Faculty Bibliography

BACKGROUND: Injection to the acromioclavicular (AC) joint can be both diagnostic and therapeutic. PURPOSE: The purpose of this study was to evaluate the accuracy of in vivo AC joint injections. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Thirty patients with pain localized to the AC joint were injected with 1 mL of 1% lidocaine and 0.5 mL of radiographic contrast material (Isovue). Radiographs of the AC joint were taken after the injection. Each radiograph was reviewed by a musculoskeletal radiologist and graded as intra-articular, extra-articular, or partially intra-articular. RESULTS: Of the 30 injections performed, 13 (43.3%) were intra-articular, 7 (23.3%) were partially articular, and 10 (33.3%) were extra-articular. When the intra-articular and the partially articular groups were combined, 20 patients (66.7%) had some contrast dye in the AC joint. CONCLUSION: This study demonstrates that despite the relatively superficial location of the AC joint, the clinical accuracy of AC joint injections remains relatively low.

UNLABELLED:Worldwide, the usage of both anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthro- plasty (rTSA) has increased significantly due, in part, to the predictability of acceptable outcomes achieved with each prosthesis type. This study quantifies outcomes using five different metrics and compares results using one platform total shoulder arthroplasty system that utilizes the same humeral component and instrumentation to perform both aTSA or rTSA. METHODS:200 patients were treated by two orthopaedic surgeons using either aTSA or rTSA. 73 patients received aTSA for treatment of osteoarthritis (OA), and 127 patients received rTSA for treatment of rotator cuff tear arthro- plasty (CTA). Each was scored preoperatively, and at latest follow-up using the SST, UCLA, ASES, Constant, and SPADI metrics, motion was also quantified. The average follow-up for all patients was 31.4 ± 9.7 months. RESULTS:All patients demonstrated significant improvements in pain and function following treatment of OA with aTSA and treatment of CTA with rTSA. No instances of instability or glenoid loosening were reported in either cohort; one instance of infection occurred in the rTSA cohort. aTSA was associated with significantly higher pre- and postoperative outcome scores and significantly larger pre- and postoperative range of motion than rTSA. However, rTSA was demonstrated to be significantly more effective at improving outcome scores, active forward flexion, and strength than was aTSA. DISCUSSION AND CONCLUSIONS/CONCLUSIONS:Significant improvements in outcome scores were observed for both aTSA and rTSA using one platform shoulder system at a mean follow-up of 31.4 months. Significant differences were observed between prosthesis type and between scoring metrics, particularly between the Constant and ASES scoring metrics. Additional and longer term follow-up is required to confirm these observed differences.

Loosening of the glenoid component is a frequent cause of failure of total shoulder arthroplasty (TSA). The etiology of glenoid component loosening is multifactorial and includes aseptic osteolysis, rotator cuff insufficiency, soft tissue instability, and infection. A loose glenoid component is frequently associated with a substantial loss of glenoid bone, which necessitates additional procedures to implant a new component. Several studies have shown that patients with a new glenoid component have better clinical outcomes, which makes successful glenoid reimplantation a priority. The reconstructive options when facing a loose glenoid component in anatomic total shoulder arthroplasty include the established techniques of reaming the high side or bone grafting the deficient glenoid combined with a one or two stage revision. Augmented glenoid components may allow surgeons to limit eccentric reaming or the extent of bone grafting necessary in a bone deficient glenoid. The reverse total shoulder arthroplasty (rTSA) is emerging as a useful reconstructive option capable of addressing bony and soft tissue problems encountered in revision TSA. The ream-and-run procedure remains the least desirable option in the face of significant glenoid bone deficiency. The increasing use of augmented glenoids and rTSA in revision TSA may provide opportunities for new areas of clinical outcomes research in this challenging reconstructive problem.

Subscapularis tenotomy for total shoulder arthroplasty has been the standard approach for shoulder surgeons that utilize the deltopectoral approach. The risk of subscapularis insufficiency after this approach has been well documented. In order to avoid subscapularis complications, Lafosse reported a technique for total shoulder arthroplasty that utilizes a trans-deltoid approach through the rotator interval that yielded satisfactory clinical outcomes. However, he also reported concerns about humeral head undersizing and inadequate osteophyte resection. We present an alternative subscapularis preserving technique that is performed through the deltopectoral interval and allows complete osteophyte excision and accurate humeral head sizing. This technique requires modified instrumentation and is facilitated by the use of an adaptable prosthesis with dual eccentricity. Case examples using this technique are presented.

BACKGROUND: Shoulder arthroplasty provides predictable pain relief and functional improvement of the shoulder for glenohumeral disease. With recent emphasis on health economic planning and rising patient expectation, physicians are encouraged to adopt more evidence-based strategies for decision-making. In the context of shoulder arthroplasty, surgeon preference and bias may play a large role in the choice of the procedure performed. The purpose of this study is to objectively examine the perceived differences and similarities, from the surgeon's perspective, between total shoulder arthroplasty (TSA) and hemiarthroplasty anticipated outcomes. METHODS: We conducted a web-based survey that asked surgeons to weigh the relative values of these procedures in relation to one another. Within the survey, there were numerous variables in which the surgeon was asked to choose the preferred surgical outcome. Ninety-eight surgeons responded to the survey. The average age was 51.7 years. RESULTS: Surgeons in our study chose pain relief and improved ROM as a more likely outcome in TSA than any level of complication and as a more likely out-come than improved strength compared to hemiarthroplasty. These results emphasized the perception amongst the polled surgeons that TSA is a preferred treatment option for patients who expect a high level of pain relief and ROM even at the expense of a decreased strength. CONCLUSION: This study is a first step in the construction of a patient oriented model for treatment decisions. With this information, we may be better able to tailor our patients' needs and wishes to the procedures that most predictably result in the outcomes they desire.

The education of orthopaedic residents is an important responsibility shared by all those involved in residency training. The education of orthopaedic residents begins with the selection process, which recognizes the importance of choosing qualified individuals who can successfully complete the training program. Education during the 5 years of required training entails the acquisition of a body of knowledge, the development of surgical skills, and the exhibition of a level of professionalism consistent with being a physician and surgeon. Residency training also requires an evaluation of performance and, when necessary, measures to improve performance or correct inappropriate behaviors. The goal at the end of the 5-year training period is to have well-qualified, skilled, and knowledgeable orthopaedic surgeons who can enter practice and provide the highest level of patient care.

Insufficiency fractures present a significant problem in patients with osteoporosis. We report a case of bilateral iliac wing insufficiency fracture following low energy injury in an 87-year-old osteoporotic woman occurring 2 weeks after primary total hip arthroplasty. There are only a few reports of insufficiency fractures involving the ilium in the literature, and diagnosis has proven challenging, as radiographs are often negative at symptom onset. Magnetic resonance or radionuclide imaging is generally necessary for definitive diagnosis. This case highlights the importance of careful perioperative management of patients with osteoporosis.

Post-patellectomy patients represent a specific subgroup of patients that may develop arthritis and persistent knee pain and potentially require treatment with total knee arthroplasty. This article reviews the treatment and functional outcomes following total knee arthroplasty in patients with prior patellectomy. A case report is presented as an example of the clinical management of a post-patellectomy patient with significant knee pain and disability treated with total knee arthroplasty. Emphasis will be placed in decision- making, specifically with the use of a posterior stabilized implant. In addition, postoperative strengthening of the quadriceps is essential to compensate for the lack of the patella and increase the success of total knee arthroplasty in this subgroup of patients.