Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 466 | Issue 3 | Mar, 2008

Editorial from Journal Editors

Richard A. Brand MD, Joseph A. Buckwalter MD, Timothy M. Wright PhD, S. Terry Canale MD, William P. Cooney MD, Robert D’Ambrosia MD, Frank J. Frassica MD, William A. Grana MD, MPH, James D. Heckman MD, Robert N. Hensinger MD, George H. Thompson MD, L. Andrew Koman MD, Peter D. McCann MD, Gary G. Poehling MD, James H. Lubowitz MD, David Thordarson MD, Robert J. Neviaser MD

Recurrent Dislocation of the Shoulder Joint

Richard A. Brand MD [object Object],Dr. DePalma was the first editor of Clinical Orthopaedics and Related Research, established by the recently formed Association of Bone and Joint Surgeons. The idea of forming the Association of Bone and Joint surgeons had been conceived by Dr. Earl McBride of Oklahoma City in 1947, and organized by a group of twelve individuals (Drs. Earl McBride, Garrett Pipkin, Duncan McKeever, Judson Wilson, Fritz Teal, Louis Breck, Henry Louis Green, Howard Shorbe, Theodore Vinke, Paul Williams, Eugene Secord, and Frank Hand) [9]. The first organizational meeting was held in conjunction with the 1949 Annual Meeting of the AAOS [9] and the first annual meeting held April 1–2, 1949 in Oklahoma City. Drs. McBride and McKeever invited Dr. DePalma to attend that meeting and join the society. According to DePalma, “Even at this small gathering, there were whisperings of the need of another journal to provide an outlet for the many worthy papers written on clinical and basic science subjects” [7]. The decision to form a new journal was finalized in 1951, and Drs. DePalma and McBride signed a contract with J.B. Lippincott Company. Dr. DePalma was designated Editor-in-Chief, and the journal became a reality in 1953 with the publication of the first volume. From the outset he established the “symposium” as a unique feature, in which part of the articles were devoted to a particular topic. Dr. DePalma served as Editor for 13 years until 1966, when he resigned the position and recommended the appointment of Dr. Marshall R. Urist. At his retirement, Clinical Orthopaedics and Related Research was well established as a major journal.,Dr. Anthony F. DePalma was born in Philadelphia in 1904, the son of immigrants from Alberona in central Foggia, Italy [1]. He attended the University of Maryland for his premedical education, then Jefferson Medical College, from which he graduated in 1929. He then served a two-year internship (common at the time) at Philadelphia General Hospital. Jobs were scarce owing to the Depression, and he felt fortunate to obtain in 1931 a position as assistant surgeon at the Coaldale State Hospital, in Coaldale, Pennsylvania, a mining town. However, he became attracted to orthopaedics and looked for a preceptorship (postgraduate training in specialties was not well developed at this time before the establishments of Boards). In the fall of 1932, he was appointed as a preceptor at the New Jersey Orthopaedic Hospital, an extension of the New York Orthopaedic Hospital. In 1939 he acquired Board certification (the first board examination was offered in 1935 for a fee of $25.00 [2]) and was appointed to the NJOH staff [1].,Dr. DePalma volunteered for military service in 1942, and served first at the Parris Island Naval Hospital in South Carolina, then on the Rixey, a hospital ship. In addition to serving to evacuate casualties to New Zealand, his ship was involved in several of the Pacific island assaults (Guam, Leyte, Okinawa). In 1945, he was assigned to the Naval Hospital in Philadelphia [1].,On his return to Philadelphia, he contacted staff members at Jefferson Medical College, including the Chair, Dr. James Martin, and became good friends with Dr. Bruce Gill (a professor of Orthopaedics at the University of Pennsylvania, and one of the earliest Presidents of the AAOS). After he was discharged from the service, he joined the staff of the Department of Orthopaedic Surgery at Jefferson, where he remained the rest of his career. He succeeded Dr. Martin as Chair in 1950, a position he held until 1970 when he reached the mandatory retirement age of 65. He closed his practice and moved briefly to Pompano Beach, Florida, but the lure of academia proved too powerful, and in January, 1971, he accepted the offer to develop a Division of Orthopaedics at the New Jersey College of Medicine and became their Chair. He committed to a five-year period, and then again moved to Pompano Beach, only to take the Florida State Boards and open a private practice in 1977. His practice grew, and he continued that practice until 1983 at the age of nearly 79. Even then he continued to travel and lecture [1].,We reproduce here four of his many contributions on the shoulder. The first comes from his classic monograph, “Surgery of the Shoulder,” published by J. B. Lippincott in 1950 [2]. In this article he describes the evolutionary development of the shoulder, focusing on the distinction between various primates, and relates the anatomic changes to upright posture and prehensile requirements. The remaining three are journal articles related to frozen shoulder [1], recurrent dislocation [3], and surgical anatomy of the rotator cuff [6], three of the most common shoulder problems then and now. He documented the histologic inflammation and degeneration in various tissues including the coracohumeral ligaments, supraspinatus tendon, bursal wall, subscapularis musculotendinous junction, and biceps tendon. Thus, the problem was rather more global than localized. He emphasized, “Manipulation of frozen shoulders is a dangerous and futile procedure.” For recurrent dislocation he advocated the Magnuson procedure (transfer of the subscapularis tendon to the greater tuberosity) to create a musculotendinous sling. All but two of 23 patients he treated with this approach were satisfied with this relatively simple procedure. (Readers will note the absence of contemporary approaches to ascertain outcomes and satisfaction. The earliest outcome musculoskeletal measures were introduced in the 60s by Larson [11] and then by Harris [10], but these instruments were physician-generated and do not reflect the rather more rigorously validated patient-generated outcome measures we use today. Nonetheless, the approach used by Dr. DePalma reflected the best existing standards of reporting results.) Dr. DePalma’s classic article, “Surgical Anatomy of the Rotator Cuff and the Natural History of Degenerative Periarthritis,” [6] reflected his literature review and dissections of 96 shoulders from 50 individuals “unaware of any (shoulder) disability” and mostly over the age of 40. By the fifth decade, most specimens began to show signs of rotator cuff tearing and he found complete tears in nine specimens from “the late decades.” He concluded,,[object Object],Thus, he clearly defined the benign effects of rotator cuff tear in many aging individuals, but also the potential to create substantial pain and disability.,Dr. DePalma was a prolific researcher and writer. In addition to his “Surgery of the Shoulder,” he wrote three other books, “Diseases of the Knee: Management in Medicine and Surgery” (published by J.B. Lippincott in 1954) [4], “The Management of Fractures and Dislocations” (a large and comprehensive two volume work published by W.B. Saunders in 1959, and going through 5 reprintings) [5], and “The Intervertebral Disc” (published by W.B. Saunders in 1970, and written with his colleague, Dr. Richard Rothman) [8]. PubMed lists 62 articles he published from 1948 until 1992.,We wish to pay tribute to Dr. DePalma for his vision in establishing Clinical Orthopaedics and Related Research as a unique journal and for his many contributions to orthopaedic surgery.,[object Object],[object Object]

