMBASE were comprehensively searched for full-text publications corresponding to these presentations and any paper published within five years of the presentation date was counted.

RESULTS

Overall, 131/266 papers corresponding to the meeting presentations were identified for a five-year publication rate of 49.2 %. Sixty two (48 %) of the papers were published in The Journal of Shoulder and Elbow Surgeons, 23 (18 %) were published in The American Journal of Sports Medicine, and 20 (16 %) were published in The Journal of Bone and Joint Surgery. The mean patient sample size included in presentations with a subsequent full-text publication was higher (154; standard error =27) than the presentations not published (93; standard error = 13) (p = 0.039). There was no correlation (p = 0.248) between the publication rate and the level of evidence of the presentations.

CONCLUSIONS

The publication rate of presentations at ASES meetings from 2005 to 2010 is similar to that reported from other orthopaedic meetings. Studies with large sample sizes should continue to be encouraged, and high quality presentations must consistently be followed up with full-text manuscript preparation in order to maximize the future clinical impact.

Effectiveness of CT for the detection of glenoid bone graft resorption following reverse shoulder arthroplasty

INTRODUCTION

Glenoid bone grafting is often used in cases of reverse shoulder arthroplasty (RSA) with glenoid deficiency. Additionally, bony increased-offset RSA (BIO-RSA) uses a cylindrical bonegraft harvested from the humeral head and is positioned beneath the glenoid baseplate to increase lateralization. Postoperative computed tomography (CT) has been used to detect glenoid bonegraft resorption, which is typically identified by a gap between the bonegraft and baseplate; however, CT images are often degraded by implant metal artifact. The purpose of this CT imaging study was to determine if a simulated bonegraft resorption gap is detectable following RSA with glenoid bone grafting.

HYPOTHESIS

CT is unable to detect bone graft resorption following reverse shoulder arthroplasty conducted with bone grafting beneath the glenoid baseplate.

MATERIALS AND METHODS

RSA with glenoid bone grafting was performed on four cadaver shoulders. Glenoid bonegraft resorption gaps were simulated by fixing the implant at six different gap widths (0, 1, 2, 4, 6 and 8mm). Clinical CT scans were acquired for each gap resulting in 6 scans per specimen. Two experienced observers (blinded) analyzed DICOM images in the axial and coronal directions, and measured gap widths using Mimics(®) software. Each observer had access to approximately 200 images per condition per specimen.

RESULTS

The sensitivity of CT imaging to positively identify bonegraft resorption was 38%, with an accuracy of 46%. Inter-observer agreement was 92%. Observers tended to visualize no-gap for most conditions. Resorption gap width measurements were consistently underestimated.

DISCUSSION

Metal artifact prevented identification of simulated bonegraft resorption gaps and observers most often determined that there was bonegraft-to-implant "healing" on CT, when in fact a gap was clinically present. This study illustrates the need for more effective imaging techniques to determine if bonegraft resorption has occurred following RSA.

Radial head implant diameter: A biomechanical assessment of the forgotten dimension

BACKGROUND

The effect of radial head implant length has been a subject of controversy, with the impact on clinical outcomes and forearm biomechanics being extensively studied. However, the impact of radial head diameter on forearm load transfer has not been examined. This study examined the influence of radial head implant diameter on forearm load transfer as measured by interosseous membrane tension and radiocapitellar joint contact characteristics.

METHODS

An upper extremity simulator was utilized to study five cadaveric specimens with three different radial head implant diameters (-2mm, anatomically sized, +2mm). A load sensing device was woven into the fibers of the central band of the interosseous membrane to quantify its tension. An inter-positional pressure measurement sensor was used to quantify radiocapitellar joint contact force and area. Axial loads of 160N were applied to the forearm during forearm rotation with the elbow at 90° of flexion.

FINDINGS

Changes to the radial head diameter did not change radiocapitellar contact force or area (P=0.4 and P=0.5 respectively). There was a linear relationship between radial head diameter and interosseous membrane tension; increasing radial head diameter increases the interosseous membrane tension (P=0.01).

INTERPRETATION

Although radial head diameter was not found to alter radiocapitellar contact area or force, the interosseous membrane tension was impacted. After radial head arthroplasty, an increase in radial head implant diameter increases the interosseous membrane tension, with a potential for increased pain and stiffness. There is also a potential for increased proximal radioulnar joint contact pressures; resulting in stem loosening or radio-ulnar pain.

Anatomical total shoulder replacement with rotator cuff repair for osteoarthritis of the shoulder

We assessed the clinical results, radiographic outcomes and complications of patients undergoing total shoulder replacement (TSR) for osteoarthritis with concurrent repair of a full-thickness rotator cuff tear. Between 1996 and 2010, 45 of 932 patients (4.8%) undergoing TSR for osteoarthritis underwent rotator cuff repair. The final study group comprised 33 patients with a mean follow-up of 4.7 years (3 months to 13 years). Tears were classified into small (10), medium (14), large (9) or massive (0). On a scale of 1 to 5, pain decreased from a mean of 4.7 to 1.7 (p = < 0.0001), the mean forward elevation improved from 99° to 139° (p = < 0.0001), and the mean external rotation improved from 20° (0° to 75°) to 49° (20° to 80°) (p = < 0.0001). The improvement in elevation was greater in those with a small tear (p = 0.03). Radiographic evidence of instability developed in six patients with medium or large tears, indicating lack of rotator cuff healing. In all, six glenoid components, including one with instability, were radiologically at risk of loosening. Complications were noted in five patients, all with medium or large tears; four of these had symptomatic instability and one sustained a late peri-prosthetic fracture. Four patients (12%) required further surgery, three with instability and one with a peri-prosthetic humeral fracture.

Consideration should be given to performing rotator cuff repair for stable shoulders during anatomical TSR, but reverse replacement should be considered for older, less active patients with larger tears.

Cite this article: Bone Joint J 2014;96-B:224–8.

The effect of excision of the radial head and metallic radial head replacement on the tension in the interosseous membrane

We measured the tension in the interosseous membrane in six cadaveric forearms using an in vitro forearm testing system with the native radial head, after excision of the radial head and after metallic radial head replacement. The tension almost doubled after excision of the radial head during simulated rotation of the forearm (p = 0.007). There was no significant difference in tension in the interosseous membrane between the native and radial head replacement states (p = 0.09). Maximal tension occurred in neutral rotation with both the native and the replaced radial head, but in pronation if the radial head was excised. Under an increasing axial load and with the forearm in a fixed position, the rate of increase in tension in the interosseous membrane was greater when the radial head was excised than for the native radial head or replacement states (p = 0.02). As there was no difference in tension between the native and radial head replacement states, a radial head replacement should provide a normal healing environment for the interosseous membrane after injury or following its reconstruction. Load sharing between the radius and ulna becomes normal after radial head Replacement. As excision of the radial head significantly increased the tension in the interosseous membrane it may potentially lead to its attritional failure over time.

Cite this article: Bone Joint J 2013;95-B:1383–7.

Neurolysis of the ulnar nerve for neuropathy following total elbow replacement

Ulnar neuropathy presents as a complication in 5% to 10% of total elbow replacements, but subsequent ulnar neurolysis is rarely performed. Little information is available on the surgical management of persistent ulnar neuropathy after elbow replacement. We describe our experience with the surgical management of this problem.

Of 1607 total elbow replacements performed at our institution between January 1969 and December 2004, eight patients (0.5%) had a further operation for persistent or progressive ulnar neuropathy. At a mean follow-up of 9.2 years (3.1 to 21.7) six were clinically improved and satisfied with their outcome, although, only four had complete recovery. When transposition was performed on a previously untransposed nerve the rate of recovery was 75%, but this was reduced to 25% if the nerve had been transposed at the time of the replacement.