Development of a Regional Model of Care for Ambulatory Total Shoulder Arthroplasty

S. H. Gallay MD, J. J. A. Lobo MD, J. Baker RN, K. Smith MD, K. Patel MD Total shoulder arthroplasty (TSA) has traditionally been performed as inpatient surgery to provide adequate postoperative analgesia via intermittent opioid administration. We developed a regional model for ambulatory TSA using continuous brachial plexus nerve block (CBPNB). We asked whether this regional model would allow us to select patients to undergo outpatient TSA using CBPNB while providing similar outcomes to those patients who were managed with CBPNB and a one-night or longer inpatient hospital stay. Of 16 selected patients, eight underwent outpatient TSA/CBPNB while the other eight had an overnight hospital stay. Outcome measures included readmission, duration of CBPNB use, pain scores, adjunctive analgesia use, range of motion, and patient satisfaction. There were no readmissions. Patients used CBPNB for an average of 6 days. The average postoperative pain score was 1/10. One patient required oral analgesics while using CBPNB. All patients were very satisfied (Likert scale) and would have the surgery again. Although these data are preliminary, the development of a regional outpatient model for TSA using CBPNB permitted integration of community care and patient satisfaction and decreased length of hospital stay.,[object Object]

Projection of the Glenoid Center Point Within the Glenoid Vault

Damian M. Rispoli MD, John W. Sperling MD, MBA, George S. Athwal MD, FRCSC, Doris E. Wenger MD, Robert H. Cofield MD Correct identification of the center point of the glenoid surface guides glenoid component placement. It is unknown whether the center point on the glenoid surface corresponds to the center of the glenoid vault at the medial extent of the glenoid prosthesis. We reviewed 20 consecutive computed tomography scans obtained preoperatively in patients with primary osteoarthritis. A glenoid center point was chosen on the glenoid surface and then projected back into the glenoid vault along the scapular axis and perpendicular to glenoid inclination. The difference from the projection of the glenoid surface center point to the center point at a 1.5-cm depth into the glenoid vault was then measured. The mean deviation of the glenoid center point at a depth of 1.5 cm from the center point at the glenoid articular surface was 1.7 mm anterior and 3.9 mm inferior. The most common deviation of the center point of the glenoid vault at the projected medial limit of the glenoid prosthesis was slightly anterior and inferior to the center point on the glenoid surface. Identifying the center of the glenoid surface coupled with alignment of the glenoid prosthesis in neutral version and anatomic inclination provides a reliable means to guide placement of glenoid components.

Augmented Glenoid Component for Bone Deficiency in Shoulder Arthroplasty

Robert S. Rice MD, John W. Sperling MD, MBA, Joseph Miletti MD, Cathy Schleck BS, Robert H. Cofield MD Asymmetric posterior glenoid wear caused by degenerative glenohumeral arthritis can be addressed by several techniques during total shoulder arthroplasty. The purpose of this study was to evaluate the midterm outcome of a posterior augmented glenoid component to determine the clinical and radiographic outcome, including complications and the need for revision surgery. Between 1995 and 1999, 13 patients (14 shoulders) underwent a shoulder arthroplasty with an augmented glenoid component to treat posterior glenoid bone deficiency. All 14 shoulders had advanced osteoarthritis. The minimum followup for these 13 patients was 2 years (mean, 5 years; range, 2–8 years). The mean age of these patients was 66 years at the time of surgery (range, 52–78 years). The mean active elevation was 160° (range, 120°–180°) and external rotation was 56° (range, 30°–90°). According to a modified Neer result rating system, 36% of patients had an excellent result, 50% a satisfactory result, and 14% an unsatisfactory result. Our results suggest patients undergoing total shoulder arthroplasty with an asymmetric glenoid component for osteoarthritis achieve satisfactory mid-term pain relief and improvement in function; however, instability is not always corrected. The advantage of this component seems marginal, and its use has been discontinued.,[object Object]

Reverse Shoulder Arthroplasty Combined with a Modified Latissimus Dorsi and Teres Major Tendon Transfer for Shoulder Pseudoparalysis Associated with Dropping Arm

Pascal Boileau MD, Christopher Chuinard MD, MPH, Yannick Roussanne MD, Ryan T. Bicknell MD, MSc, FRCS(C), Nathalie Rochet MD, PhD, Christophe Trojani MD, PhD Although a reverse shoulder arthroplasty (RSA) can restore active elevation in the cuff deficient shoulder, it cannot restore active external rotation when both the infraspinatus and teres minor muscles are absent or atrophied. We hypothesized that a latissimus dorsi and teres major (LD/TM) transfer with a concomitant RSA would restore shoulder function and activities of daily living (ADLs). We prospectively followed 11 consecutive patients (mean age, 70 years) with a combined loss of active elevation and external rotation (shoulder pseudoparalysis and dropping arm) who underwent this procedure. All had severe cuff tear arthropathy (Hamada Stage 3, 4, or 5) and severe atrophy or fatty infiltration of infraspinatus and teres minor on preoperative MRI or CT-scan. The combined procedure was performed through a single deltopectoral approach in the same session. Postoperatively, mean active elevation increased from 70° to 148° (+78°) and external rotation from −18° to 18° (+36°). The Constant score, subjective assessment and ADLs improved. The combination of a RSA and LD/TM transfer restored both active elevation and external rotation in this selected subgroup of patients with a cuff deficient shoulder and absent or atrophied infraspinatus and teres minor.,[object Object]

Contribution of the Reverse Endoprosthesis to Glenohumeral Kinematics

Jeroen H. M. Bergmann MSc, M. Leeuw MSc, Thomas W. J. Janssen PhD, DirkJan H. E. J. Veeger PhD, W. J. Willems PhD, MD After placement of a reverse shoulder endoprosthesis, range of motion is usually still compromised. To what extent this occurs from limitation in motion of the reverse endoprosthesis is, however, unclear. We measured the motion pattern of 16 patients (18 shoulders) during three active and passive range of motion tasks using a six degree-of-freedom electromagnetic tracking device. Despite rotator cuff deficiencies, glenohumeral elevation contributed roughly two-thirds of the total thoracohumeral elevation, which is comparable to healthy subjects. However, patients could not actively use the full range of motion provided by the prosthesis. Although we found considerable interindividual differences in shoulder kinematics, the limitation in glenohumeral range of motion appears related to a lack of generated muscle force and not the design of the prosthesis.,[object Object]

Glenoid Reconstruction in Revision Shoulder Arthroplasty

Bassem Elhassan MD, Mehmet Ozbaydar MD, Lawrence D. Higgins MD, Jon J. P. Warner MD Failed shoulder arthroplasty associated with glenoid bony deficiency is a difficult problem. Revision surgery is complex with unpredictable outcome. We asked whether revision shoulder arthroplasty with glenoid bone grafting could lead to good outcome. We retrospectively reviewed 21 patients who underwent glenoid bone grafting using corticocancellous bone grafting or impaction grafting using cancellous bone graft. Three patients underwent revision TSA, five patients hemiarthroplasty, 10 patients hemiarthroplasty with biologic resurfacing of the glenoid, and three patients revision to reverse TSA. The patients had minimum 25 months followup (average, 45 months; range, 25–92 months). All patients had improvement in their range of motion and the Constant-Murley score. Most improvement occurred in patients with glenoid reimplantation. Patients who underwent revision reverse TSA had improvement in shoulder flexion but decrease in external rotation motion. We conclude revision shoulder arthroplasty with glenoid bone grafting can produce good short-term outcome and glenoid component reinsertion should be attempted whenever possible.,[object Object]