Pain relief and functional results after resection arthroplasty of the shoulder

We have examined the relief from pain and the functional outcome in 18 patients who underwent resection arthroplasty of the shoulder as a salvage operation between 1988 and 2002. The indications included failed shoulder replacement in 17, with infection in 13, and chronic septic arthritis in one. The mean follow-up was 8.3 years (2.5 to 16.6). Two intra-operative fractures of the humerus occurred, both of which healed. The level of pain was significantly decreased (t-test, p < 0.001) but five patients continued to have moderate to severe pain. The mean active elevation was 70 degrees (0 degrees to 150 degrees ) postoperatively and represented an improvement from 39 degrees (0 degrees to 140 degrees ) (t-test, p = 0.003), but internal and external rotation were hardly changed. The mean number of positive answers on the 12-question Simple Shoulder Test was 3.1 (0 to 12) but the shoulder was generally comfortable when the arm was positioned at rest by the side. The mean post-operative American Shoulder and Elbow Surgeon's score was 36 (8 to 73). Despite applying this procedure principally to failed shoulder replacements, the results were similar to those reported in the literature for patients after severe fracture-dislocation. Reduction of pain is possible in one half to two-thirds of patients. The outcome of this operation in providing relief from pain cannot be guaranteed, but the shoulder is usually comfortable at rest, albeit with profound functional limitations.

Herpes zoster in the ulnar nerve distribution

Varicella zoster is a ubiquitous virus which usually affects school-aged children as Chicken Pox. While the initial disease is self-limiting and seldom severe, the virus remains in the body. It lies dormant in the dorsal root ganglia and reactivation may occur years later with variable presentations as Herpes Zoster, or Shingles. While Shingles is common, it rarely presents exclusively in the upper extremity. It is important that hand surgeons recognize the possibility of zoster infection, with or without a rash, when evaluating the onset of neuralgia in a dermatomal distribution in the upper limb. Early diagnosis allows rapid and appropriate treatment, with a lower risk of complications. We report on a case of Herpes Zoster isolated to the ulnar nerve distribution in a young woman.

Coonrad-Morrey total elbow arthroplasty for tumours of the distal humerus and elbow

We reviewed 20 patients who had undergone a Coonrad-Morrey total elbow arthroplasty after resection of a primary or metastatic tumour from the elbow or distal humerus between 1980 and 2002. Eighteen patients underwent reconstruction for palliative treatment with restoration of function after intralesional surgery and two after excision of a primary bone tumour. The mean follow-up was 30 months (1 to 192).

Five patients (25%) were alive at the final follow-up; 14 (70%) had died of their disease and one of unrelated causes. Local control was achieved in 15 patients (75%). The mean Mayo Elbow Performance Score improved from 22 (5 to 45) to 75 points (55 to 95). Four reconstructions (20%) failed and required revision. Seven patients (35%) had early complications, the most frequent being nerve injury (25%). There were no infections or wound complications although 18 patients (90%) had radiotherapy, chemotherapy or both.

The Coonrad-Morrey total elbow arthroplasty provides good relief from pain and a good functional outcome after resection of tumours of the elbow. The rates of complications involving local recurrence of tumour (25%) and nerve injury (25%) are of concern.

Modulation of 14-3-3 protein interactions with target polypeptides by physical and metabolic effectors

The proteins commonly referred to as 14-3-3s have recently come to prominence in the study of protein:protein interactions, having been shown to act as allosteric or steric regulators and possibly scaffolds. The binding of 14-3-3 proteins to the regulatory phosphorylation site of nitrate reductase (NR) was studied in real-time by surface plasmon resonance, using primarily an immobilized synthetic phosphopeptide based on spinach NR-Ser543. Both plant and yeast 14-3-3 proteins were shown to bind the immobilized peptide ligand in a Mg2+-stimulated manner. Stimulation resulted from a reduction in KD and an increase in steady-state binding level (Req). As shown previously for plant 14-3-3s, fluorescent probes also indicated that yeast BMH2 interacted directly with cations, which bind and affect surface hydrophobicity. Binding of 14-3-3s to the phosphopeptide ligand occurred in the absence of divalent cations when the pH was reduced below neutral, and the basis for enhanced binding was a reduction in K(D). At pH 7.5 (+Mg2+), AMP inhibited binding of plant 14-3-3s to the NR based peptide ligand. The binding of AMP to 14-3-3s was directly demonstrated by equilibrium dialysis (plant), and from the observation that recombinant plant 14-3-3s have a low, but detectable, AMP phosphatase activity.