Risk Factors for Readmission and Revision Surgery Following Rotator Cuff Repair

Seth L. Sherman MD, Stephen Lyman PhD, Panagiotis Koulouvaris MD, Andrew Willis MD, Robert G. Marx MD, MSc, FRCSC Risk factors for revision surgery and hospitalization following rotator cuff repair (RCR) have not been clearly identified. We hypothesized patient factors and surgeon and hospital volume independently contribute to the risk of readmission within 90 days and revision RCR within one year. Using the SPARCS database, we included patients undergoing primary RCR in New York State between 1997 and 2002. These patients were tracked for readmission within 90 days and revision RCR within 1 year. A generalized estimating equation was developed to determine whether patient factors, surgeon volume, or hospital volume were independent risk factors for the above outcome measures. The total annual number of RCR increased from 6,656 in 1997 to 10,128 in 2002. Ambulatory cases increased from 57% to 82% during this time period. Independent risk factors for readmission within 90 days included increasing age and increased number of comorbidities. Independent risk factors for revision RCR included increasing age, increased comorbidity, and lower surgeon volume. Hospital volume had a minimal effect on either outcome measure. The shift toward out-patient surgery mirrors the shift from open to arthroscopic rotator cuff repair. The finding that surgeon volume is a predictor of revision RCR reflects the findings in other orthopaedic procedures.,[object Object]

Débridement of Small Partial-thickness Rotator Cuff Tears in Elite Overhead Throwers

Scott B. Reynolds MD, Jeffrey R. Dugas MD, E. Lyle Cain MD, Christopher S. McMichael MPH, James R. Andrews MD Elite overhead throwing athletes with rotator cuff tears represent a unique group of patients with an ultimate goal of returning to their previous level of competition. We hypothesized débridement of small partial-thickness rotator cuff tears would return the majority of elite overhead throwing athletes to their previous level of competition. Preoperative and intraoperative findings on 82 professional pitchers who had undergone débridement of partial-thickness rotator cuff tears were evaluated using our database. We obtained return to play data on 67 of the 82 players (82%); 51 (76%) were able to return to competitive pitching at the professional level and 37 (55%) were able to return to the same or higher level of competition. Of the 67 patients, 34 pitchers returned a questionnaire with a minimum followup of 18 months (mean 38 months; range 18 to 59 months). SF-12 scores were above average with a mean PSF-12 and MSF-12 of 55.04 and 56.49 respectively. An Athletic Shoulder Outcome Rating Scale score of greater than 60 was found in 76.5% of pitchers. Débridement of small partial-thickness rotator cuff tears allowed a majority of elite overhead throwing athletes to return to competitive pitching, however, returning to their previous level of competition remains a challenge for many of these players.,[object Object]

Biological Augmentation of Rotator Cuff Tendon Repair

David Kovacevic BS, Scott A. Rodeo MD A histologically normal insertion site does not regenerate following rotator cuff tendon-to-bone repair, which is likely due to abnormal or insufficient gene expression and/or cell differentiation at the repair site. Techniques to manipulate the biologic events following tendon repair may improve healing. We used a sheep infraspinatus repair model to evaluate the effect of osteoinductive growth factors and BMP-12 on tendon-to-bone healing. Magnetic resonance imaging and histology showed increased formation of new bone and fibrocartilage at the healing tendon attachment site in the treated animals, and biomechanical testing showed improved load-to-failure. Other techniques with potential to augment repair site biology include use of platelets isolated from autologous blood to deliver growth factors to a tendon repair site. Modalities that improve local vascularity, such as pulsed ultrasound, have the potential to augment rotator cuff healing. Important information about the biology of tendon healing can also be gained from studies of substances that inhibit healing, such as nicotine and antiinflammatory medications. Future approaches may include the use of stem cells and transcription factors to induce formation of the native tendon-bone insertion site after rotator cuff repair surgery.

Outcome of Arthroscopic Débridement is Worse for Patients With Glenohumeral Arthritis of Both Sides of the Joint

Brian J. Kerr MD, Eric C. McCarty MD Glenohumeral arthritis in the young patient presents a difficult problem with potentially devastating sequelae. Reports in the literature suggest a role for arthroscopic treatment in patients with symptomatic degenerative joint disease of the shoulder. However, no published study directly compares patients with unipolar versus bipolar cartilage lesions. We retrospectively reviewed 19 patients (20 shoulders) younger than 55 years with Outerbridge Grade 2–4 articular cartilage changes who underwent arthroscopic glenohumeral débridements. We obtained WOOS, SF-12, SANE and the American Shoulder and Elbow Society scores at last followup. The minimum follow up time was 12 months (average, 20 months; range, 12–33 months). Three patients progressed to shoulder arthroplasty. All but three patients reported their shoulder function at 60% or better based on the SANE score. The grade of the lesion did not influence outcome scores, but patients with unipolar lesions had higher outcome scores than patients with bipolar lesions. We believe arthroscopic glenohumeral débridement in young patients with shoulder arthritis can be an effective tool in managing symptoms and delaying the need for invasive resurfacing or prosthetic replacement.,[object Object]

A Modified Technique of Arthroscopically Assisted AC Joint Reconstruction and Preliminary Results

Daniel P. Tomlinson MD, David W. Altchek MD, Jeffrey Davila MD, Frank A. Cordasco MD Surgical treatment of high-grade acromioclavicular (AC) joint separations has become analogous to ligament reconstructions elsewhere in the body with the goal being restoration of the native anatomy. Circumferential access to the base of the coracoid is essential to reconstruct the coracoclavicular ligament complex. Using some of the traditional open approaches, this access requires detaching the deltoid insertion and performing extensive soft tissue dissection. Also, poor visualization risks injury to nearby neurovascular structures. An arthroscopically assisted reconstruction offers the advantage of less soft tissue dissection and superior visualization to the base of the coracoid. We have developed a unique arthroscopically assisted technique that uses a subacromial approach to pass suture material and a tendon graft around the coracoid to reconstruct the coracoclavicular ligament complex. We describe our technique and preliminary results in 10 patients who have undergone coracoclavicular ligament reconstruction for high-grade AC separation. All patients improved subjectively with regard to pain and function at a minimum followup of 3 months (mean, 5 months; range, 3–18 months). This arthroscopically assisted technique has the potential to allow for safe and at least in the short term reliable restoration of the coracoclavicular ligament complex and provides an alternative technique to treat AC joint separations.,[object Object]

Complications After Open Distal Clavicle Excision

Efstathis Chronopoulos MD, Harpreet S. Gill MD, Michael T. Freehill MD, Steve A. Petersen MD, Edward G. McFarland MD Isolated distal clavicle excision performed as an open procedure has been considered safe and, in the literature, has been considered the standard for comparison with arthroscopic distal clavicle excisions. However, we noticed isolated open distal clavicle excision was associated with a number of complications. We therefore raised two questions about the complication rate in a cohort of our patients who had undergone this procedure: (1) What was the complication rate and how did it compare to that in the existing literature on this subject? and (2) Were the complications in our cohort similar to those previously reported? We studied 42 patients who underwent an isolated distal clavicle excision between 1992 and 2003. There were 27 complications (64%), which was substantially higher than rates previously reported. Complications in our cohort not previously reported included continued acromioclavicular joint tenderness and scar hypertrophy. Our study suggests complications after open distal clavicle excisions may be more frequent than and may differ from previously reported rates and types.,[object Object]

Surgical Treatment of Winged Scapula

Gregory J. Galano MD, Louis U. Bigliani MD, Christopher S. Ahmad MD, William N. Levine MD Injuries to the long thoracic and spinal accessory nerves present challenges in diagnosis and treatment. Palsies of the serratus anterior and trapezius muscles lead to destabilization of the scapula with medial and lateral scapular winging, respectively. Although nonoperative treatment is successful in some patients, failures have led to the evolution of surgical techniques involving various combinations of fascial graft and/or transfer of adjacent muscles. Our preferred method of reconstruction for serratus anterior palsy is a two-incision, split pectoralis major transfer without fascial graft. For trapezius palsy, we prefer a modified version of the Eden-Lange procedure. At a minimum followup of 16 months (mean, 47 months), six patients who underwent the Eden-Lange procedure showed improvement in mean American Shoulder and Elbow Surgeons Shoulder scores (33.3–64.6), forward elevation (141.7–151.0), and visual analog scale (7.0–2.3). At a minimum followup of 16 months (mean, 44 months), 10 patients (11 shoulders) who underwent split pectoralis transfer also improved American Shoulder and Elbow Surgeons Shoulder scores (53.3–63.8), forward elevation (158.2–164.5), and visual analog scale (5.0–2.9). We encountered two complications, both superficial wound infections. These tendon transfers were effective for treating scapular winging in patients who did not respond to nonoperative treatment.,[object Object]

CT Scan Method Accurately Assesses Humeral Head Retroversion

P. Boileau MD, R. T. Bicknell MD, MSc, FRCSC, N. Mazzoleni MD, G. Walch MD, J. P. Urien MD Humeral head retroversion is not well described with the literature controversial regarding accuracy of measurement methods and ranges of normal values. We therefore determined normal humeral head retroversion and assessed the measurement methods. We measured retroversion in 65 cadaveric humeri, including 52 paired specimens, using four methods: radiographic, computed tomography (CT) scan, computer-assisted, and direct methods. We also assessed the distance between the humeral head central axis and the bicipital groove. CT scan methods accurately measure humeral head retroversion, while radiographic methods do not. The retroversion with respect to the transepicondylar axis was 17.9° and 21.5° with respect to the trochlear tangent axis. The difference between the right and left humeri was 8.9°. The distance between the central axis of the humeral head and the bicipital groove was 7.0 mm and was consistent between right and left humeri. Humeral head retroversion may be most accurately obtained using the patient’s own anatomic landmarks or, if not, identifiable retroversion as measured by those landmarks on contralateral side or the bicipital groove.