Phosphorylated nitrate reductase and 14-3-3 proteins. Site of interaction, effects of ions, and evidence for an amp-binding site on 14-3-3 proteins

The inactivation of phosphorylated nitrate reductase (NR) by the binding of 14-3-3 proteins is one of a very few unambiguous biological functions for 14-3-3 proteins. We report here that serine and threonine residues at the +6 to +8 positions, relative to the known regulatory binding site involving serine-543, are important in the interaction with GF14omega, a recombinant plant 14-3-3. Also shown is that an increase in ionic strength with KCl or inorganic phosphate, known physical effectors of NR activity, directly disrupts the binding of protein and peptide ligands to 14-3-3 proteins. Increased ionic strength attributable to KCl caused a change in conformation of GF14omega, resulting in reduced surface hydrophobicity, as visualized with a fluorescent probe. Similarly, it is shown that the 5' isomer of AMP was specifically able to disrupt the inactive phosphorylated NR:14-3-3 complex. Using the 5'-AMP fluorescent analog trinitrophenyl-AMP, we show that there is a probable AMP-binding site on GF14omega.

Biological significance of divalent metal ion binding to 14-3-3 proteins in relationship to nitrate reductase inactivation

In this report we address two questions regarding the regulation of phosphorylated nitrate reductase (pNR; EC 1.6.6.1) by 14-3-3 proteins. The first concerns the requirement for millimolar concentrations of a divalent cation in order to form the inactive pNR:14-3-3 complex at pH 7.5. The second concerns the reduced requirement for divalent cations at pH 6.5. In answering these questions we highlight a possible general mechanism involved in the regulation of 14-3-3 binding to target proteins. We show that divalent cations (e.g. Ca2+, Mg2+ and Mn2+) bind directly to 14-3-3s, and as a result cause a conformational change, manifested as an increase in surface hydrophobicity. A similar change is also obtained by decreasing the pH from pH 7.5 to pH 6.5, in the absence of divalent cations, and we propose that protonation of amino acid residues brings about a similar effect to metal ion binding. A possible regulatory mechanism, where the 14-3-3 protein has to be "primed" prior to binding a target protein, is discussed.

Site-specific regulatory interaction between spinach leaf sucrose-phosphate synthase and 14-3-3 proteins

We report an Mg2+-dependent interaction between spinach leaf sucrose-phosphate synthase (SPS) and endogenous 14-3-3 proteins, as evidenced by co-elution during gel filtration and co-immunoprecipitation. The content of 14-3-3s associated with an SPS immunoprecipitate was inversely related to activity, and was specifically reduced when tissue was pretreated with 5-aminoimidazole-4-carboxamide riboside, suggesting metabolite control in vivo. A synthetic phosphopeptide based on Ser-229 was shown by surface plasmon resonance to bind a recombinant plant 14-3-3, and addition of the phosphorylated SPS-229 peptide was found to stimulate the SPS activity of an SPS:14-3-3 complex. Taken together, the results suggest a regulatory interaction of 14-3-3 proteins with Ser-229 of SPS.

14-3-3 proteins associate with the regulatory phosphorylation site of spinach leaf nitrate reductase in an isoform-specific manner and reduce dephosphorylation of Ser-543 by endogenous protein phosphatases

Three lines of evidence indicate that the 14-3-3 proteins that inactivate the phosphorylated form of spinach leaf NADH:nitrate reductase (NR) bind to the enzyme at the regulatory phosphorylation site (Ser-543). First, a phosphorylated synthetic peptide based on the regulatory site can prevent and also reverse the inactivation of phospho-NR caused by 14-3-3 proteins. Second, sequence-specific and phosphorylation-dependent binding of the aforementioned synthetic peptide to the 14-3-3 proteins was demonstrated in vitro. Third, 14-3-3 proteins were required for the ATP-dependent phosphorylation of NR (as assessed by activity measurements) in the presence of NR-kinase and leaf protein phosphatases. Lastly, we demonstrate specificity of recombinant Arabidopsis 14-3-3 isoforms in the interaction with phospho-NR: omega> chi> upsilon>>> phi, psi.