Hierarchy of Stability Factors in Reverse Shoulder Arthroplasty

Sergio Gutiérrez MS, Tony S. Keller PhD, Jonathan C. Levy MD, William E. Lee PhD, Zong-Ping Luo PhD Reverse shoulder arthroplasty is being used more frequently to treat irreparable rotator cuff tears in the presence of glenohumeral arthritis and instability. To date, however, design features and functions of reverse shoulder arthroplasty, which may be associated with subluxation and dislocation of these implants, have been poorly understood. We asked: (1) what is the hierarchy of importance of joint compressive force, prosthetic socket depth, and glenosphere size in relation to stability, and (2) is this hierarchy defined by underlying and theoretically predictable joint contact characteristics? We examined the intrinsic stability in terms of the force required to dislocate the humerosocket from the glenosphere of eight commercially available reverse shoulder arthroplasty devices. The hierarchy of factors was led by compressive force followed by socket depth; glenosphere size played a much lesser role in stability of the reverse shoulder arthroplasty device. Similar results were predicted by a mathematical model, suggesting the stability was determined primarily by compressive forces generated by muscles.

Ischial Spine Projection into the Pelvis

Fabian Kalberer MD, Rafael J. Sierra MD, Sanjeev S. Madan FRCS (Tr&Orth), Reinhold Ganz MD, Michael Leunig MD Femoroacetabular impingement may occur in patients with so-called acetabular retroversion, which is seen as the crossover sign on standard radiographs. We noticed when a crossover sign was present the ischial spine commonly projected into the pelvic cavity on an anteroposterior pelvic radiograph. To confirm this finding, we reviewed the anteroposterior pelvic radiographs of 1010 patients. Nonstandardized radiographs were excluded, leaving 149 radiographs (298 hips) for analysis. The crossover sign and the prominence of the ischial spine into the pelvis were recorded and measured. Interobserver and intraobserver variabilities were assessed. The presence of a prominent ischial spine projecting into the pelvis as diagnostic of acetabular retroversion had a sensitivity of 91% (95% confidence interval, 0.85%–0.95%), a specificity of 98% (0.94%–1.00%), a positive predictive value of 98% (0.94%–1.00%), and a negative predictive value of 92% (0.87%–0.96%). Greater prominence of the ischial spine was associated with a longer acetabular roof to crossover sign distance. The high correlation between the prominence of the ischial spine and the crossover sign shows retroversion is not just a periacetabular phenomenon. The affected inferior hemipelvis is retroverted entirely. Retroversion is not caused by a hypoplastic posterior wall or a prominence of the anterior wall only and this finding may influence management of acetabular disorders.,[object Object]

A New Method to Make 2-D Wear Measurements Less Sensitive to Projection Differences of Cemented THAs

Bertram The MD, Gunnar Flivik MD, PhD, Ron L. Diercks MD, PhD, Nico Verdonschot PhD Wear curves from individual patients often show unexplained irregular wear curves or impossible values (negative wear). We postulated errors of two-dimensional wear measurements are mainly the result of radiographic projection differences. We tested a new method that makes two-dimensional wear measurements less sensitive for radiograph projection differences of cemented THAs. The measurement errors that occur when radiographically projecting a three-dimensional THA were modeled. Based on the model, we developed a method to reduce the errors, thus approximating three-dimensional linear wear values, which are less sensitive for projection differences. An error analysis was performed by virtually simulating 144 wear measurements under varying conditions with and without application of the correction: the mean absolute error was reduced from 1.8 mm (range, 0–4.51 mm) to 0.11 mm (range, 0–0.27 mm). For clinical validation, radiostereometric analysis was performed on 47 patients to determine the true wear at 1, 2, and 5 years. Subsequently, wear was measured on conventional radiographs with and without the correction: the overall occurrence of errors greater than 0.2 mm was reduced from 35% to 15%. Wear measurements are less sensitive to differences in two-dimensional projection of the THA when using the correction method.

Type III Acetabular Defect Revision With Bilobed Components

Joseph T. Moskal MD, Michael E. Higgins MD, Joseph Shen MD Combined segmental and cavitary deficiencies of the acetabulum (American Academy of Orthopaedic Surgeons Type III) are a difficult problem that revision arthroplasty surgeons must tackle with increasing frequency. Porous-coated bilobed acetabular components are a reconstruction option that allows for increased host bone-prosthesis contact with restoration of the anatomic hip center without the use of a structural bone graft. Eleven consecutive Type III acetabular defects in 11 patients were revised with a porous-coated bilobed cup without a structural bone graft between January 1999 and January 2001 and prospectively followed. Average Harris hip scores improved from 36 preoperatively to 85 postoperatively. Radiographic analysis showed improvement in the average vertical displacement of the hip center. Average leg length discrepancies decreased from 34 mm preoperatively to 7 mm postoperatively. There have been no revisions performed or planned. Porous-coated bilobed acetabular components can provide good clinical and radiographic results at intermediate followup for treatment of Type III acetabular deficiencies. Bilobed components offer a viable option for reconstruction of Type III defects without the use of a structural bone graft or cement while maximizing the host bone-implant contact and restoring the native hip center.,[object Object]

Serum Ion Level After Metal-on-metal THA in Patients With Renal Failure

Chang Ich Hur MD, Taek Rim Yoon MD, Sang Gwon Cho MD, Eun Kyoo Song MD, Jong Keun Seon MD We retrospectively reviewed cementless THAs with metal-on-metal bearings in five patients with chronic renal failure and investigated the relations between renal failure and elevated serum cobalt and chromium levels and the side effects of these elevations. Serum cobalt and chromium levels were measured by atomic absorption spectrophotometry at a minimum followup of 2.7 years (mean, 3.9 years; range, 2.7–6.2 years) in five patients with chronic renal failure and in six patients with normal renal function after THA. Mean serum cobalt concentration was 12.5 μg/L in patients with chronic renal failure; this was more than 100-fold higher than in patients with the same prosthesis type and similar followup period, but with no known renal disease. However, the mean serum chromium concentration was 5.1 μg/L, which was within the normal range in all 11 study patients. Side effects related to elevation of serum cobalt or serum chromium concentration were not identified and overall clinical results were good 4 years after surgery. The serum cobalt level was higher in patients with chronic renal failure. Longer followup is necessary to determine any clinical effects.

Does Ion Release Differ Between Hip Resurfacing and Metal-on-metal THA?

Antonio Moroni MD, Lucia Savarino BSc, Matteo Cadossi MD, Nicola Baldini MD, Sandro Giannini MD Modern metal-on-metal hip resurfacing was introduced as a bone-preserving method of joint reconstruction for young and active patients; however, the large diameter of the bearing surfaces is of concern for potential increased metal ion release. We hypothesized there were no differences in serum concentrations of chromium, cobalt, and molybdenum between patients who had metal-on-metal hip resurfacing (Group A; average head diameter, 48 mm; median followup, 24 months) and patients who had 28-mm metal-on-metal THA (Group B; median followup, 25 months). Serum concentrations also were compared with concentrations in healthy subjects. We identified no differences in ion levels between Groups A and B. A distinction was made according to gender. Women showed a higher chromium release in Group A whereas men had a higher cobalt release in Group B. Values obtained from Group A were higher than those of the control subjects. Our data suggest metal-on-metal bearings for THA should not be rejected because of concern regarding potential increased metal ion release; however, patients with elevated ion levels, even without loosening or toxicity, could be at higher risk and should be followed up periodically.,[object Object]

Pelvic Support Osteotomy in the Treatment of Patients With Excision Arthroplasty

Khaled Mohamed Emara MS, MD Resistant hip infection in adults can be a complicated problem that does not respond to surgical and medical treatment. In such cases, the only remaining option is excision arthroplasty. This line of treatment can eradicate the infection but also is associated with poor function. In some cases, conversion of excision arthroplasty to artificial joint replacement is associated with too great a risk because of local hip surgical risks or low immunity with risk of recurrent infection. Pelvic support osteotomy with the Ilizarov modification can present an alternative solution for such patients. This study included 11 patients with resistant hip infection who were treated using excision arthroplasty. Pelvic support osteotomy then was used to improve hip stability and abductor muscle function. The Ilizarov modification was applied to correct mechanical alignment of the limb and the limb length discrepancy. Harris hip scores improved in all patients: the average score preoperatively was 43.5 (range, 31–50), whereas at final followup, the average score was 70.9 (range, 65–80). Pelvic support osteotomy, along with the Ilizarov modification, can provide an alternative treatment to improve function in patients previously managed with excision hip arthroplasty and Girdlestone surgery.,[object Object]

Potent Anticoagulants are Associated with a Higher All-Cause Mortality Rate After Hip and Knee Arthroplasty

Nigel E. Sharrock BMedSci, MB, ChB, Alejandro Gonzalez Della Valle MD, George Go BS, Stephen Lyman PhD, Eduardo A. Salvati MD Anticoagulation for thromboprophylaxis after THA and TKA has not been confirmed to diminish all-cause mortality. We determined whether the incidence of all-cause mortality and pulmonary embolism in patients undergoing total joint arthroplasty differs with currently used thromboprophylaxis protocols. We reviewed articles published from 1998 to 2007 that included 6-week or 3-month incidence of all-cause mortality and symptomatic, nonfatal pulmonary embolism. Twenty studies included reported 15,839 patients receiving low-molecular-weight heparin, ximelagatran, fondaparinux, or rivaroxaban (Group A); 7193 receiving regional anesthesia, pneumatic compression, and aspirin (Group B); and 5006 receiving warfarin (Group C). All-cause mortality was higher in Group A than in Group B (0.41% versus 0.19%) and the incidence of clinical nonfatal pulmonary embolus was higher in Group A than in Group B (0.60% versus 0.35%). The incidences of all-cause mortality and nonfatal pulmonary embolism in Group C were similar to those in Group A (0.4 and 0.52, respectively). Clinical pulmonary embolus occurs despite the use of anticoagulants. Group A anticoagulants were associated with the highest all-cause mortality of the three modalities studied.,[object Object]

Aneurysmal Bone Cysts Recur at Juxtaphyseal Locations in Skeletally Immature Patients

Patrick P. Lin MD, Christopher Brown BS, A. Kevin Raymond MD, Michael T. Deavers MD, Alan W. Yasko MD, MBA Aneurysmal bone cysts are associated with a high rate of recurrence. Many aneurysmal bone cysts arise near open physes or articular cartilage in skeletally immature patients. Fear of damaging these structures could cause surgeons to curette the tumors less aggressively. We hypothesized location of an aneurysmal bone cyst in a periarticular or juxtaphyseal location would increase the risk of recurrence. We retrospectively studied 53 patients with aneurysmal bone cysts treated between 1989 and 2004. All patients had primary disease, and all patients underwent curettage of the lesion. Ten patients (18.9%) had local recurrence. Gender, race, and size did not predict recurrence; however 12 years of age or younger was associated with recurrence. Of the 19 juxtaphyseal cysts directly adjacent to an open physis, eight developed recurrence. Of the five periarticular cysts, two developed recurrence. The data suggest the risk of recurrence is highest in pediatric patients with juxtaphyseal or periarticular aneurysmal bone cysts. Meticulous treatment of these cysts is necessary, but we believe an overly aggressive approach that destroys the physis or articular cartilage is not warranted. Preservation of these structures remains a high priority of treatment.,[object Object]

Predictors of Survival in Patients With Bone Metastasis of Lung Cancer

Hideshi Sugiura MD, Kenji Yamada MD, Takahiko Sugiura MD, Toyoaki Hida MD, Tetsuya Mitsudomi MD The prognosis of patients with bone metastasis from lung cancer has not been well documented. We assessed the survival rates after bone metastasis and prognostic factors in 118 patients with bone metastases from lung cancer. The cumulative survival rates after bone metastasis from lung cancer were 59.9% at 6 months, 31.6% at 1 year, and 11.3% at 2 years. The mean survival was 9.7 months (median, 7.2 months; range, 0.1–74.5 months). A favorable prognosis was more likely in women and patients with adenocarcinoma, solitary bone metastasis, no metastases to the appendicular bone, no pathologic fractures, performance status 1 or less, use of systemic chemotherapy, and use of an epithelial growth factor receptor inhibitor. Analyses of single and multiple variables indicated better prognoses for patients with adenocarcinoma, no evidence of appendicular bone metastases, and treatment with an epithelial growth factor receptor inhibitor. The mean survival period was longer in a small group treated with an epithelial growth factor receptor inhibitor than in the larger untreated group. The data preliminarily suggest treatment with an epithelial growth factor receptor inhibitor may improve survival after bone metastasis.,[object Object]

Expansion of the Coordinator Role in Orthopaedic Residency Program Management

Richard E. Grant MD, Laurie A. Murphy MBA, MPH, James E. Murphy MD The Accreditation Council of Graduate Medical Education’s (ACGME) Data Accreditation System indicates 124 of 152 orthopaedic surgery residency program directors have 5 or fewer years of tenure. The qualifications and responsibilities of the position based on the requirements of orthopaedic surgery residency programs, the institutions that support them, and the ACGME Outcome Project have evolved the role of the program coordinator from clerical to managerial. To fill the void of information on the coordinators’ expanding roles and responsibilities, the 2006 Association of Residency Coordinators in Orthopaedic Surgery (ARCOS) Career survey was designed and distributed to 152 program coordinators in the United States. We had a 39.5% response rate for the survey, which indicated a high level of day-to-day managerial oversight of all aspects of the residency program; additional responsibilities for other department or division functions for fellows, rotating medical students, continuing medical education of the faculty; and miscellaneous business functions. Although there has been expansion of the role of the program coordinator, challenges exist in job congruence and position reclassification. We believe use of professional groups such as ARCOS and certification of program coordinators should be supported and encouraged.

Case Report

Ali Nourbakhsh MD, Hasan A. Ahmed MCh Orth, FRCS (Tr & Orth), Thomas B. McAuliffe MA, FRCS, Kim J. Garges MD A 24-year-old woman presented with an 11-year history of bilateral hip pain. Radiographs of the hips revealed severe bilateral slipped upper femoral epiphyses; the left side was more severely slipped than the right. While moving the hips under fluoroscopy we observed motion at the physes and reproduced the patient’s pain; the motion confirmed the diagnosis of chronic slipped capital femoral epiphysis. Endocrinology tests showed hypothyroidism. After 1 year of thyroxin therapy, the patient’s pain subsided and radiographs of the hips showed fusion of the physes. This case emphasizes the importance of screening for an endocrine disorder in patients with slipped capital femoral epiphysis particularly in adults and shows fusion can occur once the underlying endocrine abnormality is treated.

Case Report

Thomas Aleto MD, Merrill A. Ritter MD, Michael E. Berend MD Vascular injuries around the hip are uncommon with hip arthroplasty. However, given the close proximity of the external iliac and femoral vessels to the hip, iatrogenic injury may occur. We describe a case of superficial femoral artery injury occurring during revision THA using an extended trochanteric osteotomy, bulk allograft, and cerclage wires. We review the available literature on vascular injury in hip arthroplasty and illustrate the great care necessary when placing cerclage wires and the importance of prompt recognition of these potentially devastating complications.

A Painful Tibial Mass in a 37-year-old Man

Seena C. Aisner MD, Marcia Blacksin MD, Francis Patterson MD, Meera R. Hameed MD
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